Short answers

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

March 2000
1. From the medical history you find the patient is on Tricyclic Antidepression medication. How would you manage this patient? Complete building the medical and the dental history to reach a proper diagnosis and find the aetiology of the chief complaint so I can start assessing the case by evaluating the available information; the overall case assessment is an essential step that allows the considerations of treatment options and a provisional treatment plan to be formulated. Consult the patients GP for any precautions should be taking or any modification to the treatment should be followed. Resolution of any acute problems and stabilisation or elimination of active disease. If it is not possible to get in contact with the GP refer to the MIMs to get more information about the drug to find out what I can or I can not prescribe Assessing and managing accordingly any emergencies situations that exist, acute pain, bleeding swellingetc Eliminating any acute problems or active diseases I will assess the periodontal tissues and elimination of any active diseases, regeneration of the periodontal attachment loos and stabilisation of gingival contours would be my next step in managing the patient. Reassessment of the periodontal situation by assessing the patient occlusal stability and plan for any restorative or prosthetic management. Finally and it is an important part is the patient consultation to present and discuss the treatment plan and give the alternative options, obtaining a patient consent/s, arrange for appointments and financial considerations Reconfirm the definitive treatment plan and make sure the patients expectations are what the result would be. Tricyclic has a side affects on the oral cavity by causing dry mouth; and systemically it causes blurred vision, constipation, and difficulty in urination; postural hypotension; tachycardia, increased sensitivity to the sun; weight gain; sedation (sleepiness); increased sweating. Some of these side effects will disappear with the passage of time or with a decrease in the dosage. Bear in mind all this information should be recorded appropriately for future follow up and to adhere to the Australian Dental Board policies.

2. A 23 year-old female comes to you with Gingival abscess in the right upper central incisor region which she had a blow to 10 days ago; since then the tooth is a bit loose, now she is complaining of pain and tenderness started two days ago. What is your management? Gathering general information including but not limited to name, age, sex, previous major operations, any medication is taken at the time she is presentedetc. mostly this is prepared and universal for all patients. Building the medical and the dental history to help building a proper diagnosis and find the aetiology of the chief complaint so I can start assessing the case by evaluating the available information; the overall case assessment is an essential step that allows the considerations of treatment options and a provisional treatment plan to be formulated. Clinical examination in both directions Extra and intra. Extra examination includes the general morphology, skeletal base, skin colour and lesions, eyes, lymph nodes, lip, breathing, TMJ and masticatory muscles. Intra orally starts with soft tissues and oral mucosa and muscles followed by the dental examination by examining the teeth and focusing on the tissues, bone and teeth next to tenderness and the blow area; and look for any attrition, abrasion, erosion, or hypominerlization on the tooth surface or any abnormality in the gingivae or hard tissues Faceting, fracture or caries of the enamel then examine the periodontal tissues and record any tooth mobility or badly restored teeth. Check the occlusal view if possible and the result of the blow on the occlusal harmony and the other tissues. Order any special tests required and in this case a periapical to start with seems to be essential. Assess the case and advise for a rigid splint or extraction and fixed prothesis lateretc and this is completely demandant on the outcome of the assessment. Transfer the treatment options to the patient in a simple language and this stage should include the approximate cost and any need for future follow up.

3. A 13 year old patient has rampant caries and gingival swelling. What are the causes? How to prevent them? What is your management? Most probable cause of the rampant caries is the frequent intake of sugar, then the oral hygiene methods that have been adapted by the patient. But we must be able to visualize adequately a childs teeth and mouth and have access to a reliable historian for non-clinical data elements.

