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LesionScenarioManagementTobacco pouchSmokeless tobacco in vestibule1. Remove etiology2. Incisional biopsy (to detect dysplasia)Frictional keratosisRecent filling/sharp cusp/Poor denture 1. Observe for 2 weeks2. Eliminate etiologyMucosal burnBurning sensationPainfulEtiology:1. electric2. thermal - hot foods3. chemical (aspirin; phenol - denture users; bleaching materials - whitening strips; hydrogen peroxide; formacresol1. Topical anesthetic2. Eliminate etiologyLichen PlanusBurning sensationAssociated with Hep CRisk of malignancy (Erosive LP)bilateral and no systemic involvement except for flexor surfaces of wristBased on being symptomatic or asymptomaticAsymptomatic (reticular)1. No TxLIDEX (fluocinonide) cream 0.05%Symptomatic (Burning sensation) - erosive/atrophic/bullous1. Topical corticosteroidsCandidiasisMay complain of taste alterationDry mouthRecent completion of broad spectrum AB: ChildrenImmunosuppressant’sSteroidal inhalerspatient admits rarely removing denture or cleaningDenture stomatitis 1. Topical AB2. Eliminate etiology3. Excisional biopsy if fibrotic lesionsAcute pseudo membranous1. Topical AB (Nystatin)Acute pseudo membranous associated with HIV or immunosuppressed 1. Systemic AB Angular cheilitis1. Topical AB2. Eliminate etiologyAcute erythematous candidiasis (due to use of broad spectrum AB)1. Topical ABuse of corticosteroid spray/inhalerMedian rhomboid glossitis - asymptomatic and long standing1. No TxMedian rhomboid glossitis - burning1. Topical ABHyperplastic (Does not rub off)1. Topical ABHairy LeukoplakiaImmunocompromisedUnder HART drugsHIVPost-transplant patientsUnclear history/Initial management1. Incisional biopsyPost-diagnosis, no complaint1. No TxPost-diagnosis, cosmetic or discomfort1. Systemic ABLupus ErythematosusImmunocompromisedstriae tend to radiate from lesionunilateral (lichen planus like)Discoid (Isolated patch in oral cavity)1. Topical corticosteroidSystemic (Butterfly rash)1. Topical corticosteroids2. Systemic corticosteroidWhite spongy nevusBilateralHereditary/Familial1. No TxErythema migransIn some parts the ‘skin’ is shed too early and so leaves a red, sore area. Other areas the skin stays on too long and has a white appearance.Red areas may be infected with CandidiasisAs the red patches are thin and raw, they tend to be sore when eating acidic things like citrus fruit or spicy foods especially chilliesAsymptomatic1. No TxSymptomatic1. Topical corticosteroid (first choice), if not, topical anestheticHairy TongueAdverse reaction to penicillinbismuth-containing compounds, such as Pepto-Bismol (for diarrhea)1. Eliminate etiology2. DebridementVerrucous Carcinoma(Associated with pouch tobacco/smokless)1. Eliminate etiology2. Excisional biopsyApthous ulcer/Canker soresAssociated with Crohn’sPainfulminor1. Topical corticosteroid (first choice); if not, then topical anestheticmajor1. Topical corticosteroid2. Systemic corticosteroid3. Medical evaluationherpetiform1. Topical corticosteroid (first choice); if not, then topical anestheticHerpes ZosterUnilateral blisters, swelling and parasthesiaPainful (vesicles burst)Itching, Tingling, Burning sensationSharp shooting pain in response to light touch (allodynia)Prolonged or exaggerated pain (hyperalgia)Fever few days back (prodromal)1. Systemic AB2. Systemic analgesicTraumatic ulcerPainful1. Observe for 2 weeks2. Topical anesthetic (first choice; if not, topical corticosteroid3. Eliminate etiologyRecurrent herpes labialisPainful (vesicles burst)Seen on keratinized tissue and also have a very erythematous borderCommon in ADULTS, seen at the muco-cut junctionPrior to rupture/in prodromal period (<24 hours)1. Systemic ABAfter rupture for labial lesions1. Topical AB After rupture for intraoral herpes1. Topical anestheticAfter rupture, but immunocompromised (or on immuno suppressant meds)1. Topical AB + systemic AB; or2. Topical anesthetic + systemic ABPrimary herpetic gingivostomatitis: ChildrenPainfulGingival erythemaMultiple small ulcers and vesicles in the attached gingivaOccurs as a sequela of upper respiratory tract infectionWithin the first 72 hours - severe(gingivostomatitis, suffering from substantial pain or dehydration. The onset is abrupt and often accompanied by anterior cervical lymphadenopathy, chills, fever (103° F to 105° F), nausea, anorexia, irritability1. Systemic AB (acyclovir)2. Topical anesthetic (dyclonine hydrochloride 0.5%)3. Systemic analgesicAfter first 72 hours -mild1. Topical anesthetic (dyclonine hydrochloride 0.5%)2. Systemic analgesicANUGAB: Amoxicillin+MetroAssociated with AIDSWith no systemic involvement1. Topical AB (CHX + H202)2. Eliminate etiology3. Systemic analgesic4. Debridement5. Medical evaluationWith systemic involvement1. Topical AB (CHX + H202)2. Eliminate etiology3. Systemic analgesic4. Debridement5. Medical evaluation6. Systemic ABHerpangina Topical anesthetic not used in children: Risk of systemic absorption/toxicityUlcers are seen on soft palate, tonsils and throat1. Topical anesthetic2. Systemic analgesicSCCIf not diagnosed, it is managed either as Leukoplakia/Erythroplakia1. Excisional biopsy 2. Eliminate etiologyPemphigus Plaque accumulation since mechanical home care can injure fragile tissues1. Medical evaluation2. Topical corticosteroid3. Systemic corticosteroid4. Systemic analgesicBenign mucous membrane pemphigoid (cicatricial)1. Medical evaluation2. Topical corticosteroid3. Systemic corticosteroid4. Systemic analgesicErythema MultiformaeAssociated with sulfa drugs1. Topical corticosteroid (first choice), if not, then topical anesthetic2. Eliminate etiology (if drugs is the etiology); not if due to herpes infectionPyogenic granulomaPregnancy (if excised during pregnancy, it will recur)1. Eliminate etiologyNo pregnancy1. Eliminate etiology2. Excisional biopsyMucoceleFluctuantD/D: Fibroma (Firm)1. Excisional biopsyHemangiomaasymptomatic and unaesthetic 1. Excisional biopsyasymptomatic 1. No TxFibromaEtiology is bitingNot painful; Does not blanch on pressure; FirmBothersome1. Excisional biopsy2. Eliminate etiologyNot bothersome1. No TxTraumatic NeuromaTrauma in not continuous 1. Excisional biopsyPapilloma/Verruca VulgarisCauliflower1. Excisional biopsySalivary gland adenomaPosterior palate; Away from apical region1. Excisional biopsyGranular cell tumourTongue; Middle aged; Male1. Excisional biopsyGingival cyst1. Excisional biopsyAbscessAcute (symptomatic) - Initial/Phase I1. Systemic AB2. Systemic analgesic3. Eliminate etiology (exo or rct)4. Debridement (Periodontal/canal) Chronic (Asymptomatic)1. Eliminate etiology (exo or rct)Epulis fissuratum (Inflammatory fibrous hyperplasia)1. Eliminate etiology2. Excisional biopsySmokers Melanosis1. Eliminate etiologyUnexpected locations - hard palate; unusual clinical changes1. Eliminate etiology2. Incisional biopsyKaposi Sarcoma1. Excisional biopsy2. Medical evaluation (if undiagnosed)Radiation mucositisBurning sensation1. Topical anestheticNevusLong standing and non-bothersome1. No TxLong standing and bothersome1. Excisional biopsyRecent and changing size1. Incisional biopsyVaricositiesNot bothersome1. No TxBothersome1. Excisional biopsyChanging size1. Incisional biopsyMucous patches of secondary syphilisLooks like geographic tongue but notSystemic involvement (infective stage)1. Systemic ABPeriodontal abscessWide zone periodontal pocket or angular bone defect; Tooth elevated in socket;Mobility with systemic involvementacute - symptomatic1. Systemic antibiotic2. Systemic analgesic3. Debridement4. Eliminate etiologychronic - asymptomatic1. Debridement2. Eliminate etiologyTrigeminal NeuralgiaSharp, stabbing, electric shock like and excruciating pain (unilateral; not sudden; triggered)1. Systemic analgesics2. Anti-convulsants (carbamazepine/gabapentin/clonazepam)3. Anti-spastic (baclofen)4. TCA (amitriptyline, doxepin, imipramin)Maxillary sinusitisIncrease of pain when bending over/while lying downNo evidence of dental infectionContinuous pain in maxillary posterior regionheadacheteeth vital1. Amoxicillin or cephalosporin + Nasal decongestants + Nasal antihistamine (Afrin)2. Azithromycin: If allergic to Amox or if infection fails to resolve3. NSAIDsBRONJ1. Mouth rinses2. Systemic AB3. DebridementPericoronitis1. 2% H202 irrigation2. ExtractionActinic CheilitisCrusted, ulcerated lower lip1. Incisional2. Excisional if malignancyDry socketThrobbing and radiating pain to the ear and inferior border of mandible3 -4 days old Bad taste and smells bad1. Irrigation with saline2. Protective dressing3. AnalgesicsTori and exostosisAsymptomatic; no complaining or concerns from the patient1. No TxSymptomatic - patient complains of pain or is concerned (traumatic ulcer) or for prosthetic fabrication1. Surgical excisionNecrotising sialometaplasia1. Debridement and saline rinses. Melanotic macule/nevusNot bothersome1. No TxBothersome1. Excisional biopsyTable 2: Red, red white lesionswhite flecks with red basepseudo membranous candidiasislimited to attached gingivadesquamative gingivitisred area with keratosislupus, lichen planusTable 3: ulcersSingle ulcer acute onsetTraumatic ulcer or mucosal burnSingle ulcer chronic onset or non healing ulcerSSCmultiple ulcers, multi focal and persistent or non healingPemphigus; pemphigoid, erosive LP, Lupussingle or multi focal, acute onset and recurrent (NO systemic involvement)recurrent apthous; recurrent herpes labialis; erythema multiformaemultiple and multi focal ulcers with systemic involvementprimary herpetic gingivostomatitis; herpes zoster; herpanginapemphigus vs pemphigoid locationpemphigus - mucosa and pemphigoid - gingivadiffuse early onsetracial pigmentationdiffuse adult onsetsmokers melanosis; drug induced - minocycline; melanoma; kaposi sarcomafocal with blanchinghemangioma; varicosityfocal no blanchingamalgam tattoo; macule; melanomaverrucous carcinoma and SCClymph nodes in SCC are non-tender, hard, fixed and rubbery. lymph nodes in VC are inflamed, tender, soft and movable.Table 4: Emergencies in dental officeImmediate/Single optionAppropriateAcute asthmatic attackHydrocortisone (severe)1. Salbutamol2. Oxygen1. Salbutamol2. Oxygen3. Epinephrine4. 