SAQ

Short answers Important: You will get ONE sheet of paper with 21 lines to answer for each SAQ! The best way to prepare is with the book by E. ODELL: Clinical Problem Solving in Dentistry (buy via Amazon) March 2000 From the medical history you find the patient is on Tricyclic Anti-depression medication. How would you manage this patient? Complete building the medical and the dental history to reach a proper diagnosis and find the aetiology of the chief complaint so I can start assessing the case by evaluating the available information; the overall case assessment is an essential step that allows the considerations of treatment options and a provisional treatment plan to be formulated. Consult the patient’s GP for any precautions should be taking or any modification to the treatment should be followed. Resolution of any acute problems and stabilisation or elimination of active disease. If it is not possible to get in contact with the GP refer to the MIMs to get more information about the drug to find out what I can or I can not prescribe Assessing and managing accordingly any emergencies situations that exist, acute pain, bleeding swelling…etc Eliminating any acute problems or active diseases I will assess the periodontal tissues and elimination of any active diseases, regeneration of the periodontal attachment loos and stabilisation of gingival contours would be my next step in managing the patient. Reassessment of the periodontal situation by assessing the patient occlusal stability and plan for any restorative or prosthetic management. Finally and it is an important part is the patient consultation to present and discuss the treatment plan and give the alternative options, obtaining a patient consent/s, arrange for appointments and financial considerations Reconfirm the definitive treatment plan and make sure the patient’s expectations are what the result would be. Tricyclic has a side affects on the oral cavity by causing dry mouth; and systemically it causes blurred vision, constipation, and difficulty in urination; postural hypotension; tachycardia, increased sensitivity to the sun; weight gain; sedation (sleepiness); increased sweating. Some of these side effects will disappear with the passage of time or with a decrease in the dosage. Bear in mind all this information should be recorded appropriately for future follow up and to adhere to the Australian Dental Board policies. A 23 year-old female comes to you with Gingival abscess in the right upper central incisor region which she had a blow to 10 days ago; since then the tooth is a bit loose, now she is complaining of pain and tenderness started two days ago. What is your management? Gathering general information including but not limited to name, age, sex, previous major operations, any medication is taken at the time she is presented…etc. mostly this is prepared and universal for all patients. Building the medical and the dental history to help building a proper diagnosis and find the aetiology of the chief complaint so I can start assessing the case by evaluating the available information; the overall case assessment is an essential step that allows the considerations of treatment options and a provisional treatment plan to be formulated. Clinical examination in both directions Extra and intra. Extra examination includes the general morphology, skeletal base, skin colour and lesions, eyes, lymph nodes, lip, breathing, TMJ and masticatory muscles. Intra orally starts with soft tissues and oral mucosa and muscles followed by the dental examination by examining the teeth and focusing on the tissues, bone and teeth next to tenderness and the blow area; and look for any attrition, abrasion, erosion, or hypominerlization on the tooth surface or any abnormality in the gingivae or hard tissues “Faceting, fracture or caries of the enamel” then examine the periodontal tissues and record any tooth mobility or badly restored teeth. Check the occlusal view if possible and the result of the blow on the occlusal harmony and the other tissues. Order any special tests required and in this case a periapical to start with seems to be essential. Assess the case and advise for a rigid splint or extraction and fixed prothesis later…etc and this is completely demandant on the outcome of the assessment. Transfer the treatment options to the patient in a simple language and this stage should include the approximate cost and any need for future follow up. A 13 year old patient has rampant caries and gingival swelling. What are the causes? How to prevent them? What is your management? Most probable cause of the rampant caries is the frequent intake of sugar, then the oral hygiene methods that have been adapted by the patient. But we must be able to visualize adequately a child’s teeth and mouth and have access to a reliable historian for non-clinical data elements. Prevention programme starts with assessing all 3 components of caries risk–clinical conditions, environmental characteristics, and general health conditions; a complete analysing of the diet regime; then build a new diet system prevents less frequent take of carbohydrates and in sever cases could include changing sugar to carbohydrate free substitute. Endorsing a good oral hygiene plan that suits the patient and the advice for a regular topical fluoride application is as important as the diet. Systemic fluoride may be applicable depends on the case and the water fluoridation program in the area. The management includes, Gathering general information including but not limited to name, age, sex, previous major operations, any medication is taken at the time she is presented…etc. mostly this is prepared and universal for all patients. Building the medical and the dental history to reach a proper diagnosis and find the aetiology of the chief complaint so I can start assessing the case by evaluating the available information; the overall case assessment is an essential step that allows the considerations of treatment options and a provisional treatment plan to be formulated. Clinical examination in both directions Extra and intra. Extra examination includes the general morphology, skeletal base, skin colour and lesions, eyes, lymph nodes, lip, breathing, TMJ and masticatory muscles. Intra orally starts with soft tissues and oral mucosa and muscles followed by the dental examination by examining the teeth and focusing on the tissues, bone and teeth next to tenderness; look for any attrition, abrasion, erosion, hypominerlization or any abnormality in the gingivae or hard tissues “Faceting, fracture or caries of the enamel” then examine the periodontal tissues and record any tooth mobility or badly restored teeth. Check the occlusal view if possible and the result of the blow on the occlusal harmony and the other tissues. Assess the case and treat according to the diagnosis outcome; bearing in mind that the target is to treat the acute problems or manage any source of pain then reserve as much as possible of the child teeth tissues. Patient with chronic periodontic disease. What are the factors that will influence the management and outcome of this patient? The overall clinical factors are: Patient age: for two patients with comparable level of the remaining connective tissues attachment and alveolar bone, the prognosis is better in the older of two. For the younger patient, the prognosis is not as good because of the short time frame in which the periodontal destruction has occurred. In some cases this is maybe because the younger patient suffers from an aggressive type of periodontitis. Disease severity: Studies have demonstrated that a patient’s history of previous periodontal disease may be indicative of their susceptibility for future periodontal break down. Prognosis is adversely affected if the base of the pocket is close to the root apex. Also the height of the remaining bone, all these should be weighed against the benefits that would accrue to the adjacent teeth if the tooth under consideration were extracted. Plaque control: bacterial plaque is the primary etiological factor associated with periodontal disease. Therefore effective removal of plaque on daily basis by patient is critical to the success of the periodontal therapy and to the prognosis. Patient complaisance/ cooperation: the prognosis for patients with gingival and periodontal disease is critically dependant on the patient’s attitude and desire to retain natural teeth, and willingness and ability to maintain good oral hygiene. Without these, treatment can not succeed. There are systemic and environmental factors such as: Smoking: Epidemiologic evidence suggests that smoking may be the most important environmental risk factor impacting the development and progression of periodontal disease. Therefore it should be made clear to the patient that a direct relationship exist between smoking and the prevalence and incidence of periodontitis. Also patient should be informed about the effects of smoking on the healing process. Systemic disease /condition: the patient’s systemic background affects overall prognosis in several ways. For example, studies have shown that the severity of periodontitis is significantly higher in patients with type I and II diabetes than in those without diabetes. Patients with diabetes or with newly diagnosed diabetes should be informed about the impact of diabetic control on the development and progression of periodontal disease. Genetic factors: periodontal diseases represent a complex interaction between microbial challenge and the host’s response to that challenge, both of which may be influenced by environmental factors such as smoking. There also is evidence that genetic factors may play an important role in determining the nature of the host response. Stress: physical and emotional stress, as well as substance abuse, may alter the patient’s ability to respond to the periodontal treatment performed. The Local Factors: Plaque /calculus: the microbial challenge presented by bacterial plaque and calculus is the most important local factor in periodontal diseases. Therefore in most cases, having a good prognosis is dependent on the ability of the patient and the clinician to remove these etiologic factors Subgingival restorations: may contribute to increased plaque accumulation, increased inflammation and increased bone loss when compared with supragingival margins. Anatomic factors: may predispose the periodontium to disease, and therefore affect the prognosis, include short, tapered roots with large crowns, cervical enamel projections (CEPs) and enamel pearls, intermediate bifurcation ridges, root concavities, and developmental grooves. Tooth mobility: the principle causes of tooth mobility are the loss of alveolar bone , inflammatory changes in the periodontal ligament, and trauma from occlusion. However, tooth mobility resulting from loss of alveolar bone is not likely to be corrected. Prosthetic / restorative factors: the overall prognosis requires a general consideration of bone level and attachment level to establish whether enough teeth can be saved either to provide a functional and aesthetic dentition or to serve as abutments for useful prosthetic replacement of the missing teeth. Caries, non vital teeth , and root resorption: for teeth mutilated with extensive caries, the feasibility of adequate restoration and endodontic therapy should be considered before undertaking periodontal treatment. Class two amalgam restoration on a molar. What factors do you consider when preparing a good proximal contact area? The extent of the cavitation of the proximal enamel will dictate the classification and, ultimately, the outline form of the cavity. There is no need to remove sound enamel, particularly from the gingival floor, just because it is undermined following removal of caries. The enamel at the gingival is not under occlusal load and can be retained, thus keeping the restoration margin out of the