NBDE 2 secrets review

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Nbde-2-Secrets-Review

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PHAR 8009 PHARMACOTHERAPEUTICS
General Principles of Pharmacology
1. Which of the following types of chemical bonding is the least likely to be
involved in a drug-receptor interaction?
a. Covalent bonding
b. Hydrogen bonding
c. Electrostatic bonding
d. Van der Wall’s forces
2. A drug which has affinity for a particular receptor but no intrinsic activity is a(n)
a. strong agonist.
b. weak agonist.
c. partial agonist.
d. antagonist.
3. A drug that forms a reversible drug-receptor complex, which consequently is
surmountable is a(n)
a. competitive antagonist.
b. irreversible antagonist.
c. noncompetitive antagonist.
d. mixed agonist-antagonist.
4. The magnitude of response obtained from optimal receptor site occupancy by an
agonist is a reflection of the drug’s
a. potency.
b. efficacy.
c. KD.
d. toxicity.
5. The passage of drug molecules across cell membranes along a concentration
gradient is achieved by
a. active transport.
b. facilitated transport.
c. passive diffusion.
d. pinocytosis.
6. The Therapeutic Index (T.I.) of a drug is defined as:
a. ED50/LD50.
b. LD1/ED99.
c. LD99/ED1.
d. LD50/ED50.
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7. Which of the following is an example of an enteric route of drug administration?
a. Oral
b. Inhalation
c. Subcutaneous
d. Intramuscular
8. The onset of action of a drug is primarily determined by the rate of
a. excretion.
b. absorption.
c. distribution.
d. biotransformation.
9. Which fraction of a drug has the potential to produce the desired pharmacological
effect. The fraction that is
a. free in plasma.
b. excreted by the kidney.
c. detoxified in the liver.
d. bound to plasma protein.
10. The maximal or therapeutic “ceiling” effect of a drug is a reflection of the drug’s
a. toxicity.
b. potency.
c. efficacy.
d. specificity.
11. Each of the following statements is true regarding drug biotransformation except
one?
a. The rate may differ significantly in various animal species.
b. It primarily occurs in the liver microsomal enzyme system.
c. It usually converts a drug to its more lipid-soluble, nonionized form.
d. It generally involves alterations of the chemical structure of the drug.
12. Which of the following best explains why drugs that are highly ionized tend to be
more rapidly excreted than those that are less ionized? The highly ionized drugs
are
a. less lipid soluble.
b. less water soluble.
c. more rapidly metabolized.
d. more extensively bound to tissue.
13. What is the primary determinant of the maximum safe dose of a local anesthetic
agent for a child?
a. Age
b. Weight
c. The procedure to be accomplished
d. The desired degree of pulpal anesthesia
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14. The time required for a 50 percent decline in the plasma concentration of a drug
as the drug is partitioned throughout the body is expressed as the drug’s
a. elimination half-life (t1/2).
b. distribution half-life (t1/2).
c. latency.
d. structural activity relationship (SAR).
15. Exponential or first order kinetics implies that
a. 50 percent of a drug is eliminated from the body per unit time.
b. a constant amount of a drug is eliminated from the body per unit time.
c. 50 percent of the drug is distributed throughout the body per unit time.
d. a constant fraction of a drug is eliminated from the body per unit time.
16. All of the following statements relate to Phase I biortansformation except which
one?
a. In a Phase I reaction a drug is oxidized or reduced
b. In a Phase I reaction a drug undergoes conjugation
c. A Phase I reaction is inducible
d. Hepatic microsomal enzymes are responsible for Phase I reactions
17. Drugs with which of the following characteristics tend to accumulate in higher
concentrations in breast milk?
a. Drugs with a low lipid solubility coefficient
b. Drugs that are highly protein bound
c. Drugs that are weak bases
d. Drugs with a pKa less than 7.0
18. Which of the following statements is correct relative to pharmacokinetic changes
in elderly patients? Age-related physiological changes include
a. decreased gastrointestinal pH.
b. increased splanchnic blood flow.
c. decreased gastrointestinal motility.
d. increased absorptive surface in the GI tract.
19. In the apothecary system 1 grain (gr) is equivalent to
a. 1000 g.
b. 1000 mg.
c. 1/1000 g.
d. 65 mg.
20. In household measures 5 milliliter (ml) is equivalent to
a. 1 teaspoonful (1 tsp).
b. 1 tablespoonful (1 tbs).
c. 15 drops (15 gtt).
d. 1 fluid ounce (1 fl oz)
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21. If you wish a patient to initiate drug therapy immediately after the prescription is
filled, the instruction to the patient should specify that the drug is to be taken
a. prn.
b. stat.
c. qh.
d. qd.
22. The heading of a prescription should include all of the following components
except which one?
a. The name and address of the prescriber and of the patient
b. The phone number of the prescriber
c. The prescriber’s DEA number
d. The age of the patient
23. In the body of a prescription, following the abbreviation “Disp.”, the pharmacist
is instructed to give the patient
a. a specific drug.
b. a specific dosage unit or concentration of the drug.
c. a specific amount (number of tablets, capsules or volume) of the drug.
d. specific instructions about the dosage regimen of the drug.
24. The Food and Drug Act of 1906
a. regulated interstate commerce in drugs.
b. prohibited interstate commerce in drugs that have not been shown to be
safe and effective.
c. regulated labeling and packaging.
d. established standards for strength and purity.
25. The law which collects and conforms most of the diverse laws related to drugs
into one piece of legislation and is further designed to improve the administration
and regulation of manufacturing, distribution, and the dispensing of controlled
substances by providing a “closed” system for the legitimate handlers of these
drugs is the
a. Controlled Substances Act of 1970.
b. 1984 Diversion Control Amendments, a part of the Comprehensive Crime
Control Act.
c. Federal Food, Drug, and Cosmetic Act of 1938.
d. Food and Drug Act of 1906.
26. Every practitioner who administers, prescribes, or dispenses controlled substances
must be registered with the
a. Food and Drug Administration (FDA).
b. Drug Enforcement Administration (DEA).
c. Centers for Disease Control (CDC).
d. National Institutes of Health (NIH).
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27. Drugs which have legal medical uses in the United States, but have a high abuse
potential are
a. Schedule I (C-I) drugs.
b. Schedule II (C-II) drugs.
c. Schedule III (C-III) drugs.
d. Schedule IV (C-IV) drugs.
28. Heroin, opium derivatives, marijuana, and hallucinogents are examples of
a. Schedule I (C-I) drugs.
b. Schedule II (C-II) drugs.
c. Schedule III (C-III) drugs.
d. Schedule IV (C-IV) drugs.
29. All of the following statements are correct about Schedule II (C-II) drugs except
which one?
a. Schedule II (C-II) drugs require a written prescription order.
b. A Schedule II (C-II) prescription order may be refilled.
c. A practitioner may telephone a prescription order to a pharmacist for a
Schedule II (C-II) drug.
d. A Schedule II (C-II) prescription order must include the DEA registration
number of the prescriber.
30. Which of the following statements is correct relative to Schedule III (C-III)
drugs?
a. A Schedule III (C-III) drug prescription order may be refilled, up to five
times within six months after the date of issue, if so authorized by the
prescriber.
b. Oral orders for Schedule III (C-III) drugs must be followed by a written
order within 72 hours.
c. Examples of Schedule III (C-III) drugs include selected opiates (morphine
and congeners, some codeine congeners (oxycodone w/APAP or w/ASA),
methadone, amphetamines, and some barbiturates.
d. A Schedule III (C-III) drug prescription order must be limited to the
amount of a drug needed to treat a patient during an emergency period.
Local Anesthetics and Analgesics
31. All of the following are algogenic substances that occur naturally in the
environment of nociceptors following acute tissue damage except which one?
a. Histamine
b. Bradykinin
c. Prostaglandin
d. Adenosine triphosphate
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32. Which of the following is a neuropeptide found in synaptic vesicles of nerve
fibers involved in pain perception and is considered to be the neurotransmitter
specific for pain?
a. Adenosine
b. Prostaglandin
c. Serotonin
d. Substance P
33. All of the following statements are correct relative to pain perception associated
with the neotrigeminothalamic tract except which one? The neotrigeminothalamic
tract
a. is composed of long A-delta fibers that connect directly to the thalamus
where they synapse with fibers that project to the primary somatosensory
cortex.
b. delivers information rapidly and permits the perception of the site,
intensity, and duration of the injuring stimulus.
c. provokes suprasegmental reflexes that modulate ventilation, endocrine
function, and circulation.
d. delivers impulses that give rise to the perception of sharp, well-localized
pain and a warning of possible progressive injury.
34. Pain, which arises slowly after injury, and is characterized as burning, aching,
dull, poorly localized, and persistent, is most likely to be due to the activation of
a. A-delta fibers.
b. C fibers.
c. B fibers.
d. A-gamma fibers.
35. Which of the following statements is correct relative to the modulation of
nociception?
a. Segmental reflexes that affect the environment of nociceptive receptors
may amplify nociception.
b. Traumatic injury provokes an efferent motor reflex in the vicinity of tissue
injury and inhibits nociception.
c. Sympathetic reflexes decrease the microcirculation in injured tissue and
inhibit nociception.
d. When tissue damage occurs, simultaneous activity in adjacent large fibers
amplifies small-fiber transmission.
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36. All of the following statements are correct relative to the intrinsic modulation of
nociception, which occurs at peripheral terminals of afferent nerves except which
one?
a. Resident immune cells in inflamed tissue express endogenous ligands,
opioid peptides.
b. In association with painful inflammatory conditions, opioid receptors on
peripheral sensory afferents are unregulated.
c. Environmental stimuli and endogenous substances, such as corticotropinreleasing hormone and cytokines, stimulate the release of opioid peptides
from resident immune cells in inflamed tissue, resulting in local analgesia.
d. Exogenous opioid agonists applied locally cannot activate peripheral
opioid receptors.
37. Severe hypotension may result from toxic blood levels of each of the following
local anesthetic agents except with one?
a. Cocaine
b. Procaine (Novocaine®)
c. Lidocaine (Xylocaine®)
d. Mepivacaine (Carbocaine®)
38. The use of which of the following local anesthetic agents is contraindicated in
patients with a history of allergic reaction to esther-type local anesthetic agents?
a. Lidocaine (Xylocaine®)
b. Mepivacaine (Carbocaine®)
c. Procaine (Novocaine®)
d. Etidocaine (Duranest®)
39. A recently introduced local anesthetic agent is available in 0.5% buffered aqueous
solution. The maximum amount recommended for anesthesia over a 4-hour
period is 30 mg. This amount is contained in how many milliliters of the local
anesthetic?
a. 3
b. 6
c. 12
d. 24
40. Which of the following local anesthetic agents is potentially the most cardiotoxic
agent in current use?
a. Lidocaine (Xylocaine®)
b. Mepivacaine (Carbocaine®)
c. Bupivacaine (Marcaine®)
d. Prilocaine (Citanest®)
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41. After receiving 1.8 cc of a local anesthetic agent, a healthy adult patient became
pale, diaphoretic and experienced a brief episode of syncope. Your most likely
diagnosis would be
a. hyperventilation.
b. vasovagal response.
c. epinephrine-induced sympathetic reaction.
d. toxic reaction.
42. The most serious consequence of systemic local anesthetic toxicity is
a. clonic seizures.
b. increased rate and depth of respiration.
c. tachycardia.
d. central nervous system (cortical and medullary) depression.
