ENDODONTIC DIAGNOSIS

• Radiographs do not determine status of the pulp as pathologic vital pulps are usually not visible on radiographs. Necrotic pulps may not produce radiographic changes in early stages. • According to SLOB rule, the object farthest from the film (most buccal) moves in the direction the cone is directed. Think about why this statement is true. • Pulp canal obliteration (calcified canal) does not, in itself, indicate need for treatment. • The objectives of pulp capping whether direct or indirect, are the formation of reparative and maintenance of a vital pulp. •

*QUESTION: Which teeth do you perform pulp evaluation/ cold test on? a. tooth only b. tooth and neighboring tooth c. tooth, neighboring teeth, contralateral tooth d. tooth, neighboring teeth, opposing tooth

*QUESTION: A tooth exhibits an apical radiolucency for a long period of time, is asymptomatic, does not have associated sinus tract, with a necrotic pulp. What is your diagnosis? a. Asymptomatic chronic apical periodontitis b. Symptomatic acute apical periodontitis c. Asymptomatic acute apical periodontitis

QUESTION: While performing a root canal on a tooth with periapical radiolucency but “without a pulp,” you obtain your access but do not find a canal. What do you do? a. Continue treatment b. Refer to an endodontist c. Take a radiograph

QUESTION: You come across a molar that is supraerupted wit irreversible . What do you do? (Need to look at patient dental chart and findings to answer) a. RCT and b. Intrusion c. Crown only d. Extraction

QUESTION: Case: Patient with tooth that has sensitivity that lingers with thermal test, sinus tract, and positive to percussion, what does the patient have? a. Irreversible pulpitis with acute periapical abscess b. Irreversible pulpitis with no acute periapical abscess c. Reversible pulpitis with acute apical abscess d. Reversible pulpitis with no acute apical abscess

*QUESTION: Prolonged, unstimulated night pain suggests which of the following conditions of the pulp? a. b. Mild hyperemia c. Reversible pulpitis d. No specific condition

QUESTION: A Chronic periradicular abscess indicates: a. Necrotic pulp b. Irreversible pulpitis c. Reversible pulpitis ENDODONTIC TESTS QUESTION: What does percussion test? a. Presence of inflammation in PDL or not b. Spread of inflammation to periodontium from PDL or not c. Responsiveness d. Pulp vitality QUESTION: What does palpation test? a. Presence of inflammation in PDL or not b. Spread of inflammation to periodontium from PDL or not c. Responsiveness d. Pulp vitality QUESTION: What does EPT test? a. Presence of inflammation in PDL or not b. Spread of inflammation to periodontium from PDL or not c. Responsiveness (does not test vitality (i.e. necrotic, reversible pulpitis, etc.) d. Pulp vitality QUESTION: EPT does not indicate? Health of the pulp

QUESTION: How do you differentiate between an endodontic versus periodontic lesion? EPT

***QUESTION: What does thermal (hot or cold) test? Hot = irreversible, Cold = reversible/irreversible a. Presence of inflammation in PDL or not b. Spread of inflammation to periodontium from PDL or not c. Responsiveness d. Pulp vitality

*QUESTION: What is the differential diagnosis of a & periradicular abscess? Vitality QUESTION: Which statement is incorrect? Do EPT for traumatic tooth ***QUESTION: If you have pain, what would be the hardest to anesthetize? a. Irreversible pulpitis and maxillary b. Irreversible pulpitis and mandibular c. Necrotic pulp and maxillary d. Necrotic pulp and mandibular QUESTION: When heat is applied to the tooth, lingering pain for several minutes indicates: Irreversible pulpitis

QUESTION: What is diagnosis for lingering pain to cold and sensitivity to percussion? Irreversible pulpitis & acute periapical abscess (acute ?)

QUESTION: A tooth is not responsive to cold or percussion and palpation is tender: (no answer with necrotic pulp and normal apex) • Necrotic pulp and chronic apical periodontitis • Irreversible pulpitis and normal apex

QUESTION: What is test to diagnose chronic periradicular periodontitis? Percussion

QUESTION: How does a tooth covered with crown react to pulp testing? Cold is a better test (thermal) QUESTION: Best way to diagnose irreversible pulpitis? With a cold or thermal test

***QUESTION: What is untrue about EPT? • It is more reliable than cold testing for necrotic teeth (false!!!) • It gives relative health status of pulp (true) • Tells if there are vital nerve fibers (true)

QUESTION: Tooth did not respond to thermal & EPT but response to palpation and percussion? Necrotic pulp

QUESTION: Most reliable way to test vitality of a tooth? Thermal test

QUESTION: Which of the following is the least important factor in referring an endodontic case to specialist? a. Dilacerations b. Calcifications c. Inability to obtain adequate anesthesia d. Mesial inclination of a molar

QUESTION: Chronic endodontic lesion has what type of bacteria? Anaerobes

QUESTION: How do you test a tooth to differentiate between and supperative (acute) periodontitis? a. Cold test b. Percussion c. EPT ENDO/PERIO ABSCESSES & LESIONS

ENDO – PERIO LESIONS

*First evaluate tooth (if treatment warranted): a. Endodontic treatment first b. Periodontal treatment second (may be combined with periapical surgery, if needed). c. Prognosis is poorest with periodontal lesions.

If Endo lesion is draining through periodontal ligament space, complete RCT & wait several months to evaluate healing of periodontal lesion. • Endo-perio: Pulpal necrosis leading to a perio problem as pus draining from PDL.

If Perio Lesion has spread to the periapical region, evaluate vitality of the pulp, institute periodontal treatment alone if vital (treatment may devitalize pulp). • Perio-endo: infection from pocket spreads to pulp causing pulpal necrosis.

QUESTION: What is initial treatment of a combination perio and endo lesion? Perform endo with RCT first. Then perio SC/RP second. QUESTION: Periapical abscess, what do you do? Incision and drainage a. Never do RCT before incision and drainage, you want to get rid of infection before proceeding with RCT. b. First step would be incision and drainage, prescribe antibiotic, and do RCT at later date. c. Use gutta percha to trace sinus tract to abscess. d. Most important thing for acute apical abscess is drainage & cleaning the canal

QUESTION: Acute perio abscesses that require drainage are usually: a. Firm and localized b. Fluctuant and localized c. Generalized firm ***QUESTION: Between the different perio and endo periapical lesions, which one has the best prognosis? • Perio that started from endo • Endo started from perio *QUESTION: Test performed to differentiate endo vs. perio lesions: Percussion (lateral percussion)

QUESTION: Indications of perio lesion vs endo lesion: Apical radiolucency and pain upon lateral pressure (not apical)

QUESTION: Which of following is not endodontic in origin: Tooth with wide sulcular pocket not extending to apex

QUESTION: Which of the following conditions indicates that a periodontal, rather than an endodontic problem, exists? a. Acute pain to percussion with no swelling b. Pain to lateral percussion with a wide sulcular pocket c. A deep narrow sulcular pocket to the apex with exudate d. Pain to palpation of the buccal mucosa near the tooth ape

QUESTION: It is possible to have an endo abscess without a sinus tract that drains pus through the PDL: True

QUESTION: What treatment is required with a tooth that has a draining sinus tract has been treated via RCT? No further treatment

***QUESTION: After an RCT in maxillary molar, what Tx would you for sinus track? No treatment ***QUESTION: Lateral periodontal abscess is best differentiated from the acute apical abscess by?

e. Pulp testing (vitality tests) f. Radiographic appearance g. Probing patterns h. Percussion i. Palpation

*QUESTION: Best way to diagnose acute periradicular periodontitis? sensitive to percussion

***QUESTION: Radiographically, the acute apical abscess a. Is generally of larger size than other lesions b. May not be evident c. Has more diffuse margins than another lesion

***QUESTION: When do you puncture an abscess? Localized chronic fluctuant in palpation

***QUESTION: A patient has a non-vital tooth with a fistula that is draining around the gingival sulcus. What kind of abscess is it? a. Endo and perio at same time b. Perio and then endo c. Only endo d. Only perio

***QUESTION: There usually is no lesion apparent radiographically in acute apical periodontitis. However, histologically bone destruction has been noted. a. Both statements are true b. Both statements are false. c. First statement is true, second is false. d. First statement is false, second is true.

*QUESTION: Based solely on the sharp transient response of pulp to hot stimuli, what is the periradicular diagnosis? a. Acute apical periodontitis b. Cannot diagnose based on information provided. c. Acute Apical abscess d. Irreversible pulpitis

QUESTION: What is the clinical ‘hallmark’ of a chronic periradicular abscess? a. Large periradicular lesion b. Sinus tract drainage c. Granulation tissue around the apex. d. Cyst formation.

QUESTION: A periradicular radiolucent lesion of endodontic origin on the radiograph may be any of these histological diagnoses except one. Mark this exception. a. A cyst b. A granuloma c. An abscess d.

QUESTION: What complete endodontic diagnosis could be completely asymptomatic but should require endodontic therapy? a. Pulpal necrosis and acute periradicular periodontitis b. Normal pulp and acute periradicular periodontitis. c. Pulpal necrosis and chronic periradicular periodontitis. d. Normal pulp and normal periapex.

QUESTION: A lesion of non-endodontic origin remains at the apex of the suspected tooth regardless of X-ray cone angulations. a. True b. False PEDIATRIC ENDODONTICS

***When to extract: • If it’s a primary 1st w/ furcation involvement: EXT • If it's a primary 2nd w/ furcation but restorable: PE (Pulpectomy, complete removal) • If it’s any other primary tooth w/ no furcation: PO

QUESTION: CASE: 5-year-old patient that fell down 2 months ago, and hit his #E (central) when he fell down. The tooth is now discolored, what do you suspect? Necrotic pulp

A. There is a red swollen lesion on the gingiva of tooth #E, what is most likely be? e. Sinus tract f. g. Periapical granuloma

B. What do you recommend for this tooth? Extraction

QUESTION: What does a radiolucency at the furcation of primary first molar in 5 y/o usually indicate? a. Erupting permanent first premolar b. Necrotic pulp c. Normal anatomy b.

QUESTION: A PA radiograph shows a radiolucency of a primary tooth: It is a normal radiolucency because permeant tooth is erupting underneath

QUESTION: Radiolucency is seen in a PA under the furcation of primary molar, what could this be due to? a. Necrotic pulp b. Roots are resorbing c. Permanent tooth caused it

QUESTION: If there is a primary tooth with necrosis and the inflammation gets down through furcation to affects permanent tooth, how does it affect the permanent tooth? Can disturb the ameloblastic layer of permanent successor or spread infection QUESTION: In a primary tooth, apical infection on the radiograph is usually where? In the furcation

***QUESTION: Most common medication for pulpectomy/pulpotomy? FOROMCRESOL ***QUESTION: Calcium hydroxide is contraindicated in pulpotomy in a child (primary teeth) because it causes irritation, leading to resorption in primary teeth. • The reason pulp capping is not used on primary teeth is the alkaline pH of calcium hydroxide or MTA, which can irritate the pulp and induce internal resorption. In permanent teeth, high pH induces reparative dentin formation.

***QUESTION: Little girl has ALL, had radiolucency in furcation of primary 2nd molar. What is the treatment? a. Extraction b. Pulpotomy c. Pulpectomy

***QUESTION: What is the best method to test newly erupted primary teeth? Percussion (most reliable)

QUESTION: What is the least reliable test on primary teeth? Electric pulp test • Don’t use EPT on primary teeth because thin enamel creates false results • Especially don’t want to use EPT after trauma

***QUESTION: 7-year-old boy has vital pulp exposure of 1st permanent maxillary molar. What do you do for treatment? Pulpotomy QUESTION: Child had caries exposure on primary 1st molar. What is your treatment? Pulpotomy

APEX ENDODONTICS *** Apexification: tx of NONVITAL tooth w/ incomplete apex formation & pulp exposure using calcium hydroxide to achieve apical closure. Want to create an apical barrier in a necrotic tooth with an open apex. (fill close to apex) ● Induce a calcified apical barrier by placing dense calcium hydroxide paste after instrumentation. Canals are obturated when barrier is formed in 3–6 months. ● Placement of an artificial apical barrier, like MTA, prior to obturation. This method, can be completed in a day or 2, appropriate when patient compliance or long-term follow-up care is questionable.

Apexogenesis: tx of VITAL tooth w/ an OPEN apex & pulp exposure using calcium hydroxide to preserve vitality and encourage the continued development of the root. Vital pulp therapy performed to allow continued physiologic development and formation of the root. (fill coronal portion) ● Place calcium hydroxide over the radicular pulp stump. Recall every 3 months to check for the pulpal status. ● RCT is indicated when the root development is completed.

Apicoectomy: Root-end resection/excision of apical portion of root. • Indications: o Persistent periradicular pathoses following endodontic treatment o A periradicular lesion that enlarges after endodontic treatment o A marked over extension of obturation material interfering with healing o When the apical portion of the root with periradicular pathosis cannot be cleaned, shaped, and obturated

Know when to do indirect pulp cap, pulpotomy, apexification (non vital teeth with MTA), and pulpectomy (ZOE if apex is not closed in primary teeth) in pediatric patients. QUESTION: A 7-year-old patient fractured the right central incisor 3 hours ago. A clinical examination reveals a 2-mm exposure of a "bleeding pulp." The treatment-of-choice is A. Pulpectomy and apexification. B. Pulpotomy with calcium hydroxide. C. Direct pulp cap with calcium hydroxide. D. One-appointment .

QUESTION: Why did you do a pulpotomy on a 7 year olds #30 exposed pulp (due to decay)? To allow completion of root formation (apexogenesis) ***QUESTION: During apexogenesis, you get all with the root except: a. Root lengthening, b. Root widening, c. Root apex closure, d. Root revascularization QUESTION: Indications for apicoectomy: RCT can’t be done by conventional means, Failed existing RCT that can’t be re-treated, and Persistent apical pathology after RCT

QUESTION: Ideal RCT re-treat is best done by conventional method of removing the filling material, debriding the canals, and refilling. However, if the tooth has been restored with a post, core, and crown, then apical curettage followed by an apicoectomy and retro-fill should be performed.

QUESTION: Periapical lesion biopsied after apicoectomy of an already RCT treated tooth. The tooth is still sensitive, with neutrophils, plasma cells, non-keratinized stratified epithelium (islands of), and fibrous connective tissue, what is it?

a. Abscess, b. Granuloma c. Cyst

• Granuloma: a mass of granulation tissue, typically produced in response to infection, inflammation, or the presence of a foreign substance

QUESTION: There is a study that shows that if there is extraradicular plaque in an infected tooth the dentist might need to do what? a. Mechanochemical irrigation and debridement of the canal b. Surgical endo (apicoectomy) QUESTION: Extraradicular biofilm theory recommends endo with: Crown down, debridement, Ca(OH)2 therapy? (irrigate and debride)

*QUESTION: The treatment of choice for a 6-year-old patient with necrotic pulp on permanent first molar: 1. Apexification (Non vital) 2. Apexogenesis (vital) 3. Root Canal Treatment

*QUESTION: Why you perform apexification (non-vital)? When you have necrosis on an open apex tooth

QUESTION: Definition of apexification: Apical closure of the root by hard tissue deposition (NONVITAL)

QUESTION: Irreversible pulpitis with open apex – Apexification

QUESTION: Tx for traumatic pulp exposure on max incisor that root has not completed formation? Apexogenesis

QUESTION: Six months ago you did a RCT on a central incisor with an open apex (young pt). You place calcium hydroxide in canal and waited the 6 months. You open the canal but can still pass #70 file through the apex. What would you do? Calcium hydroxide Zinc oxide eugenol Gutta percha

QUESTION: Pt is 13 years old and has a non-vital maxillary central. The apex is still open what do you do? A. Apexogenesis B. Apexification C. Pulpectomy D. Nothing

QUESTION: 8-year-old patient with vital pulp and open apex. What do you do? A. Apexification B. Apicoectomy C. Pulpectomy D. calcium hydroxide pulpotomy.

*QUESTION: Why are traumatized primary incisors discolored? Pulpal Necrosis & Pulpal Bleeding

TOOTH AVULSION & INTRUSIONS

Tooth Avulsion: complete dislodgment of a tooth out of its socket by traumatic injury. • Short extra-oral dry time & proper storage medium are key factors in offering favorable treatment outcome. • To slow down osseous replacement of tooth, treat root surface w/ 2% NaF solution for 20 min. *** • Splinting the tooth is for patient comfort: o Avulsion = 7-10 days with a non-rigid/flexible splint, antibiotics o Horizontal root fracture = 3 months with rigid splint o Extrusion = 2-3 weeks with a splint

***QUESTION: Reason for failure of replantation of avulsed tooth: external resorption or internal resorption

QUESTION: Most important factor about avulsed tooth/replantation: Time

QUESTION: Why would an implanted avulsed tooth (most likely?) fail? a) the dentist curettage the socket b) too much extra oral time c) the dentist clean the root surface d) failure to place the tooth in the solution

QUESTION: Before 15 min, what is success rate of avulsed tooth? 90% success rate • At 30 mins, what is the success rate? 50% success rate. QUESTION: Which is incorrect? Should rinse with water if tooth is taken out QUESTION: How long do you splint after tooth has been avulsed? 1-2 weeks or 7-10 days

**QUESTION: What is best storage media for avulsed tooth? HANK (HBSS: Hank’s balanced salt solution, Na, K, Ca + glucose)

QUESTION: Avulsed closed apex tooth should be immersed in what and for how long (to reduce root resorption) and at what pH? 2.4% sodium fluoride solution, pH of 5.5, 20 min

***QUESTION: Avulsed primary tooth out for less than 60 minutes. What do you do? Do not re-implant. Never re-implant primary teeth.

QUESTION: If tooth has open apex, and it gets avulsed, how you close it? You use MTA.

***QUESTION: Do you use calcium hydroxide for an avulsed tooth? No. You use MTA. ***QUESTION: What is the treatment of an intruded permanent teeth (intruded 5mm)? Reposition and splint (prophylactic RCT?)

***QUESTION: Which is more damaging to the PDL? a. Extrusion b. Intrusion c. Lateral luxation d. Avulsion QUESTION: Patient intrudes mature maxillary incisor (closed apex). Permanent tooth trauma due to deep intrusion causes what? Pulpal necrosis with need for conventional RCT

***QUESTION: Intrusive trauma has what percent chance of leading to pulpal necrosis? 96% ***QUESTION: A luxated tooth does not respond to EPT, why? Disruption of nerves to tooth

QUESTION: Pt. has dark permanent lateral incisor. What is the cause? a. Tetracycline b. Damage to primary tooth at age five c. Damage to permanent lateral

QUESTION: What’s the worst thing you can do to a tooth you plan to re-implant right before you do so? Scrape the tooth with a curette

ENDODONTIC MATERIALS

*** Chelating agents - bind with Ca+ and carry it out of the canal. It removes smear layer/inorganic layer in dentin to expose tubules for penetration of endo sealer & exposing bacteria. Ex. EDTA c. Chelating agents are good for sclerotic canals. Substitute sodium ions & soften canal walls.

Sodium Hypochlorite: 5.25% irrigation solution, germicidal, dissolve organic material d. Other irrigation solutions include urea peroxide (glycerol based) and 3% hydrogen peroxide.

NiTi rotary files remain better centered, produce less transportation, and instrument faster than stainless steel files due to their superior flexibility & resistance to torsional fracture. They have 10x the stress resistances of stainless steel (stronger).

The advantageous properties of SS files include: 1. Bulk strength as well as edge strength 2. Resistance to cyclic fatigue 3. Recording curves 4. Inexpensive manufacturing 5. Don’t become dull as quick at NiTi

QUESTION: Primary purpose of sodium hypochlorite? Dissolve necrotic tissue

***QUESTION: Sodium hypochlorite is used for everything except? Chelation (does not remove inorganic material)

***QUESTION: What is the job of Ca(OH)2 during a root canal procedure? Intracanal medicament

QUESTION: Which material is least cytotoxic for perforation repair? MTA

QUESTION: Which is a chelator/chelating agent for endo? EDTA, sodium hypochlorite, etc. QUESTION: What is the percentage of EDTA: 17% QUESTION: What is the function of EDTA? Remove inorganic material & smear layer QUESTION: Which one is correct about EDTA? It’s a chelating agent.

QUESTION: Contraindication for Ca(OH)2? Pulp symptomatic for last month

QUESTION: PARL seen on asymptomatic tooth. When opened, the canal is calcified. What do you do? a. Do nothing, b. Refer to endodontist c. Place EDTA ***QUESTION: Internal resorption left untreated can lead to? Pink tooth

QUESTION: Similar question: What causes “Pink Tooth of Mummery”? Internal resorption

***QUESTION: Treatment for internal resorption: RCT

QUESTION: Internal resorption shows all BUT: a. Radiograph is symmetrical with the pulp space b. Can resorb all the way to the PDL c. A treatment option is observing until resorption stops d. Resorbed to create pink tooth

***QUESTION: When a tooth is ankylosed, what type of resorption? Replacement resorption

QUESTION When you replant teeth, what will happen? Replacement bone formation (Ankylosis, will not say that)

QUESTION: The treatment-of-choice for an inflammatory external root resorption on a non-vital tooth is which of the following? a. Extraction b. Surgical curettage of the affected tissue c. Pulpectomy and obturation with gutta-percha and sealer d. Removal of the necrotic pulp and placement of calcium hydroxide e. Observation since it is a self-limiting process

• Do Ca(OH)2 every 3 months until PDL is healthy, then complete RCT

QUESTION: When a re-implanted tooth presents external resorption, what is the treatment? Instrument and place calcium hydroxide

QUESTION: Which of the following is not a property of gutta-percha? a. Radiopacity, b. Biocompatibility c. Antibacterial d. Adaptation (needs sealer to adapt well) e. *QUESTION: What is the NOT an advantage of stainless steel files? 1. More flexible 2. Less chance for breaking 3. Allows the file to be centered in canal 4. Aids depth penetration in the canal *QUESTION: All are advantages of using nickel titanium endo files over regular steel files except? a. Flexibility (yes) b. Bending memory (yes) c. Direction of the flutes (no)

QUESTION: What is the weakness of NiTi files vs regular SS files? Strength

QUESTION: Which of the following is not an advantage of Ni-Ti over stainless steel file? a. Maintains the shape of canal b. Flexibility c. Resistance to fracture ENDODONTIC FAILURES

• Most common cause of RCT failure is inadequate disinfected canals (insufficient canal debridement) • 2nd most common cause is poorly filled canals.

***QUESTION: Which case has the best prognosis? a. Perforation in external resorption b. Perforation in internal resorption c. Extruded gutta percha

***QUESTION: Least likely to result in endo failure? a. Overfilling with gutta percha b. Inadequate either obturation or cleaning and shaping c. Lateral root resorption d. Perforating internal resorption

***QUESTION: What causes grey tooth? a. Blood products in the dentinal tubules b. Internal resorption c. External resorption d. Calcified canal

• Hyperbilirubinemia: grayish-blue

QUESTION: Elective endo due to: Pulp exposure

*QUESTION: Most common cell in necrotic pulp? PMN cells

QUESTION: Biggest reason for failure of RCT? Improper cleaning of the canals

QUESTION: Root canal failed on upper canine, why? Lack of seal

QUESTION: RCT done 1.5 yrs. ago, now radiolucency and fistula - Incomplete RCT

QUESTION: Pt comes in for a RCT on a non-vital tooth with 1 mm apical lucency. 5 months later, comes back with 5 mm lucency, Why?

a. Improperly done endo, need to re-treat b. Another canal present c. Osteosarcoma d. Carcinoma

***QUESTION: Incomplete removal of bacteria, pulp debris, and dentinal shavings is commonly caused by failure to irrigate thoroughly. Another reason is failure to: A. Use broaches. B. Use a chelating agent. C. Obtain a straight line access. D. Use Gates-Glidden burs.

QUESTION: Least likely cause for failed RCT a. Gutta percha beyond apex b. Inadequate cleaning and shaping c. Poor obturation

QUESTION: Reason for failed endo? Seal 2mm away from apex Bacterial infection RCT sealer beyond apex

QUESTION: Endo file breaks when you are at 15 file, what do you do? Refer to endodontist (retrieving it was not an option)

QUESTION: You separate an endo file 3mm from the apex and obturate above it... which case will show the best prognosis? a. vital pulp w/ no periapical lesion (yes) b. vital pulp wI periapical lesion c. necrotic pulp wI no periapical lesion d. necrotic pulp wI periapical lesion QUESTION: You being the best doctor in the world, broke a 5mm dental instrument in a canal during RCT procedure, what’s the best thing to do? Tell the patient what happened, and refer her to an endodontist

QUESTION: Which has worst prognosis? File fracture, transportation, perforation through furcation QUESTION: During root canal you notice you left debris in the canal most likely due to lack of use of which? chelating agents, gates burs, broaches, irrigant, etc.

ROOT FRACTURES *** Vertical root fracture: • Characterized by crack that begins in root and extends toward the occlusal surface, usually in a buccal- lingual direction. • Endodontically treated are most susceptible (lateral condensation of gutta percha) • Most common cause in vital teeth is trauma • Elliptical or J shaped radiolucency • Symptoms: history of abscess and sinus tract, pain when biting or palpation • Narrow periodontal pocket

Horizontal Root Fracture: more common in anterior. Success and healing of horizontal root fractures requires immediate reduction of the fractured segments & the immobilization of the coronal segment for 12 weeks (3 months).

QUESTION: Patient comes back few months after RCT & crown with pain upon biting, what happened? Cracked tooth

QUESTION: Pt has pain 1 month after cementing a crown on a tooth with RCT + post. Pain has been present for several days esp during biting and cold: Vertical root fracture

QUESTION: Pt has crown cemented 2 weeks ago & is sensitive to pressure and cold, why?

***QUESTION: RCT is contraindicated for what? Vertical root fracture f.

***QUESTION: Vertical Root Fracture is most likely found? Mandibular posteriors

QUESTION: Most common tooth associated w/ : Mandibular 2nd molars • Second = mandibular first molars and maxillary premolars

QUESTION: Crack tooth syndrome is most likely found? Mandibular Molars

***QUESTION: What teeth are most likely to have crown/root fracture? Mandibular posteriors…max anteriors, mand anterior, max posteriors

QUESTION: Which tooth is least likely to fracture: Maxillary molar

*QUESTION: Cracked tooth without pulpal involvement, what is the treatment? Extracoronal restoration…Endo, occlusion reduction, amalgam with adhesive

QUESTION: What causes most vertical root fractures during RCT? Condensation of gutta percha

***QUESTION: Best indicator of vertical root fracture - Isolated deep pocket depth

QUESTION: Which allows the entire tooth to light up under transillumination? Craze lines…cracked tooth, crown & root fracture, separated tooth, etc.) • Transillumination = shows cracked tooth • Whole tooth = craze line

QUESTION: When does transilluminator show evenly through tooth: craze line…crack, fracture from crown to root ***QUESTION: Which will show up on transillumination best? Cracked tooth Fractured cusp Vertical root fracture Craze line

QUESTION: Vertical root fractures are also called cracked teeth. The prognosis of cracked teeth varies with extent and depth of crack. a. Both statements are true b. Both statements are false. c. First statement is true, second is false. d. First statement is false, second is true.

QUESTION: If two cavities were thought to be two separate fillings but upon exam it was a crack through the isthmus. What do we tx this symptomless crack with? Observe

QUESTION: Tooth w/ horizontal root fracture: Reduce & immobilize

QUESTION: How do you first treat a horizontal root fracture? Immobilize the segments Root canal therapy Splint Calcium hydroxide

*QUESTION: Horizontal root fracture: Take multiple vertical angulated x-rays QUESTION: Apical horizontal root fracture & no pain, what do you do? RCT if tested non-vital…Monitor 1 year, RCT, Scaling QUESTION: Nonvital after a fracture (should be “trauma”)? Reevaluate at a later time

QUESTION: Boy has horizontal root fracture in apical 3rd, no symptoms, no pain or mobility, what tx? Monitor (asymptomatic)…RCT, extract, pulpotomy, splint

QUESTION: A maxillary central incisor of an adult patient is traumatized in an accident. The tooth is slightly tender to percussion, is in good alignment, and responds normally to pulp vitality tests. Radiographic examination shows a horizontal fracture of the apical third of the root. The best treatment is which of the following? A. Root canal treatment B. Splint and re-evaluate the tooth for pulpal vitality at a later time C. Apexification D. Apicoectomy to remove the fractured apical section of the root followed by root canal treatment

*QUESTION: Worst prognosis for RCT? Vertical fracture during obturation…instrument gets stuck in apical 1/3, ledge formation

QUESTION: Fracture at apical 1/3, how long do you splint? 4-6 weeks, 7-10 days, 2-3 weeks

*QUESTION: Tooth #30 has huge MOD amalgam that is deep. It hurts when he eats French bread. What is the cause? Root fracture QUESTION: Patient has a line of separation corono-apical (vertical root fracture), the tooth is asymptomatic and it only hurts when patient eats French bread. What should you do? Ext only if moveable pieces. If asymptomatic & not moveable fair prognosis RCT

QUESTION: Days after placed an MOD amalgam, patient presents pain in biting and cold: check occlusion.

PULPAL ANATOMY & OTHER QUESTIONS

*QUESTION: How many canals do you expect in primary M2? 4

*QUESTION: What is the shape of the access of mandibular 1st molar? Trapezoid QUESTION: Maxillary 1st molar access opening - Triangular *QUESTION: Premolar most likely to have 3 canals? Maxillary first QUESTION: Pulpal anatomy dictates a triangular access cavity preparation in the maxillary central incisor

*QUESTION: Why do you do triangular access on incisors (ex. max central incisor?) a. To help with straight line access b. Help expose pulp horn c. To follow the shape of the crown

***QUESTION: Most critical for pulpal protection is? Remaining dentin thickness (2mm)

***QUESTION: What will not regenerate after RCT: Dentin formation…, PDL, alveolar bone

*QUESTION: Each of the following can occur as a result of successful RCT tx except what? Formation of reparative dentin

QUESTION: Pt with an RCT in a molar tooth, after one year a cyst form, the tooth was extracted, after another year the cyst was bigger what happened? Bad endo and the dentist did not curettage well when the extraction was done

***QUESTION: has enlarged pulp chamber in which direction? Apical…occlusal or apical AND occlusal (***know what tauradontism looks like on x-ray)

• Taurodontism is a condition found in the molar teeth of humans whereby the body of the tooth and pulp chamber is enlarged vertically at the expense of the roots

CARIES & BACTERIA

Cariogenic bacteria = SALIVA = S. mutans, sanguis, mitis, salivarius A. viscus Lactobacilli Veillonella A. naeslundii

Coronal caries: S. mutans and lactobacillus Root surface caries: Actinomyces viscus Early dental plaque organism: S. sanguis

Frank caries: caries that has progressed just into DEJ

Pit and fissure caries: most prevalent variant • Mostly S. sanguis and other strep • Narrow at enamel and spreads wide at DEJ (inverted V) • Great underming

Smooth surface caries: second most prevalent • Start wide at surface and converge toward DEJ (V shape)

DEJ: provides least resistance to caries and allows for rapid spread once approximated

Zones of carious enamel: translucent (deepest)→dark zone (remineralization)→body (largest, demineralizing)→surface (outermost, unaffected by caries)

Dentin caries: v shaped (base at DEJ) • Infected dentin: tubules infected with acid producing bacteria and Acidogenic and proteolytic activity result in degradation • Affected dentin: bacteria present in smaller amount; demineralization occurs but can be reversed if infected layer removed

Zones of carious dentin: Normal dentin (deepest)→subtransparent dentin (demineralization, no bacteria), transparent dentin (softer, demineralization, no bacteria)→turbid dentin (bacterial invasion, must remove)→infected dentin (many bacteria, must remove) • Zones 1-3 can remineralize (affected) • Zones 4-5 must be removed (infected)

Root surface caries: mostly elderly • Cementum rougher—greater mechanical advantage of acquiring plaque • Spreads shallow along surface, ill defined, characterized by U shape • Cementum provides little resistance—rapid progression • Initial demineralization along Sharpey’s fibers of cementum • Shallow—many can remineralize (very dark lesions) • Often asymptomatic, difficult to restore

Rampant caries: acute onset, often pain, deep and narrow presentation result in large cavitation Arrested caries: remineralized lesions, hard, black/brown—trapped debris and metallic ions, asymptomatic

Caries detector: colored dye in organic base adheres to denature collagen; distinguishes between infected and affected dentin • Explorer catch alone not indicative of caries, may produce iatrogenic cavitation

Radiographs: caries cannot be diagnosed without clinical examination, underestimate actual extent of caries

Amalgam preparations • All prepared walls and internal line angles sound be placed in sound dentin • Extend to include all decay • Enough depth and width to prevent fracture: o 1/5 distance between buccal and lingual cusps o At least 0.5 mm into dentin o Pulpal floor flat and parallel, perpendicular to occlusal surface o Line angles round and defined to avoid fracture o Mesial and distal walls diverge, lingual and buccal walls perpendicular to occlusal surface o Marginal ridge thickness must be at least 1.6 m otherwise include in preparation (class II) o Class II—proximal walls divergent occluso-gingivally, gingival floor parallel enamel rods o In class III, unsupported enamel can be left for esthetic reasons o In class V, occlusal wall longer than cervical wall (trapezoid)

Cavity classification: simple, compound, complex

*QUESTION: pH that enamel starts to demineralize – pH = 5.5 (critical pH of developing cavities)

QUESTION What is the best predictor for future caries? Past caries history

QUESTION Which is least likely to predict future caries? Amount of sugar intake Frequency of sugar intake Amount of caries and restorations

*QUESTION: Three factors that affect caries initiation: Substrate, bacteria, host susceptibity

QUESTION: Which of the following is the earliest clinical sign of a carious lesion? A. Radiolucency B. Patient sensitivity C. Change in enamel opacity D. Rough surface texture E. Cavitation of enamel

QUESTION: What is true of Strep. mutans? Can live in plaque Can live on gingival Can live in a child with no teeth Has to live on a non-shedding surface

QUESTION: Most Cariogenic? Sucrose • S. mutans adheres to the biofilm on the tooth by converting sucrose into an extremely adhesive substance called dextran polysaccharide.

*QUESTION: How do cells first attach- Dextran or lextran? • S. Mutans converts sucrose to dextran like long chain polysaccharides (glucans/fructans) using enzyme glucosyltransferase.

*QUESTION: What helps in carious progression but it is not the primary initiator for caries? Lactobacillus

QUESTION What is the most important etiologic factor in getting caries? Saliva pH Refined sugar Fluoride treatment Saliva flow

QUESTION: Know how to determine if a patient is a high caries risk? Caries restored in past three years, visible plaque, frequent snacking (>3 between meals), appliances, carious lesion present, reduced salivary flow

QUESTION: Early childhood caries affects? Centrals and molars

QUESTION: Which of the following is increasing in the US? Root caries

QUESTION: New data regarding caries shows: Increase in smooth surf caries - wrong Increase in pit/fissure caries - wrong Smooth surf caries and pit/fissure caries is same - wrong Increase in root caries

*QUESTION: Best clinical determinant of root caries? Sensitivity to cold Sensitivity to sweets Soft spot on tooth - visual & tactile methods are used for detect caries

QUESTION: Remineralized teeth are stronger than regular enamel. True

QUESTION: For a lesion in enamel that has remineralized, what most likely is true? 1. The enamel has smaller hydroxyapatite crystals than the surrounding enamel 2. The remineralized enamel is softer than the surrounding enamel 3. The remineralized enamel is darker than the surrounding enamel 4. The remineralized enamel is rough and cavitated

QUESTION: What’s the characteristic of a remineralized tooth/arrested caries? Darker, harder, more resistant to acid or further decay/caries

QUESTION: Characteristic of a lesion that is remineralized: Black, dark, bright Black, dark, opaque Black, dark, cavitated

QUESTION: Leathery brown-white lesion? Arrested, acute, chronic,

QUESTION: Which of these is NOT an important reason for a clinician to be able to distinguish remineralization? I put color. I have no idea what this was asking.

QUESTION: What is the most common site of enamel caries? Pit and fissure At the contact point Slightly incisor to contact Slightly cervical to contact

QUESTION: Where does caries start for proximal caries (class II)? Apical to proximal contact

*QUESTION: Most interproximal caries lesion happens where? Just under/below the contact

QUESTION: When do you restore a lesion? When there is cavitation When it’s half through enamel When it passes CEJ When you see it on x-ray

QUESTION: Treatment of root surface caries, what kind of dentin should not be restored? Eburnated dentin (Sclerotic dentin)

QUESTION: Smooth surface caries most likely due to? Plaque

QUESTION: Where does fluoride work the best? A. interproximal B. Pit and fissure (I saw this somewhere and it said smooth surfaces, pit and fissure is prr/sealant) C. Smooth surfaces

QUESTION: Which of the following is a factor for smooth caries & sugar in-take? Consistency (others were volume, and other option.) • Sticky consistency stays on the tooth longer, allowing bacteria to keep the pH lower longer

QUESTION: For occlusal caries, where is base & cone? Triangle point is at enamel and base to dentin, dentin base to tip at pulp. (apex to the pulp) QUESTION: What tooth is most likely to have occlusal caries? Mandibular molar

QUESTION: Caries in children depend most on amount, consistency, & time.

QUESTION: Pit and Fissure caries is described as two cones: a. Two bases are pointing toward the pulp b. Two apexes are pointing toward pulp>>>> in smooth surface (proximal caries) c. One apex toward the pulp and one base toward DEJ d. Base of both triangles facing the DEJ

QUESTION: At the DEJ, what is the difference between smooth caries (conical), occlusal (apex at occlusal), interproximal (apex at DEJ)

QUESTION: Conical shaped caries w/ broad base and apex towards pulp is commonly seen in? a. Root caries b. Smooth caries c. Pit/fissure caries

QUESTION: Most diagnostic tool for pit and fissure caries is what? Explorer catch…other options x-ray, adjacent tooth decalcify, contralateral tooth thingy

*QUESTION: 40-year-old patient with all 32 teeth. No cavities. Has stain and catch in pit of molar. what do you do? 1. Watch & observe 2. Sealant 3. Composite

QUESTION: If a dentist seals a caries lesion on the tooth, what would be the most likely result? 1. Arrest caries 2. Extension caries 3. Discoloration of tooth 4. Micro-leakage

QUESTION: Radiographic decay most closely resemble which zone of carious enamel? Body zone, dark zone, translucent zone, surface zone

QUESTION: When looking at a radiograph, what zone of caries are you looking at? Body zone Demineralization

QUESTION: If you feed a person through a tube, then you decrease risk of caries.

QUESTION: Mechanism of caries indicator: Enters the dentin and binds to the denatured collagen. • A colored dye in an organic base adheres to the denatured collagen, which distinguishes between infected dentin & affected dentin

QUESTION: What does caries indicator do –only stains Infected dentin

QUESTION: What type of caries detection is the Difoti used for? Class I Class II, Class III (detection of incipient, frank and recurrent caries) demineralization

QUESTION: DaignoDent is Class I – ONLY OCCLUSAL CARIES (pit & fissure)

QUESTION: Sensitivity theory – Hydrodynamic theory

QUESTION: Most commonly accepted theory of dentin sensitivity? Hydrodynamic theory • Postulates that the pain results from indirect innervation caused by dentinal fluid movement in the tubule that stimulates mechanoreceptors near the predentin

**DENTAL INDEX & EPIDEMIOLOGY

Index with “E/extraction” = primary dentition only DMFT and DMFS both don’t take into account these teeth: unerupted, congenitally missing, supernumerary

QUESTION: Know what DMFS stands for Decayed missing filled surface

QUESTION: DMFS is for surfaces includes 3rd molars

QUESTION: DMF index measures how permanent dentition is affected by caries

QUESTION: DMFT - measures the amount

*QUESTION: DMFT is for Permanent teeth (no 3rd molars or primary teeth)

QUESTION: Which race has a higher F in DMFT index? White

*QUESTION: Which ethnicity has most caries in kid population (highest caries incident)? Hispanics

*QUESTION: Which population has the most number of UNRESTORED (D in DMFT) caries? Blacks

QUESTION: Which of the following acronyms is only used for kids? DEFT PI, DMF, OHI-S • DEFT = for primary dentition (e=extraction due to caries) • DEFS = same but with surfaces

DENTAL BURS & HAND INSTRUMENTS

Hand instrument classification: order→suborder→class→subclass Chisel CHAD: chisel, hoe, angle former, discoid-cleoid • Cutting edge 90 degree with plane of blade, blade has one sided bevel Hatchet HEG: hatchet, excavator, gingival margin trimmer • Cutting edge parallel with plane of instrument, ends in cutting edge in plane of handle

QUESTION: Differences between 245 and 330 burs: All other dimensions the same except for length…other options were shape, what angle they form. • 245 bur is 3mm in length while 330 is 1.5mm.

QUESTION: Which bur do you use for peds? 245…18, 51

QUESTION: Which is best for occlusal convergence in a prep? 245 (169 is better for occlusal)

QUESTION: Diameter of 245 bur? 0.8 mm

QUESTION: What bur is used for amalgam retention in class II? 245 or 330

QUESTION: Example of pear shape bur: 245 (330L), 329, 330 • 245 = 330L = pear and elongated bur (tip is a cone)

*QUESTION: Bur used that converges F and L walls? 169 (tapered bur, 0.9 diameter)…#245, 7901, • If 169 is not there, pick 245.

QUESTION: What bur do you use to shape convergent walls for amalgam 169

QUESTION: Burs for smoothing out preps? More flutes and shallow (this is what red burs are) More flutes and deeper Less flutes and shallow Less flutes and deeper

QUESTION: More # of blades on carbide burs: Smoother but decreased cutting efficiency

QUESTION: Which high speed bur gives a smoother surface? Plain cut fissure bur is more smooth while cross cut fissure have a higher cutting efficiency

QUESTION: Bur used for polishing – Steel for polish, carbide have more threads

QUESTION: What is the correct method of excavation of deep caries? a. Large bur from periphery to the center b. Large bur from center to periphery c. Small bur from periphery to center d. Small bur from center to the periphery • Use the largest bur that fits, and go around the periphery and then towards the deepest

QUESTION: Rotary high speed, how many round per min? 200,000 RPM • Slowspeed goes 20-30k average, endo = usually 800

QUESTION: Chisel vs spoon application: Chisels are intended primarily to cut enamel, but spoons remove caries and carve amalgams

QUESTION: What’s the difference between an enamel hatchet & gingival marginal trimmer? Both chisels hatchets but GMT has curved blade and angled cutting edge while Enamel HA has cutting edge in plane of handle

QUESTION: Main difference and advantage of using GMT instead of Enamel hatchet? a. Bi-angled cutting surface b. Angle of the blade c. Push/pull action instead of

QUESTION: What do you not use to bevel an inlay prep? a. Enamel hatchel b. GMT c. Flame diamond bur d. Carbide bur

QUESTION: What do u not use when beveling gingival margins? Tapered diamond • Causes enamel fracture

QUESTION: How do you bevel occlusal floor (gave list of instruments) • 13, 8 • 15, 80 (GMT) • 15, 95

QUESTION: What instrument would not be used to bevel the gingival margin of an MOD prep? Enamel Hatchet

QUESTION: Proper pulpal floor depth using Bur 245? 3mm, so half of it is 1.5 mm which is proper pulpal floor depth

QUESTION: You did a prep with high speed + diamond bur and tooth is sensitive, what is it about bur and handpiece that it caused sensitivity? A) Desiccation B) Traumatized dentin C) Heat

QUESTION: Most common pulpal damage from cavity prep – Heat, dentin desiccation

QUESTION: What would cause displacement of odontoblastic processes? Thermal Desiccation Mechanical Chemical

QUESTION: What causes displacement of odontoblastic nuclei in the dental tubules? Thermal, mechanical, chemical, caries, desiccation • Related to hydrodynamic theory I think so I put thermal

AMALGAM

Pins in Amalgam: Pins should be 2mm into dentin, 2mm within amalgam, and 1 mm from the DEJ (to be safe) with no bends in the pins.

For amalgam: g. RESISTANCE: 1st = Flat floors, rounded angles (bevel in axiopulpal line angles) h. RETENTION: 1st = BL walls converge, 2nd = retention grooves/Occlusal dovetail

Strength: more compressive (10x) than tensile strength • Weak condensation during packing increases voids and weakens restoration • Improper mixing leads to weak amalgam • Thermal expansion 2x that of teeth • If amalgam exposed to moisture, water reacts with zinc to form hydrogen gas: greater expansion, decreased compressive strength, post op pain, increased corrosion • Too much mercury leads to decreased strength: can minimize mercury by good condensation and carving • Over and under mixing lead to decreased strength • Gamma 2 is the weakest phase, strongest phases don’t have mercury

Increased expansion: more mercury, shorter mixing time, small condensation pressure, increased particle size

Composition and properties: silver, tin, copper, zinc, mercury • Copper helps elimination of gamma 2 phase which decreases creep and adds strength • The smoother/more polished amalgam will have less corrosion and tarnish • Marginal leakage decreases with time because increased corrosion by products tin sulfide

*QUESTION: Acute mercury toxicity for dentists or subacute mercury poisoning symptoms, the first signs is: Nausea…other are muscle weakness (hypotonia) and hair loss.

*QUESTION: Mercury poisoning effects? Loss of hair was a choice (I looked it up, and I think that is the answer)

QUESTION: Most likely for amalgam to fail? Outline cavity design (cavity preparation)…poor condensation

QUESTION: MOD amalgam with hole why? Poor condensation • Condensation removes mercury (gamma mercury removed)

QUESTION: Most common reason for Amalgam fracture occurring in a primary tooth: Inadequate cavity prep (especially the isthmus area)

QUESTION: Most common reason for failed amalgam Moisture contamination Improper prep design - not enough depth Improper trituration Improper condensation • Most likely depth (first), then outline form

QUESTION: Patient had occlusal amalgam on tooth #30 few weeks ago, one day the dude went to Chinatown and was having lunch with his hommies. He bit down on something and the amalgam broke off. He came back to your office demanding how could this happen with a new filling. What should be crossing your mind? The prep was not deep enough.

QUESTION: When prepping the amalgam, which is incorrect? Cavo surfaces is greater than 90⁰ • Ideal cavo margin (margin between tooth and your prep) is 90 degree

QUESTION: Axial pulp should be? 0.2 - 0.5 into DEJ (at least 0.5 mm into dentin)

QUESTION: How far do you extend the pulpal floor in class I amalgam cavity on primary dentition? i. 1mm into dentin i. Just into dentin

• Total prep should 1.5 mm so 1 mm for enamel & ~ 0.5 mm for dentin

QUESTION: Greatest wear on enamel of the opposing tooth: Porcelain (zirconia)…amalgam, porcelain, microfill, hybrid composite

QUESTION: Picture of a deep amalgam w/ overhang: What is wrong with marginal ridge of DO amalgam of #29? All of the following except? OVERCARVED…occlusal wear, wedge not placed right

QUESTION: Which tooth will the matrix band be a problem with when placing a two surface amalgam? to give an idea of the anatomy of the region: Mesial on maxillary first molar b/c of the cusp of carabelli, also mesial of max 1st premolar (MOST DIFFICULT due to mesial developmental grove, contact is harder) > Distal of max molar

*QUESTION: How to account for mesial concavity on maxillary 1st premolar when restoring with amalgam: Custom wedge Acrylic within matrix Normal matrix Create overhang and recontour

*QUESTION: Two class III lesions adjacent to each other (kissing lesion). Which one do you prep first & which will be filled first? Prep larger 1st, Restore smaller 1st

QUESTION: More corrosion of amalgam is in which phase? Tin-mercury phase (gamma 2 phase) • Noble metals (gold, pd, platinum) are CORROSION RESISTANT while silver & tin erode • Most common corrosion products found with conventional amalgam alloys are oxides and chlorides of tin • Silver tarnish but copper & tin corrode

QUESTION: Zinc in amalgam, what is used for? Decreases oxidation of other elements (deoxidizer—acts as scavenger) • Zinc acts as a deoxidizer, which is an O2 scavenger that minimizes the oxides formation of other elements in the amalgam alloys during melting.

QUESTION: What type of Mercury is in the dental office? Elemental or Inorganic

QUESTION: For amalgam, the most toxic mercury is: Methyl mercury (organic mercury)…elemental mercury, ethyl mercury

*QUESTION: Type of mercury most hazardous to dentist health: Methyl mercury…ethyl mercury, inorganic mercury, elemental mercury

QUESTION: Amalgam large condenser with lateral condensation is used in: Spherical

QUESTION: What type of amalgam needs to be condensed more? Spherical

QUESTION: Material to use for best interproximal contact of a CLASS II is Admix Amalgam (others Spherical amalgam, Composite w/ and w/o filler) • Admix materials = better for proximal contacts b/c of higher condensation forces

*QUESTION: From pt images, which amalgam filling has the lowest Copper content? One that looks corroded.

QUESTION: Over triturating amalgam? sets too fast, decreases setting expansion, increase compressive strength (strength will still be fine)

QUESTION: Huge MOD in posterior? Better to restore with amalgam

*QUESTION: Placing pin in amalgam restoration, Amount in tooth/restoration/angulation = 2mm • The optimal depth of the pinhole into dentin is 2mm. • Threaded pins used in a dental amalgam restoration should be placed 2mm in depth at a position axial to the DEJ & parallel to the external surface between the pulp and tooth surface.

*QUESTION: What is wrong about retention pin? Better retention with bigger pin…other answer follows axial, 0.5mm in DEJ.

*QUESTION: What happens to amalgam if it is contaminated with water/moisture? Decrease in strength • AID: greater expansion, decreased compressive strength, post op pain, increased corrosion

QUESTION: If there is water while you are condensing amalgam, what happens? Delayed expansion (other options were severe expansion, corrosion and decreased compressive strength)….these all seem like answer choices?

QUESTION: What happen to amalgam with moisture contamination? Delayed expansion

*QUESTION: What is true of amalgam within a year after placement Marginal leakage increases as restoration ages Marginal leakage decreases as restoration ages No marginal leakage because it gets filled with corrosion products

QUESTION: You have an amalgam that is deficient at the margin by 0.5mm (concavity) and no signs of recurrent decay. What do you do: Observe/monitor, remove and replace, repair with amalgam

*QUESTION: Where is it acceptable to leave unsupported enamel? Occlusal wall of class V amalgam • It’s not a bearing surface so you can leave unsupported enamel in class V for esthetics

QUESTION: What do class I & class V amalgam ideal prep have in common? a. Both slightly extend into dentin b. Both have flat axial & pulpal wall

QUESTION: What is the reason you would do MOD onlay vs an Amalgam: Better facial contour (more ideal contours) & less Microleakage j. cusp protection (onlay) vs amalgam

QUESTION: Advantage of inlay over amalgam? Esthetics, less tooth reduction

QUESTION: Is the isthmus the same for inlay and amalgam? NO • Isthmus is convergent for amalgam & divergent for inlay.

QUESTION: Resistance form for amalgam prep: Bevel in the axiopulpal line angle to reduce stress and increase RESISTANCE form.

• Resistance = keeping the restoration from fracturing, “ways to resist stress” • Smooth floor & line angles. Flat walls are right angles of tooth’s long axis.

QUESTION: What’s the best way to prevent proximal dislodgement/fracture of class II amalgam filling? • Retentive grooves (for proximal resistance) • Converging axial walls (B&L walls) • Depth of prep

*QUESTION: Proximal retention in class II box for amalgam? Retentive grooves, convergence of facial lingual walls, bevel on axiopulpal line angle, all of the above, none of the above

QUESTION: Bitewing of tooth #18 has mesial amalgam restoration with overhang and very light contact. What lead to this? Poor adaptation of matrix band or a wedge was not placed right?

QUESTION: Position of incisal portion of matrix band? 1 mm above adjacent marginal ridge…other option 2 mm

QUESTION: Put wedge in after matrix

QUESTION: Restoration of class 2 for posterior with heavy occlusion – Amalgam…composite, microfill

GOLD INLAY/ONLAYS

Malleability – deform (without fracture) under compressive strength; ability to form a thin sheet • Greatest malleability to least: gold, silver, lead, copper, aluminum, tin, platinum, zinc, iron, and nickel

Ductility – deform (without fracture) under tensile strength; ability to stretch into wire • Greatest ductility to least: gold, silver, platinum, iron, nickel, copper, aluminum, zinc, tin, and lead.

Gold inlay/onlay Prep: divergent walls (2-5⁰ per wall), 30⁰ bevel margins for better fit, skirt – extend beyond line angle • Resistance/retention: 2-5⁰ of taper per wall as tall as possible. • Primary retention is from wall height & taper. • Secondary retention is from retention grooves, skirts, and groove extensions.

QUESTION: What is the hardest (most rigid) gold? Gold Type IV

QUESTION: When do you use base metal opposed to gold? Long span bridges (FPD) • Need it be more rigid = more base metal

QUESTION: Ductility – gold’s ability to be worked into different shapes

QUESTION: Only advantage of porcelain over gold: Esthetics

QUESTION: Advantage of gold on occlusal surface, porcelain in facial surface: Conserve tooth structure, minimal reduction? • Gold is compatible in wear with natural tooth & is more conservative, porcelain gives esthetics.

QUESTION: Reduction dimension for functional/non-functional cusps in gold and PFM? Gold: functional = 1.5, non-function = 1. PFM = 1.5-2mm

QUESTION: Why do we bevel the edge of gold- finish margins better, marginal stability and Better adaptation

QUESTION: Weakest part of the gold mod inlay is? Cement layer (cement = weakest part of cast gold restoration)

QUESTION: Zinc phosphate cement can be used for gold • Zinc phosphate is used as a cement for gold & PFM (basically metals). Zirconia can’t bond to it so we use GI.

QUESTION: What is the most accurate pulpal test to determine vitality of a tooth with a full-gold crown? Electric testing Percussion test Palpation test Thermal test

QUESTION: Recently placed gold inlay on upper tooth is opposing lower amalgam, what is the most common reason for pain afterwards? Galvanic shock • Galvanic shock Sensitivity - choose this if only question says opposing dissimilar metal.

QUESTION: Gold casting wrong? Hygroscopic expansion or setting expansion • Plaster expands during casting so gold casting will be smaller than expected

QUESTION: What property effects burnishability in gold – Yield strength

QUESTION: Main Disadvantage of gold inlay a. Deforms under load- since it is high noble gold and softer, it may have higher creep b. Wear opposing c. Cement is soluble (not soluble) d. Possible

QUESTION: How to remove a gold inlay? Section isthmus and remove in 2 pieces

QUESTION: What is the reason to burnish gold to the margin? Acute angle of gold margin QUESTION: Which is a characteristic of a gold inlay? Axial walls converge toward the pulpal floor (axial pulpal walls = divergent prep) • From facial to lingual, the axiopulpal line angle of an onlay preparation is longer than the axiogingival • line angle (if it were not, the preparation would be undercut and the onlay would not seat). For an MOD onlay prep, the axial walls must converge from the gingival walls to the pulpal wall (for the same reason, the onlay would not seat if they diverged).

INLAYS/ONLAYS

Removing cusp affects retention form Increasing intercuspal space affects resistance form Marginal ridges help with resistance form Loss of marginal ridge affects both resistance and retention

*QUESTION: Isthmus of MOD prep extends over 1/3 of intercuspal dimension, how to treat? amalgam, crown, onlay, inlay crown • Inlays when less than 1/3 intercuspal dimension is prepped

*QUESTION: Removing cusp affects retention form

QUESTION: When is onlay indicated? When cuspal coverage is needed or when cusp is undermined by not enough dentin

QUESTION: Which is the only surface not beveled for an onlay? Pulpal

QUESTION: Dentist has to reduce a weak cusp during onlay preparation is to: a) outline form b) resistance form c) retention form

QUESTION: Pt w/ onlay, 3yrs later sensitivity- cement wash out?

QUESTION: Reason for using porcelain for posterior onlay (bond to dentin, to correct occlusion, etc)

QUESTION: Use of indium (tin & iron) with alloy is mainly to provide chemical bond with porcelain

QUESTION: Purpose of addition of tin and iron to metal ceramic allows: Chemical bond, covalent bond with porcelain

QUESTION: Cut onlay & find out margin of crown w/in 1 mm of interseptal bone a. pack cord, take imp b. crown length surgery----impinges biologic width c. use amalgam

QUESTION: When is the best case to use an inlay? Patient with low caries index

QUESTION: All of the following you can use inlay except high caries risk

QUESTION: Where is the MOD inlay hitting when it contacts early during seating? Interproximal

QUESTION: What causes most post-op sensitivity in direct inlay: Polymerization shrinkage

QUESTION: Patient receives a blow to the chin. He has a MOD inlay placed on the maxillary molar 3 months earlier. Now the patient has a vague pain on biting, there are no other symptoms. Why? maxillary sinusitis, M-D fracture

QUESTION: Reasons of reduction of tooth for MOD inlay except: amount of enamel on teeth

*QUESTION: Cement for porcelain onlay HAS TO BE RESIN

QUESTION: Cement onlay & you see black lines few months later: MICROLEAKAGE

QUESTION: Coefficient of thermal expansion is most for which material? Tooth

QUESTION: Linear thermal coefficient is most for tooth- gold- amalgam- Composite (most)

PORCELAIN/PFM/CVC

Porcelain Strength: (weakest) Feldspathic porcelain

QUESTION: 14-year-old with MOD restoration, decay interproximally and undermined enamel in all cusps. - onlay - inlay - crown (b/c all cusp has undermined enamel)

QUESTION: MOD amalgam that exceeds 1/3 distance of cusp height, what would you do? MOD amalgam, MOD composite, MOD onlay, MOD inlay

QUESTION: Common feature between porcelain veneer and all-ceramic crown preparation – rounded internal

QUESTION: What is the most important thing for retention? Surface area

QUESTION: Most lab complain that the tooth is under reduced.

*QUESTION: Porcelain is stronger under compression forces

QUESTION: Porosity in PFM – inadequate condensation

QUESTION: What is the weakest porcelain? Feldspathic

*QUESTION: Best material to oppose a porcelain crown? Porcelain

***QUESTION: Silver turns porcelain (PFM) what color? Green

QUESTION: What turns a PFM green? Silver k. Silver (Ag) is not considered noble; it is reactive & improves castability but can cause porcelain “greening.”

QUESTION: What component makes a PFM green in the cervical 1/3? Copper l. at the margin its copper, other places its silver

*QUESTION: What parts of tooth prep can be managed by operator/dentist: parallelism, surface area, length, circumference

QUESTION: Wear of enamel due to porcelain on opposing

QUESTION: All are functions of opaque porcelain EXCEPT: mask metal framework to help come up with a base/stump shade for initial bond to metal to decrease contamination of additional porcelain with metal in ensuing firing and baking procedures

*QUESTION: When you receive a crown back and want to seat it what is the first thing you check for? a. Shade (Aesthetics) or internal b. Proximal contacts c. Margins

QUESTION: Where will you place the margins in an anterior PFM prep: Subgingival

QUESTION: Minimum incisal reduction in anterior PFM: 2 mm m. Mostly for esthetics & thickness of porcelain (translucency layer)

QUESTION: Facial reduction for PFM at gingival 3rd is 1.5mm

QUESTION: How much reduction would you do for a PFM crown on anterior? 1.5mm on facial incisal plane, not incisal angle

QUESTION: When you have a short crown for PFM, what do you do to increase retention of the crown? Place proximal boxes & vertical grooves to increase retention.

*QUESTION: What causes the most retention of crown? Axial taper, surface area, surface roughness, retention grooves

QUESTION: How do you make sure your all-ceramic restoration does not fracture? must have NOT LESS than 1.5mm porcelain at occlusal

QUESTION: Functional cusp bevel: structural durability

QUESTION: Why do a functional cusp bevel on a crown prep? To prevent cusp fracture & for proper casting/fabrication of the crown n. Bevel on functional cusp for extra room for porcelain. Ideal is 2 mm reduction.

QUESTION: In PFM, porcelain fractures because the junction should be? Right angle, not round o. Junction between tooth & metal = right angle p. Junction between metal & porcelain should be rounded

QUESTION: When you want to cement crown, what is the sequence? Look inside the crown (internal fit), contacts, then margin

QUESTION: Which of the following do you not do in cementation of a porcelain crown: etch enamel with hydrofluoric acid

QUESTION: What is NOT the reason why you use resin cement on all porcelain restorations? for added retention, to fill small openings at margin q. All porcelain crowns use resin cement for increased retention (bonded)

QUESTION: You have a patient who wants an all porcelain on # 8 – the incisal edge keeps breaking off and you have to come in to repair, why does it keep breaking off? Because the anterior guidance and the protrusive movements/clearance space was not properly calculated/maintained

QUESTION: #10 PFM on a patient looks longer than #7. All of the following may be the reason why the crown looks like this except? Incorrect shade. (Other choices; insufficient tooth prep (yes), too thick metal (yes), too thick porcelain (yes) – all of these could have caused it).

QUESTION: What didn’t cause the unaesthetic opacity of crown? shade selection; other choices were under-prepared tooth, too thick metal, too thick base porcelain or something like that

QUESTION: What could the reason be if you see opaque white porcelain in the incisal 1/3 facial of the PFM crown: Inadequate reduction of the inciso facial part of the tooth

QUESTION: If incisal edge of anterior PFM is opaque, it is because they had improper second plane of reduction

QUESTION: Lab over bulks porcelain, why? Not enough reduction on tooth, compensate for 20% shrinkage

QUESTION: All porcelain crown on #8 is too light but it is a good crown. What would u do and I put to whiten the other teeth. (vital tooth bleaching)

*QUESTION: ¾ gold crown advantageous except for? LESS retention than full crown

*QUESTION: Resistance to lingual displacement of ¾ crown? Lingual wall (of groove), facial wall of groove, facial aspect of prep

PORCELAIN VENEERS

When preparing for a porcelain veneer: r. Gingival third: 0.3 mm veneer reduction s. Facial third: 0.5 mm veneer reduction

QUESTION: Advantage of a direct composite vs. a veneer? Direct composite is only 1 appointment vs. veneer is at least 2

QUESTION: Most technique sensitive part of placing veneers? Preparation, color match, impressing

*QUESTION: Pt had veneers cemented with light cured resin. Now, comes back few weeks later with brown staining at gingival margins. Why? Microleakage, not enough cement, etc

QUESTION: Veneer after a month time has some brown stain: not enough cement at margin, Microleakage

QUESTION: The dentist cements the porcelain veneer with light cured resin and the patient returns with brownish discoloration at the margins, why? not enough cement or microleakage (depends on duration of pt return)

QUESTION: How much tooth structure needs to be removed on the mid facial for a porcelain veneer? 0.5 mm

*QUESTION: Patient has a veneer on incisal edge, small piece of porcelain chipped off and wants you to fix the chip only, what is the sequence of events: micro etch/micro , acid-etch (hydrofluoric acid), silanate, and bonding agent (MAS Bonding) Silane = porcelain tx to help it stick to bonding agent

QUESTION: Repairing porcelain veneer with composite microetch, etch, silanate, resin

QUESTION: What do you use to cement a veneer? • Resin cement • Polyacrylic acid (etchant for GI)

QUESTION: Opaque coming through on veneer, what’s the problem? Veneer under prepped

QUESTION: Order of bleaching and veneering process: bleach, wait 2 weeks, prep tooth, cement

QUESTION: When will you bleach teeth in anterior veneer prep? Before veneer prep, wait for 2-3 weeks After prepping veneer and then bleach After cementing veneer and bleach

QUESTION: Pt has veneers from 6-11, which fluoride do you use to not stain the veneer? A. Stannous Fluoride (stains) B. Sodium Fluoride** C. Acid Fluoride BLEACHING

*QUESTION: In-home bleaching kit, what’s the percentage? 10% carbamide peroxide

QUESTION Material used for mouthguard vital bleaching - 10% carbamide peroxide

QUESTION: H2O2 – 35% used in in-office bleaching

QUESTION: Home bleaching causes what? sensitivity

*QUESTION: Most successful teeth for bleaching? Aged yellow staining

QUESTION: What is the most effective way of bleaching teeth? In-home vital bleaching

QUESTION: Non vital bleaching is with? 35% hydrogen peroxide, carbamide peroxide, and sodium perborate.

*QUESTION: Bleach most often used in internal bleaching: sodium perborate

QUESTION: Difference b/t dentist and home bleaching - strength of peroxide

QUESTION: Best way to decrease gingival irritation w/ home bleaching? Well-fitting custom trays

QUESTION: Purpose of bleaching teeth except? getting past foramen to treat bone

*QUESTION: Most common complication of internal bleaching: cervical root resorption

QUESTION: What is worse outcome of nonvital bleaching (internal bleach for endo)? internal root resorption /CERVICAL RESORPTION.

QUESTION: You are about to prep a tooth for PFM crown, patient also needs teeth bleached, how do you go about it? – Bleach first, wait 2 weeks, prep tooth, then restoration. (Other choices, Bleach and prep 1st, then wait 2 weeks, Bleach last after prep and crown).

QUESTION: How long after vital tooth bleaching can you bond resin to it? 24 hours, 3 days, 1 week

QUESTION: Patient is complaining about a very light colored anterior PFM crown she had done sometime ago, there is nothing clinically wrong with the crown. What do you do Doctor? Bleach natural teeth (other choices, re-do the crown, put a darker shade composite on crown, some other stupid answers).

QUESTION: #8 PFM is too light but good margins and been there for 10 years – vital night guard bleaching

QUESTION: 45 yr. old woman. Anterior crown placed 10 years ago & color doesn’t match natural teeth now, appears clinically acceptable & has good margins, what will you do? a. vital bleaching b. new crown c. micro etch and composite bond

QUESTION: The prognosis for bleaching is favorable when the discoloration is caused by a. necrotic pulp tissue b. amalgam restoration c. precipitation of metallic salts d. silver-containing root canal sealers

QUESTION: The office bleaching changes the shade through all except: a. dehydration b. etching tooth c. oxidation of colorant d. surface demineralization

FIXED PARTIAL DENTURE (FPD)

Non-Rigid Connector: Key and keyway—for pontics and short span bridges where you can’t get proper draw without a lot of tooth reduction. POI is parallel to pathway of retainer. A connector that permits limited movement between otherwise independent members of a fixed partial denture. Can be solution to tilted teeth (FPD). • Mortise (female) retainer: distal aspect (mesial of most distal tooth in FPD), dovetail or cylindrically shaped • Tennon (male) portion: found on distal of Pontic) • Indications: when not able to prepare two abutments (i.e. mesially tilted 2nd molars), large or complex FPD’s, not sure of prognosis of abutment teeth (easier to fix if issue arises), mandibular arch consisting of anterior and posterior segment (flexes mediolaterially, rigid FPD would inhibit this flexure and cause dislodgement)

Rigid connector: unite retainers and pontics in which entire load is directly transferred to the abutments. • Contraindications: existing diastema is to be preserved, tilted abutment, long span bridge

Connector: portion of a fixed partial denture that unites the retainer and Pontic

Ante’s Law: Root surface of abutment teeth have to be greater than root surface of Pontic. The longer the FPD, the poorer the prognosis.

Provisional materials: PMMA, PEMA, Bis-acryl, Dimethyl siloxane, fillers • PMMA: high strength, low cost, easily repaired o Disadvantages: high exothermic setting reaction, high shrinkage, bad odor • PEMA: moderate strength, low cost, easily repaired, exothermic reaction higher than bis-acryl, but lower than PMMA o Disadvantages: easily discolored, weaker than PMMA • Bis-acryl: low exothermic reaction setting, minimal shrinkage, syringe delivery system, best indicated in single unit cases o Disadvantages: high cost, weak (breaks under moderate stress), difficult to repair • Dimethyl siloxane: akyl silicate or ethyl ortho0silicate (cross linking agent) • Fillers: tin octoate (activator)

Yield strength: most important, resistance to permanent deformation Ultimate tensile strength: maximum stress before fracturing Coefficient of thermal expansion: the metal should be slightly higher than the porcelain Noble metals: gold, platinum, palladium, rhodium, ruthenium, iridium, osmium • Corrosion resistant, oxidation resistant, higher cost than base metals • High noble =/> 60% noble and =/> 40% gold • Noble =/> 25% noble Base metal:

Classification of dental alloys: • Type I = soft = inlays • Type II = medium = inlays/onlays • Type III = hard = crowns • Type IV extra hard = RPDs

Ceramics • Metal-ceramic systems: o Feldspathic (moderate leucite): • All ceramic systems: o Feldspathic (high leucite): powder or pressed o Feldspathic (no leucite): veneering ceramic o Glass ceramics: pressed and cast ▪ Micaeous ▪ Lithium disilicate o Core ceramics: ▪ Alumina ▪ Spinel ▪ Zirconia

Properties of dental porcelain: low plastic deformation (brittle), compressive strength much greater than tensile or shear • Zirconia is stronger bur alumina is more esthetic for all ceramic crowns

QUESTION: Where do you attach a non-rigid retainer (female part) from a FPD? Distal of mesial abutment and mesial of the distal abutment

QUESTION: Most immediate sign after high occlusion on a bridge? Myofacial pain

*QUESTION: A fixed partial denture keeps breaking, why? Poor framework

QUESTION: Most common reason for PFM bridge breakage? Inadequate design…Firing schedule, high contact

QUESTION: FPD seats during framework try-in but when come back for final cementation, the doesn’t seat. Why? Interproximal (porcelain over contoured) • Check proximal contacts first when cast that fits on die cannot be

QUESTION: All ceramic FPD should cover how much of abutment? 360 degrees

QUESTION: What is the basis for classification of different FPD pontics: Relation of the pontic to the supporting tissue

QUESTION: Modified ridge lap pontic has what kind of contact? Minimal contact w/ residual ridge (lightly contacts buccal side of ridge)

QUESTION: The modified ridge lap pontic how should it touch the gum? Barely touch it (lightly contacts buccal side of ridge)

QUESTION: MOST esthetic pontic: Modified ridge lap…saddle, steins, sanitary, conical ridge lap (out of the given choices; the most esthetic of all pontics is ovate)

QUESTION: Pontic of 3-unit FPD should Rest gently on the soft tissue & should not blanch tissues.

QUESTION: Anterior teeth, which pontic is best? Ovate or modified ridge lap

QUESTION: Pontic length on a bridge, what’s most important? AP dimension, MD dimension

QUESTION: Strength of abutment connection to pontic which is more important? Occlusogingival width

QUESTION: Most important dimension that ensures the metal connector between abutment and pontic is sufficient (in 3-unit FPD bridge)? Occlusal-gingival

*QUESTION: A pontic in the bridge shows the metal, why? Under-reduction Framework was not done well (since it is a pontic this is probably the answer)

QUESTION: Edentulous space is wider than adjacent anterior tooth, how to match them? Make pontic line angles farther apart and deeper interproximal embrasures Make pontic line angles closer and deeper interproximal embrasures Make pontic line angles farther and shallower interproximal embrasure Make pontic line angles closer and shallow interproximal embrasures

*QUESTION: How do you decrease the width of an artificial tooth? Deepen the facial line angle proximally and increase the interproximal embrasure Deepen the facial line angle proximally and decrease interproximal embrasure Take the facial line angle labially (closer together) and increase the interproximal embrasure Take the facial line angle labially and decrease the interproximal embrasure.

QUESTION: How do you make a crown narrower? Move line angles more facially (closer together)

QUESTION: Ante’s law: 3 abutments, one being lateral, with 2 pontics, prognosis is good, poor, excellent? Poor

*QUESTION: Which of the following is not ideal abutment-pontic connection? Lateral Incisor-Central Incisor (other choices, Central Incisor-Lateral Incisor, Canine-Lateral Incisor, etc.) • Worst cantilever lateral abutment with central pontic

QUESTION: Which cantilever bridge would be most destructive of the abutment tooth: Lateral incisor as abutment with central incisor as pontic • Larger root surface of pontic than abutment, Ante’s Law

QUESTION: The strength of a soldered connector of FPD in enhanced by? 1. Using higher carat solder 2. Increasing height 3. Increasing width 4. Increasing gap

QUESTION: When soldering, what is the most important factor? Height

*QUESTION: What system is best for soldering adjusted FPD framework? Oxygen something, use a torch (acetylene?)