911 Acute asthmatic attack: Unresponsive to first lineEpinephrineAcute asthmatic attack: Not relieved by second line911Upper airway obstruction: Partial encourage to coughUpper airway obstruction: complete and conscious1. Abdominal thrust2. 911Upper airway obstruction: complete and conscious in special conditionsinfant pregnantobesewheel chair1. cardiac compression2. 911Upper airway obstruction: complete and unconscious1. Cardiac compression2. Head tilt3. Oxygen4. 9115. object visible (finger sweep)Mild allergic reaction1. DiphenhydramineMild allergic reaction with either CVS or respiratory involvement1. Diphenhydramine2. EpinephrineAnaphylaxis - conscious1. Epinephrine2. Oxygen3. 9114. Diphenhydramine5. HydrocortisoneAnaphylaxis - unconscious1. Epinephrine2. Oxygen3. Head tilt/Chin lift 4. 9115. Diphenhydramine6. chest compression (if vital signs absent)Angina Pectoris1. Nitroglycerin2. Oxygen*Nitro only if SBP is > 90 or DBP > 60SameNo h/o of Angina Pectoris or MI (Angina pectoris not responsive to Nitroglycerin or more than 15 minutes)1. Nitroglycerin2. Aspirin (162 - 325 mg)3. 911 (if no history of Angina/MI)Cardiac arrest: Poorly managed upper airway obstruction or MI can lead to cardiac arrest1. Ventilate and begin cardiac compression2. Oxygen3. Head tilt4. 9111. Ventilate and begin cardiac compression2. Oxygen3. Head tilt4. 9115. Automated external defibrillator6. EpinephrineCVA/StrokeUsually in olderUntreated HTN 1. 9112. Oxygen1. 9112. OxygenHyperglycemia (Diabetic coma): conscious1. 911Hyperglycemia (Diabetic coma): Unconscious1. 9112. Oxygen3. Head tilt4. CPR if no vital signsHypoglycemia (Insulin Shock): Conscious1. Oral glucose2. 911 (if oral glucose did not help)Hypoglycemia (Insulin Shock): unconscious1. Oxygen2. Head lift3. Glucagon (IM)/50% dextrose (IV)4. 911Hyperventilation(panic attack)1. Breathe into cupped hands2. If it doesn't help - MidazolamLA Toxicity: mild1. oxygenLA Toxicity: Unconscious:1. Oxygen2. Head lift3. 9114. CPR if no vital signsSyncope - consciousOxygenOral glucose if consciousSyncope - unconsciousOxygenHead liftAtropine if HR and BP are ?Ephedrine if HR is ok and BP ?Status epilepticusOxygen911Benzodiazepine/MidazolamSeizure disordersNo TxOxygenHypertensive crisisSystolic >200Diastolic > 115Transfer to MD/911OxygenTransfer to MD/911OxygenAdrenal crisis(known history; addison's disease - 20 mg of cortisol)Oxygen911Hydrocortisone (100 mg)Thyroid stormOxygen911Hypotension (Treat as Syncope)1. Oxygen2. IV Ringer’s lactate3. If HR<60: Atropine4. If HR>60: EphedrineTable 5: Summary of S/S of emergenciesEmergencyS/SUpper airway obstructionlips turn bluecomplete obstruction (silence)partial (crowing)eyes bulgingAbsence of breathing sounds; Wheezing; Stridor; Coughing; Crowing or garglingInability to speak (complete airway obstruction)If not managed properly can lead to Cardiac Arrest (dilated pupils)Asthma (Bronchospasm)unable to finish a sentence in one breathChest tightness; SOB; Wheezing; Coughing; Hypoxia; Cyanosis; TachycardiaPatient usually wants to sit upright?heart rate or BPThick stringy mucous sputumsweating (diaphoresis)chest distention (due to increased air pressure)sense of suffocationpressure or tightness on chestAnaphylaxis There will be skin signs, nose, eye, laryngeal edema, respiratory (bronchospasm), GI (cramps) and CVSOccurs within a minuteImpending doom AnxietyDerm:Itching, pruritis, hives, angioedema, rash, swelling, skin warm and red (Flushing)Resp:SOB, hypoxia, cough, Chest tightness, wheeze/stridorThroat: Hoarseness (change in voice), Laryngeal edemaCVS: *Low BP*, Weak pulse, syncope, dizziness, tachycardia; "pale and listless"Mild allergic reactionRash, hives and ItchingTingling and warmthRetrosternal tightnessNo CVS/respiratory involvementRunny noseAngioedema (perioral/periorbital)Angina Pectoris/MI: Risk factors-Smoking; HTN; DiabetesPatient is always conscious and the heart is beatingPpt factor: GERDPatient will complain “Heavy (pressure) or heavy weight on my chest”Levine’s sign (Clenched right fist held over chest)'squeezing' chest pain, usually sub sternal; mostly left side or radiates to the left arm, shoulder, jawPrecipitated by exercise or emotionPallor; SOB; Nausea; Weak pulseLasts less than 15 minuteshypotensionMIAngina more than 15 minutesNot resolved with NitroglycerinSyncopeH/O using anxiolytic medicationLOC is very quickEarly diagnosis of Syncope: Pale skin (Pallor); Perspiration (beads or droplets of sweat on forehead); “feels warm”; ClammyRapid pulse; NauseaCold extremitiesTwitchingPupils: Dilated (sign of anxiety)Tunnel Vision: See only what's in front of youLate diagnosis:LOCBP - Low; ?HRPulse – slow and weakHyperglycemia (Diabetic coma)Warm and Dry skin (cold and dry skin - hypothyrodism; pale and moist - hypoglycemia)Kussmals respirations - deep and laboured (shallow respirations - hypoglycemia)Fruit odour (Ketone or sweet smell)ThirstNeuropathy: Weakness, fatigue, tiredness, drowsinessOculopathy: Visual disturbancesFlushed face (rosy cheeks)? BPHypoglycemiaDIZZINESS; Hunger; Confusion; Nausea; Weakness; Headache; Tachycardia (HR increase); Sweating (Diaphoresis); shakingSlurred speech; RestlessMoist and cold skinChanges in mood? HR ?BPsymptoms may progress to coma and convulsions without interventionHyperventilationRestlessTingling in hands, lips and feetCarpal-pedal spasm (muscle pull)fingers numbSOBTachypnea (>20 breaths)fear of dyingCardiac arrestUnconscious, Unresponsive (cessation of respiration - apnea) and No pulse/BP drops to ZeroDilated pupilsCardio-Vascular accident/StrokeF.A.S.T.F: Face looks uneven/altered level of consciousness/pupil size unequalA: Inability to raise arm/Numbness/Paralysis of one side (unilateral) of bodyS: Aphasia/Slurring of speechT: Time to call 911Sudden severe headache (also in 'Migraine'), dizziness, nausea, muscle weakness and vomiting; Sudden rapid increase in BP;VomitingLoss of bladder/bowel controlEpinephrine reactionTachycardia; Palpitations (heart beating fast); Dizziness; Anxiety (CVS symptoms); Rapid breathing (not shallow)Throbbing headachePallor (VC of skin vessels)Significantly elevated BPLA ToxicityIrregular breathing; TremorsExcitation followed by depressionEarly (CNS):TalkativenessApprehensionExcitabilitySlurred speechDizzinessMetallic tasteVisual disturbAuditory dist (Ringing/Buzzing in the ear)DrowsinessMuscle twitchingLate:SweatingVomitingInc in HR, BP, RR and Dec. in HR, BP, RRSeizuresHypertensive crisis1. Severe headache2. Severe chest pain3. Visual disturbances (blurred vision)4. Nose bleedsAdrenal crisisAbdominal painTreat as hypotensionThyroid stormAbdominal painHyperpyrexiaTable 6: D/D of emergenciesChest PainHeadacheDifficulty breathingSeizuresMedical emergencies that need historyMedical emergencies that need no historyMI/AnginaCVA/StrokeAcute asthmaLA toxicityHypo/hyperglycemia - DiabetesMIHyperventilationEpinephrine reactionAnaphylaxisCVAHTN crisisLA toxicityPanic attackHypertensive crisisStrokeSevere hypoglycemiaAngina attackCardiac arrestHypertensive crisisHypo/hyperglycemiaCardiac arrest (no breathing)Adrenal crisisCVA/StrokeAcute sinusitisIncipient syncopeHyperventilationTMJ/Trigeminal neuralgiaAnaphylaxis/mild allergic reactionsTable 7: Summary of emergency managementAdminister ASAMIAngina - not relieved by NitroglycerineAdminister DiphenhydramineMild allergicAnaphylaxisAdminister EpinephrineAnaphylaxisCardiac arrestAcute asthma attack - if Salbutamol does not workCPRCardiac arrestAbsence of vital signs911 in conscious patientsAcute asthma not relieved by epinephrineAngina when BP is below 90/60 or with no historyAnaphylaxisComplete airway obstruction in a conscious patientStatus epilepticusSeizures with no history or lasting more than few minutesTable 8: OTC not enough and M-S painT3/T4 are first choice (NSAIDs or opiods only - not the first choice)OTC not enough and M-S pain; NSAIDs are CI or not enough; T3/T4 not enoughPercocet (acetaminophen + oxycodone)Pregnancy - M to MAcetaminophenPregnancy - M to M; OTC not enough or M to SPercocetPregnancy - M to M; OTC not enough or M to S & opiods are CIMeperidineOTC not enough and M-S pain; NSAIDs are CI; opiods are CIMeperidineOTC not enough and M-S pain; patient on HTN medication/history of MI or strokeT3/T4 (first choice); NSAIDs not first choice, because they will come backOTC not enough and M-S pain; patient on HTN medication/history of MI or stroke and NSAIDs are for more than 4 daysCI (<4 days is OK, but not the first choice)Mild painacetaminophen, low dose ibuprofenmoderate - moderately to severehigh dose of ibuprofen, naproxenmoderate - severeketorolacmoderate - severe; NSAIDs CIT3/T4severe pain; NSAIDs CIPercocetsevere pain; NSAIDs CI; allergy to codeineMeperidineAntibioticsDental/endodonticFirst choiceAmoxicillin or Pen VKAllergy to first choiceClindaAllergy to next choiceAzith or ClarithANUGFirst choiceAmoxicillin + Metronidazole or individualAllergy to first choiceClindaInfective endocarditisFirst choiceAmoxicillinDelayed allergy to penicillinCephalexin or Clinda or Azith or ClaraImmediate allergy to penicillinClinda or Azith or ClaraBlockArea coveredInfiltration/Para/Supraperiosteal*(Most common technique in Maxilla)1. Pulpal anesthesia of 1-2 mx teeth supplied by same nerve branch2. Soft tissue anesthesia of buccal mucosa for surgery; Buccal periodontium in area of injection3. Restorative and