43. High doses of circulating adrenergic amines from inadvertent intravascular
injections or potentiation of the release of endogenous catecholamines may elicit
adverse effects in some patients characterized by
a. fear, anxiety, throbbing headache, and chest pain.
b. pallor, diaphoresis, bradycardia, and syncope.
c. urticaria, hypotension, laryngeal edema, and bronchospasm.
d. faintness, tightness in the chest, excessive deep sighs, and panic.
44. The rate and extent of absorption of local anesthetic agents is a function of
a. their inherent chemical characteristics.
b. pKa of the drug.
c. pH at the site of injection.
d. all of the above.
45. Which of the following is true regarding the mechanism of action of local
anesthetics? Local anesthetic agents
a. maintain the nerve membrane in a state of hyperpolarization.
b. prevent the generation of a nerve action potential.
c. maintain the nerve membrane in a state of depolarization.
d. prevent increased permeability of the nerve membrane to potassium ions.
46. At a pH of 7.4, lidocaine (Xylocaine®), which has a pKa of 7.8, will exist
a. primarily (> 90 %) in the ionized form.
b. primarily (> 90 %) in the unionized form.
c. in an equal mixture of the ionized and nonionized forms.
d. in approximately 25 % unionized form.
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47. If the toxic dose of mepivacaine (Carbocaine®) for a given patient is 300 mg,
how many milliliters of 3% mepivacaine may be administered without producing
toxicity?
a. 5
b. 10
c. 15
d. 20
48. Cardiovascular collapse elicited by the high plasma level of a local anesthetic is
most likely causes by
a. syncope.
b. vagal stimulation.
c. histamine release.
d. myocardial depression.
49. Which of the following may not be attributed to the physiological effect of
epinephrine?
a. Cardiac arrhythmias
b. Bronchiolar constriction
c. A rise in blood pressure
d. Restlessness and anxiety
50. The use of which of the following local anesthetic agents may be the most
problematic in the management of children, the mentally retarded, or otherwise
debilitated patients who may self-inflict injuries on anesthetized regions of the
body?
a. Procaine (Novocaine®)
b. Lidocaine (Xylocaine®)
c. Mepivacaine (Carbocaine®)
d. Bupivacaine (Marcaine®)
51. Local anesthetic agents block nerve conduction by
a. reducing the permeability of nerve membrane to potassium.
b. increasing the permeability of nerve membrane to chloride.
c. increasing the permeability of nerve membrane to calcium.
d. reducing the permeability of nerve membrane to sodium.
52. Most allergic reactions to local anesthetic agents are the result of
a. Type I reactions or anaphylaxis.
b. Type II or cytotoxic reactions.
c. Type IV or delayed hypersensitivity reactions.
d. Type III or Arthus reactions.
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53. Local anesthetic agents are converted to their salts with hydrochloric acid for
clinical use because the latter are
a. less toxic and have greater efficacy.
b. more stable and have greater water solubility.
c. more stable and have greater lipid solubility.
d. more potent and cause less local tissue damage.
54. Cyclooxygenase inhibitors block the synthesis of prostaglandins, which are
known to produce all of the following physiological events except which one?
Prostaglandins
a. produce vasodilation and increase vascular permeability.
b. modulate the inflammatory response and body temperature.
c. increase nociception.
d. activate platelet receptors.
55. All of the following statements are correct about the metabolism and excretion of
cyclooxygenase inhibitors except which one?
a. The metabolism of traditional therapeutic doses normally follows firstorder kinetics.
b. After larger than the traditional therapeutic doses, the enzymes responsible
for their metabolism become saturated, and their half-lives increase
significantly.
c. Their metabolites are excreted primarily by the liver.
d. In therapeutic concentrations, they have dose-dependent half-lives that
vary from 2 to 12 hours.
56. Which of the following analgesics should be used with caution in patients with
severe hepatic disease, vitamin K deficiency, during treatment with
anticoagulants, and in patients with hemophilia because severe hemorrhage may
result?
a. Codeine
b. Acetaminophen (Tylenol®)
c. Acetylsalicylic acid (Aspirin®)
d. Tramadol (Ultram®)
57. Cyclooxygenase (COX)-1 inhibitors impair platelet adhesion and aggregation
primarily by inhibiting the synthesis of
a. thromboxane A2.
b. prostacyclines.
c. prostaglandins.
d. leukotrienes.
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58. Intolerance to all of the following drugs may be confirmed by a history of
generalized urticaria, angioedema, bronchospasm, or severe rhinorrhea, occurring
within 3 hours following drug administrations except to which one?
a. COX-1 inhibitors
b. COX-2 inhibitors
c. ASA
d. Opioids
59. Which of the following agents is a weak inhibitor of peripheral prostaglandin
synthesis, although it does appear to be a more effective COX-3 inhibitor in the
CNS?
a. Acetylsalicylic acid (Anacin®)
b. Acetaminophen (Tylenol®)
c. Ibuprofen (Motrin®)
d. Tramadol (Ultram®)
60. All of the following statements are correct regarding acetaminophen (Tylenol®)
except which one? Acetaminophen
a. has a significant antipyretic property.
b. is available in combination with oxycodone.
c. is not cross-allergenic with ASA.
d. has a therapeutically significant anti-inflammatory property.
61. All of the following are adverse effects attributable to opioids except which one?
a. Respiratory depression
b. Emesis
c. Constipation
d. Midriasis
62. Which of the following drugs is an opioid antagonist, which may be used to
reverse apnea and coma due to opioid toxicity?
a. Pentazocine (Talwin®)
b. Rofecoxib (Vioxx®)
c. Naloxone (Narcan®)
d. Methadone (Dolophine®)
63. Which of the following are pathognomonic signs of opioid overdose?
a. Miosis, respiratory depression, and coma.
b. Nausea, vomiting, diarrhea, anorexia, abdominal pain, hepatic necrosis,
and hepatic coma.
c. Tinnitus, dizziness, sweating, hyperventilation, dehydration, and
hyperthermia.
d. Restlessness, incoherent speech, delirium, convulsions, and coma.
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64. Vigorous supportive therapy for acetaminophen overdose include
a. induction of vomiting with syrup of ipecac.
b. the administration of activated charcoal and gastric lavage.
c. the administration of N-actylcysteine (Mucomyst).
d. all of the above.
65. Pain threshold refers to
a. the highest level of pain a patient will tolerate.
b. the average level of pain a patient will experience.
c. the lowest level of pain a patient will detect.
d. none of the above.
66. Each of the following methods can be used to control pain except which one?
a. Cortical depression
b. Raising the pain threshold
c. Blocking the sensory pathway
d. Depression of the autonomic nervous system
67. Injection of a local anesthetic agent into an inflamed area usually produces less
than optimal results. Which of the following best explains why?
a. Prostaglandins have stabilized the nerve membrane.
b. Inflammation reduces the availability of the free base.
c. The drug is absorbed more rapidly because of increased blood supply.
d. The chemical mediators of inflammation produce chemical antagonism to
the anesthetic agent.
68. Which of the following is the major reason for adding a vasoconstrictor to local
anesthetic formulations?
a. To decrease bleeding
b. To reduce systemic toxicity
c. To enhance the onset of action
d. To prolong the duration of anesthesia
69. Of the following local anesthetic agents, which one has significant intrinsic
vasoconstrictive properties?
a. Cocaine
b. Procaine (Novocaine®
c. Lidocaine (Xylocaine®)
d. Bupivacaine (Marcaine®)
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70. A patient placed an aspirin directly in the mandibular facial vestibule. Shortly
afterward, a well-circumscribed white, edematous patch with subsequent
desquamation appeared on the vestibular mucosa. What is your most likely
diagnosis?
a. Intolerance
b. Local toxicity
c. Allergic reaction
d. Anti-thrombotic effect
71. Cyclooxygenase (COX)-1 inhibitors should be used with caution in patients
a. taking anticoagulants.
b. with hepatic disease.
c. with hemophilia.
d. All of the above
72. The analgesic activity of morphine, which (as a function of dose) is accompanied
by respiratory depression and euphoria, is mediated primarily through its
influence on which of the following opioid receptor subtype?
a. Mu (OP3)
b. Kappa (OP1)
c. Delta (OP2)
d. Opioid-receptor-like (OP4)
73. Nausea and vomiting that are associated with the administration of opioid
analgesics is the result of direct stimulation of the
a. limbic system.
b. vomiting center.
c. chemoreceptor trigger zone.
d. opioid receptors in the G.I. tract.
74. When administered orally, which of the following opiods is considered to have
the highest dependence liability?
a. Codeine
b. Oxycodone
c. Propoxyphene
d. Pentazocine
75. Each of the following side effects can occur as a result of systemic absorption of
lidocaine except which one?
a. Increased gastric motility
b. Tonic-clonic convulsions
c. Decreased cardiac output
d. Respiratory depression
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76. A patient has a history of significant cardiovascular impairment. Based on the
functional capacity of the patient the maximum safe dose of epinephrine for this
patient is 0.04 mg. All of the following formulations represent the maximum safe
dose of a 2 % local anesthetic agent with epinephrine except which one?
a. 1 cc with epinephrine 1:50,000
b. 2 cc with epinephrine 1:50,000
c. 4 cc with epinephrine 1:100,000
d. 8 cc with epinephrine 1:200,000
77. The only available local anesthetic agent with a thiophene nucleus is
a. procaine (Novocaine®).
b. articaine (Ultracaine®).
c. lidocaine (Xylocaine®).
d. mepivacaine (Carbocaine®.
78. Allergic reactions to local anesthetic agents and analgesics are caused by
a. rapid absorption.
b. slow detoxification.
c. antigen-antibody reactions.
d. improper administration techniques.
79. Therapy with low dose ASA prevents the formation of thromboemboli by
preferentially inhibiting which of the following?
a. Phospholipase A2 synthesis in blood vessel walls
b. Prostacyclin synthesis in blood vessel walls
c. Thromboxane A2 synthesis in platelets
d. Vitamin K synthetesis in the liver
Antimicrobial Agents
80. Unless the patient has an allergy to beta-lactams, the empirical drug of choice for
the treatment of an uncomplicated odontogenic infection is
a. amoxicillin.
b. penicillin V.
c. amoxicillin with clavulanic acid.
d. cephalexin.
81. Which of the following pharmacological properties is not characteristic of
penicillin V?
a. Good activity against most facultative Gram(+) cocci.
b. Good activity against most Gram(-) oral anaerobes.
c. Beta-lactamase resistance.
d. Formulated for oral administration.
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82. Which of the following macrolids has an extended spectrum against facultative
and some obligate anaerobes and a twice a day dosage schedule?
a. Clarithromycin
b. Dirithromycin
c. Erythromycin
d. Azithromycin
83. Which of the following conditions is not an indication to empirically prescribe
clindamycin?
a. Unresolved odontogenic infection following treatment with penicillin V.
b. The treatment of a complicated odontogenic infection.
c. History of allergy to beta-lactam antibiotics.
d. If significant improvement is not noted with penicillin V in 48 to 72 hours.
84. Which of the following statements is applicable to penicillin V? Penicillin V
a. inhibits bacterial cell wall synthesis.
b. activates bacterial autolytic enzymes.
c. is destroyed in the acidic environment of the stomach.
d. Has few toxic effects.