POST/CORE

Dowel post = core build up + post in one that is cast, for retention of core & to provide support to crown • Dowel = post, dowel core = vertical stop (ferrule)

Active screw (post) vs. inactive post? o An active post is one that engages (screws into) the dentin in the canal space. Traditionally, the major concern about active posts has been the potential for vertical fracture of the tooth during placement of the post. Active posts are indicated when the canal length is insufficient to gain adequate retention with a passive post (contraindicated in any other situation) o Inactive post = cement retained.

• Posts do not reinforce teeth. Their only purpose is to retain the core. • 4-5 mm of gutta percha must remain for adequate seal if treating endo treated tooth • Post is placed in the longest root: maxillary palatal root and mandibular distal root • Post length = 2/3 to ¾ the length of the root in the bone or equal to the length of the clinical crown • Post width = critical to preserve radicular dentin around the post but no guidelines exist • Core material: amalgam, composite resin, glass ionomer, resign modified glass ionomer, cast metal • Custom cast post and core is indicated for a severely mutilated tooth • Types of pre fab posts: stainless steel, titanium, resin, zirconia, cast metal

QUESTION: Keyhole for post /core is to: Prevent rotation (post = key, hole = keyhole)

QUESTION: Cast post and core - you put extra slit - what is that for? Prevent rotation (keyway)

QUESTION: What is the advantage of a fiber post over a cast post? Fiber post has the same modulus of elasticity as dentin

QUESTION: How does a dowel post & core help prevent vertical fracture? Ferrule…Ventilating groove, bevel, vertical stop

*QUESTION: What is the point of putting a dowel post on an RCT tooth? Retain core, metal set into root canal to provide support to crown

QUESTION: How should you prepare an RCT for cast post? Need at least 4-5 mm of GP to preserve apical seal

COLOR/SHADE

Most important dimension of color: for dental restorations it is value • Hue = actual color • Value = relative whiteness/lightness or darkness/blackness, brightness • Chroma = amount of saturation

Metamerism: visual effect in which a color appears differently under different light sources

*QUESTION: Most important when selecting shade? Value…translucency, chroma, hue, color

QUESTION: Least important in selecting shade? Hue (due to lack of variation in mouth)

QUESTION: When you have color index of 100, which of the following is effected? Value (Color value is 0 = black while 100 = white)

QUESTION: A dentist adjusts the shade of a restoration using a complementary color. This procedure will result in A. Increased value B. Decreased value C. Intensified color D. Increased translucency

QUESTION: Crown #9 and #10. One of the crowns looks very light (white). What did the dentist pick wrong? Value

QUESTION: What does staining do for ceramics? Decreases value and alters chroma

QUESTION: What can’t occur with the addition of stain? Increase value…decrease value, increase chroma, increase hue, decrease chroma

QUESTION: What can’t you change? Increase value…decrease value, change chroma, hue

QUESTION: When you add a different color to a resin, you increase what? Chroma

*QUESTION: How do you change hue? Add orange to it (some sources says it changes chroma)

*QUESTION: How do you lower value in a restoration? Stain w/ Complement color or orange • When you add a complement color, the colors mix & turn grey, thus changing value

QUESTION: What complementary color do you use to darken porcelain and decrease value? Orange…gray, ochre, violet

QUESTION: If you add a complementary color yellow, what happens to the hue? Decrease red content of yellow red shade • Side note: adding yellow stain increases chroma of basic yellow shade • Pink purple makes yellow turn to yellow red

QUESTION: Which represents position on the spectral wavelength? Hue QUESTION: Which color characteristic is dependent on spectral wavelength? Hue

*QUESTION: What is best way to determine value: Open eye as wide as you can Half close eyes (squint) to increase sensitivity to better select value. Arrange the shade guide in increasing value (from light to dark)

QUESTION: Which one can human eye see, hue, value, or chroma? Value • More rods than cones so eyes are more sensitive to value

*QUESTION: How do you prevent metamerism? Look at shade under multiple light sources • Porcelain, look at it with different light sources (metamerism)

QUESTION: The phenomenon whereby various light sources produce different perceptions of color is called A. Fluorescence B. Incandescence C. Opalescence D. Translucency E. Metamerism

FUNCTIONAL/NON-FUNCTIONAL MOVEMENTS

FUNCTIONAL/NON FUNCTIONAL MOVEMENTS: ➢ Balancing LUBL ➢ Working BULL ➢ Protrusive DUML Centric Relation: Man to Max Centric Occlusion: teeth

QUESTION: Upper molar crown has a wear facet in porcelain on the MB inclination of MB cusp. Most likely associated with? Interference in protrusion & working interference

QUESTION: #30 gold crown has wear located on the MB cusp of the MB incline, cause – protrusive and working side movement

QUESTION: Non-working movement, which one is true? Lingual cusps of upper molars hit lingual inclines of facial cusps of mandibular molars.

QUESTION: Non-working contacts: mand buccal cusp lingual incline

*QUESTION: Contact on lingual portion of buccal cusp of mandibular molar, what kind of interference? Non-working, working, protrusive

*QUESTION: Contact on buccal portion of lingual cusp of maxillary molar, what kind of interference? Non-working lateral, working, protrusive

QUESTION: Wear facets on lingual incline of maxillary lingual cusp & facial incline of mandibular facial cusp on left side? pt has: left nonworking interference, protrusive interference, right nonworking interference, left working interference

QUESTION: Working side interferences are seen on what surfaces? palatal inclines of buccal cusp of upper and buccal incline of lingual cusp of lower; (the nonworking cusps on the final side are interfering) a. In MIP or CO, the buccal incline of palatal cusp of upper and lingual incline of buccal cusp of lower. b. Balanced side interferences are buccal incline of palatal cusp of upper and lingual incline of buccal cusp of lower (it’s the working cusps interfering)

QUESTION: Wear on buccal of maxillary premolars due to, due to mandibular movement working or nonworking?

QUESTION: When will the BULL rule be utilized with selective grinding? Working side

QUESTION: The mesiobuccal incline on the mesiobuccal cusp of mand molar (with stainless steel crown) has wear. This is because of movement in which direction(s): working and protrusive movement

QUESTION: Max molar on mesial slope of mesial lingual cusp, where do you have wear on lower teeth? Mesial or distal incline of either mesial facial or mid facial cusp? Distal incline of midfacial cusp

QUESTION: The mesial angle of the ML of max 2nd molar occludes with what on the man 2nd molar a. Mesial MB cusp b. Distal MB cusp c. Mesial DB cusp d. Distal DB cusp

QUESTION: Mesial angle of the L of maxillary second molar occludes with what on the mand 2nd molar.? Distal of MB CUSP

QUESTION: Pt bites down after cementing down and deviates to the right #30: Lingual incline of the buccal cusp

***QUESTION: Crown on number 30, pt tries to close, contact interference deviates to left, lingual incline of buccal cusp needs to be altered buccal incline of the lingual cusp

***QUESTION: #30 hyper occluded, deviated – incline most effected is max/mand balancing cusp?

***QUESTION: In restoring a canine protected occlusion, with anterior of about 2mm. The buccal cusps of posterior teeth should be flat, BECAUSE they will guide the protrusion. a. both are true b. only the second statement is true c. both are false d. only the first statement is true

QUESTION: What kind of occlusion if in right lateral movement all posterior teeth are not in occlusion: canine guidance

QUESTION: Which of the following would result in inaccurate terminal hinge record? acutely apprehensive patient, severe skeletal cl III, tooth contact, muscle pain, etc

QUESTION: IF you are making a crown but before you begin, when you do equilibration, what are you trying to achieve to get rid of the non-working interference? Posterior dissocculusion??

QUESTION: You have a patient who wants an all porcelain on number 8 – the incisal edge keeps breaking off and u have to come in to repair, why does it keep breaking off? Because the anterior guidance and the protrusive movements/clearance space was not properly calculated/maintained

*QUESTION: What is Bennett angle? a. it is the angle that is formed by the non-working condyle and the sagittal plane during lateral movement b. it is the angle that is formed by the condyle and the horizontal plane during protrusive movements. c. It is a difference in condylar inclination between protrusive and lateral movements d. It is the difference between in the condylar and incisal inclinations.

QUESTION: Bennett shift mainly on: lateral movement or working side

TEMPOROMANDIBULAR (TMJ) DYSFUNCTION:

TMD = Most common form of internal TMJ derangement is anterior misalignment or displacement of the articular disk above the condyle. Symptoms are localized joint pain & popping on jaw movement. a. Articular disk is pulled out of place anteriorly due to abnormal jaw mechanics; it may remain displaced (without reduction) or return (with reduction). b. Disk displacement with reduction typically causes clicking and pain with chewing. c. Disk displacement without reduction does not cause clicking but reduces maximum jaw opening to ≤ 30 mm. Surrounding tissues may become painfully inflamed (capsulitis).

Upper compartment – Translation Lower compartment – Rotation

*QUESTION: Where do the condyles go in CR? Antero-superior-medial

QUESTION: Which anatomical components are responsible for rotation of the ? Disc and condyle

QUESTION: If both condyles break, what do you get? Posterior open bite

QUESTION: Dislocation of condyle- mandible deviates opposite

QUESTION: Clicking in TMJ: internal derangement with reduction

QUESTION: Patient always had internal derangement with clicking. All of a sudden, no noise and open max 30 mm. What happened? Myofascial pain, Lockjaw, Internal derangement w/o reduction

*QUESTION: Which way is the articular disc most displaced? Anterior-medially

QUESTION: Which artery supplies the TMJ? Deep auricular, maxillary, superficial temporal…MADS d. MADS: Middle meningeal from maxillary, ascending pharyngeal, deep auricular, superficial temporal

QUESTION: Best imaging for TMD (soft tissue, disc & condyle of TMJ): MRI

QUESTION: Best diagnostic eval for TMJ disc? MRI, CT, PA radiograph

QUESTION: Rotation involves what structures? Condyle, glenoid fossa, disc, TMJ

QUESTION: Which anatomical components are responsible for rotation of the mandible? Condyle & articulating disk

QUESTION: When TMJ is in rotational movement, rotation is in the lower compartment

QUESTION: What causes TMJ ankyloses? Trauma, Rheumatoid arthritis

QUESTION: Patient can’t speak English well, she doesn’t work, she has TMJ problems, she is on meds. Which one will not affect her oral hygiene prognosis? TMJ problems e. Rationale here is; she may not be able to afford hygiene procedure, she might not understand doctor’s recommendations, and her meds can contribute to hygiene issues. TMJ problem was not serious enough, as in she can open her mouth to clean her teeth.

QUESTION: Man comes in after years of TMD with reduction and is now only able to open 25mm w/ with muscle pain. What’s his disorder? Myofacial pain syndrome f. myofacial pain syndrome (can cause clicking, limited opening, pain), internal derangement without reduction has no noises or clicking but limited opening to < 30mm

QUESTION: High school football player wears a mouthguard. He has crepitation of left TMJ & trigger zone tenderness to palpation of left temporalis area, stiffness upon wakening: Myofacial pain syndrome, TMJ dislodgement

QUESTION: Symptoms of pain & tenderness upon palpation of the TMJ are usually associated with which of the following? a. impacted mandibular third molars b. flaccid paralysis of the painful side of the face c. flaccid paralysis of the non-painful side of the face d. excitability of the second division of the fifth nerve e. deviation of the jaw to the painful side upon opening the mouth

***QUESTION: TMJ pain are mostly related to: 1- VII, 2-V3, 3-V2, 4-V111

*QUESTION: What branch off facial nerve gets damaged the most during TMJ surgery? Temporal

*QUESTION: TMJ ligaments purpose is to – limit the movement of mandible, helps open mandible, helps closes mandible

*QUESTION: Which muscle mainly responsible for positioning and translating condyles? Lateral pterygoid

QUESTION: Muscles elevating the jaw: masseter, temporal, medial pterygoid and SUPERIOR belly of lateral pterygoid

QUESTION: includes what muscle? Medial pterygoid

QUESTION: How do you treat ? Mouthguard g. Stress causes immune weakness which leads to disease and bruxism.

***QUESTION: Main function of the occlusal guard: • Distribute occlusal forces more evenly • To relax the musculature • Bruxism COMPOSITE

If patient has: t. Decay, microleakage and failure of composite u. Sensitivity, occlusion, debonding

Microfill composites are more color stable than hybrid. Microfill have the smoothest finish (smaller particle) compared to hybrid composite resin (has microfill + bigger ones for better fill), which are rougher. Rougher will pick up stain easier. v. Has reduced physical properties (ex. thermal expansion, elasticity, strength, etc.)

Flowable – Less filler content

Component of composite: Bis-GMA + dimethacrylate monomer (TEGMA, UDMA, HDDMA) + filler (silica) + photoinhibitor (camphoroquinone) w. Filler = wear resistance, translucency x. Photoinhibitor: begins polymerization when external energy (light) applied

Composition and properties: • Thermal conductivity much lower than amalgam and other metals→greater thermal protection of the pulp • Three phases: resin matrix, filler particles, coupling agent o Filler: ▪ Fine: crystalline silica (quartz), lithium aluminum silicate, glasses ▪ Microfine: colloidal silica ▪ Microhybrid: contain fine and microfine particles o Matrix: Bis-GMA (dimethacrylate), UDMA (oligomers) o Coupling agent: Silane o Initiators: benzoyl peroxide, diketone, camphoquinone o Accelerators: organic amines o Pigments: inorganic pigments • Initiators, accelerators, pigments needed to complete final composite product • Quartz and lithium aluminum = not radiopaque = avoid in posterior restorations = resemble carious lesions on radiographs

Activation: chemical, light, or both • Light: most common, diketone (absorb light), amine activator (supply free radicals) o 20-40 sec to cure (darker shades need more time) o Light = quartz-halogen bulb o Light absorbed at 470 nm • Chemical: self cure, organic peroxide initiator (benzoyl peroxide) and tertiary amine activator

Strength: compressive and flexural strength, hardness and wear • Microhybrid = higher compressive and flexural strength than microfilled • Higher filler volume = greater hardness and wear • Most fail due to tension and bending • Bond between composite and tooth is mainly mechanical

Dimensional change: • Less resin = less shrinkage (microhybrids have less shrinkage than microfilled) • Curing composite in layers = decrease shrinkage • Thermal expansion more in microfilled (have more resin) • Composite has higher thermal expansion that teeth and amalgam

Compomers: modified with polyacid group, low stress bearing areas, less wear resistant than composite, releases fluoride

Glass ionomers: fluoro-aluminosilicate glass powder and liquid solution of polymers and copolymers of acrylic acid • Class V lesions, low stress bearing areas, higher caries risk individuals • Expansion close to dentin, low solubility, high opacity

Bonding agents: etchant (remove smear layer), primer (micromechanical and chemical), adhesive (micromechanical)

QUESTION: What type of bond is composite on tooth structure? a. Chemical bond b. Mechanical bond (micromechanical) c. Organic coupling d. Adhesion

QUESTION: Two things that account for a successful posterior composite restoration? The type of resin and the type of preparation

QUESTION: Post-operative MOD composite pain, most likely due to? Hyperocclusion

QUESTION: Few days after placement of composite restoration complains of pain especially with biting but relieved by cold: Check occlusion

*QUESTION: What indicates the design of composite class I preparation Only incorporates pits of lesion - this one 2mm pulpal floor depth 45-degree bevel cavosurface

QUESTION: When doing a class 1 composite, what is the requirement: Contain to only pit and fissure caries

QUESTION: What determines composite class 2 prep? Extent of caries, Access

QUESTION: When do you replace class 2 composite? Recurrent decay

QUESTION: You are doing a composite slot on mesial and distal of 1st molar, you decide to connect the composites by crossing the oblique ridge, why? Only answer that made sense was that when Oblique ridge is less than 1.5mm so you involve it

*QUESTION: Class II prep into cementum, how should you restore? GI, Hybrid, non-restorable

QUESTION: Small occlusal fillings need to be done on posterior, what do you use – Composite? amalgam? (small lesion so don’t want to take away too much with amalgam), GI

QUESTION: Large MOD composite, what’s disadvantage? Occlusal wear

QUESTION: What is not a class I cavity preparation? gingival 1/3 of #19, Lingual pit of #7, Lingual pit of #18 • Amount of stress for composite depends on c factor:

QUESTION: C factor in class 1 composites, which one is correct? Less walls is lower C factor • For ex. class I composite: 5 bonded/1 unbound: 5

QUESTION: C factor in class 1 composites, which one is correct? More walls, higher C Factor

*QUESTION: Which has the highest C factor or stress on it? Class 1 & class 5

QUESTION: Which part of composite stains the most - Gingival proximal, facial proximal, lingual proximal, or occlusal

QUESTION: Secondary caries is most likely at Gingival margin

QUESTION: Transillumination is useful in the diagnosis of Class 1, class 2, class5, Class III

QUESTION: What do you place on a 75 y/o patient with ~ 8 class V carious lesions? GI

*QUESTION: 65 y/o pt shows several new caries in molars and premolars class V, what material would you use: a) Amalgam b) Composites c) Glass ionomer

*QUESTION: #5 cervical lesion Class V onto root: Bevel enamel and do a 90 butt margin on cementum

QUESTION: What is not an indication for restoring class V ? a. Sensitivity b. Esthetics c. Prevention of decay d. Prevention of further structure loss e. Restoring physiological contour https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4861607/ According to this article an indication for restoration is not to prevent future loss (end of abstract)

QUESTION: Class IV composite, you notice it is too light two weeks later, how do you treat? Add composite tint or do direct facial composite in new color

*QUESTION: If a dentist notices that a large but acceptable composite is too light a few weeks after placing it, what should he do? Veneer with composite

QUESTION: Class III that extends to facial. The restoration is stained but margins are perfectly sealed. However, they have bad color & pt wants it fixed. What should you do? Remove 1 mm prep and add more composite

QUESTION: Recently placed a class III comp, pt isn’t happy with it and has a huge staining on margins what to do? Replace, remove on margins and place composite, extract/implant, etc.

The above two questions are confusing. Ultimately it is better to repair an otherwise acceptable composite than replace due to esthetic reasons https://www.ncbi.nlm.nih.gov/pubmed/28232082

*QUESTION: After caries removal, sound tissue is in cementum. How do you restore? Build up with GI and place composite

QUESTION: If a Class III prep is subgingival? Restore with GI, followed by composite

QUESTION: Class III composite w/ radiolucency under it, this could result from all the following except? Composite contraction…liner, recurrent caries, contraction from shrinkage of curing,

QUESTION: Main advantage of doing direct composite over composite onlay? a. Less Shrinkage-I’ve seen this in other tests b. Better marginal adaptation, seal - best answer among the options c. Greater hardness and wear resistance •

*QUESTION: Most important factor when placing a composite in posterior teeth? Case selection and technique

QUESTION: Sensitivity after placing composite restoration in posterior is mostly likely caused by (assuming ideal occlusion?)? Due to resin polymerization shrinkage in margin, Shrinkage floor. • Inadequate peripheral seal/microleakage??? (I THINK THIS ANSWER IS CORRECT)

QUESTION: You place a conservative composite on a posterior tooth and the patient returns due to sensitivity. What is the most likely reason? Putting large amount of comp while filling, Microleakage, trauma to dentin during preparation, etch causing pulpal pain, bacteria, gap, cuspal

*QUESTION: Most common reason for replacing posterior composites: RECURRENT CARIES, inadequate margins, fracture of composite y. Two main causes of posterior composite restoration failure: secondary caries and fracture (restoration or tooth)

QUESTION: After placing a crown with composite resin 6 month ago, there is discoloration around the porcelain gingiva (brown color). What is the cause? Discoloration of resin

QUESTION: An anterior composite placed 10 years ago without caries, what is the most common reason to make a new one? Color change/staining

QUESTION: How long should you wait after bleaching to do a composite on an anterior tooth? 1 week at least

QUESTION: How long after vital tooth bleaching can you bond resin to it? 24 hours, 3 days, 1 week • if answer allows, 2-3 weeks is better

QUESTION: Why do you bevel when placing anterior composite? More surface area

QUESTION: Which one is not reason for post-op sensitivity Class I comp? Cusp deformation due to shrinkage force

QUESTION: You have a pt. with a composite filling that complains of pain to cold during chewing, you ditch it out with a bur, no more pain. What was the cause of the pain? Polymerization Shrinkage

QUESTION: Post-op sensitivity on MOD so removed a portion of the occlusal & placed more composite. What was cause: Fracture Microleakage Inadequate margins and water coming out of the tubules Acid etch Compression pulling on cusps

QUESTION: Post-op sensitivity from a recently placed Class I composite. Everything could be a reason for sensitivity EXCEPT: 1 Etchant causes pulpal sensitivity 2 Shrinkage causing gap for microleakage of bacteria 3 Shrinkage causing gap for movement of fluid out of pulp 4 Polymerization shrinkage that causes cuspal shrinkage

QUESTION: When do you see microleakage with composite restoration done without rubber dam? Same amount of time as if done with rubber dam 2 weeks later 2 months later

QUESTION: Class II composite done without rubber dam, how long until you see microleakage: 2-4 weeks, 4-6 weeks, same time as with rubber dam on

*QUESTION: Highest chance of leakage under rubber dam? Holes too close, Holes too wide, Holes too far apart

QUESTION: What is not an advantage of rubber dam when compared to not using it? Facilitates the use of water spray, Improved properties of materials, shortens operative time

QUESTION: Placement of rubber dam affect the color selection by Dehydration of tooth giving inaccurate tooth shade

QUESTION: “W” on the rubber dam clamp means it is? Wingless

*QUESTION: Pt has composite restoration with severe pain with localized swelling, Tx is? Incision & Drainage

QUESTION: Pt had a bunch of little pits in #8 central incisor, how would you fix it? Composite over pits only, or over entire tooth, or veneer w/ porcelain, etc.

QUESTION: Pt complains of a marginal stain on #8, what do you do? Polish it

QUESTION: Patient’s chief complaint is #8 and #9 don’t look right. Picture shows nothing is wrong with #9. #8 has extra enamel at the incisal-distal aspect. What do you do? Shave the inciso-distal aspect of #8 (Other choices were stupid; like put composite on both teeth, put a crown on #9, etc.)

*QUESTION: All of the following are an indication for putting a temporary on a deep caries and restoring at a later time except? Lack of time due to it being an emergency apt, weakened dentin under cusps, to assess pulp condition

QUESTION: Photo initiator of resin composite? Camphoroquinone

QUESTION: Diketones activate by? Visible light • Composite resins contain alpha diketones as photoinitiators. Blue light to produce slow reactions. Amines are added to accelerate curing time. Crosslink reaction.

QUESTION: The most radiopaque in composite is: Barium (it is a metal)

QUESTION: Most radiopaque in porcelain: a. Barium and zirconium glass b. silica c. quartz

QUESTION: Heat-cured indirect composite (stronger) vs direct composite. Which is incorrect? Heat composite is harder Heat composite is more resistant to abrasion Heat composite is done indirectly so less irritation to tooth due to less shrinkage Heat indirect composite has better bonding to the dentin and enamel

QUESTION: Which composites have more color stability? Light cure due to TEGDMA (Triethylene glycol dimethacrylate) • HEAT CURED (light cured) RESINS HAVE SUPERIOR COLOR STABILITY

QUESTION: With TEDGDMA and HEMA: Light cure to maintain proper shade

QUESTION: What is the importance of light cured vs self-cured in terms of shade balance? Less number of nitrates when you light cure

QUESTION: What is false about LED vs halogen curing lights? a. Blue light is 340-370 b. Battery powered/cordless LED is acceptable c. LED lasts longer than halogen d. Something about a photoinitiator ● Blue light is not 340-370, actually 450-750 ● We use LED curing light b/c has more narrow spectrum, less heat generated, light bulb last longer & generally smaller.

QUESTION: Lasers and LED lights don’t cure all resins b/c some resins photoinitiators have required light sources out of its range: True and correct logic.

QUESTION: Which of the following will not be good against enamel? – Porcelain, Hybrid resins (other choices, enamel, amalgam and unfilled resins ● Hybrids have silica filler, which increase hardness wear resistance & is the most abrasive.

QUESTION: Worse restorative material for canine restoration? Composite, gold, glass ionomer, amalgam z. Worst will be Composite > GIC> Amalgam> Gold (according to dental decks composite not given for class 3 DL in canines)

QUESTION: For a class 3 on a canine, all are appropriate except: Composite, gold inlay, amalgam, glass ionomer

CEMENT & MATERIALS

Base: 1-2 mm (replace dentin), glass ionomer, calcium hydroxide, zinc phosphate and zinc polycarboxylate Cement: 0.5 mm (cement) Liner: 5 microns (protect pulp), Dycal

Don’t use varnishes with composite because they may be disrupted by monomers

IRM: zinc oxide eugenol most common

Cements: • Zinc oxide eugenol: biocompatible, low pulpal irritation (sedative effect), good working time, bactericidal o Disadvantages: inhibits polymerization of PMMA, low strength, high solubility o IRM = ZOE + PMMA beads (strength) o Oil based o Eugenol inhibits the polymerization of composite resins CANNOT USE WITH COMPOSITE, temporary only • Zinc phosphate: easy to use, low cost, easy clean up, excellent track record o Disadvantages: pulp irritation (acidic—need varnish to protect pulp), solubility to oral fluids, no chemical bond, fast setting time o Water based o Final cementation but not as popular o mechanical • Zinc polycarboxylate: neutral pH, adhesion to tooth structure o Disadvantages: short working time, strength not as high o Water based o Final cementation of crowns and bridges o Not as strong as counterparts • Glass ionomer: high strength, adhesion to tooth structure, low solubility fluoride release o Disadvantages: sensitive to moisture in early stages, difficult clean up, correct powder/liquid important o Mostly used for final cementation of crowns and bridges o Micromechanical and chemical o Water based • Resin modified glass ionomer (compared to GI): decreased bond to dentin, increased microleakage, less sensitive to moisture, increased strength o Come in auto-mix carpules that eliminate mixing problems and now becoming material of choice for most situations • Resin: high strength, low solubility, adhesion o Disadvantages: increased shrinkage, technique sensitive, difficult clean up

Acid etch technique: conserves tooth structure, reduces microleakage, improves esthetics and provides micromechanical retention. Etch does improve marginal seal, helps in wetting enamel, cleans surface debris, created microspores (roughness of surface).

Smear layer: debris that consist of hydroxyapatite + altered denature collagen that fills the dentinal tubules. Removed by etchant.

GI cement/GI restorative--**think GI joe! He leads a double life and can be both a cement and restorative material! ● As a cement---low pH can cause sensitivity, pulp irritation, least erosive (because GI joe is super strong you can’t beat him up). ● As a restorative material---releases F, low solubility, thermal ins, similar therm expansion to tooth, chemical adhesion, biocompatible. However, GI has less surface hardness, compressive strength, and tensile compared to COMmander COMposite! aa. Components of GI CEMENT: alumina silicate and polycarboxylate bb. GI is brittle = high compressive, low tensile strength

Compomer: GI and composite modified with polyacid groups, used in low-stress-bearing areas (less wear resistant than composite but releases fluoride) Root caries and Class V. RMGI is better. • RMGI = GI with added resin | Compomer = Composite resin with added GI components.

*QUESTION: Beveling in acid etching composite: Increase surface area

*QUESTION: Etchant cleans the tooth & creates micropores for micromechanical retention.

*QUESTION: Etchant does all except: Provide chemical bond

QUESTION: What does acid etching NOT do? Decrease irregularities at cavosurface margin…increase surface area, remove debris, increase wettability of enamel

*QUESTION: What does acid etching NOT cause? Increased strength of composites…acid-etching does not cause. Reduced leakage, better esthetics

QUESTION: Etch removes the smear layer and exposed collagen fibers to form hybrid layer with resin

QUESTION: Hybrid layer - primer within intertubular dentin

QUESTION: If contamination occurs after etch, what should you do? Re-etch

QUESTION: The most unreliable etch system? Self-etch (all in 1 system – etch, prime, bond)

*QUESTION: Function of filler in resin—Strength (reduces polymerized shrinkage & increases hardness)

QUESTION: Filler composites: Larger fillers have more strength, but do not polish as well

QUESTION: Dentist who work with HEMA (methacrylate, acrylic) can have what kind of complication?

Contact dermatitis Anaphylaxis Immune mediation reaction Arthus phenomena

• Think acrylic allergy due to monomer

*QUESTION: What acid is in GI cement? silicate glass powder and polyacrylic acid

*QUESTION: Glass ionomer, what is the liquid made of? Powder = fluoroaluminosilicate glass; Liquid = polyacrylic acid

*QUESTION: Why do you use a cool glass slab? More powder incorporated, less powder incorporated, decrease working time

QUESTION: Purpose of a cool glass slab when mixing cement is: To incorporate the most powder into liquid as possible

*QUESTION: Which indicated for high caries risk or multiple class Vs? Glass Ionomer

QUESTION: What is the most practical way to seat a casting at the time of cementation? Grind the inside away since the other answer choices would be either impractical or not done at cementation

QUESTION: To make sure casting seats, do the following EXCEPT: • Increase thermal expansion of investment • Mix cement thin • Remove internal nodule with occlude

QUESTION: If you have a bubble in an impression for a crown that is not visible, what is going to happen with the crown when comes from the lab and you try to seated in the mouth? Crown does not seat

*QUESTION: Small void in die, crown was processed, what will happen? Crown will seat in die, but not on tooth

QUESTION: What won’t affect metal casting seated on master cast? Impression inaccuracies • It won’t fit the tooth but will fit the cast.

*QUESTION: You notice a void on occlusal of cast. Crown will: • Fit on die and not on tooth • Fit on tooth and not on die • Fit on both • Not fit on either

QUESTION: What do you not do if your crown doesn't fit? Don’t change the cement ratio mixture

QUESTION: Why do we lute all ceramic crowns with composite/resin? Increase strength, color stability, sealing of margins, enhance retention • Composite Resin - the luting material of choice to cement a ceramic crown and can provide the strongest bond.

*QUESTION: Why don't you use GI resin cement in cementation of all ceramic restoration? Its expansion could cause cracking of porcelain

QUESTION: Sensitivity of pulp in regards to cement, which is correct? Resin ionomer and glass ionomer cause highest pulp sensitivity • Zinc phosphate = acidic

QUESTION: Which cement is the easiest to remove after procedure? Zinc Phosphate cement

QUESTION: Zinc phosphate pH is 3.5, what is the significance of that? This might also cause pulp sensitivity

QUESTION: pH of ZOE (near 7), zinc phosphate: pH of 3.5—acidic irritates pulp

QUESTION: What component of cement contributes to adhesion? Polycarboxylic acid, benzoyl peroxide, others,

QUESTION: RMGI: What is the advantage beside fluoride release? Ionic bond between enamel and dentin QUESTION: You place a CaOH on the tooth for a direct pulp cap, what else is needed? Placement of a liner

QUESTION: Pulp capping: Use CaOH & in order to protect the pulp, put 2mm thickness of liner/base above CaOH

QUESTION: How do you improve the success of calcium hydroxide on a direct pulp cap? Place GI liner over calcium hydroxide

*QUESTION: Which procedure is most unsuccessful in primary tooth with deep caries? Direct pulp cap, indirect pulp cap, pulpectomy, partial pulpectomy, pulpotomy

QUESTION: The strength of Zinc Oxide Eugenol (IRM) can be increased by adding what? Methylmethacrylate (MMA) • Zinc oxide eugenol is IRM but there’s an extra component that makes it IRM which is the methylmethacrylate, which is an inactive ingredient.

QUESTION: What is the material in reinforced IRM that give it strength? A. amalgam powder B. Zinc phosphate C. Poly methyl methacrylate (PMMA) D. Titanium powder

QUESTION: Zinc eugenol is a good temp filling: gives a Good bacterial seal, high compressive strength, high tensile strength, good biological seal.

QUESTION: The main component of any root sealers is? Zinc oxide

QUESTION: What do you use to fill a root canal on the primary tooth? ZOE w/out catalyst/accelerator cc. Lack of catalyst gives it adequate working time to fill canals

QUESTION: Zinc phosphate cement is used as luting agent. The initial acidity may elicit a traumatic response if: a. Only a thin layer of dentin is left between cement and pulp b. Very thin mix of cement is used c. Tooth has already a previous traumatic injury d. No cavity varnish is used

A. a, c, & d B. an or d C. b only D. all of the above

QUESTION: If you add BIS-GMA to PMMA (acrylic): Increases strength or results in the doughy texture to have more working time

QUESTION: Crosslinking factor of P-MMA? BIS-GMA, benzoyl peroxide • Bis-GMMA- provides the CROSS LINK

QUESTION: Cross-linking in polymers leads to what? Better Strength

QUESTION: Addition of long cross-linking chains in PMMA is for what reason? Increase strength, allow doughy consistency before set, allow for addition of more powder without crazing, prevent shrinkage

QUESTION: By having excess amount of monomer in acrylic, it can create excessive amounts of what: Shrinkage, expansion, thermal conduction

QUESTION: Adding more monomer increases: a. Expansion b. Shrinkage c. Brittleness d. Harness IMPRESSION MATERIALS

Polysulfide: elastomeric, exothermic setting reaction, water as by product, need to be poured within 30 minutes • Advantages: long working time, flexible, tear resistant • Disadvantages: long setting time, very unpleasant odor/taste, highest permanent deformation

Alginate: H2O + Na alginate + Ca2SO4 → Ca alginate gel (insoluble) + NaSO4 • Decrease setting time: increase water temperature, mix more rapidly, decrease water to powder ratio • Imbibition: process of absorbing water that leads to alginate expansion • Syneresis: exudation of liquid component of gel that leads to alginate shrinkage • Irreversible hydrocolloid

Reversible Hydrocolloid: changes from gel to sol with application of heat and is reversible with cooling • Disadvantages: special equipment needed, must poor immediately, can only poor once, poor tear strength

Condensation silicone: elastomeric impression material that sets in a cross linking polymerization reaction and gives off by product ethanol • Disadvantages: must poor immediately, poor dimensional stability (ethanol evaporation), hydrophobic, low tear strength

Addition silicone: PVS, one of most popular crown and bridge impression material, there are no by products • Advantages: excellent dimensional stability (2 weeks), excellent surface detail, low permanent deformation • Disadvantages: hydrophobic, temperature sensitive

Polyether: elastomeric impression material • Advantages: excellent dimensional stability, low permanent deformation, hydrophilic • Disadvantages: some can be very rigid and difficult to remove, can absorb water

QUESTION: What happens when you take an impression & immediately swells? Angioedema (allergy reaction)

QUESTION: C1 inhibitors are used in angioedema to inhibit the complement system

QUESTION: Which of the following systems is thought to malfunction in the hereditary form of angioneurotic edema? A. C-1 esterase B. C-1q inhibitor C. CH50 consumption D. Serine phosphatase E. Complement synthetase

HYDROCOLLOID: QUESTION: Most inaccurate impression material? Irreversible hydrocolloid

QUESTION: If you decrease water temp what does it to do working time? Increases working time

*QUESTION: Alginate impression in 100% humidity, why will shrinkage occur? Syneresis, Imbibing, historgysm

*QUESTION: Which is not recommended for final FPD cast (or cast impression) impression? e. Reversible hydrocolloid a. Irreversible hydrocolloid b. Polysulfide c. PVS

QUESTION: Syneresis & imbibition applies to which impression material? Reversible hydrocolloid…Irreversible is not an option

*QUESTION: Which impression material tolerates moisture the most – Hydrocolloid…polyether, addition silicone, polysulfide

QUESTION: Imbibition and syneresis affect which one the most a. Reversible hydrocolloid b. impression compound c. polysulfide d. silicone

GYPSUM:

Gypsum bonded Setting Time: • Decreases water = decreased setting time • Increased temperature = decreased setting time • Vacuum mixing = decreased setting time, decreased setting expansion, increased compressive strength

QUESTION: Gypsum: If you increase water to powder ratio, you have Decrease expansion.

QUESTION: What decreases setting time of Gypsum: Decrease water: powder ratio

QUESTION: What happens if you increase water in gypsum stone? Decrease expansion and strength (b/c particles are farther apart)

QUESTION: Gypsum: If you have decrease spatula/mixing, you decrease expansion. If you have increase spatula/mixing, you increase expansion

QUESTION: Increased trituration time will increase compressive strength/Decrease setting expansion

QUESTION: Decrease setting time - increase spatulation time, increase water temperature, use of slurry water, decreases water: powder ratio

QUESTION: What happens when you increase water/powder ratio of an investment: increase thermal expansion, decrease thermal expansion, increase setting expansion...?

IMPRESSION MATERIAL:

*QUESTION: Most stable impression material or provides best dimensional quality: Additional silicones (aka PVS)

QUESTION: When pouring gypsum material into an impression, which material will cause the least amount of bubbles? Silicone…polysulfide, polyether, irreversible hydrocolloid

QUESTION: Most stability: Hydrocolloid reversible Hydrocolloid irreversible Polysulfide (polyvinyl sulfide, the smelly one) *PVS and polyether were not option

QUESTION: Polyvinyl siloxanes (PVS) gets affected by latex, sulfur in latex gloves retards the setting of PVS.

QUESTION: Polyether, disadvantage compared to other elastomeric? Sticks to teeth/hard to remove from teeth, longer working time, less accuracy

QUESTION: Which one most likely to get stuck in mouth? Polyether

QUESTION: Impressions, what’s wrong with polyether? It’s hard & engages undercuts

QUESTION: When compared to other materials, which of the following is the main disadvantage of using polyether elastomeric impression materials: is much Stiffer

QUESTION: Most rigid impression material: Polyether

QUESTION: Which is hardest one to remove from the oral cavity (STIFFEST)? Polyether

QUESTION: What material would you not use for a single crown: a) polyether b) Polysulfide c) PVS etc.

QUESTION: Which of the following is the best for tear strength – Polysulfide / polyether

QUESTION: Polysulfide gives out? Water

QUESTION: Catalyst of POLYSULFIDE impression material- Lead dioxide

QUESTION: Condensation silicone release – Ethyl alcohol as by product

QUESTION: Addition silicones (PVS) releases? H2 (as secondary reaction)

QUESTION: The most stable elastic impression in moisture environment? a. Polyether b. Additional silicone c. Condensation silicone d. Polysulfide

QUESTION: Which impression material is least distorted by water? Additional silicone (Condensation silicone better answer if available)

QUESTION: Property of interocclusal recording material? Low resistance to jaw closure

QUESTION: Why elastomer is not a good interocclusal record? Rebound when mounting

FLUROIDE

Fluoride BREAKSDOWN collagen, is bactericidal, Fluorapatite is more resistant to acid, decreases solubility of enamel, excreted by kidneys, & helps remineralize. Hydroxyapatite + Fluoride → Fluorapatite + Hydroxyl

Fluoride ions replace the hydroxyl radicals of the hydroxyapatite crystals in the enamel, producing fluorapatite, which is less soluble in catabolic acids produced by oral bacteria.

Fluorapatite has a lower critical pH of 4.5 (pH of dental enamel as 5.5) = harder to dissolve

Fluoridation: know the primary/secondary/tertiary prevention differences. dd. Primary: aims to prevent the disease before it occurs. Health education, community fluoridated water, sealants. ee. Secondary: Eliminates or reduces disease after they occur. Composite filling ff. Tertiary: Rehabilitates an individual in later stages to restore tissues after the failure of secondary prevention. Examples include gg. dentures and crown and bridge.

Fluoride Facts ■ Food and Nutrition Board recommends public water supplies be fluoridated when levels are significantly below 0.7 mg/L. ■ Fluorine intake of 20–40 mg/day can inhibit the important enzyme phosphatase. ■ Phosphatase is needed for calcium utilization/metabolism in tissues including the bones and teeth. ■ Fluorine intake of 40–70 mg/day can cause heartburn and pains in the extremities. ■ Just as fluoride will displace calcium in the body, calcium therapies are used to treat fluoride toxicity. ■ Topical fluoride does not cause fluorosis (occur in permanent and primary teeth). ■ School water fluoridation ≈ 4.5 times that of city water (≈1 ppm). ■ Fluoride deposit in calcified tissues over time. ■ Greatest concentration of fluoride at outermost layer of enamel. ■ Proximal and smooth surfaces benefit the most from fluoride. ■ Fluoride is excreted by the kidney (in form of urine and sweat, up to 3 mg/day). ■ U.S. Public Health set optimal fluoride = 0.7–1.2 ppm for public water. ■ Cariostatic effect of fluoride is at calcification stage of tooth development. ■ Fluoride converts hydroxyapatite to fluorapatite. ■ Fluoride ↓ solubility of enamel. ■ Toothpaste contain 1100 ppm of fluoride.

Fluoride Toxicity ■ Adult lethal dose = 4–5 g ■ Child lethal dose = 15 mg/kg ■ Odontogenic manifestation = fluorosis

*QUESTION: How many mg of fluoride in 1 L of water at 1 ppm: 1 mg

8QUESTION: Patient has 1 ppm fluoride in water. What is that equal to in mg/L? 1mg/L QUESTION: What ion gets replaced in hydroxyapatite by fluoride? Hydroxyl

QUESTION: least soluble - fluorapatite

*QUESTION: ***Fluoride works in all these ways except: Increases strength of collagen*** Fluoride BREAKSDOWN collagen, is bactericidal, fluorapatite is more resistant to acid attack, decreases solubility of enamel, excreted by kidneys, helps remineralize

*QUESTION: Fluoride helps prevent caries in all ways except? Lower pH of the oral cavity

QUESTION: Where does fluoride localize/accumulates? Outer enamel

QUESTION: Fluorosis does what? Inhibits remineralization hh. Fluoride induces (hypocalification), which is a characteristic of fluorosis that is caries resistant.

QUESTION: Fluoride spot makes enamel more resistant to future caries.

QUESTION: Fluoride does all the following, except? Direct action on plaque

QUESTION: How do you determine the severity of fluorosis? Look at the two worst teeth? Higher the fluoride level, greater degree of enamel change

*QUESTION: ADA recommends to apply in-office fluoride foam for how long? 4 minutes

*QUESTION: How many minutes do you place neutral sodium fluoride tray on teeth? 4 minutes

QUESTION: Fluoride supplementation is effective in: everybody, only kids, anyone but most beneficial to children.

QUESTION: At what age should supplemental fluoride be started? 6 months

*QUESTION: Minimum fluoride age? 6 months

QUESTION: What age does fluoride get incorporate into primary dentition? 4 months in utero

QUESTION: At what age does fluorosis of anterior permanent teeth occur? 4-6mo (others options: 0-4mo, 1year, 2years and 6 years)

QUESTION: Fluoride is given to children in schools usually by rinse with what concentration? 0.05 daily, 0.2 daily, 0.05 weekly, 0.2 weekly

QUESTION: How do they administer Fluoride in schools? 0.2% Fluoride rinse 1x week

QUESTION: What happens when a kid with primary teeth ingests fluoride? It affects their permanent teeth.

QUESTION: The drinking water supply of a community has a natural F level of 0.6 ppm. The F level is raised by 0.4ppm. Tooth decay is expected to decrease by what % after 7 years? 40%

QUESTION: The usual metabolic path of ingested fluoride primarily involves urinary excretion with remaining portion in? skeletal tissue

QUESTION: Where is the biggest storage of fluoride in tissues? Skeletal tissues

QUESTION: Where does fluoride work the best? A. interproximal B. Pit and fissure (I saw this somewhere and it said smooth surfaces, pit and fissure is prr/sealant) ***WORKS BEST ON SMOOTH SURFACES***

QUESTION: What is least likely to cause baby bottle caries? 1. Breast milk at night 2. Formula made with fluoridated water 3. Water with no fluoride 4. juice

QUESTION: Early Childhood Caries (ECC) are cause by all at night except? - bottle feeding with formula with fluoridated water - breast feeding - sippy cup with OJ - bottle feeding with processed water with no fluoride

QUESTION: ECC (early childhood caries) is usually in what location? a. Max incisors and molars b. Man incisor and molars c. Max canine d. Man canine and molar Primary max incisors (B&L), then primary molars, mandibular unaffected bc tongue blocks

QUESTION: What determines fluoride supplementation for a city - temperature

*QUESTION: Usual/recommended water fluoridation- 0.7 ppm

QUESTION: The appropriate/optimal amount of fluoride in the community water: 0.75-1.2 ppm

QUESTION: Fluoride – Toxic dose 5-10 mg/kg

*QUESTION: Maximum allowed fluoride in the water by EPA (Environmental protection agency)? 4.0 mg/liter (4 ppm)

QUESTION: Percentage of fluoride water in US - should be about 65-70%

QUESTION: What percentage of Americans have public fluoride in water: 66%, 85%, other lower numbers ii. CDC 2010 reports Americans have 79.6% water fluoridation

QUESTION: What is percentage of community water fluoridation- 67, 85, 35

QUESTION: Fluoridation for water: effectiveness: early studies showed that it prevents 50%-70% of caries in permanent teeth, however currently the effectiveness is 20%-40%

QUESTION: Effectiveness of Water fluoridation in the U.S. is 20%-40%

QUESTION: Fluoridation: daily use of tablet cause 30% reduction in new carious lesions

*QUESTION: Pt has a white discoloration with no sensitivity near cervical region of #29, what do you do? fill, 5% fluoride, do nothing

TYPE OF FLUORIDE:

QUESTION: What type of fluoride is in water? fluorosilicate acid (hydro fluorosilicate) – most commonly used, sodium fluorosilicate, and sodium fluoride

QUESTION: Types of Fluoride used in toothpaste: sodium fluoride, Stannous fluoride (most effective), sodium monofluorophosphate Stannous fluoride may stain.

QUESTION: What mouthwash is good for children with caries to rinse with? Sodium Fluoride (NaF)

QUESTION: What rinse is used at home for developmental disabled child to reduce of plaque? NaF, stannous fluoride, chlorhexidine

QUESTION: Which type of fluoride is not in toothpaste? Acidulated fluoride

QUESTION: What fluoride toothpaste should not be used in a patient with multiple porcelain crowns? Acidulated

QUESTION: What’s the concentration of acidulated phosphate fluoride is used in the dental office? 1.23%

QUESTION: Dentist places sodium fluoride on patient with GI fillings rather than acidulated fluoride because – acid of fluoride will wear away at GI. TRUE

QUESTION: What fluoride tx would you used in a pt with amalgams, PFM's, composite restorations, implants? 1.1% NaF

QUESTION: Pt has fillings and full porc. Crowns, but has decalcification on class V? 1.1 % NaF

QUESTION: Which one is not useful in managing caries in elderly? Use of 1.1% fluoride as a standard of care

***FLUORIDE SUPPLEMENTS:

QUESTION: A 2 y/o child has ingested 20mg fluoride pill. What will likely happen? coma, nausea, renal failure, cardiac arrest

QUESTION: How much fluoridation supplement would you give to a 5 y/o drinking 0.75ppm F in their water? 0 ppm

QUESTION: 3 y/o patient lives in area with 0.4 ppm fluoride. How much do you supplement? 0 ppm

QUESTION: 4 yrs. old patient lives in community w/ 0.25 ppm fluoride intake, what do you give? Give her systemic fluoride (0.5 mg/day) Apply fluoride Change diet to more fluoride intake Prescription fluoride rinse

QUESTION: 4 y/o pt with 0.4 ppm fluoride Supplement? 0.25mg/day

QUESTION: 4.5 y/o child with 0.75ppm fluoride in their water requires how much fluoride to be supplement? 0 mg

QUESTION: 7-year-old patient has no fluoride in drinking water. What do you give them systemically…? 5 mg, 1 mg, 0.25 mg

QUESTION: 7-year-old child lives in area with 0.2 ppm fluoridated water, what do you supplement? 1.0 mg/day

*QUESTION: Supplementation for 10-year-old with no other fluoride source? 1 mg/day or 1 mg/week?

SEALANTS

RECOMMEND AGE: Do sealant age 6-12

QUESTION: Sealants - mechanical micro retention binding to tooth

QUESTION: Contraindication of sealant: when you have rampant or gross caries

QUESTION: A child with no decay but deep pits and fissures, what is the Tx plan? Sealants

QUESTION: Patient has deep grooves but no decay on permanent molars, what do you suggest? Sealants

QUESTION: Ortho pt: has never had a restoration? What would you do? sealants, do nothing, etc. (agu put: do nothing)

*QUESTION: High caries risk patient, when is he indicated for sealants? Obvious clinical cavitation on the occlusal, deep fissures without caries

QUESTION: Pictures of molars in 16 y/o – does it need sealants, no treatment, Class I. Book says do sealant age 6-12, so no treatment most likely unless caries visualized.

NORMAL ANATOMY

QUESTION: Patient has bilateral white lines at occlusal plane, what is primary microscopic finding? Epithelial hyperkeratosis, frictional keratosis, linea alba

FORDYCE GRANULES: Fordyce granules (Sebaceous Prominence) = small, raised, pale red, yellow-white or skin- colored bumps/spots that appear on the penis shaft, labia, scrotum, or the vermilion border of the . No pathology.

QUESTION: Fordyce granules is what? Ectopic sebaceous gland

QUESTION: Fordyce granule is what? • salivary gland • sebaceous gland • sweat gland

VARICIES:

QUESTION: Varicosities in ventral tongue commonly seen in? elderly

*QUESTION: What causes varices on the tongue? Hypertension

QUESTION: Pt with bilateral asymptomatic blue stuff under tongue? a. hemangioma b. varices

STAFNE DEFECT (SALIVARY GLAND DEPRESSION DEFECT):

Stafne defect (lingual mandibular salivary gland depression, static bone cyst, stafne bone cyst) = depression of the mandible on the lingual surface. • Normal anatomical variant, as the depression is created by ectopic salivary gland tissue associated with the submandibular gland & does not represent a pathologic lesion.

QUESTION: Pano Radiograph of mandibular gland depression: Stafne defect (also called salivary bone cyst (another name for stafne bone cyst) on PAN)

QUESTION: Very well-defined round radiolucency posterior mandible below inferior alveolar canal on a panoramic static Stafne bone cyst (stafne defect)

QUESTION: X-ray of Stafne defect, only option was salivary inclusion defect

Post-Development Loss of Tooth Structure:

Attrition is wearing away from natural dentition.

QUESTION: All of the following cause xerostomia except? a. caries b. candidiasis c. dental attrition

*QUESTION: Most attrition of enamel is against what? (porcelain not an option in the answer) a) Enamel b) Amalgam c) Hybrid resin d) Microfill resin?

Attrition is tooth to tooth contact

QUESTION: All of the following reasons to restore erosion lesion except one, which one? a. prevents future erosion b. reduced sensitivity c. esthetic

You cannot prevent “future” erosion but you can prevent “further” erosion

QUESTION: What causes erosion? Chemical, gastric reflux, & Bulimia

QUESTION: Which one is a chemical cause of tooth destruction? Erosion jj. Type of wear from gastric acids: erosion

QUESTION: Abfraction (flexure of tooth) If it’s not too deep, don’t touch it. If deeper, fill with glass ionomer cement? Compomers

ORAL PATHOLOGY

BLOOD

Agranulocytosis: condition of severe neutrophil depletion (inadequate production, increased destruction) • Exposure to certain drugs (chemotherapeutics and antithyroid agents) • Congenital agranulocytosis or Kostmann syndrome (reduction in granulocyte colony stimulating factor) • Signs/symptoms: prodromal symptoms, swelling, bone pain, pneumonia • Oral signs/symptoms: punched-out ulcerations of the , tongue, and • Histopathology (oral ulcers): lack of hos inflammatory response • Treatment: remove offending drug, chlorhexidine (decrease ulcers), antibiotics for active infections

Aplastic anemia: inability to bone marrow to form adequate numbers of all types of blood cells • Cause is unknown (associated with exposure to benzene, chloramphenicol, viruses like HSV, EBV, HIV, parvovirus) • Most serious blood disorder associated with drug toxicity • Signs/symptoms: pallor, fatigue, lightheadedness, malaise, vertigo, spontaneous bleeding, bruising • Oral signs/symptoms: oral mucosa petechiae, oral ulcerations, gingival infections • Treatment: remove causative agent, antibiotics, blood transfusion, androgenic steroids (stimulate bone marrow), immunomodulatory therapy, bone marrow transplantation • Poor prognosis, 80% die within a year of diagnosis

Leukemia • Malignant neoplasm of blood forming tissues, characterized by abnormal proliferation of leukocytes, which replaces tissue in the bone marrow with leukemic cells. • Myeloid vs. lymphocytic, acute vs. chronic = 4 types o CML = Philadelphia chromosome • Associated with: Town syndrome, Blood syndrome, Klinefelter syndrome, Fanconi’s anemia, Wiskott-Aldrich syndrome o EBV, HTLV-1, benzene • Signs/symptoms: fever, fatigue, anemia, dyspnea on mild exertion, infiltration of other organs (organomegaly-liver, spleen), lymphadenopathy, thrombocytopenia (bruising and bleeding) • Oral signs/symptoms: petechial hemorrhages (hard and soft palate), , gingival hyperplasia (infiltration of leukemic cells) • Treatment: chemotherapy, radiation, supportive therapy • Prognosis depends on age and type of leukemia: o AML: 5 year 10-30% o ALL: ▪ Child 5 year 50-70% ▪ Adult 10-30% o CML: 2 year 60% (blast transformation-death shortly after) o CLL: considered incurable

Polycythemia Vera (Osler’s disease or polycythemia rubra vera): increase in blood volume and number of blood cells, cells generally function normally. Patient at higher risk for leukemia. Caner of red blood cells. • Primary: abnormal multiplication of progenitor marrow stem cell • Secondary: abnormal excess in erythrocytes due to other conditions—hypoxia, chronic pulmonary diseases, erythropoietin secreting tumors) • Signs/symptoms: headache, weakness, dizziness, dyspnea, epigastric pain, generalized pruitis, ruddy complexion, painful burning and erythema in hands and feet • Oral signs/symptoms: tongue and gingiva appear deep red, gingival bleeding and swelling, oral petechiae, ecchymoses, hematomas • Increased viscosity of blood can lead to strokes, MI, HTN, splenomegaly • Treatment: phlebotomy, hydroxyurea, aspirin

Sickle Cell Anemia: genetic hemogloginopathy, mainly African decent (1/350 of them), thymine substitution for adenine leads to valine instead of glutamic acid, need two alleles to inherit. • Signs/symptoms: dyspnea, fatigue, pallor, muscle/joint pain, “hair on end” skull radiograph, impaired kidney function, increased risk of strep pneumoniae infections • Oral signs/symptoms: dental radiograph may show enlarge marrow spaces but are typically non-specific • Treatment: supportive and prophylactic • Sickle cell crisis: infection, hypothermia, hypoxia, dehydration

NERVOUS

Bell’s Palsy: seventh nerve paralysis, acute, unilateral paralysis of muscles of facial expression • Cause: reactivation of HSV within geniculate ganglion, exposure to cold, local and systemic infections, diabetes, influenza, tooth extraction • Signs/symptoms: inability to smile/close eye/wink/raise eyebrow, drooping corner of mouth, eye tears, slurring speech, alteration of taste • Treatment: symptoms typically resolve in 1-2 months on their own, sometimes steroid and antiviral treatment, ocular antibiotics (prevent corneal ulceration)

Frey’s syndrome (auriculotemporal syndrome): results from injury to auriculotemporal nerve (sympathetic to sweat fibers in periauricular skin, parasympathetic to parotid gland) • When nerve fibers are damaged, may accidently reconnect with sympathetic fibers→sweating, flushing, warmth in preauricular and temporal areas immediately following salivary or gustatory stimulation • Minor’s start-iodine test • Treatment: surgery, local atropine injections, scopolamine creams

Glossopharyngeal neuralgia: unilateral sharp, lancinating, and severe pain in ninth cranial nerve distribution • Cause unknown • Signs/symptoms: episodic pain (ear canal, pharynx, nasopharynx, tonsils, posterior mandible, posterior tongue) • Triggers: yawning, talking, chewing, swallowing • Treatment: topical anesthetic, anticonvulsants, surgical resection of ninth nerve

Myasthenia Gravis: autoimmune disease where circulating antibodies to acetylcholine receptors irreversibly attach to the receptors. • May present with hyperplasia of thymus or thymoma • Signs/symptoms: progressive muscle weakness, diplopia, ptosis, extraocular muscular paresis weakening of muscles of mastication, dysphagia, dysarthria • Treatment: cholinesterase inhibitors, thymectomy • Cannot give them erythromycin

Trigeminal neuralgia (tic douloureux and atypical facial pain): severe pain in head and neck region (all other things ruled out) • Cause is usually idiopathic • Most frequently diagnosed neuralgia in US 4/100,000 • Abrupt onset of pain (elicited by light touch) over specific trigger point, distribution over one or more branches of trigeminal nerve, episode less than 60 seconds • Remission can last 6 months • Treatment: anticonvulsants (carbamazepine, phenytoin), local injection of alcohol or glycerin over trigeminal ganglion, local anesthetic of nerve or trigeminal ganglion, neurosurgery

TOOTH ABNORMALITIES

Amelogenesis Imperfecta: developmental, hypoplastic, hypomaturation, hypocalcified • Treatment: depends on types and degree—veneers, full coverage crowns, over dentures, full dentures • Autosomal dominant is main form, can be recessive and x-linked

Ankylosis: pathological fusing of cementum or dentin of a tooth root to alveolar bone • More common in primary teeth • Signs/symptoms: occlusal plane, radiographic absence of PDL, adjacent teeth can migrate and incline toward ankylosed tooth, opposing teeth can migrate in vertical dimension, results in over eruption • Treatment: extract if primary, prosthodontic build up in permanent, luxation of ankylosed teeth can help reestablish new PDL

Dens invaginatus (dens in dente): tooth within a tooth • Predominately affect maxillary later and central • Can erupt lateral root (cause inflammation), communication with oral cavity (increased risk for caries and pulp necrosis) • Complications related to are rare. Invagination opening can be restored to prevent caries and pulpal necrosis. Large invaginations that disrupt normal coronal formation may need to be extracted. Invaginations associated with periradicular inflammation should be restored and have the surrounding lesion surgically removed.

Dentin Dysplasia: loss in organization of dentin in primary and permanent teeth. • Autosomal dominant • 2 types (I and II) o Type I (“rootless teeth”): normal coronal enamel and dentin, roots shortened due to disorganized radicular dentin, teeth mobile, premature exfoliation radiographically pulp chambers of primary teeth obliterated and permanent teeth appear crescent shaped o Type II: resembles dentinogenesis imperfecta in that root length is normal, but, crowns are blue brown translucence, bulbous, and have cervical constriction, radiographically primary teeth have obliterated pulp and permanent teeth have thistle tube and contain pulp stones • Treatment: very good OH to prevent periodontitis

Dentinogenesis imperfecta: autosomal dominant, affects formation of dentin, may be seen with osteogenesis imperfecta • Signs/symptoms: blue brown discoloration/translucence, bulbous crowns with cervical constriction, early obliteration of pulp and canals, shell tooth appearance (normal enamel, thin dentin, large pulp chamber), root canals may develop microexposures (periapical inflammation, cervical fractures more common • Treatment: Full coverage of teeth with close to normal shaped crowns and roots, overlay denture

Hypercementosis: excess deposition of cementum on normal radicular cementum • Causes: occlusal trauma, adjacent inflammation, Paget’s disease of bone, unopposed teeth, acromegaly, calcinosis, arthritis, goiter • Signs/symptoms: thickening/blunting of roots, intact lamina dura, PDL present, predominantly in adults • No treatment required

Internal and External Root Resorption: • Internal causes: trauma, caries to pulp • External causes: trauma, orthodontic therapy, increased occlusal forces, periradicular inflammation, periodontal treatment, cysts, tumors • Internal resorption = pink tooth of Mummery • Treatment: remove tissue from sites of resorption o Internal: endodontic therapy o External: eliminate etiologic factors, remove soft tissue near resorption site, restore tooth structure

Supernumerary teeth (): cleidocranial dysplasia, Gardner, Sturge-Weber, Hallermann Streiff, angio-osteohypertrophy, and Curtius • Most often single teeth in permanent maxillary dentition incisor region (“mesiodens”) • Multiple supernumerary teeth are frequently found in the mandibular premolar region of mandible • Can lead to delayed eruption of normal teeth, crowding, (predispose to gingival inflammation and periodontitis) • Treatment: early removal of supernumerary teeth

Stained teeth: • Congenital erythropoietic porphyria = reddish-brown • Hyperbilirubinemia = green, grayish-blue • Dentinogenesis imperfecta = gray, bluish-brown, translucent or opalescent • Fluorosis = opaque white, yellow brown • Medications (tetracycline) = bright yellow, dark brown, green, gray, black

Clefting: • Cleft lip: medial nasal process and maxillary process o Complete = lip + alveolar arch o Incomplete = lip • Cleft palate: palatal shelves • Causes: syndromic, genetic, environmental factors • Males: cleft lip with or without cleft palate • Females: cleft palate • Treatments: rule of 10 o Primary lip closure first few months of life o Palate repair 12-18 months o Interceptive orthodontics 5-7 years o Bone grafting 9-11 years o Comprehensive orthodontics and orthognathic surgery 12 years

Cleidocranial dysplasia (dysostosis): disease of bones of skull and clavicle • Autosomal dominant • Signs/symptoms: short stature, large head with frontal bossing, ocular hypertelorism, hypoplastic midface, mobility of shoulders due to hypoplastic clavicles, high arches palate, increased prevalence cleft palate, prolong retention of primary dentition, unerupted teeth and supernumerary teeth present, narrow ascending ramus and pointed coronoid process • Treatment: none medically, dentally possible extractions, ortho, surgical exposure of permanents, orthognathic

Cherubism: posterior mandibular swelling and plump cheeks • Autosomal dominant • Signs/symptoms: painless bilateral mandibular expansion, typically at angle and rami, maxillary involvement of the tuberosities, developing teeth often displaced and fail to erupt, bilateral multilocular radiolucencies in mandible, histopathology similar to giant cell granuloma, well vascularized tissue with multinucleated giant cells • Treatment: some have remission and involution after puberty, some grow rapidly, definitive treatment not established

METABOLIC JAW DISEASES

Osteopetrosis: defect in osteoclastic bone remodeling and results in abnormally increased bone density • Infant type = autosomal recessive o Signs: broad face, hypertelomerism, frontal bossing, flattened nose, increased susceptibility to infections, narrowing of skull foramina (blindness, facial paralysis, deafness), pathologic fractures, anemia, hepatosplenomegaly, radiographic loss of cortical and cancellous bone distinction o Dentally: delayed tooth eruption, susceptibility to osteomyelitis after extractions o Poor prognosis, usually death by 20 • Adult type = autosomal dominant o Milder form o Less anemia, blindness, deafness, facial paralysis due to narrowing of the skull foramina, fractures, osteomyelitis and fracture of mandible can still occur • No definitive treatment, just supportive (antibiotics, blood transfusions)

Osteogenesis imperfecta: inherited connective tissue disease that results from impaired collagen synthesis • Type I = autosomal dominant, mild-moderate bone fragility, hearing deficits, blue sclera, opalescent dentin (DI) • Type II = autosomal recessive + dominant, extreme bone fragility, frequent fractures, 90% still born, blue sclera, DI • Type III = autosome recession + dominant = severe bone fragility, blue sclera, increase child mortality, DI • Type IV = autosomal dominant, mild-moderate bone fragility, fracture at birth, blue sclera, opalescent teeth • No curative treatment. Treat teeth.

ENDOCRINE

Hypoparathyroidism: decrease in PTH • Causes: congenital, iatrogenic, infiltration of parathyroid glands, suppression of parathyroid, HIV/AIDS, idiopathic • Level of calcium in body controlled by PTH; PTH acts on osteoclasts to resorb bone to increase levels of calcium in blood • Signs/symptoms: hypocalcemia, Chvostek’s sign (twitching upper lip when facial nerve tapped), pitted enamel hypoplasia, failure of tooth eruption • Treatment: oral vitamin D precursor, supplementary calcium

Hyperparathyroidism: increases PTH • Causes: tumor of parathyroid, parathyroid hyperplasia, chronically low levels of calcium o Primary: parathyroid adenoma or hyperplasia, parathyroid carcinoma o Secondary: chronic low levels of calcium • Signs/symptoms: kidney stones, resorption of index and middle finger bones, ground glass appearance of trabeculae, duodenal ulcers, confusion, lethargy, dementia • Oral signs/symptoms: loss of lamina dura around roots • Brown tumor of hyperparathyroidism: with persistent hyperparathyroidism o Osseous lesion, well circumscribed (unilocular or multilocular), mandible, clavicle, ribs, pelvis, histologically similar to central giant cell granuloma • Primary is treated surgically; secondary from renal failure is treated with vitamin D or renal transplant

Hyperthyroidism: excess production of thyroid hormone • Causes: thyroid tumors, hyperplastic thyroid tissue, autoimmune stimulation (Grave’s disease), pituitary adenomas • Females more frequent • Signs/symptoms: thyroid enlargement, increased metabolic rate (weight loss, tachycardia, warm skin, heart palpitation, tremors, heat intolerance), protrusion of the eyes, lid lag and lid retraction, elevated thyroid stimulating hormone levels and thyroxine (T4) • Thyroid storm: uncontrolled, can lead to delirium, elevated temperature, tachycardia, death • Treatment: radioactive iodine, propylthiouricil, methimazole, surgery

Hypothyroidism (cretinism-infant, myxedema-adult): low levels of thyroid hormone • Causes: Hashimoto’s thyroiditis (autoimmune destruction of thyroid gland) o Primary: inadequate production of thyroid hormone because abnormality of the gland itself o Secondary: result of inadequate release of TSH by pituitary gland (often seen after radiotherapy for brain tumors) • Signs/symptoms: lethargy, dry/coarse skin, swelling of face/extremities, bradycardia, decrease body temperature, skin feels cool, thickened lips, enlarges tongue, failure of tooth eruption, impaired tooth formation • Treatment: levothyroxine

Acromegaly: excessive production of growth hormone due to functional pituitary adenoma, results in continued growth despite closure of epiphyseal plates • Signs/symptoms: hypertension/heart disease, peripheral neuropathy, arthritis, excessive sweating, headaches/visual disturbances, growth in hands/feet/skull/jaws (mandibular ), coarse facial appearance, hypertrophy of soft palate, , anterior open bite, decreased interdental spacing • Treatment: remove tumor, radiation therapy, octerotide (somatostatin analogue) if can’t do surgery

Paget’s Disease of Bone: abnormal resorption and deposition of bone, bones become weak and distorted as a result of dysfunction in bone remodeling • Signs/symptoms: bone pain, bones enlarge, bowing of legs (simian stance), increased head circumference, maxillary > mandibular (increased interdental spacing), decrease bone density and trabeculation, cotton wool appearance, , increased bone vascularity (warm), increase alkaline phosphatase, osteosarcoma • Treatment: analgesics, re-eval for dentures, calcitonin and bisphosphonates (PTH antagonists—reduce bone turnover)

Scleroderma (systemic sclerosis): relatively rare, excessive deposition of collagen in various tissues, may be immunologic • Signs/symptoms: pulmonary fibrosis, cor pulmonale, acute renal failure, malignant hypertension, tight mask-like facies, microstomia (small mouth), • Oral: loss of attached gingival mucosa, gingival recession, dysphagia, PDL widening, resorption of posterior ramus of mandible/coronoid/condyle, inelasticity of mouth • Treatment: steroids, D-penicillamine (inhibit collagen production, esophageal dilation, calcium channel blockers (Raynaud’s) • Women, adults

CREST syndrome: mild variant of scleroderma, calcinosis cutis, Raynaud’s, esophageal dysmotility, sclerodactyly, telangiectasias (on tongue) • Signs/symptoms: o Calcinosis cutis = multiple movable non tender subcutaneous nodules o Raynaud’s = hands and feet become white (when cold) can become blue, upon warming turns red may be painful • Treatment: similar but less aggressive than scleroderma

INFLAMMATORY JAW LESIONS

Periapical abscess: purulent, sensitive to percussion/palpation, swelling • If in area of maxillary lateral incisors or palatal roots→drains toward palate • Mandibular second and third molar drain through lingual cortical plate • Typically perforate buccal plate when they do • Headache, malaise, fever, chills • Treatment: extraction, RCT, analgesics, antibiotics (severe cases)

Periapical granuloma: chronically inflamed granulation tissue at apex of non vital teeth secondary to presence of bacteria in root canal • May appear after periapical abscess gone, and may turn into periapical cysts • Oral: well circumscribe, pain/sensitivity may or may not be present, sometimes root resorption • Treatment: RCT or extraction, after RCT monitor 1 and 2 years; if doesn’t resolve, biopsy and apicoectomy

Osteomyelitis: inflammatory process involving medullary space of bone usually from bacterial source (chronic odontogenic infections) • Associated with ANUG • Risk factors: immunocompromised, decreased bone vascularity, chronic systemic diseases o Decreased bone vascularity: radiation, osteopetrosis, Paget’s disease • Signs/symptoms: acute—pain, fever, leukocytosis, lymphadenopathy, soft tissue swelling, sensitivity to palpation, ill defined radiolucency, chronic—pain, swelling, sinus formation, sequestration formation, purulence, pathologic fractures, patchy/ragged/ill defined radiolucencies with surrounding radiodensity, onion skin • Males, mandible • Treatment: antibiotics, drainage, surgical intervention, remove infected/necrotic bone, replace bone, immobilize jaw, hyperbaric chamber

Condensing Osteitis (sclerosing osteomyelitis): bony sclerosis around roots of teeth with associated pulpal infection • Children and young adults • Localized radiodensity around teeth roots with thick PDL • Mostly mandibular premolars and molars • Treatment: extraction or RCT

CONNECTIVE TISSUE LESIONS

Pyogenic granuloma (pregnancy tumor): vascular proliferation • Females • Frequently on gingiva as overgrowth, well vascularized fibrous connective tissue secondary to irritation or trauma, can be anywhere on body • Treatment: local surgery down to bone, remove local sources of irritation • Fast growing • Doesn’t blanch?