Prevention programme starts with assessing all 3 components of caries riskclinical conditions, environmental characteristics, and general health conditions; a complete analysing of the diet regime; then build a new diet system prevents less frequent take of carbohydrates and in sever cases could include changing sugar to carbohydrate free substitute. Endorsing a good oral hygiene plan that suits the patient and the advice for a regular topical fluoride application is as important as the diet. Systemic fluoride may be applicable depends on the case and the water fluoridation program in the area. The management includes, Gathering general information including but not limited to name, age, sex, previous major operations, any medication is taken at the time she is presentedetc. mostly this is prepared and universal for all patients. Building the medical and the dental history to reach a proper diagnosis and find the aetiology of the chief complaint so I can start assessing the case by evaluating the available information; the overall case assessment is an essential step that allows the considerations of treatment options and a provisional treatment plan to be formulated. Clinical examination in both directions Extra and intra. Extra examination includes the general morphology, skeletal base, skin colour and lesions, eyes, lymph nodes, lip, breathing, TMJ and masticatory muscles. Intra orally starts with soft tissues and oral mucosa and muscles followed by the dental examination by examining the teeth and focusing on the tissues, bone and teeth next to tenderness; look for any attrition, abrasion, erosion, hypominerlization or any abnormality in the gingivae or hard tissues Faceting, fracture or caries of the enamel then examine the periodontal tissues and record any tooth mobility or badly restored teeth. Check the occlusal view if possible and the result of the blow on the occlusal harmony and the other tissues. Assess the case and treat according to the diagnosis outcome; bearing in mind that the target is to treat the acute problems or manage any source of pain then reserve as much as possible of the child teeth tissues. 4. Patient with chronic periodontic disease. What are the factors that will influence the management and outcome of this patient? The overall clinical factors are: Patient age: for two patients with comparable level of the remaining connective tissues attachment and alveolar bone, the prognosis is better in the older of two. For the younger patient, the prognosis is not as good because of the short time frame in which the periodontal destruction has occurred. In some cases this is maybe because the younger patient suffers from an aggressive type of periodontitis. Disease severity: Studies have demonstrated that a patients history of previous periodontal disease may be indicative of their susceptibility for future periodontal break down. Prognosis is adversely affected if the base of the pocket is close to the root apex. Also the height of the remaining bone, all these should be weighed against the benefits that

would accrue to the adjacent teeth if the tooth under consideration were extracted. Plaque control: bacterial plaque is the primary etiological factor associated with periodontal disease. Therefore effective removal of plaque on daily basis by patient is critical to the success of the periodontal therapy and to the prognosis. Patient complaisance/ cooperation: the prognosis for patients with gingival and periodontal disease is critically dependant on the patients attitude and desire to retain natural teeth, and willingness and ability to maintain good oral hygiene. Without these, treatment can not succeed.

There are systemic and environmental factors such as: Smoking: Epidemiologic evidence suggests that smoking may be the most important environmental risk factor impacting the development and progression of periodontal disease. Therefore it should be made clear to the patient that a direct relationship exist between smoking and the prevalence and incidence of periodontitis. Also patient should be informed about the effects of smoking on the healing process. Systemic disease /condition: the patients systemic background affects overall prognosis in several ways. For example, studies have shown that the severity of periodontitis is significantly higher in patients with type I and II diabetes than in those without diabetes. Patients with diabetes or with newly diagnosed diabetes should be informed about the impact of diabetic control on the development and progression of periodontal disease. Genetic factors: periodontal diseases represent a complex interaction between microbial challenge and the hosts response to that challenge, both of which may be influenced by environmental factors such as smoking. There also is evidence that genetic factors may play an important role in determining the nature of the host response. Stress: physical and emotional stress, as well as substance abuse, may alter the patients ability to respond to the periodontal treatment performed. The Local Factors: Plaque /calculus: the microbial challenge presented by bacterial plaque and calculus is the most important local factor in periodontal diseases. Therefore in most cases, having a good prognosis is dependent on the ability of the patient and the clinician to remove these etiologic factors Subgingival restorations: may contribute to increased plaque accumulation, increased inflammation and increased bone loss when compared with supragingival margins. Anatomic factors: may predispose the periodontium to disease, and therefore affect the prognosis, include short, tapered roots with large crowns, cervical enamel projections (CEPs) and enamel pearls, intermediate bifurcation ridges, root concavities, and developmental grooves.