85. Which of the following antibacterial agents is an inhibitor of nucleic acid
synthesis, is beta-lactamase resistant, has good activity against oral facultative and
obligate anaerobes, and has an oral formulation?
a. Metronidazole
b. Vancomycin
c. Sulfonamides and trimethoprim
d. Chloramphenicol
86. Which of the following antibacterial agents does not target bacterial enzymes that
synthesize protein from the mRNA code?
a. Macrolids
b. Lincosamides
c. Tetracyclines
d. Vancomycin
87. Which of the following antibacterial agents would be the most effective as the
empirical drug of choice for the treatment of an uncomplicated odontogenic
infection in an otherwise healthy patient who is allergic (anaphylaxis ) to betalactam antibiotics?
a. A macrolid
b. A cephalosporin
c. Clindamycin
d. Chloramphenicol
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88. When a patient presents with a severe odontogenic infection, the empirical
antibacterial drug of choice would be
a. Metronidazole
b. Vancomycin
c. Clindamycin
d. Azithromycin
89. The combination antibacterial agent trimethoprim/sulfamethoxazole
a. sequentially blocks the folate pathway, produces synergism, and is
bactericidal.
b. inhibits specific receptors on 50S ribosomal subunits and is bacteriostatic.
c. binds to 30S ribosomal subunits and blocks the formation of the 70S
initiation complex and is bacteriocidal.
d. Alters the conformation of bacterial DNA and is bactericidal.
90. Microorganisms responsible for odontogenic infections (pulpal, periodontal,
pericoronal) are primarily
a. Gram-positive facultative organisms accompanied by Gram-negative strict
anaerobes.
b. Gram-positive aerobes cocci accompanied by Gram-negative aerobic
bacilli.
c. Gram-negative aerobic bacilli accompanied by Gram-positive anaerobic
bacilli.
d. Gram-positive strict anaerobes accompanied by Gram-negative aerobic
bacilli.
91. All of the following antibacterial agents are bactericidal except which one?
a. Penicillins
b. Cephalosporins
c. Lincosamides
d. Vancomycin
92. All of the following antibacterial agents are bacteriostatic except which one?
a. Macrolids
b. Metronidazole
c. Tetracyclines
d. Chloramphenicol
93. Which of the following bactericidal antibacterial agents is effective against
obligate Gram-negative anaerobes and is beta-lactamase resistant?
a. Penicillin V
b. Amoxicillin
c. Metronidazole
d. Cephalexin
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94. Which of the following beta-lactam antibacterial agents is effective against Grampositive and Gram-negative organisms and is mostly beta-lactamase resistant?
a. Penicillin G
b. Penicillin V
c. Amoxicillin w/clavulanate
d. Cephadrine
95. Based on their metabolic characteristics, bacteria may be classified as
a. cocci or bacilli.
b. Gram-positive or Gram-negative
c. aerobic, anaerobic, or facultative.
d. bactericidal or bacteriostatic.
96. All of the following statements are true in regard to the strategies for the medical
management of odontogenic infections EXCEPT which one?
a. The history and clinical characteristics of odontogenic infections provide
reliable data upon which empirical antibacterial chemotherapy may be
initiated.
b. Gram-positive facultative and Gram-negative strict anaerobes predominate
in all types of odontogenic infections.
c. The drug of choice should be the least toxic alternative among several
available alternatives.
d. The drug of choice should be the one with the broadest spectrum among
several available alternatives.
97. All of the following statements are true relative to issues to be considered in the
treatment of uncomplicated odontogenic infection, EXCEPT which one?
a. Penicillin V has good activity against most facultative Gram-positive
cocci and strict oral anaerobes.
b. The synthesis of β-lactamase by facultative Gram-positive cocci and strict
anaerobes is common.
c. The prescribing of penicillin V, based on statistical evidence of the
identity of offending microorganisms, eliminates the need for follow-up in
48 to 72 hours.
d. Penicillin V is a narrow-spectrum β-lactam antibacterial agent.
98. When treating an uncomplicated odontogenic infection with penicillin V and
significant improvement is not noted within 48 to 72 hours, the empirical addition
of ____________ is reasonable.
a. clindamycin
b. metronidazole
c. azithromycin
d. clarithromycin
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99. When a patient presents with an unresolved odontogenic infection following
treatment with a full course of a β-lactam agent, the administration
of____________, a β-lactamase resistant drug should be considered.
a. clindamycin
b. erythromycin
c. azithromycin
d. clarithromycin
100. The initial empirical drug of choice for the treatment of a severe
odontogenic infection is
a. metronidazole.
b. amoxicillin
c. clindamycin
d. azithromycin
101. Many oral Gram-negative anaerobes appear to be inherently resistant to
erythromycin (a macrolide) because the structure of the outer bacterial cell
membrane restricts entry of the drug. This drug resistance is an example of
a. acquired drug resistance.
b. natural or intrinsic drug resistance.
c. mutational drug resistance.
d. biofilm-related drug resistance.
102. All of the following statements are true about mutational drug resistance
EXCEPT which one? Mutational drug resistance
a. requires an initial exposure to the antibacterial agent.
b. has been related to the synthesis of β-lactamases.
c. has been related to changes in proteins associated with cell membrane
permeability and porins affecting the uptake of β-lactams.
d. has been related to modification of penicillin-binding-proteins, which
preclude the β-lactams to interact with their receptors.
103. An acquired form of drug resistance associated with the process whereby
competent bacteria acquire segments of free DNA released by dead bacteria
carrying the resistance strait to an antibacterial agent is called
a. transformation.
b. transduction.
c. conjugation.
d. transposition.

104. The transfer of plasmid DNA by direct cell-to-cell contact between the
donor and recipient microorganism takes place by
a. transposition.
b. conjugation.
c. transposons.
d. transduction.
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105. Certain bacteria block ribosomal receptor sites, a mechanism responsible
for macrolide resistance, and because macrolid-related microsomal receptor sites
overlap with the receptor sites for another antibacterial agent, these bacteria will
also be resistant to
a. penicillin V.
b. clindamycin.
c. metronidazole
d. tetracyclines.
106. Certain bacteria may develop macrolide resistance by activating efflux
pumps. These activated efflux pumps can also affect the intracellular
concentration of
a. clindamycin.
b. metronidazole.
c. β-lactams.
d. β-lactamases.
e. c and d.
107. All of the following statements are true in regard to biofilms EXCEPT
which one?
a. Once in a biofilm, bacteria appear to be 1000-fold more resistant to
antibacterial agents than when they are in their planktonic form.
b. Planktonic bacteria are recruited into the ecosystem of a biofilm by
quantum sensing.
c. Antibacterial agents fail to penetrate beyond the surface layers of the
biofilm
d. In zones of nutrient depletion or waste product accumulation within the
biofilm, antibiotic action may be amplified.
108. All of the following statements are true in regard to resistance and its
clinical relevance EXCEPT which one?
a. With each dose of an antibacterial agent, the fraction of resistant bacteria
in the individual, and potentially in the community, increases.
b. With prolonged antibacterial chemotherapy there is a risk of destroying
the normal flora.
c. Following antibacterial chemotherapy, the resistant flora tends to maintain
a survival advantage.
d. The resistant flora must allocate energy to maintain resistance trait.
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109. The antiviral agents amantadine (Symmetrel®) and rimantadine
(Flumadine®)), which are effective in the management of influenza A, exert their
antiviral effect by
a. inhibiting transmembrane M2 protein essential for uncoating the virus, a
step essential for viral penetration into a host cell.
b. inhibiting neuraminidase, an ezyme essential for mucoprotein breakdown,
a step essential for the release of the virus from an infected cell.
c. preventing the cleavage of protein precursors essential for viral
maturation, infection of new cells, and replication.
d. inhibiting DNA polymerase, as nucleoside analogs, and by inhibiting viral
reverse transcriptase, they prevent the formation of viral DNA or RNA
copies by infected cells.
110. The antiviral agents zanamivir (Relenza®) and oseltamivir (Tamiflu®),
which are effective in the management of influenza A and B, are
a. nucleotide analogs, which inhibit reverse transcriptase and slow or prevent
the formation of viral DNA or RNA copies by infected cells.
b. nonnucleotide analogs, which inhibit reverse transcriptase and slow or
prevent the formation of viral DNA or RNA copies by infected cells.
c. neuraminidase inhibitors, which inhibit mucoprotein breakdown and the
release of the virus from infected cells.
d. Nucleoside analogs, which inhibit viral DNA polymerase, inhibit viral
reverse transcriptase and slow or prevent the formation of viral DNA or
RNA copies by infected cells.
111. All of the following statements are correct about nucleotide or nucleotide
analogs EXCEPT which one?
a. Nucleotides are phosphorilated nucleosides.
b. Nucleotide analogs inhibit viral reverse transcriptase and slow or prevent
the formation of viral DNA or RNA copies by the infected cell.
c. Nucleotides consist of purine or pyrimidine bases joined to a ribose or
deoxyribose sugar.
d. Nucleotides are the basic structural units of DNA or RNA.
112. All of the following are categories of antiviral agents prescribed in the
management of HIV infection EXCEPT which one?
a. Protease inhibitors
b. Neuraminidase inhibitors
c. Nucleoside reverse transcriptase inhibitors
d. Nucleotide reverse transcriptase inhibitors
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113. Which of the following drugs is considered a prodrug, which after oral
administration is metabolized to acyclovir, a nucleside analog, and is effective in
treating HSV infections?
a. Trifluridine (Viroptic®)
b. Foscarnet (Foscavir®)
c. Valacyclovir (Valtrex®)
d. Famciclovir (Famvir®)
114. Which of the following drugs is a phosphorilated derivative of
famciclovir, a nucleoside analog, and may be helpful in treating recurrent herpes
labialis in immunocompetent patients?
a. Penciclovir (Denavir®)
b. Acyclovir (Zovirax®)
c. Docosanol (Abreva®)
d. Valacyclovir (Valtrex®)
115. Which of the following antiviral agents is valuable in treating
immunocompromised patients who are either intolerant to acyclovir or are
infected with an acyclovir-resistant strain of HSV?
a. Valacyclovir (Valtrex®)
b. Foscarnet (Foscavir®)
c. Famciclovir (Famvir®)
d. Trifluridine (Viroptic®)
116. Which of the following antifungal agents is a polyene, which binds to
erosterol in the cell wall of susceptible fungi and alters membrane permeability,
but is to toxic for parenteral administration?
a. Amphotericin B (Fungizone®)
b. Ketoconazole (Nizoral®)
c. Nystatin (Mycostatin®)
d. Flucytosine (Ancobon®)
117. Which of the following antifungal agents is nephrotoxic, but is the drug of
choice for the treatment of severe systemic mycoses?
a. Fluconazole (Dilfucan®)
b. Itraconazole (Sporanex®)
c. Amphotericin B (Fungizone®)
d. Clotrimazole (Mycelex®)
118. All of the following antifungal agents are associated with hepatotoxicity as
their most serious adverse effect EXCEPT which one?
a. Fluconazole (Dilfucan®)
b. Itraconazole (Sporanex®)
c. Nystatin (Mycostatin®)
d. Flucytosine (Ancobon®)
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119. Which of the following antifungal agents is a fluorinated pyrimidine,
which is converted into 5-fluorouradine triphosphate, an inhibitor of DNA
synthesis?
a. Flucytosine (Ancobon®)
b. Fluconazole (Dilfucan®)
c. Itraconazole (Sporanex®)
d. Clotrimazole (Mycelex®)
120. The primary line of treatment of oral candidiasis may include
a. Fluconazole (Dilfucan®) or Itraconazole (Sporanex®)
b. Nystatin (Mycostatin®) or Clotrimazole (Mycelex®)
c. Amphotericin B (Fungizone®) or Flucytosine (Ancobon®)
d. Ketoconazole (Nizoral®) or Fluconazole (Dilfucan®)
Cardiovascular Drugs
121. Which of the following diuretics inhibits both sodium reabsorption and the
secretion of potassium and hydrogen ions in the collecting tubules of the kidneys?
a. Hydrochlorothiazide
b. Triamterene
c. Furosemide
d. Spironolactone
122. Which of the following diuretics is an aldosterone antagonist?
a. Hydrochlorothiazide
b. Triamterene
c. Furosemide
d. Spironolactone
123. All of the following adverse drug effects are attributable to treatment with
a diuretic EXCEPT which one?