Peripheral Ossifying Fibroma: reactive fibrous proliferation • Exclusively on gingiva, nodular mass from papilla, usually anterior maxilla, red to pink, can be ulcerated, typically small <2cm, younger population, teeth typically not affected • Treatment: excision, remove irritation • Reveals bone formation microscopically

Malignant melanoma: chronic sun damage, light hair/skin, sunburn easy, family history • Four types: superficial spreading (most common), nodular (poor prognosis), lentigo maligna (elderly, midface), acrolentiginous (darker individuals, hard palate, gingiva, alveolar mucosa) • Treatment: surgical excisions, radial excision

DISEASES WITH

Peutz-Jeghers syndrome: freckle-like spots on hands, oral (buccal, labial, tongue, vermillion border), anus, genitals. • Intestinal polyposis (non cancerous) can lead to cancer • Autosomal dominant • Treatment: GI specialist

Addison’s disease (primary hypoadrenocorticism): insufficient production of corticosteroids from adrenal cortex due to destruction • Causes: autoimmune, infection (TB, fungal, AIDS), metastatic tumor, sarcoidosis, hemochromatosis • Signs/symptoms: fatigue, depression, weakness, hypotension, irritability • Oral: patch brown macula pigmentation on oral mucosa • Bronzing and hyperpigmentation of skin (sun exposed areas)—stimulation of melanocytes from increased ACTH levels • Treatment: corticosteroid replacement, may need to increase for oral surgery

McCune-Albright Syndrome: affects 3% of patients with polystotic fibrous dysplasia • Signs/symptoms: café au lait pigmentation, pigmented macules on oral mucosa (irregular margins) (lower lips, buccal mucosa, gingiva, palate • Treatment: same as fibrous dysplasia • Twice as common in females • Treatment: no treatment for lip lesions, lesions intraoral mimic melanoma and should be biopsied

RED AND BLUE LESIONS

Erythroplakia: not a diagnosis • Often premalignant or malignant (more than ) • Often found with severe dysplasia or carcinoma in situ

Media rhomboid : erythematous patch on dorsum of tongue anterior to circumvallate papillae (atrophy of filiform); pain or no pain; due to candidiasis

Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease): profuse and often recurrent nosebleeds, multiple telangiectasias in nasal mucosa/face/extremities, and GI bleeding • Autosomal dominant • Oral: small blanchable reddish-purple papules on lips, tongue, buccal mucosa, palate, gingiva

Hemangioma: benign proliferation of blood vessels that gradually disappear on their own • Females, birth/childhood • Flat or raised, red or blue, lips/tongue/buccal mucosa • Three subtypes: capillary (red/purple, spontaneous involution), cavernous (dark purple/blue, deeper structures, no regress), arteriovenous malformation (dark purple/blue, bruit and thrill) • Treatment: none, larger ones can use corticosteroid, arteriovenous malformation should not be excised but rather treat with embolization

WHITE LESIONS

Leukoplakia: cannot be rubbed off, not a diagnosis • Cause: tobacco, UV radiation, microorganisms, trauma, alcohol • Lesions that present as it: , frictional keratosis, tobacco pouch keratosis, nicotine , , morsicatio (chronic mucosal cheek trauma), epithelial dysplasia, SCC • Can be anywhere, cancer more likely lateral tongue, vermillion border, floor of mouth • Males, age 60 • Often show epithelial dysplasia, premalignant, SCC

Dysplasia: enlarged nuclei, prominent nucleoli, increased nuclear: cytoplasmic ratio, hyperchromatic nuclei, pleomorphic cells and nuclei, increased mitotic figures, dyskeratosis and keratin pearls, loss of cellular cohesion

White sponge nevus (familial epithelial hyperplasia or Cannon’s disease): • Autosomal dominant: keratin 4 and keratin 13 genes • Bilateral white/rough surface lesion caused by epithelial thickening of the buccal mucosa • No treatment

Hairy tongue: accumulation of keratin on filiform papillae with decrease in keratin desquamation • Causes: smoking, mints, mouth rinses, candies • Midline dorsum of tongue, just anterior to circumvallate papillae • No treatment

Oral candidiasis: fungal infection, Candida albicans, two types (yeast and hyphae) • Immunosuppression or oral flora disturbance (chronic antibiotic use) • Periodic acid-Schiff staining and KOH preparation • Treatment: nystatin (swallow), imidazole agents (clotrimazole-troches or ketoconazole-systemic), triazole agents (fluconazole-systemic) • Many types: pseudomembranous, erythematous, angular , hyperplastic, central papillary atrophy, denture stomatitis

VERRUCAL PAPILLARY LESIONS

Papilloma: benign epithelial lesion related to HPV (6 and 11), typically not malignant • Soft painless lesion, pedunculated with cauliflower like surface • Treatment: conservative surgical excision

Verruca vulgaris: virally induce squamous proliferations by HPV (2, 4, 40) • Contagious and spreads • More common on skin than oral mucosa • Typically, in children • Treatment: conservative excision

Verruciform xanthoma: hyperplastic condition with lipid laden histiocytes within oral cavity • True etiology unknown • Frequently on gingiva and alveolar tissue • Well-demarcated, soft, painless, sessile, slightly elevated mass • White, yellow-white, or red • Papillary or roughened texture • Usually small (<2 cm) • Treatment: conservative excision

Inflammatory papillary hyperplasia (denture papillomatosis): reactive tissue growth under dentures (ill fitting mainly) • Hard palate, mandibular alveolar ridge, surface of fissuratum, erythematous, pebbly surface, denture sore mouth • Treatment: remove denture, excision, cryosurgery, curettage • Combination syndrome

Inflammatory fibrous hyperplasia (): tumor like hyperplasia of fibrous connective tissue, frequently associated with flange of ill fitting denture • Folds of hyperplastic tissue, facial aspect of alveolar ridge, erythematous or ulcerated, size varies • Treatment: surgical removal, remake dentures

ODONTOGENIC CYSTS

Eruption cyst: soft tissue counterpart to dentigerous cyst, occurs in soft tissue overlying alveolar bone • Soft, translucent swelling in gingiva, associated with eruption (primary and permanent), commonly mandibular molar, if traumatized can be brown/blue • No treatment, erupts on its own

Dentigerous cyst: most common type of , encloses crown of unerupted tooth, attached to tooth at CEJ • Mainly maxillary third molars followed by maxillary canines • Younger patients, small are asymptomatic, large can have painless bone expansion, extensive cause facial asymmetry, some can be painful, infected, swollen • Unilocular radiolucency • Types: central, lateral, circumferential • Root absorption in adjacent teeth • Not diagnosed by radiograph • Epithelial lining can undergo neoplastic transformation to Ameloblastoma, SCC, or intraosseous • Treatment: enucleation, remove associated tooth, ortho, marsupialization and excision later

Odontogenic keratocyst (OKC): cyst arising from cell rests of dentinal lamina • Benign neoplasms • Men, small asymptomatic, large pain/swelling/drainage • Well defined radiolucent with small corticated margins (unilocular or multilocular) • Multiple seen in nevoid basal cell carcinoma syndrome (Gorlin syndrome) • Treatment: enucleation, curettage, possible malignancy • Tends to recur

Nevoid basal cell carcinoma syndrome: Gorlin syndrome • Autosomal dominant • Basal cell carcinomas (cheek, upper eyelids, nose, trunk), palmar and plantar pit, hyperkeratosis palms and soles, epidermal cysts/lipomas/fibromas, multiple OKC’s, bifid ribs, kyphoscholiosis, calcification of falx cerebri • Treatment: enucleation, most anomalies not life threatening

Periapical cyst (radicular cysts)

NONODONTOGENIC CYSTS

Developmental cyst: nasolabial cyst, median alveolar cyst (), (pear shape between maxillary lateral and canine, teeth vital), nasopalatine duct cyst (males), median palatal cyst

Congenital cyst: thryoglossal duct cyst (foramen cecum→thyroid gland, midline of neck, floor of mouth, tongue, near thyroid cartilage), brachiogenic cyst (anterior border of SCM), dermoid and epidermoid cysts (compressible, floor of mouth, submandibular and sublingual areas—sebaceous glands/hair follicles/sweat glands—enucleation—recurrence rare)

PSEUDOCYSTS

Traumatic bone cyst: “idiopathic bone cyst” “simple bone cysts” “latent bone cyst” • Intramedullary hemorrhage from trauma (blood clot liquefies and leaves empty space) • Cyst scalloped margins between roots of teeth • Asymptomatic, posterior mandible, well circumscribed radiolucency with scalloped margin • Treatment: curettage

Aneurysmal bone cyst: lesion of jaw that contains blood filled spaces surrounded by fibroblastic connective tissue containing giant cells and osteoid trabeculae • Well circumscribe soap bubble lesion • Mandibular expansion/ballooning • 30 years or younger • “blood soaked sponge” • Treatment: aggressive curettage, recurs rarely

VESICULOBULLOUS DISEASES

Apthous ulcers: “recurrent ” • Possible causes: allergic reaction, genetic predisposition, hematologic abnormalities, infectious agent, nutritional imbalance, stress,, trauma, hormonal influences • Non-keratinized mucosa • Recurrent aphthous major, recurrent aphthous minor, recurrent herpetiform • Treatment: topical and systemic corticosteroids

Pemphigus vulgaris: immune mediated vesiculobullous disease • Adults, male=female • Nikolsky’s sign (rubbing of uninvolved mucosae creates a blister) • Tombstone, Tzanck cells, IgG and IgM autoantibodies, desmosomes • Treatment: steroid and immunosuppression (azathioprine); fatal if not treated

Pemphigoid: autoantibodies target basement membrane, benign mucous membrane pemphigoid (cicatricial pemphigoid) is form seen in oral cavity. • Vesicles and ulcerations of skin, conjunctive of eye, nose, pharynx, esophagus, larynx • Nikolsky sign may be present • Gingival involvement (diffuse erythema) • Cicatricial (heal with scarring outside oral cavity, no scarring in oral cavity) o Ocular: subconjuntival fibrosis, adhesions, scarring (blindness) • Subepithelial, IgG and C3 • Hemidesmosomes, basement membrane

Lichen planus: cytotoxic cell mediated hypersensitivity • May be associated with hepatitis C • Two forms: reticular (most common, asymptomatic, Wickham’s striae) and erosive • Degeneration of basal cell membrane, “band like” lymphocytic infiltration adjacent to epithelium, saw tooth rete pegs, Civatte bodies • None is asymptomatic, topical/systemic steroids for symptomatic

Erythema multiforme: reactive in nature, skin of face and oral lesions • Causes: drugs (sulfa), vaccinations, viral infections (HSV) • Two forms: minor (most often HSV) and major (Stevens-Johnson syndrome—conjunctiva and genitalia) • Toxic epidermal necrolysis • “Bulls-eye” “target” lesions • Crusty bleeding lips • Females • 1/3 mortality • Treatment: topical/systemic corticosteroids and acyclovir

INFECTIOUS VESICULOBULLOUS DISEASES

Group A coxsackievirus: and hand, foot, mouth disease • Herpangina: ulcers/vesicle on soft palate/uvula/anterior tonsillar pillar, resolves in several days, fever, sore throat, vomiting, diarrhea, lymphadenopathy • Hand foot mouth: vesicles/ulcers throughout oral cavity, macules/vesicles on hands and feet, oral lesions resemble herpangina but can be larger • Treatment: symptomatic

Acute herpetic gingivostomatitis: primary herpes, HSV 1 or 2, children and adults • Malaise, fever, lymphadenopathy, vesicles in oral cavity, gingival swelling/erythema, can remain latent, reactivation with UV exposure/trauma/immunosuppression • = secondary herpes • Treatment: acyclovir, symptomatic

Varicella Zoster: chickenpox (primary) (secondary—unilateral unless immunocompromised) • Treatment: supportive, avoid ASA in children—Reye’s syndrome, vaccine

INFECTIOUS DISEASES

Actinomycosis: gram positive anaerobic bacteria • Wooden induration with central soft spot • Sulfur granules in pus • Spread does not follow fascial planes and lymph channels • 6-12 weeks antibiotics (penicillin or tetracycline)

Histoplasmosis: most common systemic fungal infection, bird and bat feces • Coin lesion (x-ray), similar to TB • Gingival: chronic proliferative granulomatous tissue lesions, painful or asymptomatic • Amphotericin or imidazoles

Syphilis: STD, treponema pallidum, direct or vertical transmission • Primary and secondary stage contagious • condyloma lata, lues maligna, gumma (large tissue ulcerations), leutic glossitis (atrophy/loss of dorsal tongue papillae), neurosyphilis (psychosis dementia, death) • Congenital syphilis: saddle nose, high arched palate, frontal bossing, short maxilla o Hutchinson’s triad ▪ Hutchinson’s teeth: screw driver like incisors, mulberry molars ▪ Interstitial keratitis: inflammation of corneal stroma ▪ 8th nerve deafness • Treatment: primary and secondary—benzathine penicillin IM, tetracycline or doxycycline 14 days if penicillin allergy, neurosyphilis—IV penicillin

BENIGN NEOPLASMS AND TUMORS

Traumatic neuroma benign soft tissue neoplasm, trauma to peripheral nerve (denture on mental nerve), smooth surface non ulcerate modules with pain

Multiple endocrine neoplasia: autosomal dominant or spontaneous mutation • MEN type I: panaceas, parathyroid, pituitary tumors • MEN type II: medullary carcinoma thyroid, pheochromocytoma, parathyroid gland hyperplasia • MEN III: pheochromocytoma, oral and intestinal ganglioneuromatosis (mucosal neuromas), 18-25 years old, metastasis higher, death by 21, marfanoid habitus

Neurilemoma (Schwannoma): benign encapsulated soft tissue neoplasm, Schwann cells, raised/freely movable nodule on sympathetic, peripheral, or cranial nerves (8th), Antoni A (Verocay bodies) and Antoni B (randomly arranged)

Neurofibroma: peripheral nerve neoplasm, Schwann cells and perineural fibroblasts, solitary or part of neurofibromatosis type I or von Recklinghausens disease

Neurofibromatosis Type I: autosomal dominant, chromosome 17, most common type is type I (Recklinghausen’s disease) • Multiple well circumscribed raised nodules (neurofibromas) of face, trunk, extremities • Neurofibromas can be found intraorally • Café-au-lait spots • Axillary freckling, lisch nodules in iris, possible malignant transformation

Fibroma: common benign soft tissue neoplasm on buccal mucosa and lower lip, hyperplastic fibrous tissues, first asymptomatic nodules, no treatment

Congenital epulis of newborn: cause unknown, lesion on alveolar ridge of maxilla in newborns, pink-red smooth surface, near canine and incisor area, females more, surgical excision (no recurrence), tumor stops growing after birth and may diminish in size

Lipoma: benign soft tissue tumor of fat tissue • Adults • Buccal mucosa, tongue, floor of mouth • Sessile or pedunculated yellow nodules and soft to palpation • Conservative local excision. Recurrence rare

Osteoma: benign tumor of mature compact or cancellous bone • Periosteal (surface of bone), endosteal (within bone) • Gardner’s syndrome (autosomal dominant)—multiple osteomas in jaws o Intestinal polyposis (100% malignant potential)—colectomy needed o Multiple endosteal osteomas of jaws (angle of mandible) o Osteomas in long bones and facial bones o Fibromas of skin o Epidermal cysts o Impacted teeth o • Males, asymptomatic, slow growing • Well circumscribed sclerotic radiopaque masses • Surgical excision, recurrence rare

Central giant cell granuloma: • Mostly asymptomatic • Nonaggressive lesions: few to no symptoms, slow growth, no root resorption or cortical perforation, low recurrence • Aggressive: pain, rapid growth, root resorption, cortical perforation, recur • Unilocular or multilocular well circumscribed radiolucency found in anterior mandible • Curettage, resection and reconstruction for aggressive, intralesional steroid injections, calcitonin subcutaneous injections, alpha interferon subcutaneous injections

FIBROOSSEOUS DISEASES

Ossifying fibroma: well circumscribed mixed density, 30-40 years old, slow growing, asymptomatic, females, treat by enucleation, surgery with bone graft, good prognosis, recurrence rare, low malignant potential

Fibrous dysplasia: fibro-osseous disease, ground glass, monostotic, polystotic, Albrights syndrome (multiple lesions, hyperpigmentation, endocrine disturbances—precocious puberty and or hyperthyroidism, craniofacial) • Painless swelling, poorly define, compression nerves and blood vessel, maxilla more, mandibular form does not cross midline, females, tooth displacement

Cemeto-osseous dysplasia: most common form of fibro osseous disease, may be sure to trauma • Periapical COD: lucent, opaque, mixed in periapical regions, vita teeth, anterior mandible, African American females • Focal COD: asymptomatic, lucent with opacities, edentulous area, mandible, abnormal healing after extractions, small • Florid COD: African American females, painless non expansive lesion, to or more quadrants, multiple confluent lobular opacities in tooth bearing area, cortical expansion absent • Surgical recontouring

DISEASES OF THE BONE

Langerhans cell disease: dendritic cells, antigen presenting, “Langerhans cell histiocytosis” “Histiocytosis X”—“Letterer-Siwe disease” and “Hand Schuller Christian disease” and “eosinophilic granuloma” • Eosinophilic = chronic localized o Cupped out radiolucency, mandible • Letterer-Siwe = acute disseminated o Young children, skin/bones/internal organs—lung and liver, fatal • Hand Schuller Christian = chronic disseminated o Males, punched out lesions skull and jaws, exophthalmos, diabetes insipidus, 20-30 years old, radiolucenies at apices of teeth “floating teeth” • Chemotherapy, curettage, intralesional steroid injections, radiation

MALIGNANCIES AFFECTING THE JAW

Multiple myeloma: proliferation of neoplastic plasma cells, plasmacytomas, IG heavy or light chain • Great than 50, blacks, male • Anemia, infections (S. pnemo, H. flu), bone pain, renal insufficiency, pathologic fractures, amyloidosis • Multiple punches out radiolucencies, soap bubble • IgG, free kappa, lambda light chains (Bence Jones proteinuriea) • Treat with thalidomide, chemotherapy, autologous stem cell transplantation for young patients

Squamous cell carcinoma: majority of oral cancers, the remainder are salivary gland , metastatic tumors, sarcomas, melanomas, lymphomas • HPV 16, 18, 31, 33 • Plummer Vinson syndrome • Lower lips, lateral or ventral tongue, floor of mouth, soft palate • Lip = 90% 5 year • Posterior tongue poor prognosis • Floor of mouth: 67% 5 year if local, 20% 5 year if metastasis • Gingival: 40% 5 year local, 10% 5 year metastasis • Surgical resection, radiation, chemotherapy, antimetabolies, alkylating agents, antibiotics, vinca alkaloids o Radiation <45 Gy or 4500 rads low risk ORN o Radiation >65 Gy or 6500 rads high risk ORN • 70% 5 year local, 15% 5 year metastasis

Verrucous carcinoma: chewing and smokeless tobacco, rarely metastasize, associated with SCC (10-15%), surgical excision, radiation contraindicated

Proliferative verrucous leukoplakia: progressive form of leukoplakia that responds poorly to treatment • Females, spread slowly, multiple sites, flat then exophytic, hyperkeratosis to dysplasia to verrucous hyperplasia to then SCC, no effective treatment

Ewing’s sarcoma: fourth most common malignancy, neuroectodermal origin, rarely in jaws, white males, 5-25 years, intermittent pains, swelling, fever, anemia, leukocytosis, radiolucent lesion onion skin, resection/radiation/aggressive chemotherapy

Osteosarcoma: osteoid neoplasm, second most common malignant neoplasm of bone, sunburst, painful swelling, loose teeth, paresthesia, nasal obstruction, epistaxis, pathologic fractures, ulceration over lesion, mixed radiolucent/opaque, symmetric PDL widening, elevated alkaline phosphatase, radial resection and chemotherapy/radiation therapy

Kaposi’s Sarcoma: malignant soft tissue tumor, HIV associated, vascular origin, human herpes virus 8, black, Russia, Poland, Italy • Patches/plaque/nodules, skin of lower extremities, oral in immunocompromised, treat with antiretrovirals for HIV chemotherapy/radiation/intralesional vinblastine/liquid nitrogen cryotherapy

ODONTOGENIC TUMORS

Ameloblastoma: most common odontogenic tumor, odontogenic epithelium, enamel organ/epithelial lining of odontogenic cyst, basal layer of oral mucosa, locally aggressive, bony expansion, conventional solid, multicystic types, slow growth, unilocular or multilocular lucency with well defined borders, variants (unicystic and plexiform unicystic, peripheral, ameloblastic carcinoma, malignant ameloblastoma

Odontogenic myxoma: most common odontogenic tumor of mesenchymal origin, posterior mandible, honeycombed, lesions cross midline, wide local excision

Odontogenic fibroma (central odontogenic fibroma): mesenchymal origin, uncommon, females, maxilla anterior, posterior mandible, root resorption

Cementoblastoma: benign neoplasm, cementoblasts, radiolucent rim around radiolucent/radiopaque lesion, slow growing, expansion of bony cortex, surgical excision

LAB VALUES: http://www.aapd.org/media/Policies_Guidelines/RS_LabValues.pdf

QUESTION: Mobile mass initially but is now sessile (fixed): Indicative of malignancy

*QUESTION: Metastasis is most common to Posterior mandible.

QUESTION: Discrete, non-tender, soft tissue swelling, what is it – Benign tumor, malignancy, bone cancer

QUESTION: What is usually seen with affected hypertrophic filiform papillae? Hairy tongue

QUESTION: Causes of Hairy tongue? Antibiotic, corticosteroid, hydrogen peroxide

• Mostly in heavy smokers, poor oral hygiene, general debilitation, hyposalivation, radiotherapy, fungal/bacterial overgrowth, certain meds.

QUESTION: Which of the following is seen with hyperplastic (or was it associated with) foliate papilla: hairy tongue, Lingual tonsil hyperplasia, median rhomboid glossitis, lymphadenopathy

QUESTION: Hyperplastic lingual tonsils may resemble which of the following? a. Epulis fissuratum. b. Lingual varicosities. c. Squamous cell carcinoma (?) d. Median rhomboid glossitis. e. Prominent fungiform papillae. (foliate papillae, not fungiform papillae)

*QUESTION: Loss of filliform papilla- Vitamin B deficiency

QUESTION: Bilateral swelling of parotid cannot be caused by: Anorexia

• Bilateral usually caused by infections. Unilateral - sialoliths or obstruction.

QUESTION: Brush tongue to reduce odor. It removes biofilm, which can be associated with overgrowth of bacteria due to meds.

*QUESTION: Transillumination of soft tissues is useful in detecting which of the following problems in a child? , Koplik’s spots, aortic stenosis, sickle cell disease

*QUESTION: Baby with nodules on the palatal, what is it? • Bone nodules • Epstein pearls • • Bohn nodule (hard/soft palate)

• Epstein pearls are whitish-yellow cysts that form on the and roof of the mouth in a newborn baby.

*QUESTION: Neonate with numerous nodules on alveolar ridge. What is it? o Eruption cyst o Bohn’s nodule o Congenital cyst of newborn

• Bohn’s nodule (keratin-filled cysts of salivary gland origin, on junction of hard/soft palate + buccal/lingual of dental ridges, away from midline)

SYPHILIS:

Congenital syphilis presentation consists of 3 phenomena (Hutchinson triad): interstitial keratitis, Hutchinson incisors, and 8th nerve deafness.

QUESTION: Indents on incisal edge with narrowing at mesial and distal? Congenital syphilis (Hutchinson’s incisors and mullberry molars)

QUESTION: Syphilis: Hutchinson triad

QUESTION: Stages of syphilis that is most infectious: Primary and Secondary, primary, secondary, tertiary, primary secondary and tertiary • In secondary syphilis, the bacteria have spread in the bloodstream and have reached their highest numbers.

SYSTEMIC LUPUS ERTHEMATOSUS:

Systemic Lupus Erythematosus - Collagen/CT multi-system disease. Unknown cause. Women 10x more frequently. Avg age = 31yo. • Presents: Malar rash, kidney problems 50% of time & lead to organ failure. Pericarditis is a frequent complication • Warty vegetation’s on valves = Libman-Sacks endocarditis. Oral lesions if evident- palate, B mucosa, gingiva.

Lupus is a chronic autoimmune disease in which the body's immune system becomes hyperactive and attacks normal, healthy tissue. This results in symptoms such as inflammation, swelling, and damage to joints, skin, kidneys, blood, the heart, and lungs.

QUESTION: Which syndrome has rash on cheeks, ulcers, kidney, etc.? Lupus

QUESTION: Which skin condition has endocarditis and glom-? Lupus

CAVERNOUS SINUS THROMBOSIS:

Cavernous sinus thrombosis (CST) = blood clot formation w/in the CS at the base of the brain, which drains deoxygenated blood from the brain back to the heart. Usually from an infection from nose, sinuses, ears, teeth or Forunculo. • Staphylococcus aureus and Streptococcus are often the associated. • Symptoms include: decrease/loss of vision, chemosis (edema of eye conjunctiva), exophthalmos (bulging eyes), ptosis, headaches (1st sign) and paralysis of the cranial nerves that course through the cavernous sinus. kk. This infection is life-threatening and requires immediate TX.

Infections in upper front teeth are within the area of the face known as the "dangerous triangle". The dangerous triangle is visualized by imagining a triangle with the top point about at the bridge of the nose and the two lower points on either corner of the mouth.

QUESTION: Cavernous sinus problem - Due to infection of upper lip/canine space, infection from max ant teeth QUESTION: Most likely to cause cavernous sinus thrombosis: valve infected by endocarditis, Soft tissue abscess in upper lip (veins of face don’t have valves)

QUESTION: Which of the following causes cavernous sinus thrombosis:

A) Subcutaneous abscess of upper lip B) Subcutaneous abscess of lower anterior region

• Infections in upper anterior teeth are within the "dangerous triangle" area, which is visualized by imagining a triangle with the top point about at the bridge of the nose and the two lower points on either corner of the mouth.

QUESTION: Cavernous sinus infection would most likely come from, Anterior maxillary teeth maxillary sinus, paranasal sinus, frontal sinus,

QUESTION: Site of infection most likely to enter cavernous sinus? Anterior triangle of face, naso-labial cyst

QUESTION: Why are you afraid of having infection in anterior triangle (i.e. upper lip)? Because there are valve-less veins that can send infection back to the brain.

QUESTION: Danger zone of Cavernous Sinus thrombosis: What is the first signs/symptoms? a. Pre-orbital swelling (bulging eye) b. Loss vision c. HEADACHE

• Most common initial symptom of CST is a headache, which develops as a sharp pain located behind or around the eyes that steadily gets worse over time. • Symptoms often start w/ in 5- 10 days of developing an infection in the face or skull, such as sinusitis or a boil.

LUDWIG’S ANGINA:

Ludwig's angina = serious bilateral cellulitis (CT infection) of the floor of the mouth, usually occurring in adults with concomitant dental infections & if left untreated, may obstruct the airways, necessitating tracheotomy. • Symptoms: swelling, pain and raising of the tongue, swelling of the neck and the tissues of the submandibular & sublingual spaces, malaise, fever, dysphagia (difficulty swallowing) and, in severe cases, stridor or difficulty breathing.

*QUESTION: Which space is not involved/associated with Ludwig's angina? Sublingual Submandibular Retropharyngeal Submental

*QUESTION: Cellulitis most of the time is unilateral. Ludwig's angina is bilateral & a complication is edema of GLOTTIS.

QUESTION: Patient has bilateral submandibular infection; tongue is elevated due infection - Ludwig's Angina • Ludwig angina = bilateral cellulitis of submandibular & sublingual spaces.

*QUESTION: What do you need to worry about the most with Ludwig’s Angina? Edema of glottis

*QUESTION: What is the main danger in Ludwig’s angina? Closing of the airway

QUESTION: Mandibular 2nd molar infection spreads to what space? Submandibular space

QUESTION: Infection on the mandibular buccal side of premolars is most likely to go where? Submandibular space

QUESTION: Infection of mandibular 2nd pm goes into Submandibular space

*QUESTION: You are extracting a mandibular 3rd molar and the distal root disappears into which space? Submandibular space

QUESTION: Which muscle separates 2 potential infection spaces from a maxillary 2nd molar? Buccinator or Masseter

QUESTION: If you have an infection in the lateral pharyngeal space, what muscle is involved? Medial pterygoid

QUESTION: Inferior Alveolar Nerve tract infection involves what space? Pterygomandibular space

SCARLET FEVER:

Bacterial infection caused by group A Streptococcus. It begins with a fever & sore throat. Sometimes, chills, vomiting, & abdominal pain. The tongue may have a whitish coating, appears swollen, and have "strawberry"-like (red & bumpy) appearance. The throat and tonsils may be very red and sore, and swallowing may be painful.

QUESTION: Strawberry tongue is seen in Scarlet fever (Also, Kawasaki disease & toxic shock syndrome)

TURNER’S TOOTH:

Turner's hypoplasia = abnormality found in teeth & presents as a portion of missing or diminished enamel on permanent teeth. Most likely occurs when developing permanent tooth is damaged by periapical infection in overlying deciduous tooth, leading to enamel defect.

QUESTION: Most probable reason for Turner Tooth? Syphilis, Trauma at birth, Trauma when young

QUESTION: Turners tooth – single tooth affected

QUESTION: Turner’s tooth is caused by: Trauma or local infection

QUESTION: What gives you Turners incisors: • Syphilis • Trauma during delivery • Trauma during pregnancy

RECURRENT APHTHOUS STOMATISIS:

Aphthous ulcers in non-keratinized tissue – herpes in keratinized tissue

Aphthous stomatitis = recurrent ulceration that are almost always painful. It occurs on freely movable mucosa that does not overlay bone. • Aphthous can be differentiated since it usually does not occur over bone, doesn’t form vesicles, and isn’t accompanied by fever or .

QUESTION: Patient has ulcer at mucolabial fold, it goes away and comes back, what could it be? Aphthous

QUESTION: Patient has occasional sores on mucolabial fold on mandibular arch that healed without scarring after a week or so? Minor Aphthous ulcer • Ulcer healing with scar tissue: major

QUESTION: Ulcer on tongue that repeats every 4 months? Apthous ulcer

QUESTION: A chancre due to Syphilis mostly resembles: 1) Cancer 2) Herpes 3) Herpangina 4) Apthous Ulcer

QUESTION: History of lesions that go away after 1 week – Recurrent aphthous ulcers

QUESTION: What don’t you treat aphthous ulcers with? Acyclovir ll. Acyclovir: Anti-viral used to tx herpes

QUES *QUESTION: Bechets syndrome produces what type of mouth lesion? Apthous Ulcers Apthous stomatitis mm. Behçet disease/syndrome is a rare immune-mediated small-vessel systemic vasculitis that often presents with mucous membrane ulceration & ocular problems. Triple-symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis.

* DISEASES: Lichen planus, mucous membrane pemphigoid (95%), and

Desquamative gingivitis = band of red atrophic or eroded mucosa affecting the attached gingiva. Unlike plaque-induced inflammation, it is a dusky red color & extends beyond the marginal gingiva, often to the full width of the attached gingiva and sometimes onto the alveolar mucosa.

QUESTION: Lichen Planus and pemphigoid = sub epithelial, and pemphigus is suprabasilar vesicle.

QUESTION: Desquamative gingivitis is associated with which 2 conditions? Lichen planus & pemphigoid

QUESTION: Most likely to cause desquamative gingivitis: Lichen planus, Pemphigus vulgaris, Pemphigoid

*PEMPHIGUS VULGARIS:

Pemphigus = autoimmune type II hypersensitivity reaction, has acanthylosis, & Tzanck cells. Antibodies are directed against the epithelium, target the desmosomal Dsg3 and cause sloughing. • Nikolsky’s sign is when the epithelium can just be rubbed off of an unaffected area HISTO: vesicles are suprabasilar and there is presence of acanthylosis

Pemphigoid = autoimmune disorder where antibodies attack hemidesmosomes. Blisters and vesicles develop—BMMP—benign mucous membrane pemphigoid. • DIFFERENT than Pemphigus vulgaris because—less severe and HISTO: vesicles are SUBepidermal and NO acanthylosis.

QUESTION: A patient has painful lesions on her buccal mucosa. A biopsy reveals acantholysis and a suprabasilar vesicle. Which of the following represents the MOST likely diagnosis?

A. Pemphigus B. Psoriasis C. D. Bullous lichen planus E. Systemic lupus erythematosus

QUESTION: Pemphigus: which was a vesicular disease & which layer it effects? Lichen Planus and pemphigoid = subepithelial, and pemphigus is suprabasilar vesicular disease.

QUESTION: Immunofluorescence of antibodies: Pemphigus - intraepithelial, desmosomes. Pemphigoid and pemphigus: which one comes apart from connective tissue? • Acantholysis is present in pemphigus • If antibody is linear… pemphigoid • If antibody is fishnet… pemphigus

QUESTION: Immunofluorescence used for dx of: Pemphigus or Lichen Planus

QUESTION: Pic that looked like herpangia in back of palate. Question stated there are Nikolsky signs, what is it? Pemphigus • Erythema multiform and pemphigus vulgaris both show Nikolsky sign

QUESTION: White film w/ positive Nikolsky – Pemphigus, tx w/ incisional biopsy (is treatment correct? Treat with medications?)

QUESTION: Sloughing of gingival epithelium in maxillary and mandibular arches: Pemphigus or pemphigoid

BENIGN MUCOUS MEMBRANE PEMPHIGOID:

Pemphigoid = autoimmune disorder where antibodies attack epidermis. Blisters and vesicles develop —BMMP—benign mucous membrane pemphigoid. This is DIFFERENT than pemphigus vulgaris because—less severe and HISTO: vesicles are SUBepidermal and NO acanthylosis.

*QUESTION: Subepithelial separation (separation of basement membrane) on immunofluorescence indicates? Benign mucous membrane pemphigoid

QUESTION: Another name for chronic desquamative gingivitis? Cicatricial pemphigoid

LICHEN PLANUS:

QUESTION: Histologically, the loss of the rete peg often is a sign of? a. Pemphigus b. Lichen planus c. Pemphigoid d. Syphilis

QUESTION: Desquamative gingivitis is associated with which two conditions: Lichen planus and pemphigoid (and lichen planus?)

QUESTION: Lichen planus: Target T lymphocyte

QUESTION: Pic of 55-year-old woman with erosion: Lichen planus (Erosive lichen planus – gingival is magenta to bright red)

QUESTION: Lichen planus most commonly found on Buccal mucosa

QUESTION: Lichen planus more common in Women

QUESTION: Lichen planus, what do you treat with? Topical corticosteroids or anti-histamines

EPIDERMOLYSIS BULLOSA:

Epidermolysis bullosa (EB) = group of inherited connective tissue diseases that cause blisters in the skin & mucosal membranes. It’s due to a defect in anchoring between the epidermis and dermis, resulting in friction and skin fragility. Its severity ranges from mild to lethal., usually affects infants/children.

QUESTION: Young child/infant exhibits ulcerations of mouth - Epidermolysis bullosa

QUESTION: A child is most likely to have which of these: pemphigus, pemphigoid, erythema multiform, Epidermolysis bullosa

QUESTION: Child formed blisters/ulcerations with minor lip irritation? Epidermolysis bullosa

QUESTION: Which pemphigoid like-lesion most often in infants? Pemphigus vulgarius Pemphigoid Erythema multiform Epidermolysis bullosa

• Small blisters that develop from mild provocation over areas of stress—ex. elbows and knees

CANDIDIASIS:

Candida forms – ulcer, erythema, white hyperplastic, white/curd

*QUESTION: HIV patient with oropharyngeal candidiasis, what would you prescribe? Fluconazole

QUESTION: Which oral medication would you give to tx vaginal candidiasis? Diflucan (fluconazole)…nystatin, griseofulvin, Monistat,

QUESTION: If pt undergoes radiotherapy for cancer, the most common oral infection that necessitates drug tx in this stage is? Candida albicans

QUESTION: Candidiasis in cancer patients due to- Chemotherapy, radionecrosis

QUESTION: Pt has multiple white patches that can be scraped off? Candidiasis

QUESTION: Oral cytology smears are MOST appropriately used for the diagnosis of which of the following? Pseudomembranous candidiasis

*QUESTION: What oral manifestation is often seen in children with HIV? Candidiasis

QUESTION: Systemic medication for Candida: Amphotericin B

QUESTION: Which is associated w/ burning mouth? Candida

*QUESTION: Lesion in the middle of tongue also pt had it on palate before and pt is healthy? Candidiasis…kaposi, syphilis

ACTINIC CHEILITIS:

Precancerous condition caused by damage to lip epithelium

QUESTION: Symptoms of ? Loss of vermillion border

QUESTION: How do you treat actinic cheilitis? • According to wiki, its 5-fluorouracil or imquimide – block DNA synthesis, but I’m not sure if those were even answer choices. • Limit sun exposure, moisturizers, vermilionectomy, cryotherapy, laser ablation, electrocautrey • Unapproved: topical retinoid, 5-fluorouracil cream, imquimod cream, photdynamic therapy

QUESTION: Actinic Chelitis: Lower lip shows epithelial atrophy and focal keratosis, same as Actinic Keratosis

QUESTION: Which of the following lesions has the greatest malignant potential? A. Leukoedema B. Lichen planus C. Actinic cheilitis D.

• Actinic cheilitis can lead to SCC

QUESTION: What problem causes bilateral ? High vertical dimension Low interocclusal space High occlusal distance Low VDO

QUESTION: Angular cheilitis for dentures, you need to increase interocclusal space. It’s associated with over closure.

QUESTION: Angular cheilitis is caused by all of the following except: a. Fungal infection b. Decreased VDO (causes it, b/c increase interocclusal distance; also cheek biting!!) c. Increased VDO (causes clicking of teeth) d. Other options

*QUESTION: What problem causes bilateral angular cheilitis? high vertical dimension, low interocclusal space, high occlusal distance, Low VDO

MEDIAN RHOMBOID GLOSSITIS:

Median rhomboid glossitis (MRG) = area of redness & loss of , situated on the dorsum of the tongue in the midline immediately in front of the circumvallate papillae. MRG created by a chronic fungal infection, and usually is a type of oral candidiasis.

QUESTION: Median rhomboid glossitis — smooth red area of tongue that lacks the lingual papillae

QUESTION: Healthy 36-year-old, red patch on palate, redness in middle of tongue: Kaposi sarcoma Syphilis Median rhomboid glossitis, Candidiasis Gonorrhea

HERPES:

Gingivostomatitis Herpetica: Initial presentation during the 1st (primary) infection is of greater severity than herpes labialis (cold sores), which is often the subsequent presentation. It's the most common viral infection of the mouth, affects both the free & attached mucosa. • Aphthous ulcers in non-keratinized tissue – herpes in keratinized tissue

Acute (primary) herpetic gingivostomatitis arise between 6 months and 5 years, with peak prevalence between 2-3 years of age. Development before 6 months is rare due to protection of maternal anti-HSV antibodies.

Drugs that are used for Herpes: Acyclovir, Valtrex (valacyclovir), Docosanol (abreva), and PENCICLOVIR

DRUG OF CHOICE: • Acyclovir or (valancyclovir – oral): herpes I, II, VZV, EBV • Ganciclovir (IV): CMV • Primary HSV: PALLATIVE

*QUESTION: 85% of people have herpes • 65-90% worldwide; 80-85% USA

QUESTION: Kid with primary herpes infection. What is the age of infection? 2 y/o, 4 y/o, 8 y/o, 10 y/o

*QUESTION: Young person w/ fever & oral vesicles: Fever = PRIMARY herpes stomatitis

QUESTION: Ways to treat kid w/ herpetic gingivostomatitis EXCEPT: a. Antibiotics b. Gives numbing anesthetic before eating c. Has pt rest and drink lots of water

QUESTION: Herpes zoster (VZV) – Valacyclovir treats herpes labialis

QUESTION: Patient gets recurrent herpetic lesions very often with gingivostomatitis. What should be done? (herpetic gingivostomatitis) Acyclovir Palliative tx Systemic antibiotics Steroids • Treatment includes fluid intake, good oral hygiene and gentle debridement of the mouth. In healthy individuals, the lesions heal spontaneously in 7–14 days without scarring.

QUESTION: Patient has all clinical signs of herpes (w/ lesion on corner of mouth that comes and goes) which medication do you recommend? – The one that ended with a “vir”. (no acyclovir in the answer choices)

QUESTION: Herpes can be diagnosed by exfoliative cytology b/c a Characteristic multinucleated cell appears in the smear of herpes infections.

QUESTION: Recurrent intraoral herpes occurs almost exclusively on mucosa overlying bone. The hard palate is the most common site.

QUESTION: Best med for herpes, CMV = Acyclovir (ganciclovir??)

QUESTION: Valcyclovir (Valtrex): Tx for herpes simplex/herpes zoster

QUESTION: Secondary herpes? Lip, gingival, and palate

QUESTION: Herpetic whitlow - Herpes on finger • Herpetic whitlow is an intensely painful infection of the hand involving 1 or more fingers that typically affects the terminal phalanx

QUESTION: Which most closely mimics dental pain: Herpes zoster, CMV, herpangina

QUESTION: Patient comes with recurrent herpetic stomatitis on the lips and history shows no signs of primary herpetic gingivostomatitis. Why? Most primary infections are subclinical.

QUESTION: Herpetic gingivostomatitis – within 3 days of onset: treat with Acyclovir 15mg/kg 5 times per day for 7 days • More than 3 days, just do palliative care (plaque removal, systemic NSAIDS, and topical anesthetics). 3 days = borderline. • Contagious when vesicles are present

QUESTION: Primary herpetic stomatitis? Reactivation of the primary can cause Recurrent herpes infection

QUESTION: Which disease is caused by the virus that causes acute herpetic gingivostomatitis? Herpes simplex 1

QUESTION: Herpes lesion intraorally, how do you treat? Palliative, acyclovir? Tx is supportive—topical before eating, analgesics, maintain fluid/electrolyte balance, anti-viral agents. DO NOT GIVE CORTICOSTEROIDS.

QUESTION: How is Acyclovir selective toxicity mechanism of action? Only phosphorylated in infected cells and inhibits viral mRNA • Acyclovir is selective and low in cytotoxicity as the cellular thymidine kinase of normal, uninfected cells does not use acyclovir effectively as a substrate.

QUESTION: Post-herpetic neuralgia cause by: (VZV) Herpes zoster, HSV 1, HSV 2, CMV • Complication of long term shingles infection

QUESTION: What does histoplasmosis oral lesion look like? Recurrent herpes h. Painful, ulcer with irregular borders, similar to cancer

QUESTION: Patient has upper denture, when he removes it, there is unilateral lesion on the palate. What could it be? – Herpes (other choices were more serious pathological lesions).

QUESTION: Pic with half the tongue (left side) that looks like herpes lesion and other nothing on it- Herpes zoster

QUESTION: Antivirals (wrong match)- Azithromycin with herpes zoster

QUESTION: Kaposi sarcoma by Herpes 8 & most likely on hard palate

TRAUMATIC NEUROMA:

*QUESTION: A patient has a RPD and a firm, swelling under the buccal flange midway between incisors and molars. What is it? Traumatic neuroma

*QUESTION: Mandibular Denture. Lump hurts & is anterior to posterior areas. What caused it? Traumatic neuroma

PYOGENIC GRANULOMA:

Pyogenic granuloma is a relatively common, tumor like, exuberant tissue response to localized irritation or trauma. It can occur anywhere in the oral cavity & develops rapidly. • 2 lesions, peripheral ossifying fibroma & peripheral giant cell granuloma, are clinically identical to the pyogenic granuloma when they occur on the gingiva. Peripheral ossifying fibroma & peripheral giant cell granuloma only occur on the gingiva or alveolar mucosa.

QUESTION: Picture said: “erythematous, bleeding swelling” mandibular swelling right next to premolars on right side? Pyogenic granuloma

*QUESTION: Pink growth on palatal between canine and 1st PM? Pyogenic granuloma…papilloma, , peripheral ossifying, irritation fibroma

QUESTION Which lesion shows the most rapid change in size? • Fibroma • Pyogenic granuloma

QUESTION: Fastest growing tumor? a. b. Pyogenic granuloma c.

QUESTION: Patient is female and pregnant and is said to have this enlargement and picture has it on the corner of her mouth (vermillion border) and she said it just developed; the picture had it shown as a boil and very red. It bleeds and is not painful – I went with Pyogenic granuloma (other option that could have made sense because I didn’t know what a varix (dilated vein) was

QUESTION: Fast growing lesion on gingiva that blanches and bleeds easily when pressed? Pyogenic granuloma

Central Giant Cell Granuloma:

Giant Cell Granuloma – multilocular radiolucent benign jaw condition, most common in anterior max/man, & in younger people, especially women. They are characterized by large lesion that expand the cortical plate & can resorb root + move teeth.

*QUESTION: Where do you find giant cells? Hyperparathyroidism…Hyperthyroidism, Hypothyroidism, Hypoparathyroidism

QUESTION: Giant cell lesion found in bone, what test would you run to help with diagnosis? Bence Jones (from multiple myeloma), calcium levels, Complete blood count

QUESTION: Giant cell lesion is most like histology of congenital epulis of the newborn. NO! —Granular cell Myeloma

SQUAMOUS PAPILLOMA:

Squamous cell papilloma = caused by infection with the human papillomavirus (HPV). When the papilloma’s are found on the skin, they are more commonly referred to as or verrucas. • Most common benign neoplasm of EPITHELIAL TISSUE ORIGIN. • It appears as a pedunculated (foot-shaped), or sessile whitish cauliflower-like mass on the tongue (posterior border), lips, gingiva, or soft palate.

QUESTION: Lesion on the palate that is verrucous and pedunculated - Papilloma

QUESTION: The causes of Verrucous xanthoma? Human papilloma virus • Xanthoma = fatty deposits under skin

QUESTION: Lesion in lip with cauliflower shape: Papilloma

QUESTION: The most common between five choices? 1- Papilloma 2- 3- Leiomyoma 4- Lymphangioma 5- Neurofibromatosis

CONDYLOMA ACUMINATUM:

Condyloma acuminatum = epidermal manifestation attributed to the epidermotropic human papillomavirus (HPV).

QUESTION: Condyloma acuminatum (genital/venereal ) is caused by which virus? HPV

QUESTION: Which of the following does not have cauliflower-like, pebbly appearance? Fibroma Verrucous carcinoma, condyloma accuminata, papilloma

QUESTION: HPV know the subtypes, 6 & 11 for condyloma accuminatum • HPV types 6 & 11 are most frequently the cause of genital warts

FIBROMA:

Fibroma = benign tumors composed of fibrous/CT tissue.

Epilus Fissuratum = benign hyperplasia of fibrous CT, which develops as reactive lesion to chronic mechanical irrigation produced by flange of poor fitting dentures.

QUESTION: Which one resembles Epilus Fissuratum – Fibroma (both share trauma as etiology)

QUESTION: Epulis fissuratum is most similar cellularly to: Fibroma, granuloma cell tumor, etc. • Fibroma (and a question about how to treat a patient with old denture and epulis – usually make new denture or modify; don’t just wear same denture)

QUESTION: There was a picture of fibroma but the term fibroma was not used instead they used another name: Focal Fibrous Hyperplasia

QUESTION: Fibromas are a result of what dysfunction? Hyperplasia…neoplasia, dysplasia

QUESTION: In most of the cases, localized fibromas are often: Hyperplasia…dysplasia, metaplasia, anaplasia,

Granular Cell Tumor: Granular cell tumor (Granular cell nerve sheath tumor, Granular cell schwannoma) = tumor that can develop on any skin or mucosal surface, but occurs on the tongue 40% of the time. It’s pseudoepitheliomatus hyperplasia: resembles SCC & congenital epulis. It is seen in inflammatory papillary hyperplasia, chronic hyperplastic candida, & blastomycosis.

QUESTION: Congenital epulis histological similar to: hemangioma, lymphangioma, Granular cell myoblastoma

QUESTION: Patient has congenital epulis. What is the histology most similar to? Granular cell tumor

LEUKOPLAKIA:

QUESTION: If you have leukoplakia for biopsy, do you incise or excise for biopsy? Incision • Incise multiple areas w incisional biopsy • Incise when you think it is cancer

Erythroplakia:

QUESTION: In smoker’s soft palate, there are red points. What could it be? Erythroplakia, initial stages of SCC, nicotinic stomatitis (hard palate), etc.

QUESTION: What presents with severe dysplasia? Erythroplakia, white sponge nevus

QUESTION: Lesion commonly found with dysplasia and carcinoma in situ -- Erythroplakia

Squamous Cell Carcinoma:

QUESTION: White people have least oral carcinoma. Black men have the worst rate of SCC.

QUESTION: Etiology of Squamous Cell Carcinoma, external factors and stress: Alcohol, tobacco, UV radiation, certain HPV types, vitamin deficiency, immunocompromised, iron deficiency anemia – Plummer Vinson syndrome • Xerostomia increases risk of SCC.

QUESTION: Lateral boarder of the tongue picture looked like squamous cell carcinoma.

QUESTION: Lesion that resembles SCC. 16 weeks and then disappears. a. papilloma b. c. papillary hyperplasia

• Skin tumor that can occur on sun-exposed areas

QUESTION: Which of the following has the best survival rate? a. Squamous cell carcinoma b. Adenocarcinoma c. Osteosarcoma

QUESTION: SCC on tongue, what you do? Incisional

QUESTION: What is the #1 risk factor for ? Tobacco

QUESTION: Most likely site for SCC? Ventrolateral tongue (other choices were weird…palate (least)…)

QUESTION: Chewing Betel nut can lead to: SCC, xerostomia, gingival recession

QUESTION: Pt has been a smoker (60 pack yr. history) & has ulcer in lower lip. Ulcer is non-indurated; what’s the most probable diagnosis? SCC

QUESTION: Most common malignancy in the oral cavity? a. Metastatic ca (most common malignancy found in bone) b. Basal cell ca (most common type of skin cancer) c. Epidermoid ca (aka SCC…I’m pretty sure this is the right answer…Xtina) d. Mucoepidermoid ca (most common salivary gland carcinoma) e. Adenoid cystic ca (second most common salivary gland carcinoma)

*QUESTION: Most malignant cancer in oral cavity? Epidermoid carcinoma (SCC)

QUESTION: Which of these is the most likely to become malignant? Low grade mucoepidermoid carcinoma

*QUESTION: What race most likely to get oropharyngeal cancer? Black

QUESTION: What percentage gets oral cancer? 3% of new cancers among males & 1.6% of new cancer among females

QUESTION: How many people in the US get oral cancer: 30,000 SSC new cases annually

QUESTION: What population has the worst survival rate for SCC? Black

QUESTION: Lowest 5-year oral cancer survival rate? Black people

VERRUCOUS CARCINOMA:

Verrucous carcinoma (VC, "Snuff dipper's cancer") is an uncommon variant of SCC. Usually seen in those who chew tobacco or use snuff orally. Most patients with verrucous carcinoma have a good prognosis due to rarity of metastasis. Large broad based exophytic papillary leukoplakia lesion

QUESTION: Which one has the best prognosis? Verrucous carcinoma in vestibule Verrucous carcinoma floor of mouth SCC floor of mouth SCC in other areas

QUESTION: Smokeless tobacco: Verrucous carcinoma

QUESTION: Verrucous leukoplakia - HPV 16 and 18

QUESTION: Most common most pathogenic location for verrucous carcinoma: Buccal vestibule

QUESTION: Verrucous carcinoma presents with: • Warty lesion • White ulcerated patch (that’s what it looks like on google images) • Smooth pedunculated lesion • Large warty mass- variant of SCC

LEUKOEDEMA:

QUESTION: Leukoedema – blue/grey/white mucosa that blanches. It disappears when stretching. Mostly bilateral. No treatment.

QUESTION: A patient presents with a bilateral, grayish-white lesion of the buccal mucosa. This lesion disappears when the mucosa is stretched. Which of the following is the MOST likely condition? A. Leukoedema B. Leukoplakia C. Lichen planus D. White sponge nevus

LEUKEMIA:

• Lymph node enlargement is the main pathologic finding. May be complicated by autoimmune hemolytic anemia.

QUESTION: Case: 20-year-old patient with bleeding gums and bruises easily. Leukemia (picture provided)

QUESTION: Patient shows up with kid that has bleeding gums, problems healing and has discomfort. Leukemia

*QUESTION: Leukemia Picture: young person that is fatigued and has a jacked-up mouth, looks like multi pyogenic granuloma, very inflamed and red gums.

*QUESTION: Most common type of leukemia in children? ALL (lymphoblastic)

QUESTION: Pt had erythematous and over past 5 weeks. And increased report of bruising on body. Cause is acute leukemia (specifically AML)

QUESTION: 6 years old patient has acute lymphatic leukemia (ALL). Her deciduous molar has a large carious lesion and furcation lucency. How will you treat this person? a. Pulpotomy b. Pulpectomy c. Extraction d. Nothing

SALIVARY GLAND TUMORS:

Salivary gland tumors: most are benign but the parotid glands still are where most malignant (cancerous) salivary gland tumors start. Classified as: nn. major salivary glands consist of the parotid, submandibular, and sublingual glands. oo. minor glands include small mucus-secreting glands located throughout the palate, nasal and oral cavity.

Most common salivary gland benign major or minor: Pleomorphic adenoma (benign mixed tumor)

Most common malignant major: Mucoepidermoid carcinoma

Most common malignant minor:

Adenoid cystic carcinoma: high grade salivary malignancy, most common malignancy o Palate most common o “Swiss cheese” microscopic pattern o Spreads through perineural spaces**

Necrotizing sialometaplasia - minor presents on the palate which is most commonly confused with carcinomas due to the ulcerated presentation. Heals without scarring.

QUESTION: Picture of an ulcerated tumor on palate? Salivary gland tumor…SCC, tori

QUESTION: Most common salivary gland tumor: Pleomorphic adenoma

QUESTION: Adenoid cystic carcinoma – Best prognosis of malignancy

QUESTION: Most common gland in Pleomorphic adenoma: *MOST COMMON TUMOR OF PAROTID GLAND* • MOST COMMON SITE = MINOR GLANDS OF PALATE

QUESTION: Which of the salivary tumor glands has the best prognosis: Mixed Tumor (pleomorphic adenoma), Adenoid cystic carcinoma (perineural spread), Mucoepidermoid Carcinoma (most common) • Malignancy mixed tumor & adenomatoid = worst

QUESTION: Peri-neural invasion is seen in: Adenoid cystic carcinoma (ACC), Pleomorphic adenoma, low grade mucoepidermoid carcinoma, OKC • ACC tumor has a marked tendency to invade nerves. Perineural invasion is seen in about 80% of all specimens.

QUESTION: Which has swish cheese appearance? Adenoid cystic carcinoma

WARTHIN TUMOR:

Warthin tumor (adenolymphoma) = benign cystic tumor of the salivary glands containing abundant lymphocytes and germinal centers

*QUESTION: Warthin tumor is most common in what gland? Parotid (don’t get mixed up with Wharton’s duct)

Ameloblastoma:

Ameloblastoma is a most aggressive & the most common epithelial odontogenic tumor. Mostly in mandibular molar area. Solid, well-defined, multicystic or polycystic (“soap bubble”) lesion – most aggressive kind and requires surgical excision

Ameloblastic Fibroma: compared to ameloblastoma - younger age, slower growth, does not infiltrate. Usually associated w/ impacted teeth

reverse polarization (follicular type), nucleus moves away from basement membrane, seen in ameloblastoma

QUESTION: Ameloblastoma histology: Stellate reticulum in bell stage, epithelium in net flex pattern • Stellate reticulum is a group of cells located in the center of the enamel organ of a developing tooth.

QUESTION: Which one can lead to ameloblastoma? Dentigerous Cyst

*QUESTION: Which describes ameloblastoma best? Local invasion

QUESTION: What is the most definite way to distinguish ameloblastoma from OKC?

a. Smear cytology b. Reactive light microscopy c. Reflective microscopy

QUESTION: Ameloblastoma: You get a picture, slow progressing, other false choices included dentigerous cyst.

QUESTION: Multiluncency in bone and ramus: Ameloblastoma

*QUESTION: X-ray: A painless, well-circumscribed radiolucency and radiopacity in the posterior mandible of 11 yrs. old boy. What is the differential diagnosis? Ameloblastic fibro –

DENTIGEROUS CYST:

QUESTION: Which lesion can become ameloblastomic? Dentigerous cyst, lymphedema, epidermoid

QUESTION: Radiographic picture: upside down molar with lucency around crown, what is it? Dentigerous cyst • STARTS AT CEJ

QUESTION: Which cyst is most likely to become neoplastic? a. Dentigerous b. Residual c. Radicular

*ODONTOMA:

Odontoma = benign tumor of odontogenic origin, commonly in mandible. It starts off lucent but develops small calcification to be radiodense lesion, can give rise to dentigerous cyst, divided into 2 categories: • Complex Odontoma – irregular calcified lesions w/ no distinct tooth components • Compound Odontoma – identifiable tooth components

*QUESTION: X-ray of compound Odontoma Compound odontoma - looks like a tooth more defined; complex odontoma – giant mass that is radiopaque but doesn’t look like a tooth.

*QUESTION: Syndrome associated with multiple odontoma- Gardner’s syndrome

QUESTION: Picture of multiple small teeth within a radiolucency around the canine: Compound odontoma, pindborg tumor, calcifying odontogenic

Tumor of mixed (epithelial and mesenchymal) origin is the odontoma. These calcified lesions take 1-2 general configurations. They may appear as multiple miniature or rudimentary teeth (compound odontoma).

ADENOMATOID ODONTOGENIC TUMOR (AOT):

Adenomatoid odontogenic tumor arises from the enamel organ or dental lamina. It’s mostly young females, maxillary, & usually associated w/ unerupted permanent tooth. pp. 2/3 tumor: adenomatoid odontogenic tumor: 2/3 in maxilla, 2/3 in female, 2/3 in anterior jaw QUESTION: AOT (Adenomatoid odontogenic tumor) radiograph picture (Exact picture used) QUESTION: Radiolucency at the end of a tooth that looks like there might be an AOT but the patient is having symptoms (I wrote periapical cyst)

QUESTION: Radiolucent lesion Between maxillary canine-lateral with radiopacity inside: adenomatoid tumor (AOT) qq. REMEMBER lesion goes to apex

QUESTION: Mixed density lesion in a young child: AOT

QUESTION: 16 y/o boy: x-ray showed maxillary anterior tooth with a radiolucency with “SPECKS” in it (yes that’s the word that was used) - Adenomatoid Odontogenic Tumor

AMELOGENESIS IMPERFECTA:

Amelogenesis imperfecta = malfunction of the proteins in the enamel: ameloblastin, enamelin, tuftelin and amelogenin. People afflicted with amelogenesis imperfecta have teeth with abnormal color (yellow, brown or grey) and have rapid attrition, excessive calculus deposition, and gingival hyperplasia.

QUESTION: Amelogenesis imperfecta is: Autosomal dominant (some forms can be recessive or x-linked)

*QUESTION: Pictures of teeth, premolars just erupted. Thick dentin, thin enamel, pulps not obliterated, and no teeth contact – Amelogenesis imperfecta (Amelogenesis imperfecta in X-ray shows open contacts)

QUESTION: Radiographic picture with large decay and radiolucency. In addition to periapical radiolucency, what other thing do you see? Amelogenesis imperfecta (tooth lacks enamel)

QUESTION: Know that Amelogenesis Imperfecta can cause: Hypoplastic pitting enamel

CALCIFYING ODONTOGENIC CYST/GORLIN CYST:

QUESTION: “Ghost cells” - keratinized calcifying odontogenic cyst

REGIONAL ODONTODYSPLASIA:

QUESTION: When does enamel hypoplasia occur? Altered matrix formation (BELL STAGE)

QUESTION: All of the following are congenital except… a. dentinal dysplasia b. amelogenesis imperfecta c. (or odontogenesis imperfecta) d. ectodermal dysplasia

QUESTION: Regional odontodysplasia: ghost teeth. (enamel, dentin and pulp are all affected. Non hereditary, eruption is delayed or doesn’t occur)

*DENTIOGENESIS IMPERFECTA vs DENTINAL DYSPLASIA:

Dentiogenesis Imperfecta: Crowns are short & bulbous, narrow roots, obliterated pulp • DI Type 1 is with osteogenic imperfecta. • DI Type 2 is not with OI. • DI Type 3 is the bradywine type, which occurs in absence of OI, exhibits multiple periapical radiolucency, shell-like appearance, & large pulp chambers/exposures.

Dentinal Dysplasia: Clinically, the dental crowns appear normal while radiographically, the teeth are characterized by pulpal obliteration, short blunted roots, & sometimes, PARL. The teeth are generally mobile, frequently abscess and can be lost prematurely. rr. DD Type 1 – radicular: shorter roots, obliterated pulp chamber. ss. *DD Type 2 – coronal: pulp enlarged, “thistle” tube appearance, primary dentition appears similar to DI type II.

*QUESTION: X-ray: Dentiogenesis Imperfecta – Obliterated pulp chamber

THIS PICTURE, KNOW IT WELL

QUESTION: What is seen with Osteogenesis Imperfecta? Dentinogenesis Imperfecta

QUESTION: Osteogenesis imperfecta is usually associated with/seen with? a. Dentinogenesis Imperfecta (DI) b. Amelogenesis imperfecta c. Hypercementosis d. Cleidocranial dysplasia

QUESTION: All of the following are differential diagnosis for Dentinogenesis imperfecta except? Ectodermal dysplasia Amelogenesis imperfecta Enamel dysplasia Dentinal dysplasia Enamel hypoplasia (AI)

QUESTION: Which is not associated with Dentiogenesis imperfecta? Ectodermal dysplasia

QUESTION: Dentinogenesis Imperfecta = poorly mineralized dentin, enamel frequently fractures from the teeth leading to rapid wear and attrition of the teeth.

QUESTION: Dentinogenesis imperfect type I is a part of osteogenesis imperfect. Has BLUE SCLERA or it can be a separate inherited dominant trait without OI (DI type II)

QUESTION: Which one is associated with dentinogenesis imperfecta? • Blue sclera (this is from osteogenesis imperfecta) •

• Other characteristics of this condition: opalescent teeth, affects both primary and permanent, teeth are bluish-brown and translucent, enamel is lost early.

QUESTION: Radiographs of a patient's teeth reveal that the crowns are bulbous; the pulps, obliterated; and the roots, shortened. These findings are associated with which of the following? Porphyria Pierre Robin syndrome Amelogenesis imperfecta Osteogenesis imperfecta Erythroblastosis fetalis

QUESTION: What is the most common? Cleft lip (Cleft Lip/palate)…dentinal dysplasia, amelogenesis imperfecta, dentinogenesis imperfecta,

QUESTION: looks like dentinogenesis imperfect WITH ONE DIFFERENCE? Dysplasia has radiolucency

QUESTION: 12 y/o boy’s X-ray shows roots are short & open apex. Sister also has same condition. What condition is this? DI - autosomal dominant AI - autosomal recessive Dentin dysplasia – autosomal dominant

QUESTION: A picture of dentin dysplasia – Short rooted teeth with periapical radiolucency

QUESTION: Some teeth appear to be clinically normal, but exhibit (1) globular dentin, (2) very early pulpal obliteration, (3) defective root formation, (4) periapical granulomas and cysts, and (5) premature exfoliation. The condition is known as which of the following? A. Shell teeth B. Dentin dysplasia C. Regional odontodysplasia D. Amelogenesis imperfect E. Dentinogenesis imperfecta

ECTODERMAL DYSPLASIA:

Ectodermal dysplasia = X-linked conditions in which there are abnormalities of 2 or more ectodermal structures (ex. hair, teeth, nails, sweat glands, salivary glands, cranial-facial structure, digits). During tooth bud development, it frequently results in congenitally absent teeth (in many cases, a lack of a permanent set and/or in the growth of teeth that are peg-shaped or pointed. Teeth develop abnormally causing or oligodontia (partial). Retained primary teeth. CONICAL shaped anterior teeth.

QUESTION: Ectodermal dysplasia expressed as? Anodontia or Hypodontia, with or without a cleft lip and palate.

*QUESTION: Congenitally missing teeth often seen in? Ectodermal dysplasia

QUESTION: Ectodermal dysplasia: which of the following is correct? It is X-linked, not autosomal dominant

QUESTION: Characteristic of Ectodermal Dysplasia is? Oligodontia (some missing teeth, > 6 teeth, not all teeth) and hypohydrotic (reduced sweating) or anhydrosis (lack of sweating)

QUESTION: Ectodermal dysplasia: Partial or complete anodontia

QUESTION: Hypohydrotic child: Ectodermal dysplasia • Sweating dysfunction, abnormal reduction of sweating due to heat

QUESTION: Ectodermal dysplasia – Sparse hair

QUESTION: Having hypodontia will prevent/undermine formation of what? Alveolus (others were maxillary and mandibular arch but not together)

*QUESTION: Hypodontia- FEWER number of teeth A. Max deficiency B. Man deficiency C. Mid-face deficiency D. Cortical bone deficiency E. Alveolar bone deficiency

• Less teeth, reduced alveolar ridge development so the vertical dimension of the lower face is reduced

Cherubism:

Cherubim - Autosomal dominant condition characterized by abnormal bone tissue in the lower part of the face. In early childhood, both the mandible & maxilla become enlarged as bone is replaced with painless, cyst-like growths.

QUESTION: Cherubim: Bilateral jaw expansion

QUESTION: A kid presents with bilateral enlargement, painless, etc. (they are implying Cherubim) what is the Tx? No Tx required

FIBROUS DYSPLASIA:

Fibrous dysplasia = bone disorder where scar-like (fibrous) tissue develops in place of normal bone. This can weaken the affected bone & cause it to deform or fracture.

McCune-Albright Syndrome — polystotic fibrous dysplasia—areas of radiolucent/radiopaque---potential for malignant transformation (café au lait)

QUESTION: Fibrous Dysplasia – Ground glass appearance, diffuse expansion of the mandible (“orange peel”)

QUESTION: Panoramic with big radiopacity?

Fibrous dysplasia: it is diffuse radiopacity-vital tooth Osseous fibroma: radiolucent vital tooth Cemento osseous dysplasia

QUESTION: 35 y/o female, picture of a couple of radiolucency lateral to lateral incisors, asymptomatic: Fibrous dysplasia i. Monostotic fibrous dysplasia may be completely asymptomatic and is often an incidental finding on x-ray

QUESTION: Which of the following is frequently accompanied by melanin pigmentation (cafe-au- lait spots)?

A. Osteomalacia B. Hyperparathyroidism C. Osteogenesis imperfecta D. Polystotic fibrous dysplasia (McCune-Albright Syndrome)

QUESTION: McCune Albright’s Syndrome – Café au lait spots (coast of Maine)—bone and skin disorder—brown spots!

CONDENSING OSTEITIS:

Condensing osteitis = periapical inflammatory disease that results from a reaction to a dental infection. It causes more bone production rather than bone destruction in the area (most common site is near the root apices of premolars and molars). Appears as a radiopacity in the periapical area due to the sclerotic reaction.

QUESTION: X-ray, what is the cause of radiopacity on the apex of the infected tooth - Condensing osteitis

*QUESTION: All are lesion are radiolucent except? Condensing osteitis (radiopaque)

TRAMUATIC (SIMPLE) BONE CYST:

Traumatic bone cyst (simple bone cyst) = nothing inside, not a true cyst b/c not epithelial lined so pseudocyst that heals by itself. It scallops around the roots of the tooth.

QUESTION: Picture said: “scalloped border, tooth is vital, patient is asymptomatic” Traumatic bone cyst

QUESTION: Young patient with traumatic bone cyst, what tx?

None, spontaneous healing (don’t think this is the answer) Surgical exploration? Curettage of the osseous socket and bony walls? intralesional steroid injections

PAGET’S DISEASE OF BONE:

Paget’s Disease (Osteitis Deformans) = chronic bone disorder where bones become enlarged & deformed – dense but fragile. Seen in pts OLDER pts. Dentures stop fitting. Develops slowly. COTTON WOOL appearance, hypercementosis, and loss of lamina dura. Labs – INCREASE serum ALKALINE phosphatase but normal serum phosphate and calcium. Risk of osteosarcomas.

QUESTION: Paget’s Disease – Cotton wool appearance of skull QUESTION: Paget’s disease Increase serum alkaline phosphatase

QUESTION: Which one most likely has potential (high incidence) for malignant transformation? osteomas, Paget’s disease

QUESTION: Which of the following has the potential for undergoing spontaneous malignant transformation? A. Osteomalacia B. Albright's syndrome C. Paget's disease of bone D. Osteogenesis imperfecta E. von Recklinghausen disease of bone

QUESTION: Paget’s disease can lead to Osteosarcoma (malignancy)

QUESTION: Denture does not fit anymore as a result of? Paget’s disease

LANGERHANS CELL HISTOCYTOSIS X:

Langerhans cell histiocytosis (LCH) = rare disease w/ clonal proliferation of Langerhans cells, abnormal cells deriving from bone marrow and capable of migrating from skin to lymph nodes. • Hand–Schüller–Christian disease is associated with multifocal Langerhans cell histiocytosis. • Oral signs: bad breath, sore mouth, loose teeth. Lesion are sharply punched out radiolucency & teeth appear as FLOATING IN AIR

QUESTION: Radiographic picture: Floating tooth not in bone, opacities in lesion, what is it? • Whole jaw cyst • Ameloblastoma • Keratocyst • Dentigerous cyst • Langerhans X

QUESTION: Hand-Schuller-Christian triad: Diabetes insipidus, exophthalmos, & lytic bone lesions (Langerhans dis).

NASOLABIAL CYST:

Nasolabial cyst (nasoalveolar cyst, Klestadt`s cyst) = rare non-odontogenic, soft-tissue, developmental cyst occurring inferior to the nasal alar region. Derived from epithelial cells retained in the mesenchyme after fusion of the medial & lateral nasal processes + maxillary prominence or due to the persistence of epithelial remnants from the nasolacrimal duct extending between the lateral nasal process and the maxillary prominence. • Patient usually presents with a slowly enlarging asymptomatic swelling.

QUESTION: Not a bone cyst? Nasolabial cyst b/c it occurs outside of bone & is a soft-tissue cyst

QUESTION: Which one is soft tissue involvement, not bone? Nasolabial Cyst

QUESTION: A patient has a swelling under the upper lip that is by her lateral incisor and raises the ala of the nose from the outside. What is it? Nasolabial cyst

QUESTION: Radiolucency radiating from root of central incisor toward midline, could be all of the below except: Nasolabial cyst… , nasopalatine cyst, some sort of fibrous dysplasia,

QUESTION: Which one not seen radiographically? Nasolabial cyst • Because this cyst is extra osseous, it is not likely to be seen on a radiograph.

QUESTION: Lining of nasolabial cyst - Pseudostratified squamous

QUESTION: What is the rarest cyst? Lateral Periodontal Cyst

NASOPLATATINE CYST:

QUESTION: The most common non-odontogenic cyst: a. Dermoid b. Thyroglossal c. Lymphoepithelial d. Nasopalatine duct cyst

QUESTION: Nasopalatine X-ray- heart shaped near central incisors

QUESTION: Nasopalatine cyst treatment? Enucleation

QUESTION: Intraoral picture of nasopalatine cyst by incisive papilla on backside of #7 & 8. The foramen and nasopalatine canal is where the incisive papilla is and if there’s a cyst there then what does it look like clinically? Soft tissue is swelling and discolored

LYMPHOEPITHELIAL CYST:

Usually an enlargement of the parotid or lacrimal gland

*QUESTION: Round yellow-white bump underneath tongue? Lymphoepithelial cyst? Yellowish cyst on floor of mouth? Oral lymphoepithelial cyst

QUESTION: Patient (young child) w/ nodules on right side of tongue that are fluid filled the rest of the mouth is WNL, no other systemic signs a. Neurofibromatosis b. Lymphangioma * c. Granular cell tumor

ODONTOGENIC KERATOCYST:

Keratocystic odontogenic tumor (OKC) = rare benign but locally aggressive developmental cystic neoplasm. often affects the posterior mandible but can extend to maxillary. Usually, a lucent unilocular lesions extending Along mandible, presents with swelling & pain, & has a high reoccurrence rate. • Originates from epithelial cell rests (stratified squamous keratinizing epithelium). • Basal cell nevus syndrome (a.k.a. Gorlin’s syndrome, multiple OKC’s seen)

*QUESTION: Which highest incidence of recurrence? • Odontogenic keratocyst • Dentigerous cyst • High recurrence, Intrabony, posterior mandible but anywhere; BCNS association

QUESTION: Initial treatment for OKC is enucleate or resect? • Conservative treatment generally includes simple enucleation, with or without curettage

NEVOID BASAL CELL CARCINOMA:

Nevoid basal cell carcinoma (Gorlin syndrome) = commonly see multiple OKCs and palmar pitting, plantar keratosis (odontogenic keratin cyst, KCOT)

QUESTION: Pt has calcified falx cerebri, multiple OKCs, bifid ribs. What syndrome does the patient have? Gorlin Goltz syndrome aka Basal cell bifid rib syndrome

QUESTION: What is most often seen with nevoid basal cell carcinoma? Odontogenic keratocyst

QUESTION: What does multiple OKC indicate? Gorlin-Goltz syndrome (also called basal cell nevus syndrome)

QUESTION: Nevoid basal cell carcinoma causes – Cyst in the jaws

QUESTION: Nevoid BCC and palmar melatonin indicative of: OKC

GARDNER’S SYNDROME:

Gardner syndrome, a variant of familial adenomatous polyposis (FAP), is an autosomal dominant disease characterized by GI polyps, multiple osteomas, and skin/soft tissue tumors. Cutaneous findings of Gardner syndrome include epidermoid cysts, dermoid tumors, and other benign tumors.

QUESTION: Which syndrome includes multiple osteomas? Gardner’s (Multiple facial osteomas & skin nodules)

QUESTION: Gardner’s syndrome has Multiple osteoma, odontoma and intestinal polyps

*QUESTION: What do Gardner’s and Peutz-Jeghers syndrome have in common? GI polyps GI polyps in Gardner’s, Peutz-Jegher, Crohn’s

*QUESTION: In Gardner’s Syndrome, there may be cancerous transform of what? Polyps in intestine

PEUTZ-JEGHERS SYNDROME:

Peutz–Jeghers syndrome = autosomal dominant disorder characterized by the development of benign hamartomatous polyps in the GI tract & hyp agonists for the insulin receptor, pigmented macules on the lips and oral mucosa (melanosis)

QUESTION: Peutz Jeghers and Pierre showed up on my exam. They gave only description and you had to diagnose.