extractions (need other injections for extractions for palate and tissue)Infra-orbital (ASA+MSA)1. Pulpal and buccal perio/soft tissue from 5 to midline (+MB of 6)2. Multiple procedures (more than two tooth)3. Use when infiltration is contraindicated due to abscessGreater Palatine1. Palatal perio from 4-82. Perio surgery, extractions, subgingival restorationsNasopalatine1. Palatal perio from 3-32. Perio surgery, extractions, subgingival restorationsPosterior superior alveolar (CI in hemophiliacs or haemorrhagics)1. Pulpal and buccal perio from 6-8 (except MB of 6)2. Use when infiltration is contraindicated or ineffective (usually just do 2 paraperiosteals on 6&8 that will diffuse to 7s)Maxillary NB (Greater palatine canal approach/High tuberosity approach)1. All the above (pulp, buccal, lingual gingiva from 1-8)2. Extensive work on one side of jaw (all 8 teeth)3. Infection contraindicates other blocks (PSA)MandibleBlockArea coveredInfiltration/Para/SupraperiostealChildren OKInferior alveolar nerve block (CI in haemophiliacs)Pulpal from 1-8; buccal perio from 1-5; Lingual perio from 1-8Buccal nerve blockBuccal perio (clamp) from 6-8MentalBuccal soft tissue from 1-4 (Restorations)IncisiveBuccal soft tissue and pulp from 1-4 (Restorations)Gow - Gates (Best for atypical facial pain)1. Pulpal, buccal and lingual from 1-82. Particularly indicated with h/o of inferior alveolar block failure; less chance of aspirationVazirani - Akinosi1. Pulpal from 1-8; buccal perio from 1-4/5; Lingual perio from 1-82. Particularly indicated with H/O of inferior alveolar block failure; less chance of aspiration3. Indicated in TrismusIntraligamentary/Intraosseous/PDL1. PDL - Don’t use on baby teeth b/c concern of premature exfoliation2. Last option for single tooth1 or 2 teeth3 or moreClass I, VClass II, III, IVClass I, VClass II, III, IV (you need buccal and lingual anesthesia)U - InfiltrationU - InfiltrationU - 5 to 5 - IONB U - 5 to 5 - IONB + NPNBL - IANBL - 5 to 5 - IANBU - 6 to 8 - PSAU - 6 to 8 - PSA + GPNBL - 6 to 8 - IANB + LBNBL - 5 to 1 - IANBL - 5 to 1 - IANBL - 6 to 8 - IANBL - 6 to 8 - IANB + LBNBI & DBuccal vestibular abscessPalatal/lingual abscessLower - I, C, PMIANBLower - any teethIANB Lower - MLBNBUpper - I, C, PMIONBUpper - I, CNPUpper - MPSAUpper - PM, MGPSwelling associated with upper 7 or extraction in presence of swellingMaxillary - GP approachSwelling associated with upper 7 or extraction in presence of swellingMaxillary - high tuberosity approachCanine space infectionMaxillary block*if extraction in presence of swelling, add infiltration to each.SummaryMental NB in children for Lower E D fillingsGG/Akinosi and childrenCIPSA and childrenCIIntrapulpal and primary teethCIIntraosseous and primary teethCIPulpotomy on lower teethIANBPulpotomy on upper teethInfiltrationMucoceleMental NBLocal AnesthesiaMaxilla: Only infiltration for children; Blocks neverFirst lineInfiltration; Naso-palatine; Greater palatineCannot use infiltration in acute infections/abscessesSecond line: Infraorbital/PSAMore than 2 teethAlone when first line is CI due to abscess (use least #)Consider Maxillary block instead of IO and PSAThird lineIntraligamentary; IntraosseousFillingsPedoInfiltration for Exo/Pulp/Resto; if fails or CI - blocksMandibleFirst lineIANB; Gow-Gates; Akinosi (In Trismus); Long buccal 6-8 (In Trismus)Second lineIntraligamentary; IntraosseousFillingFirst lineIANB; Gow-Gates; Akinosi (5-8)Mental (High failure) and Incisive (1-4)Second lineIntraligamentary; IntraosseousPedo-Before 7FillingsInfiltrationExo/Pulpotomy/RCTIAN6PDL (children with hemophilia; as supplement)Pedo-After 7Rest, endo, exoIANextraction of 6IAN + Long buccaldoes not develop soft tissue numbness after IANBUse Gow Gatesdevelops soft tissue numbness after IANB and still has during tooth preparationPDL or IOdevelops soft tissue numbness after IANB and has pain during pulp chamber penetration or canal instrumentationIntrapulpalMaxilla: still has pain after infiltrationPDL or IOPain after IANB+LB; develops soft tissue numbness; pain during access openingPDL or IOPain after infiltration during access opening in maxillaPDL or IOperiradicular surgery in maxillaInfiltrationperiradicular surgery in mandibleIANB + infiltrationlower anterior mandibular sextantIncisive NB + infiltration1: 10001mg per 1ml1: 10,0000.1 mg per 1ml1: 100,0000.01mg per 1ml1:50,0000.02 mg per ml1: 200,0000.005 mg per ml0.5%5 mg/cc1%10 mg/cc2%20 mg/ccLocal AnestheticsLA%MRDMax. carpulesBy weightLidocaine with VC2 %500137mg/kgArticaine with VC4 %50077mg/kgArticaine with VC for child4%5mg/kgBupivacaine with VC0.5 %90102 mg/kgBupivacaine plain0.5 %9010NoneMepivacaine plain3 %40076.6 mg/kgMepivacaine with VC2 %400116.6 mg/kgPrilocaine with/without VC4 %60088 mg/kgAntibioticsDrugDosageFrequencyPen V300-600mgQIDAmoxicillin250-500mgTIDClavulanate250-500mgTIDMetronidazole250-500mgTIDDoxycycline100mgQD/BIDClindamycin150-300mgQIDClarithromycin250-500mgBIDErythromycin250-500mgQIDTetracycline250-500mgQIDCloxacillin250-500mgQIDAzithromycin500mg Day 1250 mg QD Day 2-5Cephalexin250-500mgQIDPediatricAmoxicillin7-13 mg/kgTIDClindamycin2-6mg/kgQIDPen V6-12 mgQIDDrugAdult dosageAvailable strengthsSuspensionPen V300-600 QID30025mg/ml;60mg/mlAmoxicillin250-500 TID for 7 -10 days125, 250, 500125mg/5ml;250mg/5mlMetronidazole250-500 TID250, 500Doxycycline200 on first day, then 100 daily100Clindamycin150-300 every QID150, 30075mg/5mlClarithromycin250-500 every 12 hours for 7-10 days250, 500250mg/5ml; 125mg/5mlErythromycin250-500 every 6 hours or 333 mg every 8 hours250, 333125mg/5ml; 250mg/5mlAzithromycin (total dose is 1500)500 mg/day for 3 days or 500 on day 1 followed by 250 from day 2-5250, 500100mg/5ml;200mg/5mlCephalexin250-500 every 6 hours or 500 every 12 hours250, 500125mg/5ml;250mg/5mlPediatricAmoxicillin7-13 mg/kg TIDClindamycin2-6 mg/kg QIDPen V6-12 mg/kg QIDCephalexin25-100 mg/kg every 6 hoursErythromycin30-50 mg/kg/dayAntibiotic prophylaxisAntibiotic Regimen: 30 - 60 minutes before procedureAgentAdultsChildrenOralAmoxicillin2 g PO50 mg/kg POUnable to take oral mediciationAmpicillin2 g IM or IV50 mg/kg IM or IVCefazolin or Ceftriaxone1 g IM or IV50 mg/kg IM or IVAllergic to penicillin-OralCephalexin2 g PO50 mg/kg POClindamycin600 mg PO20 mg/kg POAzithromycin/Clarithromycin 500 mg PO15 mg/kg POAllergic to penicillin-Unable to take oral medicationCefazolin or Ceftriaxone1 g IM or IV50 mg/kg IM or IVClindamycin600 mg IM or IV20 mg/kg IVAnti-Fungal medicationDrugDosageFrequencyImmunocompetentNystatin oral suspension400,000-600,000/5ml units swish and swallowQID for 7-14 daysClotrimazole troches10 mg 5 times daily × 7 - 14 daysImmunocompromisedNystatin oral suspension400,000-600,000/5ml units swish and swallowQID for 7-14 daysFluconazole100 mgQD for 7-14 daysItraconazole oral solution200 mg QD for 7-14 daysPosaconazole400 mg BID day 1Then 400mg QD for 1-2 weeksCommon abbreviations for prescription writingQODEvery other dayHS or QHSBed timeACBefore mealsPCAfter mealsStatImmediatelyAnalgesicsDrugDosageFrequencyDaily Max.Available strengthsMaximum strengthSuspensionCodeine - Fast30-60mg4-6None15, 3030 2mg/mlCodeine - Controlled30-60mg4-6None50, 100, 150, 200200Oxycodone - Fast5-10mg4-6None5, 10, 2020Oxycodone - Controlled5-10mg4-6None5, 10, 15, 30, 40, 60, 8080Acetaminophen325-1000mg4-64000325, 500, 650650ASA325-1000mg4-64000162.5, 325, 500500Diflunisal1000mg first 12 H; then 500mg for next 12H12H1500250, 500500Celecoxib200mg 12 H12H40050, 100, 200200Diclofenac50815025, 50, 100100Mefenamic acid500mg first, then 250 mg61 week MAX250, 500500Rofecoxib50Once/day50 (5 days MAX)Ibuprofen200-600mg4-62400200, 300, 400, 600600Flurbiprofen50mg4-630050, 100100Naproxen500mg first; 250mg 6-81250250, 375, 500500125mg/5mlNaproxen sodium550mg first; 275 mg6-81375220, 275, 550550Ketoprofen25-50mg6-8300Etodolac200-400mg6-81200200,300,400400Floctafenin200-400mg6-81200200,400400Ketorolac10mg4-640 (5 days MAX)101015mg/mlMeperidine50-100mg4600505050mg/5mlPentazocine50450Hydromorphone2-4mg 4-6Tramadol50-1004-6Percocet5mg Oxycodone; 325 mg AcetOxycodone: 30 mgPediatricAcetaminophen10-15mg/kg4-665mg/kg or 2600160mg/5mlIbuprofen10mg/kg6-840mg/kg or 2400100mg/5ml; 200mg/5mlCodeine0.5-1mg/kg4-63mg/kg or 60mg per dose for acute painPulp pathologyPathologySymptomsPeriapical radiolucencyPercussionThermal test1. Acute periradicular periodontitis(NEW - symptomatic apical periodontitis)1. Painful response to biting/percussion2. May be due to high filling/high points (hyperocclusion)3. Not due to infection/No systemic involvement4. Overinstrumentation of root canal5. Extrusion of obturating materialNo; Widening of PDLPositiveMay/May not2. Chronic periradicular periodontitis (No, no, no, Yes)(NEW - Asymptomatic apical periodontitis or dental granuloma)Mild/No clinical symptomsYesNegativeNegative3. Acute periradicular abscess (APA)1. Rapid onset2. Spontaneous pain3. Pus formation4. Systemic involvement (Febrile and tender nodes)5. Swelling of associated tissue (muco-buccal fold and facial tissues)6. Tooth feels elevatedNoPositiveNegative4. Chronic periradicular abscessC/C: feels different1. Gradual onset2. No discomfort3. Intermittent discharge of pus through sinus tract-open/pimple-closed4. Tender to palpationYesPositiveNegative5. Irreversible pulpitisEg: pain persists even after drinking the water which subsides after few minutes (not immediately - lingering)1. Spontaneous or referred pain; Lingering/Throbbing for more than 30 sec following cold test; Extreme pain to EPT; Percussion positive or pain on biting? Nocturnal pain that radiates? Sensitivity to hot/cold (Hallmark sign)postural changes causes painpain on heat, relieved by coldpain may be accentuated by postural changes such as lying down or bending over and over-the-counter analgesics