gingival crevice, in case we are going to use the lamination “sandwich” technique. If not ditches and grooves are the best methods of developing retention; pronounced groove along the gingival floor of the mesial proximal box of 2mm depth provides a good positive retention. The main retentive form in the proximal box should be placed within the dentine at the gingival floor as well as in the facial and lingual walls. Now if the separate sections of the restoration are individually self retentive, there will be no failure at the narrow isthmus that joins the occlusal extension to the proximal box and there is no need to widen it in this case. Other wise extending it just over the contact area with the adjacent teeth is indicated and bevelling the step as well to strengthen the amalgam in this area and extra retention will be gained. March 1999 List the factors that determine the prognosis of an avulsed, traumatised upper central incisor. The single most important factor determining the prognosis of a replanted tooth is viability of the periodontal membrane left on the root prior to replantation. If the root surface is left dry, approximately 50% of the periodontal ligament cells are dead after 30 minutes; after 60 minutes, almost no cells are viable. Replantation of such tooth results in extensive pulpally-derived inflammatory resorption, or ankylosis. The critical time of dry storage seems to be between 18 and 30 minutes A storage media must be of correct osmolality and PH. Saliva allows storage for 2 hours. Normal saline solution allows the same time, while milk on the other hand allows up to 6 hours. Mechanical damage happens as a result of the process of avulsion and replantation; the damage is seen on both cells and tissues. These areas of damage appear as surface resorption defects. Socket: curettage of the socket wall and the presence or removal of a blood clot had a little influence on the healing pattern of the replanted teeth. Therefore this need not be done unless the clot prevents proper seating of the tooth. However, alveolar bone should be moulded back into position following replantation, this aids in bone healing and allows good adaptation of soft tissues. Splinting: minimal splinting and non-rigid splints permit physiological jiggling movement of the tooth which result in lower incidence of ankylosis. Care must be taken in the placement of the splints, keep it simple and avoid gingival tissues. Studies have shown that normal and hard diet resulted in significantly less ankylosis and a higher incidence of normal periodontal ligament compared with soft diet. Antibiotics: High dose of a broad spectrum antibiotic is recommended followed by at least two weeks of oral administration. Intrapulpal application of antibiotic is indicated if bacterial invasion of the pulp occurs prior to systemic antibiotic. Endodontic treatment: teeth with immature apices should be monitored clinically and radiographically since revascularisation of the pulp is possible. Teeth with mature apices rarely < 1% regain vascularity and so necrosis and infection would follow, so an endodontic treatment is advised as soon as possible. Extra oral endodontics should not be perform prior to replantation as the excessive handling of the tooth will increase the risk of additional damage to the periodontal membrane. And the filling material may increase the risk of inflammatory resorption. Discuss the choices for an MOD direct restoration for a lower molar. Amalgam- Sandwich Technique- Composite- Pins- An insulin dependent 45 year old male needs a full clearance and full upper and lower dentures. Discuss how you would manage this case. Medical considerations. Take a thorough medical history for all patients diagnosed with diabetes. Ascertain the identity of the physician treating the patient and the date of the last visit. Obtain information concerning the type of diabetes, the severity and control of the diabetes, and the presence of cardiovascular or neurologic complications. Refer any patient with the cardinal symptoms of diabetes or findings that suggest diabetes (headache, dry mouth, irritability, repeated skin infection, blurred vision, paresthesias, progressive periodontal disease, multiple periodontal abscesses) to a physician for diagnosis and treatment. Diabetic patients who are receiving good medical management without serious complications such as renal disease, hypertension, or coronary atherosclerotic heart disease, can receive any indicated dental treatment. Those with serious medical complications may require an altered plan of dental treatment. When the severity and degree of control of diabetes are not known, treatment should be limited to palliation. Food intake and appointment scheduling. To preventing insulin shock from occurring: Verify that the patient has taken medication as usual. Verify that the patient has had adequate intake of food. Schedule appointments in the morning, since this is a time of high glucose and low-insulin activity. Afternoon appointments are a time of low-glucose and high-insulin activity which may predispose the patient to a hypoglycemic reaction. Instruct patients to tell the dentist if at any time during the appointment they feel symptoms of an insulin reaction occurring. A source of sugar, such as orange juice, must be available in the dental office should the symptoms of an insulin reaction occur. Oral surgery concerns. It is important that the total caloric content and the protein/carbohydrate/fat ratio of the patient's diet remain the same so control of the disease and proper blood glucose balance are maintained. IDDM diabetics who are going to receive periodontal or oral surgery procedures may be placed on prophylactic antibiotic therapy during the postoperative period to avoid infection. Consultation with a patient's physician before conducting extensive periodontal or oral surgery is advisable. The physician may, in fact, recommend that the patient be treated in a hospital environment where infection, bleeding, and dysglycemia can be better managed. Dangers of acute oral infection. Any diabetic patient with acute dental or oral infection presents a problem in management. This problem is even more difficult for patients who take high insulin dosage and those who have IDDM. The infection will often cause loss of control of the diabetic condition, and as a result the infection is not handled by the body's defenses as well as it would be in a nondiabetic patient. The patient's physician should become a partner in treatment during this period. Oral complications. The oral complications of uncontrolled diabetes mellitus may include: Xerostomia, Infection, Poor healing, Increased incidence and severity of periodontal disease, and Burning mouth syndrome. Diabetic neuropathy may lead to oral symptoms of tingling, numbness, burning, or pain in the oral region. Oral findings in patients with uncontrolled diabetes are thought to be related to excessive loss of fluids through urination, altered response to infection, microvascular changes, and possibly increased glucose concentrations in saliva. Early diagnosis and treatment of the diabetic state may allow for regression of these symptoms, but in long-standing cases the changes may be irreversible. Potential Drug Interaction. While patients with well-controlled diabetes can be given general anesthetics, management with local anesthetics is preferable. General anesthetics should be used with caution because they can produce hyperglycemia. Your dental nurse has suffered a needle stick. What is your management for the case? IMMEDIATELY WASH THE INJURY WITH SOAP AND WATER · If splashed with a bodily fluid, thoroughly irrigate the affected area · Cover the injured area with a bandage for protection There is no need to apply agents such as bleach to the injury Risk assessment Report the incident to the practice principal/manager following first aid · Document as much of the following as possible to determine risk: 1. How did the injury occur? 2. What type of injury is it, and what is the extent of the injury? 3. What was the source of the sharp or bodily fluid? 4. How much of the source material came into contact with the affected person? 5. Was any protective clothing being used? · After initial risk assessment, seek further management and treatment If appropriate, post-exposure treatment should be implemented as soon as possible Injury management: The affected person may wish to attend their usual doctor for further care The following matters should be addressed by the treating doctor: - Infection status of source material (blood) - Counselling of the patient - Blood testing to determine whether infection has occurred - Hepatitis B immunity status of the patient (is a booster shot required?) - Need for HIV Post-Exposure Prophylaxis (PEP) · The practice must follow up the incident and make a final report - Do practice procedures need to be reviewed as a result of the incident? - Do arrangements need to be made with insurers, NSW WorkCover, etc? 24-Hour Needlestick Hotline phone 1800 804 823 September 1999 The compulsory question: what factors will you discuss with a patient for whom an impacted lower third molar is to be removed under local anaesthic before the surgery? I will explain for the patient first about in a basic word about the difference between Partial Bony impaction and complete bony impaction and the complications of both of them. 1. Complete Bony Impaction when the wisdom teeth are completely covered in bone. When the tooth is completely covered with bone it will remain completely covered with its "developmental sack" in which all teeth develop. Later in life, this sack may undergo changes and enlarge and develop into a cyst. This cyst will enlarge at the expense of the bone of the jaw. These cysts should be removed and examined by a pathologist. 2. Partial Bony Impaction when the teeth begin to erupt but are not able to erupt completely. In this situation, the upper third molars usually are positioned towards the cheek while the lower third molars usually lean forward with only part of the crown sticking through the gum. This situation can to decay and gum disease around the second molar directly in front of it. The most common complication of the partial bony impaction is that the flap of gum tissue which partially covers the erupting third molar creates a pocket where bacteria that are present in the mouth can grow and cause an infection known as pericoronitis. The swelling and infection can become very serious. The treatment for pericoronitis is extraction of the third molar tooth. Then I will discuss the risks and complications involved in the removal of third molars which are: PAIN Surgical removal of the third molars can lead to some discomfort and pain. This is usually treated with pain medication. INFECTION Because of the large number of bacteria present in the mouth post surgical infection is always possible. Patients are usually placed on prophylactic antibiotics to prevent infections from developing. SWELLING Following surgery patients may experience swelling and bruising. These symptoms vary between patients. BLEEDING Some post surgical bleeding is considered normal. This is usually minimal and is easily controlled with the pressure of biting on gauze. Inform the patient that third molars can be removed with local anaesthesia alone but many people prefer I.V. sedation during surgery. Finally there are some risks/complications that are unique to the removal of third molars. The upper third molars have roots which often are separated from the maxillary sinuses by only a very thin layer of bone. Occasionally, a small communication is established between the sinus and the oral cavity when one of the upper third molars is removed. If this is the case, the normal procedure is for the area to be sutured closed, the patient to be informed of the finding, appropriate antibiotics and decongestants to be