QUESTION: Peutz Jeghers syndrome? Not cafe au lait, but freckles on lips.

*QUESTION: Peutz-Jeghers syndrome – Multiple melanotic macules and gastrointestinal polyposis

*QUESTION: Peutz-Jeghers syndrome: Intraoral melanin pigmentation and multiple intestinal polyps

BELL’S PALSY:

QUESTION: Photo of a black person w/ unilateral eye & lip, unable to close. ID the condition? Bell’s Palsy

QUESTION: Herpes simplex is most common cause for Bell’s palsy

QUESTION: What causes bell’s palsy? Idiopathic

*QUESTION: Which cranial nerve affected bell’s palsy? Facial nerve (7th)

*ERYTHEMA MULTIFORME:

Erythema multiforme = skin condition of unknown cause, possibly mediated by deposition of immune complexes (mostly IgM) in the superficial microvasculature of the skin & oral mucous membrane that usually follows an infection or drug exposure.

QUESTION: Target lesions? Erythema Multiforme (also has positive Nikolsky sign) • Nikolsky sign - top layers of the skin slip away from the lower layers when slightly rubbed.

QUESTION: Steven-Johnson syndrome? Conjunctiva and genital problems • Stevens–Johnson syndrome, a form of toxic epidermal necrolysis, is a life-threatening skin condition, in which cell death causes the epidermis to separate from the dermis

QUESTION: Blow cold air on mucosa causing a positive Nikolsky sign a) Erythema multiforme b) herpes c) pemphigoid d) epidermolysis bullosa NO PEMPHIGUS AS ANS CHOICE.

SCLERODERMA:

Scleroderma (systemic sclerosis) = chronic systemic autoimmune disease characterized by hardening (sclero) of the skin (derma) & CT. Blue fingers, hair loss, skin hardness & skin that is abnormally dark/light. scleroderma - symmetrical widening of PDL and deposition of collagen in organs leads to organ failure.

QUESTION: Widening of PDL and loss of mandibular ramus: Scleroderma

QUESTION: CREST Syndrome = limited SCLERODERMA (usually only in lower arms & legs, sometimes face & throat)

GEOGRAPHIC TONGUE (ERYTHEMA MIGRANS):

Geographic tongue (benign migratory glossitis, erythema migrans) = inflammation of mucous membrane of tongue, usually on dorsal surface. j. Characterized by areas of smooth, red depapillation (loss of lingual papillae) which migrate over time. Cause is unknown but condition is benign.

QUESTION: Description of geographic tongue: Burning sensation on the tongue, moves around

QUESTION: Migratory glossitis picture: red-white borders – Erythema migrans

*QUESTION: Guy with lesions on his tongue that seem to move locations? Erythema migrans

*QUESTION: Cause of geographic tongue: Unknown

QUESTION: Lesion hurts after eating spicy food, has white lesions with red borders that move: Geographic tongue

BASAL CELL CARCINOMA:

BCCs = Abnormal, uncontrolled growths or lesions that arise in the skin’s basal cells, which line the deepest layer of the epidermis.

QUESTION: Oral path picture of Basal Cell carcinoma: Round bluish lesion on side of lip

QUESTION: Painless ulcer, upper lip, it grew bigger after 2 weeks - Basal cell carcinoma

MUCOCELE:

Mucocele = caused by ruptured salivary duct, commonly seen on the lower lip, & usually due to trauma. • NEVER ON THE GINGIVA

*QUESTION: Most common location for mucocele? Lower lip

QUESTION: Patient had SSC removed and now has a mucocele looking lesion on the lower lip, what is it? Mucocele, other choices fibroma, SSC

QUESTION: You get mucocele due to? Rupture of salivary ducts (trauma related)

RANULA:

* = noncancerous cyst-like swelling of CT consisting of collected mucus from a ruptured salivary gland caused by local trauma. Texture/consistency of dermoid cyst vs ranula: dermoid is doughy/rubbery consistency while ranula is more fluctuant, bluish

*QUESTION: Ranula blue mass under tongue, blue nodule on the floor of mouth, fluctuant

QUESTION: Lady presents w/ blue swelling under tongue? Ranula

QUESTION: Ranula are due to? Sialolith Mucus plug Trauma Fibrous plug

QUESTION: Trauma to floor of mouth • Mucocele • Submandibular hemangioma • Ranula

QUESTION: How do you treat a ranula? Excise (all of it)/excisional, incisional, aspiration

SIALOLITHIASIS + ANTRAL PSEUDOCYST

Sialodochitis (ductal ) = inflammation of the duct system of a salivary gland. On sialography, it may appear as segments of duct dilation & stenosis. This is sometimes termed the 'sausage link appearance'.

*QUESTION: Sialolithiasis (calcified salivary stone) is found where? Submandibular Duct (Wharton’s)

*QUESTION: Sialoliths are most common in what gland? Submandibular gland and duct

QUESTION: Some histology question about the parotid gland. Mentions “SAUSAGE LINKS”: Answer is

QUESTION: Parotid gland – Chronic sialodochitosis

QUESTION: Patients with sialadenitis (actini enlarge) caused by sialith in the duct.

QUESTION: How do you treat painful sialolith in Wharton’s duct initially? Moist heat Dilation of duct Surgically remove sublingual gland Surgically remove submandibular gland (cannulate the duct and remove stone) (massage or lemon drops not an option)

• If it is a smaller stone, moist heat is the first option

QUESTION: Patients with sialadenitis (actini enlarge) caused by sialith in the duct. It is a large, painful sialolith near the orifice of Wharton’s duct. What procedure do you do for removal? a. Transoral to unblock duct b. Extraoral to remove gland c. Cannulation & dilation (Cannulate the duct (sialotomy) to remove stone)

QUESTION: Mucous retention cyst: located on sinus floor, near the ostium, or within antral polyps • May be caused by sinus infections, allergies, or odontogenic conditions • Usually very small and can’t be seen clinically or on radiograph • No treatment needed

QUESTION: Something in maxilla Antral pseudocyst? • The mucocele is destructive and requires surgery while the Antral Pseudocyst (mucous retention pseudocyst) does not require intervention and will dissipate. • Usually no other significant findings besides radiographically, no expansion or destruction of bone • Usually maxillary sinus floor, faint opaque appearance, well delineated

QUESTION: Antral Y (they also called it an “inverted Y”) • A radiographic anatomical landmark: The Y line of Ennis (Inverted Y). It is created by the superimposition of the floor of the nasal cavity (straight radiopaque line) and the border of the maxillary sinus (curved radiopaque line).

QUESTION: What is the inverted Y made up of? Maxillary sinus & floor of nasal cavity

QUESTION: What is the isthmus of Y (where nasal floor (straight radiopaque line) and maxillary sinus (curved radiopaque line) start and meet). What are the two anatomical factors that border this? Floor of nasal cavity and maxillary sinus

QUESTION: Radiograph of earlobe and turbinate: Mucous retention cyst or antral pseudocyst in maxillary sinus…inferior nasal turbinate

QUESTION: Photo of maxillary sinus with radiopacity in one of the sinus and you have to identify the condition: Mucous retention cyst, antral cyst

ANKYLOGLOSSIA:

*QUESTION: Ankylglossitis- Tongue tied • Congenital oral anomaly that may decrease mobility of the tongue tip & is caused by an unusually short, thick lingual frenulum from tongue to FOM.

PARULIS (GUM BOIL):

Parulis = localized collection of pus in gingival soft tissue. Pus is produced as a result of necrosis of non-vital pulp tissue or occlusion of a deep periodontal pocket.

*QUESTION: Picture of #30 RCT tooth Parulis

QUESTION: Photo ID: Parulis

QUESTION: Reason for parulis - Incomplete root canal

TUBERCULOSIS:

Oral signs of tuberculosis = cervical lymph nodes, larynx, and middle ear. TB oral lesions are uncommon - usually chronic painless ulcers. • Primary lesions usually enlarged lymph nodes. • Secondary lesions on tongue, palate and lip. Rare is leukoplakia areas.

QUESTION: What does tuberculosis lesion in the oral cavity look like? Large ulcer • Painful non-healing indurated often multiple ulcers • Most frequently affected sites were the tongue base & gingiva. The oral lesions look like irregular ulceration or a discrete granular mass.

HEMANGIOMA/EXTRAVASATED BLOOD:

*QUESTION: Hemangioma excised from tongue. Which is it? Hamartoma…choristoma, teratoma • Hemangioma – positive test for blanching

QUESTION: 4 yr. old kid has hemangioma on his tongue from birth. It grew at the same rate he did. What is it? Hamartoma…choristoma, teratoma • HAMARTOMA- Normal tissue overgrowth. It grows at the same rate as surrounding tissues. • CHORISTOMA- TISSUE overgrowth in wrong location

QUESTION: What goes away from mouth by itself? Ecchymosis • Ecchymosis - a discoloration of the skin resulting from bleeding underneath, typically caused by bruising.

ALLERGIC MUCOSITIS:

QUESTION: Allergic stomatitis of the mouth is commonly seen because of what flavors in a toothpaste? Cinnamon

*QUESTION: Causes of allergic gingivitis include: a. Flavoring in toothpaste b. Food coloring in foods c. Fluoride in toothpaste

QUESTION: Patient has red gums and is told she has “”. Common cause is? Cinnamon flavoring in the dentifrice

CROHN’S DISEASE:

QUESTION: Child with granulomatous gingival hypertrophy and bleeding from rectal/anus has what? Crohn’s • Crohn’s = chronic inflammatory bowel disease that affects the lining of the GI tract.

QUESTION: Oral granulomas, aphthous ulcer, rectal bleeding is seen in: a. Wegener’s granulomatosis b. Ulcerative colitis c. Crohn’s disease

DERMOID CYST:

QUESTION: Which would be located in the floor of the mouth and be “doughy”? A Ranula B. Dermoid cyst C Lymphoepithelial cyst

• Dermoid cyst is a firm, dough-like, sac-like growth on or in the skin that is present at birth & range in size.

WHITE SPONGE NEVUS:

White sponge nevus = autosomal dominant, usually presents bilaterally/symmetrically. It usually appears before puberty. Often mistaken for Leukoplakia but leukoplakia differs in that it presents later on in life. • Shows up as thick bilateral white plaque w/ spongy texture, usually on buccal mucosa but sometimes on labial mucosa, alveolar ridge or FOM. Very rarely, gingival margin + dorsum of tongue.

QUESTION: White lesion on movable mucosa that you can’t wipe/stretch off? Leukoplakia or White sponge nevus

QUESTION: Patient has bilateral white lines at occlusal plane, what is primary microscopic finding? White Sponge Nevus

QUESTION: Buccal cheek of 60-year-old man, not wipeable? White spongy nevus…leukoplakia (more on floor 50%, tongue 25%), candida

*TRIGEMINAL NEURALGIA:

Trigeminal neuralgia:

*Age: Average age of pain onset in trigeminal neuralgia typically is 6th decade of life, but it may occur at any age. Symptomatic or secondary trigeminal neuralgia tends to occur in younger patients > 35 years

*Nature of pain: Pain is stabbing or electric shock like sensation and is typically quite severe. Pain is brief (few seconds to 1-2 minutes) and paroxysmal, but it may occur in volleys of multiple attacks. Pain may occur several times a day; patients typically experience no pain between episodes.

*Distribution of pain: Pain is one-sided (unilateral, rarely bilateral). One or more branches of the trigeminal nerve (usually lower or midface) are involved.

QUESTION: Patient feels pain on biting and feeling of fullness in maxillary posterior teeth. No decay noted, why? Atypical trigeminal neuralgia…sinusitis

*QUESTION: Carbamazepine is used for Trigeminal Neuralgia, do not use to treat constant, fascial pain. Use NSAIDS.

MAXILLARY SINUSITIS

QUESTION: Maxillary sinusitis bacteria: Strep pneumonia • Drug for max sinusitis: Amox with clavulanic acid (for b-lactamase strep)

QUESTION: Which of the following is most likely to be interpreted as toothache by the patient? Maxillary sinusitis can cause pain or pressure in the maxillary (cheek) area (e.g., toothache, headache)

CEMENTO-OSSEOUS DYSPLASIA:

Cemento-osseous dysplasia aka : • Usually 30-50 years old, African-American Female • Mandibular anterior VITAL teeth • Asymptomatic periapical radiolucencies, which transform to radiopacities • No treatment required

Cementoma (periapical cemental dysplasia) - usually occurs in the anterior region of the mandible, starting as a radiolucent lesion that eventually calcifies. Cementoma DOES NOT affect pulp vitality. Asymptomatic = no bone expansion. Periapical cemental dysplasia; periapical osseous dysplasia

*QUESTION: X-Ray: Black women, middle aged, anterior radiolucency (can be radio opaque), vital teeth: cemento osseous dysplasia, Periapical cemental dysplasia

QUESTION: Most common place for periapical cemental dysplasia: Lower anteriors

*QUESTION: #25 has radiopaque lesion at apex. It has normal PDL, vital, tissues normal, no caries or existing restoration? Periapical cemento-osseous dysplasia

QUESTION: Focal White females vital edentulous one lesion: Focal Cemento-Osseous Dysplasia • 30-50 white female • Posterior mand / asymptomatic solitary lesion

PERIPHERAL OSSIFYING FIBROMA:

Peripheral Ossifying Fibroma = gingival nodule composed of cellular fibroblastic connective tissue stroma, which is associated with the formation of randomly dispersed mineralized products (bone, cementum-like tissue, or dystrophic calcification).

QUESTION: Which of the following reactive lesions of the gingival tissue reveals bone formation microscopically? Peripheral ossifying fibroma

NEUROFIBROMATOSIS (Von Recklinghausen):

Neurofibromatosis (benign tumor of peripheral nerves) = autosomal dominant disorder that causes tumors to grow in supporting cells that make up the nerve & myelin sheath • Patients usually present with an uninflamed, slowly enlarging, asymptomatic lesion that varies greatly in size from tiny nodules to large pendulous masses. The lesion is rarely painful. café au lait spots & lisch nodules!

*QUESTION: Clinical picture with nodules & café au lait spots: Neurofibromatosis

QUESTION: Café-Au-Lait – Neurofibromatosis **Von Recklinghausen Disease—neural tumors… all these bumps all over it’s disgusting. (Remember that McCune Albright Syndrome – Polystotic FIBROUS DYSPLASIA also has café au lait spots---fibrous bone replaces normal bone…Lisch nodules, café au lait Spots-Neurofibromatosis

QUESTION: An adult patient presents with multiple, soft nodules and with macular pigmentation of the skin. Which of the following BEST represents this condition? a. Lipomatosis b. Neurofibromatosis c. Metastatic malignant melanoma d. Polyostotic fibrous dysplasia e. Bifid rib-basal cell carcinoma syndrome

QUESTION: Which of these conditions have supernumerary teeth & lisch nodule on iris? Neurofibromatosis

*QUESTION: Neurofibromatosis clinical presentations: Café au lait, lisch nodules of the iris

AURICULOTEMPRAL SYNDROME/FREY’S SYNDROME:

QUESTION: Patient has problems on one side of their face when they eat following recent parotid surgery. Also mentioned something about nerve A. Papillon Leferve B. Frey’s Syndrome (strong salivation)

*QUESTION: Auriculotemporal syndrome (Frey syndrome) - symptom where you sweat near cheek area when eating. Often after parotid surgery.

*QUESTION: Auriculotemporal nerve is severed, what are the symptoms? Gustatory sweating

ACTINOMYCOSIS:

Actinomycosis = infectious subacute-to-chronic bacterial disease caused by filamentous, gram- (+) anaerobic bacteria (Actinomyces species). It is characterized by contiguous spread, suppurative and granulomatous inflammation, and formation of multiple abscesses and sinus tracts that may discharge sulfur granules. • Most common clinical forms of actinomycosis are cervicofacial (lumpy jaw), thoracic, and abdominal.

QUESTION: Actinomycosis of jaw presents how? Lumpy Jaw

QUESTION: Actinomycosis has abscess, draining fistula, & contains yellow sulfur granules. Tx is incision & drainage + antibiotics

QUESTION: Which disease is most likely to cause suppuration? Actinomycosis

CONDYLAR HYPERPLASIA:

Mandibular condylar hyperplasia = unknown etiology characterized by persistent or accelerated growth of the condyle when growth should be slowing or ended. k. Slowly progressive unilateral enlargement of the head & neck of the condyle causes malocclusion, facial asymmetry, and shifting of the midpoint of the chin toward the unaffected side. The patient may appear prognathic.

QUESTION: A patient presents with malocclusion and a unilateral, slowly progressing elongation of her face. This elongation has caused her chin to deviate away from the affected side. The MOST probable diagnosis is which of the following? A. Ankylosis B. Osteoarthritis C. Myofascial pain D. Condylar hyperplasia

DENS INVAGINATUS:

QUESTION: Dens in dente are most commonly seen in Maxillary lateral incisor.

QUESTION: is for? Dens evagenatus NOT invagenalis

KERATOANTHOMA:

Keratoacanthoma (KA) = relatively common low-grade tumor that originates in the pilosebaceous glands and closely resembles squamous cell carcinoma (SCC).

QUESTION: Lesion looks like SCC? Keratoacanthoma

QUESTION: Keratosis happen where in the mouth? a. Palate b. Buccal mucosa c. Floor of mouth d. Upper lip

QUESTION: A picture of basal cell or Keratoancathoma ...... on the face crater like with a crust in the middle keratoacanthoma has a bump with a crusty crater in the middle, but BCC can be pink, waxy/pearly, or skin colored or brownish. BCC is more reddish/can be flat while keratoacanthoma has a crust and looks really gross

SJÖGREN’S SYNDROME:

QUESTION: Sjogren’s – Autoimmune destroy glands

QUESTION: Sjogren’s syndrome: Destruction of salivary and tear duct, dry mouth

QUESTION: Complications of Sjogren’s syndrome – Keratoconjunctivitis, it involves the genitalia too.

QUESTION: Sjogren’s Syndrome associated with all EXCEPT Herpes Keratoconjunctivitis SLE

QUESTION: What is most common with Sjogren’s syndrome? Lymphoma (or maybe lipoma or some other growth), pleomorphic adenoma, increased sweating and osteoarthritis.

QUESTION: Which articular disease most often accompanies Sjogren’s syndrome? A. Suppurative arthritis. B. Rheumatoid arthritis. C. Degenerative arthrosis. D. Psoriatic arthritis. E. Lupus arthritis.

QUESTION: Xerostomia is present in all of the following except? Options were: Sjogren’s syndrome, Vit C. Deficiency (Other parotid problems) • Xerostomia is rarely due to a vitamin deficiency

QUESTION: Sjogren’s syndrome laboratory test: SS-A / SS-B (also ANA or Rheumatoid factor)

QUESTION: Secondary Sjogren’s Syndrome: Dry eye, dry mouth, rheumatoid arthritis

QUESTION: Which of these are used in lab test for Sjogren’s? ANA (antinuclear antibody) • Typical Sjogren’s syndrome ANA patterns are SSA/Ro and SSB/La

SARCOIDOSIS:

Sarcoidosis: abnormal collections of inflammatory cells (granulomas) that can form as nodules; nodules or ulcers intraorally

*QUESTION: Treatment of sarcoidosis? Corticosteroids, antibiotics

*QUESTION: TB is similar to? Sarcoidosis

*QUESTION: Sarcoidosis? Know that it is Granulomatous

*QUESTION: Sarcoidosis commonly involved organ: Lungs

*QUESTION: Sarcoidosis is mainly related to which organ? Predominately a pulmonary disease

OSTEOSARCOMA:

Osteosarcoma = aggressive malignant neoplasm that arises from primitive transformed cells of mesenchymal origin (and thus a sarcoma), that exhibits osteoblastic differentiation, & produces malignant osteoid. • Most prevalent in children & young adults. • Paget’s disease of the bone can lead to osteosarcoma • Symmetric widening of the periodontal ligament space is an early radiographic sign of osteosarcoma. Osteosarcoma in x ray: SYMMETRICALLY WIDENED PDL SPACE, SUN-RAY APPEARANCE

QUESTION: An 18-year-old male complains of tingling in his lower lip. An examination discloses a painless, hard swelling of his mandibular premolar region. The patient first noticed this swelling 3 weeks ago. Radiograph indicate a loss of cortex and a diffuse radiating pattern of trabeculae in the mass. Which of the following is the MOST likely diagnosis? a. Leukemia b. Dentigerous cyst c. Ossifying fibroma d. Osteosarcoma e. Hyperparathyroidism

QUESTION: Most common primary malignant tumor of young people? Osteosarcoma

QUESTION: Osteosarcoma in x ray: Sun burst and symmetrical widening of PDL.

QUESTION: Enlarge PDL and radiolucency at mandibular angle? Osteosarcoma sunburst

*QUESTION: Widening of PDL is early sign of what? Osteosarcoma

QUESTION: Uniform widening of PDL and there is resorption in the bone: Osteosarcoma, fibrous dysplasia

QUESTION: Patient has paresthesia and growth in mandible: is going to be Osteosarcoma (young patient)

MULTIPLE MYELOMA:

Multiple myeloma (plasma cell myeloma) = plasma cell cancer, a type of WBC normally responsible for producing antibodies. Initially, there are often no symptoms. When advanced bone pain, bleeding, frequent infections, and anemia may occur. Complications may include amyloidosis (buildup of amyloid proteins).

Multiple myeloma/plasma cell myeloma: • Monoclonal neoplastic expansion of immunoglobulin secreting B cells • Multiple punched out bone lucencies • High M protein in serum • Bence jones protein in urine (light chains) • Treatment: chemo, poor prognosis

QUESTION: Multiple Myeloma radiographic appearance? Punched out lesions

QUESTION: 1st sign of multiple myeloma: Bone pain (in limbs & thoracic region)

QUESTION: multiple myeloma = Plasma cell

NECROTIZING SIALOMETAPLASIA:

*QUESTION: Necrotizing sialometaplasia = painless ulcer on hard palate, goes away on its own w/ no scarring

*QUESTION: The mucosa of the hard palate is the usual intraoral site for which of the following conditions? Mucocele Sialolithiasis Minor aphthous ulcer Major aphthous ulcer Necrotizing sialometaplasia

ODONTOGENIC MYXOMA:

Odontogenic myxoma = uncommon benign odontogenic tumor arising from embryonic CT associated with tooth formation. As a myxoma, this tumor consists mainly of spindle shaped cells and scattered collagen fibers distributed through a loose, mucoid material (soap bubble appearance)

QUESTION: Pic of Myxoma pt. Usually in post. mandible, no symptoms, moves teeth, cortical expansion and root displacement, always radiolucent and honeycombed pattern

QUESTION: Soap bubble lesion in x-ray, what is it? Giant cell, Odontogenic Myxoma, often seen with impacted tooth l. Soap bubble lesion= odontogenic myxoma

QUESTION: Picture of Odontogenic Myxoma: Soups bubbles.

QUESTION: Odontogenic myxoma

OSTEOMYELITIS:

Bone infection = “onion skin” appearance

QUESTION: Girl with caries into the pulp on tooth #3 – radiograph shows alternating RL/path at inferior border of mandible (a.k.a “onion skin”, bacterial) Garre’s Osteomyelitis aka chronic osteomyelitis

*QUESTION: Garre's (proliferative periostitis) and Ewing sarcoma are both onion skin

RADIOLOGY

QUESTION: When there is no barrier, how far does the dentist need to be for protection? 6 feet, 90-135 degrees

QUESTION: Most of the x-ray is converted to? Heat

QUESTION: What is the oil in the x ray tube for? dissipate the heat (cooling) purpose of oil in x-ray tube housing prevent rust, reduce radiation, dissipate heat to the target, lubricate

QUESTION: Why is there oil in x-ray tube? cools off the anode

QUESTION: Thermionic emission where? Cathode Thermionic emission = electron emission from a heated metal (cathode). The cathode has its filament circuit that supplies it with necessary filament current to heat it up.

QUESTION: Something about what is the best x-ray: short wavelength, high energy

QUESTION: What is primary source of radiation to the operator when taking x-rays? radiation left in the air scatter from the patient scatter from the walls leakage from the x-ray head

QUESTION: In performing normal dental diagnostic procedures, the operator receives the greatest hazard from which type of radiation? A. Direct primary-beam B. Secondary and scatter C. Gamma

QUESTION: What characterizes secondary radiation? coming off the matter

*QUESTION: What is the max radiation dosage for a dental professional per year? 50msv/year or 5 rem/year m. per month = 4 msv, per week = 1 msv

QUESTION: Filament produces heat in the X-ray.

QUESTION: Digital image: which is digital detector? Charge coupled device

QUESTION: MRI uses what electromagnetic wave? RADIOWAVES

COLLIMATION

*QUESTION: What does collimation do? reduces x-ray beam size/diameter & volume of irradiated tissue, reduces area of exposure, reduce amount of scatter radiation by 60% Usually with circle diameter of 2.75 in

QUESTION: Collimator function is all but: Increase penetrability

QUESTION: Collimation in x-rays - Reduces low energy radiation

QUESTION: Collimation = Block (lead)

QUESTION: Collimation does everything except: Reduce average energy of x-rays (energy is unchanged)…reduce pt exposure, reduce operator exposure, film fog, • Scatter radiation decreases with change to rectangular collimator, film fog (scattered radiation that reaches the film, unwanted darkness decreased by collimation decreases and image quality increases.

*QUESTION: Collimating device on the x ray does all except: Prevents fogging

QUESTION: Collimation Control of size & shape of x-ray beam

QUESTION: The greatest decrease in radiation to the patient/gonads can be achieved by: a. change from D to F speed b. thyroid collar c. filtration d. collimation e. high doses low frequency

QUESTION: Which of the following safety techniques provides the GREATEST DECREASE in overall radiation-risk to patients? A. Changing from Group D to Group E film B. Switching from round to rectangular collimation C. Using an automatic rather than manual processing switch D. Adding a cervical collar to a leaded apron

*QUESTION: By what % do you decrease radiation when you use a square collimator vs. rectangular? 80%

FILTRATION

Filtration is a mechanism where the low quality, long wavelength x-rays are absorbed from the exiting beam. Aluminum disks absorb lower penetrating x-rays.

Inherent filtration = glass, oil

Total filtration = aluminum

QUESTION: the use of intensifying screens Reduce the radiation

QUESTION: X-ray filters are used for? Reduced intensity of electron beam, selectively absorbs low energy photons

QUESTION: Which material is used as a filter in X-ray machines? Lead, aluminum, others

QUESTION: filter absorbs: Long wavelength

*QUESTION: X-ray tube target metal is made out of: tungsten (target = tungsten/filter = aluminum)

ANGULATION

*Elongation & foreshortening occurs when there is excessive vertical angulation

*Central X-ray needs to be perpendicular to film and object • Perpendicular to object but not film: elongation • Perpendicular to film but not object: foreshortening

*If the head/chin position is too low, the images of maxillary anterior teeth will appear elongated & the mandibular anterior teeth will appear foreshortened. • Maxillary low = elongate, narrow • Maxillary high = foreshorten, widen • Mandibular low = foreshorten • Mandibular high = elongate

*If the head/chin position is too high (a lack of negative vertical angulation, the occlusal plane of the teeth will then appear horizontal or, with a positive occlusal plane, as a "frown line.") = reverse smile line

*QUESTION: What happens when you don’t have proper vertical angulation when taking x-rays – elongation of the object other options was fuzzy pic (either resolution or contrast)

QUESTION: Change in vertical angulation when taking a PA will cause what? A. Distortion B. Magnification C. Elongation or foreshortening

QUESTION: If you take a PA and the tooth is foreshortened, why did it happen? Vertical angulation was too large

QUESTION: Foreshortening of roots caused by Excess vertical angulation

QUESTION: X-ray beam is perpendicular to the film, not to the tooth, = foreshortening

QUESTION: Overlap on bitewings due to horizontal angulation

QUESTION: X-ray with cone cut. What’s wrong. MISALIGNED XRAY TUBE HEAD, incorrect beam centering (beam not aimed at center of film)

QUESTION: Pano – max centrals look abnormally wide –Position of pt head is too far back (chin tilt upward) • If pt is positioned too far backward, the anterior teeth image will be so wide that the outline of the crowns cannot be discerned. • Chin tilt up: o Mandibular look narrow o Maxillary look wide o Negative (reverse) smile line • Chin tilt down: o Positive (excess) smile line o Severed interproximal overlapping, anterior teeth appear distorted

*QUESTION: Reversed occlusal plane on pano? Chin raised too high, Patient head/chin tilted too far upward • Chin up = frown • Chin down = steeper smile

QUESTION: Pano, with short upper roots (palatoglossus air space present)? Patient’s didn’t put tongue on the top of their mouth.

Penumbra Penumbra = the fuzzy, unclear area that surrounds a radiographic image Larger Penumbra—DECREASE contrast, less sharpness • Influenced by: o Focal spot size: the smaller the focal spot, the sharper the image ▪ Increase distance between focal spot and object = increases sharpness ▪ Decreased distance between object and film = increase sharpness o Film composition: faster film (larger crystal) leads to less sharp image o Movement: causes loss of sharpness

QUESTION: Fuzziness on outside of radiograph due to: • Umbra • Penumbra

QUESTION: Penumbra is affected by all except: • Moving x-ray tube • Moving film • X-ray dimensions/field/scatter • Film-object distance (decrease) • Reduction of film target (focal spot) distance

QUESTION: How does penumbra affect the contrast of an x-ray? Decrease in contrast

*QUESTION: Penumbra – how to prevent this in x-rays: decrease size of focal spot, increase source/target/focal spot-object distance, and reducing object-film distance (should be parallel), central ray must be perpendicular to tooth, no movement.

QUESTION: How to reduce penumbra? Choices were moving object, decrease object/source distance, decrease object/film distance

QUESTION: How do you prevent penumbra? o Should be produced from a point source to blurring of the edges of the image o Strong beam to penetrate o X-ray should be parallel (reduce object-film distance)

QUESTION: PA distortion answer according to an article online is 14%, there was answer choices 3-5%, 11-15%?

QUESTION: Pano distortion is: 25% but could range 10-30%

QUESTION: What does it look like on a pano when your patient moves during the pano? A vertical blur line vs horizontal defect.

QUESTION: Big artifact in pano which was a ghost of a necklace.

TYPE OF X-RAYS

*Water's view is best to evaluate orbital rim areas and maxillary sinus

*QUESTION: If you have lesion of maxillary sinus, what kind of radiograph do you take? Waters

QUESTION: Which is most important x-ray for diagnosis of maxillary sinus? occlusal, panoramic, MRI, Waters

QUESTION: Best to see siaolilith in Wharton's? Cross sectional occlusal Water's PAN PA

QUESTION: Best imaging for sinusitis or sinus infection: CT, but had occlusal radiograph, PA radiograph, Panoramic. Know that sinuses are best viewed with Waters technique, but this was not in answer choice neither was none of the above as a choice. Answer will either be Waters or CT!

QUESTION: Which radiograph would you use to view a fracture of the mandibular symphysis? Posterio-Anterior or Mandibular Occlusal works too. • Lateral oblique for fractures in angle, body and ramus

RADIOGRAPH ANATOMY

*Know the SLOB rule. Also know Vertical rule, which is same as SLOB but in a vertical dimension. n. https://www.youtube.com/embed/AzjvFPlZtZg Coronoid process of zygomatic process of mandible maxilla on PA

1. Coronoid process of the mandible. Examine for 15. Pterygoid plates. coronoid hyperplasia. Tip of coronoid should not be 16. Pterygomaxillary fissure. Check for cortical integrity to more than 1cm above superior border of zygomatic rule out neoplasia. arch. 17. Orbit. 2. Sigmoid notch. 18. Inferior orbital rim. 3. Mandibular condyle. Evaluate for erosions, remodeling, 19. Infraorbital canal. The infra-orbital foramen should not eburnation, subchondral cysts, osteophyte formation be viewed if the patient was properly positioned. which may signal arthritis. 20. Nasal septum. 4. Subcondylar (condylar neck) region. 21. Inferior turbinate/soft tissue concha covering. 5. Ramus of the mandible. 22. Medial wall of the maxillary sinus. 6. Angle of the mandible. 23. Inferior border of the maxillary sinus. 7. Inferior border of the mandible. Evaluate #4 - 7 for 24. Posterolateral wall of the maxillary sinus. Examine the cortical integrity. Rule out fractures. content of the sinus for the degree of pneumatization. 8. Lingula. Check for antral pseudocysts, chronic mucosal 9. Inferior alveolar neurovascular bundle (mandibular hypertrophy, polyposis, mucocele or neoplasia. canal). Follow from lingula to mental foramen. In some 25. Malar process. pts, anterior extension which exits out the lingual 26. Hyoid bone. foramen will be visible. Evaluate relationship of 27. Cervical vertebrae impacted teeth to the canal. 28. Epiglottis. 10. Mastoid process. 29. Soft tissues of the neck. 11. External auditory meatus. 30. Auricle (earlobe). 12. Glenoid fossa (temporal component of the TMJ). 31. Styloid process. 13. Articular eminence. Look for zygomatic air cell defect 32. Oropharyngeal airspace. (ZACD). 33. Nasal air. 14. Zygomatic arch.

*QUESTION: External oblique ridge & hyoid bone, tongue

QUESTION: They liked to ask intermaxillary suture a lot which comes up clear on radiograph and it looks like a fracture (which is an answer choice), but it’s not. • Median palatal suture/intermaxillary suture

QUESTION: Nose vs lip line in radiograph

LIP LINE NOSE LINE

QUESTION: Best view for zygomatic arches: Panoramic

QUESTION: You have pano, what can’t you do without intraoral photos? Space analysis

QUESTION: Pano: arrow pointing b/w posterior wall of maxilla and posterior wall of zygomatic process of maxilla: Pterygomaxillary fissure • Tear drop shaped in max sinus - Pterygomaxillary fissure

QUESTION: Identify the following on x-ray: External oblique ridge, genial tubercle, Stylohyoid ligament on x-ray a. External oblique: running down roots on mandibular molars***

b. Genial Tubercle: radiopaque line under mandibular anteriors

c. Stylohyoid ligament

QUESTION: Pano, what is the round opacity under #24 and #25: Genial tubercles, nutrient canal, zygomatic process of maxilla, normal anatomy (I had lateral canal and I put that. Other choices were all pathological findings)

QUESTION: Nutrient canals seen radiographically are most common where? Mandibular incisors

*QUESTION: There was an x-ray pointing with arrow to the lower lingual anterior. The answer was nutritional canal.

MAND. TORI

QUESTION: Vertical BWX are better than horizontal BWX because? More alveolar bone

*QUESTION: What cannot be seen with a PA? pterygoid hamulus, coronoid notch, mental foramen, mand. Canal (?)

*QUESTION: What structure can you not see on a PA radiograph? - Hamular process Visible - Mental Foramen Visible - Coronoid process Visible - Mandibular foramen (too posterior & inferior)

QUESTION: Source/object distance for lateral ceph: 5 feet, 6 feet, 15 cm, 60 cm

*QUESTION: X-ray taken from mesial of max 1st premolar, buccal root will be where? mesial, distal, occlusal

QUESTION: What can you see on a radiograph? Lingual ridge height Root dehiscence Trabeculation pattern PDL • Others are either B-L view and technically you can only see the space of the PDL not actual PDL?

EXPOSURE:

Kvp: ability for the beam to penetrate tissues, energy mA: # of x-ray in a beam radiation quantity (not quality!), density & patient dose

YOU WANT TO HAVE HIGH KVP AND LOW mA for MOST penetration

Film Speed Group Speed Range (reciprocal roentgens) C 6-12 D (Kodak Ultraspeed) 12-24 E (Kodak Ektaspeed Plus) 24-48 F (Kodak Insight) 48-96

D to E will reduce radiation by 30-40% D to F will reduce radiation by 60% F to digital reduce radiation by 40%

Dark films (overexposed/image too dense): due to incorrect mA (too high), exposure (too long), incorrect kVp (too high).

Light films (underexposed/image not dense enough): due to incorrect mA (too low) or exposure (too short), incorrect focal-film distance, or cone too far from the patient's face, or film is placed backwards.

1 퐼푛푡푒푛푠𝑖푡푦 = ; 퐼푛푣푒푟푠푒푙푦 푝푟표푝표푟푡𝑖표푛푎푙 (퐷𝑖푠푡푎푛푐푒)2

Deterministic effects: has threshold, severity of effect is dose-related Stochastic effects: no threshold & no dose-related, probability of effect /likelihood that something will happen o. Stochastic effects are associated with long-term, low-level (chronic) exposure to radiation. Increased levels of exposure make these health effects more likely to occur, but do not influence the type or severity of the effect. Radiosensitive: Bone marrow, reproductive cells, lymphoid cells, immature cells, intestine. RadioRESISTANT: muscle, nerves

QUESTION: Digital X-rays have _____ less exposure from d-films to digital films: digital has 50% less radiation exposure

QUESTION: Digital x-ray vs D speed film, numbers: 10, 30, 60, I put 60. I forget what it was asking.

QUESTION: Going from a D speed film to digital film, What’s the speed difference? Speed increases

QUESTION: By reducing film speed from D to E & still keeping film density the same. What would you need to change? Decrease Exposure time

QUESTION: Latent period is time between when you exposed patient & clinical reaction to x-ray.

QUESTION: In radiobiology, the "latent period" represents the period of time between A. cell rest and cell mitosis. B. the first and last dose in radiation therapy. C. film exposure and image development. D. radiation exposure and onset of symptoms

QUESTION: Which electron shell has highest power? (f/d... outermost shell)

QUESTION: Which electron level has the highest binding energy? N K L OR M - K is located closest to the nucleus highest energy

*QUESTION: Radiographic Picture looks washed out/too light, no contrast, what was adjusted? • Decrease kvp • Increase kvp • Increase time • Less developing solution

QUESTION: What was the problem with x-ray that appears too white? incorrect distance from target to film distance, low mA, low density.

QUESTION: If x-ray is too dark, it was too long in developer solution. Dark films (overexposed/image too dense): due to incorrect milliamperage (too high), exposure (too long), incorrect kVp (too high)

QUESTION: You take an x-ray at a certain mA, KvP and exposure time is 8 seconds when the beam is 10 inches away. What if everything were the same except the beam was 20 inches away? quadruple the exposure time

QUESTION: You increase the distance of the tube by 2x the length, how much does the x-ray exposure decrease? intensity is decreased by 4

QUESTION: If change from 8 mm cone to 16 mm, how much exposure time do you need to increase by? 2, 4, 6, 8 Remember that going from an 8 mm to 16 mm cone means the cone/target is LONGER. This is the PID (target to film distance). If the PID is increased there is LESS magnification. If the PID is shorter there is MORE magnification. Also density (darker x-ray) increases when kA, mA and exposure are increased.

QUESTION: Increase PID distance from 8 to 16, exposure time change from 0.5sec to? 0.25, 1, 2, 3...... with paralleling technique.

QUESTION: The x-ray of an interproximal underestimates the size of the actual crater (other is overestimates and is same size)

QUESTION: How do you increase the average energy of the beam? Kvp versus mA

QUESTION: Deterministic radiology effects: increases effect with dosage-direct effect

QUESTION: The severity of response increases with the amount of X-ray exposure. This effect is called: Deterministic, Stochastic, Genetic

QUESTION: Radiation that is stochastic, with non-threshold effects would a clinician notice first – leukemia, skin burn, hair loss, bone marrow effect

QUESTION: Irradiation cause saliva to have lower - sodium content

QUESTION: Know how x-rays interact with matter: photoelectric effect photoelectric effect: electrons are emitted from matter (metals and non-metallic solids, liquids or gases) as a consequence of their absorption of energy from electromagnetic radiation of very short wavelength and high frequency, such as UV radiation. Electrons emitted in this manner may be referred to as photoelectrons.

QUESTION: Radiation injury from – free radical formation from indirect, free radical from direct

QUESTION: How do you minimize exposure radiation? minimizing the amount of tissue being radiated

QUESTION: Which type of radiation is constantly in effect: Inhaled radon radiation, not terrestrial or cosmic

QUESTION: Most radiation from nature – Inhaling radon, internal, terrestrial, cosmic

QUESTION: Dentist is more exposed to what type of radiation besides machine? Scatter tube Scatter patient Scatter wall

QUESTION: How does x-rays primarily damage cells? Hydrolysis of water molecules

QUESTION: Radiation induced mutation is the result of? Hydrolysis of water molecules.

*QUESTION: Which structure is most radio sensitive: hemopoitic bone marrow

QUESTION: Radiation injury from – free radical formation from indirect, free radical from direct

QUESTION: What is most radio-resistant cell: Muscle

QUESTION: Which one of the following tissues is least sensitive to ionizing radiation: muscle, lymphocytes, squamous epithelium

QUESTION: What will cause xerostomia: chemo or radiation?

QUESTION: Radiation of 4(Gy) to the skin will cause? Erythema

*QUESTION: A higher kilovoltage produces x-rays with: Greater energy levels More penetrating ability Shorter wavelengths Increase in density

QUESTION: KVp increase leads to more penetrating, high energy

QUESTION: Increasing mA results in an increase in: Temperature of the filament & Number of x-rays produced

QUESTION: Increasing mA alone results in a film with: High contrast

QUESTION: If you increase distance, then you need to increase mA

QUESTION: How do you change from a low contrast (longer scale of contrast) to a high contrast (shorter scale) without changing density: increase mA and kvp, decrease mA and kvp, increase kvp decrease mA, decrease kvp increase mA

QUESTION: If something is a structure in mouth is thick – it absorbs more radiation, appears more radio-opaque on x-ray

OSTEONECROSIS & BISPHOSPHINATES

Osteonecrosis is more common with IV drugs like Zolmeda (zoledronic acid) and aredia (palmidronate), NOT Fosamax or boniva). Suffix: -dronate

Oral Bisphosphates IV Bisphosphates p. Alendronate (Fosamax) s. Ibandronate (Boniva) q. Risedronate (Actonel) t. Zoledronic Acid r. Ibandronate (Boniva) (Reclast) u. Pamidronate (Aredia)

*QUESTION: To get , radiation dose must be: Above 50 gys (above 60)

QUESTION: Which is greater risk for ORN? IV bis for a year, radiation 65 grays

*QUESTION: Bisphosphonates used for all except: multiple myeloma, osteomyelitis, metastasis to bones from breast cancer, metastasis to bones from prostate cancer

QUESTION: Indication for bisphosphonates: osteoporosis

QUESTION: Does bisphosphonate add calcium to bone No, it inhibits osteoclast via apoptosis

QUESTION: What is the mechanism of action of bisphosphonates? Inhibit osteoclasts

*QUESTION: Why is orthodontic contraindicated in this patient? pt is taking Aredia (IV bisphosphonates)

QUESTION: What is not true about a patient who takes Fosamax and will need an invasive procedure? Discontinue Fosamax 1 week before procedure (that stuff stays in the system longer than that)

QUESTION: Pt taking bisphosphonates for 1 yr. IV, highest risk during dental tx? Osteonecrosis

QUESTION: Pt doesn’t like her bridge & didn’t like her smile. Can you do bone graph in a bisphosphonate pt and would it last? NO BONE GRAFTING

QUESTION: A scenario about a patient who is taking bisphosphonates and gets . Diagnosis is? a. Osteonecrosis without radiation b. Osteonecrosis with radiation Answer is the first one bc it did not say anything about osteoRADIOnecrosis. You get necrosis due to the bisphosphonates.

QUESTION: Osteonecrosis of jaw - more common in mandibular & has nothing to do with radiation

QUESTION: Osteoradionecrosis most associated w/ what? Mandible

QUESTION: Osteoradionecrosis scenarios – pre-extract questionable teeth, hyperbaric oxygen pre and post if doing invasive procedures

*QUESTION: Pt has stage 1 osteonecrosis from bisphosphonate. What do you do? debride area or rinse with chlorhexidine If STAGE 1 - rinse Chlorhexidine If STAGE 2 - Refer to OS or do under Hyperbaric O2

*QUESTION: Pt has a history of osteonecrosis & IV bisphosphonates but extractions are needed, what do you do? Do it under hyperbaric O2

QUESTION: Best tx for bisphosphate pt: Section crown off & still do RCT

ANEMIA, BLEEDING TESTS & MEDS

ANEMIA

***Difference between aplastic, pernicious, sickle cell anemia • Aplastic anemia: bone marrow doesn't make enough new RBC. • Sickle cell anemia: contain abnormal hemoglobin called “sickle hemoglobin” or hemoglobin S, autosomal recessive • Pernicious anemia: body can't make enough healthy RBC b/c lack of vitamin B12. They lack intrinsic factor, a protein made in the stomach. A lack of this protein leads to vitamin B12 deficiency. • Microcytic hypochromic anemia - iron deficiency anemia (most common) • Hemolytic anemia – RBC are destroyed & bone marrow can’t produce fast enough

QUESTION: Which is not a contraindication for a patient w/ sickle cell anemia or something like that? Nitrous oxide…infection, trauma, cold

*QUESTION: Which hemoglobin is affected in sickle cell anemia? S (hemoglobin S is an inherited variant of normal adult hemoglobin)

QUESTION: Pt has sickle cell anemia & has a thrombolytic crisis, what could precipitate this? a. Nitrous oxide / oxygen use b. Cold c. Trauma d. Infection • Sickle cell anemia is seen exclusively in black patients. Periods of unusual stress or of O2 deficiency (hypoxia) can precipitate a sickle cell crisis.

*QUESTION: What disease is more predominate in males? Mandibular dysostosis (Treacher Collins syndrome) Hypothyroidism Diabetes Sickle cell anemia Hemophilia

QUESTION: Which one of the following effects males almost exclusively? Hemophilia (it is carried by the female but only effects the male) Downs Diabetes

*QUESTION: Macrocytic anemia which vitamin deficient? A, B, C, D, E

*QUESTION: Which one is microcytic anemia? Iron deficiency anemia

BLOOD TEST & MEDICATIONS + HERBAL SUPPLEMENTS

Anti- coagulants act to antagonize Vitamin K to work & prolong bleeding. INR used for Coumadin patients. Warfarin: anti-coagulant that inhibits vitamin K reductase, which resulting in depletion of the reduced form of vitamin K (vitamin KH2). Synthesis of vitamin K-dependent coagulation factors 2, 7, 9, and 10 and anticoagulant proteins C and S is inhibited (extrinsic pathway—PT)

Heparin: anti-coagulant reversibly to anti-thrombin II & prevents conversion of fibrinogen to fibrin. Dicoumarol: anti-coagulant that inhibits vitamin K reductase & affects K-dependent coagulation factors Hemophilia: X-linked, recessive disorder, Hemophilia A = Factor 8, Hemophilia B = Factor 9

*QUESTION: Pt is taking warfarin (Coumadin), what test do you run prior to extraction or surgery: INR (= 2.0-3.0)

QUESTION: What is the best way to test clotting function on a patient taking Warfarin? INR

QUESTION: Patient is taking warfarin, what could you do? Proceed with treatment because his INR is < 2.5

QUESTION: INR deals with PT. INR = 1 is normal (12 seconds) • The higher the INR, the greater the anticoagulant effect (more bleeding, higher PT value)

*QUESTION: What INR is OKAY to place implant? 2.5, 3.5, etc *Bleeding measurements: PTT 25-36 sec PT 5-7 sec platelets 150K-450K minimum platelets 50k bleeding time: less than 9 min INR: 1 do not treat with more than 3.5

QUESTION: Patient is on Coumadin, what do you do prior to extractions? Depends on INR, technically you should refer for INR a. Stop for 1 day b. Stop medication for 5 days (stop drug 5 days before, and resume the day after surgery) c. Do not need to stop medication • Don’t need to stop unless they have other co-morbid conditions and a physician’s consult instructed to do so

*QUESTION: How does warfarin work on anti-coagulation (MOA)? Decrease K+ needed to synthesize factors II, VII, IX, X

QUESTION: The most important anti-coagulant effect of heparin is to interfere with the conversion of

A. PTA to PTC. B. PTC to Factor VIII. C. fibrinogen to fibrin. D. prothrombin to thrombin.

*QUESTION: Pt taking dicumorol (Vit K antagonist) is probably treated for? Coronary infarct/Myocardial infarction

QUESTION: Coumadin (warfarin): give vitamin K

*QUESTION: Alcoholic patient comes in for extraction? order: PT/INR

*QUESTION: Severe alcoholic now recovering needs 24 tooth extraction, which tests are needed? INR, CBC

QUESTION: Alcoholic patient is about to undergo surgery. Which blood work test is most important? - creatinine - PT/ extrinsic system (Vit. K coagulation factors-2,7,9,10); used to test warfarin/Coumadin effectiveness, for liver damage, and Vit. K status - PTT intrinsic system; used to test Heparin - Bleeding time a. QUESTION: Accurate way to detect blood alcohol in the body except a. liver glucuronidation b. weight c. amount of food in stomach (amt of food in stomach dictates how fast your blood alcohol level will increase) d. percentage of alcohol in drink e. how fast you drank it

QUESTION: Best way to determine platelet function: a. platelet count b. bleeding time c. PTT d. INR

QUESTION: Aspirin burn is due to: coagulation necrosis.

QUESTION: What does aspirin affect? Extrinsic, intrinsic, bleeding time, common pathway

QUESTION: Aspirin decrease platelet function

QUESTION: What determines the bleeding time? Intrinsic, extrinsic, platelet adherence, common pathway • Bleeding time = time required for blood to stop (2-6min normal) • Bleeding time is increased in disorders of platelet count, uremia, and ingestion of aspirin and other anti-inflammatory medication

QUESTION: Aspirin has no effect on PT, PTT, or INR It affects platelets & bleeding time.

*QUESTION Aspirin is CONTRAINDICATED with which of the following drugs? A. Coumadin (Coumadin®) B. Triazolam (Halcion®) C. Barbiturates (Phenobarbital®) D. Pentobarbital (Nembutal®) E. Methylprednisolone (Medrol®)

QUESTION: Patient is taking aspirin for hypertension? Consultation with physician

*QUESTION: Clopidogrel (Plavix) and aspirin: alter platelet function, inhibits platelet aggregation irreversibly

QUESTION: What affect does Plavix has? Inhibits platelet aggregation • Given to patients allergic to aspirin, no ulcer side effect, given to patients with past ulcer history

QUESTION: Prostaglandin inhibitor will cause all except? Decrease gastric mucous • Inhibit acid secretion • Stimulate mucous and bicarbonate secretion

QUESTION: What makes prostaglandin: Arachidonic acid

QUESTION: Ginseng is an antiplatelet (interferes with coagulation – not given with aspirin). pt on warfarin, aspirin

QUESTION: Pt takes ginseng for energy, but it will interfere with ASPIRIN (not digitalis) • Ginseng = antiplatelet

QUESTION: Pt is taking ginseng, what do you want to avoid? Warfarin, NSAIDS, and Aspirin

*QUESTION: Pt taking ginseng. Which med should be avoided? • Penicillin • Aspirin • Digitoxin

QUESTION: Pt. is taking saw palmetto, what do you want to avoid? Aspirin

QUESTION: HERBAL supplement that potentiates anti-coagulation 1. St. John’s Wart 2. Saw Palmetto 3. Chamomile 4. Licorice

QUESTION: Before doing extraction you look at a patient’s CBC report. What causes you to contact patient’s physician? Hematocrit was given as 25

• Normal values are males = 45% & females = 40%

QUESTION: Pt has an INR = 1.75. What do you do after extraction to control bleeding? Keep stuffing shit in it, bite on normal gauze, squeeze b/l plate to collect bone fragments

*QUESTION: Warfarin = INR. Know numbers! I got pt with INR of 12.5, then asks what to do next. Classmate had same questions with INR of 2. • INR for patient on Warfarin should be between 2-3; may be higher (4) for patient with prosthetic heart valves • INR of equal to or less than 3.5 is fine for simple extractions • INR of normal patient not on warfarin is 1

QUESTION: Extractions for a pt with an INR of 2. what should you do? a. extract, use sutures, hemostatic agents b. gets pt off Coumadin for 2 days before extraction c. Continue treatment • Mosby’s states that normal INR of people on anticoagulants is 2.5-3.0.

QUESTION: Patient had extraction and socket is still bleeding 5 hours later? Refer for INR

QUESTION: Tooth extraction. 3 days later, area starts to hemorrhage, what is the cause? Fibrinolysis

QUESTION: PT (12-14 secs, Factors 2, 7, 9, 10) and INR are extrinsic pathway.

QUESTION: PTT – intrinsic factor 8, 9, 11, & 12 test for detecting coagulation defects of the intrinsic system – hemophiliac

QUESTION: Factor VIII is hemophilia A

*QUESTION The drug contraindicated in pt taking gingko biloba: HEPARIN

DIABETES

Hypoglycemia signs: headache, mental confusion, somnolence, tremors, nervousness, bradycardia, mydriasis (pupil dilation), diaphoresis (sweating)

QUESTION: Overweight patient that has to piss twice (x2) at night. What condition? Diabetes

QUESTION: Diabetes is more common: Black men

QUESTION: Hb1Ac: measuring glucose level over extended period

QUESTION: Diabetes patient should be monitoring daily except for what? NOT glucose in urine

QUESTION: Pt who took too much insulin will have all except? Hyperglycemia

QUESTION: Decrease in glycogenosis in the liver would be expected with Insulin

*QUESTION: Sign of hypoglycemia – bradycardia, mydriasis (pupil dilation), diaphoresis (sweating), mental confusion

*QUESTION: Pt appears disorientated & hypoglycemic what do you do? administer glucose

QUESTION: Which is a risk factor for hypoglycemia? Age, alcohol, hypertension • Risk factors for the development of hypoglycemia: exercise, alcohol, older age, renal dysfunction, infection, decreased intake of energy, and mental health issues, including dementia, depression, and psychiatric illnesses. *QUESTION: Ketone breath: Diabetes type 1/hyperglycemic

*QUESTION: Ketone breath & altered state of consciousness? Hyperglycemia

*QUESTION: Type I Diabetes can lead to: a) Aphasia b) Ataxia c) Blindness d) Deafness

QUESTION: Common complication of Type I diabetes: blindness (retinopathy)

MEDICATIONS FOR DM:

2nd generation Sulfonylureas: Enhance insulin secretion from beta cells of pancreas (glyburide, glipizide, glimepiride)

Biguanide: decrease liver glucose production, decrease intestinal absorption of glucose, improve insulin sensitivity by peripheral tissues (metformin)

Alpha glucosidase inhibitors: slow carbohydrate digestion so glucose enters blood more slowly (acarbose, miglitol)

Insulin: Rapid acting (5-15min); Short acting (30-60min); Intermediate (2-4h); Long acting (6-10h); Premixed (30-60min)

QUESTION: Glucocorticoids are contraindicated in: Diabetes • Steroids can raise blood sugar & increase the need for more medication to control sugar levels. Diabetics on steroids may have to raise their insulin dose dramatically.

QUESTION: Oral hypoglycemic drug for diabetes? sulfonylurea & metformin

QUESTION: Why don’t you give sulfonylureas to Type I diabetic patients? They do not have beta cells for insulin & Sulfonylureas MOA is to stimulate those cells

QUESTION: How do Sulfonylureas work? Stimulate insulin release from Beta cells in the pancreas, stimulate binding, decrease glucagon levels.

QUESTION: MOA of sulfonylurea- Increase insulin PRODUCTION and SENSITIVITY by Beta cells stimulation by binding to ATP- dependent K channels • Stimulating pancreatic insulin release by bind to ATP K+ channels & causing depolarization, which stimulates calcium ion influx & induces insulin secretion.

QUESTION: Metformin suppresses glucose production in liver (decreasing hepatic gluconeogenesis) decreases glucagon levels) – bind to AMP protein kinase receptors • Glucagon: Prevent glucose level from dropping too low, glycogenolysis (liver make more glucose)

*QUESTION: Proposed modes of action for the oral antidiabetic agents include each of the following EXCEPT one. Which one is the EXCEPTION? 1. Blockade of glucagon release from pancreas 2. Blockade of catecholamine release from adrenal medulla 3. Stimulation of insulin release from pancreatic beta cells 4. Action as direct receptor agonists for the insulin receptor 5. Increase affinity of tissues for utilization of available plasma glucose

QUESTION: How are the various preparations for diabetic drugs classified by? by duration of action (insulin types), MOA, etc

PERIO/ENDO DISEASE + DIABETES

Controlled diabetic patients do not get more than non-diabetic patients.

QUESTION: Controlled diabetes has same perio problems as those who don’t have diabetes: TRUE

QUESTION: What is not true regarding patient with diabetes and perio? either increase of crevicular fluid or increase of sugar in crevicular fluid (of these two choices, 1st is better because there is sugar in the fluid) • GCF glucose concentration same in diabetic and non diabetic • GFC glucose concentration increased in exudate of diabetic compared to non diabetic • GFC flow rate higher in diabetic than non diabetic • Raised levels of proinflammatory cytokines in GFC of diabetic

QUESTION: Patient with diabetes, which finding is not consistent? Increase collagenase in crevicular fluid Increase glucose in crevicular fluid Increase gram negative in crevicular fluid Decrease in thickness of basilar lamina of blood vessels in periodontium

QUESTION: Diabetic patients have more of the following except: higher glucose levels in gingiva, increased anaerobic bacteria in pockets, increased IL-1, increased collagenase

QUESTION: Diabetics are more prone to perio and are less resistant to the effects of bacteria. Both statements are true

*QUESTION: By recent studies, which one has a correlation with periodontitis? Diabetes - diabetics are 15x higher at risk

QUESTION: Pt presents with aggressive bone loss, bleeding gums, mobile teeth. What condition? • Uncontrolled diabetes • non-Hodgkin’s lymphoma

QUESTION: ASA III: Uncontrolled diabetes

*QUESTION: Periodontal disease is associated with what systemic diseases? Diabetes and HIV

*QUESTION: When would elective endo treatment be contraindicated? Uncontrolled diabetes

QUESTION: What disease will alter healing after root canal treatment? HIV or Diabetes

DM TREATMENT MODIFICATIONS

Normal HbA1C = 4-6% In controlled diabetic patients, HbA1C < 7%. Uncontrolled diabetes is > 8%.

QUESTION: Diabetes, can you place implant if HbA1c = 8: No, refer to physician

*QUESTION: Pt with hemoglobin A1C of 12%. Pt just visited the MD, what kind of TX we can do? Consult with an MD prior to tx

QUESTION: HgbA1c is 12 for a patient in your office? Get him out of there, Refer him to physician for diabetic/sugar management.

QUESTION: Treat diabetic patient 2 hours after eating & taking insulin

*QUESTION: Kidney dialysis: best to do tx when? Day after dialysis or in between days of dialysis

QUESTION: Insulin shock, what do you give? give insulin, give OJ, give oral sucrose

QUESTION: Pt is a child and is diabetic undergoes hypoglycemia in the chair if conscious give him orange juice (unconscious give him 50% dextrose IV)

QUESTION: Unconscious diabetic is treated with: 50% dextrose in IV (can’t take glucose orally)

DIABETICS (IV SEDATION):

IV sedation for DIABETICS: Schedule in the morning. If insulin-dependent, have them not eat, not take short acting insulin and take half dose of long acting insulin. If not dependent, no food and no meds until after the surgery.

QUESTION: Patient is a non-insulin dependent diabetic & needs minor oral surgery w/ IV sedation. What should he do? clear-liquids and regular dose of diabetes meds • Minor surgery: normal as long as procedure occurs within 2 hours of eating and taking meds.

QUESTION: Pt with insulin dependent diabetes & having sedation IV and LA. Ask the pt to take: high calorie food with insulin, low calorie food with insulin (reduce dose of insulin and no food)

CONGESTIVE HEART FAILURE/HEART CONDITIONS

*QUESTION: Patient with orthopnea (shortness of breath-dyspnea-while lying flat), dyspnea, pedal edema a. Emphysema b. Pulmonary edema c. COPD d. Congestive heart failure

*QUESTION: What is common symptom of CHF? Orthopnea • Other symptoms: dyspnea, fatigue, paroxysmal nocturnal dyspnea, edema

*QUESTION: Most common reason for cardiac arrest of kid? Respiratory distress, congestive heart failure, cyanotic heart disease, etc

QUESTION: What is the most common heart condition in children? Ventricular septal defects

QUESTION: Peripheral edema, increase systole Congestive heart failure

QUESTION: Patient has distended jugulars, pitting edema and dyspnea? Congestive heart failure

QUESTION: What does not describe referred pain from cardiac patient? Pain that goes away with LA

QUESTION: MI and arrhythmia difference? Thrombosis, arthrosclerosis

QUESTION: Patient has chest pain in heart region when sleeping or at rest, what kind of angina is it? a. Pseudo-angina b. Unstable angina c. Infarction

MEDICATIONS:

Hypertension:

Diuretics: • Thiazides: Diuril, hydrochlorothiazide • Loop diuretics: Lasix • K sparing diuretics: Midamor, Dyrenium • Combination: Aldactazide, Dyazide

Beta Blockers: • Cardioselective (B1): atenolol, metoprolol • Non-selective (B1 & B2): propranolol, nadolol • Combined (A and Beta): carvedilol, labetalol

Alpha 1 Blockers: doxazosin, prazosin, terazosin

Ace Inhibitors: benazepril, captopril, enalapril

Angiotensin Receptor Blockers (ARBs): candesartan, eprosartan, irbesartan, losartan

Calcium Channel Blockers: amlodipine, bepridil, verapamil

Central Alpha 2 Agonists and other Centrally Acting Drugs: clonidine, methyldopa, reserpine

Angina: Nitroglycerin, propranolol, Ca+ channel blockers (like verapamil)

Meds Effect on Body Oxygen Nitroglycerin vasodilator on coronary artery smooth muscle More O2 supply Propranolol prevent chronotropic response to epi/emotion/exercise Less O2 demand Ca+ channel blockers vasodilator of peripheral resistance Less O2 demand

Congestive Heart Failure: Glycosides like digitalis, digoxin, ACE inhibitors v. Positive inotropic effect, ↑ myocardium contraction force by inhibiting Na+/K+ ATPase & increasing Ca+ influx

Arrhythmia: Lidocaine (VA), quinidine (AF, SV), verapamil (AF), digitalis (AF, SV) w. Type 1A agents (like quinidine) – increase cardiac muscle’s refractory period x. Type 1B agent (like lido) – decease cardiac excitability y. Digitalis – decrease A-V conduction rate

QUESTION: Why is pt taking ACE inhibitor? Hypertension / CHF

QUESTION: Pt taking cardiac glycosides. What is it used for? hypertension, Congestive heart failure

QUESTION: What do cardiac glycosides (ex. digitalis) do? Inhibit Na/K ATPase & Increase Na and Ca in cell to increases the refractory period.

QUESTION: How does digitalis works? Blocks Na/K ATPase = increase influx more Ca

QUESTION: Digitalis - Increase Inotropic (contractions) effect of the heart

QUESTION: Use of digitalis: Post myocardial infarction, Supraventricular arrhythmia • Digitalis/cardiac glycoside = common indications for use is for atrial fibrillation

QUESTION: How does Digoxin work? Inhibits Na/K ATPase of cardiac cell membranes resulting in increase of Na concentration intracellularly, cardiac glycoside, increases intracellular Ca++

QUESTION: Garlic: lots of uses, usually associated with CVD • Contraindications: contraceptives and anti-viral (HIV), caution with bleeding

QUESTION: Pt has history of cardiovascular disease and now, pt is taking aspirin. Pt needs ext. What should dentist do? • Med consult with physician • Normal extraction • Stop aspirin 3 days before and 2 days after surgery

QUESTION: Mechanism of most drugs that tx arrhythmias? Decreases repolarization rate, prolongs refractory period

QUESTION: When you have atrial arrhythmia, what’s the mechanism of action for the drug for it? • You can give Quinidine, Verapamil, and Digitalis for atrial and the side mechanism of Quinidine is it increases the refractory period

QUESTION: General question about arrhythmias medications. They increase calcium inotropic effect, decrease SA node transmission, increase refractory period

QUESTION: Side effect of nitroglycerin: orthostatic hypotension and headache

QUESTION: Transient ischemic attack (TIA), what is false? Better chance to get stroke-true, patient should take nitroglycerin FALSE- give for angina to prevent heart attacks.

QUESTION: Nitrates and nitriles have what systematic effect? Vasodilation of arteries decreased BP tachycardia • Nitroglycerin is a nitrovasodilator. It produces nitric oxide, which activates guanylyl cyclase which, in turn, catalyzes the production of ⬆ cGMP.

QUESTION: Nitrates/Nitriles, how do they respond to angina? through blood vessels (dilate blood vessels)

QUESTION: How do nitrates work on the heart? relaxing and widening the blood vessels in the body, allowing more blood and oxygen to flow to the heart. Since the arteries are wider, it is easier for the heart to pump blood, so it does not require as much blood and oxygen.

QUESTION: You give the nitroglycerin to the pt with angina and heart rate goes up, what's the reason? Natural reflex to the decrease in blood pressure

*QUESTION: Amilnitrate & Nitroglycerine? Vasodilate coronary arteries for angina pectoris—chest pain caused by occlusion of coronary arteries chest pains, SOB

QUESTION: For angina drug, which drugs can’t you take: some type of hydrothiazide med

QUESTION: Diuresis (excessive urine production) after tx of angina w/ a glycoside? b/c of increased blood flow caused increased blood flow to kidney

QUESTION: Epi and Nitroglycerine: antagonist

QUESTION: Why give hydralazine with chloral hydrate? Decreases nausea • Hydralazine (Apresoline) is a direct-acting smooth muscle relaxant used to treat HTN by acting as a vasodilator primarily in arteries and arterioles to decrease peripheral resistance, thereby lowering blood pressure and decreasing afterload.

QUESTION: Main prophylactic treatment for angina? Propranolol

QUESTION: Which is not used in tx of angina? Nitroglycerin, Ca+ blocker, propranolol, thiazide (thiazides are usually diuretics)

QUESTION: Quinidine treats? SV arrhythmias

PULMONARY/LUNGS

Bronchodilator suffix –terol

QUESTION: Asthma causes constriction on bronchioles, constriction of smooth muscles & inflammation of bronchioles? Beta 2 receptor for lungs, Beta 1 receptor for heart

*QUESTION: What do asthmatic patients have problem with? Wheezing when exhaling • Wheezing exhale with high pitch

QUESTION: Child makes a wheezing sound before injection? Asthma (induced by stress)

QUESTION: COPD vs Asthma? Asthma have problem breathing in (but wheeze when exhaling), COPD has problem exhaling

QUESTION: What is the most common cause for breathing difficulty in the dental chair? Hyperventilation

QUESTION: Most common respiratory emergency in dental office? Hyperventilation

*QUESTION: Hyperventilation causes Tachycardia and tachypnea (rapid breathing)

*QUESTION: Face swelling after air spray in perio pocket: Soft tissue emphysema (sudden painless swelling) • Emphysema: constriction of air sacks

*QUESTION: Perio surgery, air into sulcus. What occurs? subcutaneous emphysema

QUESTION: Pt has emphysema. What are his symptoms? Dyspnea, wheezing, cough, chest tightness. Air sacks are all destroyed (narrowing of distal airways)

*QUESTION: Crowing sound when breathing (Stridor)? laryngospasms (blockage of upper respiratory tract)

QUESTION: Epi for laryngospasm, what does it do? (multiple answers- multiple choice with 3 answers each)- bronchodilator, increase HR, increase BP

QUESTION: Theophylline is used to prevent and treat wheezing, SOB (shortness of breath), and difficulty breathing caused by asthma, chronic bronchitis, emphysema, and other lung diseases. It relaxes and opens air passages in the lungs, making it easier to breathe.

QUESTION: Which drugs is used for asthma? Levabuterol • Albuterol was not in it, levabuterol (xopenex), ipratropium bromide/albuterol (combivent), Ipratropium bromide(atrovent), Advair (fluticasone/salmeterol), Symbicort (budesonide, formoterol), Spiriva (tiotropium), Budenoside

QUESTION: Most effective during acute asthma attack? albuterol- generic name is Salbutamol. It is a beta-2 agonist, which causes bronchodilation

QUESTION: Pt has asthmatic attack, took albuterol, and it didn’t work. What’s next step? • Epinephrine • Atropine

QUESTION: Medication for severe asthma attack Aminophylline (bronchodilator)

QUESTION: A child treated with albuterol. Why? Asthma

*QUESTION: What drug cause asthma? Aspirin (NSAID) so NO NSAIDS for asthmatic patients

*QUESTION: Which of the following drugs is can trigger asthma? a) narcotic analgesic b) NSAID c) corticosteroid d) sympatholytic amine.

QUESTION: What is used for a severe bronchial asthma attack? Albuterol, corticosteroids, aminophylline

QUESTION: Long term asthma, give corticosteroid (reduces inflammation of lungs)

QUESTION: Asthmatic only use Tylenol (not aspirin bc of hyperventilation) Bronchospasms

QUESTION: Patient begins to wheeze, what do you not do? ● Beta-2 blocker inhaler ● sit pt up & make them more comfortable ● corticosteroid inhaler ● Give oxygen

QUESTION: What causes dry mouth? Albuterol SYNCOPE

Orthostatic hypotension = (head rush or dizzy spell) is a form of hypotension in which a person's blood pressure suddenly falls when standing up or stretching. Vasovagal syncope = the most common type of fainting, is a malaise mediated by the vagus nerve.

Trendelenburg position (for anaphylaxis) - Position in which the patient is on an elevated and inclined plane, usually about 45°, with the head down and legs and feet over the edge of the table. This position is used in treating shock, but if there is an associated head injury, the head should not be kept lower than the trunk.

*QUESTION: 5-month old pregnant woman with syncope, what position do you put her in? supine with legs raise reversed Trendelenburg on her Right on her left - to avoid compression of inferior vena cava

*QUESTION: If a 3rd trimester pt all of a sudden feels a drop in BP, what do you do? Have pt lay on left side

QUESTION: Prego question – syncope, which side you put pt? Raise right hip up

*QUESTION: What causes pregnant woman to syncope? Beware of compression to inferior vena cava

QUESTION: Pregnant in supine position, what gets too much pressure? Fetus Placenta Inferior Vena Cava Superior Vena Cava

*QUESTION: Most important thing to do when patient syncope – Maintain airway, loosen up buttons, place head below heart, supine

*QUESTION: Crown disappears down patient’s throat, what position do you put them in? Supine, Upright, Trendelberg

QUESTION: Want to determine patient physiologic rest position, place in – supine, upright/standing, tredenlburg

QUESTION: Purpose of the Trendelberg position is to? maintain circulation so that the most vital organs are never hypoxic.

QUESTION: What position you place the Pt when is having syncope? TRENDELENBURG POSITION • The most common early sign of syncope is PALLOR (paleness).

QUESTION: All forms of shock have? • Hypovolemia • Decreased perfusion to tissue • Sepsis

QUESTION: Vasovagal syncope is a common cause of transient loss of consciousness

QUESTION: Syncope? Inhale ammonia to irritates trigeminal nerve sensory, 100% oxygen works except with hyperventilation syndrome.

QUESTION: High-flow 100% 02 is indicated for treating each of the following types of syncope EXCEPT one. Which one is this EXCEPTION? A. Vasovagal B. Neurogenic C. Orthostatic D. Hyperventilation syndrome

QUESTION: Most common dental complication/emergency in office? Syncope

QUESTION: You gave local anesthetic, BP went up to 200/100 and HR went up too, what could be due to? Due to vasoconstrictor injected into venous system.

QUESTION: After receiving one cartridge of a local anesthetic, a healthy adult patient became unconscious in the dental chair. The occurrence of a brief convulsion is A. pathognomonic of grand mal epilepsy. B. consistent with a diagnosis of syncope. C. usually caused by the epinephrine in the local anesthetic. D. pathognomonic of intravascular injection of a local anesthetic.

QUESTION: Signs of syncope: blood pressure falls

QUESTION: Signs of epi overdose: blood pressure and heart rate rises

*QUESTION: Carpopedal spasm seen in? asthmatic attack, hyperventilation • Carpopedal spasms are severely painful cramps of the hand/feet muscles. • May be caused by low blood calcium levels or by tetanus.

