Ramsay Hunt syndrome, or herpes zoster oticus, is a neurological Melkersson-Rosenthal syndrome is a neurological disorder

syndrome induced by the reactivation of the varicella zoster virus (VZV) that can result in recurrent facial paralysis, granulomatous swelling of the
in the geniculate ganglion. This syndrome can therefore present with lips and face, and a fissured tongue. Becomes evident in young children
altered function of the facial nerve, leading to facial muscle paralysis, loss and adolescents and the cause is unknown. Usually, the first episode of
of taste, dry eyes, xerostomia, and ear pain. As herpes zoster also causes edema will resolve within hours or days, and may resemble angioedema,
shingles, patients will often have a vesicular rash in the distribution of the but is usually more resistant to a treatment with an antihistamine.
trigeminal nerve that does not cross the midline.
Melkersson-Rosenthal syndrome is a rare neurological disorder
Ramsay Hunt syndrome is a that is characterized by recurrent,
neurological syndrome induced long lasting facial edema, facial
by the reactivation of the muscle palsy, and a
varicella zoster virus. fissured tongue.
A good mnemonic to remember
Can present with altered the symptoms is to think of
function of the facial nerve “Mells Bells” and “Rosy Red”.
“Mells”= Melkersson;
leading to
“Bells”= Bell’s palsy (facial
facial muscle paralysis, paralysis).
loss of taste, dry eyes, “Rosy”= Rosenthal;
xerostomia, and ear pain. “Red”= Red lips from granulomatous cheilitis.

Bell’s palsy is an isolated facial paralysis thought to be caused Guillain-Barre syndrome (GBS) is a rapidly progressive
by compression or irritation to the facial nerve. The cause of muscle weakness caused by immune-mediated peripheral
Bell’s palsy is unknown, but is associated with diabetes, nervous system inflammation. It involves progressive muscle
pregnancy, recent upper respiratory infection, and some viral weakness beginning in the extremities that spreads proximally.
infections (HIV and Herpes). The weakness makes half of the face Most patients that develop GBS had a prior infection (often an
appear to droop. Smiles are one-sided, and the eye on the upper respiratory infection or gastroenteritis).
affected side resists closing. include unilateral weakness or
paralysis of facial muscles, difficulty making facial expressions,
facial drooping, drooling, and changes in saliva and/or tear
production.

Sjögren’s syndrome, an autoimmune condition of acinar Ameloblastoma is a benign odontogenic tumor typically affecting
destruction with a female predilection in which antibodies attack the those over the age of 20 years. It is described to be locally aggressive, as
body’s lacrimal and salivary glands. This results in dry eyes and it can develop rapid cortical expansion, tooth displacement and root
decreased salivary flow, and patients commonly present with severe resorption, with a high incidence of recurrence (15%) following
decay. These patients have a significantly increased risk of lymphoma. treatment. On a panoramic image this can be seen as a well defined,
Imaging tests that can be used to aid in diagnosis of Sjögren’s multilocular, radiolucent lesion, with soap bubble septa which can extend
syndrome include ultrasound, sialography, and scintigraphy. through large portions of the posterior mandible. These signs and
Diagnosis of Sjögren’s syndrome will often include a minor salivary symptoms mimic what is seen in the case.
gland biopsy, anti-Ro/SSA antibody test, and Schirmer’s
test (measures tear production).
The majority of patients with
Sjögren’s syndrome test
positive for rheumatoid
factor in their serum. The
condition often accom-
panies other immune
system disorders, such
as rheumatoid arthritis
and lupus.
Methotrexate can be
used to treat
autoimmune disorders
such as Sjogren’s
syndrome and systemic
lupus erythematosus.
McCune-Albright syndrome is a form of polyostotic fibrous Sturge-Weber syndrome is a developmental condition where
dysplasia. This condition affects the bones of the skeleton, can cause vascular proliferations form in different organs including the skin (along
unilateral expansive growth of the maxilla and mandible, and is the ophthalmic nerve division) and brain. This is seen clinically as a dark
associated with multiple pigmented café au lait spots on the skin. Girls red/purple “port wine” stain on the face.
with this condition can experience early-onset puberty, and appear
much more physically mature for their age when they are young.

Addison’s disease is a disorder of endocrine origin where the adrenal Scleroderma refers to a group of autoimmune diseases characterized
glands produce decreased amounts of mineralocorticoids and by hardening and tightening of skin, muscles, internal organs, and blood
glucocorticoids. When these levels are low, the loss of negative feedback vessels.
on the pituitary gland causes a simultaneous increase in
adrenocorticotropic hormone and melanocyte stimulating hormone due Rheumatoid arthritis (RA)(hands, wrists and knees) is a
to a shared common precursor progressive chronic inflammatory condition that affects synovial joints.
protein called Nearly 50% of all patients with RA will develop TMJ symptoms. It causes
pro-opiomelanocortin. degenerative changes to tissue of the joint, potentially resulting in
Those affected can fibrous ankylosis. A notable feature of rheumatoid arthritis affecting the
develop hyperpigmenta TMJ is a progressive class II malocclusion and anterior open bite due
tion and bronzing of the to loss of mandibular condylar height as the joint erodes.
skin. In addition, Rheumatoid arthritis symptoms are often worse in the morning and
this condition can also improve throughout the day.
cause weakness,
hypotension, and
depression.
Osteoarthritis is the most common disease affecting the TMJ.
Generally, osteoarthritis is unilateral, but can occur bilaterally.
care
Osteoarthritis is a degenerative disease process affecting the articular
and patients should
cartilage of synovial joints. The condition often lacks morning stiffness
be given
and progressively worsens throughout the day. Osteoarthritis is often
intravenous
seen in patients older than 50 and progresses slowly over time,
hydrocortisone.
eventually resulting in internal derangement of the TMJ.

Neurofibromatosis type Crouzon syndrome is a genetic disorder which causes premature

1(Von Recklinghausen’s fusion of the facial and cranial sutures. This causes alterations in head
disease) can result in and face shape, commonly causing proptosis, frontal bossing, and
patients having café-au-lait maxillary hypoplasia. Those with Crouzon syndrome have normal
spots, Crowe’s sign (axillary intellectual abilities. Radiographically, the bone pattern for these
freckles), Lisch nodules individuals is known as copper beaten, where there are areas of
(spots on the iris), interchanging thickness of the skull.
and an optic glioma.
Overgrowth
of Schwann cells on a
histopathological exam,
history of seizures, and
previous pheochromocytom
a indicates neurofibromatos
is type 1.
Apert syndrome is an autosomal dominant disorder, and similarly to Pierre Robin syndrome is a congenital birth defect that is defined
Crouzon syndrome, also results in premature fusion of the sutures of the by three primary findings: micrognathia (small mandible),
skull. Both disorders have similar facial presentation, with frontal bossing, glossoptosis (downwardly displaced or retracted tongue), and cleft
hypertelorism and maxillary hypoplasia being prominent features. In palate. As a result of these conditions, these babies typically have
Apert’s syndrome, those affected also have syndactyly of the fingers, difficulty breathing and feeding early on in their lives. This condition also
whereas those with Crouzon syndrome do not. does not have any radiographic alterations to bone pattern. Can also
have Natal teeth Twins.

Trigeminal neuralgia is an episodic, excruciating, neuropathic Lateral pontine syndrome results from infarction of the anterior
pain associated with the trigeminal nerve. There are certain zones, inferior cerebellar artery (AICA). This results in ipsilateral facial paralysis,
corresponding to branches of the trigeminal nerve, that may be triggered decreased lacrimation, decreased taste from the anterior ⅔ of the
when stimulated with as little as a light touch. These areas are usually tongue, and ipsilateral pain and temperature sensation of the face.
around the eyes, cheeks, or gingiva. A common cause of this condition Contralateral loss of pain and temperature from the body is also seen.
is compression of the nerve root by a blood vessel that results in the Patients will also present with vomiting, vertigo, nystagmus, and ataxia.
nerve being damaged and hyperresponsive. It is often mistaken for
dental pain. Since the patient has no intraoral dental symptoms,
especially without resolution following endodontic therapy, she is most
likely experiencing trigeminal neuralgia.

Gardner Syndrome is an inherited disease caused by mutation of Barrett’s esophagus is a condition which forms due to a serious
the APC gene that results in lesions of the colon, skin and skeleton. An complication of gastrointestinal stomach acid reflux.
oral finding of Gardner Syndrome is osteomas (radiopacities) of the Spicy food is not a risk factor for a diagnosis of Barrett's esophagus.
skull and mandible. While this would present as a bony hard mass of Obesity is a risk factor for Barrett's esophagus. Patients with Barrett’s
the posterior mandible, radiographically are large globular radiopaque esophagus who smoke tobacco have a two-fold increased risk of
masses. Multiple odontomas and intestinal polyps, among other skin developing esophageal cancer. Smoking is a risk factor for this condition.
and soft tissue tumors. Intestinal metaplasia can occur in a patient who has a history
Cotton-wooll apearence of gastrointestinal esophageal reflux.
Of the jaws
Caused by the mutation of GERD: lower esophageal
the adenomatous
sphincter
polyposis coli (APC) gene.
Nevoid basal-cell carcinoma syndrome (Gorlin Papillon-Lefèvre syndrome is a rare autosomal recessive
syndrome) is an inherited condition associated with multiple basal cell disorder, which appears in children as hyperkeratosis and rough patches
carcinomas, palmar/plantar pits, bifid ribs, calcification of the falx cerebri, of the palms and soles of the feet, as well as aggressive inflammation of
and KCOT (radiolucencies). Also common in this syndrome are the periodontium. Tooth eruption is not affected, however the
macrocephaly, facial abnormalities, and medulloblastomas. Is associated supporting structures
with multiple basal cell carcinomas, palmar/plantar pits, and OKCs of the teeth
(odontogenic keratocists). experience severe
This syndrome is not inflammation and
associated with bone loss, causing
elevated parathyroid an extremely early loss
hormone.. of both the primary
and permanent
dentitions. Most
permanent
teeth can be
completely lost as
early as age 16.

Paget’s disease is a condition of bone remodelling which most Cleidocranial dysplasia (also known as Scheuthauer-Marie-
commonly affects older males. This can appear radiographically as a Sainton syndrome) is a genetic condition which affects teeth and bones.
radiopaque cotton wool appearance of the entire bone (the maxilla Those with the condition have frontal bossing, wide set eyes,
more common than the mandible). Paget’s disease is a progressive underdeveloped or absent clavicles, mandibular prognathism and can
metabolic disturbance of many bones that requires treatment with have supernumerary teeth. Know that it includes supernumerary teeth
bisphosphonates and sometimes calcitonin. Paget’s disease most and primary teeth that delays to fall down too
commonly affects elderly men, whereas fibrous dysplasia appears mostly
in adolescents.