aretypically ineffectiveinflammation has not yetreached the periapical tissues, thus resulting in no pain or discomfort to percussionNeutralAsymptomatic irreversible pulpitis1. Pulp polyp2. Internal resorption6. Reversible pulpitis1. stimulus suchas cold or sweet is applied and goes away within a couple of seconds following the removal of the stimulus2. Pain is not spontaneous3. Pain is sharp and transientcaries or deep restorationspain experienced is not spontaneous6. Pulp necrosisUnresponsive to any pulp testing and asymtopmaticFree gingival graftNon-aesthetic zone; Single site/narrow zoneDoes not need adequate width of attached gingivaTo increase width of attached gingivato increase depth of vestibule (reduce tension)place crown with sub-gingival marginnot used for recessionC/C: pain when brushing because no keratinized gingivaCoronally positioned flapMultiple teeth with adequate attached gingiva (CM)Minimum attached gingiva should be > 2mmrecession should be < 2mmnot the first choiceSub-epithelial CT graft1 or multiple teeth with recessionNo need for minimal width (zero AG - OK) of attached gingiva Always used for Upper CanineLaterally positioned/Pedicle flapSingle siteCI on caninedonor site cannot have recessionGingivitis modified by systemic factors (PDL) - exaggerated1. Pregnancy/puberty2. Diabetes (poorly controlled)3. Leukemia (swollen gingiva without any attachment loss)Gingival manifestations of systemic diseaseEythema MultiformaePemphigusSLEErosive Lichen PlanusAllergy to toothpaste/mouthwash/chewing gum*well controlled diabetes: Gingivitis due to plaque onlySummary of patient managementAvoid opiodsSevere Asthma, Emphysema and COPD (severe respiratory disease - pursing of lips)severe inflammatory bowel diseasehistory of drug abuseConcurrent CNS depressants usage or sedative (Benzo; Barbi)/AlcoholMonoamine oxidase inhibitor (Phenelzine, Tranylcypromine, Isocarboxazide) use within the last 14 days (Applies to only Meperidine)Children below 12 years (Applies to only Codeine)Prophylactic ABAIDS patients with CD4 below 200patients with poorly controlled diabetes (blood sugar 200-300 mg/dl)organ transplant patients who receive immunosuppressive medicationsend-stage renal diseasepatients receiving cancer chemotherapy, until 1 year after cessation of chemotherapyadvanced or acute stage of leukemia (AML) and lymphomaRecent INRwarfarin therapyliver damage caused by hepatitis, cirrhosis, alcoholismProphylactic NitroglycerinUnstable anginaAnxiolytic/sedativesany cardio conditiondiabetes mellitusseizureadrenal suppressionAvoid NSAIDsAspirin induced asthma, nasal polyps (ADENOIDS)Avoid ASA in all cases of asthmaAvoid other NSAIDs only if asthma is active or persistent (if patient is on beclamethasone)3rd trimester (Late stage of pregnancy - D)susceptible children (Aspirin)Concurrent use of anti-coagulants (warfarin, dabigatran, apixaban, rivaraxaban, edoxaban) or Lithium for bipolar disorder or anti-neoplastic dose of methotrexate, digoxin/digitalis (in elderly)H/O bleeding disorders: hemophilia and von willebrand diseaseEnd stage renal disease or severe liver impairment like cirrhosisgastric/peptic/duodenal ulcers, active GI bleeding, inflammatory bowel disease (ulcerative colitis, crohn's disease)concurrent use of Sulfonylurea oral hypoglycemics: Avoid ASA only)HTN medication (ACE inhibitors; Loop diuretics; Beta blockers)Avoid epinephrineAllergic to sulfite/sulfates (most likely asthmatic)Ingested cocaine within the previous 24 hoursAvoid local anesthetichistory of allergy to both ester and amide LAStop current medication prior to appointmentPatients who take warfarin with INR > 3.5 before surgical procedure.Delay routine treatmentany uncontrolled conditionunstable anginarecent h/o MI or stroke (< 1 month)blood pressure > 180/110end-stage renal diseaseuncontrolled asthmaactive hepatitisactive tbTreat at end of dayCOPDactive TB (emergency tx)Treat in a hospitalactive TB (emergency tx)active asthma or active hepatitis (emergency tx)uncompensated hypertrophic cardiomyopathy (emergency tx)emergency management of patients with HTN (>180/110)severe liver or renal dysfunction - end stagepoorly controlled diabetesuncontrolled seizureMinimize the use of epinephrineHyperthyroid and CVS (Myocardial infarction, pacemakers, bypass surgery, and angina, CHF, cardiac arrhythmias)Concurrent use of nonselective beta-blockers-Propranolol/tricyclic antidepressants-Amitriptyline; Doxepin; Imipramine; Desipraminehistory of strokeTCA: Imipramine, amitryptyline, desipramine, nortriptylineCOMT inhibitors: EntacaponeAvoid levonordefrin/MepivacaineTricyclic anti-depressantsSummary of diagnostic testsEPT/thermal teststooth vitalityteeth with apical lesions on x-raydifferentiate between endodontic/odontogenic and non-endodontic/non-odontogenic painestablish pulpal health prior to prosthodontic txTooth percussionteeth with h/o pain or discomfort on chewingteeth with pain following a recent restorationteeth with endodontic involvementdifferentiate between odontogenic and non-odontogenic painteeth with trauma from occlusionestablish pulpal health prior to prosthodontic txBite testteeth with h/o pain or discomfort on chewingteeth with possible cusp fracture or cracked tooth syndrometeeth with possible VRFPressure on individual cuspteeth with h/o pain or discomfort on chewingteeth with possible cusp fracture or cracked tooth syndromeAssessment of tooth mobilityteeth with periodontitis or periodontal abscessteeth with acute apical abscessteeth following dental traumateeth with trauma from occlusionteeth with possible VRFteeth with non-odontogenic apical lesionsEvaluation of occlusionteeth with pain following a recent restorationteeth with trauma from occlusionpatient with parafunctional habits (attrition)patients with TMJ problemsas part of orthodontic assessmentpatients with keratotic lesions on buccal mucosa (cheek biting) or lateral tongue (tongue biting)Test cavitywhen all test to test vitality are inconclusiveSelective LAreferred painwhen patients cannot specify whether the symptoms are from upper or lower jawwhen pulp vitality tests were inconclusivepanoramic cannot tolerate intraoral films (gag)trismusBlood testingpatient on warfarin or blood thinners or coagulopathies (INR); diabetes, renal and liver disorderspatients with viral diseases like hepatitis and HIV to rule out AIDS in cases of ANUG or major apthousCytological smearCandidiasisherpetic lesions (HSV, VZV)Microbial testinginfections beyond the alveolar processcellulitisnon-responsive infection (> 48 hours)h/o multiple AB therapyAs part of caries risk assessment in patients with rampant cariesrecurrent infections (not responding to standard tx)immunocompromised patients who present with mucosal lesions or candidal infectionsStages of Hypertension/Blood pressureStageS/DActionNormal120-139/80-89Proceed with TxI140-159/90-99Proceed with TxII160-179/100-109Proceed with TxIII180-200/110-114Avoid Elective TxIV>200/>115Refer to MD immediatelySingle tooth diagnosisPerio abscessEndo-perio lesionVRFTooth is vitalTooth is non-vital (necrotic pulp)RCT treated with postDeep pockets all around (6 sites)1 site deep pocket (12-2-2; 3-2-2)1-2 pockets (2-4 sites)Swelling or sinus tract--Systemic involvement--tender on lateral percussionPain related to the endo toothPain on chewingIncrease in mobility (grade 2)/slight tooth elevationAcute painChronicOver nightcold test negative and percussion positiveInitial Tx - debridementAppropriate - ExtractionTx - RCT for endo and NSD for perioTx - extraction primarily endo (tooth non-vital, single site deep pocket). Tx: RCTprimarily perio (tooth is vital, wide zone of pockets). Tx: debridementPatient ManagementAsthma - mild (quiescent - symptom free but on medication)anxiety reduction protocolAsthma - severe (quiescent - symptom free but on medication)Management in mildavoid opiods in severe asthmaavoid rubber dam (if in options)avoid respiratory sedatives (if in options - severe cases)avoid all NSAIDs for active or persistentshort appointmentNitrous oxide is OKAngina (stable) or MI > 1 monthanxiety reduction protocolmonitor BP and HR 5 minutes post injectionprophylactic nitroglycerinlimit use of epinephrineAngina (unstable) or MI < 1 monthavoid elective treatmentAngina (unstable) or MI < 1 month, emergencyprophylactic nitroglycerintreat in hospitalArrhythmiasanxiety reduction protocollimit epinephrine monitor BP and HR 5 minutes post injectionCongestive Heart Failure (patient on digoxin/digitalis) or hypertrophic cardiomyopathystress reduction protocolminimize epiavoid NSAIDs (if on digoxin)Congestive Heart Failure - untreated or uncontrolled (nocturnal dyspnea, ankle edema)refer to MDCOPDtreat at end of dayshort appointmentavoid respiratory sedatives (if in options - severe cases)avoid rubber dam (if in options)avoid nitrous oxide (if in options - severe cases)Chronic renal failure + Haemodialysisavoid routine treatment on the day of dialysisavoid NSAIDs because they take heparin (opiods and acetaminophen - OK)End stage renal diseaseavoid routine treatmentEnd stage renal disease and emergencyAB prophylaxisavoid NSAIDsTreat in a hospital settingKidney transplant < 6 monthsavoid routine treatmentKidney transplant > 6 monthsavoid NSAIDsAB prophylaxis (only if immunocompromised and on cyclosporine)Hepatitis - active (HBs Ag & HBe Ag)delay routine treatmentHepatitis - active & emergencyobtain recent INRMust treat in a hospitalHepatitis - acute (HBS Ag+ or elevated ALT/AST) or chronic (HBs Ag for more than 6 months)Recent INRMD consultHepatitis B/C (asymptomatic)Consult MDOrder lab testsAlcoholicsavoid sedativesAlcoholism with liver cirrhosisINRAvoid NSAIDsSevere liver dysfunction or end stage liver disease, emergencyAvoid NSAIDslab tests to determine