SEIZURES & SEDATIVE MEDICATIONS

Benzodiazepines: MOA – modulate activity of inhibitory NT (GABA) receptor Advantages vs barbs: less addictions potential, less CNS/respiratory depression, larger therapeutic index can cause respiratory depression (most adverse effect) CONTRAINDICATIONS: Pregnant, myasthenia gravis, acute narrow glaucoma, COPD, emphysema

Grand mal seizure: Phenytoin (Dilantin), Status epilepticus: Valium (diazepam)

QUESTION: Which of these is indicated for grand mal seizure? DILANTIN (phenytoin)

QUESTION: Most common seizure in children – grand mal seizures (febrile) • Febrile seizures, which occur in young children & are provoked by fever, are the most common type of provoked seizures in childhood. Then, generalized tonic-clonic (grand mal)

*QUESTION: Which of the following is the current drug-of-choice for status epilepticus? A. Diazepam (Valium®) B. Phenytoin (Dilantin®) C. Chlorpromazine (Thorazine®) D. Carbamazepine (Tegretol®) E. Chlordiazepoxide (Librium®)

QUESTION: Drug of choice of status epilepticus (seizure that last for long period)? Valium (diazepam) 5-10 mg IV / per minute

QUESTION: Diazepam is contraindicated in the following patients? Pregnancy

QUESTION: Which of the following drugs, when administered intravenously, is LEAST likely to produce respiratory depression? A. Fentanyl (opioid) B. Diazepam C. Thiopental D. Meperidine (opiate, Demerol) E. Pentobarbital

QUESTION: What drug for patient with petit mal (absence) seizures in dental office? Ethosuximide • Only 2 drugs for absence seizures (petit mal): ethosuximide (Zarontin) – only treats petit mal- and valproic acid (Depakene, Depacon) – treats grand mal, petit, and myoclonic seizures.

*QUESTION: What causes/induce seizures? a. Hyperkalemia b. Hypophosphatasia c. Hyponatremia (low sodium) d. Hypernatremia. e. Hypoglycemia

QUESTION: Epileptic pt least likely to take: a. Ethosuximide – petit mal seizures b. Diazepam - Status epilepticus c. Lasix (furosemide) – HTN loop diuretic

QUESTION: Each of the following is an advantage of midazolam over diazepam EXCEPT one. Which one is this EXCEPTION? A. Less incident of thrombophlebitis B. Shorter elimination half-life C. No significant active metabolites D. Less potential for respiratory depression E. More rapid and predictable onset of action when given intramuscularly - midazolam has a milder effect, but more long lasting

QUESTION: The clinical activity of a single intravenous dose (10 mg) of diazepam is most dependent on which of the following? A. Alpha half-life B. Beta half-life C. Renal excretion D. Enzymatic degradation E. Hepatic biotransformation

QUESTION: Each of the following are narcotics used in outpatient anesthesia EXCEPT one. Which one is this EXCEPTION? A. Fentanyl B. Sufentanil C. Meperidine D. Diazepam E. Morphine

QUESTION: Which of the following describes the titration of diazepam to Verrill's sign for IV conscious sedation? A. It is recommended as an end-point. B. It is recommended only when supplemental 02 is used. C. It is usually not attainable with diazepam alone. D. It is not recommended since it can indicate a too-deeply sedated patient. E. It is not recommended since few patients are adequately sedated at that level. • The most frequently used signs for IV diazepam sedation are ptosis, (“the Verrill sign”), altered speech and blurred vision.

QUESTION: Which of the following is the treatment of choice for lidocaine-induced seizures? Epinephrine (EpiPen ̈) Naloxone (Narcan ̈) Diazepam (Valium ̈) Flumazenil (Romazicon ̈) Succinylcholine (Anectine ̈)

SEDATIVES:

Benzodiazepines: enhance the effect of gamma amino butyric acid (GABA) at GABA receptors on Cl- channels. This increases chloride channel frequency

• α-Hydroxylation is a rapid route of metabolism unique to triazolam, midazolam, and alprazolam short sedative • Benzodiazepines: ones not metabolized by the liver (safe to use in liver failure) o LOT: Lorazepam, Oxazepam, Temazepam • Contraindication: pregnancy

Barbiturates: enhance the effect of GABA on the chloride channel but also increase chloride channel conductance independently of GABA, especially at high doses. Increases duration of Cl- channel opening. • Long-acting: Phenobarbital is used to treat certain types of seizures • Intermediate-acting. Amobarbital, pentobarbital (occasionally used for sleep), secobarbital. • Short-acting. Hexobarbital, methohexital, thiopental

Zolpidem (Ambien) and zaleplon (Sonata): short ½ life, used for insomnia, selective action @ BZ1 receptor z. Not a benzodiazepine but acts like it, reversed by flumazenil, potentiates GABA receptor

QUESTION: What’s the action of the Benzodiazepines? Facilitates GABA receptor binding by Increasing the frequency of chloride channel opening.

QUESTION: Xanax MOA, Mechanism of action of on GABA receptors: increasing the frequency of chloride channels by benzodiazepines • Barbiturates increase the duration of chloride channel opening

*QUESTION: Benzodiazepines act on: GABA receptors

QUESTION: Which benzodiazepines is used for depression & anxiety for obsessive compulsive disorder? Xanax (alprazolam)

QUESTION: Diazepam (valium) action in GABA: Anti-convulsant & sedative

QUESTION: Anticonvulsants can cause cleft palate (teratogenic effect)s

QUESTION: Valium is used for all of following except: emesis (vomiting) or insomnia

QUESTION: Diazepam -No effect on respiration as oppose to other BZ

QUESTION: Hypnosis affects what? Voluntary muscles Involuntary muscles Both voluntary and involuntary muscles Glands

QUESTION: Which of the benzodiazepine don’t you give to elderly? Long acting one (like diazepam) aa. Short to intermediate-acting benzodiazepines are preferred in the elderly (ex. oxazepam, temazepam, midazolam)

QUESTION: Benzodiazepines are great for dentistry due to an action of- amnesia and little memory of the event.

QUESTION: Best benzo for IV sedation – MIDAZOLAM

QUESTION: What does IV Midazolam do? Amnesia

QUESTION: Best benzodiazepine for pt with liver cirrhosis Oxazepam LOT: Lorazepam, Oxazepam, Temazepam

QUESTION: Which drug best reverses the effect of benzodiazepines? Flumazenil Flumazenil: Benzodiazepine antagonist b/c competitive GABA receptor.

*QUESTION: The reversal for Versed? (versed = midazolam) A. Narcon B. Flumazenil C. Naloxone (for opioids) D. Disulfuriam (for alcoholics)

QUESTION: Contraindication of lorazepam: a) pregnancy b) diabetes

*QUESTION: Benzodiazepines (diazepam, lorazepam) are contraindicated in pregnancy

QUESTION: Why do you use benzos or a barb for antianxiety? Reduced depression, does not potentiate depressants. (less respiratory depression)

QUESTION: How benzos are anxiolytic? moderate doses ANTIANXIOLYTIC and high doses is SEDATIVE

QUESTION: Sedative rebound – Antipsychotic, part of withdrawal Several anxiolytics & hypnotics have a rebound effect, which cause severe anxiety and insomnia worse than the original insomnia or anxiety disorder.

QUESTION: Which of the following barbiturates MOST readily penetrates the blood-brain barrier? Thiopental

QUESTION: Sodium Thiopental: Rapid-onset short ultra-acting barbiturate(IV) for general anesthesia

QUESTION: A patient has appointment next morning, he is anxious, and the night before he had hard time sleeping, which of the following tx would you prescribe? Ambien (sedative and makes patient sleep).

QUESTION: Chief mechanism by which the body metabolizes short-acting barbiturates is? a. Oxidation (occurs in the liver) b. reduction. c. hydroxylation and oxidation. d. sequestration in the body fats.

*QUESTION: A patient's early recovery from an ultrashort-acting barbiturate is related primarily to redistribution. breakdown in the liver. excretion in the urine. breakdown in the blood. binding to plasma proteins. ANTI-HISTAMINE MEDICATIONS

Histamine is bronchospastic and vasodilator.

H1 Anti-Histamines: competitive histamine receptor blockers • Tx of dermatologival manifestation of allergy reaction • Controlling Parkinson’s symptoms • Pre-operative meds for sedation, anti-cholinergic effects • Diphenhydramine/Benadryl – H1 anti-histamine, anti-cholinergic, sedative • Side effects: dry mouth and throat, increased heart rate, pupil dilation (mydriasis), urinary retention, constipation – anticholinergic • Allegra (Fexofenadine), Claritin (loratidine), Clarinex (Desloratidine), Zyrtec (Cetirizine) = don’t cross BBB, poor CNS penetration

H2 Anti-Histamines: reduce gastric secretions by blocking the action of histamine on parietal cells in the stomach → Cimetidine, ranitidine, famotidine, nizatidine

Epinephrine = physiological antagonist of histamine

QUESTION: Know the effects of histamine and that it is derived from histidine • Histidine decarboxylase (HDC) enzyme catalyzes the reaction that makes histamine from histidine w/ vitamin B6

QUESTION: Benadryl (diphenhydramine) - 1st generation anti-histamine - H1 blockers

*QUESTION: What is used for motion sickness? Diphenhydramine (Benadryl)

*QUESTION: What does diphenhydramine (Benadryl) cause? Xerostomia (anti-cholinergic, anti-histamine, sedative)

*QUESTION: What property of diphenhydramine causes xerostomia? a. Anticholinergic b. Antihistaminic c. Antimuscarinic

QUESTION: What property of topical diphenhydramine would alleviate pruritus (itching)? Anti-histamine • antihistamine relieves itchy/watery eyes and itchy throat by blocking a substance (histamine) released by allergies. • anticholinergic dries up a runny nose & the fluid that runs down your throat causing itching/irritation.

QUESTION: What anti-histamine causes less drowsiness: H1 blocker 2nd generation Allegra (fexofenadine), Claritin (loratidine), Clarinex (Desloratidine) Certizine (Zyrtec) because they don’t cross BBB, poor CNS penetration

QUESTION: Which one of these has the least sedative effect? (2nd generation H1 blocker) Diphenylhydramine/ Benadryl (Most) Chlorpheniramine (LEAST) Tripelennamine • Chlorphenamine, is a first-generation alkylamine antihistamine but its sedative effects are weak

QUESTION: Which antihistamine is least likely to cause drowsiness? Loratidine (Claritin)

QUESTION: Claritin/loratidine – second generation H1 blocker/antihistamine

*QUESTION: Which of the following would have slowest onset after IV administration? Diphenhydramine, loratadine, rest were H1 anti-histamine

*QUESTION: What do you give to someone who is allergic to ester & amides LA? DIPHENHYDRAMINE (BENADRYL)

QUESTION: How do antihistamines work? Competitive inhibition of histamine receptors

QUESTION: Detailed mechanism questions on H1 (histamine) compete w/ histamine to bind at H1 receptor sites. • Leads to decreased vascular permeability, reduction of pruritus, relaxation of smooth muscle in respiratory

QUESTION: Effects of H1 blocker EXCEPT: (causes CNS depression) a. CNS increase b. CNS decrease c. increase acid secretion d. respiratory depression e. local anesthesia

*QUESTION: Actions of H1 antagonist: competitive inhibition of H1 receptors so block vasodilation, bronchoconstriction, and capillary permeability Vasoconstriction, bronchodilation, and decrease capillary permeability

QUESTION: H2 antihistamine Cimetidine – decrease ulcers bb. Cimetidine (Tagamet) is a histamine H2 receptor antagonist that inhibits stomach acid production & is used as an antacid.

QUESTION: Histamine 2 blocker meds - for gastric reflux or GERD (gastric esophageal reflux disease) - Cimetidine & Ranitidine

QUESTION: What does bradykinin do? Dilate blood vessel & lower BP

QUESTION: 25 y/o female breast feeding 12m old child and currently pregnant, which sedative would you give? • Halcion • Promethazine • Nitrous • Diazepam • Phenobarbital

*QUESTION: What anxiolytic do you use for anxious 25-year-old pregnant woman who is breastfeeding? Chloral hydrate (avoid), nitrous (avoid), benzo (avoid), promethazine

OPIOIDS/ANALGESICS

Suffix for opioids -done 1. Group 1 - Opiates - Naturally occurring agents derived from the opium plant a. Morphine, codeine, thebaine 2. Group 2 - Semi-synthetics a. Hydrocodone, oxycodone, hydromorphone, oxymorphone, buprenorphine (heroin is also in this group) 3. Group 3 - Synthetics a. Fentanyl (alfentanil, sufentanil, etc.), methadone, tramadol, propoxyphene, meperidine All of the group 1 and 2 agents are structurally very similar to each other and should not be given if a true allergy exists to any other natural or semi-synthetic derivative. Group 3 agents have structures different enough that they can be given to a patient intolerant to the natural or semi-synthetics without fear of cross reactivity. They are also very different from others in this same group.

Mixed agonist-antagonist analgesic – pentazocine, nalbuphrine Naloxone – treat morphine overdone, antagonist Methadone – used in detoxification of morphine addicts

Opioids – binds to specific receptors (ex. mu receptors) in CNS cc. Symptoms: respiratory depression, euphoria, sedation, dysphoria (unease), analgesia, antitussive, constipation, urinary retention, vomiting/nausea (trigger medullary CTZ) dd. Overdose: coma, miosis (pupil constrict, pin-point pupils), hypothermia, respiratory depression (loss of sensitivity of medullary respiratory center to CO2)

*QUESTION: Which of these opioid analgesics is associated with a serious life threatening drug interaction when administered with an MAO inhibitor? Meperidine (Pethidine, Demerol) morphine fentanyl propoxyphene codeine • Can cause life-threatening hyperpyrexia reactions (fever) • Drug-drug interaction with MAOI (hydralazine) and Meperidine (opioid) so MAOI is contraindicated!

QUESTION: Opioids contraindicated in: severe head injury, renal insufficiency

QUESTION: An opiate type MAA with both agonist and antagonist properties is- pentazocine Pentazocine is a synthetically-prepared prototypical mixed agonist–antagonist narcotic (opioid analgesic) Another one is nalbuphine

QUESTION: Pt is addicted to oxycodone which contra indicated? codeine, pentazocine

QUESTION Which of the following effects are common to pentobarbital, diazepam, and meperidine? A. Anticonvulsant and hypnotic B. Analgesia and relief of anxiety C. Sedation and ability to produce dependence D. Amnesia and skeletal muscle relaxation

QUESTION: Absolute Contraindications to Opioid Prescribing: Allergy to Codeine/Oxycodone/Hydrocodone • Give Methadone or Meperidine or Tramadol instead (Group 3 synthetic)

*QUESTION: Which of the following narcotics/opioids is synthetic? Meperidine (Demerol)

QUESTION: Miosis seen in opioid abuse - Except with meperidine (an exception)

QUESTION: Use for sedation of children - Secobarbitol or pentobarbital (good for pre-op/anxious kids) • Ketamine is used in emergency situations (good anxiolytic and analgesic at low doses) • Meperidine should not be used in kids

*QUESTION: Which is not done by opiates? o Diuresis (opiates cause urinary retention) o Constipation o Bronchiolar constriction o Vomiting

QUESTION: Opioid usage shows all except: xerostomia, chronic cough (its an antitussive), diarrhea, miosis, constipation

*QUESTION: Opioid side effect – constipation

QUESTION: Opioid overdose side effect – constipation, respiratory depression, euphoria, miosis, coma • miosis = excessive constriction of the pupil of the eye.

QUESTION: Opioid OD symptoms – answer was hypotension. Other options were irritability (restlessness), hypertension, insomnia = withdrawal symptoms.

QUESTION: Symptom seen in oral opioid overdose: hypothermia, headache, insomnia, irritability (rest are withdrawal symptoms)

QUESTION: Symptoms if too much codeine? Insomnia, Cold and Clammy skin, irritable.

QUESTION: What is the most significant side effect of morphine/opioids? Respiratory depression

QUESTION: Major disadvantage of opioids is respiratory depression.

QUESTION: Which of the following symptoms is the most distinct characteristic of morphine poisoning? A. Comatose sleep B. Pin-point pupils (miosis) C. Depressed respiration D. Deep, rapid respiration E. Widely dilated, non-responsive pupils

QUESTION: If you give too much of an opioid (but it’s not an overdose!), what’s the first sign you would see? a. Irritation b. Headache c. constricted pupils and absent/slow breathing

QUESTION: Opioid Receptors- brain, spinal cord and digestive GI tract

QUESTION: Opioid cause stomach upset by acting on the brain (medullary CTZ), not on stomach receptors!

QUESTION: Opioid agonists act by: a. stimulating GABAergic neuron b. increase pain threshold c. Acting as Mu receptor agonists

QUESTION: Naloxone: use for Opioid overdose. • Naloxone blocks or reverses the effects of opioid medication, including extreme drowsiness, slowed breathing, or loss of consciousness

QUESTION: Opioid (Fentanyl, Morphine, Meperidine, Methadone, Sulfentanil, Codeine, Heroin, Dextromethorphan) reversal drug? Naloxone • Antidote for Percodone overdose (Oxycodone + aspirin)? all opiate antidote is Naloxone.

QUESTION: How does an antagonist work? No intrinsic activity, High affinity • Intrinsic activity (IA) or efficacy refers to the relative ability of a drug-receptor complex to produce a maximum functional response.

QUESTION: Antagonist: Binds to receptor but lacks intrinsic activity (doesn’t activate receptor)

QUESTION: What opiate is part of the intradermal system? Fentanyl • Fentanyl = opioid analgesic given via transdermally patch

QUESTION: Methadone helps alleviate withdrawal from heroine (opiates). • Methadone for detoxification of opioid addicts, give to heroin addicts to decrease withdrawal symptoms • Methadone is a synthetic opioid, analgesic, antitussive, anti-addictive, acts on MU receptors so produces similar effects of opioids but without addictive qualities, receptor antagonist to glutamate. Long ½ life.

QUESTION: Why is nalbuphine (NUBAIN) contraindicated in previous heroin addict? It’s a mixed agonist-antagonist which may potentiate/increase withdrawal symptoms.

QUESTION: Sedative drug such as hydroxyzine, meperidine and diazepam are carried in the blood as? a. serum b. white blood cells c. red blood cells d. hemoglobin

QUESTION: Where do opioids act? Medulla (bind to opioid receptors in CNS)

QUESTION: Where are mu receptors? Medulla

QUESTION: Codeines produces nausea because? Activates vasodilator blah blah blah Works on the medulla (stimulates medullary chemoreceptor trigger zone)

QUESTION Mechanism of how codeine causing nausea? Chemotactic receptor zone (CRZ)

QUESTION: How does morphine cause emesis (vomiting) in the body? via central action (medulla)

QUESTION: CODEINE is analgesic, antitussive (suppress coughing), anti-diarrheal, anti-hypertensive, anxiolytic, anti-depressant, sedative and hypnotic properties. IT IS ADDICTIVE.

QUESTION: If you had an allergy to codeine, what do you take for pain? random opioids, Tylenol #3, hydrocodone, acetaminophen with aspirin • ALLERGY TO CODEINE: can prescribe another opioid from different class: Meperidine or fentanyl for moderate to severe pain or acetaminophen or NSAID for mild pain.

QUESTION: Patient is allergic to codeine when you look at their medical history tab, (this is the trick about the exam, look up stuff before you answer questions), what do you prescribe him for pain? a. Hydrocodone with Acetaminophen b. Tylenol 3 c. Hydrocodone with Aspirin d. Acetaminophen + aspirin

QUESTION: What do you give to pt allergy to codeine? Propoxyphene (synthetic)

QUESTION: Allergic to Codeine, what can you give? use synthetic opioids (meperidine, tramadol) Demerol (meperidine), Pentazocine

*QUESTION: Pt has hx of codeine allergy. What drug to give? • Tylenol #3 has codeine • Vicodin (hydrocodone/paracetamol) • Naproxen • Hydrocodone

QUESTION: Pt is allergic to aspirin, what can you give? Tylenol #3 (acetaminophen & codeine)

QUESTION: What does acetaminophen do with codeine (Tylenol #3)? Increase its activity & increase how long it’s around due to clearance

QUESTION: Why opioid analgesic containing both acetaminophen and hydrocodone so effective? acetaminophen & hydrocodone works differently, and combining these effects makes it stronger • acetaminophen blocks the binding of protein w/ hydrocodone, so hydrocodone level higher in blood  stronger response • Narcotics work in brain (CNS) while NSAIDS/acetaminophen work in peripheral tissues (PNS) – 2 diff mechanisms complement each other for effective pain reduction

*QUESTION: Pt has mild pain from ortho tx. What med NOT to give? • Aspirin • Ibuprofen • Hydrocodone • Naproxen

QUESTION: What med to give for moderate post-op extraction pain? Ibuprofen, Acetaminophen, NSAID, Opioid

QUESTION: Breastfeeding mother, don’t give her what? Codeine, tetracycline, benzos • Codeine medication may be harmful to an unborn baby, and could cause breathing problems or addiction/withdrawal symptoms in a newborn.

QUESTION: Pt taking narcotic for long term what causes: headache due to increase intracranial pressure.

DRUG SCHEDULE

Tylenol 1 = 8mg codeine; Tylenol 2 = 15mg codeine; Tylenol 3 = 30 mg Codeine; Tylenol 4 = 60mg Codeine

Prescriptions for schedule II controlled substances cannot be refilled. A new prescription must be issued. Prescriptions for schedules III and IV controlled substances may be refilled up to 5 times in 6 months. Prescriptions for schedule V controlled substances may be refilled as authorized by the practitioner.

QUESTION: DEA schedules their drugs by ABUSE POTENTIAL or dependency potential (addiction)

QUESTION: DEA number required for prescribing opioids/narcotics, like codeine, oxycodone, etc. • DEA number (DEA Registration Number) is a number assigned to a health care provider by the U.S. Drug Enforcement Administration allowing them to write prescriptions for controlled substances.

QUESTION: Dentist can’t write prescription for schedule class 2 for back pain. Out of scope of practice

QUESTION: What is not true of drugs? Schedule II drugs cannot get refill without prescription. The following are true: a. Schedule 3, 4, 5 drugs CAN be filled over the phone. b. Scripts must have patients name and address c. DEA number must be on each script. • Schedule II drugs cannot get a refill. A new prescription must be written!

QUESTION: Oxycodone, Hydrocodone (changed in 2014 to schedule 2) = schedule 2 drugs

QUESTION: What can be combined with Tylenol to make it a level 2? oxycodone, codeine etc.

QUESTION Which one is a class 2 narcotic? Percoset (oxycodone + acetaminophen)

QUESTION: Vicodin schedule: 2 (acetaminophen + Hydrocodone)

QUESTION Percocet schedule: 2 (acetaminophen + Oxycodone)

QUESTION: Schedule 2: combination products containing less than 15 milligrams of hydrocodone per dosage unit (Vicodin®) QUESTION Schedule 3: products containing less than 90 milligrams of codeine per dosage unit.

QUESTION: Schedule 4 narcotic is propoxyphene (Darvon), alprazolam (Xanax), clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), midazolam (Versed), temazepam (Restoril), and triazolam (Halcion).

QUESTION: Drug schedules II or III – they are all acetaminophen with opioid except for one that was hydrocodone with NSAID (vicoprofen)

QUESTION: Schedule II narcotic and anti-psychotic neuroleptic analgesia

NSAIDS & ACETAMINOPHEN

Aspirin - baby aspirin (81mg, day), aspirin is 325mg (to 650mg) q 4-6 hrs. (max dose is 4000 mg)

Aspirin and NSAIDs inhibit platelet cyclooxygenase, thereby blocking the formation of thromboxane A2. ee. Aspirin irreversibly blocks cyclooxygenase & it’s actions persist for circulating lifetime of platelet. ff. NSAIDS inhibit cyclooxygenase reversibly & duration of action depends on drug dose/serum levels/half-life. Nonselective NSAIDs (such as aspirin, naproxen, and ibuprofen) inhibit both COX-1 and COX-2. Selective NSAIDS like Celebrx target just Cox-2.

*QUESTION: How do you treat acetaminophen overdose? N-acetylcysteine

QUESTION: Reversal of acetaminophen: NAC, N-acethylcysteine-liposome.

QUESTION: Tylenol - can cause hepatotoxicity

QUESTION: Pt has hepatic dysfunction; which pain medication can prescribe? a. Oxycodone b. naproxen c. acetaminophen

QUESTION: What is relationship between Tylenol and aspirin? Anti-pyretic and analgesic Difference: aspirin is anti-inflammatory, common: anti pyretic

QUESTION: Similarity between Advil (NSAID) and Tylenol: Anti-pyretic and analgesic

QUESTION: Which of the following does not have anti-inflammatory action? Acetaminophen

QUESTION: Aspirin causes - Reyes fever and adults, GI problems. If liver problems, give aspirin.

*QUESTION: Aspirin inhibits platelet aggregation

QUESTION: NSAID irreversible affect platelets & suppress inflammatory response.

QUESTION: NSAIDs – mech of action of suppressing platelets – inactivate cyclooxygenase decreased prostaglandin synthesis

QUESTION: Aspirin stops pain by: a. stopping the upward transduction of pain signal in the spinal cord b. interferes with signal interpretation in the CNS c. stopping the local signal production and transduction stopping the signal transduction in the cortex

QUESTION: NSAIDS. irreversible or reversible (question which of the following true about NSAIDS) …answer 1 irreversibly binds answer 2 reversibly answer 3 something about bleeding time answer 4 something about platelets a. Aspirin is irreversible, others are reversible

QUESTION: NSAID that is least likely to affect stomach – CELEBREX (Selective NSAID - Cox 2 inhibitor only) a. Cox 2 does not increase bleeding time and less platelet adhesion

QUESTION: What does not have an effect on platelets on this list of NSAIDS? Celebrex (Celecoxib)

QUESTION: Celebrex (cox 2) doesn’t stop bleeding? It causes bleeding as a side effect does not affect bleeding or platelet function

QUESTION: Dyspepsia (upset stomach), what drug can cause it? Less likely to be acetaminophen, ibuprofen (less GI upset than other nsaids). b. Ibuprofen doesn’t cause as much GI upset as aspirin.

QUESTION: CASE: Patient is taking baby aspirin (81 mg). a) How long before should you stop before surgery? b) Is it necessary to stop? No c) For long will the platelets be inhibited? 5-7days (platelet live for 8-9 days) c. aspirin stays in body for 7 days. d. Aspirin is irreversible

QUESTION: For how long will a single dose of aspirin will have effect on the platelets? 2h, 12h, 1 day, 10 days, 1 month

QUESTION: After one effective dose of aspirin, how long must you wait before there is not effect on bleeding time? 1 week

*QUESTION: Aspirin works on which pathway for pain? Cyclo-ox pathway

QUESTION: How does aspirin work to inhibit bleeding? Inhibits thromboxane A2, preventing platelet synthesis a. Aspirin affects bleeding time

QUESTION: Allergic to Aspirin? Take acetaminophen. DO NOT take ibuprofen.

QUESTION: Pt has reaction to aspirin, what else can you not prescribe? acetaminophen b. most NSAID cross-react with aspirin - meaning that they can cause the same types of reactions in aspirin sensitive people

QUESTION: If someone can’t take Ibuprofen, what can you give them? a. aspirin b. Demerol - narcotic w/out aspirin c. Percodan- narcotic w/aspirin

QUESTION: Which statement is correct for Ibuprofen? • ceiling analgesia at 400mg • safe use for pt w/ peptic ulcer

QUESTION: Asthma patient: NSAID contraindication

QUESTION: Patient is on 3-5g acetylsalicylic acid per day for 3 months, what are you the most likely to see in this patient? Increased PT and Bleeding time Increased PT and PTT Acidosis and increased bleeding time c. Causes acidosis since acetylsalicylic acid is aspirin. It’s an acid & 3g daily is a lot!

QUESTION: Ketorolac is an NSAID that inhibits prostaglandin synthesis (competitive non-selective cox inhibit).

QUESTION: Oral Ketorolac (toradol) NSAID, usually used after IV dose of Ketorolac after surgery d. Ketorolac is used to relieve moderately severe pain, usually pain that occurs after an operation or other painful procedure.

QUESTION: What would you prefer for a patient with renal vascular disease & why? a. acetaminophen b. aspirin c. ketorolac d. ibuprofen e. The other drugs are NSAIDS and they affect the kidney in a more negative way. This drug affects the liver and causes liver toxicity.

QUESTION: Tylenol – non-narcotic analgesic of choice for pt taking anti-coagulants – no anti-inflammatory properties

QUESTION: Methotrexate (immune suppressive drug) toxicity increases with use of NSAIDS or penicillin

QUESTION: 3rd trimester pregnant patient needs pain medication – options: Tylenol 325mg, Tylenol 3m aspirin, or ibuprofen 600mg?

QUESTION: Patient is pregnant and needs 2 teeth extracted. Pt needs post-op analgesic. What do you rx? ibuprofen aspirin Tylenol 3 Tylenol (acetaminophen) f. For pregnant- only give Tylenol- NOTHING WITH CODEINE

*QUESTION: What is a safe pain killer to give a woman who is pregnant? Tylenol

*QUESTION: What analgesic do you give a child with Asthma? Tylenol gg. Asthmatic only use Tylenol (not aspirin bc of hyper vent)

QUESTION: 5-year-old patient with fever and pain. What do you Rx? • Codeine • Tylenol • Aspirin • NSAID

QUESTION: If a patient had some teeth extracted & asked what drug he can take that’ll provide at least 8 hours of relief, what would you Rx? a. Tylenol b. Ibuprofen c. NAPROXEN

QUESTION: Pt wants to be able to sleep through the night following extraction what should you prescribe? Naproxen --- a nonselective COX inhibitor—NSAID

QUESTION: Naproxen – 8 hour NSAID

QUESTION: What are you worried about when a patient is on Naproxen? Drug interaction w/ aspirin antiplatelet activity

QUESTION: Which of the following has least effect on platelets/bleeding? • Aspirin • Ibuprofen • Naproxen • Difluzole (vaginal candidiasis medication) BIOPSY

*Incisional biopsy is a technique used when a lesion is large > 1 cm, polymorphic suspicious for malignancy, or in an anatomic area with high morbidity

*Excisional biopsy is used on smaller lesions < 1cm that appear benign and on small vascular and pigmented lesions. It entails the removal of the entire lesion and a perimeter of surrounding uninvolved tissue margin.

QUESTION: Pt has worn denture for 19 years, now he has a sore on buccal with swelling. What do you do? a. refer out b. biopsy c. cytology d. Relieve denture in area and re-evaluate in 2 weeks

QUESTION: White patch on buccal mucosa, what’s best way to get biopsy? Smear

QUESTION: You have a lesion in mouth, you tried to treat it, still looks the same after 2 weeks – Take biopsy

*QUESTION: Biopsy - indicated when treatment doesn’t work after 14-20 days about 2 weeks—any red or white lesion that doesn’t resolve itself in two weeks – BIOPSY THAT SHIT

*QUESTION: Patient comes in with preliminary diagnosis of candidiasis on ventral tongue and floor of mouth, white lesion rough and firmly attached. What do you do? Incisional biopsy, do cultural testing and confirm that it is/is not candidiasis

QUESTION: Oral candidiasis biopsy of choice is: a. incisional biopsy b. excisional biopsy c. brush biopsy (collects the cells for cytological smear) d. cytological smear

*QUESTION: White lesion is 2x3x2 cm, what type of biopsy? excisional biopsy incisional biopsy smear

QUESTION: What should you not do initially with a patient with desquamative gingivitis BIOPSY, topical corticosteroids (other choices were, encourage OH)

QUESTION: When you do biopsy, how do you store the specimen before it gets to oral pathologist? Formalin (answer)

QUESTION: Patient has a sore, shiny red area that when you blow air on it, a white membrane comes off and the sore starts bleeding. What should you do? Culture and Medical management (Or biopsy + Med Man)

*QUESTION: To test for malignancy, what test? Cytology, brush biopsy, Incisional biopsy

IMPLANTS

• Wait 8 weeks after extraction of infected tooth to place implant • Cooling spray used to keep bone below 47C (116F) • Osseointegration = direct adaptation of bone to dental implant, immobile clinically, no peri implant radiolucency, mean vertical bone loss less than 0.2 mm annually after first year of placement, no persistent pain

For implant placement: o Need 1 mm bone on each side (Facial/Lingual) o Min vertical height of bone to place implant - 10mm o Min width of bone is 6mm o min distance of apex of implant from nerve - 2mm o platform of implant from adjacent CEJ - apical 2-3 mm o between implants - 3mm o between implant and tooth (height of contour) is 1.5 mm o Mini implant is 2.4mm Implant Contraindications: o uncontrolled diabetes o immunocompromised patients o reduced volume and height of bone (anatomic considerations) o bisphosphonate therapy o bruxism o tobacco (relative) o cleft palate o young kids Open Tray Technique Vs Closed Tray Technique o Open tray: pick up, reduces effect of implant angulation, don’t have to put coping back into impression, impression material not deformed. Open tray is more accurate o Closed tray: transfer, easier, better for shorter interarch distance, not suitable for deep implants, don’t work for nonparallel implants, less accurate PLACEMENT

QUESTION: Diff between 1 stage and 2 stage: (1 stage) immediate loading vs (2 stage) traditional way

*QUESTION: What kind of bacteria is under implants? At the apex of root canal? Gram (-) rods and filaments anaerobic

QUESTION: What bacteria is responsible for implant failure? gram (–) anaerobic

QUESTION: Bacteria around failing implants? Gram negative, motile, strictly anaerobic

QUESTION: What is the least important factor when evaluating for implant? concavity of mandible bone density distance to mandibular cancel bone width

*QUESTION: Minimum distance between adjacent implants? 3 mm

QUESTION: How much space between implant and tooth? Answers were 1.5 mm, 2, 3.5 3,

*QUESTION: Minimal distance from implant to nerve needed (ex. IAN, mandibular canal)? 2 mm

QUESTION: Implant diameter is 3.75 mm. What is the minimum labiolingual distance required? 5.75mm

QUESTION: Minimum width (bucco-lingually) bone should be for 4 mm diameter implant? Choices were 5mm and 7mm I put 7mm (4 for diameter + 1mm each side = 6)

*QUESTION: If implant with width of 4 mm is used, what should be the buccolingual width of the ridge? a. 6mm b. 8mm c. 4mm d. 10mm

QUESTION: Esthetics of a maxillary central anterior implant replacement is determined by • adjacent tissue • perio health of adjacent • wax up to full contour • emergence profile

QUESTION: Where should you put implant platform in esthetic area? at level of alveolar crest, below opposing tooth gingiva, 1mm subgingival to adjacent teeth CEJ, etc.

QUESTION: To obtain ideal emergence profile, where should the Implant head be in relation to adjacent gingival margin? 1-2mm above, 3-5 mm above, same level, 1-2 mm apical

QUESTION: Cervical position while placing an implant, how should the implant be placed in relation to adjacent CEJ? 2-3 mm apical the adjacent CEJ

Rest platforms placed 2-3 mm below adjacent CEJ.

QUESTION: Which of the following is bad for placing implants except? Radiopaque lesions

QUESTION: When placing implant in the mandibular posterior, how do you ensure you don’t hit IAN?

Look at panorex and measure with mm caliper look at PA and put some screen over to measure move the nerve down and “be very careful when placing implant”

*QUESTION: What causes the least buccal-lingual resistance to lateral forces Two 5mm diameter splinted implants Two 4mm diameter splinted implants One 5mm diameter implant One 4mm diameter implant

Q*UESTION: In anterior maxilla, for a 4mm diameter implant, how far apical to the CEJ of adjacent tooth for optimal emergence profile? 1 mm above cej of adj tooth 1 mm below cej of adj tooth 2-4 mm below cej of adj tooth

OSSEOINTEGRATION

*QUESTION: How does titanium of an implant help in Osseointegration? Forms titanium oxide layer

*QUESTION: Similarity between bone and implant? Vascular bundle below the bone

*QUESTION: Implants osteointergrate best in? Anterior mandible

QUESTION: Best area to place implant? Anterior mand

QUESTION: Worst/least successful implant placement? MAXILLARY POSTERIOR lowest quality/density, more trabulation less cortication in maxillary posterior, Type 4 bone

QUESTION: How does fibers grow from crest of bone to implant? Perpendicular with implant parallel with implant

QUESTION: How does gingival fibers orient next to implant? parallel to implant with no insertion perpendicular with insertion parallel with cuff perpendicular with cuff

Periodontium: you have long JE and CT (parallel and circular only)

QUESTION: Implant success is determined by what? Mobility Basic criteria for implant success are immobility, absence of peri-implant radiolucency, adequate width of the attached gingiva, absence of infection Average bone loss of 0.2mm for the first year is acceptable

*QUESTION: During uncovering, you realized implant is mobile & there is bone loss - failed implant, extract it!

*QUESTION: What main reason implants fail? Surgical error Lack of early loading Inadequate occlusal design does not osseointegrate

QUESTION: Major mechanisms for the destruction of Osseointegration are: Related to surgical technique Similar to those of natural teeth Related to implant material Related to nutrition

QUESTION: What is the worst type of force for an implant? Horizontal

QUESTION: When you place an implant, widening of crestal bone is seen because of which force? Horizontal

QUESTION: What causes the greatest incidence of implant failure? Smoking Osteoporosis with HTN Hypotension Allergy to antibiotics

*QUESTION: Where should implant/abutment interface ideally be? At height of alveolar crest

*QUESTION: Trauma from occlusion in implants – not gingivitis

QUESTION: All are symptoms of TFO (trauma from occlusion) on an implant except? Gingivitis, pain, loosening of implant, breakage of abutment screw.

QUESTION: 1 mm crestal bone remains around implant after 1 year, why? inflammation, heavy occlusal load

QUESTION: Which of these show clinically acceptable results of implant placement? Peri-implant pathoses implant mobility bone loss less than .1mm per yr.

QUESTION: Pt has an implant. Do the connective tissue and epithelium attach the same as they do to natural tooth, meaning biological width? A. Both attach the same B. Neither attach the same C. epi attaches the same but not connective tissue** D. CT attaches the same but not Epi.

QUESTION: Epithelial attachment for implant? • Hemidesmosome* (epithelial attachment to tooth structure and implant are the same) • fibronectin

IMPLANT SURGERY

QUESTION: What speed and torque for implant is used? High Torque, slow speed

QUESTION: Use slow speed handpiece and high torque drill to place implants

QUESTION: In implant preparation, which of the following can be used? A) hydroxyapatite irrigation b) High Speed Hand Piece c) Low torque Drill d) Saline Coolant QUESTION: Why you use irrigation in implant surgery? To prevent bone from overheating (other options were to keep it clean, etc)

QUESTION: When doing an osteotomy for implant placement, why do you use saline? to help cool down the bone

QUESTION: When placing an implant, how you keep the temperature of the bone below 56 degrees C? Alkaline irrigation

QUESTION: What is the temperature limit before bone dies in implant procedure? 47⁰C for 1-5 minutes

QUESTION: Temperature you don’t want to exceed during implant placement? They had 26, 36, 56. (No 47. I chose 56)

QUESTION: CASE - Case shows a picture of a bridge, when you look at it closely it resembles a Maryland bridge because lateral is intact. What to do if Maryland is removed? regular bridge implant because lateral was intact

QUESTION: Contraindications to implant placement? Adolescents

QUESTION: Never place implants in a patient that had cleft palate

QUESTION: Bruxism is an implant CI.

QUESTION: Implants not CONTRAINDICATED – older patient

QUESTION: What is the success rate of implants in 10 years? 80%

QUESTION: 13 y/o present for implants? wait until 18-20 y/o

QUESTION: All affect implant placement EXCEPT – smoking 1 pack a day, cardiovascular disease, uncontrolled diabetes, radiation of 60 Gy

QUESTION: What environment factor alters healing? Smoking

QUESTION: All these are contributing factors for why implant would fail in this pt except? smoking, diabetes, AGE, etc. QUESTION: Implant treatment are better option for smoker than perio surgery because perio surgery in smoker doesn’t work as well as non-smoker. a. Both statements are true but unrelated b. Both statements true and related c. First statement true but reason is not d. Neither the statement or the reason is true

QUESTION: When getting crown for implant, what occlusal scheme is preferred? Metal occlusal is preferred QUESTION: When you use screw over cement retained? when you don't have space occlusally hh. need more interocclusal space for cemented

QUESTION: What is the purpose of external hex screw? Anti-rotational ii. Hex screw implant – prevent rotation of the crown

QUESTION: Implant internal component helps with what? Prevents rotation of the abutment QUESTION: A lot of implants have external hex, what is it used for? • Stabilization of abutment • For cementation

QUESTION: What is the component of the implant that replicates implant in cast? Analogue

QUESTION: What is most important for osseointegration in implant procedures? How well the surgical procedure is managed.

QUESTION: Osseointegration of implants should be assessed: prior to placement of restorative abutment

QUESTION: At what appointment do you first check osseointegration? a) before taking the final impression b) before placing the abutment c) before cementing the crown

QUESTION: All of the following are true about surgical stents except? It tells you the number of implants you can place. Other choices were, angulation of implant, location implant, thickness of implant. I think number of implants to be placed is decided before the stent at the time of CT x-ray or during a consult)

QUESTION: Why do you use a stent? make sure implants are aligned properly

QUESTION: Stent - surgical template for angulation of bur for implant placement

QUESTION: What will you do when implant is inclined too buccally & you don’t want the screw to be seen on the buccal surface of crown? Angled abutment

QUESTION: Implant placed in facial angulation, what do you do to prevent facial access for screw abutment? place an angled abutment & cement it down; other options is correct implant placement or put composite where facial access for screw will be QUESTION: Implant placed at angle where screw hole will be on buccal surface. What do you do so that you can’t see screw on buccal? Cover with composite Angled abutment cemented Remove implant

QUESTION: Preload of implant is comparable to what force a. torque b. compressive jj. Compressive force presses the components of the system together & normally does not introduce any mechanical problems in the anchorage unit itself. kk. Tensile loading refers to a force that tends to separate components

QUESTION: What is the problem with preloading a screw implant? Low loading can make it loose high loading can make it loose low loading can lead to implant creep or something High loading can lead to implant creep ll. High frictional forces between components decrease as a result of creep leads to a decrease in preload

QUESTION: What do you want to do first when taking an impression of the implant and abutment splinting the 3 implants with a bar? Make sure the abut is attached right when the pt comes check fit of custom tray insert impression coping insert imp coping with acrylic

QUESTION: Advantages of an open tray impression - Reduce effect of implant angulation

QUESTION: Most common complication for crown? Screw loosening QUESTION: When not to immediately load an implant? • Denture in contact • Bone grafting with GTR

QUESTION: Do we probe like normal for an implant? Yes

QUESTION: How to clean implant- prophy cup, plastic scalers, not stainless steel! MULTIPLE IMPLANT: FPD, IMPLANT SUPPORTED, IMPLANT RETAINED

QUESTION: You are considering the placement of an upper and lower implant-retained complete denture. How many implants will you place in the anterior region? a. maxillary one and mandibular one b. maxillary two and mandibular two c. maxillary four and mandibular two d. maxillary four and mandibular six mm. If implant supported complete denture, add 2 more screws to each.

QUESTION: When there is FPD from natural tooth to implant, the max stress is concentrated on the SUPERIOR PORTION OF THE IMPLANT. QUESTION: If implant and bridge are done with natural tooth, what is the complication? there is a lot of force on crown of implant that causes fracture.  diff mobility QUESTION: Where do you put occlusal rests for implant supported RPD? NONE

QUESTION: After implant placement, an edentulous patient should: a. avoids wearing anything for 2 weeks b. immediately have healing abutments placed over the implants c. should wear an immediate denture to protect the implant site

QUESTION: At the time of delivery of an implant supported prosthesis, only 2 of the 3 implants seat. What do you do next? separate the prosthesis and re-index it

QUESTION: Implant retained fixed prosthesis, doctor took radiograph and it showed 2 out of 3 implants seat positively with good margin. What should doctor do after? • section and index • tighten screw • take another x-ray

ORAL SURGERY

• Most common emergency in dental office is syncope • Most common complication of office based anesthesia is a loss of airway • Malignant hyperthermia = rare inherited disease, persistent contraction is given succinylcholine or Halothane, treat with Dantrolene • Phlebitis = inflammation of superficial vein • Laryngospasm = forceful involuntary spasm of laryngeal musculature, treat with pure oxygen, if persists use succinylcholine, last resort cricothyroidotomy • Mesiodens is the most common supernumerary tooth • Patients should wait 6 months after CABG surgery prior to elective tooth extraction • Palatal root of maxillary first molar is the most common root to be accidently displaced into the maxillary sinus • Steps in extraction: maxillary before mandibular, posterior before anterior • Nerve injury: o Neurapraxia = mild injury with not axonal damage, spontaneous recovery within 4 weeks o Axonotmesis = axonal damage but intact endoneural and perineural sheath, Wallerian degeneration, potential recovery in 1-3 months o Neurotmesis = complete severance of axon with gap, no recovery without surgery • Always confirm with radiograph after repositioning a tooth/teeth • Non-rigid splint recommended for subluxation, luxation, avulsion, to avoid ankylosis • Pulp necrosis is common with tooth luxation and avulsion • Nasal bone fracture is the most common facial fracture; second is • Bilateral mandible fractures may result in posterior displacement of the tongue resulting in airway obstruction • Fracture of right condyle will cause deviation to the right and vice versa • Reverse Towne’s radiograph: shows condylar heads and necks

QUESTION: The most frequently impacted teeth are? Mandibular 3rd molars (followed by maxillary 3rd molars and maxillary canines)

*QUESTION: Most common impacted tooth? Maxillary canines (3rd molars not options)

*QUESTION: Which tooth is least likely to be missing? a. Canine b. 2nd pm c. Lateral incisors d. 3rd molar

• Most commonly missing teeth are the 3rd molars, 2nd premolars and maxillary lateral incisors

*QUESTION: What is least missing tooth congenitally? Canines…premolars, 3rd molars, lateral incisors

QUESTION: Extractions in orthodontic treatment would include: Maxillary 1st premolars

QUESTION: Where does mandibular branch of trigeminal nerve come thru? Foramen Ovale

EXTRACTIONS

QUESTION: Ectopic eruption of mandibular 1st molar in relation to primary mand 2nd molar cause some resorption, tx management? Extract primary 2nd molar…separation, disking of 2nd molar

*QUESTION: What order do you extract upper posterior molars & why? 3rd M, 2nd M, 1st M to prevent fracture of tuberosity

QUESTION: Most likely to cause nerve damage during extraction? Nerve canal overlaps root apices…nerve canal narrows

QUESTION: MOST common complication of extraction? Root fracture…hemorrhage, infection

QUESTION: Radiograph of mandibular molar extraction site. Patient came back having pain & pus in that area Osteomyelitis (dry socket not a choice)…other options were radicular cyst, lateral cyst, etc.

QUESTION: X-ray of older woman. Tooth was extracted 3 years ago. The area still hurts and has exudate, shows cotton-wool radiograph over the ridge area, "prob wrong") what is it? Osteomyelitis…residual cyst, two other lesions that are radiolucent • Cotton wool appearance is seen in Paget’s disease. Paget’s disease is know to lead to osteosarcoma.

QUESTION: Patient with osteomyelitis after extraction, what do you do? Curettage the walls of the socket to remove infection

QUESTION: Extraction of #30, which way do you section? Buccal- lingual

*QUESTION: Resorption of bone takes place in which direction after extraction?

a. Downward/inward b. Downward outward c. Forward inward QUESTION: After fracture of a mesial root tip on a molar extraction, what’s the first thing you do? Get hemostasis and visualize the root…other options take an x-ray, pick at it with root pick, surgical retrieval

QUESTION: Which direction do you luxate the tooth? Children: Palatably (molars are positioned more palatably and palatal root is strongest) Adults: buccally!

QUESTION: When do you do serial extraction? a. For space deficiency in mandibular anterior region b. For space deficiency in mandibular posterior region c. For space deficiency in maxillary anterior region d. For space deficiency in maxillary posterior region

*QUESTION: Biggest risk with extracting a lone single remaining maxillary molar? Fracturing tuberosity (lone molar usually ankylosed)

QUESTION: When extracting an erupt maxillary molar, what is most like cause of complication? You can have broken tuberosity/sinus floor

QUESTION: Can tell if a tooth ankylosed: Emits different sound to percussion…If submerged • Decks state that an ankylosed tooth emits an “atypical sharp sound on percussion” soooo I think different sound is right.

QUESTION: Minimum platelet count for oral surgery? Routine ok with 50,000 • Emergency can be done with as little as 30,000 if work with hematologist and use excellent tissue management technique

*QUESTION: You extracted a tooth and gave Penicillin. The next day, patient has high fever, swelling, & dysphagia. What do you do? a. Change to different antibiotic b. Refer to OMFS c. Add another drug to regimen

THIRD MOLAR EXTRACTIONS

What is the hardest 3rd molar to remove? Mesioangular maxillary third • Mesioangular impactions are the most difficult to remove, while vertical and distoangular impactions are the easiest to remove.

QUESTION: When extracting, where is the max 3rd molar most likely to be displaced? A. Infratemporal fossa B. Maxillary sinus

QUESTION: How do you extract molars with divergent roots? Hemisection

QUESTION: In which direction do you luxate a distoangular maxillary 3rd molar? Distobuccal…distopalatal, palatal, mesial

*QUESTION: What is the easiest 3rd molar impaction to remove? Distoangular

QUESTION: Extraction of complete horizontal bony impaction of #32, what is the main concern? Damage to nerve QUESTION: Third molar (#16) half bony, half soft tissue impaction is the most common and easiest to take out. Both statements false

QUESTION: FMX, question about right side of patient, #1 and #32 were both impacted, how would you describe these impacted teeth? #1 disto-angular impaction, #32 horizontal impaction

*QUESTION: Greatest risk to injure IA nerve on extraction of 3rd molars: Lack of visualization of end of roots Root tips sit on top of mandibular canal Horizontal impaction

QUESTION: Indication to extract 3rd —making space for ortho, prevent crowding, pt has pain during eruption, there’s an infection

QUESTION: 65 y/o has hypertension and congestive heart disease, referred to you to TE impacted molar, absolute indication to do the TE is when: Radiograph shows bone pathology Prevent distal pocket of 2nd molar Prevent jaw fracture Prevent distal caries for 2nd molar

QUESTION: Patient has pain, trismus, inflammation for 3rd molar, Tx? Extraction

QUESTION: Know treatment Without surgery = clean and antibiotics With surgery = Before surgery, control infection, incision and drainage, irrigate, antibiotics, then remove the 3rd molar

QUESTION: Which direction do you luxate tooth #1 and #16? – Distally and Buccally

SURGERIES

Oro-antral communication Tx depends on the size: < 2 mm DO NOTHING 2-6 mm AB, nasal decongestant + figure 8 suture >6 mm = flap surgery

QUESTION: Mylohyoid surgery can accidentally damage to what nerve? Lingual nerve

QUESTION: Where are you most likely to damage a nerve in vertical release of flap? Lingual… Wharton’s duct and the sublingual gland • Avoid vertical incisions on lingual and palatal

*QUESTION: When doing flap surgery on mandible, what structure do you watch for? Mental nerve…mentalis attachment

QUESTION: Oro-antral communication of 4mm, what do you do? Figure 8…observe, buccal flap, palatal flap

*QUESTION: Oro-antral communication 2mm, treatment? No treatment needed *QUESTION: You see sinus is open by 2mm after an extraction, what do you do? Do nothing and observe

QUESTION: If you have 3mm uninfected root into sinus, what you do? You do one an attempt, and if unsuccessful, leave it alone, no surgery

QUESTION: What is the Caudwell Luc technique? Removal of root tip from max sinus, incision over canine fossa

OS SURGERY – MEDICAL COMPLICATIONS

QUESTION: 5 yr. old kid with Adderall prescription that needs an extraction. Do you need to change the dosage? No change

*QUESTION: Patient is about to undergo radiotherapy, what do you? – Extract all questionable teeth before radiation (another answer said, EXT all teeth before radiation)

*QUESTION: Therapy to avoid osteoradionecrosis? Extract questionable teeth in area to receive 60+grays

QUESTION: A patient has begun radiation therapy in the mandible and needs teeth extracted. What do you do? Do endodontic therapy and amputate the crown without any trauma to soft tissue or bone

QUESTION: A patient received radiation therapy and requires extraction, what should the treatment be? Extraction Extraction with alveoloplasty and sutures Extraction with alveoloplasty of basal bone and suture Pre-extraction and post-extraction hyperbaric oxygen

*QUESTION: Patient is taking IV bisphosphonates and need tooth extraction? RCT then coronectomy and seal Hyperbaric oxygen followed by TE Antibiotics and TE Atraumatic TE

QUESTION: If pt has been on IV bisphosphonates for two years and needs extraction? Do root canals and keep roots, no TE!

QUESTION: All of the following are contraindicated for bisphosphonates, except? Do RCT (other choices were invasive procedures)

QUESTION: Patient has BRONJ & bone is exposed, what is treatment? SCRP and chlorhexidine rinse (anti-bacterial rinse, and oral antibiotics)…hyperbaric oxygen

QUESTION: Osteoradionecrosis: Swelling, degeneration and necrosis of the blood vessels with resulting thickening of the vessel wall. What do you do? Use hyperbaric oxygen for angiogenesis

OS INSTRUMENTS

Common OS instruments: • #9 Periosteal elevator

Mandibular: • #17 extracting forceps is for mandibular molars without fused roots (pediatrics?) • #23 mandibular cowhorn for mandibular molars** • #74 ash forceps for mandibular premolars • #151A mandibular forceps for mandibular premolars o #151A is modification of #151, and it’s for mandibular premolars only • #222 is for mandibular molar with fused conical root • Cryer elevator is best for single retained root of extracted mandibular molar

Maxillary: • #65 bayonet-shaped forceps for maxillary incisors or roots • #150 universal forceps for all maxillary except third molar • #88 upper cowhorn for first and second maxillary molars • 286 for maxillary root tips

QUESTION: What number forceps to use when extracting mandibular premolars: 151A

*QUESTION: What forceps are best for a mandibular premolar extraction? #17, #23, #74, #151, #150

*QUESTION: The universal forceps #151 is commonly used for extracting ______. a. Maxillary anteriors b. Maxillary molars c. Mandibular molars d. Maxillary premolars

QUESTION: The #65 forceps is typically used for removing ______. a. Canines b. Premolars c. Molars d. Root tips

QUESTION: During extraction of a mandibular molar, the mesial root break. What instrument you use for root tips? Cryer forceps

QUESTION: Elevator can be used to advantage when… a. Interdental bone is used as fulcrum b. Multiple adjacent teeth are to be extracted

QUESTION: Elevator in oral surgery acts as what type of machine? Lever…wedge

SUTURE:

QUESTION: What kind of suture do you use if you are only removing tissue on one side of tooth? Interrupted…sling, continuous, etc. *QUESTION: What suture do you use when only buccal tissue is displaced? Interrupted QUESTION: What suture do you place when you only displace facial surface of mandibular teeth? Interrupted…mattress, continuous, etc.

QUESTION: What does an interrupted suture accomplish? a. Brings the flap closer b. Covers all exposed bone c. Immobilizes the flap

*QUESTION: What suture contains wicks that allows bacteria to enter/invade extraction site? Gut Silk Nylon

QUESTION: There is an incision on the corner of lip, where do you put suture? Movable to fixed tissue

QUESTION: If there is a 2 cm laceration on lip, what type of suture do you do? Continuous…in middle and work both ways, reconnect orbicularis oris first, reconnect vermillion border first

ALVEOLAR OSTEITIS:

QUESTION: Most common negative outcome of routine tooth extraction? Alveolar osteiitis (dry socket)…hemorrhage, infection

QUESTION: Patient is a smoker, what is pt more at risk of getting after extraction? Dry socket

*QUESTION: Pathophysiology of dry socket. How do dry sockets develop? Blood clots not forming (fibrinolysis of clot) *QUESTION: What causes (dry socket)? Active dislodgement of blood clot (fibrinolysis of the clot)

*QUESTION: What is the main symptom of alveolar osteitis? Pain

*QUESTION: Alveolar osteitis (dry socket) treatment? NO ANTIBIOTICS or curettage needed. Just medicinal dressing. • Irrigate with saline, sedative dressing (eugenol-based), change every 48 hours, control pain (analgesic drugs)

*QUESTION: Ways to tx dry socket except: a. Curette walls to make socket bleed b. No non-narcotic analgesic as needed c. Sedative dressing d. Flush out debris w/ sterile solution

QUESTION: All are treatment for dry socket except? Need for oral antibiotics

QUESTION: Multiple questions about when you would not give antibiotics: all the answers were alveolar osteitis (all the others had a systemic infection i.e. cellulitis), other questions about osteitis is how would/wouldn’t you treat alveolar osteitis

FACIAL FRACTURES:

Le Fort II - Separation of the maxilla, attached nasal complex from the orbital and zygomatic fractures Le Fort III - Nasoethmoidal complex, the zygomas, and the maxilla from the cranial base which results in craniofacial separation Pathognomonic sign: Periorbital/hematoma, diplopia (double vision) and /or subconjunctival hemorrhage, infra-orbital nerve damage

Type of X-rays to see Fractures:

Panoramic >>>> best for mandible fracture Reverse Towne’s >>>> for condyle fracture Submentovertex>>>> for zygomatic fracture Water’s >>>> for maxillary sinus CT >>>> facial fracture

QUESTION: Key sign of mandibular fracture? Occlusal discrepancy or change in occlusion

*QUESTION: Patient has a condylar fracture, what happens when mandible grows? Asymmetric growth with damaged side lagging (unaffected side will continue to grow)

QUESTION: Child has mandibular trauma, what do they have later? Midline facial asymmetry

QUESTION: What is the primary consequence of trauma to jaw in kids? Retards growth (normal def. of jaw, vs retarded growth vs hypertrophic growth on one side, etc.)

QUESTION: Fracture in condyle leads to lag of growth which leads to what? Malocclusion

QUESTION: Most common area of fracture in children? Condyle…coronoid, symphysis • MOST COMMON: condyle (29%) 2nd most (angle of mandible 24.5%) – still growing, mostly cartilage • LEAST COMMON: coronoid (1.3%) 2nd least (ramus of mandible 1.7%) – not attached to anything

QUESTION: Ankylosis of condyle most likely due to? Fracture/Trauma

QUESTION: How long do you splint a closed fracture for (i.e. mandible fracture)? 6 weeks

QUESTION: In cllosed reduction, immobilize mandible for how long? 6 weeks • The standard length of maxillomandibular fixation (MMF) is 4-6 weeks.

QUESTION: Paresthesia occurs most commonly in what type of mandibular fracture? Angle fracture

QUESTION: Lower lip numbness is seen in what kind of mandibular fracture? Angle fracture (fracture distal to mandibular foramen, close to IAN)

QUESTION: Most common surgery for maxilla? LeFort I

QUESTION: Lefort I fracture are associated with? Nasoethmoidal air cell Frontal sinus Maxillary sinus Mastoid air cell

QUESTION: Guerin sign is a feature of what Le Fort fracture? LeFort 1 Fracture • Guerin’s sign: ecchymosis in the region of greater palatine vessels.

QUESTION: LeFort I = brings the lower midface forward, from the level of the upper teeth, to just above the nostrils. Lefort I fracture: "floating palate", Disturbed occlusion, palpable crepitation in upper buccal sulcus

QUESTION: LeFort II = separation and mobility of the midface, gagging on posterior teeth, anterior open bite

QUESTION: LeFort III = brings the entire midface forward, from the upper teeth to just above the cheekbones.

QUESTION: Lefort II most common injured nerve: Infraorbital nerve

QUESTION: Subconjunctival hemorrhage seen in what fracture? Zygomaticomaxillary complex…Lefort 1, nasal, frontal sinus

QUESTION: A patient experiences numbness of the left upper lip, cheek, and the left side of the nose following a fracture of his midface. This symptom follows a fracture through the A. Nasal bone B. Zygomatic arch C. Maxillary sinus D. Infraorbital rim

QUESTION: What was the most common fracture in the face? Zygomaticomaxillary complex (I believe correct answer is nasal according to AID)

QUESTION: Which radiograph would you use to view a fracture of the mandibular symphysis? A-P or CT

QUESTION: What age does mandibular symphysis fuse/close? 6-9 months…birth, 3

QUESTION: Fracture of which part of the face would compromise patient’s respiration? • Fracture through the body of mandible (bilateral) • Fracture to condyle • Fracture to angle of mand

*QUESTION: You get punched on lower right & broke the jaw. What do you worry about? Contralateral condylar fracture

*QUESTION: So you decide to fight back and you knock the guy out by hitting him on the right side of the jaw/mandible, where is the other site of the fracture? Fracture is always on opposite side condyle

a. Left condyle b. Right condyle c. Both d. Right mandible QUESTION: When pulling out a tooth, the jaw fractures. What do you do? Open flap to see all of the fracture, remove all the fractured pieces, remove all the fractured pieces that are not attached to periosteum

*QUESTION: What X-rays do you take to confirm horizontal fracture? 3 X-rays moving vertically *QUESTION: Horizontal fracture easily seen with? Multiple vertical angulated x-rays

QUESTION: What is best view to see zygomatic process? Submentovertex (SMV)

QUESTION: Which of the following images shows better the mid-facial fracture? Waters QUESTION: What causes the most trauma in the US? Auto-accidents (in 3rd world is knife fights)

QUESTION: Panoramic showing lucency going inferior over the body of mandible close to the angle. You are informed that the patient was involved in an accident. Identify the lucency: a. Pharyngeal airspace b. Fracture c. Artifact-retake radiograph

ORTHOGNATHIC SURGERY:

Osteotomy: surgery where bone is cut to shorten, lengthen, or change its alignment

Distractive Osteogenesis (DO): surgical process used to reconstruct skeletal deformities and lengthen the long bones of the body. • Benefit of simultaneously increasing bone length and the volume of surrounding soft tissues. • Easier in children, shows less relapse. • Two surgical procedures, hospitalization time is less but more discomfort -- Compliance of patient and parent is a difficulty in DO

Bilateral Sagittal Split Osteotomy (BSSO) – surgery where mandibular is split bilateral & moved to more balanced/functional position • Correct • Stable for normal/decreased facial height but high relapse for pt w/ high mandibular plane angles. • BSSO is the most commonly used osteotomy for mandibular advancement or retraction

QUESTION: Most commonly used surgery for mandibular augmentation? Bilateral sagittal osteotomy

QUESTION: BSSO = Vertical Osteotomy used to: push mandible forward or backward for class II.

QUESTION: How would you repair a Class II malocclusion? BSSO (bilateral sagittal split osteotomy) Correction of severe class II: • Maxillary Impaction and autorotation of the mandible • BSSO

*QUESTION: Worst complication of BSSO? Damage to Inferior alveolar nerve/Paresthesia

QUESTION: During which surgery do you have most chance of paresthesia of lip & tongue? a. BSSO b. Vertical ramus osteotomy c. Inverted L

QUESTION: Patient wants to fix Class III occlusion, what you going to do? a. Lefort 1 with BSSO b. Lefort 1 c. BSSO • Max palatal expansion with BSSO • BSSO is for CLASS II (lengthen undeveloped mandible) • Rapid palatal expander is for crossbite or minimal class III

QUESTION: 16 year old girl would need to do Lefort + BSSO to correct – can’t do RPE because she’s too old

QUESTION: How long do you splint mandibular BSSO? You don’t do MMF, as there is internal plate. Use an occlusal splint to help with occlusion but not wired shut. Keep splint on 4-6 week.

QUESTION: Which of the following is the MOST common postoperative problem associated with mandibular sagittal-split osteotomies? a. Infection b. TMJ pain c. Periodontal defects d. Devitalization of teeth e. Neurosensory disturbances

QUESTION: A patient has a skeletal deformity with a Class III malocclusion. This deformity is the result of a maxillary deficiency. The treatment-of -choice is A. Orthodontics. B. Surgical repositioning of the maxilla. C. Anterior maxillary osteotomy. D. Posterior maxillary osteotomy. E. Surgical repositioning of the mandible.

*QUESTION: What’s the main difference between distraction osteogenesis and a regular osteotomy? DO has more stability during wide span of movements

*QUESTION: Distraction osteogenesis: when to use over conventional: Bigger stable movements

QUESTION: Complication following distraction osteogenesis (DO): Long term follow up

PERIODONTICS

*QUESTION: Which ethnic group has the most chronic periodontitis? Black males

QUESTION: Black males have the highest incidence of chronic periodontitis

PERIODONTAL IMMUNE RESPONSE:

Periodontitis: Initial = PMN, early = lymphocytes, establish = plasma cells

Medical Conditions leading to periodontal disease: ( http://www.hindawi.com/journals/ijd/2014/850674/tab1/ )

DDM (diabetes) Histiocytosis X HIV/AIDS Hypophosphatasia Leukocyte adhesion deficiency (LAD) Chediak-Higashi syndrome Leukemia Papillon Lefevre syndrome Neutropenia Down syndrome Acrodynia Ehlers-Danlos syndrome

Red Complex – group of bacteria grouped together based on their association w/ periodontal disease o Red complex = P. gingivalis, Tannerella forsythia, treponema denticola o BOP & deep pockets Orange Complex - Fusobacterium, prevotella, campylobacter o Precedes red complex, plaque formation & maturation

QUESTION: Red complex has 3 bacteria’s: P. Gingivalis, Tannerella forsythia, Treponema denticola

*QUESTION: Which one is predominant in sulcular fluid? PMN’s

QUESTION: What is predominate in established gingivitis? Plasma cells

QUESTION: Which of the following species is a usual constituent of floras that are associated with periodontal health? Streptococcus gordonii

QUESTION: What bacterial species is not associated with (chronic?) periodontal disease? a. Actinomyces species (associated with juvenile periodontitis) b. P. gingivalis c. Capnocytophaga

QUESTION: Bacteria that is not in chronic periodontitis? Actinomyces viscosus (pellicle) C. rectus T. forsythia P. gingivalis.

*QUESTION: Which is related to periodontal disease? Gram negative bacteria

QUESTION: What is the 1st step in bacterial plaque formation on a tooth? Pellicle formation (glycoproteins, enzymes, proteins, phosphoproteins). o 2nd step is adhesion and attachment of bacteria o 3rd step is colonization and plaque maturation

QUESTION: What does plaque depend on? Bacterial interactions & bacterial polymers. It does NOT depend on host antigen.

*QUESTION: Which is not part of plaque formation? Host antigen, extracellular bacterial polymers

QUESTION: Most plaque retentive thing – Calculus

QUESTION: Gingival recession, other than plaque amount, is related to – Age, tobacco, etc.

QUESTION: Plaque index is used for what? Track gingivitis progression Track disease activity To know plaque amount Patient motivation

*QUESTION: Which one is not a periodontal risk factor? Malnutrition, smoking, oral hygiene, diabetic mellitus

QUESTION: Which of the following things are associated w/ periodontal disease? Diabetes Mellitus…atherosclerosis, low birth weight of babies

QUESTION: Difference between primary and secondary occlusal trauma? Periodontal support/healthy periodontium (Primary)

QUESTION: Healthy patient, probing shows bleeding, what could this be due to? Gingivitis

QUESTION: Which is least likely to occur with occlusal trauma? Gingivitis

QUESTION: Gingival index/perio index. Know their flaws: Perio index flaws are that the gingival recession was not taken into account. • Gingival index: each of the 4 gingival areas of the tooth is given a score from 0 (normal) to 3 (severe inflamed), mostly based on color. Score is totaled per tooth or added all together/ (total teeth #) to give GI person score. • GI doesn't consider PD, degree of bone loss or any other qualitative changes in periodontium.

QUESTION: What is Gingival Plaque Index? a. Nominal like mild, moderate, severe b. Ordinal include numbers: like furcation involvement 1,2,3 c. Interval like Celsius degree d. Ratio e.g. Kelvin degree, or BP measurement (cannot be zero), length (cannot be negative), weight

QUESTION: What is CPITN? Community Periodontal Index of Treatment Needs

QUESTION: What is predominant in plaque 2 days after prophy? Gram (+) cocci and rods • Gram + cocci and rods normally present, gingivitis transition includes Gram (–) rods and filaments followed by spirochetal and motile organisms.

QUESTION: With the development of gingivitis, the sulcus becomes predominantly populated by a. gram-positive organisms. b. gram-negative organisms. c. diplococcal organisms. d. spirochetes.

QUESTION: Supragingival calculus: Main crystals are hydroxylapatite 58%

QUESTION: Chronic periodontitis has G (--) anaerobes.

*QUESTION: Chronic periodontitis: has P. gingivalis (gram -)

QUESTION: Fusobacteria nuceatum has what specific characteristic? Bridging microorganism between early & late colonizers of dental plaque

QUESTION: All syndromes are associated w/ periodontal problems accept a. Stevens-Johnson syndrome (target lesions - conjunctiva and genital problems) b. Papillon-lefevrev syndrome (palmoplantar keratoderma with periodontitis) c. Down syndrome (related) d. Hypophosphatasia (bone disease similar to rickets, premature loss of primary teeth) e. Acrodynia (pain, discoloration of hand/feet, chronic heavy metal

QUESTION: Least cause of bone loss around primary teeth? Hypophosphatsia, leukemia, Plaque

QUESTION: Which of the following causes bone loss? a. C3a, C5a b. Endotoxin c. Interleukin d. B glucorinidase

QUESTION: What cytokine responsible for osteoclasts? IL-1, IL-8, IL-5, IL-3

QUESTION: Stress long term cause problem in periodontium b/c It increases cortisone and cortisone brings immune system down

DEHISCENCE & FENESTRATIONS

*QUESTION: What is it called when you have a hole in the bone that exposes the root? Fenestration

QUESTION: Dehiscence: Loss of buccal or lingual bone overlying a tooth root, leaving the area covered by soft tissue only

QUESTION: Dehiscence - loss of alveolar bone on the facial (rarely lingual) aspect of a tooth that leaves a characteristic oval

QUESTION: Each of the following osseous defects would be classified as infrabony EXCEPT one. Which one is this EXCEPTION? A. A trough B. A dehiscence C. A hemiseptum D. An interdental crater

CLINICAL ATTACHMENT LOSS & BIOLOGICAL WIDTH

*QUESTION: Biological width is 2 mm.

QUESTION: Biological width is from the alveolar crest to the base of the sulcus.

QUESTION: Biologic width definition: junctional epithelium and ______attachment to the tooth above the alveolar crest (at least 2mm) a. gingival sulcus b. epithelial attachment c. connective tissue

QUESTION: How to determine attachment loss? From CEJ to sulcus (depth of pocket)

QUESTION: Which of the following factor is most critical in determining the prognosis of periodontal disease? 1. Probing depth 2. Mobility 3. Class 3 furcation 4. Attachment loss QUESTION: Attachment loss: loss of connective attachment w/ apical migration of the JE away from the CEJ

QUESTION: The depth of sulcus is 5mm, the distance between CEJ and the base of sulcus is 2mm.what is the attachment loss: 2 mm

QUESTION: If recession is 2 mm and probing is 1 mm, how much attachment loss? 3 mm

QUESTION: If you have 1 mm recession and can probe 3 mm, how much attachment loss is there? 4mm

PERIO TREATMENT:

*QUESTION: Perio treatment sequencing for mild-moderate chronic periodontitis? Plaque control, Sc/Rp, caries control, perio surgery

*QUESTION: Why you do perio before ortho: Because perio can cause gingival and osseous changes

QUESTION: When is the perio prognosis that poor? Class 2 mobility Deep class 2 furcation Deep probing with suppuration (indicates tooth fracture)

QUESTION: Which teeth commonly relapse after perio tx (poor long-term prognosis)? Maxillary molars due to furcation anatomy

QUESTION: Where perio Tx is more difficult? Maxillary molars due to trifurcations.