a. Xerostomia
b. Dehydration
c. Hypotesion
d. Gingival hyperplasia
124. All of the following conditions are indications for treatment with a diuretic
EXCEPT which one?
a. Edema due to congestive heart failure
b. Hypertension
c. Thromboembolic disorder
d. Hepatic or renal failure
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125. Which of the following drugs is a competitive β1-adrenergic receptorblocking agent?
a. Lisinopril (Zestril®)
b. Metoprolol (Toprol XL®)
c. Losartan (Cozaar®)
d. Pravastatin (Pravachol®)
126. All of the following conditions are appropriate indications for the
administration of a competitive β1-adrenergic receptor blocking agent EXCEPT
which one?
a. Angina pectoris
b. Tachyarrhythmia
c. Acute migraine
d. Hypertension
127. All of the following adverse drug effects may be attributable to
competitive β1-adrenergic receptor blocking agents EXCEPT which one?
a. Bradycardia
b. Tachypnea
c. Heart failure
d. Mental impairment
128. Which of the following drugs may mask hypoglycemia in diabetic
patients?
a. Competitive β1-adrenergic receptor blocking agents
b. ACE inhibitors
c. Calcium channel blocking agents
d. AT2 receptor antagonists
129. Which of the following drugs inhibits the conversion of angiotensin I to
angiotensin II, produces vasodilatation, suppresses aldosterone synthesis, and
potentiates the vasodilatating effects of bradykinins and prostaglandins?
a. Benazepril (Lotensin®)
b. Irbesartan (Avapro®)
c. Diltiazem (Cartia XT®)
d. Spironolactone
130. All of the following adverse drug effects are attributable to treatment with
an ACE inhibitor EXCEPT which one?
a. Dysgeusea
b. Angioedema
c. Masking the signs and symptoms of hypoglycemia
d. Persistent cough
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131. All of the following pharmacological effects are attributable to calcium
channel blocking agents EXCEPT
a. relaxation of vascular smooth muscle.
b. relaxation of the myocardium.
c. increased conduction velocity.
d. increased myocardial oxygen delivery.
132. Adverse drug effects associated with calcium channel blocking agents
include all of the following EXCEPT
a. gingival hyperplasia.
b. hypotension.
c. angina pectoris (coronary steal syndrome).
d. recurrent hypoglycemia.
133. Patients taking a calcium channel blocking agent may have all of the
following medical diagnoses EXCEPT
a. congestive heart failure.
b. angina pectoris.
c. hypertension.
d. supraventricular tachycardia.
134. Which of the following drugs is an α2-adrenergic receptor agonist, which
reduces sympathetic outflow from the nervous system and decreases vascular tone
and heart rate?
a. Doxazosin
b. Clonidine
c. Terazosin
d. Amlopidine (Norvasc®)
135. Competitive α1-adrenergic receptor antagonists are prescribed primarily
for the treatment of
a. angina pectoris.
b. hypertension.
c. congestive heart failure.
d. cardiac arrhythmia.
136. Which of the following drugs is an HMG-CoA reductase inhibitor, a ratelimiting enzyme in the synthesis of VLDL and LDL, and increases the
concentration of HDL?
a. Gemfibrozil
b. Simvastatin (Zocor®)
c. Fenofibrate (Tricor®)
d. Niacin (Niacor®)
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137. All of the following drugs may be effective in the treatment of cardiac
arrhythmias EXCEPT
a. Isosorbide mononitrate
b. Atenolol
c. Nifepidine
d. Digoxin
138. Which of the following drugs inhibits the sodium/potassium ATPase
pump, increasing intracellular calcium ion concentrations and cardiac contractility
(positive inotropic effect)?
a. Atenolol
b. Digoxin (Lanoxin®)
c. Benzapril (Lotensin®)
d. Valsartan (Diovan®)
139. The daily administration of low doses of aspirin interferes with platelet
aggregation by inhibiting the
a. release of ADP from platelet storage granules.
b. synthesis and release of platelet thromboxane A2.
c. activation of fibrinogen.
d. activation of von Willebrand factor.
140. Which of the following agents inhibits platelet aggregation induced by
adenosine diphosphate?
a. Ibuprofen (Motrin®)
b. Clopidogrel (Plavix®)
c. Glycoprotein IIb/IIIa antagonists
d. Acetylsalicylic acid (Aspirin®)
141. Warfarin depresses the production (carboxylation) of inactive proenzymes
of the prothrombin group of coagulation factors, which include all of the
following except factor
a. II.
b. VIII.
c. IX.
d. X.
142. Which of the following agents activates plasma antithrombin III and
inhibits thrombin (factor IIa
) and factor Xa
?
a. Clopidogrel (Plavix®)
b. Glycoprotein IIb/IIIa antagonists
c. Warfarin (Coumadin®)
d. Heparin
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143. After treatment with acetylsalicylic acid is stopped, cyclooxygenase
activity recovers as a function of platelet turnover in about
a. 4 hours.
b. 48 hours.
c. 4 to 7 days.
d. 24 hours.
144. The therapeutic level of warfarin (Coumadin®) is monitored using the
International Normalized Ratio (INR), which requires a determination of the
patient’s
a. bleeding time.
b. partial thromboplastin time (PTT).
c. prothrombin time (PT).
d. platelet count.
145. The anticoagulant therapy of patients with prosthetic heart valves is
optimal when the INR is
a. < 2.
b. between 2 and 3.
c. between 3 and 4.
d. > 4.
146. Before invasive dental procedures, an assessment of the patient’s level of
anticoagulation is imperative to ensure values that may preclude problematic
bleeding yet maintain therapeutic anticoagulation. These goals may be achieved if
on the day of the procedure the patient’s INR is
a. < 2.
b. between 2 and 3.
c. Between 3 and 4.
d. > 4.
147. Which of the following coagulation factors is/are the most sensitive to
heparin-antithrombin III complex inactivation?
a. Factors IIa
(thrombin) and Xa
b. Factors VII and IX
c. Platelet factor 4
d. Platelet factor 3
148. A patient who gives a history of taking potassium chloride (Klor-Con®) is
predictably also taking a(n)
a. calcium channel blocking agent.
b. diuretic.
c. β1-adrenergic receptor antagonist.
d. ACE inhibitor.
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Endocrine and Metabolic Agents
149. All of the following statements are true in relation to the primary
physiological effects of glucocorticosteroids EXCEPT which one?
Glucocorticosteroids
a. regulate cell metabolism at the level of translation and transcription.
b. promote gluconeogenesis.
c. regulate sodium retention in the distal convoluted tubule of the kidney.
d. have pronounced anti-inflammatory effects.
150. All of the following medical conditions may be treated with a
glucocorticosteroid EXCEPT which one?
a. Lymphocytic leukemia
b. Cushing’s disease
c. Asthma
d. Allergic rhinitis
151. All of the following statements are true in regard to estrogen EXCEPT
which one? Estrogen
a. may inhibit the release of gonadotropin-releasing hormone (GnRH) from
the hypothalamus.
b. may reduce the release of LH and FSH from the anterior pituitary.
c. may enhance the release of GnRH during the follicular phase.
d. is an effective chemotherapeutic agent in the treatment of breast
carcinoma.
152. Which of the following hormones competitively binds to estrogen
receptors on certain tumor cells and other target tissues and produces a nuclear
complex that decreases DNA synthesis and inhibits estrogen effects?
a. Tamoxifen (Nolvadex®)
b. Estradiol (Climara®)
c. Conjugated estrogens (Premarin®)
d. Conjugated estrogen/medroxyprogesterone (Prempro®)
153. Which of the following hormones, when taken by a man, may suggest the
medical diagnosis of prostatic carcinoma?
a. Medroxyprogesterone
b. Raloxifen (Evista®)
c. Conjugated estrogen (Premarin®)
d. Methylprednisolone
154. Which of the following oral contraceptive formulations more closely
resemble normal physiological concentrations of progestins?
a. Monophasic
b. Biphasic
c. Triphasic
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155. All of the following statements are true about anabolic steroids EXCEPT
which one? Anabolic steroids
a. are testosterone derivatives.
b. are prescribed primarily for their masculinization effects.
c. may be effective in the treatment of refractory anemia, wasting diseases,
and corticosteroid-induced catabolism.
d. tend to have more “building” effects than androgenic steroids.
156. All of the following statements are true in regard to thyroid hormones
EXCEPT which one? Thyroid hormones
a. act synergistically with epinephrine to enhance gluconeogenesis and
hyperglycemia.
b. enhance tissue sensitivity to cathecolamines possibly by upregulation of
adrenergic receptors.
c. are involved in thermoregulation.
d. in supraphysiological dosages produce myedema.
157. The mechanism of action of which of the following agents, prescribed for
the prevention of osteoporosis, more closely mimics the action of calcitonin?
a. Vitamin D
b. Parathyroid hormone
c. Alendronate (Fosamax®)
d. 1,25-dihydroxycholecaciferal
158. All of the following hormones are associated with a hyperglycemic effect
EXCEPT which one?
a. Prednisone
b. Estrogen
c. Insulin
d. Progesterone
159. All of the following statements are true in regard to oral hypoglycemic
agents EXCEPT which one?
a. Some oral hypoglycemic agents may stimulate insulin release from
pancreatic β-cells.
b. Some oral hypoglycemic agents may increase glucose output from the
liver.
c. Some oral hypoglycemic agents may increase the sensitivity of peripheral
target cells to insulin.
d. Oral hypoglycemic agents may produce weakness, dizziness, hunger,
sweating, tachycardia, tremor, visual disturbances, and altered mentation.
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Respiratory Drugs
160. Obstruction of the respiratory passages may result in
a. stagnant hypoxia.
b. hypoxic hypoxia.
c. anemic hypoxia.
d. histotoxic hypoxia.
161. All of the following statements are true in relation to H1-receptor
antagonists EXCEPT which one? H1-receptor antagonists
a. inhibit histamine-induced vasodilatation.
b. increase capillary permeability.
c. produce xerostomia.
d. are additive with CNS depressants and produce sedation.
162. In the management of reactive airway disease (asthma), the therapeutic
emphasis is on prevention with
a. Sympathomimetic bronchodilators.
b. Leukotriene-receptor antagonists.
c. Anticholinergic agents
d. Inhaled glucocotricosteroids.
163. Which of the following drugs relaxes bronchial smooth muscles by acting
on β2-adrenergic receptors?
a. Albuteral (Albuterol Aerosol®)
b. Montelukast (Singulair®)
c. Fluticasone propionate (Flovent®)
d. Ipratopium (Atrovent®)
164. Which of the following drugs is a selective and competitive leukotrienereceptor antagonist effective in the management of chronic asthma?
a. Albuteral (Albuterol Aerosol®)
b. Montelukast (Singulair®)
c. Salmeterol/fluticasone (Advair Diskus®)
d. Ipratopium/albuterol (Combivent®)
165. The respiratory rate of patients with which of the following diagnosis is
most likely to be modulated by O2 concentrations?
a. Reactive airway disease (asthma)
b. Acute bronchitis
c. Emphysema
d. Allergic rhinitis
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166. Preventive therapy substantially reduces the risk of developing clinically
active tuberculosis following exposure. The current therapeutic regimen is 6 to 12
months of daily
a. Rifampin (Rifadin®).
b. Isoniazid (INH®)
c. Ethambutol (Myambutol®)
d. Ciprofloxacin (Cipro®)
167. For the empirical treatment of immunocompetent patients with pulmonary
and extrapulmonary tuberculosis likely to be caused by susceptible organisms, the
initial drug regimen is with
a. Daily isoniazid (INH®).
b. Daily isoniazid (INH®), rifampin (Rifadin®), and pyrazimanide for two
months.
c. Daily or twice-weekly isoniazid (INH®) and rifampin (Rifadin® for four
months.
d. Daily ethambutol (Myambutol®) or streptomycin.