Osteomalacia. This condition involves a softening of the bones that is

often related to a vitamin D or calcium deficiency. COPD:
Decreased serum calcium.
• Emphysema occurs due to the
Decreased serum phosphate.
Decreased vitamin D. breakdown of alveoli walls, collapsing the
Increased serum alkaline phosphatase
alveoli and trapping air within the lungs.
 Stevens-Johnson Syndrome (SJS), painful ulcers on the lips
Ectodermal dysplasia is an X-linked recessive genetic condition following ingestion of antibiotics, as well as a recent history of flu-like
that results in abnormalities of structures of ectodermal origin, such as symptoms following antibiotic use. a severe skin reaction caused by
missing teeth and hypoplastic hair and/or nails. Hypodontia, multiple a reaction to medications or an illness. Common symptoms include
conical-shaped teeth, and light, brittle hair are key characteristics skin pain, fever, body aches, rashes, blisters, and peeling skin. In cases of
of ectodermal dysplasia Connected with Missing teeth drug-induced SJS, symptoms may appear roughly one to three weeks
Dentes conoides, ausência de glândulas sudoríparas, after first taking the medication. While SJS may occur in response to a
hipodontia ou anodontia, brittle hair and nails. 1º trat: orto; recent herpes simplex virus infection, it is not considered a minor form of
2: prótese; 3: implante após 21anos. herpes simplex.
SJS is classified as a delayed T-cell mediated type IV hypersensitivity
reaction

Van der Woude syndrome is an autosomal dominant disorder Multiple myeloma is a cancer of plasma cells, a type of white blood
characterized by the presence of lower lip pits and either cleft lip cell that normally produces antibodies. “CRAB” is an acronym used by
with/without cleft palate or isolated cleft palate. Lip pits form as a result healthcare professionals to recognize common signs of multiple
of improper fusion of the four growth centers of the lower lip in fetal myeloma. These include: Calcium elevation
development. (hypercalcemia), Renal failure, Anemia, and Bone damage.
Van der Woude syndrome is characterized by the presence of lower lip Myeloma cells can suppress the formation of red blood cells, decreasing
pits and either cleft lip with/without cleft palate or isolated cleft the number of red blood cells thus leading to anemia.
palate. Myeloma cells can stimulate osteoclasts and suppress osteoblasts,
Alveolar sounds are produced by placing the tongue tip on or leading to the development of osteolytic bone lesions.
immediately in front of the alveolar ridge. Bence Jones protein is an immunoglobulin light chain found in the
urine. Detection of these proteins is suggestive of multiple myeloma in
the context of target organ manifestations including kidney failure, lytic
bone lesions, anemia, and large numbers of plasma cells in bone marrow.
When denosumab (Prolia®) is used for cancer therapy the bone in the
extracted socket is at risk of necrosis, leading to medication induced
osteonecrosis of the jaws.
Cardiac amyloidosis is associated with multiple myeloma and causes a
“stiff” heart and cardiac myocyte hypertrophy.
Medications such as dexamethasone and bisphosphonates are typically
used to treat multiple myeloma.

Granular cell tumor is a type of benign or malignant tumor of Multiple endocrine neoplasia type 2B (MEN2B), an
Schwann cell origin. The patient’s biopsy would demonstrate cells with extremely rare autosomal dominant disorder characterized by tumor
abundant cytoplasm containing eosinophilic granules. The lesion growths in the oral cavity, eyes, and in multiple endocrine organs. MEN2B
would most likely be located on the anterior and dorsal of the tongue, causes multiple endocrine organs to be overactive and secrete excess
and are particularly common on the dorsal tongue, although granular cell hormones. The most common tumors are the medullary thyroid
tumors can appear on any skin or mucosal surface. carcinoma (almost always present) and pheochromocytoma. These
patients may also have a marfanoid habitus demonstrated by long arms,
legs, and fingers.

• Common findings in multiple endocrine neoplasia type 2B

(MEN2B) include medullary thyroid
carcinoma, pheochromocytoma, long arms, legs, and
fingers.
Erythema multiforme is a skin condition of unknown cause that Pemphigus vulgaris is a form of type II hypersensitivity, rare
often follows infection or drug exposure. It is characterized by raised, autoimmune blistering condition, in which antibodies are formed against
erythematous target lesions that are symmetrically distributed across the
desmosomes in the upper layers of the skin. This results in acantholysis,
body. Oral manifestations of this disease include edema, erythema and
the breaking apart of intercellular connections and subsequent blistering.
erythematous macules of the lips and buccal mucosa. In rare cases, these
Like mucous membrane pemphigoid, this disease will present itself on
symptoms are accompanied by the formation of vesicles and bullae that
the oral mucosa, as well as the genitals, esophagus, nose, and anus.
rupture.. Erythema multiforme is an acute, immune mediated condition
In pemphigus vulgaris antibodies are formed against desmosomes
that is characterized by target-like lesions, erosions and bullae on the
Generalized
skin. This condition is caused by viral infections as well as certain
ulcers within
medications and drugs.
the oral cavity
superficial erosion, pseudomembrane
with a positive
formation of the oral mucosa, crusting
Nikolsky sign
of the lips and target lesions the onset
(sloughing on
of which is associated with ingestion
pressure), and
of penicillin-clavulanic acid.
a biopsy
revealing
supra-basilar
lesions.

Mucous membrane pemphigoid : an autoimmune Chronic osteomyelitis is an infection of the bone lasting
subepithelial blistering disease that is marked by erosive lesions on for over 4 weeks. This infection presents radiographically with a
both the skin and mucous membranes. It is most commonly observed in
moth eaten appearance, seen as a mixed radiolucent and
the oral mucosa, whereby these lesions can present themselves as
radiopaque, ill-defined lesion usually near an infected tooth or
desquamative gingivitis - an erythematous, shedding, and ulcerated form
of gingivitis. extraction site. Chronic osteomyelitis presents radiographically
Biopsies will reveal the separation of the epithelial cells from the with a moth eaten appearance.
basement membrane and the loss of hemidesmosomal
proteins. Furthermore, the sinuses, genitals, anus, and cornea of the
eyes are affected and in this case the patient is presenting
with symblepharon, a condition in which the bulbar and palpebral
conjunctive form an abnormal adhesion to one another. Refer to
Ophtalmologist. another autoimmune blistering
condition, presents with similar intraoral findings
to pemphigus vulgaris, but can be distinguished
from one another by the location of its lesions:
MMP lesions are found sub-basilar as
autoantibodies are directed against the basement
membrane,

Langerhans cell histiocytosis, which is classified as a malignant A radiopaque lesion with no radiolucent rim is seen to be present apical,
lesion (according to the National Cancer Institute) of histiocyte origin, but not attached to the roots of tooth 19. Since the lamina dura of
affecting young children, and follows an aggressive course. It is more tooth 19 is intact, this finding is most likely idiopathic
common in children and adolescents. These lesions have a characteristic osteosclerosis, which refers to an area of increased bone production
ice cream scoop presentation, which make the teeth appear as though with unknown etiology. It is most commonly found in the mandible at
they are floating in air. They are well defined, non-corticated lesions, and root apexes, between roots, and/or separate locations away from the
do not displace or resorb teeth. Langerhans cell histiocytosis may also teeth. Because the lamina dura of the tooth in question is intact, this
affect the skin, specifically in areas of where there is creasing of the body finding is most likely idiopathic osteosclerosis.
such as the inner elbow or axillary folds.
A cementoblastoma is a benign odontogenic Amelogenesis imperfecta can be an autosomal dominant,
autosomal recessive, or X-linked genetic condition that results in the
neoplasm of cementoblasts that is most commonly
intrinsic alteration of enamel, which appears as lacking or poorly formed
associated with posterior mandibular teeth. It will enamel on radiographs. cannot see the enamel in the x ray but you can see
present as a well-defined radiopaque mass dentin and normal pulp

attached to the root with a radiolucent peripheral

line that causes obliteration of the root and
subsequent root resorption.

Dentinogenesis imperfecta is an autosomal Dentin dysplasia is an autosomal dominant genetic

dominant genetic condition that results in the condition that results in the intrinsic alteration of dentin and can
intrinsic alteration of dentin, giving crowns a short, present as either teeth with chevron pulps (type I) or thistle tube-
bulbous appearance on radiographs Cannot see the shaped pulps (type II).
pulp. Acontece no estágio de BELL (11 weeks) /
Associated w/ blue sclera (osteogenesis imperfecta)
/ Can occur in primary teeth and permanent
Brown teeth

Regional odontodysplasia involves a quadrant of teeth Shape

that exhibit short roots, open apices, and enlarged pulp
chambers, which give the appearance of “ghost teeth” on
radiographs

Shape of a mandibular canal access: odontoblasts cementoblasts

Dysgeusia = Von Ebner Gland

Lichen planus (LP) is thought to be caused by a T cell– The international normalized ratio (INR) is a standardized number
collected by a lab from a prothrombin time test that measures the
mediated autoimmune reaction against basal epithelial
amount of time and relative ease it takes for a blood clot to form using
keratinocytes in people with genetic predisposition.
the extrinsic pathway of the clotting cascade. For patients taking
Reticular lichen planus can be identified by the white, lacy warfarin (Coumadin®), PT/INR is typically used to evaluate whether the
patches, known as Wickham striae on the buccal mucosa. patient is taking the correct dose. The INR will provide the patient’s
Purple pruritic papules on the skin is a common finding healthcare provider with helpful information about the dosage of the
with reticular lichen planus. Fisrt choice: topical steroids medication, as well as whether the patient poses a bleeding risk that may
contraindicate invasive surgery.

Less or 1.5: Within normal coagulation profile, no contraindications to

treatment including oral surgery

1.5 – 2.5: Can proceed safely with oral surgery without altering dose of
warfarin, use strategies for local hemostasis

2.5 - 3.5: Normal INR on anticoagulants, can proceed safely with

treatment, including oral surgery without altering dose of warfarin, use
strategies for local hemostasis

Greater than 3.5: Defer treatment, obtain medical consult.

Simple bone cyst (traumatic bone cyst): These According to the CDC, the
human papillomavirus (HPV)
lesions are well defined, radiolucent, have upper borders vaccine is recommended at ages 11-12 years to protect against
which scallop the teeth, do not cause expansion, and usually cancer-causing HPV infection. However, the vaccine is available to
have no associated symptoms. Intraosseous cysts, that do not patients beginning at age 9, and 2 doses are required if the patient is
actually have a cystic lining, that appear predominantly in the between ages 9 and 14 if given 6 to 12 months apart. For patients
starting the HPV vaccine regimen after 15 years of age, 3 doses are
mandible. The cause of these may be unknown or from a
required and should be given at least 6 months apart. Since this patient is
traumatic blow to the jaw.
25 years old, she will require 3 doses of the HPV vaccine.
Following trauma to the jaw, intraosseous hemorrhage occurs,
and then the blood clot eventually disintegrates. Treatment Key Takeaway:
includes curettage in an attempt to initiate bleeding to allow for • For patients starting the HPV vaccine regimen after 15 years
healing and bony filling of the cavity. of age, 3 doses are required.
• For patients starting the HPV vaccine regimen at age 9, 2
doses are required.

Sickle cell anemia is a genetic blood condition which causes Odontoma: Most common Odontogenic tumor,
crescent moon shaped red blood cells. This disease will decrease the Compound is mini tooth like “anterior”
effectiveness of oxygen transport, causes vaso-occlusion, and can cause Complex is amorphous irregular mass “Posterior”
recurrent infections. The patient may experience tonsillitis and These tumors may sometimes cause bony expansion, and can result
adenotonsillar hypertrophy which can lead to airway obstruction, one of in tooth impaction. Radiographically, these are well defined radiopaque
the risk factors for OSA. Sickle cell disease causes interproximal alveolar structures with radiolucent capsules. This is not representative of this
bone step ladder patterns, large trabecular spaces, increased medullary patient’s radiographic lesion.
spaces, thinning of the inferior mandibular border, and thickening of
lamina dura. Vertical "hair-on-end" striations can be seen on the skull in
a cephalometric radiograph. African patient got splenectomy sickle cell
anemia has splenomegaly Children with sickle cell anemia living in sub-
Saharan Africa have an increased risk of having palpable splenomegaly,
which is further increased while receiving hydroxyurea treatment. Large
spleen at baseline were associated with lower blood counts, consistent
with hypersplenism.
Schwannoma, a benign peripheral nerve sheath tumor. These Pleomorphic adenoma is the
palisading schwann cells will give rise to Antoni-A (dark) and most common benign salivary
Antoni-B (light) areas. lesion on the tongue, which is the most gland tumor, appears on the
common site for intraoral schwannomas. These tumors are well hard palate, and has a water
circumscribed and grow slowly but can impede function when chestnut-like appearance.
large. They are treated by surgical excision. Histologically pleomorphic
adenoma examination reveals
myxoid stroma with myoepithelial cells.