severityhospitalLiver transplant patients on immunosuppressantProphylactic ABHypertension controlledanxiety reduction protocollimit use of vasoconstrictorsmonitor BP and HR 5 minutes post-injectionStroke or CVA < 1 monthAvoid elective txStroke or CVA > 1 monthanxiety reduction protocolminimize epimonitor BP and HR 5 minutes post-injectionStroke or CVA < 1 month and emergencyanxiety reduction protocolminimize epiavoid NSAIDsrecent INRtreat in a hospitalTB -active (productive cough, weight loss, night sweats)delay routine treatmentTB -active -emergencytreat in hospitaltreat at end of dayWarfarin (patients with prosthetic heart valves)obtain a recent INRavoid NSAIDsWarfarin (if INR > 3.5)stop warfarin 2 days before surgery or adjust current medicationDabigatran (no need for INR)stop 2 days before procedureavoid NSAIDsrefer to MD for major proceduresASA and clopidogrel are used in patients with drug-eluting metal stents and if placed in the last 1 yearavoid elective treatmentsSeizuresstress reduction protocolDiabetes - uncontrolleddelay routine treatmentHyperthyroidism - uncontrolleddelay routine treatmentAdrenal suppressionAnxiety reduction protocolcorticosteroids if stressful procedure (if in options)Diabetes - controlledconfirm hba1cstress reduction protocolearly morning appointmentMonitor pulse, bp, respirationHyperthyroidismMinimize epiHemophilias (congenital coagulopathies)*avoid PSA & IANBavoid NSAIDsMedical consultorder lab testsBisphosphonates - oralnone of the aboveBisphosphonates - IVavoid elective surgeryBisphosphonates - IV - emergencyAB prophylaxisPregnancy (trimester not mentioned)none of the abovePregnancy (3rd trimester)short appointmentAvoid NSAIDsPregnancy (1st trimester)Avoid nitrous oxideAIDS/HIVAB prophylaxis (if CD4 < 200 and neutrophils < 500)MD consultorder lab testsGIAvoid NSAIDsAvoid opiods (severe IBD)short appointmentmedical consultation if GI symptoms are activeEmergencyAlcoholics: Drug interactionsAnalgesics: Avoid ASA, NSAIDs and AcetaminophenAB: Ketoconazole, Cephalosporins, MetronidazoleAnxiety: AvoidNarcotic analgesic (Use acet or NSAIDs)ChemotherapyAvoid NSAIDsChronic LeukemiaAvoid ASA and NSAIDsHemophilia(normal prothrombin time (PT) and bleeding time & prolonged PTT)Avoid ASA/NSAIDs (Hemophiliacs have problem with clotting time)BRONJ: AnalgesicAcetaminophen/Codeine Bronj: Analgesic avoidNSAIDsOrtho Single tooth CBRemovable hawley +finger/T springSingle tooth CB with deep biteAdd posterior bite planeSingle tooth CB with lack of space in maxillaPalatal arch expansionUnilateral CB with functional shiftBilateral arch expansion (Hyrax)Unilateral CB with functional shift in case of active thumb suckingQuad helixUnilateral CB with NO functional shiftUnilateral arch expansionstraightbite OKhigh pullopen bitecervicaldeep biteClass III due to maxillary deficiencyReverse pull head gear to advance maxillaClass III due to mandibular excess (mild)Chin cupClass III due to mandibular excess (severe)Orthognathic surgeryDisking of primary caninesSpace gaining; mild to moderate crowding; parent or child CCDisking of primary molarsSpace regainingExtraction of 1 or 2 primary caninesPremature loss of canine on one side; CD4ImmediatelyCross bite with functional shift Anterior single tooth CBDeciduous (4-6)Space managementEarly mixed (6-9) 6 and 1 eruptedPosterior cross bite without functional shiftHabit breakingClass I severe crowding leading to serial extractionFace mask/reverse head gear for skeletal Class IIIRPERemoval of inverted mesiodensUse of lingual archDisking for mild crowdingLate mixed (9-14); prior to pubertal growth spurtModerate to severe crowdingFunctional Jaw orthopedics (Frankl) for Class II malocclusion (Myo)After completion of growthOrthognathic surgery for severe skeletal class IIIApplianceIndicationBand and LoopMissing D prior to eruption of 6 and lateral incisorCrown and LoopMissing D with a grossly decayed abutment ETranspalatal1. Bilateral loss of primary molars2. Hygienic3. May not prevent mesial tippingNance1. Indicated for multiple loss of primary teeth (bilateral molars)2. Not hygienic3. Prevents tipping and rotation of molars4. Causes molar distalization (Space regainer)Lingual arch1. Loss of multiple primary teeth during mixed dentition2. Cannot be used before complete eruption of 63. Arch length maintenance until permanent premolars and canines have eruptedCaseS/SManagementDental open bite1. Evidenced by the only front six or eight teeth not touching when you bite2. Have non-nutritional habits3. Proclined anteriors1. Elastics (Fixed ortho)2. Habit breaking appliances if first molar erupted3. Bite blockSkeletal open bite1. Evidenced by only the very last molars touching when you bite2. Have breathing issues (nasal obstruction)3. Mouth breathing habit; Exposed nose4. Steep mandibular plane angle5. Long narrow face or long lower facial height; Convex profile6. Short upper lip with a “Gummy smile”1. Orthognathic surgery to correct the increased LFH2. During growth spurts: Use Myofunctional appliances (Activator; Frankel IV)3. High pull head gear with chin cup4. Posterior bite blocksDental deep bite1. Usually seen in Class II Div I: Excessive overjet allows 2. Trauma to palatal gingiva3. Early Tx by proclining the incisors1. Deep bite with short upper lip/gummy smile: Intrude anteriors with bite plane2. Deep bite with normal upper lip: Extrude molars3. Myofunctional: Bionator4. Procline incisors; molar distalizationSkeletal deep bite1. Short face or short LFH2. Flat mandibular plane angle1. Cervical head gear2. Myofunctional appliances (Herbst; Twin)3. Orthognathic surgeryDental anterior cross bite1. Profile is straight/Class I molar2. Most commonly involved is LATERAL INCISORS (over retention of deciduous)3. In ceph evaluation the angles SNA, SNB, ANB are within normal limitsSkeletal anterior cross bite1. Molar in Class III relation 2. Generally involves multiple teeth3. Class III growth pattern, molar class IIIDental posterior cross bite1. Few teeth are involved1. If in mixed dentition: Quad helix (slow expander)2. If in permanent dentition: TPA, Fixed ortho3. Cross elastics with fixed appliancesSkeletal posterior cross bite 1. Multiple teeth involvedRapid maxillary expansion using HyraxAnterior cross bite with functional shiftClass III in CO and Class I in CREliminate the discrepancy; Limited treatmentAnterior cross bite without a functional shiftTrue class IIIFace mask or reverse head gearBolton excessHyperdontia; SupernumeraryBolton deficiencyHypodontia-Peg laterals; Missing due to extraction or congenitalReassess in 9 to 12 monthsIf the patient is on a habit breaking applianceFacial photographs; intra-oral photographs; models; panoramicall ortho patientsPeriapical radiographsimpacted caninessuspicion of root resorptionaggressive periodontitissevere crowding in Class IIIAntero-posterior cephalometric radiographIf there is facial asymmetry (deviated nose)Lateral cephalmost all Hand-wrist film(s)growth modifications in skeletal class IICone-beam CT(s)TMJ assessment; Localizing impacted canines*Ways to decrease overbite – Intrude incisors, Procline incisors, Erupt molars, Distalize/tip back molarsConditions requiring AB prophylaxis (4)Use of prosthetic or human or porcine cardiac valves/prosthetic material in cardiac valve repair such as valvular annuloplasty ringPrevious Infective EndocarditisCardiac transplantation recipients who develop cardiac valvulopathy/who developed a problem with the valveCongenital heart disease (CHD):1. Fully repaired: Whether by surgery or by catheter during the first 6 months after the procedure2. Unrepaired: Cyanotic CHD, including palliative shunts and conduit3. Partially repaired with residual defects at the site or adjacent to the site of a prosthetic patch/deviceConditions previously required but not anymore (11)1. Mitral valve prolapse with or without regurgitation2. Rheumatic heart disease3. Bicuspid valve disease4. Calcified aortic stenosis5. Congenital heart condition such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy6. Coronary artery bypass graft surgery7. Heart transplantation9. Heart murmur10. Stent placement11. Appetite suppressant phen-fen (phentamine andfenfluramine) medication12. Patent ductus arteriosus13. Previous Kawasaki disease14. Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators15. Coarctation of the aorta16. Pulmonic stenosisDental procedures requiring AB prophylaxis (9)SurgeryPeriodontal procedures including SRPEndo instrumentation beyond the apex or apical surgerySubgingival placement of AB fibres or stripsBands but not bracketsIntraligamentary (PDL) and intraosseous injectionProphylactic cleaning of teeth or implants where bleeding is anticipatedReplacement of avulsed toothSuture removalDrugsName of drugWhat is it?Patient managementAdvair (fluticasone propionate and salmeterol)asthma and chronic obstructive pulmonary disease (COPD)lamotrigine and mephenytoinanti-epilepticMethyldopa and Clonidine, PhenoxibenzamineAlpha blockersPrazosin, Phentolamine, TrazodoneAlpha blockersQuinidineSupra Ventricular Tachy Arrhythmias and Atrial FibrillationTolbutamideSulfonylureaChlorthalidoneDiureticsHydralazineHTNEzetimibeLower cholesterolNorgestrel; ethinyl estradiolBirth controlAripiprazoleAnti-psychoticglipizide, glyburide, gliclazide, glimepirideRepaglinide and nategliniderosiglitazone, pioglitazoneacarbose, miglitol, voglibosesitagliptin, saxagliptin, vildagliptin, linagliptin, alogliptindapagliflozin and canagliflozinbromocriptineEpsilon aminocaproic acidprevent clot lysis in hereditary clotting disordersSaquinavirHIVKetoconazole inhibits cytochrome P450 and may result in increased plasma levels of saquinavirRitonavirUse of sedative/hypnotics is contraindicated (e.g., diazepam,midazolam) because of