Gastrointestinal Drugs
168. Nausea and vomiting are induced by the activation of a number of
receptors, which include all of the following EXCEPT which one?
a. Opioid mu receptors.
b. Dopamine (D2) receptors
c. Histamine (H1) receptors
d. Serotonin (5-HT3) receptors
169. Which of the following drugs binds electrostically to positively charged
proteins in ulcerated tissue and retards acidic and proteolytic damage?
a. Ranitidine (Zantac®)
b. Cisapride (Propulsid®)
c. Metoclopromide (Reglan®)
d. Sucralfate (Carafate®)
170. Which of the following drugs is considered to be a prokinetic agent, which
is effective in decreasing the contact time between the gastric acid and the
esophageal tissue and is also an effective entiemetic agent?
a. Metoclopromide (Reglan®)
b. Omeprazole (Prilosec®)
c. Cisapride (Propulsid®)
d. Famotidine (Pepcid®)
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171. Prostaglandin analogs such as misoprostol (Cytotec®) enhance the gastric
mucosa’s resistance to injury by all of the following mechanisms EXCEPT which
one? By
a. maintaining mucosal blood flow.
b. promoting the diffusion of acid back into cells of the epithelial lining.
c. stimulating the secretion of mucus.
d. stimulating the secretion of bicarbonate.
172. The medical management PUD may include all of the following agents
EXCEPT which one?
a. Antibacterial agents
b. H2-receptor antagonists
c. Proton pump inhibitors
d. COX-1 inhibitors
173. Which of the following drugs prescribed for the management of PUD
suppresses gastric acid secretion by inhibiting the parietal cells’ H+/K+ ATPase?
a. Antacids consisting of mixtures of magnesium hydroxide, aluminum
hydroxide, calcium carbonate, and sodium bicarbonate compounds.
b. Bismouth subsalycilate (Pepto-Bismol®)
c. Lansoprazole (Prevacid®)
d. Metronidazole (Flagyl®)
174. The medical management of patients with constipation may include the
administration of an agent from any of the following major classes of drugs
EXEPT which one?
a. Bulk forming agents
b. Anticholinergic agents
c. Irritants
d. Lubricants
175. Which of the following major classes of drugs prescribed by oral health
care providers is the most likely to cause acute diarrhea?
a. COX-1 inhibitors
b. Opioid analgesics
c. Antibacterial agents
d. Anxiolytic agents
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CNS Pharmacology
176. The net effect of the interaction of benzodiazepines with their receptors is
to enhance the inhibitory properties of the neurotransmitter
a. dopamine.
b. GABA.
c. serotonin.
d. norepinephrine.
177. Which of the following agents is available to reverse the sedative effects
of benzodiazepines after anesthesia, conscious sedation for brief surgical or
diagnostic procedures, or after overdose?
a. Midazolam
b. Clorazepate
c. Flumanezil
d. Triazolam
178. The basic mechanism for all seizures appears to be related to biochemical
lesions that interrupt the synthesis, storage, release, or post-synaptic actions of the
inhibitory neurotransmitter
a. GABA.
b. acetylcholine
c. dopamine.
d. serotonin.
179. Which of the following conditions is considered neurochemically to be a
striatal dopamine deficiency?
a. Depression
b. Parkinson’s disease
c. Mania
d. Psychosis (schizophrenia)
180. Which of the following conditions relates to low concentrations of
norepinephrine, dopamine, and/or serotonin?
a. Depression
b. Mania
c. Psychosis (schizophrenia)
d. Organic brain syndrome
181. Which of the following conditions is characterized by a functional excess
of norepinephrine and serotonin?
a. Psychosis (schizophrenia)
b. Depression
c. Organic brain syndrome
d. Mania
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182. An excess of dopamine and an increase in the number of dopaminergic
receptors in the CNS characterize
a. Parkinson’s disease.
b. mania.
c. psychosis (schizophrenia)
d. organic brain syndrome.
ANS Pharmacology
183. Which of the following drugs may be used for the treatment of myasthenia
gravis, and lead to excessive salivation, miosis, hypotension, bradycardia, and
bronchospasm?
a. Anticholinesterases
b. Cholinergic (muscarinic)-receptor antagonists
c. Ganglionic (nicotinic)-receptor blocking agents
d. Neuromuscular (nicotinic)-receptor blocking agents
184. Which of the following conditions respond to treatment with cholinergic
(muscarinic)-receptor agonists?
a. Atony of the GI tract
b. Atony of the bladder
c. Glaucoma
d. All of the above
185. Which of the following drugs may be used to decrease gastric motility to
control diarrhea, to produce mydriasis, to inhibit excessive secretions, or to reduce
excessive side effects of anticholinesterases?
a. Cholinergic (muscarinic)-receptor antagonists
b. Ganglionic (nicotinic)-receptor blocking agents
c. Neuromuscular (nicotinic)-receptor blocking agents
d. All of the above
186. Which of the following agents may be used to facilitate tracheal intubation
and to obtain relaxation of skeletal smooth muscles for gastrointestinal and
orthopedic procedures?
a. Cholinergic (muscarinic)-receptor antagonists
b. Ganglionic (nicotinic)-receptor blocking agents
c. Neuromuscular (nicotinic)-receptor blocking agents
d. Cholinergic (muscarinic)-receptor agonists
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187. With an overdose of a cholinergic drug, one would expect to see each of
the following signs EXCEPT which one?
a. Sweating
b. Mydriasis
c. Bradycardia
d. Copious serous saliva
Cancer Chemotherapeutic Agents
188. Which of the following therapeutic interventions is the most effective in
the treatment of disseminated cancer?
a. Surgery
b. Chemotherapy
c. Radiotherapy
d. All of the above
189. In the S phase of the cell cycle
a. RNA and other proteins are synthesized in preparation for mitosis.
b. DNA is synthesized.
c. RNA and other proteins are synthesized.
d. All biochemical activities are performed except those related to cell
reproduction.
190. Which of the following cancer chemotherapeutic agents are purine,
pyrimidine, or folic acid analogs and, which become incorporated into DNA
where they may prevent the synthesis of nucleotides or may be phosphorilated to
nucleotides and result in faulty transcription and translation?
a. Alkylating agents
b. Antibiotics
c. Plant alkaloids
d. Antimetabolites
191. Which of the following cancer chemotherapeutic agents interact with
tubulin, disorganize the mitotic spindle and arrest cell division?
a. Steroid hormones
b. L-asparaginase
c. Plant alkaloids
d. Alkylating agents
192. Which of the following cancer chemotherapeutic agents bind covalently to
double stranded DNA and prevent DNA transcription?
a. Antibiotic anticancer drugs
b. Alkylating agents
c. Hormonal anticancer drugs
d. Antimetabolites
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193. Which of the following anticancer drugs are isolated from the fungal
species Streptomyces?
a. Specific metabolic inhibitors such as mitotane.
b. Antibiotic anticancer drugs
c. Antimetabolites
d. Alkylating agents
Adverse Drug Effects
194. All of the following adverse drug events are associated with the
administration of therapeutic dosages of a drug, are predictable, and are,
consequently, preventable EXCEPT which one?
a. Cytotoxic reactions
b. Idiosyncratic reactions
c. Drug-drug interactions
d. Drug-food interactions
195. All of the following adverse drug events are generally independent of the
dose and are rarely predictable or avoidable EXCEPT which one?
a. Immunologic/allergic reactions
b. Pseudoallergic reactions
c. Cytotoxic reactions
d. Teratogenic reactions
196. All of the following mechanisms are considered to be pharmacodynamic
drug-drug interactions EXCEPT which one?
a. Pharmacological interactions
b. Cytotoxic reactions
c. Drug-related receptor alterations
d. Physiological interactions
197. When drug A competes for plasma protein-binding sites with drug B, the
interaction will FIRST affect
a. drug absorption.
b. drug distribution
c. drug metabolism
d. drug excretion.
198. Genetic polymorphism of cytochrome P450 enzyme activity is considered
to be the primary factor responsible for
a. drug-food interactions.
b. drug-disease interactions.
c. idiosyncratic reactions.
d. allergic reactions.
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199. Which of the following allergic reactions is associated with IgE antibodies
fixed in tissue, mainly mast cells?
a. Immediate hypersensitivity reactions
b. Delayed hypersensitivity reactions
c. Cytotoxic hypersensitivity reactions
d. Local immune-complex reactions
200. When a drug is converted to reactive metabolites capable of covalent
binding to DNA, it may produce
a. a pseudoallergic reaction.
b. a developmental effect
c. an oncogenic effect
d. an idiosyncratic reaction.
1
Mock Endo National Board Questions
1. To ensure better thermal and protective insulation of the pulp during a capping procedure, calcium
hydroxide should be:
A. Applied to a thickness of 3.0 mm.
B. Placed in all cavity preparations.
C. Covered with a stronger base.
D. Preceded by application of a cavity varnish.
E. Preceded by application of a zinc phosphate cement.

2. In shaping and cleansing the canal of a vital maxillary central incisor, a practitioner has inadvertently
perforated the apical foramen. This error can result in each of the following EXCEPT one. Which one is
this EXCEPTION?
A. Pain to the patient
B. Enlargement of the foramen
C. Trauma to the apical tissue
D. Necrotic tissue being forced into the apical tissues

3. A dentist restored an endodontically treated tooth with a case post-and-core and a metal ceramic
crown. Three months later, the patient calls and complains of pain, especially on biting. Tooth
mobility is normal, as are the radiographs. The most probable cause of pain is:

A. A loose crown.
B. Psychosomatic
C. A vertical root fracture.
D. A premature eccentric contact.
4. Calcium hydroxide is generally the material-of-choice in vital pulp capping because it:
A. Is less irritating to the pulp.
B. Encourages dentin bridge formation.
C. Seals the cavity better than most other materials.
5. The ideal bone graft should do each of the following EXCEPT one. Which one is this EXCEPTION?
A. Induce osteogenesis
B. Withstand mechanical forces
C. Produce an immunologic response
D. Become replaced by host bone.
2
6. During the preparation of a Class II cavity, which of the following permanent teeth pulp horns will be
the most subject to accidental exposure?
A. Distofacial of a maxillary first molar
B. Distofacial of a mandibular first molar
C. Facial of a mandibular first premolar
D. Lingual of a mandibular first premolar

7. A diagnostic test failed to identify five cases of true disease. This type of failure is known as a:
A. False negative.
B. False positive.
C. Positive predictive value.
D. Negative predictive value.
8. Which of the following is the most effective way to reduce injury to the pulp during a restorative
procedure?
A. Prepare dentin with slow-speed burs
B. Use anesthetics without vasoconstrictors
C. Minimize dehydration of the dentinal surface
D. Keep the dentinal surface clean by frequent irrigation
9. Aging of the pulp is evidenced by an increase in:
A. Vascularity.
B. Cellular elements.
C. Fibrous elements.
D. Pulp stones.
10. A patient is experiencing a throbbing pain in a specific tooth. This pain is aggravated by heat and
relieved by cold. The tooth is sensitive to percussion. The most likely diagnosis is:
A. Occlusal trauma.
B. Periodontal abscess.
C. Irreversible pulpitis.
D. Hyperemia of the pulp.
11. Which of the following is the most consistent finding in systemic infections?
A. Fever
B. Tachypnea
C. Lymphadenopathy
D. Abscess formation
E. Cellulitis formation
3
12. When providing endodontic treatment for a patient who has a history of rheumatic heart disease, the
dentist should especially avoid which of the following?