Mucoepidermoid carcinoma
is the most common salivary gland
malignancy, affecting all age ranges.
It is most commonly found in the
parotid gland and is composed of
mucous and intermediate cells
arranged in cyst like structures.

Varicella zoster virus is the virus that causes “chicken pox” in Down syndrome is a condition in which a person has an extra
children and adolescents with first inoculation. After recovery, the virus chromosome #21. The presence of the extra chromosome
then remains latent predominantly in the trigeminal ganglion, but also changes how the body and brain develop, with most individuals
the dorsal root ganglion.
having a mild or moderate intellectual disability.
Recurrence may occur in up to 10-20% of patients. Reactivation
(recurrence) of the latent virus causes a condition known as shingles,
leading to formation of vesicles and ulcers in a unilateral distribution that Common characteristics of down syndrome include flattened
do not cross midline. These lesions can be found on the skin, or facial profile, delayed tooth eruption, macroglossia,
intraorally . hypodontia.
The patient often experiences a
prodrome of symptoms such Protruding tongue
as fever, headache, and malaise Flat nasal bridge
prior to the presence of oral lesions.
Upward-slanting almond-shaped eyes
cyclophosphamide (Cytoxan®),
Patient is argumentative and uncooperative
which is an immunosuppressant
medication that is known to
precipitate recurrence of infection Voice control is a technique that uses the controlled alteration
by varicella zoster virus of voice volume, tone, or pace to direct the child’s behavior or
to gain their attention. Voice control is indicated for patients that
display avoidant or defiant behavior.

Rubeola (measles) virus. Patients may initially present with small,

Hypopnea does not involve the complete cessation of airflow and gas intraoral ulcerations known as Koplik spots (see
exchange. below) that often precede other symptoms by 2-3 days. There are 3 “C’s”
Apnea is the complete cessation of breathing lasting for a period of over of the prodrome of measles and include coryza (runny nose), cough,
10 seconds. and conjunctivitis. Following these symptoms, a blotchy red rash will
Common causes and risk factors for sleep apnea are: appear on the face and spread to the trunk and extremities. Treatment
• Excessive weight for measles is symptom management, vaccination is important for
• Increased neck circumference prevention.
• Smoking
• Alcohol use
• Male
• Older age
• Narrowed airway, which can be caused by a retruded tongue
Sleep apnea is a well-known cause for hypertension, not vice versa.
Female gender is not a risk factor for obstructive sleep apnea.
Sleep apnea describes a common condition in which breathing stops
and restarts, due to physical or neurological causes, multiple times
during sleep. Symptoms of sleep apnea include loud snoring, GERD,
bruxism, frequent nighttime awakenings, and cardiovascular
symptoms.
Chicken pox is caused by the contagious varicella-zoster virus (VZV) Scarlet fever is caused by exposure to group A
and is often seen in young children. It is characterized by an itchy, Streptococcus bacteria and similar to rubeola (measles), occurs in young
blister-like rash across the body. Less commonly, raised lesions can be children. The signs and symptoms of Scarlet fever include a very sore
seen intraorally that develop into painful ulcerations. Patients do not erythematous throat, fever (>101℉), a red skin rash covering the body,
usually develop a cough or runny nose as seen in this patient with rosy red cheeks, and strawberry tongue. Koplik spots are seen in
rubeola (measles). Rubeola, not Scarlet fever.

Hand-foot-and mouth disease that is usually seen in young Mumps is a typical childhood illness caused by paramyxovirus.
children and is caused by the Coxsackie virus. A rash is seen on Possible complications of this illness include orchitis (inflammation of the
the palms of hands and the soles of the feet. Patients also develop testis), parotitis (inflammation of the parotid glands),
painful oral ulcers. This disease is most common in those under the age and pancreatitis (inflammation of the pancreas). Therefore, the only
of 5. symptom not found in mumps is nephritis. The infection is typically self-
limiting and requires supportive therapy. Mumps is spread by droplets
of saliva or mucus from the mouth, nose, or throat of an infected
person, usually when a person coughs or sneezes. Mumps can also
spread when items used by an infected person that have been
contaminated by saliva or mucus, such as eating utensils, drinks, or lip
balm, are shared.

Blastomycosis is an endemic to the Great Lakes and Ohio River Impetigo. This condition refers to a bacterial skin infection most
valley area. Blastomycosis is caused by inhalation of spores from the commonly by Staphylcoccus aureus or Group A Streptococcus that
dirt and is not considered communicable between infected persons. presents as yellow pustules on the face, arms, or legs and is frequently
seen in school age children. This infection is transmitted mainly
through direct contact with lesions. Impetigo presents
as yellow pustules on the face, arms, or legs in school age children and is
transmitted through direct contact.
 Erysipelas, which is a group A streptococcal infection of the dermis
HIV:
and is characterized by a raised, well-demarcated, red rash on the face,
A viral load of 200 copies/mL is considered viral suppression.
but can also affect the extremities or trunk. Erysipelas develops following
Less than 50 copies/mL = undetectable
minor trauma that involves a break in the skin, such as a bruise, cut, or
Although 500 copies/mL and 1,000 copies/mL are considered a lower
abrasion. This patient has a history of erysipelas and symptoms that point
viral HIV load, it is not low enough to be considered virally suppressed.
to a current infection, indicating a recurrent case of erysipelas.
20 copies/mL is generally considered an undetectable viral load. This is
Prior to scheduling this patient for his next appointment, it would be
even lower than viral suppression and is the goal of antiretroviral
appropriate for the patient to have treatment for his current infection by
treatment for HIV. Toxoplasmosis is acquired by eating poorly cooked
his primary care physician.
meats or seafood, or through contact with cat feces.
Those with acquired immunodeficiency syndrome (AIDS) can
demonstrate infection with or reactivation of the parasite Toxoplasma
gondi if their CD4+ cell count drops substantially (< 100 mm3).

The reverse transcriptase enzyme from a human immunodeficiency

virus infection function to convert the single-stranded stranded RNA
viral genome into double-stranded DNA.

Thromboplastin time (PTT) test = hemophilia and heparin use Herpangina, caused by an infection with Coxsackievirus A. It often
Platelet count is 20,000 platelets per microliter of blood, which puts
presents clinically with a sore throat, trouble swallowing, and
the patient at a risk of spontaneous bleeding. This very low platelet
occasionally a fever. Small red macules that progress to ulcers are
count requires further investigation before proceeding with dental
often present on the soft palate and tonsillar pillars. The virus is
treatment for this patient.
transmitted by a fecal-oral route or by respiratory droplets.
HEMOPHILIA: a hereditary BLEEDING DISORDER that mostly
affects MALES, where it takes a long time for blood to clot and
abnormal bleeding occurs. A true hemophiliac has prolonged
partial thromboplastin time (PTT), but normal prothrombin
time (PT), bleeding time (BT) and platelets.
The Complete Blood Count (CBC) is normal in people with
hemophilia. However, if a person with hemophilia has unusually
heavy bleeding or bleeds for a long time, the hemoglobin and
the red blood cell count can be low.

Xerostomia and dysgeusia are oral manifestations associated with IMPRESSION MATERIALS
hyperglycemia due to uncontrolled diabetes. Diabetes is a major risk
factor for periodontitis. This is due to dysregulation of the body’s ALGINATE: most inaccurate, imbibition anda syneresis,
immune system and inflammatory response. Patients with uncontrolled
diabetes with long term hyperglycemia are at higher risk of periodontitis pour 10 min
and increased probing depths found on exam.
POLYSULFIDE RUBBER: water byproduct, most syneresis,
• Hyperglycemia refers to elevated blood glucose levels and
occurs in those with diabetes 30-45 min to pour
• Xerostomia, dysgeusia, and increased probing depths are
common oral manifestations in patients with hyperglycemia CONDENSATION SILICONE: alcohol byproduct, 30 min
to pour

POLYETHER: very stiff, easy influenced by water,

imbibiton, 60min to pour

ADDITION SILICONE (PVS) : no byproducts, inhibited by

sulfur in latex gloves
Denosumab (Prolia®) is a monoclonal antibody effective for treating internal resorption: also called as pink tooth of mummery,
osteoporosis. odontoclastoma, chronic perforating hyperplasia of pulp, Internal
The antiresorptive effects of denosumab (Prolia®) diminish 6
granuloma.
months after the medication is stopped.

The treatment for osteonecrosis includes systemic antibiotics and

chlorhexidine rinses to prevent spread of infection and initiate healing.
Conservative surgery may be required in advanced cases in
order to reach bleeding bone with increased capability of healing.
Prednisone (Deltasone®) decreases vascularity and causes an
increased risk for post-extraction complications.
Bisphosphonate-related osteonecrosis of the jaws (BRONJ) or
medication-related osteonecrosis of the jaws (MRONJ) frequently
present as a non-healing extraction socket.
Bisphosphonates work primarily by inhibiting the function of
osteoclasts.

For radiographic visibility of a lesion, some sources state the minimum amount of demineralization
that has to occur is 30%.

Fluoride can help to reduce demineralization by lowering the critical pH value. Fluoride
ions interact with hydroxyapatite to form fluorohydroxyapatite, which has a
lower critical pH value compared to carbonate-substituted hydroxyapatite.
Fluorohydroxyapatite has a critical pH of 4.5. Hydroxy ions replaced in hydroxyapatite

Fluorohydroxyapatite is formed when fluoride ions interact with carbonate-substituted hydroxyapatite.

Fluorohydroxyapatite has a critical pH value of 4.5.

The order of prevalence of missing permanent teeth is as

follows: third molars > mandibular second
premolars > maxillary lateral incisors > maxillary second
premolars.

In terms of variability in morphology, the most variable tooth

0,7ppm (0,07mg of fluoride for 1L of water)
with the exception of the third molars is the maxillary lateral
incisors.

The most commonly congenitally missing primary tooth is

the maxillary lateral incisors.
Heredity is the most frequent cause of congenitally missing
The halo effect describes the dental health benefits that a water teeth.
fluoridation program provides to communities in other areas.
Transposition is a developmental disturbance that causes the
0.7 mg/L is the optimal amount of fluoride in community water. position of two adjacent teeth to interchange.
This an update from the previous recommendation, which was a
range between 0.7 mg/L to 1.2 mg/L. Of the anterior teeth, the mandibular lateral incisor presents
with 2 canals and 2 foraminas approximately 44% of the time.
This patient is a chronic carrier of the hepatitis C virus (HCV). This
patient has a positive anti-HCV antibody which means that they have Infection status Duration of infection Anti-HCV Ab NAT Symptomatic
at one point been exposed and infected by the HCV. The follow-up
test is a HCV Nucleic Acid Test (NAT), which is a PCR looking for the Acute HCV < 6 months + + +
presence of HCV RNA. This patient also has a positive NAT meaning
they have active HCV in the bloodstream. The acute stage of HCV
is within the first six months of initial infection. Since this patient Resolved HCV ≤ 6 months + - -
was diagnosed two years prior, they are in the chronic stage of the
disease. Compared to patients with chronic infections, patients Chronic HCV ≥ 6 months + + +/-
with acute infections will be positive for IgM anti-HBc

Hepatitis B serology testing involves 4 specific markers to determine a patient’s infection or immunity status.
1. Hepatitis B surface antigen (HBsAg) - a protein on the surface of the hepatitis B virus. A positive HBsAg result indicates the person is infectious
and is positive in acute and chronic infections.
2. Hepatitis B surface antibody (anti-HBs) - the presence of anti-HBs indicates the patient is recovering or is immune to the hepatitis B virus
infection. Anti-HBs is positive in patients who are immune to the virus due to vaccination or natural infection.
3. Hepatitis B core antibody (Anti-HBc) - this marker indicates recovery and immunity from hepatitis B virus infection. It is positive in acute and
chronic infections, and in people who are immune to the virus due to natural infection.
4. Antibody to Hepatitis core antigen (IgM anti-HBc) - this marker is positive during acute infections or recent infections within 6 months. IgM
antibodies are replaced with IgG antibodies over time.
5. Antibody to Hepatitis core antigen (IgG anti-HBc) - this marker is positive during chronic infections or in patients that have recovered from
HBV infection.
6. A patient with an acute infection will be positive for IgM anti-HBc, whereas a patient with chronic infection will not. Additionally, the
combination of positive HBsAg, negative anti-HBs, and negative anti-HBc IgG indicates that a person is in the acute phase of hepatitis B.