the potential for oversedation.Ritonavir is formulated in alcohol. Therefore, metronidazole in alsocontraindicated.Isosorbide dinitrateCoronary atherosclerosisTreat like stable anginaOral Path notes:Bilateral lesions:reticular LPwhite spongy nevusleukoedemahairy leukoplakiafordyce granulesprodromal symptoms which mimic dental pulp pain: herpes zosterPatients with deep periodontal pockets and heavy deposits of plaque and calculus may develop an acute periodontal abscess after SRPOral MedicineAggressive Periodontitis (4 acceptable combinations)Amox + MetroDoxyMetroCiprofloxacinTests done to diagnose aggressive periodontitis: microbial testing, probing and bitewingsSinusitis: severe headache, runny nose, pain on percussionnon-odontogenic (2): Amox/Clavulanic acid; Azithodontogenic (2): Amox; Pen VKEmergency notes:Nitroglycerin: Contraindicated if VIAGRA is taken 24/48 hours priorStatus epilepticus: Seizures of greater than 5 minutes or more than one seizure within a five-minute period without the person returning to normalcy/recovery. Tx: Lorazepam/MidazolamHypoglycemia, Syncope and LA toxicity have very similar S/S: Difference is based on timing. Hypoglycemia: Feels sick before procedurethere is no oxygen in the immediate management of: upper airway obstructionPrescription tips:Option A - acceptable prescription (should be first choice) only goes with option C - drug name spelled incorrectlyOption D - drug is CI due to past allergy, don't select anything elseOption D - drug is CI due to past allergy which was immediate (anaphylaxis) or severe (like bronchospasm), select option E as well - life threatening drug as well (for example: immediate allergy to penicillin and you give amoxicillin)Option D - drug is CI due to past allergy which was delayed and you give from same group, don't select option life threatening optionDon't know the allergy type? just select CIPen V is used for dental infectionsAmoxicillin is used for ANUG, GAP, and dental infections with systemic involvementMacrolides are used for sinus infections and when allergy to penicillin or clindamycinDental infection: Pen V/Amoxicillin, next clindamycin, next azithromycin/clarithromycinCodeine plain - never first choice. Must be always in combination with acetaminophen and maxed out.Clindamycin 300 mg; Disp - 2; take 1 hour before procedure: Acceptable Rx (300 mg × 2 or 150 mg × 4)Codeine and oxycodone can be stand alone when acetaminophen is maxed outRifampin and analgesic: cannot give oxycodone as analgesicInsufficient duration or frequency or any item in the sig. goes with incorrect/ambiguous instructionsUntil finished is incorrect for analgesics, options: incorrect frequency (or incorrect duration) and incorrect instructions1-2 is incorrect instructions for antibioticsUntil finished or gone is OK for antibioticsHydrocodone as anti-tussive: not available in CanadaClotimazole: not available in Canada (not first choice)In case of HTN taking diuretics, ACE or beta blockers, NSAIDs should be less than 4 days. If instructions does not include the 4 day rule, the drug is CIKetorolac has a 5 day rule. if more than 5 days, excessive durationAnalgesics should always have PRN in the prescription. If it says PRN pain, don't calculate maximum doseIf the prescription does not say PRN pain calculate maximum dosage, but select incorrect instructionIf PRN pain, don't select J or K (duration)If you see NSAIDs/opiods prescribed for M - M pain, the answer is: Not the first choiceModerate to severe pain, NSAIDs CI: T3 or T4. allergy to natural opiods: meperidine, pentazocine or propoxyphene can be consideredmild to moderate pain in individuals who cannot tolerte opioids in combination with acetaminophen or NSAIDs: TramadolTake 1-2 erythromycin pills, what is mistake: Incorrect number of pills per administration (no range for antibiotics)Duration for antibiotics is fixed, anything less or more is insufficient or excessive durationactive wheezing with expiration is severe asthmaSelect drug is life threatening in the following conditions:Patient is on warfarin and NSAID is prescribedASA in susceptible children (if they have chicken pox, influenza or flu-like illness)Codeine in children below 12 yearsIf past history mentioned 'severe' bronchospasm to ASA or any NSAID or type 1 HS reaction: Any other NSAID is life threateningDrug is CImild allergy to aspirin: NSAIDs are CIsevere COPD: Opiods are CIPregnancy trimester: NSAIDs are CIOTC not enough + HTN: NSAIDs more than 4 days is CIAntibiotics CImild allergy to penicillin: Amox is CIsevere allergy to penicillin: Cephalexin is CIAnalgesics and Antibiotics reviewmild to moderate painnew tooth eruptionchronic periodontal abscessuncomplicated extractionortho treatmentmoderate to severeacute dental abscessdry socketsevere pericoronitisANUGfree gingival graftopen extractionRadiology Tips:do not choose bitewing and periapical in patients with severe trismus (20 mm or less)jaw opening of 30 mm is fine.Bone loss: Physiologic (age, primary tooth exfoliation, extraction socket, under bridge) + pathological (rarefying osteitis, periodontal abscess, E-P lesion, radicular cyst, periodontal splint) + periodontal (around tooth) + peri-implantic bone lossDens invaginatus can have RO periapicallyBoth cysts and benign neoplasms are more likely than malignant neoplasms to resorb rootsTalon's cusp mostly on incisors and dens evaginatus mostly on premolarsDentigerous cyst - pericoronal; OKC - whole tooth (mark - impacted tooth as well)Buccal caries: does not obliterate pulp canalMalignant lesions destroy bone uniformly. In osteomyelitis, areas of radiographically normal-appearing bone are frequently seen between the areas of destruction. Sequestra are not present in malignancy.Enamel pearl has a radiolucent rim around itwhen peg shaped lateral are present, more chances of canine impaction. If diagnosed in mixed dentition - RPE and if in ages 11-16, extract primary canine.Defective restoration: recurrent caries - replaceopen contacts - replacepoor contour (over*/under)overhang - need not replace*over contour should be very significant to be called defective restoration. Sometimes overcontoured to close space intentionally.Retentive pins within the crown - acceptable (irrespective of angulation); if sticking out - unacceptableAll ceramic crowns: opacity compared to dentin with a distinct outline due to silicaSupra-gingival calculus looks like a ring around cervical areaDifference between gold crown and SSC: Gold - cannot see through and margins well adapted; SSC - can see through and margins look openPulp calcification: stones, sclerosis, obliteration or calcificationRetained roots can be marked for caries if they look obviousMesial of 36/46 looking like pulpal sclerosis? could be lingual root overlapExtraction socket vs healed socket: For extraction socket, you must see lamina dura clearly; whereas for healed socket, you should not see.Osteoporotic bone marrow defect: diagnosis by exclusion; more common in missing teethIn aggressive periodontitis, select furcation radiolucency for all 6sDifficulty factors for extraction: extensive restorations (any tooth with crown/core build-up/cusp buid-up, MOD; any endo treated tooth; lower primary molars, long roots, severe internal resorption)Tx of vertical bone loss: GTREndo notes:Cast post and core: mainly on single rooted teethPins: 2mm in dentin and 2 mm into amalgamSelect voids only if they are distinct. If you notice clear voids, then select under fillingvoids represent incomplete obturation/compactionSealer puff is acceptable endo. But, can be considered foreign bodyLedge formation - new canal due to iatrogenic reasons. Choose under filling and under instrumentationZipping/apical transportation (no new canal). On x-ray, it will look like a tear drop or like a flat end tapered bur. Apical perforation (GP sticking out) goes with over instrumentation and over filling (extrusion) if RCT if good; over extension (poor RCT or single cone)Apical radiolucency (instrument sticking out): apical perforation and over instrumentationSeparated or broken instrument goes with under filling and under instrumentationSilver cone: inappropriate material and under fillingUntreated canal: missed canal, under instrumentation and under filledApical scar: h/o RCT or periapical involvementOver hang: Below the seat. Every over hang is an over contour. Select both*Under contour: Does not follow anatomy. Open contact is an under contourFactors that complicate RCT:anatomy: taurodontism, dens in dente, fusionlack of coronal tooth structure (interfered with isolation)pulp stones/calcified chambers; calcified root canals; pulp obliterationextreme root curvature - >30 degrees or 'S' shapedroot canal morphology - c shapedroot formation - open apexany internal resorptionlength: short or longpreviously RCT treated toothexternal resorption with perforationtilted or rotated teethaccessory canals/ canal subdivision/ extra rootbridge abutment toothextensive restoration (full crown coverage), more than a conservative MODtooth trauma: complicated crown fracture, HRF, intrusion, avulsion, lateral luxationposition in the arch: upper second/third molarspresence of extensive caries (caries removal will result in loss of tooth structure which complicates clamp placement)Factors that complicate extractionsankylosishypercementosisless than 2/3rd root formationmore than 1/3rd root inside maxillary sinus or pneumatisation of maxillary sinus (there will be missing tooth)mostly lower 8: proximity to IANCIncrease in bone density (evidence of bruxism) or evidence of COapical lesions - radicular cystsapical lesions close to sinus if sinus floor is liftedroot cariesinternal/external resorptionroot morphology: curved/bulbous/divergent roots - primary