Tooth mobility: the principle causes of tooth mobility are the loss of alveolar bone , inflammatory changes in the periodontal ligament, and trauma from occlusion. However, tooth mobility resulting from loss of alveolar bone is not likely to be corrected. Prosthetic / restorative factors: the overall prognosis requires a general consideration of bone level and attachment level to establish whether enough teeth can be saved either to provide a functional and aesthetic dentition or to serve as abutments for useful prosthetic replacement of the missing teeth. Caries, non vital teeth , and root resorption: for teeth mutilated with extensive caries, the feasibility of adequate restoration and endodontic therapy should be considered before undertaking periodontal treatment. 5. Class two amalgam restoration on a molar. What factors do you consider when preparing a good proximal contact area? The extent of the cavitation of the proximal enamel will dictate the classification and, ultimately, the outline form of the cavity. There is no need to remove sound enamel, particularly from the gingival floor, just because it is undermined following removal of caries. The enamel at the gingival is not under occlusal load and can be retained, thus keeping the restoration margin out of the gingival crevice, in case we are going to use the lamination sandwich technique. If not ditches and grooves are the best methods of developing retention; pronounced groove along the gingival floor of the mesial proximal box of 2mm depth provides a good positive retention. The main retentive form in the proximal box should be placed within the dentine at the gingival floor as well as in the facial and lingual walls. Now if the separate sections of the restoration are individually self retentive, there will be no failure at the narrow isthmus that joins the occlusal extension to the proximal box and there is no need to widen it in this case. Other wise extending it just over the contact area with the adjacent teeth is indicated and bevelling the step as well to strengthen the amalgam in this area and extra retention will be gained.

March 1999
1. List the factors that determine the prognosis of an avulsed, traumatised upper central incisor. The single most important factor determining the prognosis of a replanted tooth is viability of the periodontal membrane left on the root prior to replantation. If the root surface is left dry, approximately 50% of the periodontal ligament cells are dead after 30 minutes; after 60 minutes, almost no cells are viable. Replantation of such tooth results in extensive pulpallyderived inflammatory resorption, or ankylosis. The critical time of dry storage seems to be between 18 and 30 minutes A storage media must be of correct osmolality and PH. Saliva allows storage for 2 hours. Normal saline solution allows the same time, while milk on the other hand allows up to 6 hours. Mechanical damage happens as a result of the process of avulsion and replantation; the damage is seen on both cells and tissues. These areas of damage appear as surface resorption defects.

Socket: curettage of the socket wall and the presence or removal of a blood clot had a little influence on the healing pattern of the replanted teeth. Therefore this need not be done unless the clot prevents proper seating of the tooth. However, alveolar bone should be moulded back into position following replantation, this aids in bone healing and allows good adaptation of soft tissues. Splinting: minimal splinting and non-rigid splints permit physiological jiggling movement of the tooth which result in lower incidence of ankylosis. Care must be taken in the placement of the splints, keep it simple and avoid gingival tissues. Studies have shown that normal and hard diet resulted in significantly less ankylosis and a higher incidence of normal periodontal ligament compared with soft diet. Antibiotics: High dose of a broad spectrum antibiotic is recommended followed by at least two weeks of oral administration. Intrapulpal application of antibiotic is indicated if bacterial invasion of the pulp occurs prior to systemic antibiotic. Endodontic treatment: teeth with immature apices should be monitored clinically and radiographically since revascularisation of the pulp is possible. Teeth with mature apices rarely < 1% regain vascularity and so necrosis and infection would follow, so an endodontic treatment is advised as soon as possible. Extra oral endodontics should not be perform prior to replantation as the excessive handling of the tooth will increase the risk of additional damage to the periodontal membrane. And the filling material may increase the risk of inflammatory resorption.

2. Discuss the choices for an MOD direct restoration for a lower molar. Amalgam- Sandwich Technique- Composite- Pins3. An insulin dependent 45 year old male needs a full clearance and full upper and lower dentures. Discuss how you would manage this case. Medical considerations. Take a thorough medical history for all patients diagnosed with diabetes. Ascertain the identity of the physician treating the patient and the date of the last visit. Obtain information concerning the type of diabetes, the severity and control of the diabetes, and the presence of cardiovascular or neurologic complications. Refer any patient with the cardinal symptoms of diabetes or findings that suggest diabetes (headache, dry mouth, irritability, repeated skin infection, blurred vision, paresthesias, progressive periodontal disease, multiple periodontal abscesses) to a physician for diagnosis and treatment. Diabetic patients who are receiving good medical management without serious complications such as renal disease, hypertension, or coronary atherosclerotic heart disease, can receive any indicated dental treatment.