QUESTION: Which tooth is most commonly lost due to long term care in periodontal patients? Maxillary molar, max pm, man molar, man pm

QUESTION: If you have a through-and-through furcation involvement (class III furcation) on a tooth with 5 mm of root left in the bone, what do you do? Extract the tooth (preferred treatment) Splint Place Implant

QUESTION: Patient with class III furcation and 3 mm exposure? Extract

QUESTION: If you have a grade III furcation, you can do all of the following except a. Section it and crown both as PFMs (hemisection) b. Tunneling procedure c. GTR (guided tissue regeneration) • Better for Class II, least successful for class III

QUESTION: Tx option: Class 2 almost class 3 furcation? Main goal of tx on class 2 is converted to class 1 furcation by doing GTR

QUESTION: Recommended treatment for a Class II that is almost a class III furcation: Convert class II to a class I by doing GTR Tunneling Extraction

QUESTION: Class 2 and 3 furcation, all of the following would be a part of tx plan except? gtr, tunnel prep, odontoplasty the class 2 to a class 1 furc, extract + place implant, hemisection

QUESTION: Most likely shape of furcation is? Wide but still not very accessible to dental tools, others used variations of that.

QUESTION: When you have a through and through furcation (Grade 3 at least), 1. It’s wide enough and you can clean it 2. It’s wide enough and the curette is too big to clean it 3. It’s narrow enough and you can’t clean it 4. Its narrow enough and the currete is too small to clean it

QUESTION: Root amputation of MB root – Cut at furcation and smoothen for patient to keep clean

QUESTION: What is most common periodontitis periodontal diagnosis in school-aged children: aggressive PD, ANUG, Marginal gingivitis

QUESTION: Antibiotic therapy and debridement have minimal effect for? ANUG, Localized aggressive, Chronic periodontitis

QUESTION: How do you treat gingivitis in puberty: Debridement and OHI

*QUESTION: Percentage to be considered generalized perio? > 30%

QUESTION: Diagnosis for 40-year-old female w/ generalized bone loss, localized vertical bone defect, and gross calculus: Chronic periodontitis

QUESTION: Which of the following PDL diseases cause rapid destruction of alveolar bone? 1. Periodontal abscess 2. ANUG 3. Chronic periodontitis

QUESTION: Two patients, old and young person w/ same perio. Which has better prognosis? Older patient (b/c younger pt had shorter time frame to get to the same condition so more aggressive in nature)

QUESTION: Most common to cause mobility- trauma, advanced perio, periapical pathology

QUESTION: Which of these is reversible with tooth movement? • Tooth mobility • Bone resorption • Crestal bone • Gingival recession • Attachment loss

ORAL HGYIENE INSTRUCTIONS & MEDICATIONS

*QUESTION: Best for interproximal plaque removal in teeth without contacts: floss, waterpick, Interproximal brush

*QUESTION: What is not able to reach the interproximal? Toothbrush

*QUESTION: Best brushing technique to clean periodontal pockets: A. Charters B. Sulcular (another name for modified Bass) C. Whitman’s

QUESTION: Least effective for crevicular plaque? Water irrigating device (waterpik), nylon, toothbrush Water irrigation removes debris (not plaque)

QUESTION: Which of the following is likely to be abrasive after osseous surgery? Water pik, toothbrush, toothpick, rubber gum stimulator

QUESTION: Class 2 furcation, which instrument is the worst to clean a class II furcation? Tooth brush, floss, waterpik, Rubber stimulating tip Rubber tip is for interdental papilla

QUESTION: Toothbrush and floss, how much can it reach in perio pocket? Toothbrush 0 mm, floss 2-3 mm Toothbrush 2-3 mm, floss 0mm Toothbrush = 1 mm, floss = 2-3 mm

*QUESTION: What can make teeth green? Bacteria, gingival hemorrhage, medications or hyperbilirubinemia (ALL of them)

*QUESTION: Green and orange stains on maxillary incisors can usually be attributed to A. drugs. B. diet. C. poor oral hygiene. D. fluoride consumption E. Genetics

QUESTION: What are proper ways to reinforce OHI: verbal and written in the dental office, verbal only, video tape

QUESTION: What is most difficult to maintain oral hygiene with home preventive care? • pit and fissure • proximal smooth surface • facial smooth surface • lingual smooth surface

QUESTION: Why don’t you use Acidulated Fluoridated Toothpaste? Ruins Polish of Crown

QUESTION: How does Listerine act? Antiseptic mouth rinse is a broad-spectrum antimicrobial & kills bacteria associated with plaque and gingivitis by disrupting the bacterial cell wall. • Bacterial cell wall destruction, bacterial enzymatic inhibition, and extraction of bacterial lipopolysaccharides.

*QUESTION: Action of Listerine? Uncharged phenolic compound

QUESTION: What daily oral rinse would you give to a medically compromised child for plaque control? Chlorhexidine, Listerine, Nystatin, stannous fluoride, sodium fluoride

QUESTION: The role of chlorhexidine is cause: Substantivity (anti-plaque)

QUESTION: Action of chlorhexidine: binds to cell wall Cell membrane disruption/rupture, fluid leaks out, cell lysis (CHX bursts membranes)

QUESTION: Use of chlorhexidine Reduce plaque accumulation Broad spectrum against gram positive and negative bacteria and fungi – Positively charged

QUESTION: What does sodium pyrophosphate do? Plaque removal Removing crystals of Ca+ and magnesium, inhibits mineralization of biofilm/staining (inhibits Ca+ phosphate from binding)

QUESTION: Why are inorganic pyrophosphates in anti-tartar toothpaste? It acts as a tartar control agent, serving to remove calcium and magnesium from saliva and thus preventing them from being deposited on teeth (chelating + abrasion)

QUESTION: Why is inorganic pyrophosphate in tooth paste? prevent calcium phosphate crystals, decrease number of bacteria growth

QUESTION: Periostat: 2x daily 20 mg, has doxycycline, which works by inhibiting collagenase/protein synthesis

QUESTION: Periostat’s mechanism of action: inhibits collagenase, inhibits ribosome 50s, periochip, Reduces elevated collagenase activity in gingival crevicular fluid of patients with adult periodontitis; no antibacterial effect reported at this dose

QUESTION: Doxycycline use? Intramicrobial which inhibits MMP (matrix metaloprometase) Sub-antimicrobial dose doxycycline (SDD, periostat) inhibits matrix metalloproteinase (MMP)

QUESTION: Root surface tx with what agents? Use citric acid, fibronectin and tetracycline

*QUESTION: Which is least complicating for OH? Fixed bridge, rheumatoid arthritis, Open contact

PERIO INSTRUMENTS

QUESTION: Probing furcation from facial is best. Better access to facio-mesial furcation from facial.

QUESTION: Best way to detect furcation – Curve perio probe (naber probe), curette, straight perio probe

*QUESTION: Best angle to place curette on root is 45⁰- 90⁰ for working strokes.

QUESTION: What edge of curette do you want to be in contact at line angle? Lower 1/3

QUESTION: Curette, which third adapts tooth? Apical Third, Middle Third

QUESTION: Which part of instrument do you place on line angle of tooth: Middle third Third including tip Third closest to handle or entire edge

*QUESTION: Which gracey curette is used for the mesial surface of distal root in max tooth? 11-12

SCALING & ROOT PLANING: QUESTION: What is not the initial treatment for gingivitis? SCRP, OHI, Corticosteroids

QUESTION: Sc/RP removes Diseased cementum

*QUESTION: What is not an objective of Sc/Rp? Remove cementum

QUESTION: Just did Sc/RP on pt w/ recession. What’s the best way to prevent sensitivity to newly exposed root surface? Keep root surface free of plaque

QUESTION: After you do Sc/RP, how does new attachment form? Long junctional epithelium

QUESTION: Direction of root planning? From base of pocket to CEJ

QUESTION: What kind of gingiva is favorable for SCRP? More edematous gingiva

QUESTION: Best results from SCRP will be from a patient who has: edematous gingiva, fibrotic gingiva, loss of attachment

QUESTION: What do you do if after S/RP, there are 2 probing sites of 6 mm? Perio Surgery

QUESTION: Pt had SRP & they came back for perio maintenance but there are still 5-6 mm pocket. What do you do? Open debridement

QUESTION: Why do you check occlusion in pts with perio abscess? Many perio lesions are caused by occlusion Edema can cause teeth to supra erupt Some other choices were pretty good to, but I can’t remember what they were

QUESTION: What’s the FIRST thing you do in maintenance appointment (recall)? Update medical history (other choice were address patient’s pain, prophy, etc.)

*QUESTION: What do you not do at the perio maintenance apt.? SRP pockets of 1 – 3mm

QUESTION: What happens after the periodontal re-eval, what should the recall interval be set as? The recall interval is set but may be changed if the patient’s situation changes, should be less to motivate pt, more to motivate pt

QUESTION: The normal recall appointment between periodontal treatment: 3 months

QUESTION: Best time for supportive periodontal therapy? 3 months post SCRP

QUESTION: How do you determine perio maintenance recall – Different for each patient

*QUESTION: Pt is on a periodontal recall system. What best denotes good long term prognosis? BOP (bleeding), Plaque, Deep pockets

QUESTION: BOP most indicative of what? Inflammation

*QUESTION: How long does it take to form mature plaque after removal? 24-36 hours (1-1.5 days)

*QUESTION: Mature plaque in • 1-2 hrs. • 6-8 hrs. • 10-12 hrs. • 24-48 hrs.

QUESTION: How many hours until plaque accumulation (after brushing or eating?)? 1 hour

QUESTION: Which part of dental anatomy on a central collects the most plaque? Facial surface, lingual surface, cingulum, mamelon, gingivopalatal groove

ULTRASONIC:

Ultrasonic Instruments - active portion is the tip, 20-45k cycles/seconds • Magnetostrictive: elliptical vibration pattern, all sides of tip are active (4 sides total) • Piezoelectric: linear sonic pattern, 2 sides are more active (sides are only active) • CONTRAINDICATED in patients with pacemaker, communicable diseases, titanium implants (use plastic tip), kids

QUESTION: Each of the following is a mode of action of an ultrasonic instrument EXCEPT one. Which one is this EXCEPTION? A. Lavage B. Vibration C. Cavitation D. Sharp cutting edge of tip

QUESTION: Mode of action of ultrasonic: Vibration in elliptical (magnetostrictive), sonics is linear

QUESTION: Which is true? Water and air from sonic kill bacteria

*: Aggressive periodontitis usually presents with: • rapid loss of attachment and bone destruction (1st M & incisors 1st) • familial aggregation • depressed neutrophil function or defective PMN • hyper-responsive macrophage, w/ elevated levels of prostaglandin E2 (PGE2) and interleukin 1β • except for the presence of periodontal disease, patients are otherwise healthy • elevated level of Aggregatibacter actinomycetemcomitans & sometimes, Porphyromonas gingivalis, capnocytophaga • progression of pathogenesis may be self-limiting, good response to antibiotics

Localized Aggressive periodontitis: 1st molar & incisors, circumpubertal onset, robust serum antibody response to infective agents: the dominant serotype antibody is IgG-2. Most common in blacks. Tx: surgery, tetracycline, metronidazole antibiotics w/ amoxicillin AA & capnocytophaga bacteria

Generalized Aggressive periodontitis generalized: patients < 30 y/o, poor serum antibody response AA, and in some cases, of P. gingivalis

*QUESTION: Localized aggressive periodontitis show bone loss on first molars and incisor

*QUESTION: Where are the most teeth lost in local aggressive periodontitis? Maxillary molars

*QUESTION: What kind of bone loss do you see in aggressive periodontitis? Vertical. Others answers were horizontal, mesial distal, interprox.

QUESTION: Reason pts get aggressive periodontitis? Host can’t fight off

QUESTION: What are two things in common among generalized aggressive periodontitis & chronic periodontitis? Distribution among the teeth

QUESTION: Classical sign of aggressive periodontitis? Tooth mobility & deep pockets with lack of inflammation are initial signs of LAP.

QUESTION: Which of the following is not associated w/ Localized Aggressive Periodontitis? Local factors (i.e. inflammation, plaque, calculus) consistent w/ bone loss

*QUESTION: Which of the following is not true about local aggressive periodontitis? Affect less than 30% Tx is scaling & systemic antibiotic Genetic component Not too much gingival inflammation (this is true?)

*QUESTION: What is not a characteristic of localized aggressive periodontitis (LAP)? Severe bone loss in anteriors Deep probing depths for first molars Generalized gingival inflammation

QUESTION: What is not associated with LAP (Localized aggressive periodontitis): Calculus

*QUESTION: Initial tx for Localized aggressive periodontitis Sc/RP Antibiotics Sc/RP and Antibiotics Antibiotics for 1 week and then Sc/RP

QUESTION: Best way to treat localized aggressive periodontitis? a. chlorhexidine b. H2O2 rinse c. systemic antibiotic • Localized aggressive perio, treat with tetracycline

QUESTION: 18-year-old female w/ > 5 mm pocket on central and 1st molars? Localized aggressive Perio

NECROTIZING ULCERATIVE GINGIVITIS (NUG/ANUG)

Acute Necrotizing Ulcerative Gingivitis (Trench mouth): • Usually 15-35 yrs old • Punched out papilla  painful bleeding gums, ulceration of interdental papilla w/ necrotic slough (“Vincent’s infection”) • Sometimes, fetid odor (halitosis) & metallic taste • Bacteria: anaerobic fusobacteria + spirochetes (ex. prevotella intermedia) • Tx: debridement + antibiotics (metronidazole) + OHI

QUESTION: Bacteria’s present in ANUG? fusiform, spirochetes & prevotella intermedia

QUESTION: For NUG or ANUG, which microorganisms predominate? Spirochetes

QUESTION: Patient comes in with gingivitis, no pocketing, pseudomembranous coating that’s gray on gingiva? ANUG

QUESTION: Patient has interpapilla damage, periodontal condition, what could this be due to? ANUG

QUESTION: Cratered gingival = ANUG (NUG) – punched out papilla

QUESTION: Which of the following is the most appropriate initial treatment for a patient with HIV-associated necrotizing ulcerative gingivo-periodontitis?

A. Debridement and anti-microbial rinses B. Definitive root planning and curettage C. Administration of antibiotics D. Gingivectomy and gingivoplasty

*QUESTION: For ANUG: Normally, you don’t give antibiotic. You only do debridement, rinse, and oral hygiene. But if the patient has a fever or systemic indications like HIV, give metroniadozle.

QUESTION: Tx for NUG pt with no systemic involvement? Debridement, chlorhexidine, OHI

QUESTION: First step in initiation treatment of HIV necrotizing ulcerative gingivitis? Debridement and antibacterial rinse, antibiotics, gingivectomy

PREGNANCY & PUBERTY:

Pregnancy gingivitis has altered metabolism of progesterone.

*QUESTION: Pregnant women have more gingivitis why? Hormones (progesterone)

*QUESTION: Which one of these bacteria are associated with pregnancy? P. intermedia

QUESTION: Pregnancy gingivitis caused by? hormones (progesterone) & P intermedia

QUESTION: Pregnant patient, you should not give what meds? Tetracycline, metronidazole, gentamicin and vancomycin should be avoided

QUESTION: Bacteria most associated with puberty? P. Intermedia

QUESTION: Picture of gingival hyperplasia on 14-year old girl – Hormonal-induced

DRUG-INDUCED GINGIVAL HYPERPLASIA:

Drug Induced Cyclosporine Gingival Hyperplasia

QUESTION: Patient’s interpapilla gingiva is swollen Anticonvulsant meds (Dilantin/phenytoin)

QUESTION: What’s the #1 cause of medication induced gingival hyperplasia? Anticonvulsant meds Dilantin (30% of all drug induced)

QUESTION: All the following drugs cause gingival enlargement (hyperplasia) except? a. Phenytoin b. Cyclosporin c. Nifedipine d. Digoxin

*QUESTION: Medication that causes gingival hyperplasia? Verapamil (calcium channel blocker, hypertension)

QUESTION: All of the following drugs cause gingival hyperplasia except? Verapamil, Diltiazem (CALCIUM CHANNEL BLOCKER), phenytoin (Dilantin), nifedipine and cyclosporine—all do.

QUESTION: Patient is on calcium blockers, picture show gingival hyperplasia, what do you do? Tell them to see their doctor to switch meds

QUESTION: When pt is on immunosuppressant’s for transplanted liver, what happens in the mouth? CT overgrowth & hyperplasia cyclosporine will lead to gingival hyperplasia

PERIODONTIAL SURGERY

INCISIONS/FLAPS:

Periodontal Flaps: Periodontal flap preferred for mandibular anteriors. Lateral repositioning is done for gingival recession.

Modified Widman flap: Internal bevel incision & instrumentation for root therapy, not pocket depth reduction but removes pocket lining & pocket shrinks after healing.

Displaced flap: PD reduction. Excisional procedure of gingiva = gingivectomy. Internal bevel gingivectomy but also reverse bevel. Final placement of flap determined by first incision.

Apical positioned flap: Internal bevel incision for pocket elimination (by apical position) and/or increases width of attached gingiva. Best position is 2 mm apical to alveolar crest.

Distal wedge = cut to removal of excessive soft tissue distal to a terminal tooth. It’s to treat pockets through internal thinning to gain access to bone on the distal aspect of terminal teeth.

Advantages: close wound procedure (healing by primary intention), access to bond, preserve zone of keratinized gingiva

QUESTION: The most common incision given by oral surgeons is? a. envelope flap b. y incision c. Z incision d. Semilunar incision

*QUESTION: Doing flap surgery on mandible, what structure do you watch for? Mental nerve (If 3rd molar TE= Lingual)

QUESTION: Apical position flap are contraindicated in what location? Maxillary palatal

QUESTION: Where can you not do apical flap? Lingual of maxillary molars

QUESTION: When doing extrusion of canine, these flap techniques can be used except 1) Envelope flap 2) Semilunar flap 3) Apical repositioning flap

***QUESTION: Where are you most likely to damage a nerve in vertical release of flap? Lingual, Wharton’s duct and the sublingual gland avoid vertical incisions in lingual and palatal

***QUESTION: Vertical or oblique flap, where do you make incision? At line angles

***QUESTION: Modified Widman flap can be characterizing by all BUT? internal bevel incision, replaced flap, Reflected beyond mucogingival line

• It is internal bevel incision and replaced/nonrepositioned flap. • Flap reflection with the MWF approach is only 2-3 mm beyond the alveolar crest and not beyond the mucogingival junction. (Mosby)

QUESTION: I had many modified Widman flap qs, where do you make incision to? (T/F: to the base of pocket. I put false, not sure tho)

QUESTION: With a modified Widman flap, you mostly reduce bone if…achieve good tissue adaptation to neck of teeth? a. adapts the flap margin?? b. osseous restructuring?? c. removal of infected osseous tissue d removal of malignancy tissue

QUESTION: What type of incision for maxillary palatal tuberosity reduction? T, Y

QUESTION: Which of the following statements about the flap for the removal of a palatal torus is correct? A. The most optimal flap uses a midline incision which courses from the papilla between teeth #8 and 9 posteriorly to the junction of the hard and soft . B. The most optimal flap is a reflection of the entire hard palate mucoperiosteum back to a line between the 2 first molar teeth. C. The most optimal flap uses a midpalatal incision that courses from the palatal aspect of tooth #3 across to the palatal aspect of tooth #14 D. The most optimal flap is shaped like a "Double-Y", with a midline incision and anterior and posterior side arms extending bilaterally from the ends of the midline incision.

*QUESTION: Distal wedge contraindication? On 3rd molars without attach gingiva

***QUESTION: CI when using distal wedge technique: Not enough keratinized tissue

QUESTION: Distal Wedge limited to: • Formation of the ramus • Long buccal nerve • Mental nerve

QUESTION: A tooth had epithelium above CEJ, what flap would you use? Undisplaced/Replaced flap

QUESTION: Long junctional epithelium is coronal to CEJ and margin is around CEJ, what type of flap would you use? Apical position flap, Widman flap, replace flap

***QUESTION: What type of flap do you use in crown lengthening? Apical Repositioning Flap

QUESTION: Crown lengthening procedure, what would you do? Modified woodman flap or Apical repositioned flap w/ osteotomy and osteotomy

*QUESTION: RCT w/ post and core and crown lengthening, why do crown lengthening? Ferrule effect, adequate crown length

QUESTION: To expose a mandibular lingual torus of a patient who has a full complement of teeth, the incision should be… a. Semilunar b. Paragingival c. In the gingival sulcus and embrasure area d. Directly over the most prominent part of the torus e. Inferior to the lesion, reflecting the tissue superior

***QUESTION: If removal of torus must be performed to a patient with full-mouth dentition, where should the incision be made? a. Right on the top of the torus b. At the base of the torus c. Midline of the torus d. From the gingival sulcus of the adjacent teeth

QUESTION: What has the biggest effect on the flap? a. initial incision b. extensiveness of reflection c. post-op oral hygiene d. final position of flap

QUESTION: During maintenance therapy, pt has recurrent 6mm pocket on M of #4 and D of #20. What is 1st tx option? Flap surgery scaling root planning with local microbial administration

QUESTION: To prevent exposure of a dehiscence or fenestration, what kind of flap do you do? partial or split thickness flap

QUESTION: Split thickness flap involves what tissues? Mucosa (only) or submucosa, epithelium and CT (submucosa) surface mucosa (consisting of epithelium, basement membrane, and connective tissue lamina propria

QUESTION: In a partial thickness flap, what do you cut through? Epithelium, connective tissue, but NOT periosteum

QUESTION: Perio flap that expose bone - Full thickness

QUESTION: Full thickness flap will result in bone atrophy (or loss) in:

Thin periradicular bone (so do partial-thickness flap for this) thick periradicular bone thick interproximal bone thin interproximal bone

GINGIVECTOMY & GINGIVOPLASTY

Gingivectomy: Excision of gingiva, provides visibility & accessibility for complete calculus removal & thorough root smoothing to create favorable environment for gingival healing & gingival contours. • Goal: Eliminate suprabony pockets, eliminate gingival enlargements or eliminate suprabony periodontal abscess • DO NOT DO gingivectomy if osseous recontouring is needed, if pocket depth is apical to mucogingival junction, if there is inadequate attached gingiva, or is esthetics is a concern. Gingivoplasty: Reshaping of gingival to create physiological gingival contours in the absence of a pocket.

The 3 incisions necessary for flap surgery: A. First (internal bevel) incision B. second (crevicular) incision C. third (interdental)

Wound Healing: Primary Intention healing – tissue surface has been approximated/closed. Ex. stitch, flap, glue. Very little tissue loss Secondary Intention healing – extensive wound, considerable tissue loss, edges can’t be brought together. Ex. ulcer, Sc/RP, gingivectomy. Repair time is longer, greater scaring, increased infection Tertiary Intention Healing – delayed/secondary closure, delayed suturing/wound closure. Ex. poor circulation or drainage to wound area so wait, tissue grafts

QUESTION: What direction is the reverse bevel (internal bevel) incision? Axial toward bone

QUESTION: Know about internal bevel incision and where to cut: Apical to the base of the periodontal pockets, but coronal to the MGJ.

*QUESTION: What is purpose of “bleeding incisions” in gingivectomy? location of dehiscence location of alveolar defects Guide for incision

QUESTION: Bleeding spots established in gingivectomy to? outline incision line

QUESTION: How does a site heal after a gingivectomy? Long junctional epithelium

QUESTION: Indications for gingivectomy – hyperplastic gingiva & suprabony pockets

*QUESTION: Few questions on when to do and not to do gingivectomy? infrabony pockets, little attached gingiva, high smile line

QUESTION: Which is contraindicated in 2nd molar region to reduce deep pocket with limited attached gingiva? Gingivectomy

QUESTION: Patient has very little keratinized gingiva, which of the following flaps should you not do: gingivectomy

QUESTION: Pt has a PFM #18 molar with minimum keratinized gingiva with deep pocket depth. Which of the following way is not acceptable is a way to minimize pocket depth? Gingivectomy

QUESTION: Gingivectomy is contraindicated in: when the sulcus is apical to gingival groove sulcus is apical to convexity of tooth sulcus is apical to the crest of alveolar bone (infrabony)

QUESTION: Which of these is a contraindication to a gingivectomy? the pocket extends beyond the mucogingival junction (also infrabony pockets present)

QUESTION: What should be considered for gingivectomy? level of attached gingiva degree of attachment loss

QUESTION: The base of the incision in the gingivectomy technique is located

A. in the alveolar mucosa. B. at the mucogingival junction. C. above the mucogingival junction. D. coronal to the periodontal pocket. E. at the level of the cementoenamel junction

*QUESTION: Gingivectomy incision: Excisional (external bevel incision)

QUESTION: How many mm per day does epithelium grow over connective tissue? 0.5-1 mm, 1-2 mm, 2-3 mm

*QUESTION: How does external bevel gingivectomy heal? Primary intention, secondary, tertiary, granular tissue formation

QUESTION: How does a gingivectomy heal? Secondary intention

QUESTION: After a gingivectomy, how does the site heal? a. from the epithelium of the pockets b. epithelium of the adjacent alveolar mucosa c. endothelium of the blood vessels d. primary intention

QUESTION: External bevel incision for a gingivectomy, where is the incision made? apical to epithelial tissue vascular bundle Junctional epithelium (apical to base of pocket (epithelial attachment)

PERIO REGENERATION & REPAIR

Regenerative surgery - for regeneration with bone graft while flap surgery - to get access for better S/RP.

*Regeneration - type of healing that completely replicates the original architecture & function. It involves the formation of a new cementum, PDL, and alveolar bone. See PDL, bone, cementum

*Repair - replacement of loss apparatus with scar tissue, which doesn’t completely restore the architecture or the function of the part replaced. End product is the establishment of long junctional epithelium attachment at the tooth-tissue interface. See long junctional epi, CT

QUESTION: Following flap surgery, new junctional epithelium can form on either cementum or dentin, junctional epithelium is reestablished as early as one week. First is False, second is true. Not on dentin, JE is reestablished in 1-3 weeks

*QUESTION: After you perform a flap surgery, where do you see regeneration? Epithelial attachment via long junctional epithelium & connective tissue adhesion.

QUESTION: The soft tissue-tooth interface that forms most frequently after flap surgery in an area previously denuded by inflammatory disease is a B. collagen adhesion. C. reattachment by scar. D. long junctional epithelium. E. connective tissue attachment.

*QUESTION: Periodontal regeneration involves – Sharpey’s Fibers, Cementum and Alveolar Bone

QUESTION: Type of healing in S/RP and free gingival graft: LJE and CT

QUESTION: What do you want from perio flap? Regeneration of PDL, cementum & bone

QUESTION: After flap surgery, where does repair occur? PDL moves occlusally, apically, laterally

QUESTION: After periodontal surgery, what type of healing is it most of the time? Repair

GINGIVAL GRAFT, BONE GRAFTS, GBR:

Guided bone regeneration (GBR): place barrier membranes to direct the growth of new bone & gingival tissue at sites with insufficient volumes or dimensions of bone or gingiva for proper function, esthetics or prosthetic restoration. Guided tissue regeneration blocks the re-population of the root surface by long junctional epithelium and gingival connective tissue to allow cells from the PDL and bone to re-populate the periodontal defect. Types of Soft Tissue Grafts: Connective-tissue grafts – most common method used to treat root exposure. Skin flap is cut at the palate & tissue from under the flap (subepithelial connective tissue) is removed & stitched to the gum tissue surrounding the exposed root. Free gingival grafts – Similar to a CT graft, free gingival grafts use palatal tissue but instead of making a flap and removing tissue under the top layer of flesh, a small amount of tissue is removed directly from the roof of the mouth & then attached to the gum area being treated. This method is used most often in people who have thin gums to begin with & need additional tissue to enlarge the gums. Pedicle grafts – gum grafted from or near the tooth needing repair. The flap (pedicle) is only partially cut away so that one edge remains attached & the gum is then pulled over or down to cover the exposed root and sewn into place.

*QUESTION: 3 things you need when doing GTR: bone, Sharpey’s fibers, & cementum

QUESTION: Correction of an inadequate zone of attached gingiva on several adjacent teeth is best accomplished with a/an? a. apically repositioned flap. b. laterally positioned sliding flap. c. double-papilla pedicle graft. d. coronally positioned flap. e. Free gingival graft.

*QUESTION: How do you fix gingival recession in anterior region? pedicle graft (laterally repositioned flap, never lose blood supply)

QUESTION: Purpose of lateral graft (Pedicle graft) For gingival recession

QUESTION: 8-year-old with anterior crossbite, has recession on anteriors. What type of tx would you do? a. chlorhexidine b. lateral sliding graft c. pedicle graft

QUESTION: Free gingival graft gets blood from base first.

QUESTION: Free gingival graft: Which area can be affected: ▪ Greater palatine nerve bundle ▪ Nasopalatine nerve bundle ▪ Nasopalatine artery ▪ Greater palatine artery

QUESTION: Most likely to be damage (complication) when you take tissue from gingival graft? Damage to greater palatine neurovascular bundle

*QUESTION: What nerve is most likely injured when transferring donor tissue to area of free gingival graft (mucosal graft)? Greater palatine

QUESTION: Mucosal graft epithelization by connective tissue from underlying tissue (recipient site)

QUESTION: Where does the epithelial cells for a graft come from? a. Donor epithelium b. Donor connective tissue c. Recipient epithelium d. Recipient connective tissue

QUESTION: What has ultimate effect on the thickness of epithelium of free gingival graft? a. Recipient epithelial tissue, b. donor epithelial tissue, c. donor CT d. recipient CT

QUESTION: What is the disadvantage of a connective tissue graft? Two surgical sites

QUESTION: You only have 4 mm of bone (alveolar ridge) above max sinus, how do you do bone graft? fill graft towards sinus fill graft towards alveolar ridge fill graft towards mresial Don’t add to alveolar ridge, it’s not going to integrate so fill towards sinus

*QUESTION: Only 4mm of bone below ridge and sinus where do you place graft? Floor of sinus (NOT Top of ridge)

*QUESTION: What graft is best for sinus lift? Autogenous & alloplastic

*QUESTION: Your patient was referred to an oral and maxillofacial surgeon for an implant, and you were advised that she was going to need a sinus lift procedure with placement of an autogenous bone graft. What is the definition of that graft? A. The graft will use an artificial, bone-like material. B. The graft uses bone from another human being. C. The graft uses the patient's own bone, taken from another site. D. The graft uses bovine bone, or bone from another animal species.

QUESTION: Which is the most predictable when restoring an edentulous mandibular ridge? Autograft

QUESTION: What is a graft from a different species? Xenograft

QUESTION: How to replace large chunks of mandible? Autogenous graft

QUESTION: What is the most osteogenic? ONLY Autograft

** LEARN THIS!

*QUESTION: Freeze dried cadaver bone is a type of what graft? Allograft

QUESTION: Decalcified freeze dried bone allograft: has bone morphogenetic proteins (BMP)

QUESTION: Best allograft material: freeze dried bone

QUESTION: Freeze dried bone has the advantage of having which protein: bmp/pdgf (bone morphogenic protein, Platelet-derived growth factor)

*QUESTION: Which hormone is used to bone graft? BMP (bone morphologic protein)

QUESTION: Which type of grafts causes bone growth? Osteoinductive, Osteoconductive OsteoINDuctive Allograph, autograph

QUESTION: Maxillary canine is contraindicated in a grafting procedure.

*QUESTION: Least likely to need bone graft? one wall, two wall, three wall wide, three wall narrow Wide & deep 3 wall defect = GTR, narrow 3 wall defect = bone graft regeneration?

QUESTION: Best prognosis for bone graft: narrow 3 wall defect

QUESTION: Best prognosis for a guided tissue regeneration? three walled defect

QUESTION: Recession of a single tooth, what do you do? • Double papilla graft • Free gingival graft (anterior-pedicle) • Apical repositioning

QUESTION: Facial recession on mandibular canine of 14-year-old graft not indicated? Reposition with ortho?

QUESTION: Which is least likely to be successful facial soft tissue graft? – Lower 1st premolars (no canine in the choices)?

QUESTION: Least desirable place to place graft: mandibular 1st premolar space

QUESTION: Tx for Class II furcation involvement (also called cul-de-sac)? GTR

QUESTION: Class 3 furcation, which not an option? GTR Class III furcations are least successful in GTR procedures.

QUESTION: The purpose of GTR is to prevent: Long J.E, migration of PDL cells, migration of CT cells

QUESTION: In guided tissue regeneration, inserted material is preventing which of the following attached to tooth structure? • epithelial • connective tissue (hinder the migration of fibrous CT while supporting the growth of bone) • gingival GTR excludes gingival epithelial cells to allow progenitor cells to close the wound. Gingival epithelium and connective tissue are excluded by the membrane. Progenitor cells form cementocytes and fibroblasts which form new cementum and PDL fibers. This gives you regeneration of the attachment apparatus and not long junctional epithelium. LJE is not as strong as the original attachment apparatus (which is lost by debridement).

QUESTION: The purpose of a barrier: Apical movement of PDL cells, coronal movement of PDL cells

QUESTION: Which tx is best for Class III furcation? a. guided tissue regen—NOT THIS b. apical flap c. HEMISECTION d. root amputation hemisection = mand molar, to treat Class II or III furcation invasions root amputation = max molars

QUESTION: In a through and through furcation lesion, which is the least appropriate treatment? GTR

QUESTION: Contraindication for max molar with class II furcation? hemisection w/ crown

QUESTION: How to treat an RCT mand molar that has Class III furcation involvement: hemisection and place 2 crowns to act as 2 premolars. Root amputation is for maxillary teeth.

QUESTION: Hemisection of mandibular molar, which has best prognosis: • Furcation that is more coronal or apical • Furcation that is more coronal

QUESTION: Hemisection, one wall remaining (interproximal wall) what’s it called: hemiseptum One wall defect – usually only one interdental wall remains and is called hemi septum if remaining wall is proximal. Poor prognosis for periodontal regeneration since it is difficult to stabilize the graft material to be used in its proper place.

*QUESTION: Bony area between two premolars has no mesial, facial and lingual wall, what is it called? Hemiseptum

QUESTION: Indication for periodontal/surgical dressing: Healing the tissue, Protect the wound

QUESTION: What is surgical dresses? Just protect wound, DOES NOT accelerate

QUESTION: Reverse architecture- interproximal is lower than on facial and lingual

QUESTION: Reverse architecture: Interdental bone is apical to the crestal bone

QUESTION: After periodontal surgery, the dentist leaves interproximal bone apical to radicular bone. What is this called? negative architecture.

QUESTION: Most important issue that determines success after periodontal surgery? Plaque control of the area

FRENECTOMY:

Sequence to close diastema in a child with low labial frenum: 1) wait for the canines to erupt 2) close the diastema with ortho 3) perform the frenum surgery

QUESTION: 10 y/o kid has a thick upper buccal frenum with diastema between 8 & 9. Tx? wait until upper permanent canines erupt (then, do frenectomy) frenectomy use elastics

QUESTION: If diastema is caused by a frenum, you don’t do a frenectomy until the canines have erupted.

QUESTION: All of the following are risk for ortho treatment except? Frenal displacement (other choices, were plaque management, bone loss, resorption)

QUESTION: Which of the following explains why the Z-plasty technique used in modifying a labial frenum is considered to be superior to the diamond technique? a. it is less traumatic b. it is technically easier c. it requires fewer sutures d. it decreases the effects of scar contracture e. it allows for closure by secondary intention - improves the appearance of scars and purpose is to relax the frenum pull  less contracture

ORTHODONTICS

Sagittal: curve of SPEE Anterior-posterior Frontal: curve of Wilson Left and right

Problematic = high rate of relapse

FACIAL CHARACTERISTICS & GROWTH:

*QUESTION: Dolichocephalic – long narrow face

QUESTION: Which is correct? Growth of Mandible is both intramembranous and endochondral.

QUESTION: Scammon Growth curve: Neural tissue grows until what age? 5 y/o (this was the number on the test, but on book it is about 6-7)

QUESTION: Which tissue show most growth in first 6 years and then plateau? lymph, neural, genital

QUESTION: Which system is most fully developed at birth? o muscle system o neural system o gonadal system

QUESTION: Which grows faster, maxilla or mandible? Maxilla grows earlier and faster (b/c it is closer to brain)

QUESTION: What is the best radiograph for showing prediction about ossification? Wrist hand radiograph

QUESTION: Majority of the tissues in FACE are derived from? A) ectoderm b) mesoderm c) ectoderm and mesoderm d) endoderm

QUESTION: Eruption sequence of pediatrics? Central-Central, Lateral-Lateral, 1M-1M, Canine-Canine, 2M-2M

QUESTION: Overjet in permanent teeth should be? 2-3mm

QUESTION: The space for the eruption of permanent mandibular second and third molars is created by the A. apposition of the alveolar process. B. apposition at the anterior border of the ramus. C. resorption at the anterior border of the ramus. D. resorption at the posterior border of the ramus.

QUESTION: Additional space for successive eruption of permanent maxillary molars is provided by A. interstitial bone growth. B. appositional growth at the maxillary tuberosity. C. continuous expansion of the dental arch due to sutural growth. D. an increase in palatal vault height due to alveolar growth.

QUESTION: Low occlusal plane leads to what? decreased biting force, other options were tongue biting, excessive bite force

OCCLUSION:

Arch length: Distal 2nd PM to distal 2nd PM or Mesial M1 to Mesial of M1 Arch width: Inter-canine space

Class II = convex, Class III = concave

QUESTION: What do you do to camouflage class 2? Extract upper premolar

*QUESTION: Facial profile of class 2 malocclusion? Convex

*QUESTION: Normal class 1 occlusion has maxillary MB cusp in buccal groove of mandibular molar.

QUESTION: Little girls, ortho casts were taken, what occlusion class is she? Class 1 (her 1st permanent molars were out, mesiobuccal cusp of upper 1st molars on buccal-lingual groove on lower 1st molars.

*QUESTION: What’s the occlusion when MB cusp of max 1st molar is distal to buccal groove of mand 1st molar? CLASS III

*QUESTION: Distalized occlusion w/ upright central anterior and deep bite: Class II div II

QUESTION: What's the difference between primary class II and permanent class II? Shallow grooves, Broad contacts

QUESTION: Class III is due to what? Maxillary retrusive & mandibular protrusion

QUESTION: Most common type of occlusion in primary teeth: Flush terminal plane

QUESTION: Highest percentage of occlusion in the US? class I, class II, class III

QUESTION: What Percentage of population have class I normal occlusion? 30%

QUESTION: Most common patients to have anterior tooth fractures or trauma? Class II div I

QUESTION: Most likely to cause fracture in children? Class II division I

QUESTION: Class III patient: which of the following is not helpful in establishing whether pt has retrognathic maxilla or prognathic mandible? photographs, study models, ceph analysis, clinical exam

*QUESTION: A child who has a distal step in the primary dentition generally develops which of the following molar relationships in the permanent dentition A. Class I B. Class II C. Class III

QUESTION: What happens to the permanent molar occlusion in the presence of a flush (straight) terminal plane and mandibular primate spaces? A. Erupts end-to-end; early mesial shift into Class I occlusion B. Erupts end-to-end; late mesial shift into Class I occlusion C. Erupts with Class II tendency D. Erupts with Class III tendency

QUESTION: Class II is formed with distal step.

QUESTION: Class I can be formed with flush terminal or mesial step

QUESTION: Where are the primate spaces? • Maxillary = between lateral and canine • Mandibular = between canine and first molar

QUESTION: What makes space for mandibular teeth when they erupt? Primate space

QUESTION: What is the purpose of primary teeth? Space holder of permanent teeth

QUESTION: Premature loss of which tooth will cause mesial drift of permanent tooth? Primary 2ndmolar

QUESTION: The space difference between primary canine, first & second molar and the succedaneous teeth: Leeway space • MD width primary canine + first molar + second molar • MD width permanent: canine + first premolar + second premolar • Mandibular = 3-4 (3.6) • Maxillary = 2-2.5 (1.8)

*QUESTION: The late mesial shift of a permanent first molar is primarily the result of closure of which of the following spaces? A. Canine B. Leeway C. Primate D. Extraction

QUESTION: What will account for the anterior space for the perm. mandibular incisors? a. Flaring of the max incisors b. Primate space!! c. Leeway space Because this is the space between the canines and the central incisors; Leeway is for posteriors

QUESTION: What allows for more space for eruption of permanent lower incisors? Allow them to protrude buccally Use primate space Use early mesial shift (which actually is primate space) Leeway space (aka late mesial shift)

QUESTION: Premature loss of which would lead to arch length deficiency? Primary canine

QUESTION: If a mandibular primary canine is prematurely lost, what would happen? Incipient malocclusion Insufficient arch size in anterior region When laterals erupt, canine’s root are resorbed When canine is shed, midline will shift in the direction of the lost tooth.

QUESTION: Child lost both his primary mandibular canines prematurely, what does this lead to? Lack of arch space

QUESTION: Primary tooth lost prematurely, what does that do to permanent tooth? Delayed eruption of perm If the kids’ primary molar is lost, the eruption is delayed. If the pt loses primary after age 7, eruption is accelerated

QUESTION: Which of the following dimensions are compared in the transitional dentition analysis? A. Arch width to arch length B. Leeway space to freeway space C. Leeway space to size of tooth D. Space available to space required E. The arch perimeter of the primary and transitional dentition

QUESTION: Moyers predict MD canine & premolars using a table, with the sum of all 4 primary lower incisors.

QUESTION: A dentist will perform a Moyers' mixed dentition analysis. Which of the following teeth will be measured to predict the size of the unerupted canines and premolars? A. Maxillary incisors B. Mandibular incisors C. Primary molars and canines D. Maxillary incisors for the maxillary arch; mandibular incisors for the mandibular arch

QUESTION: What happens with intercanine distance after mixed dentition? a. increased b. decreased c. stable, no change

QUESTION: What does the Moyers probability chart predict when a transitional dentition analysis is performed? a. The widths of mandibular anterior teeth b. The space available for permanent canine and premolars c. The width of permanent canines and premolars d. The space needed for alignment of permanent mandibular central and lateral incisors

QUESTION: Tanaka predict MD canine & premolars width using 1/2 of sum of all 4 lower incisors

QUESTION: Ugly duckling phase: diastema between maxillary centrals (#8 & #9) Maxillary central incisors can also be quite distally inclined when they first erupt When maxillary centrals erupt, they move labially & have diastema. When permanent canines erupt, centrals move mesially to close diastema.

QUESTION: The ugly duckling phase refers to? Mixed dentition

QUESTION: Ugly duckling stage: Wait for canines before doing ortho on centrals

QUESTION: Pt has minor crowding in the anterior mandibular region that has displaced the centrals. How you fix it? Do stripping. Ortho stripping (IPR, ContacEZ) = filing down the teeth, usually for 1-3 mm crowding

CROSSBITE, OPENBITE, ARCH LENGTH/WIDTH, & APPLIANCES

Most posterior cross-bites appear to be unilateral. Usually, due to bilaterally underdeveloped maxilla with a shifting of the mandible to one side during closure.

Common Ortho Appliances:

Palatal Expander (RPE): nn. best < 15 yrs old oo. widen the maxillary

Reverse Pull Headgear: pp. attached to braces & pull distally, anchor to head qq. correct A-P discrepancies, slow maxillary growth, correct overjet

Lower Lingual Holding Arch: rr. prevents man molars from shifting forward, spread crowded teeth ss. 2 bands on lower molars + U-shaped bar tt. Used for bilateral man molar loss after perm incisors or loss > 1 tooth in man Nance Holding Arch: uu. 2 bands around molars + acrylic button on palate vv. Space maintainer, premature loss or if 1st molars need to be prevented mesial shift

Hawley Retainer: ww. Removable, used after braces to maintain

Band & Loop: xx. early tooth loss & space maintenance yy. loss of a first primary molar

QUESTION: Anterior permanent tooth most likely to erupts in crossbite? Maxillary laterals

*QUESTION: What head gear would you use to correct a class III? Reverse pull headgear (also called protraction facemask)

QUESTION: Which headgear is used for pt who needs to bring maxilla towards protrusive? Reverse pull/facemask (protraction headgear)

QUESTION: A patient with maxillary arch constriction of 3 mm and a posterior crossbite, what will you see? Normal midline Midline shift towards the unaffected side Midline shift toward the affected side

QUESTION: Patient has 3 mm palatal constriction, what is most likely complication? Bilateral crossbite

QUESTION: Hawley appliance is NOT used for correction of skeletal crossbites.

QUESTION: Unilateral posterior crossbites in kids are usually due to a MANDIBULAR SHIFT, treat w/ MAXILLARY EXPANSION

QUESTION: Pt w/unilateral posterior crossbite o True unilateral maxillary constriction & functional crossbite o Mandibular shift o Bilateral constriction If true unilateral maxillary constriction fix using unequal W arch or asymmetrical maxillary expansion

QUESTION: What is indicated for the tx of unilateral posterior cross bite? Elastics from lingual of max molar to Buccal of mand molar A single tooth cross bite can be adjusted by placing cross elastics from maxillary lingual to mandibular buccal.

QUESTION: When to fix cross bite in a child? ASAP/correct immediately

QUESTION: What kind of appliance for posterior cross bite and when? Quad Helix (with digit sucking) or Palatal Expander, correct immediately

Quad Helix Appliance

*QUESTION: Most common cause of anterior crossbite open bite: thumb sucking, lack of interdental arch space, mouth breathing • Anterior cross bite = skeletal deformation • Anterior open bite = thumb sucking, lack of interdental arch space, mouth breathing

QUESTION: If patient has their nose always stuffed (chronic nasal congestion) & they breathe through their mouth, what happens? Anterior open bite, some of the other choices posterior open bite, constriction on arches

*QUESTION: Mouth breakers have a facial feature: incompetent lip, convex profile, narrow palatal vault, bilateral crossbite

QUESTION: Anterior crossbite is done by all except: functional shift vs lower third of face is hypertrophied

QUESTION: Leveling of mandibular teeth OPEN BITE (treats the overbite)

QUESTION: 8-year-old child, there is a recession in a mandibular incisor with posterior crossbite, which of the following treatment options is the least acceptable? a. oral hygiene instruction b. graft c. correction of cross bite d. observation

QUESTION: 10-year-old child loses primary first molar, what is the space maintenance appliance needed? None, since premolar erupting at this age

QUESTION: 10 y/o patient has crown on first primary molar and second primary molar is going to be extracted due to caries. What should be done in order to maintain space? 1. Nothing - because premolar is about to erupt 2. band loop 3. distal shoe

QUESTION: Can tx all with appliances except crepitus.

QUESTION: Loss of a primary right 1st molar in a 3-year-old child requires placement of a: a. band and loop b. distal shoe c. removable acrylic appliance d. none of the above

QUESTION: Lower 1st molar come out too early, what do you do? Band and Loop

QUESTION: Child lost primary 2nd molar: distal shoe

*QUESTION: Most common space maintainer - band and loop

QUESTION: Patient has a stainless steel crown on tooth #L (primary man 1st M), it’s going to be EXT, but what else will be needed? Do band-and-loop for space maintenance

QUESTION: Characteristics of a band and loop space maintainer include all of the following except? Potential for decalcification if the cement is lost provide space maintenance provides food trap if not properly soldered provides occlusal stop to prevent opposing dentition from supraerupting If leakage from cement, it can lead to recurrent decay

QUESTION: What does band and loop NOT do? Does NOT create a vertical stop

QUESTION: What is the primary reason for restoring primary teeth? To maintain arch space

QUESTION: What tooth is the most important to keep for space maintenance: Primary 2nd molar

QUESTION: What is the most common tooth that involves space management in primary teeth? 2nd molar

QUESTION: How to do measure the projected arch length space for permanent teeth? Arch length: Distal 2nd PM to distal 2nd PM or Mesial M1 to Mesial of M1 Arch width: inter-canine space

QUESTION: What tooth erupting FIRST would cause some sort of arch discrepancy? Man 2nd perm molar erupting before the 1/2nd man perm premolar

QUESTION: Lower 1st primary molar tooth has lower permanent premolar underneath, what will determine when the premolar will come in? a. How fast roots of 1st primary molar resorbs b. age of patient c. how much of root of premolar is formed

QUESTION: What race has most deep bites? White Severe deep bite is nearly twice as prevalent in whites as blacks or Hispanics, while open bite > 2 mm is 5x more prevalent in blacks than in whites or Hispanics

QUESTION: The best age to correct a thumb sucking habit is: during primary dentition. Kids are easier to desensitize (5-6 years) • Mild displacement of the primary incisor teeth is often noted in a 3-4 y/o thumb sucker, but if sucking stops at this stage, normal lip and cheek pressures soon restore the teeth to their usual positions. • If the habit persists after the permanent incisors begin to erupt, orthodontic treatment may be necessary to overcome the resulting tooth displacements.

TOOTH DEVELOPMENT

*Teeth erupt through bone when 2/3 formed, erupt through gingiva when ¾ formed.

*Permanent teeth erupt lingual & inferior to primary teeth

*QUESTION: What stage does supernumerary or hypodontia anomalies occur? Initiation stage, histodifferentiation, proliferation

*QUESTION: What physiologic stage is supernumerary teeth? Initiation

QUESTION: Post emergence eruption is mostly result of: root development, bone growth Phase begins as tooth emerges through gingiva & moves into occlusal contact.

QUESTION: The primary tooth is missing/extracted. The perm tooth root is 1/3 formed. What is driving the eruption of the perm tooth? Either something about vascular supply to the tooth or the fact that the root is 1/3 formed

QUESTION: When does tooth (crown) start to emerge in the oral cavity? a. When root starts to form b. Only after crown has been formed WHEN DONE CALCIFYING c. After complete root formation d. After ¾ root has been formed (through gingival) (2/3 erupts through bone!)

QUESTION: How long for the root to complete formation after eruption? 2.5 - to 3.5 years

*QUESTION: Apical root closes---2 ½ - 3 ½ years after eruption

*QUESTION: Calcification of premolar tooth at birth? NO

*QUESTION: Pt has 12 primary teeth & 12 permanent teeth, what the patient’s age? 8.5 yrs. old

*QUESTION: Which direction do succedaneous anterior teeth erupt? Lingual

*QUESTION: If a child’s permanent mandibular incisors are erupting but their primary mandibular incisors are still there, where would they erupt? they would erupt lingually

ORTHO TREATMENT PLANNING Labial bow for tipped teeth: • Passive labial bow - treats overjet • Active labial bow – for incisor retraction Ortho Sequence: 1st - Light Round Wires: level and align 2nd - Rectangular/Square wires: corrects vertical discrepancies (working arch wires), control crown & root movement 3rd- Light Round Wires: Finishing arch wires (finishing touches) Rectangular wire is used for root torque. Round wire basically moves the tops of teeth (above gums) to level, align, and rotate them but the root part lags behind and needs to be straighten within the jaw bone w/ rectangular wires.

QUESTION: Edgewise bracket - for intrusion motion (ortho brace bracket)

*QUESTION: Ortho case: Patient’s upper central were little flared & needed to be uprighted more, what appliance do you use? Rectangular Arch Wire (Other choices were headgear, facemask, etc)

*QUESTION: Advantage of rectangular orthodontic wires – Control crown and root movement

QUESTION: Center of tooth when ortho is tipping it? Middle of root, apex, 0.5 of apex Junction of apical and middle 1/3 of root

QUESTION: Force put on crown, where is center of translation or rotation? Halfway down root, CEJ, past apex (center of resistance)

QUESTION: Ortho finger springs are used for? To fix tipping of anterior mand and maxillary teeth (mesiodistal tipping, close diastema)

QUESTION: How do you prevent rotation in ortho? Anti-rotational clasp

QUESTION: What is moderate crowding? less than 4 mm is moderate (>4 = severe crowding)

QUESTION: How to treat a patient with 16mm of overjet: Ortho w/ surgery, premolar extraction route

QUESTION: Patient needs ortho with partially erupted #17 and #32. Radiographically, both teeth had crowns with distal area that are susceptible pericoronitis. What do you do? EXT both teeth surgically

QUESTION: You need to ortho for kid with very poor oral hygiene. What treatment is best? Removable

QUESTION: Best time to fix lingually inclined incisors? When canines erupt

QUESTION: If a child has 3mm crowding on the lower and permanent canines haven’t erupted, what do you do? Nothing

QUESTION: Primary anterior tooth intruded 5mm. How would you treat it? • Extract • Splint • Ortho to bring it down

QUESTION: Ortho uprighting of molar, what is the common problem & what should you do? Occlusal interferences - need to adjust occlusion

QUESTION: Why would you move a tooth (ortho) before doing perio? More likely to get bone loss after perio surgery Easier to move now Stable teeth are harder to access

QUESTION: A light force applied to the periodontal ligament during orthodontic treatment is considered? a. intermittent b. direct c. continuous d. indirect

QUESTION: Which one of the following doesn’t happen in the PDL during ortho movement? Chemical change in PDL

QUESTION: Orthodontic movement- widened PDL due to decalcification? Due to tension • Compression (where tooth is moving toward) and tension side (where tooth is moving away from). First, widened PDL occurs on tension side in presence of light prolonged orthodontic forces, indicating tooth movement is soon to begin. • Compression side: osteoclasts are removing lamina dura • Tension side: Osteoblasts are laying down new bone

QUESTION: Which of the following soft tissue elements (fibers) are commonly associated with relapse following orthodontic rotation of teeth: Supracrestal

Supracrestal fibers, in particular transseptal fibers, have been implicated as a major cause of postretention relapse of ortho treatment.

QUESTION: What causes rotation of a tooth after ortho therapy? Transseptal fibers

QUESTION: What fibers cause reversal of a rotated tooth after ortho treatment? Transseptal fibers

QUESTION: Finish ortho tx in a non-compliant patient, what do you do for retention – fix retention, removable retention, supracrestal fiberotomy

QUESTION: Ortho Case: 14 yr. old kid w/ pano; all PM’s congenitally missing except #28 (missing 7 of them); retained primary molar crowns over congenital missing PM’s ▪ 4 primary teeth are ankylosed & 4 perm teeth are missing (BOTH FALSE) ▪ Using a ceph, you have to tell if facial profile is convex, straight, or concave all 3 were CONVEX ▪ This case was dental class III but w/ convex profile ▪ Given ANB = 6, What class is it? Class II ▪ Other ortho pt: explorer catches in a pit of #19? What would your tx be? PRR

QUESTION: Ortho Case: 15 yr. old kid. Upper & lower canines are ectopically erupted out of the arch; besides that, everything else was normal in this case. i. How do u treat? 1. Extract 1st PM’s & bring canines into arch OR take out 4 canines & keep PM’s (take out canines) 2. if you’re going to extract 1st PM’s, what would you NOT use: 150, 151, 3_, 2_ _ (answer must be 1 of the last 2; look em up) if 222(universal 3rd molars), if #32 universal bayonet so (222?) ii. This case was Class I iii. Ortho pt has never had a restoration? What would you do? sealants, do nothing

QUESTION: Permanent 1st molar ectopically erupting with slight resorption of primary teeth. Tooth most likely needs ortho, what would you use? separating device (Can use elastic separators)

QUESTION: Ectopic maxillary molar eruption needs what? Ortho intervention oooLATERAL CEPHALOMETRICS:

Website: http://www.theyoungdentist.com/uk/features/articles/780-a-beginners-guide-to-lateral-cephalometric-radiographs A point (A): The point of the deepest concavity anteriorly on the maxillary alveolus B point (B): The point of the deepest concavity anteriorly on the mandibular symphysis Sella (S): The midpoint of the sella turcica (pituitary fossa) Nasion (N): The most anterior point on the fronto-nasal suture Orbitale (Or): The most anterior, inferior point on the infraorbital rim Porion (Po): The upper midpoint point on the external auditory meatus Anterior Nasal Spine (ANS): The tip of the anterior nasal spin Posterior Nasal Spine (PNS): The tip of the posterior nasal spine Gonion (Go): The most posterior, inferior point on the mandibular angle Gnathion (Gn): The most anterior, inferior point on the mandibular symphysis Menton (Me): The most inferior point on the mandibular symphysis Pogonion (Pog): The most anterior point on the mandibular symphysis

Important Ortho Relationships: Frankfort Plane: orbitale – porion Mandibular plane (MnPl): gonion – menton Maxillary plane (MxPl): anterior nasal spines (ANS) - posterior nasal spines (PNS) ANB: angle represents the relative A/P position of the maxilla to the mandible & is used to find skeletal class

ANB = SNA – SNB, normal ANB is 2-3⁰ (+) ANB angle = maxilla is positioned anteriorly relatively to the mandible (Class I or Class II malocclusion cases). (--) ANB angle = maxilla is positioned posteriorly relative to the mandible (Class III malocclusion cases).

The normal range is 1-5. >5 indicates a Class II skeletal jaw relationship, protrusive maxilla or retrognathic mandible. <1 indicates a Class III skeletal jaw relationship, deficient maxilla or prognathic mandible.

QUESTION: Esthetic analysis, # of vertical proportions in the face? Five Vertically by 5 lines (4 planes) Horizontally by 3 lines (2 planes)

QUESTION: What does a bigger SNA means? Maxilla is more protrusive SNA-SNB=ANB maxilla to mandible relationship

QUESTION: Female w/ ANB angle = 6⁰, what skeletal classification? Class II (protrusive maxilla or retrognathic mandible)

QUESTION: ANB = -4⁰: Class III

QUESTION: ANB is -6 degrees, what’s the facial profile? Class III

QUESTION: SNA 76 AND SNB 78, what’s the facial profile? 76-78 = ANB = -2⁰ so pt is Class III

*QUESTION: SNA AND SNB 78, what’s the facial profile? 78-78 = ANB = 0⁰ so pt is Class III

QUESTION: SNA 82 AND SNB 80, what’s the facial profile? 82-80 = ANB = 2⁰ so pt is Class I

*QUESTION: Frankfort’s horizontal plane = porion (upper external auditory meatus) to orbitale (inferior border of orbit)

QUESTION: Fox plane is parallel to Camper’s line (alar of nose – mid tragus line) – for anterior-posterior plane Fox plane is parallel to Interpupillary line – for anterior plane

QUESTION: Fox plane landmarks: Lower ala upper tragus and Interpupillary distance

PHARMACOLOGY

PHARMACOKINETICS:

Enterohepatic circulation: Substances that undergo enterohepatic circulation are metabolized in the liver (by conjugation), excreted in the bile, and passed into the intestine (where bacteria break some of the conjugated drug, releasing the unmetabolized drug again) where they are reabsorbed across the intestinal mucosa (returns to systemic circulation) and returned to the liver via the portal circulation. Drugs may remain in the enterohepatic circulation for a prolonged period of time as a result of this recycling process. thus increase in their half-lives.

First pass effect: After a drug is swallowed, it is absorbed by the digestive system and enters the portal circulation to the liver. Alternative routes of administration (e.g., intravenous, intramuscular, sublingual) avoid the first-pass effect.

Therapeutic index - estimate of the margin of safety of a drug. Higher TI = more safe TI = 퐿푒푡ℎ푎푙 푑표푠푒 50 퐸푓푓푒푐푡𝑖푣푒 푑표푠푒 50 Potency: response to a drug over a given range of concentrations. Depend on dose of drug; less mg for same efficacy has more potency Bioavailability: Highly absorbed drug (high bioavail.) requires a lower dose that poorly absorbed. Most important determinant of drug dose is POTENCY of drug. (the proportion of a drug or other substance that enters the circulation when introduced into the body and so is able to have an active effect.) Efficacy: max effect/intensity of the drug. Depends on level of drug binding to its receptor (antagonists are not efficient/no intrinsic activity) Max effect is also called as intrinsic activity. Elimination rate of a drug influences its half-life, determines the frequency of dosing required to maintain therapeutic plasma drug levels.

Idiosyncrasy: abnormal response to drugs due to various factors, hard to predict

QUESTION: Epinephrine = physiological antagonist of histamine & nitroglycerin Doesn’t act on same mechanism (epi = α vasoconstriction vs nitro = smooth muscle dilatator) but opposing action Same mechanism = competive antagonist; physiological antagonist = competing physiological effects

QUESTION: What best describes biotransformation? Increase in polarity, more ionized and more water soluble Whatever helps its excretion – polar and more water soluble

*QUESTION: In relation to their parent drug, conjugated metabolites are what? more ionized in plasma (more water soluble)

QUESTION: What happens to a drug after conjugation? more ionic, more hydrophilic, more active

QUESTION: What do you use sodium bicarbonate for? All drugs or alcohol (Phenobarbitals) Excretion of acidic drugs is accelerated with sodium bicarbonate

QUESTION: Excretion of an acidic drug will be enhanced if the patient is given which of the following? Sodium bicarbonate

QUESTION: After drug goes through liver? More water soluble and less lipid soluble.

QUESTION: First pass metabolism: Enzymatic degradation in the liver prior to drug reaching its site of action

QUESTION: First pass refers to: Enterohepatic circulation, metabolism in liver

QUESTION: Oral drugs – Undergo 1st pass metabolism in liver.

QUESTION: What is used to determine whether a drug will cross glomerulus: attached to a protein or not; other option is whether the drug is acid or base; other is if its positive or negatively charged

QUESTION: Which drug absorbs better in stomach acid? Weak acid

QUESTION: In order for a drug to do its effect in what state should it be? Weak acid, Weak base Lipid soluble - NON ionized drugs are soluble in lipid. Hydrophobic Hydrophilic-

QUESTION: When a drug does not exert its maximum effect is because it’s bound to? Albumin gamma beta something alpha drugs highly bound to plasma proteins will not enter liver to be metabolized, resulting in longer half-life.

QUESTION: What protein is used to attach to medication: alpha or beta or gabba globulin, albumin

QUESTION: Which of the following best explains why drugs that are highly ionized tend to be more rapidly excreted than those that are less ionized? The highly ionized are A. less lipid soluble. B. less water soluble. C. more rapidly metabolized. D. more extensively bound to tissue.

QUESTION: Therapeutic Index LD/ED is a measure of: safety of drug

QUESTION: LD50 means at this dose, 50% of the test animals died

QUESTION: What is bioavailability of a drug? amount of drug that is available in blood/plasma

QUESTION: What does bioavailability measured? How much drug is absorbed in the circulation Blood to urine ratio

QUESTION: What pharmacokinetic factor influences the need for multiple doses in a day (dose rate)? half-life; other option is bioavailability, or clearance

QUESTION: Drug dosing has to do with: half life

QUESTION: Two different drugs with same dosages, bind to the same receptor, and cause same intrinsic affect. However, they have different affinities for the receptor. In which aspect these 2 drugs are similar? a. ED50 b. LD50 c. Potency d. Efficacy Efficacy because they can both produce the same maximal response if enough is given

QUESTION: Drug A has greater efficacy than Drug B – Drug A will produce higher effect at lower dose. Drug A has a higher potency.

QUESTION: Fixed dose drug A w/ low dose of Drug B increase drug B effect when same dose of drug a is give w/ increased does of drug B: competitive antagonist, synergism, partial agonist partial agonists bind & activate a given receptor, but have only partial efficacy at the receptor relative to a full agonist.

QUESTION: Three carpules (2 ml carpules, 40 mg/ml) of local anesthetic X are required to obtain adequate local anesthesia. To obtain the same degree of anesthesia with local anesthetic Y, five carpules (2 ml carpules, 40 mg/ml) are required. If no other information about the two drugs is available, then it is accurate to say that drug X: is less potent than drug Y. is more efficacious than Y. is less efficacious than drug Y. X&Y are = in potency & efficacy. (?)

QUESTION: The maximal or "ceiling" effect of a drug is also correctly referred to as the drug's A. agonism. B. potency. C. efficacy. D. specificity.

ALPHA & BETA ADRENERGIC DRUGS:

Adrenergic Receptor blockers: α/β adrengic drugs act by blocking competitive inhibition of post-junctional adrenergic receptors

Effect of Epinephrine in presence of α/β receptors: Epinephrine stimulates both α/β receptors  HR increased, vasoconstriction Epinephrine reversal – when also taking α blocker (ex. prazosin, chlorpromazine) cause decrease in BP b/c β-mediated vasodilation predominates ● Beta2 trumps A1 so vasodilation happens & BP decreases Vagal reflex – blocked by atropine, vagus stimulates decrease heart rate If a patient on a nonselective beta-blocker receives a systemic dose of epinephrine, however, the beta-blocker prevents the vasodilation, leaving unopposed alpha vasoconstriction. (alpha-1)

Receptor activation would cause:

Eye: mydriasis (A1, B) – Dilation of pupil

Heart: increased contraction (B2)

Vascular smooth muscle: vasoconstriction (A1)

Skeletal muscles: vasodilation (B2)

Bronchial muscle: dilation (B2)

Sweat Glands: sweating

Alpha-1 agonist: increase smooth muscle tone, vasoconstrictor  ↑ BP Alpha-2 agonist: given orally b/c they cause hypotension by reducing sympathetic CNS outflow

QUESTION: What does Alpha-1 do? Vasoconstriction of peripheral vessels (smooth muscle)

QUESTION: When you stimulate alpha 1 receptors what happens? a. Vasoconstriction b. Hypertension

QUESTION: What does alpha-1 receptors do to the heart? Vasoconstriction, increase blood pressure, increase peripheral resistance, mydriasis (pupil dilution) and urinary retention

QUESTION: Adrenaline (epinephrine) – Stimulates alpha 1, 2 and beta 1, 2 receptors

QUESTION: Heart has beta-1 receptors.

QUESTION: Slow infusion of epinephrine will cause which of the following and know which receptor is responsible - Alpha 1 (Vasoconstriction during anaphylaxis), Beta 1 (Increases cardiac output), Beta 2 (bronchodilation)

QUESTION: Patients BP spike after EPI, what receptor? B1

QUESTION: Hemostatic agents in retraction cord target what receptor? • a1 (vasoconstriction) • b1 • b2 • gaba • muscarinic receptor

QUESTION: Retraction cord with epinephrine can cause: increase HR, BP do not use in hyperthyroid or cardiac disease.

QUESTION: After using a gingival retraction cord, tissue reacts by recession. Where do you see this the most? Lingual, buccal, interproximal.

QUESTION: Smooth muscle relaxation is caused by which of the following drugs? a. prazosin (alpha 1 blocker…blocks vascular smooth muscle constriction) b. atropine (anticholinergic) c. theophylline (treat asthma, COPD…it relaxes bronchial smooth muscle…so I guess it does do smooth muscle…) d. amphetamine (psychostimulant…increase wakefulness) - answer should be an alpha-1 antagonist/blocker

QUESTION: Which of the following combinations of agents would be necessary to block the cardiovascular effects produced by the injection of a sympathomimetic drug? Atropine and prazosin Atropine and propranolol Prazosin and propranolol Phenoxybenzamine and curare Amphetamine and propranolol sympathomimetic drug injection (ex. NE) stimulates α/β receptors so α-blocker prazosin + β blocker propranolol is needed. Atropine is an muscarinic/cholinergic receptor blocker that would stimulate heart (opposite effect)

QUESTION: Each of the following drugs produces vasoconstriction of vessels if injected into the gingiva EXCEPT one. Which one is this EXCEPTION? Epinephrine (EpiPen®) Terazosin (Hytrin®) Levonordefrin (Neo-Nedfrin®) Phenylephrine (Neo-Synephrine®) Norepinephrine (Levophed®) Terazosin, selective alpha-1 antagonist, is used to tx HTN & enlarged prostate (BPH)

*QUESTION: Epinephrine + propanol: increases BP, decreases HR Propranolol is a nonselective beta blocker so epi only acts at only alpha receptors, which in the periphery are mainly alpha-1 receptors This causes vasoconstriction & Increased ⬆ BP  increased firing, which triggers aortic and carotid sinuses  increased vagal activity on the heart  decreased ❤ ⬇ HR.

*QUESTION: Change propranolol for? Metoprolol ... little change on HR, but no marked increase in BP. METOPROLOL = selective B blocker and is ok to use with EPI!

QUESTION: Propranolol + epinephrine = bad reaction due to: drug interaction, anxiety, allergy

QUESTION: Patient taking propranolol with epinephrine. What receptor caused hypertensive crisis? -alpha 1 -alpha 2 -beta 1 -beta 2 If a patient on a nonselective beta-blocker receives a systemic dose of epinephrine, however, the beta-blocker prevents the vasodilation, leaving unopposed alpha vasoconstriction. (alpha-1)

QUESTION: What is the effect seen when propranolol and epinephrine are injected simultaneously - in cases of mild reactions it causes hypotension; in severe reaction it is malignant hypertension

QUESTION: All these drugs alter ionic movement except - Propranolol, others were CCB, HCTZ, and Digoxin

QUESTION: A patient receiving propranolol has an acute asthmatic attack while undergoing dental treatment. The most useful agent for management to the condition is? a. Morphine b. Epinephrine c. Phentolamine d. Aminophylline e. Norepinephrine Aminophylline: Bronchodilator, class theophylline

QUESTION: The drug-of-choice for the treatment of adrenergically-induced arrhythmias is: quinidine. lidocaine. phenytoin. Propranolol

QUESTION: Direct alpha sympathomimetic: clonidine (alpha2), gueanethidine (indirect acts on neurons to inhibit NE release), methyldopa (alpha2).

QUESTION: Epinephrine Reversal with? Alpha adrenoceptor blockers (ex. phenoxybenzamine) inhibit the vasoconstrictor effect but not the vasodilator effect of epinephrine = low BP instead of high BP

QUESTION: Epinephrine reversal: after giving a patient epinephrine, following hypertension, which of these drugs would cause a drop in BP? Phenoxybenzamine

QUESTION: What receptor or signaling pathway is linked most directly to α2-adrenoceptor stimulation? Inhibition of adenylyl cyclase through GI, resulting from stimulation of α2-adrenergic receptor, leads to intracellular ⬇ cAMP

AMPHETAMINES (INDIRECT- ACTING SYMPHATHOMIMETICS)

Indirect-acting sympathomimetic drugs: amphetamine, tryamine, ephedrine = stimulate release of stored NE TCA & cocaine block NE re-uptake MAOI block enzymatic NT destruction

NE stimulates both alpha & B1 receptors more than B2.

FOR ADHD (Attention-deficit/hyperactivity disorder):

Methylphenidate = Ritalin ● Methylphenidate: blocks dopamine uptake in central adrenergic neurons by blocking dopamine transport or carrier proteins.

Amphetamine = Adderall ● Amphetamines & cocaine: increase catecholamine NE SERETONIN DOPAMINE release as a primary mechanism. o Amphetamines stimulate CNS alpha receptors ● Adderall: psychostimulant medication composed of amphetamine and dextroamphetamine, which increases the amount of dopamine and norepinephrine in the brain

QUESTION: ADHD diagnosis = more boys than girls

QUESTION: Which one is true about ADHD? most common in boys

QUESTION: Amphetamines – lead to NE release in brain stimulate the release of norepinephrine from central adrenergic receptors & at higher dosage, release of dopamine

QUESTION: Methylphenidate = Ritalin, Amphetamine = Adderall.

QUESTION: Kid is taking Adderall (amphetamine) & is very anxious what do you do? Tell him to stop taking amphetamine on the day appointment Amphetamine can induce anxiety, and are contraindicated for patients that are very nervous

QUESTION: Side effect of Amphetamines – Insomnia (difficulty of falling asleep)

QUESTION: Amphetamines, what are symptoms? Increased heart rate & excitability

QUESTION: Indirect sympathomimetic drug? Diphenyl amphetamine

*QUESTION: Pediatric pts taking amphetamine every day, what can be observed in pt’s health history? ADHD The kid has ADHD, know the medication for ADHD. Methylphenidate was one of the medications they asked

AUTONOMIC: ANTICHOLINERGIC & CHOLINERGIC DRUGS

Cholinergic drugs – slow heart, constrict pupils (miosis), stimulate GI smooth musc, stim sweat, saliva Cholinergic crisis: bradycardia, lacrimation, salivation, voluntary muscle weakness, diarrhea, bronchoconstriction – tx w/ atropine Salivary secretion increases with use of Pilocarpine, Neostigmine (cholinergic agonists)

Anticholinergic agent: blocks the neurotransmitter acetylcholine in the CNS/PNS. Atropine/scopolamine overdose: confusion, hallucinations, burning mouth, hyperthermia – tx w/ Physostigmine Salivary secretion DECREASES with use of atropine and scopolamine (anti-cholinergic)

***Direct-acting cholinergic agonist = pilocarpine, methacholine (used for xerostomia) Indirect-acting (prevent enzyme breakdown): Reversible anti-cholinesterase = Physostigmine (CNS/PNS) & neostigmine (PNS only) Irreversible anti-cholinesterase = Insecticides + organophosphate (tx by regenerate AcH using pralidoxime)

Competitive muscarinic receptor blockers = Atropine, scopolamine, propantheline

Know which drugs mimic parasympathetic (cholinergic), be able to pick from a list which does not belong (Acetylcholine, Atropine, d- tubocurarine, neostigmine, Nicotine, Physostigmine, Pilocarpine) ***Atropine: Muscarinic antagonist (anticholinergic), antidote for organophosphates and insecticides, blocks vagal reflex, tachycardia ***Belladonna derivatives – anticholinergic ***Neostigmine: cholinesterase inhibitor, doesn’t penetrate BBB, tx of M. gravis, increase salivation ***Physostigmine: used for atropine & scopolamine overdose, tx of glaucoma, acetylcholinesterase inhibitor ***Pilocarpine: Muscarinic agonist, for glaucoma and xerostomia ***Scopolamine: anticholinergic agent, used for motion sickness & in eye drops to induce mydriasis (dilation),

QUESTION: What is used for motion sickness? Scopolamine

QUESTION: Neostigmine and pilocarpine increase? Salivation Pilocarpine (muscarinic agonist) & neostigmine are parasympathomimetic that acts as a reversible acetylcholinesterase inhibitor. They increase salivation, urination, bronchoconstriction, bradycardia, miosis (pupil constrict), vasodilation

QUESTION: Glycopyrrolate effect? Reduce salivary (muscarinic anticholinergic)

*QUESTION: Atropine: is sympotatic, decrease salivation

QUESTION: What meds decrease saliva? atropine, scopolamine Pilocarpine, methacholine, neostigmine, etc. cause salivation.