prescribed, the patient to be instructed to avoid Valsalva manoeuvres (tasks which build up pressure in the sinus like nose blowing and bearing down forcefully) and the patient reappointed for follow-up. Most often this results in an uneventful healing period with no further treatment being required. Occasionally, the area will heal open rather than closed in which case an additional small surgical procedure will be required to close the communication. The lower third molars often have roots that lie very near or even wrapped around the inferior alveolar nerve. This is the nerve that supplies feeling to the lip, teeth and tongue on each side of the mouth. Occasionally, when a lower third molar is removed, that nerve will be bumped or bruised and if so a change in sensation may be noted on that side. It is important to understand that this is a sensory nerve and does not affect the ability to move the parts of the oral cavity to which it gives sensation (feeling). In most cases, the nerve heals itself but, because nerves heal slowly, it may take six months to one year before return of normal sensation. Very rarely, the damage to the nerve is permanent. Finally, the normal precautions, risks and benefits of extraction of any tooth Choose two of the following four questions: What are the factors that will reduce the radiation exposure of patient, describe how each factor affects the reduction of patient exposure. The largest single contributor of man-made radiation exposure to the population is medical and dental diagnostic radiology. In total, such radiations account for more than 90% of the total man-made radiation dose to the general population. It is generally agreed by experts in the scientific community that radiation exposure to patients from medical and dental radiographic sources can be reduced substantially with no decrease in the value of diagnostic information derived. The risk to the individual patient from a single dental radiographic examination is very low. However, the risk to a population is increased by increasing the frequency of radiographic examinations and by increasing the number of persons undergoing such examinations. For this reason, every effort should be made to reduce the number of radiograms and the number of persons examined radio-graphically, as well as to reduce the dose involved in a particular examination. To accomplish this reduction, it is essential that patients not be subjected to unnecessary radiological examinations and, when a radiological examination is required, it is essential that patients be protected from excessive radiation exposure during the examination. The recommendations outlined below are directed toward the dentist and the operator of dental X-ray equipment. These recommendations are intended to provide guidelines for the elimination of unnecessary radiological examinations and for reducing doses to patients. Also, included are recommended upper limits on patient doses for certain common dental radiographic examinations. 9.1 Guidelines for the Prescription of Dental Radiographic Examinations The dental practitioner is in the unique position to reduce unnecessary radiation exposure to the patient by eliminating examinations which are not clinically justified. The dental practitioner can achieve this by adhering to following basic recommendations. A radiographic examination should be for the purpose of obtaining diagnostic information about the patient to aid in a clinical evaluation of the patient and treatment when warranted. Routine or screening examinations, in which there is no prior clinical evaluation of the patient, should not be prescribed. It is considered a bad practice to radiograph patients unnecessarily, as in a standard survey, and this is especially deplored when done on children. It is also considered bad practice to take radiograms before a clinical examination by the dentist. These two practices constitute the largest potential abuse of radiology in dentistry. It should be determined whether there have been any previous radiographic examinations which would make further examination unnecessary or allow for an abbreviated radiographic examination. When a patient is transferred from one practitioner to another, any relevant radiograms should accompany the patient or should be requested from the previous dentist. The number of radiographic views required in an examination should be kept to the minimum practical, consistent with the clinical objectives of the examination. In prescribing radiographic examinations of pregnant or possibly pregnant women, full consideration should be taken of the consequences of foetal irradiation. The developing foetus is sensitive to radiation damage that can result in congenital defects. In dental radiology, good radiation protection practice reduces the foetal dose to an acceptable minimum and dose levels which do not constitute a significant hazard. It should be emphasized that precautions to reduce radiation exposure to the patient should be taken all the time because a woman of child bearing capacity may be unaware of her pregnancy. Repeat radiographic examinations should not be prescribed simply because a radiogram may not be of the "best" diagnostic quality, but does provide the desired information. A patient's clinical records should include details of all radiographic examinations carried out. 9.2 Guidelines for Protecting the Patient During Radiographic Examinations It is possible to obtain a series of diagnostically acceptable radiograms and have the patient dose vary widely because of differences in the choice of loading factors and film speeds. It is the responsibility of the operator and dental practitioner to be aware of this and to know how to carry out a prescribed examination with the lowest practical dose to the patient. The recommendations that follow are intended to provide guidance to the operator and dental practitioner in exercising responsibility towards reduction of radiation exposure to the patient. The operator must not perform any radiographic examinations not prescribed by the dental practitioner responsible for the patient. The dose to the patient must be kept to the lowest practical value, consistent with clinical objectives. To achieve this, techniques appropriate to the equipment available should be used. It is recommended the X-ray loading factors charts be established when using X-ray units which do not have preprogrammed anatomical feature settings. The loading factors chart must be established after optimizing the film processing procedure. Fluoroscopy must not be used in dental examinations. Dental radiography must not be carried out at X-ray tube voltages below 50 kilovolts (peak) and should not be carried out at X-ray tube voltages below 60 kilovolts (peak). Dental X-ray equipment should be well maintained and its performance checked routinely. Accurate calibration of the equipment should also be carried out on a regular basis. The quality of radiograms should be monitored routinely, through a Quality Assurance program, to ensure that they satisfy diagnostic requirements with minimal radiation exposure to the patient. The patient must be provided with a shielded apron, for gonad protection, and a thyroid shield, especially during occlusal radiographic examinations of the maxilla. The use of a thyroid shield is especially important in children. The shielded apron and thyroid shield should have a lead equivalence of at least 0.25mmof lead. In panoramic radiography, since the radiation is also not adequate and dual (front and back) lead aprons should be worn. The primary X-ray beam must be collimated to irradiate the minimum area necessary for the examination. The primary X-ray beam should be aligned and the patient's head positioned in such a way that the beam is not directed at the patient's gonads and is not unnecessarily irradiating the patient's body. The fastest film or film-screen combination consistent with the requirements of the examination should be used. The film processing technique should ensure optimum development and should be in accordance with the recommendations given in section 6.1. Sight developing must not be done. Dental X-ray films must be examined with a viewbox specifically designed for this purpose. While recommended dose limits have been defined for radiation workers and the general population, no specific permissible levels have been recommended, to date, for patients undergoing diagnostic radiographic procedures. For patients, the risk involved in the radiographic examination must always be weighed against the requirement for accurate diagnosis. Information from the Dental Exposure Normalization Technique (D.E.N.T.) program is used to provide realistic sets of limits. These recommended upper and lower limits are presented in Table 4. Any patient skin dose greater than the upper limit presented is an indication of poor film processing techniques or sub-standard equipment performance. The lower limits indicate the point where any gain in dose reduction may be reflected by a loss of diagnostic quality of the film. http://www.hc-sc.gc.ca/hecs-sesc/ccrpb/publication/99ehd177/chapter9.htm 11 years child has a class II division I malocclusion; he is a thumb sucker; discuss the causes and how you would manage the case Woman has been wearing an excellent upper denture for sometimes. She has lost all of the lower molars but the anterior teeth are still present. What are the important considerations that you would discuss with the patient in order to accept a lower partial denture? A woman comes to you and you find that she is on Tricyclic Anti-depression medication. How would you manage this patient? Has been answered before Unknown Date: Patient in dental surgery got unconscious, breathless and decrease of pulse rate; how would you manage this condition and what is your diagnosis? The unconsciousness is caused by Cerebral Hypoxia, my diagnosis is Syncope and/ or Physical Shock. The management, Lower head slightly and elevate legs and arms / for pregnant women, roll on left side/ Administer Oxygen at 10L flow/minute Administer spirits of ammonia Apply cold compresses to forehead Keep monitoring and recording vital signs To manage the slow pulse, Administer 0.4 mg atropine IV to increase heart rate Repeat up to 1.2 mg, then consider use of additional vasopressors /epinephrine 0.3-0.5 mg SC or IM, IV with ACLS training/ If there is no pulse start CPR and treat as Cardiac arrest accordingly. 8 years old patient shows with small occlusal carious lesions on 46, what is your management? 20 years old patient comes with a fracture in the middle third of the root of 21, what sort of management you would suggest? 