A. Underinstrumentation of a vital tooth
B. Overinstrumentation of a vital tooth
C. Underinstrumentation of a necrotic tooth
D. Overinstrumentation of a necrotic tooth
13. The day after receiving an inferior alveolar nerve block, a patient experiences limited ability to open his
mouth. Which of the following structures was most probably injured?
A. The medial pterygoid muscle
B. The stylomandibular ligament
C. The deep fibers of the masseter muscle
D. The posterior belly of the digastric muscle
E. The inferior head of the lateral pterygoid muscle
14. An endodontic instrument separated in the apical third of a root canal. The fragment is 3 mm long and is
tightly lodged. No radiographic changes at the apex are evident. The practitioner should:
A. Extract the tooth.
B. Resect the apical section of the root containing the broken instrument.
C. Perform an apicoectomy and place a reverse filling.
D. Complete the root canal filling to the level of the instrument and observe.
15. A new patient had root canal therapy performed seven months ago in another country. No historical
radiographs are available. The root canal filling appears to be satisfactory, the tooth is asymptomatic,
and there is no associated sinus tract. However, a small periapical radiolucency is evident. Which of the
following is indicated?
A. Incision and drainage
B. Nonsurgical retreatment
C. Re-evaluation in six months
D. Apicoectomy and apical amalgam
E. Prescription of an appropriate antibiotic
16. Which of the following describes the character of dentinal tubules at the pulpal end when compared to
those at the enamel end?
a. More per unit surface area and more wider in diameter.
b. Less per unit surface area but much wider in diameter.
c. More per unit surface area and smaller in diameter.
d. Less per unit surface area and smaller in diameter.
4
17. What would be the end result and prognosis of untreated internal resorption?
a. Perforation into external surface of root which would heal if left undisturbed.
b. Perforation into external surface of root with a marked low prognosis for any treatment.
c. No untoward incident would occur provided no future trauma is sustained.
d. Calcification of the root canal system with a guarded prognosis
18. There usually is no lesion apparent radiographically in acute apical periodontitis. However,
histologically bone destruction has been noted.
a. Both statements are true
b. Both statements are false.
c. First statement is true, second is false.
d. First statement is false, second is true.
19. Based solely on the sharp transient response of pulp to hot stimuli, what is the periradicular diagnosis?
a. Acute apical periodontitis
b. Cannot diagnose based on information provided.
c. Acute Apical abscess
d. Irreversible pulpitis.
20. What is the clinical ‘hallmark’ of a chronic periradicular abscess?
a. Large periradicular lesion
b. Sinus tract drainage
c. Granulation tissue in the periapex.
d. Cyst formation.
21. A periradicular radiolucent lesion of endodontic origin on the radiograph may be any of these
histological diagnoses except one. Mark this exception.
a. A cyst
b. A granuloma
c. An Abscess
d. Dentigerous cyst
22. What complete endodontic diagnosis could be completely asymptomatic but should require endodontic
therapy.
a. Pulpal necrosis and acute periradicular periodontitis
b. Normal pulp and acute periradicular periodontitis.
c. Pulpal necrosis and chronic periradicular periodontitis.
d. Normal pulp and normal periapex
23. Vertical root fractures are also called cracked teeth. The prognosis of cracked teeth varies with extent
and depth of crack.
a. Both statements are true
b. Both statements are false.
c. First statement is true, second is false.
d. First statement is false, second is true.
5
24. A lesion of non-endodontic origin remains at the apex of the suspected tooth regardless of X-ray cone
angulations.
a. True
b. False
25. While viewing a working length radiograph of #5, you discover another root on the mesial shot (x-ray
cone mesial). The second root seems to be distal on the mesial shot. Which anatomic root is it?
a. Palatal
b. Distal
c. Buccal
d. Mesial
26. The X-ray beam usually displaces lingual roots in what direction on the radiograph?
a. Same direction as beam
b. Opposite direction of beam
c. Does not displace Buccal roots
d. Vertically.
27. The buccal object rule can be used for vertical angulations as well.
a. True
b. False
Endodontic case
Patient walks into your dental office for an emergency visit. He complains of a throbbing tooth ache since 5
days. He seems to point in the lower right quadrant
28. What do you do first?
a. Clinical examination
b. Take radiographs
c. Medical and dental history
d. Prescribe antibiotics and pain killers
6
29. On clinical and radiographic examination, you find that #31 is non-responsive to thermal and elcetric testing
and also not responsive to percussion or palpation. You observe a radiolucency around the distal root of #31
with extensive secondary decay under a class 2 amalgam. What do you do next?
a. Refer for endodontic therapy of #31
b. Access the tooth yourself for pulpectomy and CaOH dressing.
c. Prescribe antibiotics and pain killers.
d. Look for another site as the cause of the chief complaint.
30. On further investigation, the patient admits to clenching and grinding his teeth during sleep and even at
work when stressed. Further, the patient hurts worse in the mornings when he yawns and also explains that
touching certain areas of the jaw evokes greater pain. What do you do next?
a. Ignore the patient’s comments.
b. Test the ‘areas’ which invoke the pain.
c. Anesthetize the patient
d. Start the root canal therapy.
31. The pain is evoked by palpating along the lateral border of the ramus of the mandible. What is most likely
cause of the patient’s pain and how would you confirm this?
a. Masseter muscle refering pain to the lower molars confirmed by palpation of the muscle.
b. Mylohyoid refering pain to the lower molars confirmed by local anesthesia.
c. Fracture of the ramus confirmed by digital palpation.
d. Psychological confirmed by prescription of anti-depressants.
32. How do you advise the patient?
a. Quit job
b. Try and curb the grinding and use a night guard
c. Regualr use of analgesics
d. Antibiotics for the acute symptoms
33. Does the patient still require endodontic treatment on #31?
a. Yes
b. No
7
o For the radiographs below, mark the location of the Xray tube, the direction of the Xray beam and
buccal-lingual position of the ‘X’box.

A
B
A
B
A
B
1
Behavior Guidance in Dental Office
n Parental input (positive or negative) is by far
the most important predictor of pediatric
patient behavior
n Fear is one of the most frequently
experienced childhood emotion.
n In managing the fearful child, the dentist
should first attempt to determine the degree
of fear and the factors responsible for it.
Common Pediatric Behavior
Management Techniques
n Modeling: The pedo patient views another pedo patient who is cooperative, and
is used as a “model.”
n Tell/Show/Do: The dentist tells the patient what will happen (“I will look at your
teeth with my mirror”), then show the patient the mirror, then does the procedure
(looking at the teeth). Tell/Show/Do is not useful for injections, extractions, etc.
n Wording Choices: Using simple, pleasant words for actions and instruments can
help. The acid etch “taste like lemon juice,” the cotton roll c an be a “tooth
pillow,” the handpiece can be a “water sprayer.” Even the injections can be a
“mosquito bite.” These language choices can reduce fear and anxiety.
n Voice Control: The use of a loud authoritarian voice tone is useful for limitsetting and for stopping dangerous behavior.
n HOME(Hand over Mouth Exercise): May return the patient to a calmer state. The
hand is placed over the mouth, and the patient is told in a stern voice, that the
hand will be removed when the undesirable behavior stops.
The First-Time Dental Patient
n Time of the Appointment: Time may influence the
behavior. Early morning hours are reserved for young
children.
n Length of Appointment: The apprehensive or fearful child
should have relatively short appointments (less than 45
minutes) until the child becomes fully indoctrinated and
gains confidence in himself or herself and the dentist.
n First Visit Procedures: If active pain or infection does not
exist, a first visit is often limited to procedures that are
reasonably comfortable of the child (exam, prophy,
fluoride, x-ray, and possible sealants).
Premedication
n Often useful for long surgical and operative procedures and for fearful,
nervous, and apprehensive children.
n May be indicated for children with behavioral problems
n Ataraxic drugs have proved to be effective in reducing anxiety and tension
without putting the patient in a hypnotic state.
n The drug acts indirectly on the autonomic nervous system by upsetting the
balance of the sympathetic and parasympathetic mechanisms.
n Many dentist have found it effective to prescribe ataraxic drugs the night
before the appointment and repeat the dose 30-45 min. prior to the appt.
n Ataraxic drugs (promethazine-Phenergan, chlorpromazine –Thorazine).
Both are phenothiazine derivatives, and hydroxyzine (Atarax), a cortical
depressant chemically unrelated to most others.
Indications for use of General
Anesthesia
n Children with developmental disability to the
degree that communication is impossible
n Children in whom all other methods have
proven unsuccessful
n Patients allergic to other anesthetics
n Patients who suffer from hemophilia
n Patients with involuntary movement
n Patients with systemic disorders and/or
congenital anomalies
1
Clinical Pedodontics
Cavity Preparation Principles in
Primary Teeth
• In general – Primary teeth preparations are
smaller, more delicate, and more rounded than
their permanent counterparts
• Specifics (Class II preparation)
– Axial-pulpal line angle should be rounded to reduce
the stresses and the buccal and lingual walls should
parallel the external crown outline form of the tooth
– Rounded internal line angles will result in…
• Less concentration of stresses
• Reduced restoration fracture
• Permit more complete condensation of the amalgam
Cavity Preparations (cont.)
• Specifics (Class III preparation)
– Dovetail placed on lingual or labial of prep will
allow for additional retention and necessary
access to insert the restorative material
– Greater strength composite bonding systems
can reduce the need for the mechanical
retention
Cavity Bases and Liners
• Important Points
– Purpose of base prior to condensation is to
provide thermal insulation for the pulp.
– Use of calcium hydroxide influences formation
of secondary dentin.
• Initiates local inflammatory response at site of
contact between pulp and calcium hydroxide
Stainless Steel Crowns
• MOD preparations are difficult on primary first
molars due to small tooth size and loss of tooth
structure. SSC’s are often indicated instead.
• Indications for use:
1) Extensive carious lesions
2) Hypoplastic Teeth
3) Teeth showing dentinogenesis or amelogenesis imperfecta
4) Restoration after pulpotomyin which there is an increased
danger of fracture
5) For crown and loop space maintainer
6) For habit-breaking appliances
7) Restoration of fractured teeth
Indirect Pulp Cap
• Only those teeth with deep caries that are
free of symptoms should be selected.
• Procedure should include:
– Removal of gross caries
– Allowing some caries to remain, if its removal would result in an
exposure
– Calcium hydroxide or zinc oxide eugenol placed and covered by
temporary filling
– Allow process to arrest and secondary dentin to form for 6-8
weeks
– After time has elapsed, remove arrested carious dentin, place
calcium hydroxide if sound dentin found, and restore
conventionally.
2
Pulpotomy
• Indication – coronal pulp shows evidence of
inflammation or degenerative change, but radicular pulp
is still healthy.
• Two common techniques:
1)Calcium hydroxide technique – recommended for permanent
teeth with incomplete root formation. Coronal pulp is removed
and calcium hydroxide is placed. RCT should be completed
once root formation has completed
2)Formocresol technique – recommended for primary teeth with
carious exposure. Coronal pulp is removed, cotton pellet
moistened with formocresol is placed in contact with the pulp
stumps and remains for 5 minutes. Zinc oxide eugenol is placed
over exposure site and the tooth is restored.
*fistulas, PAPs in the furcation, and abscess are contraindications
to both pulpcaps and pulpotomy*
Internal Resorption
• Most frequently seen evidence of
abnormal response to pulpotomy.
• A destructive process believed to be
caused by osteoclastic activity.