teethimpacted or rotated teethbaby teeth with permanent tooth underneath (very close to furcation)if extensive restoration (MOD) and RCT on adjacent tooth or on the toothtaurodontismnon-MOD, but lingual extension of MO/DO or cusp build-upisolated tooth on a atrophic mandible or maxilla (tuberosity #)adjacent tooth: 7, 8. if 7 has a large restoration (MOD) or is RCT, it further complicatesLA tips:commonly used ester: benzocaine (topical)safe LA in pregnancy: lido and priloPrilocaine avoided in methmoglobinemia and sickle cell anemiaallergy to ester, rest of the esters are CIallergy to amide, rest are OKPain during access opening, infiltration already given: PDL/IntraosseousPain during pulp perforation or canal debridement, infiltration already given: IntrapulpalPatients who have a hereditary trait known as atypical pseudocholinesterase have an inability to hydrolyze ester-type LAallergy to PABA: esters are CIallergy to sodium metabisulfites: use plain LA (epinephrine and Levo is CI)cocaine intake in the last 24 hours: avoid epinephrine If patient weight is less than 70 kgs, formula = weight × MRD/18 × %Intrapulpal: CI in necrotic pulpsIntraosseous: Always plain.Bleeding disorder, blocks that are CI: IANB, GG, V-A, PSA, Maxillary NBIf lip is numb after IANB and patient is still having pain: Supplemental (IO/PDL)Extraction of 14: Infiltration + GPScenario: RCT on 46, still has pain during tooth preparation after 1 carpule via infiltration. Answer: IANB (Long buccal would be incorrect because buccal periodontium already anesthetized via infiltration.Maxillary NB CI in: Children and hemophiliacsPeriapical surgeryUpper: InfiltrationLower: IANB + InfiltrationExtraction of upper 8s: PSA + InfiltrationGow-Gates and Akinosi: Never in children (Intraligamentary is OK. It prevents self-mutilation)What is the maximum dose of epinephrine given to a cardiac patient? 0.04 mg (healthy - 0.2g mg); levonordefrin - 0.2 mgLevo 1:20,000 equals 1:100,000 epiExercise: How many milligrams of Mepivacaine are contained within 1 cartridge of Mepivacaine 3%?3% = 30 mg/ml1 cartridge = 1.8 ml1.8 ml has 54 mg of MepivacaineExercise: How much lidocaine in a cartridge of lidocaine 2% with epinephrine 1:100,000? How much epi?1:100,000 = 0.01 mg/ml1 cartridge = 1.8 ml1.8 ml will have 0.018 mg of epinephrineOrtho tips:Patient deviates his lower jaw forward upon closure into class III: posterior bilateral crossbite without a functional shift and anterior crossbite with a functional shiftWhat are acceptable methods of closing Diastemas? lingual arch or hawley's with finger springs and fixed orthocontraindication for serial extractions is deep biteWhat intervention is indicated when permanent maxillary canines are observed radiographically to be erupting palatally? Extraction of the primary maxillary canineWhich primary tooth, if lost prematurely, will most frequently result in space loss? Mandibular second molarEctopic eruption occurs when the erupting first permanent molar begins to resorb the distal root of the second primary molarThe incidence of posterior crossbites is increased in children with significant tonsillar and adenoid obstruction. Eighty percent of children with a grade 3 obstruction have posterior crossbitesredundant lips: applies only to lower lip (inside is seen)upper lip is 1/3rd LFHAnatomic cross bite (Skeletal) vs Functional Cross Bite (Thumb sucking for example) differ in: Anatomic Cross Bite or skeletal cross bite will have smooth closure in centric occlusionif you see more than 1/2 of CI: incompetent lips and short upper lip (looks like 'bow')at rest 3-4 mm separation is normalgummy smile (> 2 mm of gum show) - maxillary excess. Tx: Orthognathic surgerycan't see any maxillary teeth on smiling - maxillary deficiency. Tx: Orthognathic surgeryOverbite: 30% is normal6 years, 85 missing: Band & Loop9 years, 85 missing: Lingual archIf primary teeth missing bilaterally in maxilla: nance palatal archIf primary teeth missing bilaterally in mandible: lingual archaddition information: smooth CR -CO on closure: true unilateral CBA thick maxillary frenum with a high attachment (sometimes extending to the palate) is common in the primary dentition and does not require treatment. However, a large midline diastema in the primary dentition may indicate thepresence of an unerupted midline supernumerary tooth (mesiodens - only if between central incisors) and often warrants an appropriate radiograph. The permanent maxillary central incisors erupt labial to the primary incisors and often exhibit a slight distal inclination that results in a midline diastema. This midline space is normal and decreases with the eruption of the lateral incisors. Complete closure of the midline diastema, however, does not occur until the permanent canines erupt. Treatment of residual midline space is addressed orthodontically at this time.Diastema in mixed dentition before eruption of canines is normal.Activator/Bionator is used for: Class II + DeepbiteWhat is the space maintainer of choice for a 7-year-old child who has lost a lower primary second molar to caries? Lingual archWhat is the space maintainer of choice for a 5-year-old child who has lost an upper primary second molar to caries? Distal shoeBolton discrepancy (between 6 - 6)missing or supernumerary toothpeg lateralmacro or microdontiafusion/geminationnonresponsive to pulp testing because of calcification, recent history of traumaPreviously Treated: A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials other than intra-canal medicaments.Previously Initiated Therapy: A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (e.g., pulpotomy, pulpectomy).Tx of Intrusive luxation: RCTPerio Tx1. Emergency: Extraction of symptomatic hopeless tooth2. If only one chart is given; its Phase I or Initial phase of treatment: Pick Non-surgical debridement (all patients regardless of final tx); Systemic AB therapy if a case of Aggressive periodontitis; symptomatic hopeless teethEvaluation: If patient is not motivated and inconsistent oral hygiene practices, repeat SRP - no surgery3. Phase 2 (surgery): Oral hygiene improved, patient is motivated and even then if:PPD < 5 +BOP (anterior/posterior): OF debridement alonePPD > 5 + BOP (anterior): OF debridement alonePPD > 5 + BOP (posterior): OF debridement with apically positioned flap (CI if 6,7,8 have sensitivity)Gingivectomy (only if it is a chief complaint for children)GTR + bone graft (lower 6, 7 - 3 walled defect with class II furcation and no mobility; 8 - extract)Distal wedge: deep pocket distal to last molar (if 8, extract)Non-symptomatic extractions: periodontal abscess; grade II mobility with deep pockets; grade II mobility with grade III furcation*For GTR: OF debridement alone is OK (don't select OF debridement with apically positioned flap)*Management of furcationGrade 3 or 4 in upper 6,7: Root resection with no mobility (3 rooted - 2 rooted)Grade 2 in lower 6, 7: GTR with bone graftGrade 3 or 4 in lower 6, 7: Hemisection or bicuspidization (molar into 2 premolars)CGP and gingivitis options:if CGP or CAP, don't select gingivitis option; can select gingival manifestation of systemic disease or gingivitis modified by systemic factorsIf CLP or LAP, can select gingivitis or gingival manifestation of systemic disease or gingivitis modified by systemic factorsMiller's Class I & II: no loss of interdental tissue or bone - good candidate for root coverageMiller's class III & IV and question is about generalized recession - none of the above, cannot do anything*Apically positioned flap: To increase the width of attached gingiva (crown lengthening/pocket elimination)Marwan Cases:Temperature: <37.5C/99.5 F is normal. If you see 38 C/>100F: FebrileAggresive periodontis Patient complaint: Bite is shifting/midline is not coincident; Visits dentist regularly-Aggressive periodontitisIn perio chart look for 6 and 1: If both have a wide zone pocket, suspect aggressive periodontitisfamilial aggregation (siblings, parents)Radio: Vertical loss of bone in an “arc-shape” extending from the distal of the 2nd premolar to the mesial of the 1st molarabsence of systemic diseases. If yes, it will be periodontal manifestation of systemic disease (Papillon Lefevre)Localized aggressive periodontitis (circum pubertal): First molar (4) & first incisor (8) and any two (2) other permanent teeth (total 14)Generalized aggressive periodontitis (age 30): First molar (4) & first incisor (8) and any three (3) other teeth (total 15 and above)Pain increase when lying down: SinusitisBP in cardiac arrest is zero (no pulse)Conditions that can proceed to cardiac arrest: poorly managed MI and upper airway obstructionwhen you select ANUG/ANUP: don't select any gingivitis optionsIf lab says, mild dysplasia: re-call and monitor only if not in danger zone and patient is non-alcoholic and non-smoker.Asthmatic and used steroid inhaler – Patient is moderate asthmatic: Causes candidiasis (Using oral steroids: Severe form of Asthma)Anxiolytic/sedatives at CI in COPDEPTEPT will be falsely negative for permanent teeth with open apices, trauma, sedated patient or calcified and for primary teethEPT can't be done on full crowned teeth (full coverage crown with 4 mm recession - EPT OK)EPT not done on childrenAvoid electro surgery, ultrasonic scaling and EPT on patients with cardiac pacemakers.Delayed cold test response: Due to pulpal calcificationCracked tooth: Random pain to cold test; Pain upon biting; sensitivityAvoid 1:50,000 epi in HTN, CHF, Arrythmias, MI/AnginaIf patient feels his 'heart is pounding' or 'heart is beating fast' with pain while administering LA: Epinephrine reaction. Which should NOT be prescribed for a patient receiving warfarin (Coumadin?): Acetylsalicylic acid, Ketorolac, Metronidazole, Erythromycin, Clarithromycin (MAKE - C); One that is prescribed /given safely is Codeine/Oxycodone/Penicillin (COP)*Cone beam CT: abnormal massesRecent MI: last 30 daysNitrous oxide/oxygen is contraindicated for patients: first trimesterSystemic AB in generalized aggressive periodontitis: amoxicillin + metronidazoleDuring mixed dentition (after eruption of permanent first molars and incisors): Age 6-7 yearsImmediately following the eruption of permanent second molars: Age 13-14 yearsDon't select operculectomy in exam for pericoronitisCriteria for referral to a hospital:difficulty swallowing/breathingsevere dehydrationtrismusswelling extending beyond alveolar processElevation of the tongueBilateral submandibular swellingLeukocytosis (WBC> 10,000)MPDSrelated to bruxism and clenchinghyperactivity of muscles (diffuse pain)more severe during tension & stressnocturnal bruxism - more severe in morningbi-temporal headachex-ray is normalAnterior disc displacement with reduction: no pain, no tx, clicking sound - yesAnterior disc displacement without reduction: no clicking soundlimited openingdeviation of mandible to affected sideTx: analgesics, night guard, tmj surgeryMRI: best for TMJFever since 3 days, but now temperature is 37 C: Patient must have taken analgesics (OTC)Sudden drop in BP: AnaphylaxisSudden drop in BP with a light headed feeling, tremors with muscle twitching: SyncopeDiphenhydramine in anaphylaxis: Appropriate, not immediatemucosal burn due to aspirin will sloughIf additional info mentions no evidence of bone loss, then rule out periodontitis irrespective of recessionRule for gingivitis: <10% sites - No gingivitis of 6% has average blood glucose of 126. At 7% it is 154Another name for absence seizures? Petit malSudden onset Primarily in childrenBlank stareSlow blinking of eyelidsShort duration (5-30 seconds)may not know it is happeningRapid recoveryGrand MalLoss of consciousnessClenched teeth, tongue bitingIncontinenceUsually lasts from 2-5 minutesWhat does status epilepticus mean? Prolonged seizure activity; can last for more than an hour and has the highest mortality rateIf the patient recovered from the CVA within 10 minutes, what is it called? Transient Ischemic Attack (TIA)Patient on warfarin therapy: They receive cardiac stentsPatient management:mild gagging: short appointment; severe: anxiolytic/sedativespatient taking antacids: short appointmentPatient with a long QT interval: Erythromycin is CTnormal respiratory rate: 16-20normal hb in men: 14-18 g/dlnormal hb in women: 12-16 g/dlwhite blood cell: 4,000 - 10,000 cells/mm3neutrophils: 50-70%lymphocytes: 30-40%Platelet count: normal values = 150,000—450,000Prothrombin time (PT): normal value = 10—13.5 secondsPartial thromboplastin time (PTT): normal value = 25—36 secondsBleeding time: normal value = < 9 minutesCephalosporins should not be used in patients with immediate-type hypersensitivity reaction (urticaria, angioedema. or anaphylaxis) to penicillins.dizzy and unwell with ? in BP ? heart rate: DD - syncope and LA toxicity (single option)Patient management in mitral valve prolapse only: NONE of the aboveCase Scenarios:1. A 25-year-old woman presents with the chief complaint of spontaneously bleeding gingiva. She also notes malaise. On oral examination you find that her hygiene is excellent. Would you suspect a local or systemic basis for her symptoms? What tests might you order to make a diagnosis?Answer: Spontaneous bleeding, especially in the face of good oral hygiene, is most likely of systemic origin. Gingival bleeding is among the most common presenting signs of acute leukemia. Management: Medical evaluation and lab tests2. A 60-year-old woman presents with the complaint of numbness of the left side of her mandible. Four years ago she had a mastectomy for treatment of breast cancer. What is the likely diagnosis? What is the first step you take to confirm it?Answer: As the metastatic lesion grows, it puts pressure on the inferior alveolar nerve and causes paresthesia.5. A patient presents for extraction of a carious tooth. In taking the history, you learn that the patient is receiving chemotherapy for treatment of a breast carcinoma. What information is critical before proceeding with the extraction? Answer: The major organ system affected by cytotoxic chemotherapy is the hematopoietic system. Patient’s white blood cell count and platelet count before initiating treatment and in consultation with physician.6. What oral findings have been associated with the diuretic hydrochlorothiazide?Answer: Lichen Planus7. What is the minimal acceptable platelet count for an oral surgical procedure?Answer: Normal platelet count is 150,000—450,000. In general, the minimal count for an oral surgical procedure is 50,000 platelets. However, emergency procedures may be done with as few as 30,000 platelets.8. Should oral surgical procedures be postponed in patients taking aspirin?Answer: Elective procedures, if at all possible, should be postponed in the patient taking aspirin.9. What are the considerations in treating patients infected with the HIV virus and treated with azidothymidine (AZT)?Answer: Patients taking AZT should have a CBC every 2 weeks. Before oral surgical procedures, a CBC should be done to determine whether the patient is neutropenic or thrombocytopenic10. A patient with HIV infection requires an oral surgical procedure to remove teeth after severe bone loss due to H1V-related localized periodontitis. What precautions should be taken?Answer: It is estimated that 10—15% of patients with HIV develop immunogenic thrombocytopenic purpura (ITP). The anti-platelet antibodies appear to be found more frequently in advanced stages of the disease. Affected patients should have a CBC before any oral surgical procedure. If the platelets are low (below 150,000), the procedure should be done only after consultation with the patient’s physician and with the knowledge that bleeding may be increased. The patient may require platelet transfusions to control postoperative bleeding.12. Is it safe to treat a patient who has had a heart transplant in an outpatient dental office?Answer: The patient most likely will be taking prednisone and cyclosporine. Erythromycin and ketoconazole inhibit the metabolism of cyclosponine.13. Hypothyroid patient?Answer: Dental care should be deferred until after a medical consultation.14. Facial paralysis, tinnitus, deafness, and vertigoAnswer: Herpes ZosterOrthodontics does it tell you?Significant finding - aortic septal defectPatient on current medication of nitroglycerinPatient on current medication of ASA 81 mgAllergy to PABAAvoid ester LAMarginal gingivitis + LymphadenopathyANUGSevere weight loss recentlyHIV; ImmunocompromisedPatient is allergic to sulfa drugsAcute throbbing toothacheWarfarin related to PTPT increases (normal PPT & bleeding time)Pain did not get better after taking TylenolIrregular dental visitStarted 2 days ago and got worst recentlyLymph nodes are sensitive to touchPatient on lamivudineBeing treated for Hep BDifference between APP & APASystemic involvement in APAPrilocaine is ester or amideAmidePatient on triamtereneDiureticAcute pain on tooth which gets better by drinking cold waterSevere sensitivity to hot and cold a few days ago and now it is spontaneousSignificant finding - bicuspid valve diseaseCurrent medication - beclomethasone inhalerAvoid NSAIDs; may develop candidiasisCurrent medication - oral contraceptivesPatient complains of tightness and heavy pressure in chest and looks anxiousPatient starts coughing and complains from difficulty breathingToothache on chewing food or closing the jawPain was on and off for few weeks, but for last 2 nights it got more intense and waking up the patientPatient is type 1 diabeticPatient has a h/o stroke 1 year agoAllergic to procaineCurrent medication - NPH insulinCurrent medication - warfarinCurrent medication - furosemidePatient has already been taking tylenol for 2 days, but still has pain. He wants a stronger analgesic for toothacheTeeth broke during play yesterdayTeeth broke (crown fracture) with no sign of pulp exposure, but sensitive to cold air and mild discomfort on chewingComplains of weakness and starts to shake, few minutes later loses consciousnessPatient suffers from senile osteoporosisKnee replacement surgery last yearPatient has mild depressionCurrent medication - AlendronateOsteoporosisCurrent medication - ImipraminePain on biting hard foods and eating cold foods and sugar which started 2 months agopatient says he is afraid of dental treatment and needlesSelect anxiolytic medication/sedativesh/o infective endocarditis 8 yearsh/o hip replacement last yearDifficulty breathing, which emergency?Difficulty closing mouthSevere pain radiating to ear and bad taste in mouthCurrent medication: prednisoneAllergic to aspirinSuddenly loses consciousnessDuring extraction, tooth falls and gets into throat, patient jumps and starts coughing. Immediate management?Pain started few weeks ago, triggered by chewingCurrent medication: GlyburideCurrent medication: hydrochlorothiazideLong standing asymptomatic Leukoplakia (social: smoker) Incisional and eliminate etiologydeep mesial decay; periapical radiolucency; cold test turned out to be negative and percussion test revealed to be positive; tender lymph nodesNecrotic pulp; acute periradicular abscessAllergic to penicillinClindamycinDosage of clindamycin150-300 mg, QIDInitial management of chronic generalized periodontitisNon surgical debridement Narrow zone pocket: 2 deep pockets, one buccal and one lingual out of 6 probing depthsEndo-perio lesionmaximum number of cartridges of 2% lidocaine, 1:100000 epinephrine in a cardiac patient2Links: ................
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