Serological Markers Results Interpretation

1 most commom cause: viral
Liver cirrhosis most commom: viral
HBsAg - 2 most commom: alcohol
Hepatitis C: no vaccine
anti-HBc - Hepatitis B: high risk transmission, ultrasonic scaler not safe
Susceptible Oral manif: jaundice, petechiae and xerostomia.
IgM anti-HBc -
Most common cause: viral hepatitis such as hepatitis B
anti-HBs -
and C. The viral form of hepatitis is also a major cause
of liver cirrhosis and liver carcinoma.
HBsAg - Hepatitis D, similar to hepatitis B and C, is transmitted
through direct contact with blood or other body
anti-HBc Positive fluids. Only occurs in people who are also infected with
Immune due to natural infection the hepatitis B virus.
IgM anti-HBc - Hepatitis A and E are transmitted through the fecal-
oral route, or through ingestion of contaminated food
anti-HBs Positive
or water
Hepatitis B and C are transmitted through
HBsAg - percutaneous contact with contaminated blood or
other bodily fluids.
anti-HBc -
Immune due to hepatitis B vaccination Hepatitis describes inflammation of the liver and can be
IgM anti-HBc -
caused by viruses, chemicals, drugs, alcohol, and can
anti-HBs Positive
also have a genetic etiology. Hepatitis has multiple oral
manifestations but an increased risk or incidence of
periodontal disease is not one that has been
HBsAg Positive documented.

anti-HBc Positive
Jaundice is caused by an excess of bilirubin in the
Acute infection
blood which builds up because of the decreased function
IgM anti-HBc Positive
of the liver in hepatitis, which normally removes it from
anti-HBs - the bloodstream.
Petechiae can occur in hepatitis because of
a decrease in the production of coagulation
HBsAg Positive
factors, which normally occurs in the liver.
Xerostomia is a common symptom seen in patients with
anti-HBc Positive
Chronic infection
hepatitis.
IgM anti-HBc -

anti-HBs -
 The human immunodeficiency virus (HIV) replication cycle can be broken down into several steps:

1) Viral binding to the host cell

2) Viral fusion and entry into the host
3) Viral DNA formation by reverse transcription using reverse transcriptase
4) Viral integration into the host DNA
5) Viral RNA is transcribed from integrated host DNA and will be used as new virus RNA. This genomic viral RNA is used to make viral proteins.
6) Viral proteins and RNA are packaged within host cell membrane
7) Virus is released and proteases cleave polyproteins forming an infectious, mature virion

ANTIBIOTICS The current infective endocarditis guidelines according to the ADA

- Sulfonamides : inhibit folate synthesis. Sulfadiazine requiring prophylaxis are:
- Fluoroquinolones: inhibit DNA synthesis. Ciprofloxacin, • prosthetic cardiac valves
Levofloxacin • prosthetic material used for cardiac valve repair
- Penicillins (Amoxicillin, Ampicillin) and Cephalosporins • a history of infective endocarditis
(Cephalexin): inhibit cell wall synthesis
• a cardiac transplant with valve regurgitation due to a
- Tetracyclines: inhibiting the 30S ribosomal subunit. Broadest
structurally abnormal valve
antimicrobial spectrum. Doxycycline
- Macrolides (Azithromycin, Erythro..) and lincosamides
• unrepaired cyanotic congenital heart disease

(Clindamycin, Licomyc) :inhibiting the 50S ribosomal subunit.

• any repaired congenital heart defect with residual shunts
or valvular regurgitation
do not require prophylaxis are listed below:
The most effective antimicrobials against anaerobic organisms
are metronidazole, the carbapenems (imipenem, meropenem and
• Joint replacement
ertapenem), chloramphenicol, the combinations of a penicillin and • Mitral valve prolapse (with or without regurgitation)
beta-lactamase inhibitor (ampicillin or ticarcillin plus clavulanate, • Heart murmurs
amoxicillin plus sulbactam, and piperacillin plus tazobactam), • Rheumatic heart disease
tigecycline • Bicuspid valve disease
• Calcific aortic stenosis
Tetralogy of Fallot (TOF) is a rare congenital condition that consists of four
different heart defects: pulmonary trunk stenosis, right ventricular
• All other congenital heart conditions such as atrial septal
hypertrophy, a ventricular septal wall defect and an overriding aorta. defect, ventricular septal defect, and hypertrophic
Patients generally have a full repair of TOF when they are infants which cardiomyopathy
includes placing a patch of pericardium or prosthetic material over the
ventricular septal defect, and reconstructing the pulmonary valve with
prosthetic material. Patients with repaired TOF require antibiotic
prophylaxis before dental treatments, either due to presence of
prosthetic material in the heart or residual shunts or leakages.

difference
between a low
level
disinfectant and
moderate level
disinfectant:

B) It kills
Tuberculosis
 Herpesvirus Associated Clinical Diseases

Herpes simplex virus 1 Gingivostomatitis, keratoconjunctivitis,

(HHV-1) herpes labialis, herpetic whitlow,

encephalitis

Herpes simplex virus 2 Genital herpes, neonatal herpes

(HHV-2)

Varicella-Zoster virus Chickenpox, shingles, encephalitis

(HHV-3)

Epstein-Barr virus (HHV-4) Mononucleosis, Burkitt lymphoma

Cytomegalovirus (HHV-5) Mononucleosis, congenital CMV, AIDS

retinitis

Human herpesviruses 6 Roseola infantum

Factors Recommendation for
and 7 (HHV-6, HHV-7)
Treatment

Human herpesvirus 8 Kaposi sarcoma

Low doses of bisphosphonates + Invasive dental treatment can be
(HHV-8)
less than 2 years of usage performed

Oral bisphosphonates for less than 4 Invasive dental treatment can be

years performed

Oral bisphosphonates for less than 4 2 month drug holiday prior to

years + surgery and after surgery do not

corticosteroid/antiangiogenic restart medications until soft

medication tissue healing has occurred

Oral bisphosphonates for more than 2 month drug holiday prior to

4 years + surgery and after surgery do not

corticosteroid/antiangiogenic restart medications until soft

medication tissue healing has occurred

High IV bisphosphonate use Procedures that involve direct

(monthly) osseous injury should be avoided

The patient is a 68 year old female who has osteoporosis and has
been treating this condition with intravenous (IV) zoledronate
(Zometa®) for 5 years. Because the patient has been taking IV
bisphosphonates for a prolonged period of time, the premolar
should not be removed at this time.
Oral prevalence: 0,06% - IV prevalence: 10%
>Etidronate - low potency >zoledronate - high potenc
The treatment of the patient’s severe gingival recession is influenced by a
variety of factors. Of the following answer choices, the factor that is least likely
to influence the treatment plan is the age of the patient. Although age can
influence the patient’s decision making on the types of interventions she
prefers, it is much more important to know the gingival status, bone height, and
inflammation.

A. Keratinized gingiva remaining

D. Crestal bone height
To determine the likelihood of regaining root coverage, Miller's
classification system is used. This system classifies based off of the
mucogingival junction (determined by the keratinized tissue remaining) as
well as the interdental bone loss (determined by the crestal bone height).
These two factors largely influence the success of treatment.

Hamp class II defect is actually the most ideal for regenerating the
furcation as it provides the deepest narrowest defect with the most
available bony walls for a bone graft

One and two wall defects do not have as much bony surface area for a
successful bone graft. Therefore, instead of trying to regenerate the
defect, osseous resection is typically performed in order to recontour
the bone and create positive architecture.

Miller’s Class Characteristics

I • Recession doesn’t extend to mucogingival junction

• No loss of interdental bone or soft tissue
• 100% root coverage

II • Recession extends to or beyond the mucogingival

junction
• No loss of interdental bone or soft tissue
• 100% root coverage

III • Recession extends to or beyond the mucogingival

junction
• Mild/moderate interproximal bone or soft tissue loss
present.
• Partial root coverage

IV • Recession extends to or beyond the mucogingival

junction
• Severe interdental bone or soft tissue loss
• No root coverage

B. Presence of inflammation
The presence of inflammation affects the treatment plan significantly because it affects the long term prognosis of any
treatment (surgical or otherwise). Whether it is modifying cleaning habits, giving oral hygiene instruction or performing scaling
and root planing, these treatments must be considered to the treatment plan.

Key Takeaway:
• In terms of gingival recession, the most important factors to determine the efficacy of treatment are the keratinized
gingiva remaining and crestal bone height.
 Chief Complaint/ Radiographic
Pulpal Diagnosis EPT Thermal Testing
History Findings

Normal pulp - Normal + +

Normal or widened
Reversible pulpitis Cold sensitivity + ++
PDL

Hot or cold
Symptomatic Normal, widened
sensitivity, lingering + ++ with lingering pain
irreversible pulpitis PDL, or PARL
pain

Asymptomatic No clinical Widened PDL or

+ -
irreversible pulpitis symptoms PARL

Normal, widened
Pulp necrosis Variable - -
PDL, or PARL

PDL = periodontal ligament, PARL = periapical radiolucency

Chief Complaint/ Radiographic

Apical Diagnosis EPT Thermal Testing Percussion
History Findings

Normal apical tissues - Normal +/- +/- -

Symptomatic apical Normal or

Biting sensitivity - - +
periodontitis widened PDL

Asymptomatic apical
- PARL - - -
periodontitis

Normal, widened
Acute apical abscess Pain with swelling - - +
PDL, or PARL

Chronic apical abscess "Bump in the gum" PARL - - -

Asymptomatic or
Increased
Condensing osteitis variable pulp +/- +/- +/-
radiopacity
symptoms

PDL = periodontal ligament, PARL = periapical radiolucency

 A Kennedy class 1 arch has the most distal
posterior teeth missing in both sides and
requires bilateral distal extensions.
A Kennedy class 2 arch has the most distal
posterior teeth missing on one side and
requires a unilateral distal extension.
A Kennedy class 3 arch has at least one
bounded edentulous space, but it does not
cross the midline like a class 4.
A Kennedy class 4 arch has one bound
edentulous space crossing the anterior
midline. (NO INDIRECT RETAINER)

Indirect retainers are used to

prevent rotation of the denture base away
from the tissue.
Indirect retainers are used in Class I, II, and IV
RPDs (tooth and tissue supported).
In determining the Kennedy classification of
the partially edentulous arch, it is important to
start with the most posterior edentulous areas.
The left side has a distal extension, but the right
side does not as the third molar will be used as
an abutment (Applegate Rule #3). Therefore, it
is a class II arch with four bounded edentulous
spaces (class II mod 4).