Those with serious medical complications may require an altered plan of dental treatment. When the severity and degree of control of diabetes are not known, treatment should be limited to palliation. Food intake and appointment scheduling. To preventing insulin shock from occurring: Verify that the patient has taken medication as usual. Verify that the patient has had adequate intake of food. Schedule appointments in the morning, since this is a time of high glucose and lowinsulin activity. Afternoon appointments are a time of low-glucose and high-insulin activity which may predispose the patient to a hypoglycemic reaction. Instruct patients to tell the dentist if at any time during the appointment they feel symptoms of an insulin reaction occurring. A source of sugar, such as orange juice, must be available in the dental office should the symptoms of an insulin reaction occur. Oral surgery concerns. It is important that the total caloric content and the protein/carbohydrate/fat ratio of the patient's diet remain the same so control of the disease and proper blood glucose balance are maintained. IDDM diabetics who are going to receive periodontal or oral surgery procedures may be placed on prophylactic antibiotic therapy during the postoperative period to avoid infection. Consultation with a patient's physician before conducting extensive periodontal or oral surgery is advisable. The physician may, in fact, recommend that the patient be treated in a hospital environment where infection, bleeding, and dysglycemia can be better managed. Dangers of acute oral infection. Any diabetic patient with acute dental or oral infection presents a problem in management. This problem is even more difficult for patients who take high insulin dosage and those who have IDDM. The infection will often cause loss of control of the diabetic condition, and as a result the infection is not handled by the body's defenses as well as it would be in a nondiabetic patient. The patient's physician should become a partner in treatment during this period. Oral complications. The oral complications of uncontrolled diabetes mellitus may include: Xerostomia, Infection, Poor healing, Increased incidence and severity of periodontal disease, and Burning mouth syndrome. Diabetic neuropathy may lead to oral symptoms of tingling, numbness, burning, or pain in the oral region. Oral findings in patients with uncontrolled diabetes are thought to be related to excessive loss of fluids through urination, altered response to infection, microvascular changes, and possibly increased glucose concentrations in saliva. Early diagnosis and treatment of the diabetic state may allow for regression of these symptoms, but in long-standing cases the changes may be irreversible.

Potential Drug Interaction. While patients with well-controlled diabetes can be given general anesthetics, management with local anesthetics is preferable. General anesthetics should be used with caution because they can produce hyperglycemia. 4. Your dental nurse has suffered a needle stick. What is your management for the case? IMMEDIATELY WASH THE INJURY WITH SOAP AND WATER If splashed with a bodily fluid, thoroughly irrigate the affected area Cover the injured area with a bandage for protection There is no need to apply agents such as bleach to the injury Risk assessment Report the incident to the practice principal/manager following first aid Document as much of the following as possible to determine risk: 1. How did the injury occur? 2. What type of injury is it, and what is the extent of the injury? 3. What was the source of the sharp or bodily fluid? 4. How much of the source material came into contact with the affected person? 5. Was any protective clothing being used? After initial risk assessment, seek further management and treatment If appropriate, post-exposure treatment should be implemented as soon as possible Injury management: The affected person may wish to attend their usual doctor for further care The following matters should be addressed by the treating doctor: - Infection status of source material (blood) - Counselling of the patient - Blood testing to determine whether infection has occurred - Hepatitis B immunity status of the patient (is a booster shot required?) - Need for HIV Post-Exposure Prophylaxis (PEP) The practice must follow up the incident and make a final report - Do practice procedures need to be reviewed as a result of the incident? - Do arrangements need to be made with insurers, NSW WorkCover, etc? 24-Hour Needlestick Hotline phone 1800 804 823

September 1999
The compulsory question: what factors will you discuss with a patient for whom an impacted lower third molar is to be removed under local anaesthic before the surgery? I will explain for the patient first about in a basic word about the difference between Partial Bony impaction and complete bony impaction and the complications of both of them. 1. Complete Bony Impaction when the wisdom teeth are completely covered in bone. When the tooth is completely covered with bone it will remain completely covered with its "developmental sack" in which all teeth develop. Later in life, this sack may undergo changes and enlarge and develop into a cyst. This cyst will