46 years old attends your clinic complaining of pain in TMJ area with clicking during the opening of his mouth; how would you manage this case? 30 years patient attends your clinic seeking a bleaching to his teeth after he has read about a new way of getting white teeth in a magazine; what would you do? Emergency Treatments Unconsciousness Lower the head slightly and elevate legs and arms ( for pregnant women, roll on left side) Administer O2 at 10L. Flow/min Administer spirits of ammonia Apply cold compresses to forehead Monitor and record vital signs Reassure patient in case of low blood pressure, Lower head and raise arms and legs Start 5% dextrose and lactated Ringer’s IV Administer vasopressor drug (epinephrine 0.3-0.5 mg SC or IM, IV with ACLS training Slow Pulse less than 60 beats per minute: Administer 0.4 mg atropine IV to increase the heart rate Repeat up to 1.2 mg, then consider use of additional vasopressors Cardiac Arrest Airway- lift chin, clear airway if necessary, and observe for breathing Breathing- inflate lungs with mouth to mouth resuscitation, give 2 initial quick breaths, and perform endotracheal intubation and positive pressure Oxygen Circulation- check carotid pulse; if pulse is absent, compress sternum 2 t o3 finger widths above xiphoid process. One operator: 15 compressions, 2 inflations-rate of 80 compressions/min Two operators:15 compressions, 2 inflations-rate of 80compressions/min -continue resuscitation until spontaneous pulse return 4. Drugs IV- start 5% dextrose lactated ringers with ( ACLS training) a. Epinephrine 0.5-1.0 ml 1:1000, repeat every 5 minutes prn b. Sodium bicarbonate 1m Eq/kg initially and initial dose every 10 minutes until circulation is restored (or as governed by arterial blood gas measurement) c. Atropine sulfate indicated if pulse is less than 60/min and systolic blood pressure below 90- initial dose of 0.5mg, repeat every 5 minutes but not to exceed 2.0 mg total dose 5. Other drugs used cardiac arrest (with ACLS training) a. Lidocaine (anti-arrhymic agent) b. Calcium chloride (increase in myocardial contractility) c. Morphine sulphate (for pain relief) Monitor and record vital signs, drug administrations, and patient response. Ambulance, emergency room, and medical assistance should be called. Diabetic coma Place patient in supine position Administer Oxygen If patient is conscious, give patient a high sugar-containing drink as Glucola or orange juice If patient is unconscious, a glucose paste can be applied to the buccal mucosa. A dentist with ACLS training can start an IV 5% dextrose and run IV as fast as possible Monitor and record vital signs Activate EMS system by calling 000 Transport patient to emergency room if some improvement is not fairly rapid. And if in doubt treat as an insulin shock. Response to treatment, Insulin shock rapid improvement following carbohydrate administration. Diabetic coma, no improvement after carbohydrate administration and slow improvement (6-12 hours) after insulin administration. Acute Adrenal Insufficiency Conscious, Position patient semi-reclining Monitor and record vital signs Administer Oxygen Administer steroids hydrocortisone 100mg, or dexamethasone 4 mg IV May have to transfer to hospital for lack of fluids Unconscious Position patient supine Monitor and record vital signs Administer Oxygen Call 000 Reviews patient history Administer steroids hydrocortisone 100mg, or dexamethasone 4 mg IV Administer vasopressor (epinephrine 0.5ml) Rapid transfer of patient to hospital. A woman who is on “tricyclic antidepressant” comes to you for dental treatment. Discuss how you will manage this patient. R: At first is important to know her medical history and we should be in contact with her GP. Patients on antidepressant therapy may have some humour and behaviour changes which is important to know. The symptoms and treatment may have effect on her management. Tricyclic antidepressant may cause postural hypotension so the treatment should be carried out in the supine position. Care must be taken to upright the patient slowly to avoid ataxia when ambulant and before discharge. TCA have atropine-like action that may cause xerostomia so it might increase the patient risk of caries and periodontal disease and in edentulous patient it may interfere on complete denture retention and predispose to candidiasis. GA should be avoided once TCA increase risk of arrhythmias with GA. The use of opioid may cause Hypo or hypertension. There is no clinical evidence about TCA interaction with LA containing epinephrine (adrenaline) leading to hypertension. A woman has been wearing an excellent upper denture for sometime. She has missing lower molars and sound anterior teeth remaining in the lower arch. What important considerations will you discuss with the patient to make her believe in order to accept a lower partial denture? First of all we have to inform her importance of using each tooth, so she will understand the importance of replacement of lost teeth. Since she has no lower molars, she can’t eat properly because she just grinds food with lower anterior teeth which can cause problems like: early attrition of superior anterior teeth on denture She can’t grind food correctly which may cause an increase in acid producing by the stomach. Affect aesthetic in anterior region of denture Explain what changes a RPD would be result in her face since the absent of molars the bone will shrink and her cheek would have a shrinking appearance. Her tmj could be affected because the absent of molars. What factors will you discuss with a patient for whom an impacted lower third molar is to be removed under local anaesthesia, before the surgery? Before the surgery we have to explain clearly about how taking care, the management and casual emergency that may happen post-operatively. Everything should be given in noted in a sheet and a talking reinforcement. Furthermore, patient should be make aware of the possibility of some problems like nerve damage, trismus and swelling. Also an advice on a suitable analgesic (e.g. Ibuprofen) that should be taken before the LA wears off. Sometimes the user of an antibiotic should be useful when considered portion of bone will be removed or chronic infection is evident. The use of chlorhexidine 0,05% mouthwash could be useful against infections. What are the factors which will reduce the exposure of the patient to radiation in a dental surgery? List the factors and describe how each affects the reduction of patient exposure. In reducing patient exposure we should take some precautions like: - try to reduce as much as possible the number of r-rays - Dental radiograph must not be carried out at r-ray tube voltages below 50 kilovolts (peak) and should not be carried out at r-ray tube voltages below 60 kilovolts - Dental r-ray equipment should be well maintained and its performance checked routinely. Accurate calibration of the equipment should also be carried out on a regular basis. - The patient must be provided with shielded apron for gonad protection and thyroid shield. The use of thyroid shield is especially important in children. Minimum of a 0,25mm of lead. - The primary bean should be aligned in such way that the beam is not directed at the patient’s gonads and is not unnecessary irradiating the patient’s body. - Speed of film: obtain maximum sensitivity consistent with the image quality required for the diagnostic task. - The primary bean should be collimated to irradiate the minimum 2 area necessary for the examination. Radiographs should be taken using doses of radiation according to the ALARA principle – As Low As Reasonable Achievable. A 11 y.o child has a Cl.II division 1 malocclusion. He is a thumbsucker. Discuss the caused and how you will manage the malocclusion with the mother of the patient. Thumb sucking is a deleterious habit and is greatly related with class II division I malocclusion. It is also not an easy problem to correct in children once it could be connected with psychological and social factors. The mother is a paramount key in helping child to stop thumb sucking so we have to explain her about what this habit cause once class II division I may cause some problems like gingivitis, bad breath because of incompetent lips. Furthermore, the vestibular inclinations of incisors cause a greater risk of trauma fracture. In the management we have to aim the reduction of overjet and overbite. So, deep assessment would be done. Removable appliance should be useful in aid stop thumb sucking if the child is cooperative. If not some visits to a psychologist should be considered. The key to planning is the canine relationship; we have to tip canine back into class I relationship. Once canines are in class I, retro cline upper incisors to reduce overjet. The best way for achieve this is by two-arch fixed appliance as we can control overjet and overbite. By the and of the treatment the thumb sucking habit must be stopped. Moisture control Isolation and moisture control is required to aid visibility, prevent contamination during moisture sensitive techniques, maintain a relatively aseptic environment, and protect the patient from caustic materials and aspiration of foreign material. For each work we can use a type of moisture control which is suitable for us. These types are: High-volume suction: eg. Aspirator. Aids in vision and reduces aerosol Low-volume suction: eg. Saliva ejector. Many designs are available. Aids vision and aids patient’s comfort and we reduce the need of swallow or spit-out. Compressed air: This do not remove moisture but redistribute the moisture to somewhere else. It cannot be used alone. Aids in drying tooth or cavity surface. Absorbent pads: are often triangular in shape, placed buccaly. Useful when working on upper molar teeth Rubber dam: Provides the optimum means of isolation. Effective isolation. Prevents salivary contamination, inhalation or ingestion of foreign bodies, contamination of materials. Protects airway and protects patient from potentially irrigants. Control soft tissue and aids visualisation. Provides physical barrier from oral fluids and reduces bacterial load of aerosols. It can be used to isolate one tooth or a number of teeth. Retractions: used to aid in visualization and control gingival exsudate where caries are subgingival or prior to impression taking Can be used imbibed with an astringent. Care must be taken to not traumatize anaesthetised tissues. Electro surgery: May be indicated where margin extends subgingivally and gingival overgrowth is hampering restoration placement or impression taking. Indication and technique of pit and fissure sealants. Once it is not cost effective to seal all occlusal surface we should select some cases which include patient selection: Children with impairment (special needs) Children at high risk (caries in the primary dentition) Teeth at high risk (teeth with deep fissure or pits) Sealant should be applied as soon as practicable and within 2 years of eruption. Only sound teeth should be sealed. If there is suspicion of caries, investigate with a small bur and provide sealant restoration. Technique: Prophylaxis (clean with rotatory bristle brush and pumice to remove pellicle) Wash, isolate and dry the tooth Etch for the time recommended by the manufacturer with 30 – 50% phosphoric acid. Wash for 15 seconds , if salivary contamination, re-etch Dry tooth very well Apply sealant and cure Check – try to remove Check occlusion Moisture control is crucial. Salivary contamination lead to markedly reduction of the retention. What advise would you give to a patient who has a darkened upper central incisor? A single discoloured tooth is usually relationed wuth non-vital tooth. So we have to advice the patient about RCT. Take a R-ray to check RCT if it already exists. In RCT tooth we would advice him about bleaching techniques if tooth is sound and not very restored. I would explain him about bleaching technique that I would remove the gutta-percha 2mm bellow amelo-cemental juntction then place a thin layer of CI cement, remove any stained dentin and place a paste of perborate and seal. If the tooth was very restored or not sound I would advice him about PJC or porcelain crows that would be more suitable on this case. A controlled, non-insulin dependant diabetic patient requires extraction of tooth 47. What are the treatment precautions, if any? There is some precaution we should take in managing diabetics patients for surgery. Once the major concern for dental practioner treating diabetic patients is hypoglycaemia, we should take some precautions like: Perform the surgery soon after meal times Try to manage patient in short appointment A morning appointment should be better Patient should maintain oral hypoglycaemic drugs and carbohydrate intake as usual Ensure emergency glucose and drugs to hand. Prescribe antibiotic and analgesics judiciously for prophylaxis to prevent infection secondary to delayed healing. Premedication in anxious patient with benzodiazepines Use gradual position changes to avoid postural hypotension Medical considerations. Take a thorough medical history for all patients diagnosed with diabetes. Ascertain the identity of the