Value is the aspect of color that describes the lightness and darkness of a color and it is measured from 0 (black) to 100 (white). It is the most
important parameter for shade selection and it is the first thing to match for prosthetics.
Women: + cones see color better = HUE
Men: + rods see VALUE better
Periodontitis Staging
Periodontal Stage I Stage II Stage III Stage IV
Stage

Severity Greatest 1-2 mm 3-4 mm ≥ 5 mm

interdental
clinical
attachment loss

Percent bone Coronal third Coronal third Middle third or apical third
loss (<15%) (15% - 33%)

Teeth lost to No tooth loss ≤ 4 teeth ≥ 5 teeth

periodontitis

Complexity • Probing • Probing depths • Probing depths In addition to Stage

depths ≤ 5mm ≥ 6mm III complexity:
≤ 4mm • Mostly • Vertical bone • Bite
• Mostly horizontal bone loss ≥ 3mm collapse, drifting
horizontal loss • Class II or Class III • Masticatory
bone loss furcation dysfunction
• Tooth mobility ≥
2
• < 20 remaining
teeth
Extent • Localized (<30% of teeth involved)
• Generalized (>30% teeth involved)
• Molar/incisor pattern

Key Takeaway:
• A patient with 5mm of clinical attachment loss and a collapsed bite has stage IV periodontitis.

The correct order for these structures from lateral to medial is:
Inferior alveolar nerve → inferior alveolar artery → lingual nerve

The inferior alveolar nerve and artery are lateral to the lingual nerve where they enter
the mandibular foramen. The lingual nerve is medial to the mandibular ramus where it
provides innervation to lingual tissues, the tongue, and the floor of the mouth.

• Third molars with a mesioangular relationship tend to be the simplest to

extract.
• Third molars with a distoangular relationship are the most complicated to
extract.

INBDE Pro-Tip: Remember that the artery is sandwiched in the middle of the two
nerves.
• The lingual nerve is at risk of being damaged when raising
mucoperiosteal flaps in mandible during third molar
extraction cases.
• More positive aspiration rate: IAN.
• local anesthesia given not working next where to give given answer : posterior superior

INBDE PRO-TIP:
• A good mnemonic to remember the branches of the
facial nerve is to remember the sentence
"To Zanzibar By Motor Car."
• They correlate with
the Temporal, Zygomatic, Buccal, Marginal and Cervical branches of the facial nerve
The patient complains of chest pain or angina, which is caused by a lack of oxygen to the heart due to reduced blood flow. He was subsequently treated
with nitroglycerin, which vasodilates the coronary arteries to improve oxygenation of the myocardium. Because the patient’s symptoms are resolved after the
administration of nitroglycerin, the patient is considered stable and the most appropriate next step for his management is to monitor vitals.

A. Activate emergency medical services

If the patient had not responded to treatment with nitroglycerin, it is important to activate EMS as it is a medical emergency that could progress to a
myocardial infarction. However, the patient’s symptoms are resolved and this is not needed for this case.

B. Administer oxygen
Administering oxygen can be a reasonable adjunct when managing angina if the patient’s oxygen saturation is below 94%. However, the patient is no longer
symptomatic and does not demonstrate any signs of respiratory distress.

C. Administer aspirin
Aspirin reduces platelet aggregation and thins the blood, which can help prevent increasing size of the clot. Since the patient's symptoms have resolved, it is
unlikely they are experiencing a myocardial infarction.

Key Takeaway:
If the symptoms of angina resolve following nitroglycerin administration, vitals should be monitored and the patient referred to a physician. Nitroglycerin is a
venodilator and coronary artery dilator that decreases preload and increases myocardial perfusion. In addition to known hypersensitivity or allergy to
nitroglycerin, sildenafil (Viagra®) use within 24h is an absolute contraindication for nitroglycerin since it is a phosphodiesterase 5 inhibitor and causes
vasodilation. Both Viagra® and nitroglycerin are powerful vasodilators and when taken together they can produce dangerously low blood pressure.
Below is a summary of the clinical findings involved in the caries risk assessment form for a child who is ≥ 6 years old. Any one or more conditions in the “high
risk” column place the child at a high caries risk. Because the patient has at least 1 interproximal caries lesion (seen in radiograph) and active white spot caries
lesions, the patient is in the “high risk” category. Typically, the recommendation for children in this “high risk” category is a recall every 3 months.

High risk Medium risk Low risk

Poverty Recent immigrant Fluoridated water

> 3 sugary snacks per day Special health care needs Adequate oral hygiene

> 1 interproximal carious lesion Defective restorations

Non-cavitated white spot lesion Intraoral appliance

Low salivary flow

Key Takeaway:
• The recommendation for children in a “high risk” caries category is a recall every 3 months.
The single best predictor of future caries is the presence of past caries. All other risk factors vary in caries prediction depending on population of study and age
group. Children who experience decay in their primary teeth are considered high risk for future dental decay of the permanent dentition. Past caries provides
valuable information regarding the patient’s susceptibility to tooth decay, indicating that this will likely continue to occur unless there is a change in the oral
environment.

Uncooperative kid travelled long distance= Silver diamine fluoride for Arrest caries, Uncooperative, Can't follow up treatment,
also used in root sensitivity
A caries risk assessment is a tool used to identify risk indicators and factors that may contribute to the formation of decay. This should be completed for
children above the age of 6, which provides a comprehensive questionnaire to assess for risk factors and indicators. The three main criteria are contributing
conditions (fluoride exposure, diet, family caries experience, dental home), health conditions (special needs, conditions which affect salivary flow), and clinical
findings (plaque, decay, inadequate restorations). All of these factors can contribute to decay, however, caries is a multifactorial disease process, so the presence
of one risk factor may not predict future caries. Therefore, although low salivary flow, high number of Streptococcus mutans, and a cariogenic diet can
increase the incidence of decay, some patients naturally have protective factors which may prevent this from occurring. Therefore, multiple factors usually have
to be present to predispose the patient to decay, so one risk factor alone is not a good indication.

Key Takeaway:
• The single best predictor of future caries is a history of caries.
Of the following medications listed above,
only ibuprofen is contraindicated during the third
trimester of pregnancy. It is a nonsteroidal anti-
inflammatory drug (NSAID) that acts to reduce pain
and inflammation by inhibiting the enzyme
cyclooxygenase (COX). These medications may cause
serious adverse effects such as the premature closure
of the fetal ductus arteriosus, especially if used after
20 weeks gestation (second to third trimester). This
places ibuprofen in category D in the third trimester
(definitions for the categories shown below).

B. Acetaminophen (Tylenol®)
Acetaminophen is an analgesic that reduces the production of prostaglandins that cause inflammation and swelling. It is considered one of the safest over-the-
counter analgesic medications to take during pregnancy and is in category B.

C. Amoxicillin (Moxatag®)
Amoxicillin is an bactericidal antibiotic that destroys bacteria by inhibiting cell wall synthesis. It is also considered safe to take during pregnancy and is
in category B.

D. Lidocaine (Xylocaine®)
Lidocaine is a local anesthetic that is a voltage-gated sodium channel blocker that stops action potential propagation in nerves. Once again, they are considered
to have almost no negative effects on the mother and the fetus in pregnancy. Therefore, it is placed in category B.

Key Takeaway:
• Ibuprofen is contraindicated during the third trimester of pregnancy.
• Acetaminophen is one of the safest analgesic medication to take during pregnancy.
• Promethazine (Phenergan®) is commonly used during pregnancy to treat morning sickness and
hyperemesis gravidarum.
The patient presents with a history of alcoholism and hepatic cirrhosis, indicating impaired liver function. Patients with hepatic cirrhosis should avoid use of
nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, as these drugs can decrease glomerular filtration rate (GFR) and impair renal function in
patients with advanced chronic liver disease or cirrhosis.
Acetaminophen is generally well tolerated in patients with chronic liver disease or cirrhosis up to a daily dose of 2g provided they are not consuming alcohol.
Opioids analgesics such as fentanyl and hydromorphone are generally good choices for patients with chronic liver disease or cirrhosis, as opioids do not
impair renal function.

Key Takeaway:

• Avoid use of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients

with hepatic cirrhosis.
 Tooth Stage Variation

Initiation Missing teeth, changes in tooth number

Bud Changes in tooth number

Cap Fusion, gemination, dens invaginatus

Bell Macrodontia, microdontia, amelogenesis imperfecta, dentinogenesis imperfects, dens evaginatus

Apposition Concrescence, enamel pearls, Turner's hypoplasia

Calcification Fluorosis

Key Takeaway:
• Fusion occurs when two tooth buds join to form what clinically looks like one large crown and occurs during the cap stage.
• The number of teeth in the arch will be normal in patients with gemination.
• The number of teeth in the arch will be less than normal in patients with fusion.

The best age to carry out a bone graft to fill in open space within the palate is between 8-12 years of age. A rough timeline for the treatment of cleft lip and

palate is outlined below. The majority of cleft lips are isolated cases, with only 10% of cleft lips being associated with a syndrome, including Down syndrome and

Van der Woude syndrome.

Age Treatment

0-5 months Orthopedics

3-6 months Cleft lip repair

6-12 months Cleft palate repair

5-6 years Nose/lip revision surgery

8-12 years Bone graft surgery

12-15 years Orthodontics

15-18 years Orthognathic surgery

18+ years Prosthodontics

Key Takeaway:

• The best age to carry out a bone graft to fill in open space within the palate is between 8-12 years of age.
 An Ellis class III fracture is defined as crown fracture with pulp exposure and involves the enamel, dentin, and pulpal tissue. The patient will require pulpal
treatment since the pulp has been exposed. Since the child is 7 years old, the central incisors have likely just recently erupted and root development will not
be completed for approximately another 2 years (~9-10 years of age). With an immature root apex, partial pulpotomy and restoration should be performed
to maintain the vitality of the radicular pulp to allow for apexogenesis, or completion of root development.

Treatment Size of exposure Bleeding present Time since injury Root apex

Pulp cap Small/pinpoint Little bleeding < 24 hours Complete apex

Pulpotomy Large Yes > 2 hours Immature apex

Pulpectomy Small or Large Either > 2 hours Complete apex

Ellis Classification Description

Class I Simple fracture with only enamel involvement

Class II Crown fracture with enamel and dentin involvement

Class III Crown fracture with enamel, dentin, and pulpal exposure

Class IV Non-vital tooth, with or without crown structure involvement

Class V Traumatic tooth avulsion

Class VI Root fracture with or without crown fracture

Class VII Displacement of tooth without crown fracture

best prognosis: for root fractures - apical third

poorest prognosis: Cervical 1/3 of the root fractures and
vertical root fracture

Dental Injury Splinting Time A concussion injury to a tooth is a traumatic injury where the tooth has no mobility and no
displacement, but the periodontal ligaments become injured and inflamed, leading to soreness
and possible bleeding. The most appropriate treatment is monitoring.
Avulsion 2 weeks
A subluxation injury involves the tooth having no displacement in the socket, but there
Extrusive luxation 2 weeks is increased mobility. The periodontal ligaments rip and bleed in this injury process. The
treatment of a subluxation injury is to splint for 1 to 2 week.

Subluxation 2 weeks Extraction: This measure may be necessary in cases where there was avulsion of a tooth from
its socket entirely for longer than one hour. The likelihood of saving a tooth under this
Lateral luxation 4 weeks circumstance decreases drastically.

Avulsed teeth that do not involve alveolar fracture should be immobilized in a flexible splint
Intrusive luxation 4 weeks
for 2 weeks. This time frame allows for the periodontal ligament to heal and decrease the risk of
ankylosis. The tooth should be re-evaluated at this time and continued to be evaluated at regular
Alveolar fracture 4 weeks intervals for up to 5 years.