• No reason for occurrence
Alveolar Abscess
• Occasionally develop a few months after
pulp therapy has been completed.
• Tooth is asymptomatic.
• Fistulous opening may be present –
indicates chronic infection.
• Will appear as radiolucency
radiographically.
• Primary teeth with evidence of abscess
should be removed.
1
COMMON
PATHOLOGIC LESIONS
&
NBDE II
PATHOLOGY REVIEW
Dr. Parish P. Sedghizadeh
Test Logistics
• 2 days
–Multiple Choice questions (200 a.m. + 200 p.m.)
• Dental and Specialty topics admixed
• Pathology/Radiology questions have
images supplement – quality suboptimal
–Cases with questions (10-13 cases/9-14
questions each ‡ 200 questions a.m. then out)
• Pathology and other specialty questions are
distributed throughout the exam, including the
case section. Also 1-3 histology and 4-8
general pathology questions.
– Diagnosis and Treatment planning emphasis
A
Vesiculo-Ulcerative
Differential Dx:
• Lichen Planus
• Pemphigoid
• Pemphigus
Vulgaris
– May present as: Desquamative
Gingivitis!
– Immune-mediated conditions
– Immunofluorescent studies
———————-‡
2
B
C
3
D E
F G
H I
4
J
K
L
5
6
7
8
1
DISEASES OF THE
TEETH AND JAWS
Enamel Hypoplasia
• Local or systemic factors that interfere with the
normal matrix formation.
• Presents enamel surface defects and irregularities.
• Causes:
• Nutritional deficiency
• Neurologic defects (eg, cerebral palsy)
• Nephrotic disorders
• Allergies
• Local infection and trauma
• X-rays
• Rubella
Dentinogenesis Imperfecta
• Hereditary developmental
disturbance of the dentin in
the absence of any systemic
disorder.
• Similar dental changes may
be seen in conjunction with
systemic hereditary disorder
of bone, osteogenesis
imperfecta.
• After the primary dentition is
complete, enamel breaks
away from the incisal edge
and the occlusal surface.
• Characteristics:
• grayish/brownish
opalescent color
Dentinogenesis Imperfecta (Con’t)
• Characteristics (Con’t)
• Bulbous crowns
• Cervical constriction
• Obliterated pulp chambers and canals
• Tx: Full coverage. Enhance esthetics and to prevent
gross abrasion of the tooth structure.
Amelogenesis Imperfecta
• Group of conditions that
demonstrate developmental
alterations in the structure
of the enamel in the
absence of a systemic
disorder.
• Defective tooth structure is
limited to the enamel.
• Teeth are
yellowish/brownish in color.
• The enamel becomes
stained due to the
roughness of the surface
and the increased
permeability.
• Tx: Depends on the severity.
Mostly full coverage (since the
dentin structure is normal, the
teeth can be prepared for standard
crowns).
• Decrease hypersensitivity
• Improve esthetics
• Prevent gross abrasion of
the tooth structure.
Anodontia
• Implies the complete failure of the teeth to
develop.
• It is one of the manifestations of
ectodermal dysplasia.
• Since the absence of teeth predisposes to
a lack of growth of the alveolar process,
the construction of dentures is complicated.
2
Oligodontia (Partial Anodontia)
• When a number of the primary teeth fail to develop.
• Other ectodermal deficiencies are usually evident.
• The size of the primary teeth that are present may be
normal or reduced.
• The anterior teeth often have a conical shape, which is
characteristic of oligodontia associated with an
ectodermal dysplasia.
• The teeth most frequently missing are the mandibular
second bicuspids, the maxillary lateral incisors, and the
maxillary second bicuspids.
Additional Definitions
• Hypodontia
• Hyperdontia
• Microdontia
• Macrodontia
1
Part II COMPONENTSENDO
ÀClinical Diagnosis, Case Selection,
Treatment Planning, and Pt management 14
ÀBasic Endodontic Treatment Procedures 8
ÀProcedural Complications 3
ÀTraumatic Injuries 2
ÀAdjunctive Endodontic Therapy 1
ÀPost- Treatment Evaluation 2
ÀApproximately 60% of the
questions are repeats from
previous exams
BOARD REVIEW
À PULP BIOLOGY
À TOOTH ANATOMY
À PULP DIAGNOSIS
À ROOT CANAL THERAPY
À ENDODONTIC SUCCESS-FAILURE
À MISCELLANEOUS PULP BIOLOGY
PULP COMPOSITION
À In the normal dental pulp, which of the
following histologic features is (are) the lest
likely to appear:
A) Cell-free zone of Weil
B) Palisade odontoblastic layer
C) Lymphocytes and plasma cells
D) Undiffentiated mesenchymal cells
PULP COMPOSITION
À Which of the following cells are
characteristic of chronic inflammation of the
dental pulp:
a) Neutrophils
b) Eosinophils
c) Lymphocytes
d) Macrophages
e) Plasma cells
1) a,b,c & d 2) a,b, & d only 3) a,b, & e only
4) a, c & e 5) c, d & e only
2
AGING OF PULP
ÀAging of the pulp is
evidenced by an
increase in fibrous
elements
PULPAL NERVOUS
SYSTEM
ÀEfferent nerves found in the dental pulp
are:
– sympathetic post ganglionic fibres
HYDRODAMIC THEORY TYPES OF DENTIN
À PRIMARY
À SECONDARY
À TERTIARY
– REACTIONARY
– REPARATIVE
À TUBULAR
À PERITUBULAR
À INTERTUBULAR
À GLOBULAR
À INTERGLOBULAR
À SCLEROTIC
ACCESSORY CANALS
À Studies indicated that patent blood vessels
course in lateral or accessory canals connecting
the coronal and/or radicular pulp with the PDL.
À They appear to be distributed at any level of
the root as well as on the floor of the pulp
chamber.
À Distribution of lateral canals
– 17% in the apical third
– 8.8% in the middle third
– 1.6% at the coronal portion
ACCESSORY CANALS
À A non-carious tooth with deep periodontal
pockets that do not involve the apical third of
the root has developed an acute pulpitis. There
is no history of trauma other than a mild
prematurity in lateral excursion. What is the
most likely explanation for the pulpitis?
1) Normal mastication plus toothbrushing has driven
microorganisms deep into tissues with subsequent pulp
involvement at the apex.
2) During a general bacteremia, bacteria settled in this
aggravated pulp and produced an acute pulpitis.
3) Repeated thermal shock from air and fluids getting into
the deep pockets caused the pulpitis.
4) An accessory pulp canal in the gingival or the middle
third of the root was in contact with the pockets.
3
APICAL FORAMEN
APICAL FORAMEN
À Initial instrumentation in endodontic
tx is done to:
a) Radiographic apex
b) Dentino-enamel junction
c) Cemento-dentinal junction
d) Cemento-pulpal junction
CEMENTUM
ÀCELLULAR – APICAL THIRD OF
ROOT
ÀACELLULAR
TOOTH ANATOMY
MANDIBULAR 1st MOLAR
À Approximately what per cent of
mandibular first molars exhibit two
distal canals?
1) 0
2) 0.1
3) 0.3
4) 0.6
5) 0.75
4
MAX 1ST MOLAR
À BUCCAL HOOK PALATAL ROOT
À 4 CANALS
À MB1 (MB); MB2 (ML)
À 74% 2nd canal
– Half have a separate foramen
À The most common curvature of the palatal root of the
maxillary first molar is to the
1) facial.
2) mesial
3) distal
4) lingual
MAX FIRST BICUSPID
À EASIEST TOOTH TO PERFORATE
À MESIAL CONCAVITY
À CANAL NUMBER: 90% 2, 10% 1
À RADIOGRAPH
À SLOB / Clark’s Rule/BUCCAL OBJECT
RULE
À CONE SHIFT
The teeth that are easiest to perforate by slight mesial or
distal deviation from proper angulations of a bur are
mandibular incisors and maxillary first premolars
MAX LATERAL INCISOR
ÀPOSSIBLE SEVERE
DISTAL
CURVATURE
IN APICAL 1/3
ÀCURVE MAY HAVE
A PALATAL ASPECT
TO IT
MAX LATERAL INCISOR
À Which of the following teeth are the
least likely to have more than 1 canal
1) Maxillary lateral incisors
2) Mandibular lateral incisors
3) Mandibular first premolars
4) Maxillary second premolars
5) Maxillary second molars
MOST CONSISTENT ROOT
CANAL ANATOMY
À MAXILLARY CUSPID
DIAGNOSIS
5
DIAGNOSIS
¾ PULP
¾ PERIRADICULAR
¾ ENDO- PERIO
¾ REFERRED PAIN
¾ SINUS TRACTS
¾ CYST AND GRANULOMA
¾ RESORPTION
¾ NON-ODONTOGENIC
¾ ANKYLOSIS
PULP DIAGNOSIS
À NORMAL
À REVERSABLE PULPITIS
À IRREVERSABLE PULPITIS
À NECROTIC
PULP DIAGNOSIS
À Which is most likely to cause pulp necrosis:
1) Intrusion
2) Extrusion
3) Lateral displacement
4) Concussion
À Prolonged, unstimulated night pain suggests which of
the following conditions of the pulp?
1) Pulp Necrosis
2) Mild hyperemia
3) Reversible pulpitis
4) No specific condition
PERIRADICULAR
DIAGNOSIS
À ACUTE PERIRADICULAR
PERIODONTITIS
À ACUTE APICAL ABSCESS
À CHRONIC PERIRADICULAR
PERIODONTITIS
À CHRONIC PERIRADICULAR ABSCESS
– SUPPURATIVE PERIRADICULAR
PERIODONTITIS
À SUBACUTE PERIRADICULAR
PERIODONTITIS
À NORMAL
PERIRADICULAR
DIAGNOSIS (contd) À How to differentiate between acute apical abscess and acute
periodontal abscess:
– Pulp vitality test
À Percussion is a dental diagnostic procedure used in
determining whether periodontitis exists!
À The pathognomic symptom of chronic apical periodontitis
is:
1) Swelling
2) Intermittent pain
3) Tenderness to palpation
4) Tenderness of percussion
5) None of the above
À Radiographs reveal a deep, distal carious lesion
on the suspect tooth. The apical periodontal
ligament appears normal most probable
diagnosis for the condition of the pulp and the
apical periodontal ligament is
1) Vital pulp
2) Necrotic pulp
3) Irreversibly inflamed pulp
4) Inflamed apical periodontal ligament
5) Uninflamed apical periodontal ligament
a) 1& 4
b) 1 & 5
c) 3 & 4
d) 3 & 4
e) 3 & 5
6
ENDO PERIO
À PRIMARY ENDO
À PRIMARY PERIO
À PRIMARY ENDO – SECONDARY PERIO
À PRIMARY PERIO – SECONDARY ENDO
À TRUE COMBINED LESION
À PULP TEST – PROBE
ENDO PERIO
ENDO PERIO ENDO PERIO
ENDO PERIO REFERRED PAIN
ÀSITE OF PAIN – WHERE IT IS FELT
– LOCATION
ÀSOURCE OF PAIN – ORIGIN
ÀREFERED PAIN – THE SITE AND
SOURCE ARE NOT THE SAME
7
SINUS TRACT
• The cone should The cone should
track back to the track back to the
source of infection
• This will This will
demonstrate which demonstrate which
root of the molar is root of the molar is
affected
Presence of sinus tract Presence of sinus tract
SINUS TRACT
1. Conventional RCT, Conventional RCT,
antibiotics not needed. antibiotics not needed.