QUESTION: If patient has xerostomia, what medication won’t you give? Atropine – anticholinergic

QUESTION: What drug does not cause miosis of the eyes? Atropine

QUESTION: Insufficient cholinesterase leads to hypotension? (bradycardia) Other answers: tachycardia, restlessness,

QUESTION: Pt have bradycardia, what should we give him? Atropine b/c atropine will increase heart rate causing tachycardia.

QUESTION: Drug to decrease saliva because you want to take an impression- ATROPINE (DECREASES), Pilocarpine (INCREASES), Neostigmine (INCREASES)

QUESTION: Atropine poisoning tx: Physostigmine

QUESTION: Patient salivates a lot, what is tx before surgery? Atropine **antimuscarinic

QUESTION: Xerostomia pt, give pilocarpaine or cevimeline. Cimeviline just like pilocarpine to increase salivation in xerostomia

QUESTION: What drug do you give to a pt with xerostomia? Pilocarpine

QUESTION: Pilocarpine used for? parasympathomimetic alkaloid, for tx of glaucoma and xerostomia.

QUESTION: What is the side effect of pilocarpine (Tx of dry mouth) in toxic dose? Bradycardia and hypotension Apnea Cardiac shock Nontoxic side effects>>> excess sweating and salivation, bronchospasm

QUESTION: Propantheline bromide (pro-Banthine): anti-cholinergic (anti-muscarinic), relieve cramps or spasms of the stomach, intestines, and bladder.

QUESTION: Which of the following groups of drugs is contraindicated for patients who have glaucoma? Adrenergic, Cholinergic, Anticholinergic Adrenergic blocking

QUESTION: Which of the following drug groups increases intraocular pressure and is, therefore, contraindicated in patients with glaucoma? A. Catecholamines B. Belladonna alkaloids (anti-cholinergic) C. Anticholinesterases D. Organophosphates (cholinergic)

QUESTION: A patient has a deficiency in acetylcholinesterase. After giving her this drug, action is prolonged. I put d-tubocurarine (inhibits acetylcholine receptor weakness of skeletal muscles) QUESTION: Decrease of pseudocholinesterase would lead to increase in? Succinylcholine or tubocurare

QUESTION: Administration of succinylcholine to patient deficient in serum cholinesterase would cause… a. convulsions b. Hypertension c. prolonged apnea d. Acute asthma attack

QUESTION: 2-3 questions on miosis (opioids + cholinergic) vs mydriasis (anticholinergics + increase serotonin) and which drugs or conditions cause which?

DOPAMINE DRUGS Hypotension and shock Alpha and beta receptors Peripheral vasoconstriction

Carbidopa/Levodopa (Sinemet): most potent combo med for Parkinson’s. Carbidopa addition prevents levodopa from being converted into dopamine in the bloodstream, peripheral enzymatic degradation so more reaches the brain. Therefore, a smaller dose of levodopa is needed to treat symptoms. L-dopa is a precursor to NT like dopamine, norepi, and epi. It’s a sympathomimetic & is used in tx of Parkinson’s to increase dopamine

QUESTION: A patient who has Parkinson’s disease is being treated with levodopa. Which of the following characterizes this drug’s central mechanism of action? a. it replenishes a deficiency of dopamine b. it increases concentrations of norepinephrine c. it stimulates specific L-dopa receptors d. it acts through a direct serotonergic action

QUESTION: Cause of Parkinson? Dopamine deficiency, give them methyldopa (levodopa) to increase dopamine in the CNS

QUESTION: Why do you need to take carbidopa with levodopa: prevents breakdown of levodopa before it crosses the blood brain barrier

QUESTION: How does carbidopa tx Parkinson’s disease? potentiates effects of dopamine

ANTI-PSYCHOTICS:

Anti-psychotics: sedate, blunt emotional expression, attenuate aggressive & impulsive behavior. Produce anticholinergic adverse effects, dystonias and extrapyramidal symptoms. Tardive dyskinesia most common after several years. Phenothiazines (PTZ): Block DA receptors, act on the extrapyramidal pathway

QUESTION: Where in the brain do anti-psychotics works? blocking the absorption of dopamine

QUESTION: What catecholamine does Phenothiazine (anti-psychotic) affect? Dopamine, serotonin, acetylcholine

QUESTION: Phenothiazine (anti-psychotics) side effect: Tardive Dyskinesia

QUESTION: What acts on extrapyramidal? Phenothiazines (chlorpromazine)

QUESTION: Onset of action of antipsychotic is: 5-6 days

QUESTION: What is the most common psych disorder? Anxiety??, depression??, ADD, schizophrenia

QUESTION: Lithium is used for treatment of? Manic phase of bipolar disorder

DEMENTIA & DEPRESSION

QUESTION: Patient is in her 70’s, she lives alone, what could she be suffering from? Depression

QUESTION: Most common psychological problem in elderly? Depression

QUESTION: Old people have dementia as the most prominent psychiatric issue: depression

QUESTION: What is associated with depression? Age, economic status, professional status, etc.

QUESTION: Main sign of dementia: a. confusion b. short term memory loss c. long term memory loss short term memory loss = first main sign. Long term loss occurs later.

QUESTION: Dementia – don’t retain short term memory

QUESTION: Which is not a sign of dementia: long-term memory loss

QUESTION: Most common mood disorder: generalized anxiety or depression?

ANTI-DEPRESSANTS: Category Common Medications Notes Selective serotonin Prozac, Zoloft, axil, Laxapro, Luvox Well tolerated reuptake inhibitors (SSRIs) Inhibits serotonin reuptake Tricyclic antidepressants Rarely used due to side effects Inhibits serotonin/5-HT, norepi, muscarinic M1, histamine H1, (TCA) TCA 2nd generation- Nortriptyline α-adrenergic receptor (Pamelor, Aventyl), Desipramine Caution in cardiac patients: risk of AF, AV block, or ventricular (Norpramin), Protriptyline tachycardia. (Vivactil), Amitriptyline More lethal in overdose than newer antidepressants. Don’t take w/ MAOI Monoamine oxidase Rarely used due to side effects Inhibit MAO type A & B, enzyme that breaks down serotonin, inhibitors (MAOIs) Phenelzine, tranylcypromine dopamine, norepi Significant drug interaction w/ opioids & sympathomimetic amines (don’t give w/ phenylethylamine or phenylephrine) Serotonin-norepinephrine Venlafaxine (Effexor), duloxetine reuptake inhibitors (SNRIs) (Cymbalta)

Buspirone (Buspar): partial agonist at a specific serotonin receptor (5-HT1A). Doesn’t cause CNS depression/muscle relaxant or anti- convulsant

QUESTION: Where in the brain do anti-depressants works? decrease amine-mediated neurotransmission in the brain

QUESTION: Tricyclic anti-depressant (TCA) mechanism of action: inhibit reuptake of NE and 5-HT (serotonin)

QUESTION: TCA 2nd generation- Nortriptyline (Pamelor, Aventyl), Desipramine (Norpramin), Protriptyline (Vivactil)

QUESTION: What catecholamine do tricyclic antidepressants affect? Dopamine, serotonin, acetylcholine

QUESTION: Patient is taking TCA anti-depressants what do you take into consideration? Limit duration of procedures, keep in mind the epinephrine limit

QUESTION: Side effect of having TCA and epi: HTN, hypotension, hyperglycemia, hypoglycemia

QUESTION: Most common antidepressant does what? • Inhibits reuptake of NE, 5-HT, & DA (TCA) • Inhibit reuptake of 5-HT (SSRI) • Inhibit reuptake of N & 5-HT (SNRI) • Inhibit MAO; prevent breakdown of NE & 5-HT (MAOI) • Block D2 receptor (phenothiazine)

QUESTION: If someone has a history of depression & wants to quit smoking, what do you give? Zyban (Bupropion), it’s an anti- depressant & smoking cessation aid not Chantix (smoke cessation only)

QUESTION: Amitriptyline – most common tricyclic antidepressant, inhibits reuptake of NE and serotonin

QUESTION: Zoloft works on what receptor? Presynaptic monoamine transporters (inhibit reuptake of 5-ht) Sertraline hydrochloride (Zoloft) = selective serotonin reuptake inhibitor (SSRI)

QUESTION: Prozac (fluoxetine) - acts on serotonin (SSRI)

QUESTION: What do you use St. John’s Wart for? Depression St. John’s Wart = noncompetitive reuptake inhibitor of serotonin yeah because is for depression

QUESTION: What does St. John's Wart do? Decrease the body immunity

QUESTION: St johns wart- used for? Depression, don’t use with benzodiazepines and HIV medication In HIV pt, it interacts w/ anti-HIV drugs & reduces their function so the immunity decreases

QUESTION: Know drugs used for conscious sedation SSRIs/BDZ Diazepam and Prozac (fluoxetine) SSRI: citalopram (celexa), fluvoxamine (luvox), fluoxetine (Prozac), sertraline (Zoloft) Benzodiazepines: diazepam (valium), versed (midazolam), Ativan (lorazepam) Opiates: morphine, Demerol (meperidine)

QUESTION: Buspirone - psychotropic w. anxiolytic; low CNS depression, low psychomotor skill impairment Buspar—different from benzodiazepines because it does NOT cause CNS depression, muscle relaxant, or anti-convulsant!!!!!** UNIQUE!!! Anxiolytic and antidepressant

ANTI-INFLAMMATORY/CORTICOSTERIODS:

Side effect profile: gastric ulcers, immunosuppression, acute adrenal insufficiency, osteoporosis, hyperglycemia, redistribution of body fat.

QUESTION: Strongest glucocorticoid/long-acting Corticosteroid? Dexamethasone

QUESTION: Negative effect of chronic use glucocorticoids? Infection, reduce inflammation, hyperglycemia

*QUESTION: GI effects with corticosteroids: Ulcers

QUESTION: Long term side effect of corticosteroids- osteoporosis and hyperglycemia

QUESTION: What is the side effect of prolonged corticosteroid therapy? Osteoporosis

*QUESTION: Too much cortisone causes what to bone? Osteoporosis Osteopetrosis Osteosclerosis

QUESTION: Long term glucocorticoids use- shows all of following except? Hypoglycemia does lead to: osteoporosis, hyperglycemia, immunosuppression

QUESTION: Where do you see moon faces? steroid treatment

QUESTION: Contraindication for corticosteroid use: Diabetes (also: HIV, TUBERCULOSIS, CADIDIASIS, PEPTIC ULCER)

QUESTION: Aspirin contraindicated with: Corticosteroid use • Can cause stomach bleeding , steroid decrease production of protective gastric mucus

QUESTION: Steroid insufficiency: 200mg/two weeks in last 2 years, 20 mg 2 weeks in last 2 years, 10 mg or 1 mg

*QUESTION: Critical dose of steroids for adrenal insufficiencies - 20 mg of cortisone or its equivalent daily, for 2 weeks within 2 years of dental treatment

*QUESTION: Least amount of cortisone to affect the adrenergic system? 2 mg for 2 weeks for 2 years

QUESTION: Pt taking corticosteroid with rheumatoid arthritis, pt needs TE, why would you consult with physician? full blood panel, assess for adrenal insufficiency • Want to make sure pt can produce enough corticosteroid with addition to what they are taking so you won’t have over inflammatory response from TE

QUESTION: Pt on 3 months tx of steroids, what is your tx? No tx and consult GP for dose

QUESTION: If a pt. has been using 10 mg of corticosteroid for 10 years, what would you do for pt. before any tx? Have pt continue and increase the dose

QUESTION: Cortisone exerts its action by binding to intracellular receptor, receptors on membrane, proteins in plasma • Enter cell and bind to cytosolic receptor migrate to nucleus gene expression or with plasma membrane on target cells

QUESTION: If pt doesn’t get steroid tx in time for their temporal vasculitis, what will have happened? • hearing loss • vision loss • retro-ocular headache

QUESTION: Asthma – long-term asthma give corticosteroid to decrease inflammation • Inhaled corticosteroids are the most effective medications to reduce airway inflammation and mucus production.

NITROUS OXIDE:

Contraindications: head injury, bowel obstruction, pneumothorax, middle ear and sinus disease, upper respiratory infection, COPD, first trimester of pregnancy, with whom communication is difficult (autistic patients), having contagious disease

Prolonged exposure can cause bone marrow suppression and peripheral neuropathy

Relative contraindications: cardiovascular conditions, pregnancy (teratogenic effect), nasal congestion, children with high anxiety,

QUESTION: Nitrous oxide is in the blue cylinder (oxygen in green)

QUESTION: Nitrous oxide oxidizes the cobalt in vitamin B12, resulting in the inhibition of methionine synthase. Nitrous oxide has greater analgesic potency than other inhaled anesthetics

QUESTION: Dreaming while on nitrous is what? Overdose or normal

QUESTION: How do you check to see if the oxygen (reserve) bag is okay? It shouldn't be that full or that collapsed

QUESTION: Contradictions of nitrous oxide use: Hypertension, pregnancy

QUESTION: What is an absolute contra-indication for the use of Nitrous Oxide? Sickle cell anemia, nasal congestion,

QUESTION: Device used in evaluation of N20? Pulse oximeter (measure amount of O2 in blood)

QUESTION: The correct total liter flow of nitrous oxide-oxygen is determined by the amount necessary to keep the reservoir bag 1/3 to 2/3 full.

QUESTION: Nitrous oxide: Total flow rate 4-6 L per min

*QUESTION: Max amount of Nitrous Oxide for a kid a. 40 % b. 50% c. 70% (for Adult)

QUESTION: Nitrous safety switch happens at what percent? 70%

QUESTION: Percent nitrous that can NOT increase beyond because of a safety? 70%

QUESTION: Abuse of nitrous oxide it results in peripheral neuropathy.

QUESTION: Why is nitrous oxide used on children? Alleviate anxiety

QUESTION: Child with fear is best treated with: nitrous oxide

QUESTION: What is an adverse/most common effect of nitrous? Nausea

QUESTION: If patient does not have 100% oxygen after nitrous oxide? Diffusion hypoxia

QUESTION: Nitrous should not be given in 1st trimester of pregnancy

QUESTION: When is nitrous contraindicated for a child? upper respiratory tract infection

QUESTION: When is nitrous contraindicated? Asthma or COPD

LOCAL & GENERAL ANESTHESIA

LOCAL ANESTHESIA:

Local anesthesia: comprised of lipophilic ring, intermediate chain, hydrophilic amino group • The intermediate chain is either an ester or an amide bond and determines classification • Adding vasoconstrictor: decreases rate of absorption, minimizes systemic toxicity, and helps with hemostasis • Infection causes tissue to become acidic which leads to an increase in ionized form of LA. This prevents passage of LA through nerve membrane, decreasing effectiveness. • Inside sheath, non-ionized form turns back to ionized form which does the following: o Prevents inflow of sodium o Rate of depolarization is slowed o Threshold potential is not reached o Prevents formation of action potentials • Small, unmyelinated nerve fibers (pain, temperature, autonomics) more sensitive to local anesthetics than larger, myelinated nerve fibers • LA can be mixed with sodium bicarbonate to alkalinize the solution in order to decrease pain upon infiltration and increase effectiveness. • Following injection, sensation will be lost in following order: pain→cold→warm→touch→deep pressure→motor • Seizures are the most common adverse effect resulting from systemic absorption of toxic amounts of local anesthetics

LA Toxicity Signs: circumoral (around the mouth) numbness • Initial: tachycardia, hypertension, drowsiness, confusion, tinnitus, metallic taste • Later: tremors, hallucinations, hypotension, bradycardia, decreased cardiac output • Latest: unconsciousness, seizures, ventricular dysrhythmias, respiratory and circulatory arrest • Children and elderly at greatest risk

LA Allergy: true hypersensitivity reactions to LA is rare. Esters (PABA derivatives) more likely to induce allergic reactions than amides. • Methylparaben (bacteriostatic preservative) may be causative agent in many hypersensitivity reactions.

Methemoglobinemia: hemoglobin oxidized to methemoglobin and cannot bind/carry oxygen. • Excessive doses of prilocaine, benzocaine, lidocaine (PBL) • Signs: “chocolate” covered blood vessels in surgical field, cyanosis, decreased pulse oximetry • Treatment: IV methylene blue (1-2 mg/kg of 1% solution over 5 minutes)

LA Mechanism of Action: LA work on impulse conduction directly by: Inducing reversible & dose-dependent reduction of AP height → progressing to total inhibition Blocking Na+ entry into cells → prevent expected transient permeability increase Non-ionized form of LA penetrates tissue readily (through the nerve sheath and membrane)

LA Chemistry - Most LA consist of: Lipophilic group (ex. aromatic ring) = facilitates penetration into nerve sheath Intermediate chain (ester or amide link) = ester is more prone to hydrolysis so shorter action duration Hydrophilic 2⁰ or 3⁰ amino terminus = weak base that is either charged or uncharged

Esters (no I before –caine) Amides (“I” before –caine) Cocaine Lidocaine Procaine Mepivacaine Chloroprocaine Ethidocaine Tetracaine Bupivacaine Benzocaine Prilocaine Ropivacaine Articaine Metabolized by pseudocholinesterase in plasma/liver Metabolized in liver by microsomal cytochrome P450 esterase, releases PABA enzyme (N-dealkylation, hydroxylation)

Exceptions:

Prilocaine – plasma + kidney, Articaine – has ester group, conjugated in plasma)

Amide derivatives: Xylidine, Toluidine, Thiophene • Xylidine Derivatives (amides) – Lidocaine, Mepivacaine, Bupivacaine, and Etidocaine • Toluidine Derivatives: Prilocaine • Thiophene Derivative: Articaine

***Onset: pKa (lower is more rapid) ***Potency: lipid solubility (higher solubility is more potency) ***Protein binding: duration (increased binding is longer duration)

Onset of Action depends on: • Injection site • Nerve morphology/sensitivity o A-δ & C fibers (conduct pain sensation) are blocked w/ less [LA] than Aα motor fibers. • Tissue pH: more acidic/ionization (infection) means slower onset • pKa of drug: pKa – pH = log [ionized/unionized]

Duration of action: diffusion away from site of action • MAJOR FACTOR, depends on vascularity of tissue surrounding the nerve. • Protein binding: high protein binding leads to prolonged duration (ex. bupivacaine, etidocaine, tetracaine)

MAXIMUM allowable dose of 2% lidocaine with 1: 100,000 EPI • 7 mg/kg for adult • 4.4 mg/kg for pediatrics

Max dose of Epinephrine: Max dose of epi for cardiac pt: 0.04mg (2 carps of 1:100k epi, 1 carp of 1:50k epi, or 4 carp of 1:200k epi max = 4 carps) Max dose of epi for healthy person: 0.2 mg (8 carp of 1:100k epi)

Each 1.8 cc (ml) cartridge of 2% lidocaine with 1:100k epinephrine has: • 20 mg/cc of lidocaine, 36 mg of lidocaine, 0.018 mg of epinephrine

QUESTION: Know where L.A. metabolized? Amides made in P450 enzyme of liver. Esters in pseudocholinesterase of plasma.

QUESTION: Mode of action of Lidocaine: Block sodium channels

QUESTION: What is the mechanism of local anesthetics? Blocks Na channels intracellularly

QUESTION: Mechanism of action of local anesthesia on nerve axon – decreases sodium uptake through Na+ axon channels

QUESTION: What is the primary reason for putting epi in LA? to slow its removal from the site. PROLONG DURATION OF ACTION

QUESTION: Adding a vasoconstrictor to local anesthesia does all the following EXCEPT: a. Decreases rate of absorption b. Increases duration of action c. Minimizes toxicity and helps homeostasis d. all of above

QUESTION: Local anesthetics broken down by what: biotransformation

QUESTION: Patient got LA injection & started breathing fast, hands and finger are moving, heart rate is up - You injected into a blood vessel

QUESTION: Patient get LA injection, he started to breathe a lot, HR goes up, due to what? cardiovascular response to vasoconstrictor

QUESTION: HTN pt. you just gave 4 carpules of 2% xylocaine with 1:100k epi. BP went up to 200/100. what’s possible mechanism/cause? Due to vasoconstrictor injected into venous system.

QUESTION: You gave local anesthetic, BP went down to 100/50 and HR went down too, what could it be due to? Syncope

QUESTION: Infection around a tooth & can't numb patient, why? Infection reduces the free base amount of anesthetic (lowers pH)

QUESTION: Why doesn’t anesthesia work when you have an infection? Decreased pH (acidic environment) leads to more ionized form (less nonionized)

QUESTION: Abscess, give LA, decreased in effect, why? LA is unstable in low pH or LA is in ionized form, needs to be in free base form or unionized form to cross membranes

QUESTION: Where do you inject if infiltration in the area will not be able to avoid the infection? Block

QUESTION: As LA becomes more ionized, it becomes more water soluble, less effective

QUESTION: If you have pain, what would be the hardest to anesthetize? a. Irreversible pulpitis and maxillary b. Irreversible pulpitis and mandibular c. Necrotic pulp and maxillary d. Necrotic pulp and mandibular When irreversible pulpitis, the teeth that are hard to anesthetize are the mandibular molars > mandibular premolars > maxillary molars & premolars > mandibular anterior teeth. fewest problems w/ the maxillary anterior teeth

QUESTION: The pKA of an anesthetic will affect what. Metabolism, potency, peak effect? ONSET

QUESTION: When do you know that it is a non-odontogenic pain? When pain is not relieved with LA

QUESTION: How do you treat lidocaine overdose? Diazepam

QUESTION: What slows the metabolism of lidocaine? Propranolol stays in system longer because propranolol slows down heart slower blood delivery to liver metabolism of lidocaine is slower stays in system longer)

QUESTION: How much epi for a cardio pt? 0. 04mg

QUESTION: Which of the following anesthetic can be used as topical? butamben, dibucaine, lidocaine, oxybuprocaine, pramoxine, proparacaine, proxymetacaine, and tetracaine

QUESTION: Which pair of anesthetics is most likely to cause cross allergy? Lidocaine and mepivocaine

*QUESTION: What anesthesia do you give IV for ventricular arrhythmia? a. Quinidine b. Lidocaine

QUESTION: Cocaine overdose symptoms? pinpoint pupils or mydriasis (pupil dilation)

QUESTION: What is not on cocaine overdose? pinpoint pupil - Cocaine OD—mydriasis - Opiate OD—pinpoint pupil

QUESTION: Which LA causes vasoconstriction? Cocaine Cocaine has intrinsic vasoconstrictive activity

QUESTION: Cocaine is a natural drug

QUESTION: Pt is in rehab for cocaine, what you prescribe for pain? ADVIL

*QUESTION: Prilocaine causes methemoglobinemia (when given over 500mg) Symptoms of methemoglobinemia: cyanosis, headache, confusion, weakness, chest pain

QUESTION: Administer 600 mg of prilocaine. What possible result? Methemoglobinemia can be treated with methylene blue

QUESTION: Levonordefrin is added to certain cartridges containing mepivacaine to: increase vasoconstriction.

QUESTION: best LA to use w/o vasoconstrictor: a. pro b. benzo c. lido d. articaine e. mepivicane (carbocaine)

QUESTION: Articaine (septocaine): metabolized in blood first. unique bc it is an Amide, but has an ester group that is metabolized in the bloodstream

QUESTION: Articaine - conjugated at blood Stream

QUESTION: Anesthesia of facial nerve will cause all except: • instant muscular dysfunction in half the face • excessive salivation • inability to smile • inability to close eye • corner of mouth will droop

QUESTION: Which drug is LEAST likely to result in an allergy reaction? a. epinephrine b. procaine c. bisulfite d. lidocaine

QUESTION: Pt taking MAO inhibitors what you CAN NOT give him: epinephrine, opioids (Meperidine) Local anesthetics containing EPI are contraindicated in patients taking MAO inhibitors.

QUESTION: Mix MAOI and epi to get? HTN

QUESTION: What is the best indicator for success of intra-pulpal anesthesia? feel the back pressure during injection

QUESTION: What is the best predictor for pulpal anesthesia? Concentration of anesthetic Volume of anesthetic Back pressure Type of anesthetic back pressure anesthesia stops hemorrhage, anesthesia after 30 sec, patient doesn’t feel it

QUESTION: Local anesthesia: PSA does not numb MB of M1

QUESTION: Which order will sensation disappear? 1. pain, 2. temp, 3. touch, 4. pressure

QUESTION: Which is incorrect: PSA numb palatal tissue

QUESTION: The dentist is performing a block of the maxillary division of the trigeminal nerve into which anatomical area must the local anesthetic solution be deposited or diffused? a. pterygomandibular space b. pterygopalatine space c. retropharyngeal space d. retrobulbar space e. canine space

QUESTION: MS more or less anesthetic? Use Mepivicaine (no epi)

QUESTION: For a patient with multiple sclerosis

A. epinephrine is contraindicated in local anesthetic. B. the amount of anesthetic needed for a given procedure is less than for a normal patient. C. the amount of anesthetic needed for a given procedure is more than for a normal patient. D. a single cartridge of anesthetic will most likely not last as long as it would for a normal patient.

LIDOCAINE CALCULATIONS:

QUESTION: Lidocaine calculation: a cartridge that contains 1.8 ml of solution at a 2% (20mg/ml) lidocaine concentration, how much drug? 36 mg/ml of drug (20 mg/ml X 1.8 ml/cart. = 36 mg/ml)

QUESTION: Lidocaine calculation: 2% lidocaine or 1:100,000. how much anesthetic is in a cartridge? 36mg

QUESTION: Max dosage of 2% lidocaine for a kid in mg/kg: 4.4 mg/kg MAXIMUM allowable dose of 2% lidocaine with 1: 100,000 EPI - 7mg/kg for adult’s 4.4mg/Kg for Pedo

QUESTION: Numb the kid, how many hours is the soft tissue numb? 3 hrs

QUESTION: When you numb IA nerve, which roots of primary teeth are numb?

*QUESTION: Kids have higher pulse, basal metabolic activity & higher respiratory rate but lower BP

QUESTION: Typical pulse for a 4-year-old is 110 (12 yr. old is 75, adult is 70)

QUESTION: 20 kg child how many mgs of lidocaine can you give: 88mg Max lidocaine w/ epi for kids = 4.4 mg/kg X 20 kg = 88 mg

QUESTION: Kid is 16kg, How many mg max amount of lidocaine? 70mg

QUESTION: 88 lbs. (40kg) child patient is given 2 cartridges 1.8 ml each of 2% lidocaine with 1: 100,000 epinephrine. Approximate what % of maximum dosage allowed for this patient was administered? a. 10% b. 20% (8 carpules max of lido) c. 40% d. 60% 88lbs*2.2 kg/lb. = 40 kg. 40kg*4.4mg/kg (max dose for lido) = 176mg = max dose for this patient; 36 mg x 2 cartilages = 72 mg injected  72mg injected/176mg = 40%

QUESTION: 50 lb. patient given 5 carps of 2% lido with 1:100k epi. During procedure 20 min later, he started twitching his arms and legs & went unconscious (convulses), why? Overdose of lidocaine, overdose of the epi (causes HTN), allergy

“ QUESTION: Maximum recommended dosage of lidocaine HCl injected subcutaneously (not IV) when combined with 1:1,00,000 epinephrine is? a. 100 mg b. 300 mg c. 500 mg d. 1 gram

QUESTION: 3.6ml of 4% prilocaine contain how much anesthesia? a. 72 mg b. 80 mg c.144 mg d. 360 mg 4% prilocaine = 40 mg/mL; 3.6 mL x 40 mg/mL = 144 mg

QUESTION: How many carps of 4% [X] anesthetic should be given if maximum amount that you want to give is 600mg of drug? - approximately 8 carps (go over calculation) 4% = 40 mg/mL = 600/40 = 15 mL/1.8ml (in 1 carp) = 8 carps

QUESTION: The maximum allowable adult dose of mepivacaine is 300 mg. How many milliliters of 2% mepivacaine should be injected to attain the maximal dosage in an adult patient? a. 5 b. 10 c. 15 d. 20 e. 25 2% mepivicaine = 20mg/ml; 300mg/20 = 15 mL

QUESTION: Maximum dose of mepivicaine? 400mg Maximum dosage: prilocaine (600 mg) > articaine + lidocaine (500 mg) > Bupivacaine (90 mg)

QUESTION: A recently-introduced local anesthetic agent is claimed by the manufacturer to be several times as potent as procaine. The product is available in 0.05% buffered aqueous solution in 1.8 ml. cartridge. The maximum amount recommended for dental anesthesia over a 4-hour period is 30 mg. This amount is contained in approximately how many cartridges? a. 1-9 b. 10-18 c. 19-27 d. 28-36 (approx. 33 cartridges) e. Greater than 36 0.05% = 0.5 mg/mL = 30m mg/ (0.5 mg/mL) = 60 mL/ (1.8 mL/carp) = 33.3 carp

QUESTION: What determines max. dose for anesthetic for a child? Weight

GENERAL ANESTHESIA:

Inhalation anesthetics: nitrous oxide, isoflurane, halothane, desflurane, sevoflurane, enflurane

Nitrous oxide: • Need minimum 30% oxygen • Side effects: headache, nausea/vomiting, lethargy, diffusion hypoxia • Prolonged exposure can lead to: bone marrow suppression (megaloblastic anemia, leukopenia) and neurological deficiencies (peripheral neuropathies, pernicious anemia) • Potent analgesic, weak general anesthetic

IV/Enteral Anesthetics: • The risk of respiratory depression and coma is less for benzodiazepines than barbiturates

Barbiturates: act as sedative and hypnotic, potent anesthetics, weak analgesics • Depress CNS, works on GABA receptors, increase duration of chloride channel opening→decrease neuronal firing • Prolong GABA inhibitory effect in reticular activating system (RAS) • Thiopental sodium (Pentothal): very short acting agent, high lipid solubility • Methohexital (Brevital): very short acting agent • Phenobarbital (luminal): long acting agent

Benzodiazepines: act as anxiolytic, anticonvulsant, antispasmodic, sedative, hypnotic, amnesic (anterograde amnesia) • Enhance GABA binding to GABA receptor, increase frequency of chloride channel opening-->decrease neuronal firing • PO and IV forms • Short acting (<6 hours): triazolam (Halcion) PO, midazolam (Versed) PO/IV • Intermediate-acting (6-10 hours): alprazolam (Xanax) PO • Long acting (>10 hours): diazepam (Valium) PO/IV, lorazepam (Ativan) PO/IV, chlordiazepoxide (Librium) PO/IV

Flumazenil: reversal agent for benzodiazepine, competitive antagonist at GABA receptor, effect only lasts 20 minutes (resedation can happen)

Propofol (Diprivian): sedative, hypnotic, highly lipophilic • Good for outpatient anesthesia due to rapid induction and recovery, and lower incidence of nausea/vomiting

Ketamine: dissociative anesthesia, phenylcyclidine derivative (PCP), NMDA receptor antagonist, short acting, cardiovascular stimulant • Sedation where patient appears awake, but is unconscious, and does not feel pain

Chloral hydrate: sedative and hypnotic, CNS depressant, frequently used in children, contraindicated in hepatic and renal impaired patients

Opioids: analgesia and euphoria, act as agonist on mu, delta, kappa, and sigma receptors in CNS • Fentanyl (Sublimaze), Sufentanil (Sufenta), Alfentanil (Alfenta), Morphine, Codeine, Meperidine (Demerol) • Adverse effects: pruritis, nausea/vomiting, urinary retention, constipation, miosis, respiratory depression

Naloxone: reversal agent for opioid overdose.

*QUESTION: A 26-month old child w/ 12 carious teeth. How to treat? a. General Anesthesia b. Oral sedation c. Nitrous oxide d. local anesthesia

*QUESTION: Kid under general anesthesia: give chloral hydrate and midazolam

QUESTION: Pt is under oral sedation. You should monitor everything except? • Respiration • Oxygen saturation level • Electrocardiogram • Skin and oral mucosa color

QUESTION: #1 cause for problems during IV sedation? Hypoxia

QUESTION: A 77 years old female 110 lbs. weight requires removal of mandibular teeth under local anesthesia. She is apprehensive. The appropriate dose of IV diazepam to sedate her? a. 5 mg b. 10 mg c. 15 mg d. 20 mg 2mg for midazolam IV, 10 mg diazepam IV

QUESTION: Pt goes home from elective orthognathic surgery and in 24hrs, without sign of inflam or edema, but a fever of 102oF- Atelectasis (or pneumotosis – depending on answers) a. Atelectasis and pneumotosis = most common cause of fever within 24 hour of GA

ANTIBIOTICS

PREMEDICATION REQUIREMENTS:

Premedicate these conditions: artificial heart valve, previous IE, congenital heart (valvular) defect, total joint replacement w/ co- morbidity Preventive antibiotics prior to a dental procedure are advised for patients with: 1. Artificial/prosthetic heart valves 2. History of infective endocarditis 3. Certain specific, serious congenital (present from birth) heart conditions, including: o unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits o a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure o any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device 4. Cardiac transplant that develops a problem in a heart valve.

Pre-med with odontogenic infection: • Amox for SBE prophylaxis • Penicillin for odontogenic infections • Tetracycline for periodontal infections (better penetration, stays in bone tissue longer)

Amoxicillin Clindamycin Adults: 2g orally 1hr prior to appointment Adults: 600mg orally 1hr prior to appointment

Children: 50 mg/kg (not to exceed adult dose) orally 1hr Children: 20mg/kg orally 1hr prior to appointment prior to appointment

*QUESTION: Which procedure least likely to produce bacteremia? extraction, non-surgical endo, oral prophylaxis

QUESTION: Condition that DOES NOT require antibiotic prophylaxis o Prosthetic heart valve o Rheumatic heart valve o Congenital heart formations o Cardiac pacemaker

QUESTION: Indication for antibiotic prophylaxis: Prosthetic valve

QUESTION: Prophylactic treatment for prosthetic heart valves – premedication required

QUESTION: Prophylactic treatment for Pacemaker – No premedication required Just stay away from ultrasonic and electric testing/ electro cautery

QUESTION: (Again with different options) need premedication for… congenital heart defect with severe problems

QUESTION: Kid had unrepaired cyanotic congenital heart disease with something valves. Premedicate with amoxicillin and you need to know the dosage so that you pick the right dosage 60 lb. kid. 50mg/kg dosage.

***QUESTION: What is the pre-medication dosage for child 44 lbs.? 1-gram amoxicillin 1 hour prior Tx 44 lbs. = 20Kg X 50mg/Kg = 1000mg = 1g Amoxicillin

***QUESTION: Pt w/ mitral valve prolapse w/ regurgitation – don’t premedicate

***QUESTION: (Patient’s medical tab say he is allergic to Amoxicillin), He needs to be premedicated, what do you prescribe? Clindamycin, 600mg 1hr before the dude shows up for the appointment. For kids 20mg/kg

QUESTION: If patient is allergic to ampicillin, then what antibiotic should be given? **CEPHALEXIN probably the answer… if allergic to pen give 2 g of it.

• Not allergic to penicillin: 2g of amoxicillin 1-hour prior (50mg/kg for kids) • Not allergic to penicillin but unable PO: 1g cefazolin or 2 g ampicillin IM or IV 1-hour prior (50mg/kg for kids) • Allergic to penicillin: 600 mg clindamycin 1-hour prior (20mg/kg for kids), 2 g cephalexin 1-hour prior (50mg/kg kids) • Allergic to penicillin and unable to PO: 600 mg clindamycin IV 1-hour prior

QUESTION: Man has accident and pin placed in arm. What antibiotic prophylaxis does he need? None

QUESTION: Pt w/ total knee replacement but was taking Amoxicillin for a while; how do you premeditate? NO (or MED CONSULT)

QUESTION: Knee surgery-no prophylaxis Patient with pen allergy-true or false-patient had knee replacement True-patient needs premed and would take amox-no not true

*QUESTION: Pt had hip replacement 10 years ago, what do you use to premeditate? No premedication needed

***QUESTION: Pt needs antibiotic prophylaxis. He is taking penicillin already, what do you give him? Clindamycin

***QUESTION: Regular premedication case: Give amoxicillin 2g 1hr b4

***QUESTION: What is recommended prophylaxis for pt that can’t take penicillin? Clindamycin

QUESTION: prophylaxis antibiotic: Pt with heart transplant with valvulopathy

QUESTION: IE pre-medications why? Benefits of premedication outweigh potential harm associated with penicillin

QUESTION: Endocarditis definition: inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves (native or prosthetic valves) • Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect.

QUESTION: Infectious Endocarditis pre-medication definition? For patients who have cardiovascular problems and are at risk of infection over their lifetime

QUESTION: When is it appropriate to prescribe antibiotic prophylaxis in patient with previous infective endocarditis? If consequence of potential infection is detrimental to life

QUESTION: Which of these procedures pose a risk for Infective Endocarditis? • Primary teeth shedding • RCT • Some sort of surgery • IA injection

***QUESTION: Guideline of antibiotic prophylaxis, especially for kids - for kids, Amox is 50mg/kg and Clindamycin is 20 mg/kg

***QUESTION: Know the doses for someone that is allergic to penicillin, what you can give them? Clarithromycin or azithromycin 500mg

QUESTION: If a patient is allergic to Ampicillin, what else can you premedicate with? Clindamycin 600mg 1, Cephalexin 2g, Azithromycin 500 mg, or Clarithromycin 500 mg all 1-hr before

ANTIBIOTICS:

Erythromycin (Azithromycin and Clarithromycin) are macrolides. They are –static & bind to 50S ribosomal unit to inhibit protein synthesis. Penicillin is bactericidal and inhibits peptidoglycan cell wall by binding to transpeptidase

QUESTION: Most bacteriostatic meds works by: Inhibiting protein synthesis

QUESTION: Broad spectrum antibiotics like tetracycline: Increase superinfection and resistance

QUESTION: Broad spectrum antibiotics Increase superinfection (candidiasis) and resistance

QUESTION: Why don’t we use broad spectrum antibiotics? Produce resistant bacteria

QUESTION: If you increase spectrum of bacteria, it leads to more infections

QUESTION: Antibiotics are least useful for tx of this periodontal conditions: LAP, NUG, Chronic periodontitis

QUESTION: Antibiotic metabolism is affected by chronic tx with what drugs? Benzodiazepines, barbs, SSRI, TCA

*QUESTION: Pt is taking an antibiotic, which is metabolized in the liver. Metabolism of this antibiotic is decreased by which drug? a. TCA b. SSRI c. Phenothiazine d. Diazepam

QUESTION: You give antibiotics through IV, patient experience sudden allergic reaction, what’s the FIRST thing you do? Remove the IV line (others were clear airway, give oxygen, etc.)

QUESTION: Penicillin, why is this so good to give as an antibiotic? Low toxicity, cheap, not a lot of people are allergic

QUESTION: Mechanism of action of penicillin is closely related to? Keflex (cephalexin) • Bactericidal against gram (+)

QUESTION: What is the effect of Penicillin and Cephalosporin’s Cell wall synthesis via beta lactam ring

QUESTION: Transpeptidase enzyme is inhibit by penicillin • Transpeptidase, a bacterial enzyme that cross-links the peptidoglycan chains to form rigid cell walls

QUESTION: Which of the following penicillin would be used to treat a Pseudomonas infection?

Nafcillin (Unipen) Amoxicillin (Amoxil) Benzedrine penicillin (Bicillin) Phenoxymethyl penicillin (Pen-Vee K) Ticarcillin (Thar) • Ticarcillin is a carboxypenicillin. Its main use is for the treatment of Gram-negative bacteria, particularly Pseudomonas aeruginosa.

QUESTION: Why does penicillin have decreased effectiveness in abscess? Hyaluronidase, pen unable to reach organism

QUESTION: With cyst, why doesn’t penicillin work well? Because can’t penetrate cyst barrier

QUESTION: #1 dental antibiotic for an infection within 24hrs is Pen VK 1gm booster and 500mg q6h • Penicillin V potassium is a slow-onset antibiotic, bactericidal against gram (+) cocci & major pathogen of mixed anaerobic infections. In the absence of an allergic reaction, penicillin VK is the drug of choice in treating dental infections

QUESTION: For an infection: give PenVK 500mg → give 1g at once and then 500 mg every 6 hours (7 days)

*QUESTION: What antibiotic is used for endo, pulpal involvement? PEN VK (yes it actually says VK together)

QUESTION: All are true except? Cephalosporin has a broader spec than Penicillin • Cephalosporin is a beta lactam antibiotic, bactericidal, 1st generation more concentrated on gram (+), more resistant to beta lactamase than penicillin

QUESTION: Chlortetracycline- Broadest antibiotic effect

*QUESTION: Tetracycline mechanism of action: Protein synthesis inhibitor (30s), bacteriostatic

QUESTION: How does tetracycline work? Block activity of collagenase, bind to 30S (block AA linked tRNA) • Tetracycline is usually not used because they cause yeast infections, as well opportunistic infect.

QUESTION: Doxycycline - act on 50S ribosome (there were no 30S choice) • Doxycycline reversibly binds to the 30 S ribosomal subunits and possibly the 50S ribosomal subunit(s), blocking the binding of aminoacyl tRNA to the mRNA and inhibiting bacterial protein synthesis. • It’s a tetracycline, treats malaria, broad spectrum

QUESTION: Something about periodontal dressing and that it has 20mg of Doxycycline and asks about its mechanism (there was nothing about bacteriostatic or inhibits 30S ribosome): Inhibits collagenase 20 mg = no anti-bacterial effect but it inhibits collagenase

QUESTION: Which antibiotic is anti-microbial and anti-collagenlyctic? clindamycin, doxycycline, metronidazole, amoxicillin

*QUESTION: Tetracycline does not do one of the following: reduce host response reduce bacterial infection reduce host collagenase decrease gingival crevicular fluid flow

*QUESTION: Minocycline & Doxycycline: all are true except? Both increase GCF secretion, both released in GCF (Gingival crevicular fluid) tetracycline is NOT more concentrated in GCF more than in blood • Minocycline: effect toward MRSA, skin infections, acne, rosacea, less likely to become resistant, stain • Tetracycline: cause sunburn, can use antacids/iron supplements/vitamins when on it, more uses

QUESTION: Mechanism of action of Minocycline in the Arestin: Decrease collagenase activity • Minocycline, another tetracycline antibiotic, has also been shown to inhibit MMP activity.

QUESTION: What drug has the highest concentration in crevicular fluid? Tetracycline

QUESTION: Which one of the following drug is chelated with Calcium? Tetracycline • Also chelates magnesium and iron

QUESTION: Which drug would inactivate the latter? Antacids-Tetracycline • Don’t take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. Antacids and milk reduce the absorption of tetracycline.

QUESTION: Tetracycline is bacteriostatic

QUESTION: What is most affected by tetracycline? Enamel or Dentin, causes intrinsic stain

QUESTION: What age are you most likely to get an infection that resulted in enamel hypoplasia or tetracycline staining? Before 4 months in utero for primary; birth for permanent

QUESTION: What medication do you not give to lactating female? Codeine and tetracycline

QUESTION: Pt allergic to penicillin, what could be cross-reactive? Cefatriaxone (3rd gen cephalosporin)

QUESTION: What drug has cross allerginicity with Penicillin? Cephalosporins (Cephalexin—1st generation) • Both have Beta lactamase ring. If pt has allergic to penicillin, then pt has allergy to cephalosporin (possibly)

*QUESTION: Child comes in with an oral infection and is NOT allergic to Pen. What do you prescribe? o Penicillin o Amoxicillin o Tetracycline

QUESTION: Pt is taking tetracycline. Which of the following drugs would be contraindicated? Penicillin

QUESTION: What happens when you have penicillin and decide to prescribe tetracycline with it? Tetracycline will decrease the efficacy of Penicillin

• Tetracycline is bacteriostatic whereas penicillin is bactericidal. The two mechanisms of action (CIDAL+STATIC) cancel each other out because when you need bacterial growth to actually use penicillin, but you don’t have that growth when you prescribe Tetracycline. ANTAGONISTS

QUESTION: Penicillin and erythromycin taken together cause: (cidal vs static) • summation • potentiation • antagonists Ssomething else that I understood as meaning they do the same thing

QUESTION: Erythromycin – bacteriostatic – inhibits protein synthesis (50S)

QUESTION: #1 side-effect of erythromycin is? Stomach upset

QUESTION: In lethal doses of erythromycin, what do you see? Hepatocellular, GI damage

QUESTION: Myasthenia gravis patient, what can’t you give them? Erythromycin, clarithromycin, penicillin or Imipenem

QUESTION: If you have maxillary sinusitis, what antibiotic would you give? Amoxicillin with clavulanic Acid (Augmentin) • Clavulanic acid increases spectrum of action & restored efficacy against amoxicillin-resistant bacteria that produce β- lactamase.

QUESTION: What does clavulanic acid do when is mixed with amoxicillin (Augmentin)? Decrease sensitivity to b-lactamase

QUESTION: Clavulanic acid in amoxicillin - Prevents beta lactam degradation by beta lactamase producing bacteria

QUESTION: Augmentin: blocks the action of penicillinase, penicillinase resistant

QUESTION: Metronidazole - prescribed in necrotizing ulcerative gingivitis (NUG) or aggressive periodontitis • Metronidazole is contraindicated in patients on alcohol causing disulfiram type of reaction • Has red urine

QUESTION: Metronidazole: given for aggressive periodontitis. Makes your pee a different color? True

QUESTION: Antibiotic against only anaerobes and parasites (protozoa)? Metronidazole

QUESTION: Which med kills only anaerobes and parasites: Metronidazole

QUESTION: Clostridium difficile (colon inflammation) is treated with metronidazole. Unless pt is pregnant or breastfeeding, then use vancomycin.

QUESTION: Mechanism of Metronidazole • disrupts cell wall synthesis • enzyme poisoning • fungal protozoa disruption: activated via bacteria→forms radicals→reacts with nucleic acid→cell death

QUESTION: Best treatment of localized aggressive periodontitis: Tetracycline, Doxycycline

QUESTION: Which antibiotic is NOT inhibit cell wall synthesis? • Amoxicillin • Vancomycin • Azithromycin (this inhibits protein synthesis)

QUESTION: Gentamycin (aminoglycosides) - May cause auditory nerve deafness • Bactericidal

QUESTION: aminoglycosides: Ototoxicity and nephro toxicity

QUESTION: Antibiotic that helps with MRSA: Vancomycin

QUESTION: Pseudomonas colitis: c. difficile and Clindamycin

QUESTION: Which of the following describes clindamycin? • Inhibits proteins synthesis (50S) a. inhibits cell wall synthesis b. does not penetrate well into bony tissue c. it usually given in combination with erythromycin d. is effective against gram-negative bacteria only e. is effective against most anaerobes

QUESTION: Which of the following describes ciprofloxacin (Cipro®)? Inhibits cell wall synthesis. Effective against Pseudomonas aeruginosa Effective only against anaerobic bacteria. An antibiotic-of-choice for treating otitis media in young children. Effective against oral anaerobes.

o Inhibits DNA gyrase, gram (+) and (-), don’t use in patients with myasthenia gravis

QUESTION: Exposure to chloramphenicol (antibiotic) is associated with what? Aplastic anemia

ANTI-CANCER DRUGS:

*QUESTION: Anti-cancer drugs are least likely to cause what? Ulcers, thromboembolism

QUESTION: What’s an adverse effect of a drug that you can’t mix with antibiotics? Methotrexate because it won’t clear out of the system, specifically with amoxicillin. • Penicillin can decrease elimination of methotrexate (cancer drug), increasing risk of methotrexate toxicity, which can cause seizures.

QUESTION: AMOX AND METHOTREXANE: DON’T MIX!!

QUESTION: Methotrexate (MTX) is an: antimetabolite and antifolate drug. Used for tx of cancer, autoimmune diseases, ectopic pregnancy, and for the induction of abortions. It inhibits folic acid metabolism.

QUESTION: Which drug will be used to treat an overdose of methotrexate? Leucovorin • Methotrexate toxicity effects can be reversed by folic acid (leucovorin)

QUESTION: Which medication for anticancer works on folate synthesis/ prevents folic acids synthesis/prevents folic acid production: Methotrexate

QUESTION: Methotrexate is an anti-cancer drug that inhibits folate reductase

QUESTION: Drug agonist antagonist of folic acid? Sulfa, Trimethoprim, Methotrexate • Antagonists = aminopterin, methotrexate, pyrimethamine, trimethoprim, triamterene

QUESTION: Anti-cancer drug (Mechlorethamine), that was an alkylating agent, what was its effect? Neurotoxic

QUESTION: Alkalizing anti-cancer drug called procarbazine causes: Hepatotoxicity • Inhibits CYP450, increased effect of barbiturates, phenothiazines, and narcotics. Has monoamine oxidase inhibition properties (MAOI), and should not be taken with most antidepressants and certain migraine medications.

QUESTION: Non-alkylating anti-cancer side effect? myelosuppression (BONE MARROW SUPPRESSION)

ANTI-VIRAL MEDICATIONS:

Common Anti-viral: Amantadine: Influenza A, Parkinson’s, block viral membrane matrix protein M2 (virus can’t fuse with cell membrane) Oseltamivir (Tamiflu) & zanamivir: influenza A and B, influenza neuramidase inhibitor Acyclovir: Herpes I, II, VZV, EBV, phosphorylated by herpes virus encoded enzyme, inhibits viral DNA polymerase Gancyclovir: CMV, works same as acyclovir Ribavirin: Hep C and respiratory syncytial virus, inhibits synthesis of guanine nucleotides and viral mRNA

QUESTION: Picture of lesion at corner of mouth, patient says it comes and goes now and then, what type of infection would you suspect? Viral

QUESTION: Amantadine is an anti-viral and anti-parkinsonian or anti-TB and its anti-viral.

*QUESTION: Which one is an antiviral agent? Amantadine

QUESTION: What anti-viral is used to for all the these: HSV, VZV, CMV? Valacyclovir

QUESTION: What virus causes Posthepatic neuralgia? Varicella zoster virus

QUESTION: Acyclovir has selective toxicity mechanism of action b/c: inhibits viral mRNA inhibits cellular mRNA in infected cells only phosphorylated and activated in infected cells • Inhibits mRNA, doesn’t work on DNA

QUESTION: Which of the following is not properly matching the anti-viral med with the virus that caused the disease? Retrovir was matched with coxsackie (retrovir is used for HIV/AIDS)

QUESTION: Give drugs and paired it with the disease. Choose the wrong pair: Retrovir with varicella zoster

HIV & HIV MEDICATIONS:

QUESTION: HIV patient with sinusitis due to what? Murcomycosis

QUESTION: Most reliable measure of HIV progression? CD4 count, viral load QUESTION: CD4 count and T-cell count for HIV symptoms: pt had HIV CD4 less than 200

*QUESTION: Pt has viral load of 100,000: pt has high virus load and prone to infection

QUESTION: Pt’s viral load was 100,000, and T cell count was 50. What is the right statement? Pt’s T cell count is too low • Healthy T-cell count: 500-1500 units/ml

*QUESTION: Which of the following is not a risk of oral cancer a. Tobacco b. Alcohol c. HPV d. HIV

QUESTION: Which of the following agents is used for HIV infection? a. amantadine (Parkinson’s) b. acyclovir (Herpes) c. zidovudine (also called AZT) d. ribavirin (Hep C) e. isoniazid (TB)

QUESTION: What oral manifestation is seen in children with HIV? Candidiasis

QUESTION: Fungal agent for HIV: Fluconazole or ketoconazole

QUESTION: Candidiasis & HIV, what do you give systemic or topical anti-fungal? Nystatin

ANTI-FUNGAL MEDICATIONS: Azoles “conazol”: inhibit lanosterol conversion to ergosterol; blocks synthesis of ergosterol Polyenes: bind to ergosterol on cell membrane and create a pore/transmembrane channel • Includes Amphotericin B • Nystatin

Topical anti-fungal: Mycelex (clotrimazole), Nystatin, Ketoconazole

Systemic anti-fungal: Fluconazole (Diflucan), Amphotericin B, Ketoconazole Know “FAK”

Flucytosine: inhibit DNA synthesis, systemic Griseofluvin: interacts with microtubules to disrupt mitotic spindle and inhibit mitosis

QUESTION: Easy question on Nystatin: “swish & swallow”

QUESTION: Systemic antifungal: Fluconazole (diflucan)

QUESTION: Medication for angular chelitis: Nystatin

QUESTION: Oral anti-fungal infection: Nystatin • Clotrimazole(Mycelex) and Nystatin are oral anti-fungal medications

QUESTION: Griseofulvin: used for athlete’s foot. Treat fungal infections such as ringworm, "jock itch," and athlete's foot.

QUESTION: Clotrimazole mechanism of action: Alter the enzyme for synthesis of ergosterol, which alters cell membrane permeability

QUESTION: Mechanism of miconazole (antifungal): inhibits the synthesis of ergosterol a critical component of the cell membrane

QUESTION: Best topical antifungal? Mycelex REMOVABLE PARTIAL DENTURES

Kennedy Classification • Class 1 = bilateral distal extension o Indirect retention necessary • Class 2 = unilateral distal extension • Class 3 = all tooth supported o Indirect retention not necessary o Almost as good as FPD • Class 4 = single edentulous area crossing the midline (cannot have modifications)

SUPPORT (rigidity, vertical forces): Denture base, major connector, and rests STABILITY (rocking, horizontal forces): minor connector (lingual plates, guide planes, etc.) RETENTION: indirect and direct retainers (never major connector)

Major maxillary connectors: posterior palatal strap, U-shape/horseshoe (least favored due to too much flexibility), AP palatal strap, full palatal plate Major mandibular connectors: lingual bar (most common), lingual plate, Kennedy/double lingual bar, labial bar • For lingual bar, need 8 mm space (3mm away from gingival margins + 5mm for the bar) • Cross section of lingual bar = half pear shaped

Retentive clasp: can be direct or indirect and suprabulge or infrabulge • Suprabulge = Aker’s or C clasp • Infrabulge = Roach or bar (I, J, T, L, etc.)

Reciprocal clasp: passively touches above the height of contour, middle 1/3 of the crown Functions: • Provide stability & reciprocation against retentive arm • Denture is stabilized against horizontal movements • Acts as indirect retainer (prevent minor rocking)

Indirect retainers: prevents distal extension from moving away from the underlying tissue during function • Located on the opposite side of fulcrum line, assist direct retainer to prevent denture displacement • Should be placed far from distal extension base

Primary stress bearing area/retention: Mandibular – buccal shelf (slow resorption, access determined by buccinator attachment) Maxillary: ridges in RPD, hard palate

Yield strength: the stress at which a material exhibits a specified limiting deviation from proportionality of stress to strain

REMOVABLE PARTIAL DENTURES COMPONENTS:

*QUESTION: Purpose of Major Connector Stability and Rigidity Stability and Retention Retention and Rigidity Rigidity and Esthetics

QUESTION: Requirement of a major connector? Rigidity

QUESTION: Purpose of the reciprocating arm of clasp: Stabilization (resists the lateral forces exerted by the retentive arm when it passes through the height of contour)

QUESTION: Reciprocating arm Counteracts the effects of direct retainer, stabilizes the tooth, indirect retainer

QUESTION: Function of clasp arm? Both stability (reciprocal arm) and retention (retentive arm)

QUESTION: Reciprocal clasp is: Placed on or above the height of contour (middle 1/3)

QUESTION: Reciprocal anchorage in ortho – Equal and opposite forces…bodily movement, tipping, rotation

QUESTION: Where does the retentive clasp engage on abutment: Passively on the suprabulge (retentive clasp can be suprabulge or infrabulge)

QUESTION: Retentive clasp is not base metal alloy (it must be flexible)

QUESTION: What is function of rest? Support (To resist the horizontal tissue force)

QUESTION: The purpose of the rest seat is: prevent displacement of RPD toward tissue and transfer the forces of mastication to supporting teeth

QUESTION: What’s the purpose of an indirect retainer? To prevent distal extension from lifting up (Kennedy class I)

QUESTION: Function of minor connector? Stability

QUESTION: Main purpose of buccal flange of maxillary denture? Stability

QUESTION: What does not have an effect on clasp flexibility? Amount of undercut • These affect clasp flexibility: type of metal, taper, width, and length all have an effect on clasp flexibility

QUESTION: What is the primary retention (support?) for mandibular denture? Buccal shelf QUESTION: Primary stress bearing area in mandible: Buccal shelf QUESTION: What is main area of support for distal extension RPD? Buccal Shelf (second would be ridges)

QUESTION: Primary support for max denture – Ridges (second would be palatal rugae)

QUESTION: Best indicator for success of denture is – Ridge health

QUESTION: Definition of a combination clasp: Cast reciprocal arm and a wrought wire retentive clasp • Opposite of what you would think. • Indicated in distal extension cases with undercut on mesio buccal surface

QUESTION: What connects major connector with occlusal rest seats? Minor connector

QUESTION: What is reason for the altered cast technique when doing a distal extension RPD? Support…other oprtions were esthetics, retention, resistance

QUESTION: What property of RPD framework will limit adjustments of clasps? Yield strength Ductility Stiffness

*QUESTION: What mechanical property effects permanent composition for RPD clasps? Stiffness Yield strength Ductility Hardness

QUESTION: When treatment planning an RPD for a patient what’s the first thing you do? Mount casts…other options were find undercuts, find abutments, extract hopeless and perio teeth.

QUESTION: Best way to evaluate available space for rests? Mounted casts

QUESTION: Which of the following explains why a properly designed rest on the lingual surface of a canine is preferred to a properly designed rest on the incisal surface? A. The enamel is thicker on the lingual surface. B. Less leverage is exerted against the tooth by the lingual rest. C. The visibility of, as well as access to, the lingual surface is better. D. The cingulum of the canine provides a natural surface for the recess.

QUESTION: After surveying and designing which is the first step you do? Reduce axial for proximal plate

QUESTION: How should distal extension RPD fit in comparison to other RPDs? Passive clasp fit

QUESTION: Pt presents with a restricted floor of the mouth, only 6 mandibular anterior teeth and diastema b/w several teeth, which of the following major connector is appropriate for this patient? Lingual plate with interruptions in the palate at the diastemas

QUESTION: First step in realigning a distal extension denture would be what? Try in the framework

METAL CHARACTERISTICS

QUESTION: What prevents corrosion on a noble metal? Chromium or nickel

QUESTION: What is expected from a high noble metal? Corrosion or no tarnish

*QUESTION: For an RPD denture frame or PFM crown, what metal is responsible for most allergic reaction? Nickel…other options were chromium, cobalt or copper

RPD ERRORS:

QUESTION: What happens when no indirect retainer on distal extension? Distal extension pops off the tissue QUESTION: Insufficient indirect retention on RPD when what happens? Distal extensions lift away from mucosa QUESTION: Patient complains that their new bilateral distal extension RPD “feels loose.” Edentulous bilateral rocking of denture. What is the issue? Inadequate indirect retainers or inadequate seating of denture QUESTION: RPD rocks when you apply pressure on either side of fulcrum line, why? Inadequate indirect retainer QUESTION: Pt complains “it feels loose” from a new bilateral distal extension RPD. Why? I put retainers are passive on the abutments they should fit passive. Indirect retainer

QUESTION: With mandibular bilateral distal extension RPD, when you place pressure on one sides the opposite side lifts and vice versa, what is the problem? a. No indirect retention used b. Rests do not fit c. Acrylic resin base support d. Occlusion

*QUESTION: When you push on the distal extension of a lower RPD, and the indirect retainer rest comes up, how do you treat? a. Reline (if its excessive altered cast) b. Tell them to use denture adhesive c. Tighten clasps

QUESTION: The main reason of breaking of RPD clasp? High Module of Elasticity (less likely to change shape – less deformation = VERY RIGID)

QUESTION: Pt comes in with an interim partial denture. When you fabricate it in cast partial, how is it going to be different? a. Aesthetics of teeth b. Retention c. Resistance to occlusal loading (because the interim doesn’t have rest seats)

QUESTION: In a maxillary complete denture opposing a mandibular bilateral distal extension (Kennedy class 1), why is the anterior of the wax rim of maxillary beveled? Length is good esthetically but there is not enough interocclusal space at that length

QUESTION: Why would you bevel the upper occlusal rim? Insufficient inter-arch space despite length being adequate for esthetics

QUESTION: Patient has occlusal rims prepared and bevels the maxillary, why?

a. VDO and length of max occlusal rim was adequate b. VDO was incorrect bur length of occlusal rim was adequate c. Always bevel max occlusal rim d. Length of occlusal rim is adequate for esthetics but VDO was wrong

KENNEDY CLASSIFICATION:

QUESTION: In which classification is a direct retainer very important? Kennedy Class 2

*QUESTION: Describes a denture with bilateral edentulous space anterior to natural teeth: Kennedy Class IV

QUESTION: Which type of Kennedy classification doesn’t have a modification? Kennedy Class IV

QUESTION: Reline for Kennedy class one: Make sure RPD is seated

COMPLETE DENTURES

Neil’s Lateral Throat Form: • Class 1 = large, favorable • Class 2 = in between • Class 3 = small, unfavorable

Wright’s Tongue Position: • Class 1 = normal, favorable • Class 2 = retracted, unfavorable

Three critical factors for successful complete dentures: • Stability: resistance of the denture base against lateral forces • Support: resistance to the forces directed against the tissues • Retention: resistance to dislodgement of the denture base away from the tissues

Freeway space: usually 1-3 mm, VDO = VDR- Freeway space Epulis Fissuratum: overgrowth of intraoral tissue caused by chronic irritation, usually an overextended denture flange

QUESTION: Which one of the following is usually an issue for denture patients? Lower denture

QUESTION: Retention of denture is impacted by Saliva flow (THIN & watery saliva is better and aids in adhesion) • Decreased salivary flow from protein deficiency

QUESTION: Disadvantage of reduced saliva? Reduced retention

QUESTION: Saliva and denture, which one is correct? Relationship that leads to denture and tissue adhesion, no relationship

QUESTION: Physiologic rest position: When mandible and all of supporting muscles are in their resting posture, muscle guided position

PALATAL SEAL & PALATAL TORI

QUESTION: Primary stability for a complete denture on maxillary? Palate (palatal rugae) and residual ridges

QUESTION: Posterior extension of post palatal seal is: 2mm past vibrating line (Fovea Palatini)

QUESTION: Which 3 things determine the posterior palatal seal? Throat form, tissue type and fovea location • Posterior palatal seal aids in retention of the denture. • Before placing palatal seal, dentist will evaluate – vibrating line, throat configuration, tension of tissue throat form (Neil’s lateral throat form), tissue type and fovea location.

QUESTION: Which of the following best explains why the dentist should provide a posterior palatal seal in a complete maxillary denture? The seal will compensate for: A. Errors in fabrication. B. Tissue displacement. C. Polymerization and cooling shrinkage. D. Deformation of the impression material.

QUESTION: Excessive depth of the posterior palatal seal usually results in A. Unseating of the denture. B. a tingling sensation. C. greater retention. D. increased gagging.

QUESTION: If the palatal vault is too deep: Vibrating line is more pronounced and forward • The higher the vault, the more abrupt & forward the vibrating line is. • In the palate class III variation, there is a high vault in the hard palate. Soft palate has an acute drop and a wide range of movement. The vibrating line is much more anterior and closer to the hard palate. This gives a narrow posterior palatal seal area.

QUESTION: When do you remove palatine torus? If it prevents seating of denture and to increases posterior palatal seal QUESTION: Patient is going to get dentures and he has palatine tori, why should it be removed? To increase peripheral seal

QUESTION: When should palatal tori be removed for a denture patient? 1. If undercut-so can’t be cleaned 2. If posterior to vibrating line 3. 3mm anterior to vibrating line - interferes with posterior palatal seal 4. When denture is created around tori and functions properly

QUESTION: Pt has bilateral maxillary tori that extends to the posterior palatal seal. You need to make an upper and lower complete. What should you do? Remove tori and then make complete denture

QUESTION: Guy has no upper teeth and palatal tori that extends to soft palate. What type of major connector to use? Horseshoe, AP, Palatal strap (unless option to remove)

QUESTION: Reason for splint in palatal torus removal: Prevent infection, flap necrosis, hematoma formation (for sure hematoma, others?)

QUESTION: Mandibular tori in first premolar and canine. If you were to remove the tori, would you have the patient sign an informed consent of lingual nerve injury? Yes

FACEBOW TRANSFER & PLASTER INDEX

*QUESTION: To approximate hinge axis what do you use? Face-bow

*QUESTION: What does the facebow do? Translates the relationship of the maxilla to the terminal hinge axis using a 3rd point of reference

QUESTION: Primary purpose of plaster index of occlusal surface of max denture before removing the denture from the articulator and cast: Preserve face-bow transfer

QUESTION: Why take plaster index? Teeth are then put back exactly in their original position aided by plaster key QUESTION: You delivered a set of complete dentures. Why do you take impression of max denture and mount it to articulator? (clinical remount): So you don’t have to take facebow registration again (preserve facebow)

*QUESTION: Lab & clinical remount, why are they done? Establish and maintain VDO and correct errors in capturing VDO Remounts are done if CO needs to be corrected or if VDO is incorrect • To correct errors in occlusion that have occurred during processing • To return dentures to correct VDO • To restore centric and bilateral balanced occlusion

QUESTION: Dentist mounted maxillary cast without using facebow, but now wants to increase vertical dimension 4mm. What should be done? a. Open articulator 4mm (adjust articulator) b. Get new CR (most anterior superior) c. Take new facebow d. Lateral movements e. Change condylar inclination f. Increased VDR

QUESTION: What should you do if VDO was increased after mounting? New CR and Remount

SOUNDS & VDO/VDR

S sound = closest speaking space; distance between incisal edges of mandibular incisors to palatal surfaces of maxillary incisors; gives VDO of speech (important when evaluating VDO)

F/V sounds = maxillary incisal edge position relative to the wet-dry line of the lower lip

M sound = made by contact of the lips; useful in bringing the mandible to its rest position

QUESTION: At what appointment do you check the proper placement of teeth? Teeth try-in *QUESTION: When do you check for sibilant sounds? Teeth try-in QUESTION: At what visit do you test phonetics in complete denture? Teeth try-in QUESTION: When do you check phonetics for a CD/CD? Wax try-in/Teeth try-in

QUESTION: Making F sound – Teeth touches lip (labiodental)

*QUESTION: At denture try-in, where would the teeth touch compared to vermilion border when saying “F” sound? They would just contact (Labiolingual center to the posterior third of the lower lip = wet-dry line)

*QUESTION: What sound will a patient have trouble with if the upper anterior teeth are too superior and forward for denture teeth? F and V QUESTION: Too labially placed upper anterior teeth. What sounds are hard to say: Fricative (F-V)

QUESTION: What sound do you use to check if VDO and anterior teeth are set correctly for denture teeth? S sound QUESTION: Asked about what sound will determine VDO? S sound. This will bring teeth slightly together with 1-1.5 mm separation. QUESTION: S, z, and -ch sounds the teeth must be: Close together or far apart QUESTION: When the denture wearer says “S” sounds & the posterior teeth are touching, why? Excessive VDO (need to decrease)

QUESTION: Which position depends on patient’s posture (sitting up vs laying down)? VDR…other options are CR or VDO and something else)

QUESTION: Patient has short lower face and sagging lips. What should you do? Increase VDO

QUESTION: Patient has clicking with dentures. What could this be due to? Inadequate resting space, insufficient interocclusal distance, too little VDR, excessive VDO

• VDR = measurement when the mandible is in “physiologic” rest position. • VDO = measurement when the teeth or occlusion rims are in contact.

QUESTION: A patient who has a moderate bony undercut on the facial from canine-to-canine needs an immediate maxillary denture. There is also a tuberosity that is severely undercut. This patient is best treated by A. Reducing surgically the tuberosity only. B. reducing surgically the facial bony undercut only. C. reducing surgically both tuberosity and facial bony undercut. D. leaving the bony undercuts and relieving the denture base.

*QUESTION: An examination of a complete denture patient reveals that the retromolar pad contacts the maxillary tuberosity at the occlusal vertical dimension. To remedy this situation, which of the following should be performed a. Reduced the maxillary tuberosity by surgery b. Covers the tuberosity with a metal base c. Increases the occlusal vertical dimension d. Reduces the retromolar pad by surgery e. Omit coverage of the retromolar pad by the mandibular denture.

QUESTION: Immediate denture and has undercuts and tuberosity, what do you do? Remove tuberosity…remove both, don’t remove any?

QUESTION: Patient feels fullness of upper lip after delivery of complete denture: Overextended labial flange

TISSUE CHECK

QUESTION: After a couple of months of delivery of upper and lower complete, patient complains of burning of lower lip (mandibular ridge?)? Impinges of mental nerve…candida infection

QUESTION: You give patient a maxillary denture and they come back with generalized soreness under the denture. No sore spots or anything visible clinically, what's causing this? Significant malocclusion (gross occlusal misalignment) …allergy QUESTION: Soreness all along the ridges? Hyperocclusion QUESTION: Pt has general soreness along ridges from complete denture, what should you do? Adjust occlusion…reline

QUESTION: Pt has worn denture for 19 years, now he has a sore on buccal with swelling, what do you do? Relieve denture in area of sore and re-evaluate in 2 weeks…refer out, biopsy, cytology QUESTION: A 6x3 mm asymptomatic white lesion seen under old man wearing a denture for 19 years, what is first thing done at initial treatment? Adjust and check in one week • Relieve any trauma, watch for 2 weeks, then biopsy, when your biopsy, you can do incisional

QUESTION: What is the main reason for removing complete dentures at night? To allow tissues to rest QUESTION: Patient has mobile upper anterior maxillary tissue that is inflamed. Before making new denture, what do you do? A) Gingivectomy B) Apply conditioner to existing denture C) Make new denture that will immobile the existing tissue D) Something else

QUESTION: No posterior teeth & incisal wear on the anterior why? Absence of posterior teeth (loss of posterior support) *QUESTION: Reason for cheek biting with dentures? Inadequate horizontal overjet (lack of horizontal overlap of posterior teeth or insufficient VDO) …lack of vertical overlap, Increased VDO not enough horizontal overlap of posterior teeth, insufficient VDO

QUESTION: You fit new completed denture and the patient complains of cheek bite, what will you do? a. Grind buccal of lower teeth b. Grind buccal of upper teeth c. Grind lingual of lower teeth d. Grind lingual of upper teeth

DENTURE PROCESSING QUESTION: Which denture base is not light cured? a. Pressure formed b. Injectable molding c. Some other type of molding d. Pour or fluid resin technique QUESTION: A denture tooth falls off the denture after processing, why? There was residual wax

DENTURE SET UP

QUESTION: How far do we extend a maxillary complete denture? To the Hamular notch

QUESTION: Why don’t you set denture teeth on the incline up towards the retromolar pad? Because it dislodges the denture

QUESTION: Which of the following explains why mandibular molars should NOT be placed over the ascending area of the mandible? A. The denture base ends where the ramus ascends. B. The molars would interfere with the retromolar pad. C. The teeth in this area would encroach on the tongue space. D. The teeth in this area would interfere with the action of the masseter muscle. E. The occlusal forces over the inclined ramus would dislodge the mandibular denture.