When a tooth is intruded, the treatment depends on whether or not the apex of the root is open
Root fracture 4 weeks
or closed. An open apex means that the root has not finished developing and will continue to
grow. Because the patient is 6 years old, this is likely the case for him as it takes around 2-3 years
Root fracture (cervical ⅓) 4 months after eruption to finish root development. Therefore, the best treatment option is to allow the
tooth to re-erupt and correct itself.
No treatment is recommended for a root fracture in the apical portion. The hope is that the
root tip will naturally resorb as the permanent tooth begins to erupt.
A rigid split or an extraction is indicated if the root fracture occurred in the coronal half of the
root.
Contact dermatitis is a red, itchy rash caused by the direct contact of an offending chemical or antigen with the skin. It is a type IV
hypersensitivity response that results from the langerhans cells in the skin binding to the antigen. These cells then interact with T-lymphocytes which drive the
localized inflammatory response.
Type I hypersensitivity is a reaction mediated by IgE antibodies which occurs in anaphylaxis, allergic reactions. IMMEDIATE Amoxicillin reaction.
Type II hypersensitivity is a reaction mediated by IgG or IgM antibodies. Examples include rheumatic heart disease and Graves’ disease, or Hashimoto’s
thyroiditis.
Type III hypersensitivity is a reaction mediated by IgG antibody-antigen immune complexes. Examples include rheumatoid arthritis and systemic lupus
erythematosus.
Key Takeaway:
Contact dermatitis is a type IV hypersensitivity response. CAN BE TO AMOXI FEW DAYS LATTER!!
The type I hypersensitivity reaction is a fast, immediate response to an allergen that occurs within minutes of exposure. It involves an IgE-mediated
release of antibodies that leads to mast cell degranulation and the release of vasoactive molecules such as histamine. Individuals rapidly develop
bronchoconstriction, widespread vasodilation, and increased capillary permeability.

Type Name Mediators

I Immediate, Anaphylactic, Asma IgE

II Cytotoxic, Antibody-dependent IgM, IgG, Complement, MAC

III Immune-Complex IgG, Complement, Neutrophils

IV Delayed T-cells
The type IV hypersensitivity reaction is the only type of reaction that is not antibody mediated. In this reaction, T helper cells are activated by antigen
presenting cells and macrophages are activated by T memory cells to produce an inflammatory response.

The patient’s response to the treatment is an example of allergic asthma where an irritant causes the airways to narrow, swell, and produce excessive mucus.
This is an example of a type I hypersensitivity reaction, which is an immediate reaction that involves IgE. These IgE antibodies are released in response to the
allergen and bind to mast cells, which release histamine and a whole host of inflammation mediators to cause the allergic response.
Immunoglobulin A (IgA) antibodies are typically found in the respiratory system, digestive tract, ears, and eyes. They act as a first line of defence against
pathogens by inhibiting bacterial and viral adhesion to epithelial cells.
Type II hypersensitivity reactions are antibody-mediated immune reactions where IgG or IgM is directed against the body. Examples include Graves disease or
Hashimoto’s thyroiditis.

The patient’s response to amoxicillin is an example of an allergic reaction where an allergen causes various symptoms such as a skin rash, hives, swelling, and
shortness of breath. This is an example of a type I hypersensitivity reaction, which is an immediate reaction that involves immunoglobulin E (IgE).
These IgE antibodies are released in response to the allergen and bind to mast cells, which release histamine and a whole host of inflammation mediators to
cause the allergic response.

The patient’s current symptoms and history of recent amoxicillin use prior to the appointment is consistent with a Type 1 hypersensitivity reaction. Type 1
hypersensitivity reactions are mediated by IgE antibodies which cause mast and basophil cell degranulation. These cells release histamine and other vasoactive
compounds which are responsible for symptoms including a rash, difficulty breathing, edema, and hives. Symptoms can begin within a few minutes.

Hypersensitivity reactions

Type I Type II Type III Type IV

Time Minutes to hours Hours to days Hours to days Days

Course

Examples Anaphylaxis Acute transfusion reaction Rheumatoid arthritis Contact dermatitis (poison ivy)
Food Hemolytic disease of the Systemic lupus Tuberculin or TB skin test
allergies newborn erythematosus (SLE) Reaction to medication few days later
Drug (Steve Johnson Synd)
allergies
Eczema
Asthma

Type 2 hypersensitivity reactions are IgM and IgG-mediated and trigger complement activation which leads to cell and tissue damage. This type of
hypersensitivity reaction can take hours to cause symptoms.
Type 3 hypersensitivity reactions are immune complex-mediated. These immune complexes deposit themselves in tissues like the skin, kidney or joints, as seen
in rheumatoid arthritis and systemic lupus erythematosus. This type of hypersensitivity usually requires hours or days to cause symptoms.
Type 4 hypersensitivity reactions are cell-mediated, where the body’s own CD4 and CD8 cells develop strong responses to antigens. This sensitization of the
immune system towards a specific antigen can take days.

Key Takeaway:
• Type 1 hypersensitivity reactions to medications can cause severe, life-threatening symptoms within minutes of administration
The bacterial cell wall is a rigid structure surrounding the bacterial plasma membrane. It consists of peptidoglycan, a series of polysaccharide chains linked by
amino acids, that provides the cell with integrity and protection. There are two types of cell walls, a thick wall surrounding gram positive bacteria, and a thin wall
surrounding gram negative bacteria. Each of these influences the bacterial pathogenicity and their ability to evade host defenses and antibiotics. These
peptidoglycan sheets contain protein structures and glycolipids that allow for cell signaling, entrance of nutrients, and modelling to accommodate cell division.
Peptidoglycan is a polymer structure that makes up the bulk of bacterial cell walls, not the plasma membrane.
Bevel in axiopulpal angle

A Preferred Provider Organization (PPO) is a type of dental

insurance plan that accepts both preferred providers (aka in-
network offices) and non-preferred providers (aka out-of-network
offices). Choosing an out-of-network provider will require the
patient to pay upfront at the time of service, but the staff can file
the claim and proceed with the direct reimbursement process
afterward.
Following implant placement, several stages of healing occur. Wound healing, including healing within the oral cavity, can be broadly categorized into 4
stages: hemostasis, inflammation, proliferation, and maturation/remodeling.

Stage Time frame Physiological processes Relation to implant healing

Hemostasis Minutes to hours Vasoconstriction

Clotting factor release and thrombus formation

Inflammation Hours - seven days Infiltration of neutrophil granulocytes, macrophages,

lymphocytes
Phagocytosis of debris
Migration of keratinocytes

Proliferation One - six weeks Migration and proliferation of endothelial cells, fibroblasts, Junctional epithelium around plant evident
and epithelial cells at 2 weeks
Formation of granulation tissue and re-epithelization via Tissue maturation and collagen fiber
keratinocytes organization evident at 4-6 weeks
Angiogenesis Formation of biologic width and barrier
Wound contraction epithelium evident at 6 weeks
Collagen synthesis and deposition

Maturation/ Six weeks - years Continued deposition of collagen

remodeling Secretion of growth factors, matrix metalloproteinases
(MMPs)

Similar to how hard tissue healing leads to osseointegration, soft tissue healing leads to marginal soft tissue attachment and esthetic outcomes. Soft
tissue healing occurs soon after implant placement, starting with inflammatory cells within the area creating a dense fibrin network. This network is soon
replaced with collagen fibers by fibroblasts, forming a fibrous connective tissue.

By 4-6 weeks post-implant placement, there is a mature epithelial barrier and an organized collagen matrix within the peri-implant mucosa. Compared to
the collagen fibers surrounding a natural tooth, the collagen fibers around an implant run parallel to the implant itself.

Key Takeaway:
• An organized collagen matrix is formed around the implant 4-6 weeks after implant placement.
Methotrexate is a chemotherapeutic and immunosuppressive drug used to treat the patient’s rheumatoid
arthritis. This medication inhibits dihydrofolate reductase and blocks DNA and RNA synthesis in rapidly
dividing cells. Methotrexate, even in low doses, can impair kidney function, which in turn can delay
wound healing and cause poor hemostasis.

Although methotrexate can certainly increase the risk of MRONJ, it is still a relatively rare complication.
 GINGIVAL GROWTH INDUCED BY DRUGS

Anticonvulsants

Phenytoin, sodium valproate, phenobarbitone, vigabatrin, primidone,

mephenytoin, and ethosuximide are some of the drugs that cause
gingival hypertrophy. However, phenytoin is the anticonvulsant most
associated with gingival enlargements.

Immunosuppressants

Cyclosporin, sirolimus, and tacrolimus. Cyclosporin is the most

frequently prescribed immunosuppressive drug.

Calcium Channel Blocker

These include nifedipine, verapamil, and diltiazem.

Stafne defect represents a depression of the mandible created by Oral hairy leukoplakia (OHL) that is caused by Epstein-Barr
ectopic salivary gland tissue. Radiographically, it is a unilateral oval
virus in an HIV positive, immunocompromised patient. OHL commonly
shaped radiolucent defect in the posterior region of the mandible
presents as a white plaque on the lateral borders (BILATERAL) of
below the inferior alveolar canal. It is a normal anatomical variant and
the tongue that doesn’t rub off. The development of oral hairy
requires no treatment.
leukoplakia may be an indication that HIV antiviral therapy is not
sufficient and the disease is progressing. Oral hairy leukoplakia is most
often seen in patients with a CD4+ count of less than 500 cells/µL.
 MOA
-Warfarin: Inhibit vitamin K reductase resulting in depletion of reduced
form of vit K; Decrease K+ needed to synthesize factors II, VII, IX, X.
-Omeprazole: Proton pump inhibitor, is a selective and irreversible
proton pump inhibitor. It suppresses stomach acid secretion by specific
inhibition of the H+/K+-ATPase system found at the secretory surface of
gastric parietal cells.
-Isoniazid: for Tuberculosis. Side effects: hepatoxicity, peripheral
numbness, upset stomach. OK for pregnant.
-Lisinopril: ACE inhibitor. is an angiotensin converting enzyme inhibitor
(ACEI), preventing the conversion of angiotensin I to angiotensin II.
Flushes out water and sodium. Side effect: cough, angioedema,
hyperkalemia, rashes. DON’T increase urination.
-Ibuprofen: non-selective, reversible inhibition of the cyclooxygenase
enzymes COX-1 and COX-2 MAX. DOSE: 4mg
-Aspirin: anti-pyretic, Anti-inflammatory and antirheumatic, Prevent
platelet aggregation, Irreversible cox I and II inhibitor
-Metformin: decreases hepatic glucose production, decreases intestinal
absorption of glucose, and improves insulin sensitivity by increasing
peripheral glucose uptake and utilization.
-Naloxone is used to rapidly reverse opioid toxicity by acting as an
opioid receptor antagonist.
-Nitroglycerin: vasodilation
-Buspirone is an 5HT1 receptor partial agonist and it is an anxiolytic
typically used for generalized anxiety disorder. This medication is
actually known to alleviate symptoms of depression. Common side
effects of buspirone include headaches, nervousness, excitement,
nausea, diarrhea, insomnia, xerostomia and confusion. Chest pain,
confusion, fast or pounding heartbeat, fever, incoordination, mental
depression, muscle weakness, numbness, tingling, pain, or weakness in
the hands or feet, skin rash or hives, sore throat, stiffness of the arms or
legs, uncontrolled movements of the body.
Nystatin relines the Buspirone is better for anxiety, Bupropion use may present with an
denture; increased risk of worsening depression and mental health.
Local: Nystatin, -Methotrexate is an anti-metabolite that can be used in chemotherapy
clotrimazole; as well as psoriasis and rheumatoid arthritis treatment. It inhibits purine
Systemic: fluconazole, and pyrimidine synthesis, which would inhibit the proliferation of
amphotericin B; malignant cells as well as lymphocytes. This explains its usage as a
chemotherapeutic drug and an anti-inflammatory drug:
Choriocarcinoma, leukemia in the spinal fluid, osteogenic sarcoma,
breast cancer, and head and neck cancer
Side effects: fever, vomiting, diarrhea, thrombocytopenia,
anemia, gastrointestinal disturbances, hepatotoxicity, and oral
ulcerations.
-Hydrochlorothiazide side effects: dizziness, headaches,
xerostomia, arrhythmias, and hypokalemia.
- Albuterol: beta-2 agonist
- Humira® (adalimumab) is an immunosuppressant drug used to
treat rheumatoid arthritis.
When aspirin and probenecid, a medication used to treat gout, are taken
together a drug-drug interaction occurs that results in a decreased effect of
the probenecid.
A. Anticoagulants
When aspirin and anticoagulants are taken together, there is an increased
bleeding tendency.
D. Methotrexate
When aspirin and methotrexate are taken together, increased methotrexate
toxicity can occur.
EMERGENCIES
- Diabetic ketoacidosis = Fruity smelling breath
- Myocardial infarction: MONA Morphine - Oxygen – Nitroglycerin
(0,4mg 2x 5 min between) – Aspirin
Symptoms: most commonly presents with substernal chest
pain with radiation to the left arm or jaw. Anxiety, shortness of
breath, sweating, and weakness are also commonly present.
When a patient with a history of coronary artery disease complains of
left arm and chest pain, remember to stop treatment and administer
at least 1 dose of sublingual nitroglycerin. Emergency medical services
(EMS) should be contacted if symptoms do not improve after
administering the first dose of nitroglycerin. During the first 6
months, emergency dental treatment can be provided under
appropriate care, which sometimes requires treatment in a hospital
setting. Elective care can usually commence after 6 months, while
taking extra precautions (possible oxygen and nitroglycerin
administration).
- Hypoglycemia, or low blood sugar less than 70 mg/Dl: Give orange
juice or IM glucagon/IV dextrose if unconscious
Symptoms: include dizziness, weakness, drowsiness, confusion, tremor,
palpitations, anxiety, and sweating.
- Anaphylactic shock: AEIOU Albuterol-Epinephrine (0.3 mg 1:1000) –
IM anti histamine (diphenidramine 25mg) – Oxygen – U call 911.
Symptoms: Hives, chest tightness, and trouble breathing are cardinal
signs and symptoms of an allergic reaction
- Angina: ONA Oxygen – Nitroglycerin (0,4mg 2x 5 min between) – call
911 - Aspirin (160mg), chest pain at rest
For a patient experiencing angina, if there is no resolution
of symptoms following 3 doses of nitroglycerin, the
next step in the management of the patient is to activate
EMS and then aspirin.
- Stroke (TIA and CVA): oxygen and call 911
Symptoms: Sudden numbness or weakness in the face, arm, or leg,
especially on one side of the body. Sudden confusion, trouble
speaking, or difficulty understanding speech. Sudden trouble seeing in
one or both eyes. Sudden trouble walking, dizziness, loss of balance, or
lack of coordination.
- Cardiac Arrest: performing CPR, obtaining a defibrillator, and
calling emergency medical services.
Symptoms: Sudden chest pain combined with loss of consciousness.
Following feelings of crushing chest pain, the patient collapsed. This
indicates lack of perfusion to vital organs and the brain. This patient
may be experiencing cardiac arrest, and the appropriate management
involves performing CPR, obtaining a defibrillator, and
calling emergency medical services.
- Nitroglycerin is NOT recommended to treat cardiac arrest
and cannot be administered to an unconscious patient.
Sildenafil (Viagra®) is an absolute contraindication for
nitroglycerine use.
Nitroglycerin can only be administered in cases of suspected
angina or myocardial infarction when the systolic blood
pressure is above 90 mmHg.