physician treating the patient and the date of the last visit. Obtain information concerning the type of diabetes, the severity and control of the diabetes, and the presence of cardiovascular or neurologic complications. Refer any patient with the cardinal symptoms of diabetes or findings that suggest diabetes (headache, dry mouth, irritability, repeated skin infection, blurred vision, paresthesias, progressive periodontal disease, multiple periodontal abscesses) to a physician for diagnosis and treatment. Diabetic patients who are receiving good medical management without serious complications such as renal disease, hypertension, or coronary atherosclerotic heart disease, can receive any indicated dental treatment. Those with serious medical complications may require an altered plan of dental treatment. When the severity and degree of control of diabetes are not known, treatment should be limited to palliation. Food intake and appointment scheduling. To preventing insulin shock from occurring: Verify that the patient has taken medication as usual. Verify that the patient has had adequate intake of food. Schedule appointments in the morning, since this is a time of high glucose and low-insulin activity. Afternoon appointments are a time of low-glucose and high-insulin activity which may predispose the patient to a hypoglycemic reaction. Instruct patients to tell the dentist if at any time during the appointment they feel symptoms of an insulin reaction occurring. A source of sugar, such as orange juice, must be available in the dental office should the symptoms of an insulin reaction occur. Oral surgery concerns. It is important that the total caloric content and the protein/carbohydrate/fat ratio of the patient's diet remain the same so control of the disease and proper blood glucose balance are maintained. IDDM diabetics who are going to receive periodontal or oral surgery procedures may be placed on prophylactic antibiotic therapy during the postoperative period to avoid infection. Consultation with a patient's physician before conducting extensive periodontal or oral surgery is advisable. The physician may, in fact, recommend that the patient be treated in a hospital environment where infection, bleeding, and dysglycemia can be better managed. Dangers of acute oral infection. Any diabetic patient with acute dental or oral infection presents a problem in management. This problem is even more difficult for patients who take high insulin dosage and those who have IDDM. The infection will often cause loss of control of the diabetic condition, and as a result the infection is not handled by the body's defenses as well as it would be in a nondiabetic patient. The patient's physician should become a partner in treatment during this period. Oral complications. The oral complications of uncontrolled diabetes mellitus may include: Xerostomia, Infection, Poor healing, Increased incidence and severity of periodontal disease, and Burning mouth syndrome. Diabetic neuropathy may lead to oral symptoms of tingling, numbness, burning, or pain in the oral region. Oral findings in patients with uncontrolled diabetes are thought to be related to excessive loss of fluids through urination, altered response to infection, microvascular changes, and possibly increased glucose concentrations in saliva. Early diagnosis and treatment of the diabetic state may allow for regression of these symptoms, but in long-standing cases the changes may be irreversible. Potential Drug Interaction. While patients with well-controlled diabetes can be given general anesthetics, management with local anesthetics is preferable. General anesthetics should be used with caution because they can produce hyperglycemia. Discuss what precautions you might take, and what post-operative instructions you might give a patient for whom you had removed a tooth at 5pm on a Friday afternoon, if you were leaving immediately for the weekend away yourself. Some precautions should be take to avoid post operative complications specially if T would a take a weekend off. Precautions include: Advice the patient to do not intake any medication that contains acetylsalicylic acids. Eg: asprin Gathering patient’s health information to the correct post-operative management. Minimize as much as possible any osseous trauma to avoid swelling. Inform about possible bleeding and swelling. Cold compress and compression is useful in the management of bleeding and swelling. Prescription of a non-steroidal anti-inflammatory to take after surgery . Chlorhexidine 0,05% mouthwash will aid against infections. Outline the different factors that may affect the stabilization and retention of full upper and lower dentures. On both: Peripheral seal : over-extension will result in denture that is displaced in function Contact area between denture and tissues: As close an adaptation of denture base to mucosa as possible to maximize the surface tension effects of saliva. Close fit Viscosity/volume of saliva: xerostomia decrease retention Placement of teeth in neutral zone Balanced occlusion free from interfering contacts Correct shape of polished surfaces so that muscle action tends to re-seat the denture. Muscle action Greater vertical dimension – freeway space On upper dentures: Post dam Lower denture: Usually a problem because the residual ridge is often not enough to gain retention Design a brief list of “medical history” questions to be used as part of a patient’s overall history-taking procedure. Some questions as follow should be formulated for gathering some medical history information from patient in order to achieve the best way of management in dentistry: Are you fit and well? Have you ever been admitted to hospital? If yes, give the details Have you ever had an operation? Have you ever had any heart trouble or high pressure? Have you ever had any chest trouble? Have you ever had problems with bleeding? Have you ever had asthma, eczema , hay fever? Are you allergic to any other drugs? Have you ever had: Rheumatic fever? Diabetes? Epilepsy? Tuerculosis? Jaundice? Other infection disease? Are you pregnant? Are you taking drugs, medications or pills? Who is your doctor? Write short notes on the diagnosis and management of “dry socket”. Diagnosis: Pain onset 24 to 48 hours after extraction, frequently with noticeable odour and bad taste. The socket is in extremely pain and looks inflamed and exposed bone is usually visible. Management: Irrigation under LA or not and dress the exposed bone with ALVOGYL or ZOE packs. Topical metronidazole is an alternative. Chlorhexidine mouthwash may help. NSAIDs are analgesic of choice. Write short notes on the clinical assessment phase of the insert visit for a removable partial denture. Once any fitting surface roughness is eliminated, the denture are tried in separately, adjusting undercuts contacts if required. The extension, occlusion and articulation are then adjusted if necessary. Give the patient written and verbal instructions about oral hygiene, how to clean dentures correctly and the natural teeh once using of denture will increase plaque accumulation. Write short notes on alternatives to removable partial denture forsingle maxillary anterior tooth replacement. Alternatives in replacement a single anterior tooth could be: Fixed Bridges: if the adjacent teeth are greatly restores and the patient is disposed on afford with the cost. Cantilever bridge: Depend on which tooth is absent. Indication is in replacement of anterior tooth with low occlusal forces. Eg lateral incisors. Adhesive bridge: In low occlusal forces, one or two abutment could be used. When adjacent teeth are sound. Don’t need greatly reduction of teeth, just in palatine or lingually Implant What would be your recommendation tohte parents on fluoride for a 3 years old boy? We should explain to parents that child with 3 years old should have a daily ingestion dose of fluoride which aid in prevention of caries and fluoride will aid in mineralization of pré-eruptive teeth (permanent) and in prevention of caries and remineralization on desmineralized post-eruptive teeth. Depending on water fluoride supply we will advice a daily fluoride tablet which will vary the dosage(will vary between 0-0,5mg) depending on the concentration of fluoride in water supply. I would explain about amount of toothpaste on child’s toothbrush that will be not bigger than a pea size. And in spite of toothpaste pleasant taste, the child should spit out everything when finishing brushing. TOPICAL FLUOR ? Osseointegrated implants. Explain to the patient advantages and disadvantages so he can make a decision. Advantages: As our life span increases, a permanent dental replacement like implants is increasingly important as we get older. While dentures and removable bridges are usually loose and unstable, implants provide you with dental replacements that are both natural looking and very functional. Implants look much better, and feel better, than traditional removable bridges, and offer the same force for biting as bridges that are fixed in place. Implants will last your lifetime. Disadvantages: Implants are a major investment and not without risk. The extensive use of implants can cost tens of thousands of dollars to achieve a great result. It is also a very time consuming procedure when having many implants placed. As this procedure is surgery, it is very important to research and find a well credited cosmetic dentist that you are comfortable with. For some people there are varying degrees discomfort or pain, which subsides in a couple of days. As with similar types of surgery, bruising and minor swelling might also develop shortly after the procedure. The crown (false tooth placed on top) will need to be replaced in ten to fifteen years. Patient had hepatitis 10 years ago. What would be your additional information that you have to get from patient and how can that effect your dental management of that patient? A 15 years old patient, still have deciduous canine present in the mouth, no evidence (clinically) of permanent successor. What would be your treatment? A 15 years old patient in general should has the canines been erupted. Once the presence of the teeth can’t be observed by visualization, palpation should be done in order to feel by touching the ridges buccaly and palataly to find ant protuberance. If not felt by touching, I would take a R-ray to investigate the presence of a possible impacted canine. Usually more than one r-ray should be take in order to see the correct position of an impacted canine tooth. When impacted canine tooth is diagnosed, an orthodontic extrusion following a surgery to access the tooth should be realized. Describe the procedures that would ensure the correct sterilization of dental burs and handpieces. Discuss types of sterilization methods and verification procedures to ensure correct sterilization. Used burs should be considered as contaminated and appropriate handling precautions should be taken during reprocessing. Gloves, eye protection and a mask should be worn. Other measures may be required if there are specific infection or cross-contamination risks from the patient. The burs can be transported wet or dry and should be protected from damage to the cutting edges. If transported wet there is an increased chance of staining or corrosion. Prolonged storage in disinfectant solutions may result in corrosion and should be avoided. PREPARATION FOR CLEANING There are no special requirements unless infection controls require the use of a disinfectant, in which case a disinfectant agent validated for processing of dental burs must be used and the disinfectant manufacturers’ instructions must be followed DRYING Dry the burs using paper towelling or dry heat not exceeding 140ºC. PACKAGING FOR STERILIZATION If using a vacuum autoclave pack the burs in dedicated bur stands or pouches validated for sterilization. If using a non-vacuum autoclave the burs should not be