enlarge at the expense of the bone of the jaw. These cysts should be removed and examined by a pathologist. 2. Partial Bony Impaction when the teeth begin to erupt but are not able to erupt completely. In this situation, the upper third molars usually are positioned towards the cheek while the lower third molars usually lean forward with only part of the crown sticking through the gum. This situation can to decay and gum disease around the second molar directly in front of it. The most common complication of the partial bony impaction is that the flap of gum tissue which partially covers the erupting third molar creates a pocket where bacteria that are present in the mouth can grow and cause an infection known as pericoronitis. The swelling and infection can become very serious. The treatment for pericoronitis is extraction of the third molar tooth. Then I will discuss the risks and complications involved in the removal of third molars which are: PAIN Surgical removal of the third molars can lead to some discomfort and pain. This is usually treated with pain medication. INFECTION Because of the large number of bacteria present in the mouth post surgical infection is always possible. Patients are usually placed on prophylactic antibiotics to prevent infections from developing. SWELLING Following surgery patients may experience swelling and bruising. These symptoms vary between patients. BLEEDING Some post surgical bleeding is considered normal. This is usually minimal and is easily controlled with the pressure of biting on gauze. Inform the patient that third molars can be removed with local anaesthesia alone but many people prefer I.V. sedation during surgery. Finally there are some risks/complications that are unique to the removal of third molars. The upper third molars have roots which often are separated from the maxillary sinuses by only a very thin layer of bone. Occasionally, a small communication is established between the sinus and the oral cavity when one of the upper third molars is removed. If this is the case, the normal procedure is for the area to be sutured closed, the patient to be informed of the finding, appropriate antibiotics and decongestants to be prescribed, the patient to be instructed to avoid Valsalva manoeuvres (tasks which build up pressure in the sinus like nose blowing and bearing down forcefully) and the patient reappointed for follow-up. Most often this results in an uneventful healing period with no further treatment being required. Occasionally, the area will heal open rather than closed in which case an additional small surgical procedure will be required to close the communication.

The lower third molars often have roots that lie very near or even wrapped around the inferior alveolar nerve. This is the nerve that supplies feeling to the lip, teeth and tongue on each side of the mouth. Occasionally, when a lower third molar is removed, that nerve will be bumped or bruised and if so a change in sensation may be noted on that side. It is important to understand that this is a sensory nerve and does not affect the ability to move the parts of the oral cavity to which it gives sensation (feeling). In most cases, the nerve heals itself but, because nerves heal slowly, it may take six months to one year before return of normal sensation. Very rarely, the damage to the nerve is permanent. Finally, the normal precautions, risks and benefits of extraction of any tooth Choose two of the following four questions: 1. What are the factors that will reduce the radiation exposure of patient, describe how each factor affects the reduction of patient exposure. The largest single contributor of man-made radiation exposure to the population is medical and dental diagnostic radiology. In total, such radiations account for more than 90% of the total man-made radiation dose to the general population. It is generally agreed by experts in the scientific community that radiation exposure to patients from medical and dental radiographic sources can be reduced substantially with no decrease in the value of diagnostic information derived. The risk to the individual patient from a single dental radiographic examination is very low. However, the risk to a population is increased by increasing the frequency of radiographic examinations and by increasing the number of persons undergoing such examinations. For this reason, every effort should be made to reduce the number of radiograms and the number of persons examined radio-graphically, as well as to reduce the dose involved in a particular examination. To accomplish this reduction, it is essential that patients not be subjected to unnecessary radiological examinations and, when a radiological examination is required, it is essential that patients be protected from excessive radiation exposure during the examination. The recommendations outlined below are directed toward the dentist and the operator of dental X-ray equipment. These recommendations are intended to provide guidelines for the elimination of unnecessary radiological examinations and for reducing doses to patients. Also, included are recommended upper limits on patient doses for certain common dental radiographic examinations. 9.1 Guidelines for the Prescription of Dental Radiographic Examinations The dental practitioner is in the unique position to reduce unnecessary radiation exposure to the patient by eliminating examinations which are not clinically justified. The dental practitioner can achieve this by adhering to following basic recommendations.