- Hyperventilation: DON´T OXYGEN, paper bag

- Vasovagal Syncope /Orthostatic hypotension: supine position
- ASTHMA: Albuterol inhaler Adrenaline and albuterol both can be used
as emergency drug Both relax smooth muscles Here patient is
asthmatic best choice would be albuterol.

-Contraindications to the use of nitrous oxide include nasopharyngeal

obstruction, closed air-containing tissue spaces, bleomycin
chemotherapy, claustrophobia, chronic obstructive pulmonary
disease .
 In healthy individuals, the maximum dose
Local Anesthetic Maximum dose (mg/kg)
of epinephrine that can be given in a
dental appointment is 0.2 mg. A standard
Lidocaine (2% without epinephrine) 4.4 2% lidocaine with 1:100,000 epinephrine
contains 0.018 mg epinephrine. As such,
Lidocaine (2% with 1:100,000 epinephrine) 7 the maximum number of carpules of 2%
lidocaine with 1:100,000 epinephrine can
Lidocaine (2% with 1:100,000 epinephrine) pediatric 4.4 be calculated to be 11 carpules.
CDV Pt (ASA 3 or ASA4): 0,04mg
Articaine (4% with 1:100,000 epinephrine) 7 1:200= 4 carpules
1:100= 2 carpules
1:50 = 1 carpule
Mepivacaine (3% without epinephrine) 4.4

Bupivacaine (0.5% with 1:200,000 epinephrine) 1.3

 Stage Patient’s thoughts Dentist’s actions

Pre- Not thinking of quitting Offer support

Key Takeaway:
contemplation Defensive
• During the preparation
Not receptive to help stage of smoking cessation,
patients are interested in quitting
but have not actively tried yet.
Contemplation Considering quitting Increase patient confidence The definition of preparation is
taking steps forward to change a
Aware of consequences of smoking
habit or behavior and expressing a
desire to change
Open to help
• A key step in preparation to
quit smoking is choosing a quit
Preparation Getting ready to quit Provide patient with resources (pharmacotherapy, date.
-When a patient has no interest in
Understand benefits of quitting support, behavioral strategies)
quitting smoking or changing their
behavior/habit this is
Action Actively trying to stop smoking Discuss relapse prevention, withdrawal, weight gain called precontemplation.

Maintenance Remaining cigarette free Discuss coping strategies

Follow up with patient

The 5 A’s of Tobacco cessation

Step Description are: Ask, Advise, Assess, Assist, Arrange. In this
case, the patient is willing to quit smoking as they
Ask Identify and document tobacco use status are interested in discussed pharmacotherapy
options for cessation. Therefore, the dentist
should assist the patient in quitting goals.
Advise Recommend tobacco cessation Advise refers to urging every tobacco user to quit.
Arrange refers to following up on the patient’s
Assess Determine whether the user is willing to make a quit attempt attempt to quit.
Key Takeaway

Assist Help the patient develop and carry out an action plan to quit
• For a patient who is willing to start to quit
smoking, the best course of action is
to assist them by helping them develop
Arrange Schedule a follow up meeting with the patient and carry out an action plan to quit.
A pulpotomy is indicated when a traumatic injury and exposure of the
pulp has occurred >72 hours ago and it is vital. Pulpotomies are
generally only done on primary vital teeth .
A pulpectomy is the removal of all pulpal tissues in the tooth, both
coronal and radicular. A pulpectomy in a primary tooth would be
indicated if the tooth is non-vital and restorable.
A direct pulp cap would be indicated in healthy, vital teeth when there is
caries or a mechanical exposure into the pulp that is <2mm. A direct
pulp cap is done when there is a small pulpal exposure on a vital
tooth that occurred within 24 hours. Direct pulp caps are not generally
done on primary teeth due to the risk of internal root resorption.

CHRONIC INFLAMMATION (draining fistula) = Macrophages AUTONOMY: states that dentists have a duty to respect the patient’s
are involved in both acute and chronic inflammation, macrophages begin to be rights to self-determination and confidentiality.
recruited about 48 hours after injury occurs. Macrophages are the dominant - The patient understands the benefits, risks, and alternatives of the
phagocytic cell type during chronic inflammation. Macrophages are monocytes
treatment she is requesting and still wants to proceed. If you refuse to
that have migrated from the bloodstream to bodily tissues.
provide this treatment, you would be in conflict with which principle?
- A patient walks into the dental office and needs a filling. After
ACUTE INFLAMMATION (drained abscess): NEUTROPHILS Neutrophils are the
discussing all of the treatment options, the patient elects to go forward
main cell type found in acute infections
with an amalgam filling. What ADA principle of ethics is this
demonstrating?
Facial cellulitis is a firm, erythematous swelling that is commonly
- The patient understands the prognosis of performing the requested
associated with fevers. Doughy consistency.
treatment. Continuing to refuse her this treatment is in conflict with
which part of the Code of Ethics?
-“I am moving and need my x-rays sent to my new dentist.” Radiographs
sent to another dentist. The dentist’s actions are an example of which of
the following fundamental ethical principles?
- Car accident just happened: What ethical principle is violated if you
force the patient to go to the emergency room as opposed to treating
them in your chair?
INFORMED CONSENT: Dentist must share information with and obtain
consent from the patient: Must inform patient about nature of procedure,
benefits, risks, costs, and alternative treatment options including no
BENEFICENCE: Government of a profession, Reporting abuse and treatment. Otherwise held accountable for assault and battery.
neglect, Research and development MINORS: Age 1-7 =infant, not responsible for actions. Age 8-14 =
- When a dentist suspects a case of abuse of a child, elderly, or competent. Age 15-17 = responsible.
disabled patient, they must report the case to the appropriate Minors younger than 18 can give implied consent but not actual consent
authorities immediately. No actual proof of the abuse is required to make = EXCEPTION if they are emancipated (freed from care and control of
the report. parents), parent, pregnant, or in emergency situation
- You are told the child fell down two days ago and hurt himself.
Reporting your suspicions of child abuse to the appropriate authorities
falls under which principle NON MALEFINCENCE: dentist being obligated to do no harm to the
- Patient presents with a swollen cheek in the lower-left region. Intraoral patient. Professionals (the dentist) have a duty to protect a patient from
evaluation yields gross caries on all dentition. The lower left is fluctuant in harm. Education, Consultation and Referral, Use of auxiliary personnel.
the vestibule. The dentist fails to report the dental neglect and proceeds -Previous narcotic and benzodiazepine abuse. Which ethical principle is
with the treatment. violated if benzodiazepines are prescribed for anxiolysis? the dentist is
- Reminding a patient to avoid sugary beverages like soda, floss more causing harm to the patient by violating their sobriety
frequently, and showing them the proper way to brush their teeth is an -The dentist takes on this case even though it is outside the scope of
example of what ADA principle of ethics? practice that they are comfortable with. This conflicts with which principle
- The patient claims that she has not been feeling well over the past 2 - Amalgam restorations are considered durable, reliable, and safe. If the
days. The clinician decides to reschedule the patient until she follows up patient's existing restorations are sound and intact, the dentist may be
with her physician. Given the history of heart failure, the dentist is doing more harm than good in replacing them with composite.
ensuring that the patient seeks medical attention to avoid any poor - Knowing when to refer out a difficult case that is not in the dentist's
outcomes. The dentist is practicing the ethical principle scope of practice is an example of what ADA principle of ethics?
of beneficence by acting for the benefit of the patient. - As the dentist is about to infiltrate the anesthetic, he pokes his own
- Intellectual property, such as patents and copyrights, cannot be finger, causing pinpoint bleeding. The dentist thinks nothing of it and
used to restrict research and practice, but rather must be available for delivers the anesthetic to the patient with the same needle
researchers to use and try out for the betterment of the public. - What ethical principle is demonstrated by the dentist by staying up-to-
CHILD ABUSE: Ages 0 to 3 are most commonly abused or neglected date on new technologies
Occurs all socioeconomic levels, ethnicities and cultures, and religions. - Abandonment and dismissal of a patient from a dentist’s practice falls
About 30% of abused and neglected children will later abuse their own under nonmaleficence and when this occurs the dentist is obligated to
children. provide care to the patient for 30 days while he or she finds a new dentist
adult abuse: Talk with pt 1 st ¬ Competent: ask them privately ¬ Not to take over his or her care.
competent: report DHHS
JUSTICE: professionals have a duty to be fair in the dealings with VERACITY: dentist must communicate truthfully with the patient.
patients, colleagues, and society. Pt selection, emergency, expert Representation of care, representation of fees, advertising,
testimony, rebates and split fees, - If a patient comes into the office with -“My last dentist wanted to replace all my fillings because he told me
an aggressive demeanor or displays inappropriate behavior towards they were poisonous, but I moved before he could do the work. Can you
the dentist and/or the staff, this is grounds for dismissal from the replace them for me?”
practice. - This patient is the dentist's uncle and is offered the "friends and
- It is essential to deliver all dental treatment without prejudice and family discount" by having the patient's copay waived. Which ethical
therefore all treatment options should be presented regardless of principle is violated in this case? If a dentist accepts a patient's insurance,
financial ability. but then waives the copayment to give the patient some sort of
- Patient HIV presents for scaling and root planing of all four quadrants "discount". This is considered overbilling and is deception and
under local anesthesia due to significant subgingival calculus. The scaling misrepresentation of fees to the third party or insurance company, as the
and root planing will be performed while wearing two pairs of gloves fee will appear to be higher than what the patient is actually charged.
- Not providing all possible treatment options due to the patient’s This is also a type of insurance fraud.
inability to afford treatment violates what ethical principle? - Submitting a different dental procedure to the insurance company
- Agreeing with the patient and relaying disparaging comments about other than what you actually did is insurance fraud and violates
the prior dentist and their service conflicts with which principle? the representation of fees component of veracity.
-Dentists are not allowed to offer or accept rebates or split fees from - Saying that your services are superior to other dentists in your area
other dentists to whom they have referred patients (rebates and split violates the advertising component of veracity, as it is a subjective
fees). statement and is unethical to use in any advertisement.
-Dentists have a civil duty under the ethical principle of justice to - Removing a patient’s old amalgam restorations because of the risk of
provide testimony and professional opinion as an expert witness if mercury toxicity violates the representation of care component of
called upon to testify for a deposition or in a court of law. veracity because the treatment is being represented in
- Slandering another dentist is a violation of what ADA principle of a misleading manner.
ethics