packed or wrapped but be contained in dedicated bur stands with perforated lids. STERILIZATION Autoclave the instruments for a holding time not less than three minutes at a temperature of between 134 and 137ºC. Other validated time/temperature regimes may be used. The holding time is the minimum time for which the minimum temperature is sustained. Handpiece Sterilization/Asepsis The following outlines the accepted protocol for sterilization/asepsis of dental air-powered handpieces. NOTE: The motor of your slow-speed handpiece cannot be sterilized. Before removing handpiece from the hose following treatment, wipe all visible debris from handpiece and briefly operate air/water system to flush water and air lines. Remove handpiece from hose and clean all external surfaces with gauze or scrubbing brush saturated with isopropyl alcohol. Do not use ultrasonics. Dry thoroughly with gauze. Clean internal parts of handpiece to remove aspirated debris and wear products. Lubricate if required. Refer to manufacturer’s maintenance and lubrication. CRITICAL STEP: Insert a bur, disc, or prophy cup in handpiece, connect to delivery system tubing, and operate for 15-20 seconds to distribute lubricant throughout handpiece. Omitting this step prior to sterilization may lead to excess lubricant accumulating in the working assembly and "gumming" up the rotating assemblies during the heat cycles. This may cause subsequent slowing and/or stoppage of the handpiece. Wipe away excess oil expelled at the head of the handpiece during this step. Fiberoptics: remove all excess lubricant from fiberoptic interfaces and exposed surfaces. Lubricant and/or dirt can be forced between individual fiber strands during pressure sterilization and lead to darkening or dimming of fiberoptic bundle. Do not use strong solvents on fiberoptic faces or the epoxy binder between the fibers may dissolve. Remove bur, disc, or prophy cup and disconnect handpiece from tubing. Make sure hand- piece or component is clean and dry both internally and externally. Place handpiece in a sterilization bag and deliver it to Central Sterilization. Before attaching sterilized handpiece to unit hose, flush air-water lines of hose for 20-30 seconds. Attach handpiece to unit hose and run for 20-30 seconds. Handpiece is now ready for patient use. Discuss principles of infection control in dental practice. Infection control is of primordial importance in clinical environment, where some precautions should be done: - Immunization of all clinical staff against hepatitis B and commo illness - Get medical and social history every patient. - Using gloves and mask and eye protection - Surgery design and equipment: Moderns equipment which minimize touching in some surfaces - cleaning and sterilizing instruments - All staff must be trained in cross-infection control and every practice must have a written infection control policy. - Treatment of work surfaces: during use, instruments should only be placed on sterilized surfaces - Aerosol: Minimize these by high-volume suction. - Blood spillages. Immediately cover with disposable towels, treat with 10000 ppm hypochlorite sodium - Disposal of sharps: Sharps must be placed in a rigid sharp containers - Rinse and disinfect all laboratory items prior to dispatch to lab - Transmissible spongiform encephalopathy: these include Creutzfeldt-Jakob disease and variant. Patients with known history of these should be treated in specialized environments as routine autoclaving foes not destroy the causative agent. Flush handpiece for 30 seconds with bur in place. Flush suction with water Flush spittoon Always wear heavy duty gloves, eye protection and face mask when handling contaminated instruments. Handling of contaminated instruments should be reduced to a minimum to reduce the risk of percutaneous injury. Discuss the procedures involved in surgery preparation between patiens. Following a patient treatment session, the following protocol for processing and sterilization shall be employed: Remove all disposable "sharps" from contaminated work area (cart top and bracket table) after completing care, and place in the sharps container in the operatory Remove all disposable waste from the activity area and discard, taking care to properly dispose of materials designated as infectious, or regulated waste (any body fluid). Pre-soak in ultrasonic solution, if needed, for dried-on body fluids. All instruments must be cleaned prior to packaging for sterilization in an ultrasonic cleaner with the appropriate cleaning solution for at least 12 minutes. Handling of instruments during the cleaning should be done with heavy gauge utility gloves to minimise the risk of accidental injury. Even with utility gloves, never reach into a container, or ultrasonic containing reusable sharps. Instead, rinse the instruments, then invert the container onto an appropriately covered surface. The ultrasonic cleaner lid must be in place during the cleaning cycle. Instruments are to be rinsed with water following cleaning and spread on paper towels and allowed to dry. Handpieces must be externally cleaned with a brush or paper towel and detergent to remove external debris prior to sterilization. ??????? Discuss the management of blood-contaminated instruments following a dental surgical procedure. Discuss the procedures for managing an operator needle-stick injury following infiltration anaesthesia. wound should be washed (and not scrubbed) for several minutes with soap and water, or a disinfectant with known activity against BBVs (10% iodine solution or chlorine compounds) It is very important not to scrub the injury since this may inoculate the virus into the tissues Pressure above the wound to induce bleeding from the contaminated injury should also be performed cover the wound with appropriate dressing. Establish hepatitis antibody status of injured party. Need for HIV Post-exposure Prophylaxis (PEP) Blood testing to determine whether infection has occurred. Take detailed information about the injury, including how long ago it happened, how deeply the skin was penetrated, whether or not the needle was visibly contaminated with blood, and any first aid measures used. The appropriate agency notification of injury form which includes: . Name of the source individual (affix patient ID label); . If the source of the blood in unknown, this must also be documented Discuss those aspects of full denture construction that you would check at the try-in stage. On this stage of full denture construction I should check if the vertical dimension of occlusion is correct , check the horizontal jaw relationship, anterior and posterior occlusal planes, check stability , extension, the position of teeth, aesthetic and phonetic. The trial denture should be examined critically prior to insertion. Asses tooth position and if not a chairside adjustment should be done. On this stage , the patient will see how denture will appear so I must allow him to opine about tooth shape, shade and colour. Only when dentist and patients are satisfied, the trial dentures may be sent to the technician. Discuss the adverse effects that removable partial dentures may have on dental-oral tissues. Discuss the role of the dental surveyor in removable partial denture. The dental surveyor is used on constructions of RPD. Some of its function is: establish path of insertion define those undercuts which may be used to retain denture define those undercuts which require blocking out prior to finish Surveying the diagnostic cast Recontouring abutment teeth on the diagnostic Contouring wax patterns Measuring a specific depth of undercut on aiding the construction of clasps Placing intra coronal retainer Surveying and blocking out the master cast Describe and discuss common post-insertion problems that a patient may complain of at the 7-day check visit following full upper and lower denture insertion. Some problems are common in post-insertion dentures which include: pain: this can be due to a variety of causes, including a roughness of the fitting surface, errors in the occlusion, lack of FWS, a bruxing habit, a retained root, or other pathology. Forward or lateral displacement of a denture due to a premature contact can lead to inflammation of the ridge on the lingual or lateral aspect, respectively. With continued resorption bony ridges become prominent and the mental foramina exposed, which can lead to localized areas of specific pain. Looseness: more common in the lower than upper dentures and can be due to dentures factors or patient factors. Dentures factors is connect with faults in denture construction which may be incorrect peripheral extension, teeth not in neutral zone , unbalanced articulation or polished surfaces unsatisfactory. Patient factors include inadequate volume or amount of saliva, poor ridge form and low adaptive skills. Burning mouth: this can be due to: Local causes e.g. greatly occlusal vertical dimension sensitivity to acrylic monomer. Systemic causes e.g. the menopause, deficiency states, cancerophobia, xerostomia. Speech problems: some difficulties may be related in trying speech some letters like F , V, D, S , T, TH and it is due to teeth position or incorrect overjet or overbite or thickness of the acrylic palatally. Clicking teeth: due to greatly OVD or lack of retention Cheek biting: Possibly teeth are in neutral zone or an buccal overjet of molars. Reduce buccal surface of lower molars. Describe relationship between crown and biological width. Apical abscess. After inferior block anaesthetic, numbness of lip, tongue and buccal site; however patient still feels pain. Describe the reason and how to manage it. Management of patient with diabetes and allergy to penicillin. = 9 but in pacient allergic to penicillin we should change on antibiotic-therapy to Erythromycin or clindamycin. A 12 year-old patient has avulsed an upper central incisor just 20 minutes ago. The parent phones your surgery for advice. What would be your instructions over the phone? Outline your management of the case. The management will change a little depending on trauma or fracture in alveolar bone. My first advice when parents have called me would be to do not touch the root nor scrap root surface in order to clean. Handle the tooth by the crown only and put the tooth into a Hank's Balanced Salt Solution if possible. If not, put into Milk , Saline solution or Saliva. If these solutions are not available, water could be use because the drying of the tooth is the worst thing to happen. Tell the parents to immediately coming to my office. In office environment I would assess completely the local of injury, look for soft tissues injury, fracture of the alveolar bone. In managing the tooth I would just handle it by the crown and rinse with saline solution. I would anaesthetise the socket, and gently irrigate and aspirate (without entering) in order to remove foreign bodies and clot. Then reimplant the tooth manually into the socket and suture soft tissues. Then a acid-etch splinting with orthodontic wire should be done and remain for 7 to 10 days but if the tooth is still mobile, the splint should remain until the tooth become with acceptable mobility. Advice parents and child about home care which include: a. No biting on splinted teeth b. Soft diet c. Maintenance of good oral hygiene Prescription an analgesic and antibiotics(?) and referral to a physician for tetanus vaccine. Advice parents that the tooth should be reviewed each 3 to 6 month for surveying the degree of success of reimplantation. A patient with a lower molar extracted one week ago presents with pain associated with both TMJ’s. what is the possible diagnosis and treatment? The possible diagnosis is a TMD probably caused by too much pressure by the dentist on the jaw or pushing the jaw posteriorly when extracting the tooth. Treatment includes a soft diet, moist head, a mild pain medication and limited jaw function for 1-2 weeks. Prescribe an