A radiographic examination should be for the purpose of obtaining diagnostic information about the patient to aid in a clinical evaluation of the patient and treatment when warranted. Routine or screening examinations, in which there is no prior clinical evaluation of the patient, should not be prescribed. It is considered a bad practice to radiograph patients unnecessarily, as in a standard survey, and this is especially deplored when done on children. It is also considered bad practice to take radiograms before a clinical examination by the dentist. These two practices constitute the largest potential abuse of radiology in dentistry. It should be determined whether there have been any previous radiographic examinations which would make further examination unnecessary or allow for an abbreviated radiographic examination. When a patient is transferred from one practitioner to another, any relevant radiograms should accompany the patient or should be requested from the previous dentist. The number of radiographic views required in an examination should be kept to the minimum practical, consistent with the clinical objectives of the examination. In prescribing radiographic examinations of pregnant or possibly pregnant women, full consideration should be taken of the consequences of foetal irradiation. The developing foetus is sensitive to radiation damage that can result in congenital defects. In dental radiology, good radiation protection practice reduces the foetal dose to an acceptable minimum and dose levels which do not constitute a significant hazard. It should be emphasized that precautions to reduce radiation exposure to the patient should be taken all the time because a woman of child bearing capacity may be unaware of her pregnancy. Repeat radiographic examinations should not be prescribed simply because a radiogram may not be of the "best" diagnostic quality, but does provide the desired information. A patient's clinical records should include details of all radiographic examinations carried out. 9.2 Guidelines for Protecting the Patient During Radiographic Examinations It is possible to obtain a series of diagnostically acceptable radiograms and have the patient dose vary widely because of differences in the choice of loading factors and film speeds. It is the responsibility of the operator and dental practitioner to be aware of this and to know how to carry out a prescribed examination with the lowest practical dose to the patient. The recommendations that follow are intended to provide guidance to the operator and dental practitioner in exercising responsibility towards reduction of radiation exposure to the patient. The operator must not perform any radiographic examinations not prescribed by the dental practitioner responsible for the patient. The dose to the patient must be kept to the lowest practical value, consistent with clinical objectives. To achieve this, techniques appropriate to the equipment available should be used. It is

recommended the X-ray loading factors charts be established when using X-ray units which do not have preprogrammed anatomical feature settings. The loading factors chart must be established after optimizing the film processing procedure. Fluoroscopy must not be used in dental examinations. Dental radiography must not be carried out at X-ray tube voltages below 50 kilovolts (peak) and should not be carried out at X-ray tube voltages below 60 kilovolts (peak). Dental X-ray equipment should be well maintained and its performance checked routinely. Accurate calibration of the equipment should also be carried out on a regular basis. The quality of radiograms should be monitored routinely, through a Quality Assurance program, to ensure that they satisfy diagnostic requirements with minimal radiation exposure to the patient. The patient must be provided with a shielded apron, for gonad protection, and a thyroid shield, especially during occlusal radiographic examinations of the maxilla. The use of a thyroid shield is especially important in children. The shielded apron and thyroid shield should have a lead equivalence of at least 0.25mmof lead. In panoramic radiography, since the radiation is also not adequate and dual (front and back) lead aprons should be worn. The primary X-ray beam must be collimated to irradiate the minimum area necessary for the examination. The primary X-ray beam should be aligned and the patient's head positioned in such a way that the beam is not directed at the patient's gonads and is not unnecessarily irradiating the patient's body. The fastest film or film-screen combination consistent with the requirements of the examination should be used. The film processing technique should ensure optimum development and should be in accordance with the recommendations given in section 6.1. Sight developing must not be done. Dental X-ray films must be examined with a viewbox specifically designed for this purpose. While recommended dose limits have been defined for radiation workers and the general population, no specific permissible levels have been recommended, to date, for patients undergoing diagnostic radiographic procedures. For patients, the risk involved in the radiographic examination must always be weighed against the requirement for accurate diagnosis. Information from the Dental Exposure Normalization Technique (D.E.N.T.) program is used to provide realistic sets of limits. These recommended upper and lower limits are presented in Table 4. Any patient skin dose greater than the upper limit presented is an indication of poor film processing techniques or substandard equipment performance. The lower limits indicate the point where any gain in dose reduction may be reflected by a loss of diagnostic quality of the film. http://www.hc-sc.gc.ca/hecs-sesc/ccrpb/publication/99ehd177/chapter9.htm

2. 11 years child has a class II division I malocclusion; he is a thumb sucker; discuss the causes and how you would manage the case 3. Woman has been wearing an excellent upper denture for sometimes. She has lost all of the lower molars but the anterior teeth are still present. What are the important considerations that you would discuss with the patient in order to accept a lower partial denture? 4. A woman comes to you and you find that she is on Tricyclic Anti-depression medication. How would you manage this patient? Has been answered before