HEPATITIS Contaminated Blood CB CANCER

• Hep A= fecal-oral most common neoplasm in oral cavity = SCC
• Hep B= contaminated blood Squamous Cell carcinoma—arises from the keratinocytes in the stratum
• Hep C= contaminated blood spinosum
• Hep D= prior infection with Hep B -Oropharyngeal squamous cell carcinoma has been increasingly
associated with human papillomavirus (HPV) strains 16 and 18.
• Hep E= fecal-oral
HEP B 30% risk of transmission after percutaneous injury -Oral cancer, or oral squamous cell carcinoma, is caused by oncogenes
or the inactivation of tumor suppressor genes, but is not associated with
• DNA virus, Dane particle, Vaccine is available
the human papillomavirus (HPV)
• Postexposure prophylaxis is vaccine and possibly
Primary risk factors of oral cancer include tobacco and alcohol
immunoglobulin
HEP C: 1.8% risk of transmission after percutaneous injury consumption. Heavy drinkers can have up to a 5x increased risk of
developing oral cancer over their lifetime. Oral cancers are commonly
• RNA vírus, No vaccine or postexposure prophylaxis is available
seen on the lateral tongue and floor of the mouth, and present as
HIV: 0.3% risk of transmission after percutaneous injury slow-growing solid masses and/or ulcers.
• RNA virus -Actinic keratosis, which is a premalignant lesion that presents as a scaly
• Diagnosed when antibodies to HIV are detected in blood by erythematous patch on the lower lip. These can often undergo malignant
ELISA test transformation to squamous cell carcinoma and are treated in a variety of
• No vaccine is available; Postexposure prophylaxis is course of ways depending on the size, location and severity of the lesion. One of
antivirals these methods is laser ablation, which uses a CO2 laser to remove the
TB: Inhalation of infected droplet nuclei lesion. Other methods of treating actinic keratosis include excisional
• Diagnosed by symptoms, sputum culture, chest x-ray, or a surgery, electrocautery, and medications such as 5-fluorouracil.
positive tuberculin skin test
• Patient should not be seen for elective dental care, and while in
dental clinic must wear mask and cover mouth when coughing

Leukoedema is a white-blue-gray lesion of the buccal mucosa that

disappears when tissue is stretched.
This lesion is often seen in smokers and
is seen more commonly in
African-Americans.

White sponge nevus is a hereditary disorder of the oral mucosa. It

is often a bilateral thickened white lesion of the buccal mucosa that has
a velvety appearance. These lesions will
appear in childhood or in adolescence.
These lesions will not disappear when
stretched and have a very low incidence
of malignant transformation
A few reasons for patient dismissal include: a failure to keep The Department of Health and Human Services
appointments, chronic tardiness, drug seeking behavior, noncompliance
and consistent refusal of medical advice, failure to pay account (HHS) is a cabinet-level executive branch of the U.S.
balance, and harassment of staff. government that exists to protect the health of all
Disability or a dentist’s inability to treat a patient in a wheelchair is not
Americans and provide essential human services.
an acceptable reason to dismiss the patient.
When the patient is being dismissed, the dentist is legally obligated to The HHS is the federal government’s principal agency
describe the untreated conditions and the consequences of leaving involved with all healthcare services. The HHS
them untreated prior to dismissal.
When a patient is dismissed, radiographs must be transferred to the
administers multiple federal programs consisting of
new dentist or patient upon request. This can not be withheld due to social services programs, civil rights and healthcare
unpaid balances of the patient, as radiographs are an important privacy programs, disaster preparedness programs,
diagnostic tool. It would be unethical to withhold this critical information
required for the patient's future treatment. and health-related research. Examples of programs
that HHS funds include the Food and Drug
The best course of action for a patient who comes into your office
Administration (FDA), Health Resources and
and smells of alcohol is to respectfully ask the patient to leave and to
reschedule the patient for another time. Services Administration (HRSA), the Centers for
Disease Control and Prevention (CDC), and
It is unethical for a clinician to alter the medical record after a
the National Institutes of Health (NIH).
complication has occurred to attempt and protect themselves from
litigation.

Hawley retainer with active finger spring on permanent molar allows

PICO is a mnemonic that is used to help formulate clinical research for adjustment to produce a slight distal pressure against the permanent
questions. first molar. Typically, this can move the molar distally about 2 mm in a
period of 2-4 months and can correct tipping of the tooth.
P = Population, Patient, or Problem Lower lingual holding arch is a bilateral, fixed space maintaining
I = Intervention appliance. It is indicated in bilateral loss of lower molars.
C = Comparison Distal shoe space maintainers are utilized in cases where the second
O = Outcome primary molar is lost prematurely to help guide the first permanent molar
P: Population/Patient/Problem - How would I describe the problem or into place. In this case, the permanent first molar has already erupted. A
a group or patients similar to mine? distal shoe space maintainer would not correct the mesially tipped tooth
I: Intervention - What main intervention, prognostic factor or exposure 30.
am I considering? band and loop is used when there is unilateral loss of a primary first
C: Comparison - Is there an alternative to compare with the molar.
intervention? Extraction of permanent teeth is indicated when space loss is 4 mm or
O: Outcome - What do I hope to accomplish, measure, improve or more.
affect? A nance appliance is used in the maxillary arch in the mixed dentition
stage as a space maintainer or to create anchorage by holding the
anteroposterior position of the maxillary molars.

A quad helix is a fixed palatal expander composed of four helical

loops. It is capable of applying more force anteriorly or posteriorly
depending on how it is activated.
Space loss occurs quickly within 6 months of tooth loss or extraction.
Determine association not causation

-both researcher and participants do not know participating in study given

answer = Double blind study
-Cases of 1,00,000 from 2010 to 2019 guess?
a) incidence b) prevalence c) sensitivity d) specificity ¬
The wording is important to answer this question.
We don't know if 1Mcases are new ones or not
Incidence is rate and prevalence is percentage
Prevalence for small people short time, Incidence long time.
Prevalence refers to proportion of persons who have a
condition at or during a particular time period, whereas incidence refers to
the proportion or rate of persons who develop a condition during a particular
time period.
Case control studies are more likely to be impacted by bias. Case control studies are retrospective.
Case-control studies compare a group of cases (people with a certain condition) and a group of controls (people without that condition).

-A prospective cohort studies takes a random sample from a healthy population and
follows them over time to see the incidence of new disease. Etiology: relative risk.
-A cross-sectional survey takes a random sample from the population in time and
surveys them for information. looks at data from a population at one point in time,
which is the “cross section easy to conduct and can be carried out
rather quickly and inexpensively.
-A case study is a finding or narrative about one specific case. Typically, it is about a
rare or unknown case/condition. The outcome of each subject in a case control
study is known at the start of the investigation and puts the study at a higher risk of
being impacted by recall bias
A single group study is a non-randomized clinical trial that takes a group of patients
with disease and compares them with a historical control group.
A concurrent control group is another type of non-randomized clinical trial that
takes 2 different groups from a disease population and gives them 2 different
treatments.
-P-values measure the percent probability that the difference in results is due strictly
to chance. This is also known as type I ( ) error. In most studies, a p-value of 0.05 or
below is accepted as statistically significant.
-A lower p-value means that the study was less likely due to random chance. This is
much more preferred than a higher p-value. = reject null hypothesis
-A 95% confidence interval estimates a likely range of values for the true
population. It shows a range of values that 95% of the population likely falls in.
- The null hypothesis is a hypothesis that there will be no difference between two
groups
- number needed to treat (NNT) represents the number of patients that would need
to be treated. Most ideal value is 1.
- Power is the probability that a study detects an effect when there is an effect to be
detected. A higher power is always preferred, greater than 0.8.
- Correlation coefficients measure how strong of a relationship exists between two
variables. The values range between -1 and 1, where value of 1 indicates a strong
positive relationship, a value of -1 indicates a strong negative relationship, and a
value of 0 indicates no relationship.
- odds ratio measures the association between two factors in a population. It
represents the odds that an outcome will occur given an exposure compared to the
odds an outcome will occur without the exposure.
If the odds ratio equals 1, the exposure does not affect the odds of the outcome
If the odds ratio is greater than 1, the exposure is associated with an increased odds
of the outcome
If the odds ratio is less than 1, the exposure is associated with decreased odds of the
outcome
Hawthorne effect describes the phenomenon where participants in a study alter
their behavior since they are aware they are being observed.
 Tooth Location of Displacement
Radiograph
Commonly used to view
type
Maxillary First/Second molar Maxillary Sinus
Periapical Periapical radiolucency, root fractures, impacted teeth

Comprehensive view, temporomandibular joint, Maxillary Third molar Infratemporal Fossa

Panoramic
sinuses, impacted teeth, jaw lesions

Vertical Mandibular Third molar Submandibular Space

Bone levels, interproximal areas
Bitewing

Horizontal
Posterior caries, interproximal caries, crown margins
Bitewing

Key Takeaway:
• Vertical bitewings are useful to evaluate
patients horizontal and vertical bone loss.
• Horizontal bitewings are useful in visualizing interproximal
areas and are the best choice for
detecting interproximal caries.

A fractured mandibular condyle is likely displaced anteriorly

and medially due to the force of contraction of the lateral
pterygoid muscle. The lateral pterygoid is the only muscle
of mastication that is not attached to the ramus
of the mandible.
The lateral pterygoid is the only muscle responsible for
depressing, or opening the mandible. The lateral pterygoid
attaches at the medial condylar neck and the capsule
of the TMJ, and allows for translation of the mandibular
condyles.
Facial palsy involves signal disruption of the
facial nerve (CN VII), affecting the muscles of
facial expression.

Eagle's syndrome is a painful condition which occurs when

the stylohyoid ligament becomes calcified and places pressure on
adjacent nerves and anatomic structures. The cause of this calcification
is unknown, but occurs more commonly in those between 40 and 60
years old.
Signs of Eagle's syndrome include pain during swallowing and head
movement, shooting pains from the throat to the jaw, ringing of the
ears, or feeling like something is stuck in the throat.