analgesic (e.g. Paracetamol 1000mg, 4 hourly) A patient who requires extraction of an impacted 3rd molar has a history of bleeding after extractions. What would be your management of the case? First of all take a complete medical history in order to gathering information about bleeding disease and ask about anticoagulant therapy. In general some precautions should be taken prior to a dental extraction. I should ensure that platelet level of > 50-75 x 10(9)/l , levels lower than this require platelet transfusion with IV anti-histamine and hydrocortisone cover prior to surgery. Local measures avoiding bleeding should be done in surgery. Suture is always needed on these cases. Advice cold compress … Discuss the effects of cigarette smoking on general health and its impact on oral health. What would you tell your patients to encourage them to stop smoking? Smoking is now identified as a major cause of heart disease, stroke, several different forms of cancer, and a wide variety of other health problems. The vast majority of deaths caused by smoking occur through development of heart disease and lung cancer, followed by chronic bronchitis, stroke, peripheral vascular disease and other circulatory diseases, and cancers other than lung. Smoking has several negative effects on the mouth and teeth. Smoking stains the teeth and calculus brown. Smoking also greatly increases the risk of gum disease. Smoking reduces the blood flow to the oral tissues and gums, hence lowering the resistance to plaque bacteria. Smoking is also a major cause of oral cancers. The type and appearance of oral cancers varies greatly. The most common sites for oral cancer include the lips, side of the tongue, and under the tongue on the floor of the mouth. Also smoking cause bad breath and loss of taste. I would explain him everything about smoking damage to health and oral health that would make him think about stop smoking. I also would emphasise his oral appearance that would be much better after stop smoking. When placing a proximal-occlusal (Class II) amalgam restoration, how do you ensure that the proximal surface of the restoration is properly contoured? When placing a Class II amalgam restoration some precautions should be taken once at least one proximal contacting wall has been removed. The use of a matrix is essential and its purpose is: substitute for the missing wall so that adequate condensations forces can be applied permit re-establishment of a proper contact point with the adjacent tooth restrict extrusion of amalgam and prevent the formation of an “overhang” at the gingival margin Provide adequate physiological texture to the proximal surface, especially in the area of the contact point To ensure correct proximal surface a matrix band should be selected, fitted to the tooth and used in conjunction with a wedge. The gingival edge of the matrix should extend 1mm gingival (if possible) to the gingival margin. The occlusal height of the band should be at least 1mm above the height of the marginal ridge crest. The wedge is inserted and its body should be gingival to the gingival cavosurface margin. The matrix band should be in contact with the adjacent tooth during condensation. The wedge will slightly separate the teeth to compensate for the thickness of the matrix band and ensure that the final restoration has a suitable contact point. On condensation: Place small increments of amalgam into the deepest part of proximal box and condense using vertical and lateral condensation forces. Condense amalgam at the proximal box and then in reminder of cavity preparation. Over pack the occlusal surface by 1 – 2mm. Carving: Do not initiate carving unless the production of amalgam “shaving”. Always carving parallel to cavosurface margin. First cave within matrix band with a discoid carver to expose the occlusal cavosurface margin of preparation. Carve the height of the marginal ridge to correspond to the height of the marginal ridge of adjacent tooth. Carve the occlusal embrasure using the tip of an explorer. Remove the matrix band and wedge. The proximal contour should require a little carving. Amalgam excess on the vertical walls of the proximal box may be removed. Any amalgam excess and overhang should be removed. Discuss the possible sequelae of preparing and placing full veneer crowns with subgingival margins. Discuss factors affecting long-term prognosis of avulsed anterior tooth. Some factors should be considered about affecting long-term prognosis in avulsed tooth. It is closely related to extra-alveolar, dry-storage time. Teeth stored dry for > 30 minutes have a very poor long-term prognosis, but replantation may still be worthwhile, as failure is usually by replacement resrobtion which is slow. (i.e. tooth may last several years) and maintains bulk of alveolus. If tooth is replanted within 2 hours after avulsion and stored in saliva, milk or Hank’s Balanced Salt Solution the prognosis is good. Discuss factors affecting selection of suitable material for direct MOD restoration on lower molar. A 25 year-old patient presents with abcess on tooth 36. how would you manage? The management requires drain pus and relief occlusion, if indicated. Drainage of pus can often be achieved by entering the pulp chamber with a high-speed diamong bur. The tooth should be steadied with a finger to prevent excessive vibration. After drainage has been achieved, irrigate with sodium hypochlorite and it is preferable to prepare the canal and place a temporary dresser. Leaving the tooth on “open drainage” should be avoided if possible, but if absolutely necessary for less than 24 hours, as after this time further contamination will occur. If a fluctuant swelling is present in the soft tissues, this should be incised to achieve drainage. Antibiotics should be prescribed if there is systemic involvement or if the infection is spreading significantly along tissue planes. When the acute symptoms have subsided, RCT must be performed or the tooth extracted. How do you manage a patient with Anaphylactic shock(reaction)? Clinical recognition Early sensations of warmth, itching especially in axillae and groins feelings of anxiety or panic Progressive erythematous or urticarial rash oedema of face, neck, soft tissues Severe hypotension (shock) bronchospasm (wheezing) laryngeal oedema (dyspnoea, stridor, aphonia, drooling) arrhythmias, cardiac arrest Note: The onset of severe clinical features may be extremely rapid without prodromal features. Management: Cease administration of any suspected medication Place patient supine with legs raised, if possible Inject adrenaline IM: - 0,25ml for small adults ( > 50Kg) - 0,50ml for average adults (50 – 100Kg) - 0,75ml for large adults (< 100kg) - Up to 500mg of hydrocortisone IV. - Up to 20mg of chlorpheniramine slowly IV - O2 by mask, RPD treatment plan It is important to enquire about previous denture history and asses the reason for failure or success. Relief of pain and any emergency treatment. History and exam, including a thorough clinical and radiographic assessment of remaining teeth and edentulous areas. It is important an oral and extraoral examination. Unless immediate dentures planned, extract any teeth with poor prognosis Oral Hygiene and periodontal treatment Preliminary design of partial denture Carry out restorative treatment required Modify design if necessary and commence prosthetic treatment. Management of patient with heart disease. There are some implications in the management of patient with heart disease and it should be straightly respected. In general, managing patient with heart disease consist in: Gathering information about medical history, medication therapy, dental history. Always be prepared for emergencies. Patient should be managed in a quiet and calm environment that reduces anxiety and stress. Sedation with medication should be considered in anxious patient. effective local anaesthesia - max 0.040 epinephrine avoid anticholinergic drugs monitor blood pressure, pulse – use pulse oximeter antibiotic prophylaxis in some heart disease (e.g. rheumatic heart disease) avoid GA avoid fatigue avoid routine invasive care for 6 months s/p MI – myocardial infarct consider that this patient usually are under anticoagulant therapy Consult patient’s physician to clarify any doubt about the disease. do not use epinephrine in retraction cords and astringent medications Choosing between restoration modalities. When choosing a modality of dental restoration we should consider: Duration: some materials can last more than others. E.g. direct resin filling may last less than a indirect technique using gold. Occlusal forces: It is very important when choosing modality of restoration because it deals with the success of restoration. E.g. Adhesive bridge only can be considered on low occlusal forces. Aesthetic Galvanic reaction: Some metals can’t be in contact between them once it starts galvanic reaction that can reduce the success of restoration. E.g. Amalgam shouldn’t be in contact with gold. The amount of caries, structural tooth remaining. Bio-compatible with soft tissues Space maintainers. Primary teeth have many functions, one of which is to hold the place for the permanent teeth. Premature loss of the primary teeth can cause spacing problems with the permanent teeth if no space maintainer is placed. The proposed space maintainer will hold open the space so that the permanent tooth will be able to erupt into its correct position and alignment. Without a space maintainer, the remaining teeth drift into the space before the permanent tooth erupts resulting in loss of space. When this has occurred, the permanent tooth is forced to move out of alignment and comes in crooked Tongue thrusting. Over dentures. An overdenture derives support from one or more abutment teeth by completely enclosing them beneath its fitting surface. Advantages: alveolar bone preservation around retained tooth. Improved retention, stability and support Preservation of proprioception via PDL Improved crown to root ratio, which decrease damaging lateral forces Increase masticatory forces Additional retention possible using attachments Aids transition from partial denture to full denture Disadvantages: RCT probably required To avoid excessive bulk in region of retained tooth, denture base may need to be thinned, which increase likelihood of fracture Increase maintenance for both patient and dentist Indications: Motivated patient with good oral hygiene. Because of decreased retention and stability of lower denture and greatly rate of mandibular resorption. Overdentures are particularly useful for lower dentures or free-end saddle. Cleft lip and palate Hypodontia Severe toothwear Choosing abutment teeth Ideally: bilateral, symmetrical with minimum of one tooth space between them. Order to preference: canines, molars, premolars and incisors. Healthy attached gingival, adequate periodontal support (> ½ root in bone), and no or limited mobility Is RCT required and if so is it feasible? Preparation of abutment teeth Removal undercuts only Preparation of crown for thimble/telescopic gold coping. RCT, tooth cut to dome shape and access cavity restores with amalgam or an adhesive restoration RCT and gold coping over root face RCT and precision attachment Most problems are caries on abutment and periodontal breakdown Immediate dentures. An immediate denture is a prosthesis used to replace one or more teeth and inserted on the day of extraction of the tooth or teeth. General features: Immediate dentures may be used for complete or partial dentures. They should be considered as transitional. Treatment planning: When many teeth are to be extracted, consideration should be given to either staging of extractions or post-immediate dentures. Reasons for immediate dentures: Aesthetics Psychological Improved masticatory function Stabilisation of wound Problem with immediate dentures: Lots of aftercare required Frequent adjustments Often do