Unknown Date:
1. Patient in dental surgery got unconscious, breathless and decrease of pulse rate; how would you manage this condition and what is your diagnosis? The unconsciousness is caused by Cerebral Hypoxia, my diagnosis is Syncope and/ or Physical Shock. The management, Lower head slightly and elevate legs and arms / for pregnant women, roll on left side/ Administer Oxygen at 10L flow/minute Administer spirits of ammonia Apply cold compresses to forehead Keep monitoring and recording vital signs To manage the slow pulse, Administer 0.4 mg atropine IV to increase heart rate Repeat up to 1.2 mg, then consider use of additional vasopressors /epinephrine 0.3-0.5 mg SC or IM, IV with ACLS training/ If there is no pulse start CPR and treat as Cardiac arrest accordingly. 2. 8 years old patient shows with small occlusal carious lesions on 46, what is your management? 3. 20 years old patient comes with a fracture in the middle third of the root of 21, what sort of management you would suggest? 4. 46 years old attends your clinic complaining of pain in TMJ area with clicking during the opening of his mouth; how would you manage this case? 5. 30 years patient attends your clinic seeking a bleaching to his teeth after he has read about a new way of getting white teeth in a magazine; what would you do?

Emergency Treatments Unconsciousness

1. Lower the head slightly and elevate legs and arms ( for pregnant women, roll on left side) 2. Administer O2 at 10L. Flow/min 3. Administer spirits of ammonia 4. Apply cold compresses to forehead 5. Monitor and record vital signs 6. Reassure patient - in case of low blood pressure, a. Lower head and raise arms and legs b. Start 5% dextrose and lactated Ringers IV c. Administer vasopressor drug (epinephrine 0.3-0.5 mg SC or IM, IV with ACLS training - Slow Pulse less than 60 beats per minute: a. Administer 0.4 mg atropine IV to increase the heart rate b. Repeat up to 1.2 mg, then consider use of additional vasopressors

Cardiac Arrest
1. Airway- lift chin, clear airway if necessary, and observe for breathing 2. Breathing- inflate lungs with mouth to mouth resuscitation, give 2 initial quick breaths, and perform endotracheal intubation and positive pressure Oxygen 3. Circulation- check carotid pulse; if pulse is absent, compress sternum 2 t o3 finger widths above xiphoid process. a. One operator: 15 compressions, 2 inflations-rate of 80 compressions/min b. Two operators:15 compressions, 2 inflations-rate of 80compressions/min -continue resuscitation until spontaneous pulse return 4. Drugs IV- start 5% dextrose lactated ringers with ( ACLS training) a. Epinephrine 0.5-1.0 ml 1:1000, repeat every 5 minutes prn b. Sodium bicarbonate 1m Eq/kg initially and initial dose every 10 minutes until circulation is restored (or as governed by arterial blood gas measurement) c. Atropine sulfate indicated if pulse is less than 60/min and systolic blood pressure below 90- initial dose of 0.5mg, repeat every 5 minutes but not to exceed 2.0 mg total dose 5. Other drugs used cardiac arrest (with ACLS training) a. Lidocaine (anti-arrhymic agent) b. Calcium chloride (increase in myocardial contractility) c. Morphine sulphate (for pain relief) Monitor and record vital signs, drug administrations, and patient response. Ambulance, emergency room, and medical assistance should be called.

Diabetic coma
1. 2. Place patient in supine position Administer Oxygen

3. If patient is conscious, give patient a high sugar-containing drink as Glucola or orange juice 4. If patient is unconscious, a glucose paste can be applied to the buccal mucosa. A dentist with ACLS training can start an IV 5% dextrose and run IV as fast as possible 5. Monitor and record vital signs 6. Activate EMS system by calling 000 7. Transport patient to emergency room if some improvement is not fairly rapid. And if in doubt treat as an insulin shock. Response to treatment, a. Insulin shock rapid improvement following carbohydrate administration. b. Diabetic coma, no improvement after carbohydrate administration and slow improvement (6-12 hours) after insulin administration.

Acute Adrenal Insufficiency

Conscious, 1. 2. 3. 4. 5. Position patient semi-reclining Monitor and record vital signs Administer Oxygen Administer steroids hydrocortisone 100mg, or dexamethasone 4 mg IV May have to transfer to hospital for lack of fluids

Unconscious 1. 2. 3. 4. 5. 6. 7. 8. Position patient supine Monitor and record vital signs Administer Oxygen Call 000 Reviews patient history Administer steroids hydrocortisone 100mg, or dexamethasone 4 mg IV Administer vasopressor (epinephrine 0.5ml) Rapid transfer of patient to hospital.