QUESTION: During try-in of mandibular denture, you want to check for Full movement of the tongue and do all working movements

QUESTION: If teeth on the wax try-in don’t occlude like they did on the articulator what do you do? Remount, redo teeth set-up, and retry

QUESTION: What is the main benefit of immediate complete denture? Esthetics

QUESTION: When making a denture base, the hamulus is too close to the retromolar pad? Surgery…don't put base on hamulus don't put base on retromolar pad or increase vertical dimension? *QUESTION: In an edentulous patient, the coronoid process can a. Limit the distal extension of the mandibular denture. b. Affect the position and arrangement of the posterior teeth. c. Limit the thickness of the denture flange in the maxillary buccal space. d. Determine the location of the posterior palatal seal of the maxillary denture. e. That’s the area where the mandibular turns from horizontal to vertical

QUESTION: Coronoid process displace upper denture if: Distobuccal of maxillary is too bulky

QUESTION: What can the coronoid process do when mouth is opened? Dislodge denture (mandibular denture = masseter)

QUESTION: What will happen in mouth is opened while performing maxillary border molding? Coronoid process will block buccal extension

QUESTION: Best way to prevent speech problems in complete dentures? Keep teeth in same position

QUESTION: Made patient denture which shows to much of max teeth. There are 3 mm of freeway space. What would you do? a. Lift occlusal table? b. Decrease VDO? c. Remake complete denture?

QUESTION: You are correcting the VDO of a patient. Your articulator eminentia is originally set at 20 degrees but you later correct it to 45 degrees. What do you do next? a. Adjust Bennet angle, b. new centric relation record c. increase the VDO, others d. Decrease incisal guidance, or increase compensating curve

• Bennet angle is calculated using condylar incline so you can adjust Bennet angle too

QUESTION: If denture teeth were set to a 20-degree condylar setting, when the teeth need to be at 45 degrees, what will need to be changed? a. Incisal guidance increased b. Posterior cusps decreased c. Increase compensating curve

• Another acceptable answer would be decrease incisal guidance (to compensate for increase in condylar guidance). A steep condylar path requires a steep compensating curve or decreased incisal guidance

QUESTION: The condylar guidance is increased from 20 to 45 degrees, what do you do? Increase the compensatory curve

QUESTION: A patient presents for try-in evaluation of balanced occlusion of complete maxillary and mandibular dentures. A dentist notes that protrusive excursion results in separation of posterior teeth. This dentist can best correct this problem by A. changing the condylar inclination. B. increasing the incisal guidance. C. Increasing the compensating curve. D. using a flat plane cusp for the posterior teeth.

QUESTION: If protrusion of denture causes dislodging what do you do? Increase compensating curve

*QUESTION: While setting condylar inclination on articular using protrusive, what do you do with the pin? Remove the pin (lift up)

QUESTION: Incisal guide pin positioned up while checking protrusive, why? Determine condylar guidance

QUESTION: Reason for Incisive guide table? Anterior guidance • When making a guide table, lift the pin up about 2 mm

QUESTION: What is the best way to preserve the anterior guidance? Translating the horizontal & vertical relationship onto the incisal table

QUESTION: How do you determine the angle of the incisal table? By the horizontal plane (occlusal plane) of occlusion and a line in the sagittal plane between incisal edges of maxillary and mandibular central incisors (midline).

QUESTION: Which plane is most important on anterior guidance? Horizontal/occlusal

QUESTION: Patient with class III will have the mandibular incisal angle? Decreased or Increase

QUESTION: CASE: Lower natural anterior teeth, upper PFM anterior teeth. Lowers had incisal wear facts, what do you think this is due to? Heavy incisal guidance

A. Same patient: a picture of him doing incisal guidance, what is this patient doing? – Incisal guidance (lower teeth and upper teeth were at edge to edge position)

B. Same patient: when he does anterior guidance, what is happening to the TMJ? Translation (upper compartment)

QUESTION: If you have a retruded tongue habit with full denture, what results? Difficulty swallowing

*QUESTION: Border molding of lingual mandibular portion done by what movement? Wetting of lips with tongue

DENTURE MUSCULATURE:

QUESTION: Mandibular denture border sitting on what muscle due to its orientation of its fiber? Masseter *QUESTION: Posterior buccal extension of a mandibular complete denture is limited by: Masseter muscle QUESTION: What muscle can you impinge on with denture (mandibular?)? Masseter…medial pterygoid, or lateral pterygoid

QUESTION: The (mandibular) denture base completely covers (sits on) what muscle? a. Medial pterygoid b. Lateral pterygoid c. Masseter d. Buccinator (Fibers of buccinator and buccal shelf)

QUESTION: What muscle covers dentures flanges & doesn’t affect stability? Buccinator

*QUESTION: Denture will not be displaced by which muscle due to direction of fibers? Buccinator…masseter, lateral pterygoid, medial pterygoid

QUESTION: Which muscle will not interfere with the denture base? a. Buccinator b. Lateral pterygoid c. Masseter

QUESTION: When you are taking an impression for a lower denture, which muscle is on the lingual? Mylohyoid (should extend inferior but not lateral to mylohyoid) QUESTION: Which muscle helps border hold in the posterior lingual flange? Mylohyoid • Other muscles that help are: palatoglossus, superior pharyngeal constrictor, genioglossus (lingual border of mandibular impression) QUESTION: Mandibular complete denture can interfere with what muscle in lingual side? Mylohyoid QUESTION: Lingual flanges of a mandibular denture can be affected by which muscle? Mylohyoid

QUESTION: What determines lingual border of Mandibular impression? Superior Pharyngeal Constrictor and Mylohyoid Muscle • For buccal it is the masseter

QUESTION: What muscles help in retention of lower complete denture: Palatoglossus, Superior pharyngeal constrictor, Mylohyoid and Genioglossus

QUESTION: Denture outline in border molding affected on the lingual of mandible by what? Palatoglossus, Superior pharyngeal constrictor, Mylohyoid and Genioglossus

QUESTION: You would relieve a mandibular denture in the area of the buccal frenum to allow which muscle to function properly? Orbicularis oris

OVERDENTURES:

*QUESTION: How do you protect roots under an overdenture? RCT with cast copings

*QUESTION: What is not important for an overdenture? Clinical crown size

*QUESTION: Which teeth roots are retained under an overdenture? Mandibular Canine (dense bone areas) • Preference = canine->premolars->incisors->molars • Bilateral, symmetrical, with healthy attached gingiva, adequate perio support (>1/2 root in bone), limited/no mobility

QUESTION: What is the best way to treat the teeth of a tooth supported lower denture? Use metal copings to cover teeth

QUESTION: A patient has acromegaly and needs dentures. Which denture will not fit? Maxillary or Mandibular

QUESTION: If acromegaly is not controlled: Lower jaw protrudes (class III occlusion, may need to set-back mandibular)

QUESTION: Which of the following is the endocrine involvement that is related to the jaw deformity? a. Acromegaly b. Cherubism c. Albrights d. Paget’s

QUESTION: First sign of increased (we think in reference to VD) occlusion? TMJ problems…myofascial, attrition, abfraction

COMBINATION SYMDROME:

Kelly (combination) syndrome: specific changes cause by a mandibular Kennedy class I removable partial denture opposing a maxillary complete denture (5 characteristics): • Bone loss in anterior maxilla, overgrowth of maxillary tuberosity, papillary hyperplasia of hard palate, supraeruption of mandibular teeth, and bone loss under distal extension

Plummer–Vinson syndrome (PVS) also called Paterson–Brown–Kelly syndrome or sideropenic dysphagia: rare disease characterized by difficulty in swallowing, iron deficiency anemia, glossitis, cheilosis and esophageal webs.

QUESTION: Which is not a symptom of combination (Kelly) syndrome? Increased VDO

QUESTION: Guy has treatment plan that may be susceptible to combination syndrome, so what is the ultimate goal when you make his complete upper denture and lower RPD? Balanced occlusion on both anterior and posterior teeth of mouth in centric relation…other option was wanting balanced occlusion (didn’t mention ant vs post teeth, during excursive movement)

QUESTION: What is the most likely cause of the patients flabby anterior tissue (in relation to a case?): Caused by combination syndrome…caused by decreased VDO

QUESTION: A flabby, maxillary anterior ridge under a complete denture is frequently associated with A. V shaped ridges B. Class II patients C. Osteoporosis D. Retained natural mandibular anteriors

DISORDERS/SYNDROMES

QUESTION: What causes problems in babies in embryo? Teratogens (Any agent that can disturb the development of an embryo or fetus) Carcinogen

QUESTION: Definition of teratogen: Any agent that can disturb the development of an embryo or fetus. Teratogens may cause a birth defect in the child. Or a teratogen may halt the pregnancy outright.

MUSCLE DYSTROPHY

Muscular dystrophy: group of muscle diseases that weaken the musculoskeletal system & hamper locomotion. Characterized by progressive skeletal muscle weakness, defects in muscle proteins, and the death of muscle cells and tissue. Muscular dystrophy: muscle weakness, “long face” which is characterized by a lower vertical facial height and open bite/

QUESTION: Muscle dystrophy; after local anesthetic is most likely due to? Lidocaine toxicity, increase duration of action, increase onset, Can’t be supine

QUESTION: Pt w/ muscular dystrophy condition: Longer lower face with open bite

QUESTION: What can be seen on a patient with muscle weakness of the face? Cross bite, buccal tilting of molars, long upper face, Lower face with open bite

QUESTION: Considerations for muscular dystrophy: increase in dental disease if OHI is neglected, weakness of muscles of mastication (decrease biting force, open mouth breathing)

ADDISON’S DISEASE & OTHER ADRENAL DIEASES

Addison's disease (primary adrenal insufficiency/ Random fact: Kennedy had it!): chronic endocrine disorder, adrenal glands do not produce enough steroid hormones (too little cortisol & sometimes, insufficient aldosterone). • Symptoms generally come slowly & include abdominal pain, weakness, skin darkening and weight loss. • Adrenal crisis may occur with low blood pressure, vomiting, lower back pain, and loss of consciousness. An adrenal crisis can be triggered by stress, such as from an injury, surgery, or infection. • Tx: give cortisol

QUESTION: Acute adrenal insufficiency: Hypotension

*QUESTION: Addison’s shows up as what in the oral cavity? Pigmentation on buccal mucosa, Pigmentation of mucosa, Hyperpigmentation

QUESTION: Pheochromocytoma: neuroendocrine tumor in medulla of adrenal gland Excess catecholamines (ex. epi)

CEREBRAL PALSY:

Cerebral palsy (CP): group of permanent central motor/movement disorders that appear in early childhood, caused by abnormal development or damage to the parts of the brain that control movement, balance, muscle tone, and posture. Signs and symptoms vary & include: poor coordination, stiff muscles, weak muscles, and tremors. Other problems w/ sensation, vision, hearing, swallowing, and speaking.

QUESTION: Lots of questions on cerebral palsy (something about whether or not it is a developmental disorder) (2nd after autism)

QUESTION: CP patient - which is not true? a. 95% have cognitive impairment b. all bruxism c. Increase in periodontitis

QUESTION: Cerebral palsy – patient will have spastic oral mucosa during treatment.

QUESTION: Pt has involuntary uncoordinated movements with larynx problem? Cerebral palsy

QUESTION: Common finding in a patient with cerebral athetoid palsy: Anterior Teeth fracture a. Cerebral athetoid palsy: damage to basal ganglia, has both hypertonia/hypotonia

CLEFT LIP/PALATE:

• Orofacial clefts occur in 1:600 to 1:1000 live births • More common in male, 3:2 • Cleft lip more common in males, cleft palate more common in females • Most common in Asians, least common in African Americans • Cleft lip = lack of fusion between maxillary process and medial nasal processes (maxillary process and frontonasal process) • Cleft palate = lack of fusion between palatal shelves

QUESTION: Case: Black girl around 7 years old presents with unilateral cross bite; she had a cleft palate that was fixed. Palate in picture looks like a triangle and laterals are towards the palate.

A) What is the pigmentation? Racial pigmentation B) What is the most likely cause of the crossbite? Due to cleft palate… early loss of laterals,

*QUESTION: When does cleft lip and palate develop? 6-9 weeks in utero

*QUESTION: Patients with cleft lip and palate, what occlusion is mostly seen? Class III malocclusion

QUESTION: Pt had cleft lip and palate. Later in life during ortho analysis, what do you see? Deficient maxilla…normal mand

QUESTION: Most prevalent developmental deformity in Maxilla? Cleft Palate

QUESTION: What is more commonly seen? o Amelogenesis imperfect o Ectodermal dysplasia o Dentinogenesis imperfect o Cleft lip and palate

QUESTION: What is cleft palate class III? Soft, hard, lip, alveolar process

QUESTION: What mostly causes cleft lip/palate? Multi-factorial…genetic, autosomal dominant, autosomal recessive, environmental

QUESTION: All of the following are the reasons for closing a cleft lip except? Support the premaxilla on a unilateral cleft Help speech Support the ala of the nose

QUESTION: Speech problems associated with cleft lip and palate are usually the result of? Inability of soft palate to close air flow into the nasal area

QUESTION: A cleft lip occurs following the failure of permanent union between which of the following? A. The palatine processes B. The maxillary processes C. The palatine process with the frontonasal process D. The maxillary process with the palatine process E. The maxillary process with the frontonasal (medial nasal prominence?) process

QUESTION: Age for repair of cleft palate w/ normal canine eruption: When canine tooth is ¾ formed (8-9years old) (AID says 12-18 months)

QUESTION: When correcting cleft problem, how do you end/finish? Suturing lip

*QUESTION: Percentage of cleft lip and cleft palate in Caucasians? 1/750 • Asians = 1/500, Asians have it the most common

QUESTION: Cleft lip is seen in how many Americans? 1/300. 1/700. 1/1100, 1/1500

QUESTION: Cleft palate is seen in how many Americans? 1/300. 1/700. 1/1000, 1/1500

QUESTION: Incident of cleft palate & lip in US - 1 in 1000 vs Incident of cleft palate w/out lip in US – 1/2000 (CDC 2012)

QUESTION: Patient was Angle’s Class I according to molar relationship but Skeletal class III because of ANB and cleft palate

QUESTION: What surgery will a pt with cleft palate most likely need? Move mandible back (mandibular set back) …move maxilla up, • Pt get cleft lip & palate surgery. This usually causes future Class III tissues so at later age, they need to come back to move the mandible to correct Class III (mandibular setback)

*QUESTION: How does a kid with fetal alcohol syndrome present with? Cleft lip…anencephaly, midface deficiency

TREACHER COLLINS SYNDROME:

Treacher Collin’s Syndrome: autosomal dominant. Usually presents w/ cleft palate, shorten soft palate, malocclusion, anterior open bite, enamel hypoplasia An inherited condition in which some bones and tissues in the face aren't developed.

QUESTION: Which disorder has the least developmental delay? Treacher Collins syndrome

*QUESTION: Treacher Collins has loss (hypoplasia) of zygomatic bone. What do patients with cleidocranial dysplasia have? Loss of clavicle

QUESTION: Describes patient saying they have mandibular hypoplasia, malformed ear, lower eyelids, ear pinna – Treacher Collins

QUESTION: Treacher Collins syndrome → know pt's are not mentally retarded and they have ear abnormalities

DOWN SYNDROME/BIRTH DEFECTS: Trisomy 21/Down Syndrome manifestations: o Mandibular prognathism o Thickened tongue (macroglossia) o Midfacial hypoplasia Class III profile o Delayed eruption of teeth o Supernumerary teeth o Doesn’t have a higher chance of caries but does have a higher change of periodontal disease

*QUESTION: What is true of patients with Down Syndrome/trisomy 21? Lower incidence of dental caries b. Immune protection: elevated salivary S. mutans specific IgA

*QUESTION: What is a characteristic of patients with Down syndrome? midfacial hypoplasia

QUESTION: What ortho manifestation does Turner syndrome and trisomy 21 associated with? short midface

QUESTION: What is orbital hypertelorism? Wide-set eyes (seen in Crouzon, Cleidocranial dysostotosis, Gorlin Syndrome, Down’s syndrome)

*QUESTION: Hypertelorism definition: Increased distance between eyes, or other body parts

QUESTION: Which does NOT result in delayed development? Trisomy 21, Trisomy 18 (Edward syndrome), Hurler Syndrome (mucopolysaccharides), Cru di Chat c. Edward’s syndrome: small head (microcephaly) accompanied by a prominent back portion of the head (occiput), low-set, malformed ears, abnormally small jaw (micrognathia), cleft lip/cleft palate, upturned nose, narrow eyelid folds (palpebral fissures), widely spaced eyes (ocular hypertelorism)

BONES AND SUTURE LINES:

QUESTION: What resembles epiphyseal plate? Synchondrosis d. Synchondrosis: almost immovable joint between bones bound by layer of cartilage (ex. vertebra, epiphyseal growth plate)

QUESTION: What age does the mandibular symphysis close? 6-9 months e. Symphysis: two flat bones grow together & join

QUESTION: Sphenooccipital closure, what kind of tissue fills it in? Cartilage f. Interstitial growth – occurs by the mitotic division and deposition of more matrix around chondrocytes already established in the cartilage. Ex – CONDYLE, nasal septum, and spheno-occipital snychondrosis

QUESTION: Which of these undergo suture closure latest? • sphenoethmoidal • Sphenoccipital • Intrasphenoid • Intraoccipital

QUESTION: What is synostosis? ABNORMAL FUSION OF BONES

QUESTION: What is craniosynostosis? Early closure of suture between bones

CROUZAN SYNDROME:

Autosomal dominant, 1st brachial arch syndrome, mutation in fibroblast growth factor receptor II fibrous joints between certain bones of the skull (cranial sutures) close prematurely (craniosynostosis).

BEATEN METAL SKULL

Crouzon’s syndrome Most notable characteristic of Crouzon syndrome is cranial synostosis, but it usually presents as brachycephaly, which results in the appearance of a short and broad head, exophthalmos or proptosis (bulging eyes due to shallow eye sockets after early fusion of surrounding bones), hypertelorism (greater than normal distance between the eyes), hypoplastic maxillary, & mandibular prognathism

*QUESTION: Synostosis – early/late closing of sutures - Crouzon syndrome

QUESTION: Patient w/ deficient mid-face, proptosis, etc? Crouzon syndrome

QUESTION: Pt has ocular proptosis, , premature suture closing (synostosis)? treacher-Collins Crouzon Pierre robin cleidocranial

HURLER & HUNTER’S SYNDROME:

Both are lysosomal storage disease (MCUOPOLYSACCHARIDOSIS) HURLER SYNDROME (mucopolysaccharidosis type I (MPS I), gargoylism): autosomal recessive disorder due to buildup of glycosaminoglycans (GAG, formerly known as mucopolysaccharides) due to a deficiency of alpha-L iduronidase, an enzyme responsible for the degradation of mucopolysaccharides in lysosomes heparin sulfate and dermatan sulfate occurs in the body.

HUNTERS SYNDROME (mucopolysaccharidosis II (MPS II)): genetic X-linked recessive disorder, due to defect in anchoring between the epidermis and dermis, resulting in friction and skin fragility. Deficiency in enzyme iduronate 2-sulfatase (I2S) also, leading to GAG build up.

QUESTION: Hurler and Hunter’s syndromes, what do they have in common? They both have mucopolysaccaridosis & buildup of GAGs

QUESTION: Mucopolysaccharosis is a common finding in Hurler and Hunter syndrome

QUESTION: Hunter syndrome has what? Lysosome storage disease. Get abdominal hernias, ear infections, prominent forehead, enlarged tongue, ID, stiff joints

CLEIDOCRANIAL DYSPLASIA: • Delayed ossification of midline structures

QUESTION: What is the most significant finding in cleidocranial dysplasia? Supernumerary teeth…odontoma, sparse hair, multiple impacted teeth, retained teeth (also seen)

QUESTION: Cleidocranial syndrome: X ray with absence of clavicle

QUESTION: Which will give you very narrow facial structures and delayed eruption of permanent teeth? • Cleidocranial syndrome • Downs syndrome

QUESTION: Many questions (5) on Cleidocranial dysplasia: Multiple unerupted supernumerary teeth, Retention of primary teeth, delayed eruption of permanent teeth, Missing clavicle

QUESTION: What allows for compression of skull during birth (change shape)? Fontanelles • Fontanelles close anterior 12-18 months, posterior 3-4 months

PAPILLON LEFEVRE SYNDROME:

Papillon–Lefèvre syndrome (PLS) - palmoplantar keratoderma w/ periodontitis. It’s an autosomal recessive disorder caused by a deficiency in cathepsin C. g. Severe perio early/young loss of primary & permanent teeth after eruption of 1st molar h. Hyperkeratosis of palm & feet sole

QUESTION: 15 yr. old w/ edentulous and keratosis on hands and feet. They gave ugly picture of thick soled feet. Papillon Lefevre syndrome

QUESTION: What is Papillon–Lefèvre syndrome? You get periodontitis, keratosis on hands and soles, and premature loss of primary teeth.

QUESTION: Hyperkeratosis in hands and feet – Papillon-Lefevre Syndrome

PIERRE ROBIN SYNDROME:

Pierre Robin Syndrome: unknown cause. Characteristics: micrognathia, (tongue falls back in the throat, hard to breath), high arch palate, cleft palate, and absent gag reflex. Teeth appear when baby is born.

*QUESTION: Pt has glossoptosis, micrognathia, and cleft palate? Pierre Robin syndrome a. Glossoptosis = refers to the downward displacement or retraction of the tongue

QUESTION: Triad of cleft palate, glossoptosis and absent gag reflex. What is it? Pierre-Robin Syndrome

WEBBER SYNDROME:

Sturge-Weber syndrome: neurological disorder present at birth. Characterized by a port-wine stain on the face and brain or eye abnormalities due to overabundance of capillaries near skin surface. Sometimes seizures or neurological symptoms

QUESTION: Sturge-Weber syndrome? vascular malformation, eye and hemangioma

*QUESTION: Sturge Webber syndrome: Port Wine Stain

QUESTION: Sturge Weber syndrome – port wine stain; Angiomatosis of leptomeninges

METABOLIC SYNDROME

QUESTION: Pt has high cholesterol, hypertension and diabetes, metabolic problem, which does he have: metabolic syndrome

QUESTION: Pt has BMI of 36, is overweight & has high cholesterol. What syndrome? Metabolic Syndrome

QUESTION: What is the normal % fat intake per day- 30% zz. Recommended daily dose of fat: 30% of total calorie and saturated fat is 10% of daily calorie intake

THYROID & PARATHRYOID DISEASE

THYROID DISEASE:

*QUESTION: Which is not endocrine gland? Parotid…parathyroid, thyroid, adrenal

QUESTION: Which do you give a hyperparathyroid child for normal development of teeth? Vitamin D (Brings in Ca+)

QUESTION: Thyrotoxicosis symptoms – Diaphoresis (sweating), fever, hypertension and tachycardia, delirium • Thyroid storm is a severe version of thyrotoxicosis

QUESTION: Thyrotoxic pt. manifestation? Tachycardia

QUESTION: LA with epinephrine contraindicated in? Hyperthyroidism, uncontrolled diabetes, hypothyroidism

*QUESTION: Symptoms of hypothyroid attack: Loss of brain function due to severe, longstanding low levels of thyroid hormone in the blood • Hypothyroidism primary symptoms are altered mental status, hypothermia, hypoglycemia, hypotension, hyponatremia, hypercapnia, hypoxia, bradycardia, hypoventilation may also occur.

*QUESTION: Myxedema is due to? Severe hypothyroidism • Myxedema: swelling of skin, waxy consistency

QUESTION: With which endocrine systemic disease does thick hair become thin hair? Hypothyroidism

*QUESTION: PT was gaining weight, has lower voice, fine hair, feels cold – Hypothyroidism • Symptoms of hypothyroidism: weight gain, bradycardia, cool to touch/cold, fatigue

QUESTION: Which thyroid drug doesn't let iodine bond to hormone? Radiated Iodide (for hyperthyroidism)

QUESTION: Graves’ Disease (Hyperthyroidism) - Exophthalmos

QUESTION: Thyroid hormone decrease, which drug do you give? Levothyroxine (for hypothyroidism)

PARATHYROID DISEASE & HYPOPHOSPHATASIA

Hypophosphatasia - metabolic bone disease, low alkaline phosphatase

*QUESTION: Increase in alkaline phosphatase is related to? Hyperparathyroidism

*QUESTION: Decreased alkaline phosphatase is related to: Hypophosphatasia

QUESTION: What disease causes decrease in alkaline phosphatase? Hypophosphatasia, Malnutrition, Hypothyroidism, pernicious anemia

QUESTION: Central Giant Cell Granuloma is seen with pts with which condition? Hyperparathyroidism

QUESTION: Osteoporosis is associated with which of the following diseases? Hyperparathyroidism

ETHICS & PATIENT/PRACTICE MANAGEMENT

Ethics:

• Beneficence- “Do good”. • Patient Autonomy- “Self-governance”. • Non-maleficence- “Do no harm”. Dentists are to keep skills and knowledge up-to-date and practice within their limits in order to protect the pt from harm. • Justice- “Fairness”. • Veracity- “Truthfulness”.

LOTS OF ETHICS QUESTIONS: what to say what to do in these situations. If your patient is looking around a lot at your masks and gloves, safety equipment, what’s the most appropriate response? Some of the answers are vague. (YUP –Vic)

ETHICS PRINCIPLES:

QUESTION: Tell patient that he needs to take of amalgam fillings because they are not good for his health (hazardous): Not practicing veracity (truthfulness)

*QUESTION: Pt presents with amalgam restorations in good shape and the dentist suggest to change them for composites due to systemic toxicity of the amalgam. What ethic principle is the dentist is violating? Veracity

QUESTION: What principle has to do with a patient’s self-governance & privacy? Autonomy

*QUESTION: Something about dentist needs to keep up to date with new technology and learn and practice new procedures: Non- maleficence

QUESTION: Dentist refers a difficult case to a specialist, what ethic principle is this? Non maleficence • Having non-maleficence is knowing your limitations and referring patients out to specialist

INFORMED CONSENT:

*QUESTION: Informed consent = autonomy

*QUESTION: Informed consent – figure out if patient is able to understand and sign

QUESTION: What you do first before getting informed consent? make sure patient can sign or has guardian, consult physician, discuss options with relatives, etc.

*QUESTION: 82 y/o pt comes w/ younger person who hands the dentist paper saying the pt has a legal guardian. Now what? You must have consent of this guardian before treating the 82 y/o pt.

QUESTION: The 16 yr. old can take the decisions for the elder pts if: If the elders are deaf and dumb, if the boy makes the payment, if the elders are over 60yrs, if the kid has the power of an attorney

QUESTION: Consent - do not need to discuss the witness signature (I think)

QUESTION: When should patient sign informed consent forms for surgery? AFTER there has been a discussion w/ the dentist about the surgery

QUESTION: Inform consent must contain all except: Cost of Tx

QUESTION: If you don’t obtain informed consent, what kind of offense is this? Battery

QUESTION: Emancipated minor: if the kid is under 18, know exceptions of how they become emancipated minor 1. Emancipated minor assumes most adult responsibilities before reaching the age of majority (usually 18). If she/he graduated from high school, has been married, has been pregnant, or responsible for his or her own welfare and is living independently of parental control and support.

QUESTION: How is FACT witness is different from expert specialist? 2. Fact witness = individual, who has personal knowledge of events pertaining to the case & can testify as to things they have personally observed or witnessed. They may not offer opinions, which are the province of the expert witness 3. Expert witnesses offer opinions, unlike a fact witness, that may assist the judge in understanding technical knowledge in order to support their ability to make a sound ruling in a case. An expert witness can be a credentialed specialist in fields.

EMOTIONAL RESPONSE:

Apathy- indifferent Empathy- to walk in their shoes, share the emotional state they are feeling Sympathy- to be concerned about someone, do not have to share the same emotional state as them.

QUESTION: Child came with a history of aggressive behavior and is crying, then should the dentist show empathy or sympathy or control

QUESTION: Rapport best with: empathy; other choices were sympathy, compassion

QUESTION: What best characterizes rapport? Understanding patient’s feeling and talking with patient

QUESTION: Definition of rapport? mutual openness / harmonious relationship Rapport = mutual sense of trust and openness between individuals that, if neglected, compromises communication. Rapport: a close and harmonious relationship in which the people or groups concerned understand each other's feelings or ideas and communicate well.

QUESTION: A successful practice is built on - friendship COMMUNICATION? Good clinician-patient relationship

QUESTION: What is the best to communicate with patient- apathy, empathy, or some other stuff

QUESTION: Empathy is not: shared personal experiences, Imagination, understanding

QUESTION: Which do you not need to show empathy to the patient? a. open-mindedness b. sharing personal experiences** c. reflection and showing understanding

QUESTION: Definition of Empathy – Patient wanted to give you paperwork, and you acknowledge their concerns

QUESTION: When should the dentist NOT use para-phrasing? a. When trying to speak to a patient in his second language b. When the dentist is upset with what patient says c. when giving factual values

QUESTION: Finding out whether a pt is listening: Eye contact

QUESTION: Which statement is NOT correct about “Paraphrasing”? to put in your own words Paraphrasing: repeating, in one’s own words, what someone has said. This serves to confirm one’s understanding, validate a patient’s feelings, convey interest in the patient’s experience (thereby building rapport), and highlight important points.

QUESTION: Patient complains of pain in relation to a particular tooth. The best answer/reply of the dentist would be: If you came here earlier things would not be bad If you took more care this would not have happened I will take care of everything

QUESTION: While the dentist is preparing a large carious lesion in Tooth #30 for a restoration, a pulp exposure occurs. The patient angrily shouts at the dentist, "Your incompetent 'creep'- -you're responsible for this problem!"- Of the following possible responses the dentist could make, which one is the most emphatic?

A. Calm down, I can still restore your tooth adequately. B. Not when I'm preparing a tooth with caries like you had. C. I can see that you're very upset. You thought the tooth could be restored and now this problem has occurred. D. If you took care of your mouth the way you should, I wouldn't have been close to the pulp. E. I'm sorry this happened, but we must get on with the procedure.

QUESTION: When the dentist enters the operatory, the patient, who is new to the office, stands close to the wall, has his arms folded, and is looking at the floor. The dentist should initiate communication by saying which of the following? A. Let's get going; I've got a lot to do. B. What are you angry about? C. Didn't my assistant get you seated? D. You seem uncomfortable; did you have a bad dental experience? E. Hi, I'm Doctor Wilson, what brings you here today?

*QUESTION: Pt complains of high fees of dentist, how should the dentist answer? Fee is fine according to the geographic area, it is fair and reasonable, I have to make a living too

QUESTION: Patient says, “I’ve been brushing like you showed me but I still have cavities.” What do you do? ➢ Go over OHI? ➢ Tell him you understand that it is frustrating?

QUESTION: The closest a dentist should get to their patient is? Tap their shoulder

QUESTION: Reason to not have parent in room with dentist and kid? Communication barrier between dentist and child, OSHA violation, HIPAA violation,

QUESTION: Health behavior: Precontemplation/contemplation/action definition

Precontemplation stage of change are not even thinking about changing their drinking behavior. They may not see it as a problem, or they think that others who point out the problem are exaggerating.

Contenplation: Individuals in this stage of change are willing to consider the possibility that they have a problem, and the possibility offers hope for change. However, people who are contemplating change are often highly ambivalent. They are on the fence. Contemplation is not a commitment, not a decision to change.

QUESTION: Pt. says, “I do not have time to quit smoking.” What stage is s/he in? A: Precontemplation, contemplation, action, denial SMOKING Nicotine Replacement Therapy (NRT) Method Availability Description Over-the- Nicotine Patches The nicotine patch is placed on the skin and gives users a small and steady amount of nicotine. Counter Over-the- Nicotine gum is chewed to release nicotine. The user chews the gum until it produces a tingling feeling, and Nicotine Gum Counter then places it between their cheek and gums. Nicotine Over-the- Nicotine lozenges look like hard candy and are placed in the mouth. The nicotine lozenge releases nicotine as Lozenges Counter it slowly dissolves in the mouth. A nicotine inhaler is a cartridge attached to a mouthpiece. Inhaling through the mouthpiece gives the user a Nicotine Inhaler Prescription specific amount of nicotine. Nicotine Nasal Prescription Nicotine nasal spray is a pump bottle containing nicotine, which is put into the nose and sprayed. Spray Other Quit Smoking Medications Method Availability Description Bupropion, also known as Zyban®, helps to reduce nicotine withdrawal and the urge to smoke. Bupropion can be used safely with NRT. Also for depression. Bupropion Prescription C.I. contraindicated in patients with a seizure disorder, current or prior diagnosis of anorexia nervosa or bulimia, or undergoing abrupt discontinuation of alcohol, benzodiazepines, barbiturates, and antiepileptic drugs. Varenicline, also known as Chantix®, helps to reduce nicotine withdrawal and the urge to smoke. It also blocks the effects of nicotine from cigarettes if the user starts smoking again. C.I: Alcohol Intoxication, Depression, Increased Cardiovascular Event Risk, Coronary Artery Bypass Graft, Heart Attack, Varenicline Prescription Acute Syndrome of the Heart, Angina, Transient Ischemic Attack, Stroke, Peripheral Vascular Disease, Severe Renal Impairment, Seizures, Feel Like Throwing Up, Schizophrenia, Manic-Depression, Having Thoughts of Suicide, Habit of Drinking Too Much Alcohol. DON’T COMBINE WITH PATCHES

TYPES OF CONDITIONING:

Operant Conditioning: 4. Positive reinforcement: Positive consequence that increases behavior i. you brush, you get sticker 5. Negative reinforcement: Removal of negative consequence that increases behavior i. Stop pain from toothache, pt realizes he should brush 6. Positive punishment: aversive Conditioning, negative consequence that decreases negative behavior i. every time you don’t brush, you have to clean your room 7. Negative punishment: Removal of positive stimulus in order to decrease an undesirable behavior i. don’t brush, no allowance 8. Operant extinction: child cries, don’t give attention (yeah this crap showed up –Vic)

Basically, know that reinforcement is more effective than punishment because in punishment, you have resentment, you avoid the punisher, and you are not taught positive behavior.

Most important component of systematic desensitization is exposure to fearful stimulus

QUESTION: During the child's first visit, the dentist requested that the parents wait in the reception room. The child cries moderately, but tearfully, throughout the dental examination and prophylaxis. The dentist "gave her permission" to cry while he/she worked and then took no notice of her crying. Her crying diminished in intensity over time and then stopped. With respect ONLY to the crying behavior, the dentist has A. used positive reinforcement. B. used negative reinforcement. C. extinguished the behavior. D. ignored the problem.

QUESTION: Pt with manic depression disorder that he/she is not willing to get treated for, is now getting dental treatment from you. What do you see in this patient: A) bipolar b) depression c) excitement?

QUESTION: Definition of Operant extinction? Removal of reinforcements in order to decrease a behavior • Disappearance of a previously learned behavior when the behavior is not reinforced.

QUESTION: Behavior shaping: Providing positive reinforcement for approximation of behavior you are desiring

QUESTION: Which describes a stage in Piaget’s model of cognitive development? I put preoperational.

Piaget proposed 4 stages of cognitive development: 1. Sensorimotor stage = extends from birth to the acquisition of language 2. Pre-operational stage = starts when the child begins to learn to speak at age 2-7. 3. Concrete operational stage = ages of 7-11 (preadolescence) years, characterized by the appropriate use of logic 4. Formal operational stage = adolescence and into adulthood, roughly ages 11-20, intelligence through the logical use of symbols related to abstract concepts.

QUESTION: A behavior modification device (ie thumb sucking deterrent) is an example of: POSITIVE PUNISHMENT (negative consequence that decreases negative behavior)

QUESTION: Patient is given oral habit reducing appliance to prevent an oral habit, what is this considered? POSITIVE PUNISHMENT

QUESTION: Providing reward for desired behavior: Positive reinforcement

QUESTION: Eye contact, smiling, and telling pt doing good job (praising) is what type? Social reinforcement

QUESTION: Desensitization works if the base of the behavior problem is Fear

*QUESTION: Main disadvantage to desensitization? Time

QUESTION: Classical conditioning, which is an example? – Pain (as in, you see dentist, you assume pain is coming) What is an example of stimuli in classical conditioning: Dentist (all others were responses)?

QUESTION: What is an example of conditioned stimuli with pt that have had previous bad experiences? dental chair (all others were responses)

QUESTION: Conditioned stimulus? a. Dental chair b. High blood pressure c. Fear d. Anxiety

*QUESTION: How to deal with angry patient? Listen and validate emotion, agree with patient, ignore anger then investigate after

PEDIATRIC BEHAVIOR MANAGEMENT:

QUESTION: How to reduce stress & dental anxiety? Tell-show-do

QUESTION: Based on Frankl behavioral rating scale, what is the rating that indicates positive rapport with dentist? Rating 4

QUESTION: 6-year-old intellectually disabled child. Treatment is a recall. Would you give sedation, antianxiolytic, voice control or positive reinforcement? • With ID, you want to be short and brief, explain things, tell-show-do, and REWARD. Positive reinforcement.

QUESTION: What is the best way to treat a developmentally disabled patient? Consistency • Disabled pt, should be treated by flattering, permissible, consistency

QUESTION: Autistic kids have what characteristic? Repetitive behavior

QUESTION: Disable patient comes in and not cooperative, how should you act? Permissiveness (give patient freedom & treat in the way patient feel comfortable)

QUESTION: Patients with autism will usually show? a. decreased rate of caries b. heightened sense of lights and sounds c. the compassion to interact with people 9. Children with autism are easily overwhelmed by sensory overload, which can cause “stimming” (flapping of arms, rocking, screaming, etc.). 10. Autistic children are hypersensitive to loud noises, sudden movement, and things that are felt.

QUESTION: Child patient – you smile, tell him good job, and pat him on the shoulder. These are examples of negative reinforcement, social reinforcement, or token reinforcement.

QUESTION: If kid complained and whined in the beginning but at the end, is very good: you compliment how well they were at the end of the procedure.

QUESTION: Voice control method used with children’s - Aversive conditioning (punishment to deter unwanted behavior, ex. hand over mouth)

QUESTION: What is the purpose of the voice control technique? Sets boundaries Aversive conditioning

*QUESTION: 8-year-old patient, 1st dental visit ever, scared of dentist? What’s the most likely answer? a. Television b. Parents c. Peers

QUESTION: If a child is afraid, allow the child to express fears

QUESTION: How do you treat a fearful child? use sedation, let him watch another patient,

QUESTION: Young patient is scared b/c he has no control what to do? tell him to raise his hand if he needs a break/ you to stop

QUESTION: A kid is on recall appointment and is not cooperative. You should do voice control followed by? Alternating appraisal

QUESTION: Patient is very young and fearful first time you meet them – try to talk to them, go down at their height.

QUESTION: Patient 2 yrs. old and scared, who do you ask to help position the patient? ask parent to position patient for you get assistant to do it you do it yourself

QUESTION: The restraining of uncooperative 2 yr. child should be done by. Dentist, Assistant, Parent

QUESTION: 4-year-old kid, best position? Knee to knee with head on dentist lap Knee to knee with head on parent’s lap

QUESTION: Patient comes in with 1-year-old child, how do you do exam? Parent and dentist are knee to knee, baby's head is in dentist's lap

QUESTION: 8-year-old boy, when will he behave better? Mom inside the dental office Dad inside the dental office Nobody inside

*QUESTION: What is a 2 yr. old most afraid of? 4 yr. old? • 1-3 yr. old: SEPARATION • 4-6 yr. old: UNKNOWN Pediatric fears correlated with age

QUESTION: Uncooperative 2-year-old, what are they scared of? Separation anxiety

QUESTION: 4-5-year boy is scared of? Unknown

QUESTION: You help a child help recognize what they are afraid of and make outward positive connection: Cognitive restructuring (psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts)

*QUESTION: Behavior Modeling: When the kid is afraid and you use a sibling or someone older to show how they should behave

QUESTION: A 4 yr. old child management? Empathy sympathy and respect

QUESTION: Replacing words like LA with sleepy juice is called as Euphemism (relabeling)

QUESTION: Pedo 1st visit. Multiple carious teeth on anteriors. During anesthesia is well cooperative and doesn’t cry or move. Once begin tx, begins to cry. What do. o Keep working o Voice control o More anesthesia o Oral sed o N20

ANXIETY:

Fear: results from anticipation of a threat arising from an external origin.

Anxiety: results from anticipation of a threat arising from an unknown or unrecognized origin. Anxious patients are the most difficult patients as they often cause the dentist to become anxious as well.

*QUESTION: Difference between fear and anxiety – anxiety has no specific cause (generalized), fear has a localized cause, fear decreases pain and anxiety increases pain, fear is painful, anxiety is a disease

QUESTION: Dental anxiety can be caused by patient’s helplessness. What would reduce it? Telling the patient to raise her/his hand when feels pain

QUESTION: A patient is going to the dentist and has never had local anesthetic. He recently got a flu vaccine and is now afraid of needles. The fear is due to what? Location Generalization Translation

QUESTION: Define anxiety according to Freud and K: aversive inner state that people seek to avoid or escape

QUESTION: What do Freud and Erikson say about anxiety? Inability to overcome a conflict in a particular stage that will lead to anxiety. Inadequate resolution becomes anxiety 11. An inadequate resolution would indicate a child's insecurity and anxiety. 12. An Adequate Resolution would mean that a child was able to overcome the conflict in each stage and develop properly. This applies similarly to the other 8 stages.

QUESTION: Patient has dental fear, what is most likely due to? previous traumatic dental procedure

QUESTION: What would most cause a man to have anxiety? traumatic past experience, or finances, peers, unpleasant staff

QUESTION: Constantly exposing the pt to get from the fear factor is desensitation

QUESTION: Systematic desensitization- 3 steps: Construct a hierarchy, relaxation exercises, associate components of hierarchy with relaxation state

QUESTION: Panic attacks usually produce a sense of unreality, a fear of impending doom, or a fear of losing control.

OTHER PARTS OF THE ADA ETHNICS CODE: FEES, ADVERTISING/MARKETING, CREDIENTIALS

Fees (discusses overbilling), Advertising & marketing, ethics (patient values & harm), credentials (dentist cannot state they are certified in a specialty when they’re not) Not included: List of credentials needed to be a dentist, licensure

*QUESTION: What is not included in the ADA code of ethics? • Licensure by credential • Advertising • patient values • Fees ▪ Credential needs to be a dentist (licensure)

QUESTION: What cannot be advertised by a general dentist? a. Cost b. Specialty c. License agreement

*QUESTION: A dentist has an ethical obligation to report a colleague in all these situations except? a. working under substance abuse b. advertising on electronic media c. abusing patients

QUESTION: if you find problems with a medical conditions and a certain drug (interaction), who do you contact? OSHA, FDA, EPA

QUESTION: If there is an adverse reaction to a medication in the office, who do you notify? a) FDA b) CDC c) HIPPA d) OSHA e) EPA.

QUESTION: Asked which statement was correct for HIPPA? Must give privacy form to pt but you don’t need confirmation of receipt, fax and email standard, etc.

QUESTION: What’s not the reason for rising dental costs? Number of dental students in dental schools

INSURANCE & GOVERNMENT DENTAL CARE:

Medicaid – income based Medicare – age based (elderly, > 65 y/o) States & federal government share in the cost of Medicaid, States may pay health care providers directly on a fee-for-service basis or states may pay for Medicaid services through prepaid, capitated payments to health plans or other entities. Within federally imposed upper limits for certain services, each state has broad discretion to determine the payment method and payment rate for services

Pt pays for service fee/insurance pays the rest: • Insurance pays a flat fee/patient pays the rest – co payment • Provider is paid per patient not per procedure – capitation • HMO – limited to selection • PPO – allows patient selection

HMO’s – dentists are paid a fixed rate for each individual per month. Dentist is paid regardless patient was seen or not. If value of services exceeds payments, dentist’s loss. If payment exceeds value of services, dentists gain.

QUESTION: What does Medicaid cover? Extractions, one-time denture, children until 18.

QUESTION: If you need a medical record from your patient’s physician, your patient needs to give you a permission to do that. Based on which principal/policy? I picked Medicaid/Medicare because the choices were CDC, OSHA, blood borne, some random nonsense. There wasn’t HIPAA

QUESTION: What sector of government provides funding for dental care? Medicaid, Medicare, grant, HMO

QUESTION: Who pays for Medicare: Federal program that pays for covered health services for most people 65 years old and older and for most permanently disabled individuals under the age of 65.

QUESTION: Government spends most of the money in Medicare, Medicaid, HMO.

QUESTION: Medicare is a federal program that provides health care for elderly. It does not cover dental. Answer: Both statements are true

QUESTION: Most aid for finance: Medicaid, Medicare, and HMO

QUESTION: Most dental procedures for the elderly are paid for by out of pocket cash.

QUESTION: Which of the following is the leading payer for dental treatment? Insurance or self-pay

QUESTION: Who pay for most of dental care? a. government b. insurance c. cash patients

QUESTION: Majority of health service in USA: private insurance

QUESTION: who pays most of dental Tx: 56% patients, 33% third parties private insurance

QUESTION: 73yo woman makes $23,000/year. how should she receive dental care? • Medicaid • Medicare • Private insurance

QUESTION: A 65 yr. old lady living on 40k pension per year, wants to get dental treatment. She does not have any other physical abnormality besides tooth pain in her molars. From where does the money covered for her treatment come from? a. Medicaid does not cover dental for adults b. Medicare. - does not cover dental for elders c. Private Insurance - private dental IF she has it d. Others insurance.

*QUESTION: What is the name of the federal funded medical care for the elderly and its coverage? a. Medicare wI dental coverage b. Medicare w/o dental coverage c. Medicaid wI dental coverage d. Medicaid w/o dental coverage

QUESTION: Insurance question about adverse selection (adverse selection deals with the idea that those at higher risk are more likely to buy an insurance policy. If the price for the policy is the same for nonsmokers and smokers, it is more likely that smokers will buy the insurance, because it is more “worth it” to them—because they are at higher risk for disease. This is averse to the insurance. So the prices need to be different. • only take pt with high risk • only take pt with low risk • take both • something about taking pt of all ages

QUESTION: Know about capitation: Dentist is paid a fixed fee to see patients enrolled in program; HMO = capitation dental plan

QUESTION: You work at a HMO office and the patient has used up all his yearly benefits, what can you do? a. still accept the same fee under the HMO* this is what I put, but I don’t know b. Charge your regular fee like you would for cash pt

QUESTION: Your office is fee schedule and pt needs new crown but pt used up all of her allowance (or something like that)? what do you do? Charge the same fee

QUESTION: Which one is related to employee insurance, where you get a discount from the insurance and also you can go to a dentist of your preference? PPO, HMO

QUESTION: Insurance allows pt to only see certain set of providers…. PPO, HMO, Closed panel

QUESTION: Which one is related to a dental insurance, that only allows you to go to a group of dentists at a specific location? – Closed Panel (other choices were open panels and other things)

QUESTION: Company offers dental insurance to its employees that can go to selected dentist, what is this example of? Closed panel

QUESTION: Which of the following represents a dental program in which eligible patients receive services at specified facilities from a limited number of dentists? A. An open-panel B. A closed-panel C. A capitation group D. A prepaid group

QUESTION: Direct Reimbursement: self-funded group dental plan in which the employee is reimbursed based on a percentage of dollars spent for dental care provided, and which allows employees to seek treatment from the dentist of their choice.

QUESTION: If you are an employer and you provide your employee with reimbursements for dental care they received from a dentist of their choice it is called: Direct reimbursement

QUESTION: patient goes to the dentist and needs to pay something before seen: Copayment

QUESTION: What happened in 1997: SCHIP (state children insurance health program) 13. SCHIP (State Children's Health Insurance Program) provides matching funds to states for health insurance to families with children. It covers uninsured children in families with incomes that are modest but too high to qualify for Medicaid.

QUESTION: 1997 law passed that state must look after children that cannot afford healthcare - State Children's Health Insurance Program (SCHIP) AKA Children's Health Insurance Program (CHIP)

INSURANCE TERMS:

Unbundling - separating of a dental procedure into component parts with each part having a charge so that the cumulative charge of the components is greater than the total charge to patients who are not beneficiaries of a dental benefit plan for the same procedure.

Bundling - opposite of unbundling & can occur on the insurance carrier end. It’s the systematic combining of distinct dental procedures by third-party payers that results in a reduced benefit for the patient/beneficiary.

Upcoding or overcoding is defined by the ADA as "reporting a more complex and/or higher cost procedure than was actually performed."

Downcoding is defined by the ADA as "a practice of third-party payers in which the benefit code has been changed to a less complex and/or lower cost procedure than was reported except where delineated in contract agreements."

QUESTION: Dentist did not accept a copayment and did not report it to the 3rd party (insurance)? Overbilling

QUESTION: Dentist charge for $500 for a crown. insurance only covers $400. Dentist waves copayment ($100) but still let insurance knows that he charges $500 for crown, what’s this action called? a. Down coding b. Overbilling

QUESTION: The dentist charges separately for core build up and the crown but the insurance company says that the core builds up is part of crown. What is this called? Bundling

*QUESTION: Doctor billed insurance couple of procedures, when actually there is a global procedure that combines them all, what did he commit? Unbundling

QUESTION: Dentist does the treatment for 2 crowns but the insurance company paid for one crown, what is it? Downcoding

QUESTION: You performed a two surface restoration and coded it that way. Insurance came back with coding it as only one surface restoration. What is this called? Downcoding or upcoding

QUESTION: What is it called when a dentist charges several procedures instead of one? a. upcoding b. downcoding c. unbundling d. bundling

QUESTION: The patient retires & loses health benefits. The treatment is done on the next day. The pt requests that the dentist enter the previous day’s date and the dentist does so. What is this called? Fraud

ABUSE:

Child abuse sign: 14. multiple untreated injuries 15. lag time between injury and tx 16. comminuted facial fractures 17. parents with different stories 18. Most common in children under 3 Abuses that have to be reported to authorities - colleague practicing with chemical impairment, colleague advertising falsely on media, child abuse, domestic violence, elderly abuse

QUESTION: When treating elderly patients what should be your concern? Health of patient

QUESTION: What’s true about child abuse cases? You’ll see at least 2 a year

QUESTION: It is mandatory to report all except: child abuse, reaction to drug, etc.

QUESTION: You suspect child abuse. Who do you call? Social services

QUESTION: If there is an elderly woman in your chair & you think there might be abuse. What do you have to do? Tell family or tell human health services

QUESTION: Which is not true of elder abuse: Most of the elder abuse is at victims home Mostly it is by the victim’s relative Elder’s abuse is often over reported and exaggerated

*QUESTION: Unauthorized use of elderly’s ATM card is not a sign of abuse but in some situations, it is under consideration. (Both are true)

*QUESTION: Elderly abuse is often: underreported

QUESTION: Dentist potential for abuse not likely due to 1. Vulnerability 2. Pressure of being perfect 3. Knowledge and access to drugs 4. Stress

DENTAL PRACTICE:

QUESTION: When opening a dental practice, what makes it more successful? Better communication

QUESTION: What do general dentists report as being their biggest issue? Fearful patients, business/financial issues, staff training

QUESTION: Patient is bothering the dentist, dentist got upset. The assistant drops instruments on the floor & the dentist was so mad that he had it out with the assistant. What you you call that reaction? Transference • Transference is an unconscious redirection of feelings from one person to another

QUESTION: Most eye injury in practice happens to who: dentist, dental assistant, hygienist, custodian

QUESTION: Least chance of needle injury? Setting up, Cleaning up, Recap

QUESTION: When do you most likely get a puncture wound: pre procedure, during, post-procedure cleanup, needle recapping

QUESTION: Most injury/percutaneous cuts happen when recapping needles

QUESTION: What test for every year? Hep B

QUESTION: Dentist can diagnose which of the following? Bulimia (reflected in oral condition)

QUESTION: A patient comes in with rampant decay. What is the primary responsibility of the dentist? Figure out etiology of decay FIRST

QUESTION: Patient is in your office for a treatment plan, all of the following should be done when you explain the proposed treatment to the patient, except? Use professional terminology (other choices were the risk of not getting a procedure done, the fee of the procedure, etc.)

QUESTION: New patient comes into office, what do you do 1st visit? Full exam, record probing, med history, impressions.

QUESTION: First step before/in treatment planning: Make sure patient doesn't need translator, consult with physician about pre- existing medical conditions

QUESTION: Patient is ready to hear your treatment plan, all of the following are true except? Guarantee the success of treatment!

QUESTION: First step in tx planning is? Treat the initial pain and discomfort of the pt. Other choices were see how you can make a preventative plan, treat all restorations.

QUESTION: Proper order for treatment planning – Emergency care, disease control, reevaluation, definitive treatment, maintenance care

QUESTION: Which are the two most imp. steps for diagnosis: History and clinical examination QUESTION: Best way to determine outcome of disease? a. Med history of the patient (If the lab test was choose may be that) b. ESR lab results

QUESTION: Patient comes to your office, complains about how other dentists did really bad job, and tells you how you are the best dentist in the world. What mental condition is she suffering from? Borderline Personality Disorder

QUESTION: Pt comes in saying she’s been to 5 different dentists the last 6 months. A few minutes later, she’s telling you how great of a dentist you are and that she’ll refer all of her friends to you. This example of: Borderline. Other choices were paranoia & schizoid. - Borderline personality disorder (BPD) is a serious mental illness marked by unstable moods, behavior, and relationships.

QUESTION: Patient with bipolar disease comes in for dental care, choses not to take his medication and states he is in the “manic phase,” what do you expect from treating this patient? He will have unpredictable reactions during the treatment, he is will be obsessed about is esthetics (not sure if it means he is going to be continuously manic or just general bipolar disorder)

QUESTION: When trying to change a person, what is most important? Trying to determine whether they are willing to change

*QUESTION: Patient who has a complex medical history that is not debilitating but will require medical management and dental modifications – ASA 3 • ASA2- mild systemic disease, ASA3-severe systemic disease

QUESTION: You have a test that is not accurate but gives consistent result: this means test is Reliable

QUESTION: Which of the following are necessary for a test to be accurate: Specificity, reliability, Validity

QUESTION: Something about nonverbal vs verbal communication: Nonverbal is not as reliable

QUESTION: Dentists have to have proper accommodations for disabled people. Dentists have to treat HIV people the same as others. Both statements are true

QUESTION: American disabilities act does not include HIV: False

CLEANING UP:

QUESTION: One patient left, and before getting another patient, how would you clean your operatory? Use disinfecting spray let it sit for 10 minutes and then wipe off

QUESTION: Disinfection? Destroy majority of microorganisms but not bacterial spores. • Bacterial spores = benchmark organism for sterilization

QUESTION: Benchmark for sterilization: Bacillus spores • I think it’s Clostriduim Botulinium

*QUESTION: Mycobacterium is the benchmark for disinfection

QUESTION: Definition of disinfectants – Chemical applied to Inanimate objects (non-living)

QUESTION: Antiseptic: can be safely applied to tissues, but will kill most living organisms (normal flora)

QUESTION: Denaturation of the proteins - Alcohol and autoclave; Coagulation of proteins - dry heat

*QUESTION: Steam Autoclave: 15-20 minutes at 121⁰C & 15 psi.

QUESTION: Which method of sterilization needs higher temperature: steam dry heat – 160 C or 320⁰ F oxide pressure

QUESTION: Temperatures for autoclaves is governed by: FDA

*QUESTION: Which method of sterilization does not corrode instruments/burs? – Dry Heat, Ethylene oxide

*QUESTION: Which method of sterilization does not dull carbide instruments? Dry heat

*QUESTION: Sterilization most destructive to burs & causes rusts: Steam heat, dry heat, unsaturated vapor, chemical, ethylene oxide

QUESTION: What is best to sterilize carbide burs? DRY HEAT or unsaturated chemical vapor no corrode or dull • Ethylene oxide is for heat-sensitive instruments

QUESTION: Anti-retraction valves - used to prevent aspiration of patient materials into some dental handpieces and waterlines – prevent patient to patient cross-contamination

OSHA (Occupational Safety and Health Administration):

QUESTION: What’s not found on the OSHA poster? How many days each employee is allowed to work with that chemical

QUESTION: Which one applies to OSHA guideline? Update it once a year!

QUESTION: What are the hep B vaccine rules by OSHA? all must always be offered and able to get the vaccine

QUESTION: Once a year, you have to check for one of the following: HIV HEP B HEP C

QUESTION: If worker didn’t get Hep B vaccine because he is more concerned about HIV? Tell him it’s easier to get hep B must sign that they legally don’t want

QUESTION: Who is at least risk for HEP B infection? a) Food servers b) Down syndrome c) drugs addicts QUESTION: OSHA does all except: material safety data sheet MSDS, which is made by manufacturer

QUESTION: Who is in control of writing the material safety data sheet (MSDS): Manufacturer

QUESTION: Hazard Communication Standard: created by OSHA to make sure employees know about hazardous/toxic materials

QUESTION: Hazard Communication Standard states – every chemical hazard has to be evaluated then reported to employer & employees

QUESTION: HAZARD COMMUNICATION LAW: a) created by OSHA b) What does it control: amalgam, sharps, blood

QUESTION: Hazardous communication regulation a. train worker right after you hire (T/F) b. train worker when new hazardous product in office (T/F)

QUESTION: OSHA sets bloodborne pathogen standard for dentistry, HIV and HBV

DENTAL STATISTICS & STUDIES

(There were AT LEAST 5 q’s on this crap….)

T test: The t test is one type of inferential statistics. It is used to determine whether there is a significant difference between the means of two groups. With all inferential statistics, we assume the dependent variable fits a normal distribution. • Used to compare whether the means of two groups are statistically different • Assume that standard deviation is unknown • Small sample size

Z test: A z-test is a statistical test used to determine whether two population means are different when the variances are known and the sample size is large. • Used to compare the means of two groups are statistically different if the variances like standard deviation are known • Large sample size.

Chi-square test: Chi-square is a statistical test commonly used to compare observed data with data we would expect to obtain according to a specific hypothesis. • Tests correlation b/w two independent variables • Experimental value vs theoretical value

Case control study — RETROSPECT study that compares people that have the disease to people that do not have the disease. Also, looks back to see how the risk for the disease is compared to actually getting that disease. • Start with disease and look backwards for exposure • How many exposure to a certain risk factor did a person have to something before getting disease as compared to those who do not have the disease

Cohort study — PROSPECTIVE study where there is more than one sample/cohort and evaluations are done to see how certain risk factors the groups have are related to developing a certain disease. • One or more samples followed prospectively and subsequent status evaluations with respect to disease or outcome are conducted to determine which initial participants exposure are associated with it.

Cross sectional study — EPIDEMIOLOGICAL study that looks at the entire population. Not like case control, that only studies a certain group with a specific characteristic. • All variables measured simultaneously at one point in time • Example: It was observed that there was less caries in certain geographic areas. Higher fluoride in water supplies was suspected as the probable cause

Longitudinal Study —TIMED study that looks at a certain set of people (same people) over a long period of time.

Hypothesis Generating Observational Studies Descriptive studies - time, place, person Ecologic studies - use groups rather than individuals Correlation studies - measure linear relationship between two factors within defined groups, no cause and effect established

Clinical Trial — Use randomization and blinding to compare effects of treatment with non-treatment. This is the Gold Standard for establishing cause and effect. • Trials to evaluate the effectiveness and safety of medications or medical devices by monitoring their effects on large groups of people. • Clinical research trials may be conducted by government health agencies such as NIH, researchers affiliated with a hospital or university medical program, independent researchers, or private industry. • Typically, government agencies approve or disapprove new treatments based on clinical trial results. While important and highly effective in preventing obviously harmful treatments from coming to market, clinical research trials are not always perfect in discovering all side effects, particularly effects associated with long-term use and interactions between experimental drugs and other medications.

QUESTION: If a dentist is reading an article, where should he look for the definition of dependent and independent variables? method, introduction, discussion, results, summary

QUESTION: Where would you look in a scientific journal to find the dependent and independent variables o Intro o Materials o Methods o Conclusion o Summary

QUESTION: What section states the purpose of the research? INTRO (ABSTRACT)

QUESTION: All are the qualities of a double blind study except? You need 2 control groups.

QUESTION: Researcher wants to find incidence of oral cancer in nursing home what study? Cross-sectional

QUESTION: I had one about a teacher and doing a survey on kids = Cross sectional

QUESTION: Research done to determine caries rate at a nursing home. What kind of study is this? Cross-sectional

*QUESTION: Which type of study determines relative risk ratio: Cohort

*QUESTION: What parameter study lets you have a risk quotient? Cohort

QUESTION: Efficacy, what study would you do? CASE CONTROL • Looking back at specific cases to analyze if something was effective

QUESTION: Cohort: Studying for the next 10 years

QUESTION: Study among smokers & nonsmokers in a period of 6 years (2000-2006) to develop disease? Cohort, cross sectional

QUESTION: What type of study lets you find causation- Analytical, cross-sectional, case-control, cohort

QUESTION: Myasthenia Gravis patients are involved in a study. The doctor is conducting a study and is trying to find out how many of these patients has periodontitis. What study is he conducting? Case control study

QUESTION: The problem with this study is that you don’t know if the disease came from drinking or not. What study is it? By: drinking/nondrinking Followed a group for 6 years’ cohort

QUESTION: Dentist is doing research on 5 unrelated patients with different background. He records data……etc. Dentist is doing what kind of research? a. Clinical trial b. cohort c. sectional

QUESTION: Study group A and B give some agents for plaque control then compare which agent is more effective. Which study is that? Clinical trial

QUESTION: A study is done to determine the effectiveness of a new antihistamine. To do this, 25 allergic pts. are assigned to one of the two groups, the new drug (13 pt’s), placebo (12 pt’s). The pts are followed for 6 months. This study is called: Cohort, Cross- sectional, Case controlled, historical cohort, clinical trial. (assigned or give is the clue)

QUESTION: A study is designed to determine the relationship between emotional stress and ulcers. To do this, the researchers used hospital records of pt's diagnosed with peptic ulcer disease and pt. diagnosed with other disorders over the period of time from July 1988 to July 1998 . The amount of emotional stress each pt. is exposed to was determined from these records. This study is: A) Cohort B) Cross-sectional C) Case-study* D) Historical Cohort E) Clinical Trial

QUESTION: A researcher conducting a research between student’s self studying and those attending lectures what is the independent variable? students participating in research, material studied, Students results, Lecture of self study ATTENDING LECTURE or SELF STUDY (INDEPENDENT VARIABLE) STUDENTS RESULT (DEPENDENT VARIABLE)

QUESTION: Analyze statistical difference between two means? T-test

QUESTION: Crossover study advantages: influence of confounding covariates is reduced because each crossover patient serves as his or her own control and are statistically efficient and so require fewer subjects than do non-crossover designs (even other repeated measures designs).

QUESTION: Means of caries risk assessment for 3 groups: white, black, Hispanic what test do u use to compare? A) chi square b) variance c) t-test

QUESTION: How do you compare between 2 constant variables? CHI SQUARE, regression analysis

QUESTION: Two groups of 100 ppl, gave them different foods & asked how they felt afterwards. which test to compare the 2 groups answers chi squared test

QUESTION: Want to compare 2 groups of people, male and female for something, what test do you look at? Multiple regression, Chi square Test, T-test

QUESTION: What test measures 2 nonparametric data? Chi-square, normal distribution, spearman, wilcoxin, kruskal wallis

QUESTION: Given a case – what is the dependent variable? independent variable influences a dependent variable, or variables. Ie: effect of Temperature on plant growth, temp = independent and growth; height, weight, # of fruits = dependent

QUESTION: Confounding variants - a third variable or a mediator variable, can adversely affect the relation between the independent variable and dependent variable. This may cause the researcher to analyze the results incorrectly. The results may show a false correlation between the dependent and independent variables, leading to an incorrect rejection of the null hypothesis.

QUESTION: If you have a study of confounding variable – Minimize confounding variables by randomizing • Mnimize confounding variables by randomizing groups, utilizing strict controls, and sound operationalization practice all contribute to eliminating potential third variables.

HYPOTHESIS:

Null hypothesis (H0) is a hypothesis which the researcher tries to disprove, reject or nullify. 19. Refers to the common view of something, while the alternative hypothesis is what the researcher really thinks is the cause of a phenomenon.

Type I and Type II Null hypothesis: 20. Type I Error- rejecting the null hypothesis when it is true. This is an alpha error. Another way to say this is, to reject a null that should be accepted. 21. Type II Error- accepting a false null hypothesis. This is a beta error. Another way to say this is, to accept a null that should be rejected.

Null hypothesis (H0) is true Null hypothesis (H0) is false Type I error Correct outcome Reject null hypothesis False positive True positive Correct outcome Type II error Fail to reject null hypothesis True negative False negative

If the observed probability is ≤ .05 (5%), null hypothesis is rejected & outcome is judged as “no effect”. In this case, the alternative hypothesis is adopted

If the observed probability is >0. 5% the decision is to accept the null hypothesis & results are called “not statistically significant.

Sensitivity – percent of persons with the disease who are correctly classified as having the disease 22. True Positive (TP) - Those that actually have it 23. False negative (FN) - Those that are misdiagnosed as not having it 푇푃 푆푒푛푠𝑖푡𝑖푣𝑖푡푦 = 푇푃 + 퐹푁 Specificity – percent of persons without the disease who are correctly classified as not having it 24. True Negative (TN)-Those who are ACTUALLY disease free 25. False positive (FP)- Those that are misdiagnosed as not as being disease free 푇푁 푆푝푒푐𝑖푓𝑖푐𝑖푡푦 = 푇푁 + 퐹푃 Incidence – new cases

QUESTION: Experiment was done and error = 0.05 was the goal but when completed it was 0.01. The question asks what type of error was it? a. Type I b. TYPE 2 c. no error: Error of less or equal of 0.5 no statistical significance.

QUESTION: P-significant value is equal to 0.01, your theory should be right, so you you will reject null hypothesis

QUESTION: Type I – False rejection of null hypothesis (false negative/incorrect rejection) = less dangerous in terms of research and Type II – false acceptance of null hypothesis (false positive/failure to reject) – less problematic because no conclusion is made from a rejected null. But type 2 is more dangerous medically because a patient is diagnosises as HEALTHY when they actually have the HIV.

QUESTION: The power of a statistical analysis is ultimately to: reject the null

QUESTION: Incidence is when number of people like to get disease in given time

QUESTION: Dentist in his clinic notices a new disease this is? incidence

QUESTION: What is the statistical measure for the total number of cases per population, regardless of time of onset? I put prevalence

QUESTION: For a population, the research divides the number of disease cases by the number of people. By so doing, this investigator will have calculated which of the following rates? a. incidence b. odds ratio c. prevalence d. specificity

QUESTION: Specificity: Proportion of truly nondiseased persons who are so identified by a screening test (measures “how good a test is at correctly identifying nondiseased persons). Sensitivity tests identifying diseased persons.

QUESTION: Dentist finds a group of individuals are free of (do not have the) dental disease: specificity Specificity (without disease) and sensitivity (with disease)

QUESTION: If a dentist was able to correctly ID disease free patients w/ the diagnostic study, it has? high specificity.

QUESTION: Specificity, true negative

*QUESTION: Study says 95 out of 100 people had the disease what is lab value: 95% sensitivity

*QUESTION: A study failed to report 5 cases of caries. What is this called? 1. True Positive, 2. True Negative, 3. False Positive, 4. False Negative

QUESTION: Incidence of caries in your office this year is 300 out of 1000, last year it was 200, so what is it for this year? 10% Incidence refers to NEW cases so the answer is (300-200)/1000 = 100/1000 = 0.1

QUESTION: Dentist has 300/1000 patients with periodontitis; last year only 200 had periodontitis, what is the incidence for this year: 10%

MEAN, MEDIAN, MODE: mean (average) median (middle number) mode (number that shows up the most)

QUESTION: Which does not describe the spread of data? Median. Range. Variance, stand deviation, standard error

QUESTION: What do you use for average Q? Mean, median, mode

QUESTION: Which of the following represents the variability about the mean-value of a group of observations? A. Sensitivity B. Standard deviation C. t-Statistic D. Specificity

QUESTION: Histogram is used to show (standard deviation): mean, correlation of 2 variables, variance

QUESTION: Outliers control: 1. mean 2. median 3. mode 4. standard deviation

QUESTION: An outlier has the biggest effect on which of the following? Standard deviation

ORGANIZATION MEANS

Categorical (nominal) is like black hair, blonde hair

Ordinal: order or rank • Ex. Low, medium, high or high school, college, graduate school

Interval is like ordinal but the values are EQUALLY SPACED – 10, 15, 20,

Cardinal indicate quantity, tells how many

Nominal names or ID something

Ratio

*QUESTION: Your office uses perio scale 1= gingivitis 2= mild perio 3= moderate/severe etc, what type of scale is this? Nominal, ordinal, ratio, cardinal

QUESTION: GI mild, moderate severe – Ordinal

QUESTION: Pulse + BP + Kelvins, what kind of measurement? nominal, ordinal, interval, ratio

QUESTION: temperature – kelvins is ratio and Celsius is Interval (32 is freezing) is interval

QUESTION: Best scale for gingival index? a. ratio b. nominal c. interval

RANDOM QUESTIONS

*QUESTION: When you smile, what is the black space buccal of teeth and next to cheeks? Buccal corridor

*QUESTION: Initiation of first menstruation cycle (menarche) is best indicative of what? Cognitive age, dental age, skeletal age

QUESTION: Menarche onset: before growth, during peak of growth, after peak of growth

QUESTION: Neuropraxia: transient episode of motor paralysis with little or no sensory or autonomic dysfunction. It describes nerve damage in which there is no disruption of the nerve or its sheath. • Interruption in conduction at the axon (reversible nerve damage)

QUESTON: Axon damage most likely to cure itself? Neuropraxia

QUESTION: Neuropraxia involves: both perineurium and epineurium, only perineurium, only epineurium, none of the above (temporary damage, nerve left intact)

QUESTION: What is Trephination? Hole is drilled or scraped into the human skull

QUESTION: Patient has HEB B antigens (HBsAg) in surface. What state is patient? A. Chronic B. Acute hepatitis contagious C. Acute hepatitis not contagious

QUESTION: If pt has HBsAb (antibody), that means that he was either vaccinated or recovered form infection

QUESTION: Patient has POSITIVE HEP B test, all of his organs will be affected except: Pancreas Kidney GI Thyroid

*QUESTION: Biggest difference across cultures regarding pain: Variability in pain threshold rather than pain tolerance Variability in pain tolerance rather than pain threshold Difference in stimulus awareness rather than pain tolerance Difference in stimulus awareness rather than pain threshold

*QUESTION: Most common cause of frequent urination during 3rd trimester? Pressure of uterus on bladder, gustatory diabetic

*QUESTION: Innervation of soft palate? Glossopharyngeal

*QUESTION: Best to use on infected oral wound? Hydrogen peroxide, chlorhexidine

QUESTION: Which one is associated with bilirubin? Kernicterus • Kernicterus is a bilirubin-induced brain dysfunction.

QUESTION: Multiple Endocrine Neoplasia Syndrome: MEN- adrenal over production

QUESTION: CASE: b. What is her dental age based on x-rays advanced, chronological lags behind dental c. Tx for #D TE d. What to do with lesion on distal of #S (look incipient, resorbed): apply fluoride varnish every week, do DO comp or amalgam, observe and reassess next visit, disc the distal surface e. Both child and guardian should receive oral health instructions, oral health care should include daily fluoride rinses Both statements are true

*QUESTION: Macroglossia seen in all EXCEPT? Causes of MACROGLOSSIA • Inflammatory------glossitis • Traumatic------post operative edema • Metabolic causes------myxedema, amyloidosis, lipoid priotenosis, chronic steroid therapy and acromegaly. • Congenital causes------cretinism, hemangioma, lymphangioma, downs syndrome, beckwith-weidman syndrome, generalized gangliosidosis syndrome, mycopolysachridosis.