not equate to patient’s perceived expectations, functionally or aesthetically Sometimes considerable post-extraction discomfort Clinical Aspects Removing teeth from cast: the correct method of trimming a tooth to be extracted from a cast before immediate denture construction is to cut across from one gingival papilla to another following ridge contour. Socketing of teeth is not desirable as this limitis clot size and decrease fibrous tissues deposited. Flanges: If possible, immediate dentures should have full flanges rather than be gum fitted. This ensures peripheral seal although may involve undercut trimming at insertion Follow-up: At the time of immediate denture insertion, some checks are not possible as the patient may be locally anaesthetised or swollen. Ideally the patient should be seen the following day occlusal and other checks to be made. Clinical procedures: Assessment. Warn the patient about the effects of resorption and the need for early rebasing/replacement. Primary impressions Second impressions in alginate or silicone Recording occlusion. Where there are sufficient posterior teeth remaining, a wax wafer should suffice, and this can be taken at the same visit as impressions are recorded. Try-in. ?? Extraction of remaining teeth as atraumatically as possible Finish. Repeated removal and insertion of the denture should be avoided, therefore adjustments should be limited to making the patient comfortable. They should instructed not to remove the denture before the review appointment in 24h. Review. The fitting and occlusal surfaces are adjusted as required. If the dentures are unrententive they will require temporary reline. Recall. Regular inspection of immediate dentures is important as rapid bone resorption means that they will require rebasing early. However, this should be deferred, if feasible, for at least 3 months after extractions. A possible regimen is 1 week, 1 month, 3 months, 9 months, and than yearly. Problems – denture unrententive and gross occlusal error How do you manage a patient on steroid therapy and long standing rheumatoid arthritis? A patient with rheumatoid arthritis requires a special dental management since Rheumatoid arthritis is a serious systemic disease which is painful and fatiguing and can lead to significant disabilities that make it difficult for patients to look after their teeth and gums. Furthermore these patients often are in medication therapy which can deal with increase risk of infections and bleeding. In managing these patients we should take some precautions as follow: Gathering information by taking medical history with attention to the disease. E.g. How long do you have arthritis? Can you brush your teeth? Flossing? Type of medications? Dental care needs to be planned according to the individual needs of the patient, their degree of disability, their comorbid conditions, age, and the drugs they are taking. Short dental appointments: Patients often have pain on TMJs when maintain mouth opened for a long time. Asses if aspirin or NSAIDs are affecting platelet function – If intake call the person’s physician or specialist if any concerns. Reduce the stress as it can deal with adrenal crisis When in steroid therapy, asses for how long time and quantity Steroid therapy may cause increase risk of infection, difficulty wound healing and increase bleeding and hypotension. Antibiotic prophylaxis for this cases Patients undergoing minor surgical procedures under local anaesthesia are at very low risk, if any, for developing adrenal crisis so they just need to keep their usual dose. However, patients taking high doses of steroids should double the usual dose on the day of the surgery. Thus, for patients undergoing general anaesthesia for minor surgery 100 mg hydrocortisone intramuscularly should be administered and the usual glucocorticoid medications maintained. For major surgery 100 mg hydrocortisone delivered as a bolus pre-operatively followed by 50 mg 8-hourly for 48 hours is adequate. in case of adrenaline insufficiency pat should be given a shot of 100mg hydrocortisone Write a prescription for Penicillin and Analgesic for a 8 year-old child. Dr. Rafael Maia 35 Guapore Street Phone: 3455-5597 Name: Joao da Silva Age: 8 years Address:32 Stanhope Street D.O.B: 12/0 Newton , SA Rx – Ibuprofen 200mg 200 mg 3–4 times daily preferably after food Rx - Amoxicillin oral suspension 250 mg/5 mL 250 mg (5ml) 3 times daily Number of items: 2 Dr. Rafael Maia (signature) Date: For dental treatment only How to manage patient on Tranquiliser therpy? 6-8 weeks old rigid intrusive with alveolar fracture. Chronic periodontitis. Phase I Therapy 1.Diagnosis Before any treatment is performed or prescribed, the patient must have a complete diagnosis. This must include: a medical and dental history intra and extraoral examination appropriate x-rays must be available laboratory tests such as the IL-1 genetic susceptibility test, microbiology sampling or chairside tests are usually performed at this time. 2. Risk Assessment Risk Assessment and the determination of prognosis is essential in order to develop the most appropriate therapeutic alternatives. 3. Treatment Plan If acute infection, accompanied by diffuse non-localised oedema, suppuration and pain, the dentist may consider adjunctive antibiotics at this time. The goal for this possible use of systemic antibiotics to take the patient out of a potentially dangerous situation. This occurs when the appropriate antibiotic is prescribed and consumed by the patient. In an acute situation, fever, pain and malaise are often present. Antibiotics should be accompanied by local mechanical treatment in order to attempt to establish drainage and remove any foreign body that may be contributing to the infectious process or preventing its resolution. The antibiotics of choice for acute periodontal infections are: Amoxicillin 1000mg every 8 hours for at least 5 days. For patients allergic to Penicillins , Erythromycin or Clindamycin is the medication of choice NOTE: It is imperative that the dentist follows up with the patient within the first 24 hours to determine if he or she is responding to the treatment. If the response is not satisfactory, referral to a dental specialist or physician is essential and mandatory. 3. Scaling and root planing Most periodontal lesions will respond to scaling and root planing. This difficult to perform procedure reduces oedema, inflammation and probing pocket depths. It accomplishes this desired clinical outcome by physically removing plaque, calculus and other pocket contents. The routine use of systemic chemotherapeutic adjuncts is not recommended because its use will only suppress the etiologic agents, lead to adverse side effects and the development of resistant strains. Adjunctive local antimicrobials are often used at this time with varying degrees of success. Chlorhexidine rinses twice a day are excellent ways to help the patient control plaque. 4. Oral hygiene instructions Oral hygiene instructions are paramount for the long-term reduction of plaque and the maintenance of the clinical status of the patient. Failure to properly insure that the patient has the appropriate tools to control plaque will lead to the perpetuation or initiation of periodontitis. 5. Elimination of local factors Elimination of local factors other than plaque and calculus that may contribute to periodontal destruction should be performed as part of initial therapy. These include but are not limited to: Eliminating restorative overhangs and over-contoured crowns Correction of ill-fitting prosthetic appliances Restoration of carious lesions Orthodontics Elimination of open contacts Elimination of occlusal trauma Extraction of hopeless teeth Control systemic risk factors Systemic risk factors can also affect treatment outcomes and therefore should be controlled or corrected if possible. Consultation with the patient's physician is often indicated. Some examples include: Diabetes Smoking Pregnancy Host immune system compromise Medications Substance abuse Re-evaluation After initial therapy a minimum of 2- 4 weeks is usually needed to be able to evaluate specific areas for continued breakdown and or stability. Signs of poor response to initial therapy include: inflammation of the gingival tissues persistent or increasing probing depths lack of stability of clinical attachment plaque levels not consistent with periodontal health. In sites that had periodontal surgery, more time is needed to allow complete healing of the periodontium. A minimum time of 3 months post operatively is suggested. Signs of a desirable outcome include: Significant reduction of clinical signs of gingival inflammation Reduction of probing depths Stabilisation or gain of clinical attachment Radiographic resolution of osseous lesions Progress toward occlusal stability Progress toward the reduction of clinically detectable plaque to a level that favours periodontal health. Rampant caries. It is an extensive, rapidly progressing caries affecting many teeth in the primary &/or permanent dentition caused by frequent ingestion of sugar &/or reduced salivary flow Severe early childhood caries may also be caused by the prolonged and frequent intake of sugar-based medications; however, both pharmaceutical companies and doctors are more aware of the problem and the number of alternative sugar-free preparations is increasing. Management: Removal of aetiological factors (education, artificial saliva) Fluoride rinses for older age groups (daily 0.05%) 1º dentition – may need to extract teeth of poor prognosis and concentrate on prevention for permanent dentition 2º dentition – need assessment of long-term prognosis for teeth. Final treatment plan should be drawn up in consultation with orthodontist A patient comes to you and complains of bad breath. What are the different investigations. Bad breath has different etiologic factors, I would investigate what probably is causing bad breath. What you eat affects the air you exhale. Certain foods, such as garlic and onions, contribute to objectionable breath odor. Once the food is absorbed into the bloodstream, it is transferred to the lungs, where it is expelled. Brushing and flossing. If don’t brushing and flossing correctly particles of food remain in the mouth, collecting bacteria, which can cause bad breath Tongue brushing. Ask about tongue brushing and evaluate it. Periodontal disease. Evaluation regarding plaque accumulation, calculus. Xerostomia. Saliva is necessary to cleanse the mouth and remove particles that may cause odor. Tobacco. Bad breath may be the sign of a medical disorder, such as a local infection in the respiratory tract (nose throat, windpipe, lungs), chronic sinusitis, postnasal drip, chronic bronchitis, diabetes, gastrointestinal disturbance, liver or kidney ailment. Vertical dimension in RPD. Management of Class V (size2) lesion in a 15 year-old Although cervical cavities are seen less frequently in younger patients, they are an increased problem in older age-groups with gingival recession. Resin composite, compomer or Glass Ionomer are the preferred material in this situation. Amalgam should be avoided due to possibility of lichenoid reaction. Once caries has been removed the occlusal margin should be bevelled. The cervical margin should not be bevelled as it has been shown to increase microleakage. The materials are ideally placed incrementally under rubber dam isolation. A patient comes to you for a recall visit and informs you she is 3 months pregnant. What is your line of management? Oral care is an essential component of the overall health of a pregnant patient but there are several issues that dentists should consider when managing pregnant patients. Should avoid elective dental procedures at first trimester of pregnancy, only hygiene instruction and cleaning. I would advise she to come back in a few weeks once the 2nd trimester is the safest period for routine dental care.