2. Will heal in 2 Will heal in 2-4 weeks after 4 weeks after
conventional RCT
3. If present, post RCT do If present, post RCT do
apical surgery with apical surgery with retrofill retrofill
(answer for the board) (answer for the board)
LATERAL PERIODONTAL
CYST
ÀVitality test
ÀNot of pulpal origin
GLOBULOMAXILLARY
CYST
ÀMythical lesion allegedly located
between maxillary lateral incisor and
cuspid
ÀVitality test
GRANULOMA
Periapical Inflammation
• An extension of pulpal An extension of pulpal
inflammation inflammation
• Periapical tissues will Periapical tissues will
become involved before become involved before
total pulpal necrosis total pulpal necrosis
• Bacteria and Bacteria and
inflammation by inflammation by
products leak through AF products leak through AF
and start inflammation
Apex
Granuloma
APICAL CYST
8
NON-ODONTOGENIC
CONDENSING OSTEITIS
À Confirm vitality
ÀHistory of tooth
or restoration
ÀRCT vs No RCT
CEMENTOMA
ÀVitality test
ÀRadiolucent/opaque lesion
ÀCalcifying fibroma
ÀPredominant location lower anteriors
ÀEthnic link observed (Predominantly
among African-American)
CEMENTOMA
ANKYOLOSIS
À Which is the most important sign of
Ankylosis:
1) Dull sounding
2) Resonant
3) Cessation of eruption
4) Cross bite INFECTION
9
BACTERIA
ÀKakehashi, Stanley, Fitzgerald
À1965
ÀBacteria are the problem
INFECTION SEVERITY
ÀRESISTANCE OF HOST
ÀVIRULENCE
ÀPOPULATION/NUMBER
CHRONIC
INFLAMMATION OF THE
PULP
ÀLYMPHOCYTES
ÀMACROPHAGES
ÀPLASMA CELLS
FATE OF
EXTRARADICULAR
INFECTION
ÀSOME PROBLEMS SUCH AS
ACTINOMYCOSES ARE
EXTRARADICULAR AND MAY
REQUIRE SURGERY TO RESOLVE
THE INFECTION.
ÀTRUE CYSTS
ÀOSTEOMYELITIS
ÀBIOPSY AND CULTURE
WHY DO WE HAVE A
PROBLEM
BACTERIA!!!
CRITERIA for SUCCESS
ÀELIMINATE BACTERIA
ÀPROTECT AGAINST BACTERIA
¾ Severity of the course of a periapical
infection depends upon the :
1) Resistance of the host
2) Virulence of the organism
3) Number of organism present
4) All of the above
5) Only 1 and 2
10
CRITERIA for SUCCESS
ÀWhat is the radiographic sign of
successful pulpotomy in a permanent
tooth?
1)Open apex
2)That the apex has formed
3)Loss of periapical lucency
4)No internal resorption
RESORPTION
PHYSIOLOGIC OR PATHOLOGIC
LOSS OF TOOTH STRUCTURE
SURFACE RESORPTION
ÀA PHYSIOLOGIC PROCESS
CAUSING SMALL SUPERFICIAL
DEFECTS IN THE CEMENTUM AND
DENTIN THAT UNDERGO REPAIR
BY DEPOSITION OF NEW
CEMENTUM
ÀUSUALLY NOT DETECTABLE ON A
RADIOGRAPH
SURFACE RESORPTION
PRESSURE RESORPTION
ÀORTHODONTIC TOOTH MOVEMENT
ÀTOOTH ERUPTION
ÀTUMORS
Pressure ResorptionOrthodontics
11
Pressure Resorption-Eruption Pressure Resorption-Eruption
INFLAMMATIORY
RESORPTION
ÀBACTERIA
ÀEXTERNAL
ÀINTERNAL
ÀPATHOLOGIC LOSS OF TOOTH
STRUCTURE RESULTING IN A
DEFECT IN THE ROOT AND
ADJACENT BONE
INFLAMMATORY
RESORPTION
INFLAMMATORY
RESORPTION
REPLACEMENT
RESORPTION
À ANKYLOSIS
À TRAUMA
À IDIOPATHIC
À PATHOLOGIC LOSS OF TOOTH
STRUCTURE WITH THE INGROWTH OF
BONE INTO THE DEFECT
À FUSION OF BONE TO CEMENTUM OR
DENTIN
12
External Replacement
Resorption
ÀIdiopathic
ÀExtracanal invasive resorption
ÀCervical resorption-most common name
ÀExternal invasive resorption
ETIOLOGY OF RESORPTION
ÀUNKNOWN
ÀTRAUMA
ÀORTHODONTICS
ÀINTERNAL BLEACHING
ÀBACTERIA
EXTERNAL RESORPTION
ÀSURFACE
ÀPRESSURE
ÀINFLAMMATORY
ÀREPLACEMENT
ÀINFLAMMATORY PERIRADICULAR
LESIONS ALWAYS RESULT IN
RESORPTION OF BOTH BONE AND
TOOTH
EXTERNAL INVASIVE
RESORPTION
External
Invasive
Resorption
CERVICAL
RESORPTION
INTERNAL RESORPTION
13
INTERNAL RESORPTION
ÀSURFACE
ÀINFLAMMATORY
ÀNECROTIC TEETH ALWAYS HAVE
INTERNAL INFLAMMATORY
RESOPRPTION
ÀPERFORATION
INTERNAL RESORPTION
INTERNAL RESORPTION
DIFFERENTIATION OF
INTERNAL AND
EXTERNAL RESORPTION
ÀINTERNAL
– REGULAR
– ROUND
– CENTERED, USE SLOB RULE
ÀEXTERNAL
– IRREGULAR, MOTH EATEN
– OFF CENTER, USE SLOB RULE
INTERNAL RESORPTION EXTERNAL RESORPTION
14
TREATMENT
ÀINTERNAL RESORPTION
9 ENDODONTIC TREATMENT
9 MAY BE DIFFICULT
– PERFORATION
– APICAL
TREATMENT CONTINUED
ÀEXTERNAL INFLAMMATORY
9 CALCIUM HYDROXIDE
9 CONTROL INFECTION
9 FILL CANALS
EXTERNAL
INFLAMMATORY
RESORPTION
TREATMENT CONTINUED
À EXTERNAL REPLACEMENT
– CALCIUM HYDROXIDE
– CONTROL INFECTION
– FILL CANALS
À AVULSION
– GUARDED TO HOPELESS
À IDIOPATHIC
– PROGNOSIS DEPENDS ON EXTENT AND
LOCATION
15
ROOT CANAL THERAPY
ROOT CANAL THERAPY
À Access
À Irrigants
À Files
À Sealers
À Gutta Percha
ACCESS
The objectives of the access
preparation are to:
À 1. Provide unobstructed visibility into all canals.
À 2. Allow files to be passed into each canal without binding
on the walls of the access preparation (straight line access to
avoid ledge).
À 3. Allow obturation instruments to fully enter each canal
without binding on the walls of the access preparation.
À 4. Include removal of all caries and defective restorations.
À 5. Make possible the removal of all pulp tissue.
À 6. Removal of the roof of the pulp chamber.
ACCESS
ÀOVAL
ÀTRIANGULAR
ÀTRAPEZOIDAL- Mandibular molar
with 4 canals.
ACCESS
À Which of the following can cause a ledge
formation:
1) Infection
2) Remaining debris within the canal
3) No straight line access
À A mandibular molar has 4 canals. How
should the access opening be:
1) Round
2) Oval
3) Trapezoidal
4) Triangular
16
IRRIGANTS
IRRIGANTS
À EDTA
À SODIUM HYPOCHLORIDE
EDTA
ÀEDTA- 16-20% solution
ÀChelating agent
ÀDecalcifies dentin
ÀRemoves smear layer
SODIUM HYPOCHLORITE
À5.25% NaOCl
ÀDissolves organic material
ÀKills bacteria
ÀSterilize GP, (wipe with alcohol
afterwards)
FILES
PRECURVE FILES
À Precurve all stainless steel files prior to
placement in a canal
À Precurving files is indicated
1 for files sizes #35 and over.
2 in canals that are even slightly curved.
3 as a way to negotiate past canal obstructions.
4 All of the above
5 Only (1) and (2) above
6 Only (2) and (3) above
17
SEALERS
SEALERS
Zinc oxide eugenol – Kerr Sealer
Resin – AH26
Paste fill
Which of the following represents the
basic constituents of most root canal
sealers:
Answer: Zinc oxide
Other Root Canal Therapies
ÀApexification
ÀPulpotomy
ÀApexogenesis
ÀApicoectomy
ÀPulp Cap
APEXIFICATION
APEXIFICATION
À NECROTIC IMMATURE TOOTH
À CONFIRM DIAGNOSIS
À ACCESS – DEBRIDMENT
À SODIUM HYPOCHLORITE – INSTRUMENTATION
À PLACE CALCIUM HYDROXIDE
À PLUGGER, LENTULO SPIRAL, COMPACTOR,
MESSING GUN
À What kind of procedure should be performed on a
tooth with necrotic pulp and unfinished root tip
– apexification
DIAGNOSE
ACCESS
DEBRID
INSTRUMENT
DISSOLVE
18
APEXIFICATION APEXIFICATION
APEXIFICATION
APEXOGENESIS
A vital pulp therapy procedure
performed to encourage continued
physiological development and
formation of the root end. This term is
frequently used to describe vital pulp
therapy performed to encourage the
continuation of this process.
19
APEXOGENESIS
À What is best sign for success of
apexogenesis
– Continuous completion of apex
APEXOGENESIS
APEXOGENESIS MTA – Mineral Trioxide
Aggregate
ÀDr Mahmoud Torabinejad, Loma Linda
ÀModified Portland Cement
ÀBismuth oxide
ÀVery good seal
ÀExpands slightly when sets with moisture
ÀLong setting time
Uses for MTA
ÀPulp cap
ÀPerforation repair
ÀPulpotomy
ÀApexification
ÀApical barrier
Other products
ÀWhite MTA
ÀSOC – Silicate Oxide Compound
ÀUSC – Universal Silicate Cement
20
PULPOTOMY
PULPOTOMY
ÀPulp cap
ÀPartial/Cvek
pulpotomy
ÀPulpotomy
ÀDeep pulpotomy
ÀPulpectomy
PULP CAP
WHY PULP CAP ???
ÀMAINTAIN NORMAL PULP VITALITY
ÀRETURN PULP TO NORMAL
ÀAVOID ENDODONTIC TREATMENT
ÀAVOID EXTRACTION
ÀAVOID EXTENSIVE TREATMENT
ÀPOSTPONE ENDODONTIC
TREATMENT
PULP CAP
DIRECT
À Pulp capping and pupotomy
can be more successful in newly
erupted teeth than in adult teeth
because :
1. a greater number of
odontoblast are present
2. incomplete development
of nerve endings
3. open apex allows for
greater circulation
PULP CAP
DIRECT
À Calcium hydroxide is generally
the material of choice in vital
pulp capping because :
1) Encourages dentin bridge
formation
2) Is less irritating to the pulp
3) Seals the cavity better
4) Adheres well to dentin
21
To ensure better thermal
and protective insulation
of the pulp during a
capping procedure ,CaOH
should be covered with
stronger base
Pulp cap
traumatic exposure
INDIRECT PULP CAP INDIRECT PULP CAP
INDIRECT PULP CAP INDIRECT PULP CAP
22
INDIRECT PULP CAP INDIRECT PULP CAP
REPLANTATION
ÀWHEN BOTH SURGERY AND
RETREATMENT ARE DIFFICULT
THEN EXTRACTION AND
REPLANTATION MAY BE THE
TREATMENT OF CHOICE
ENDODONTIC SUCCESS – FAILURES
FAILURE – SUCCESS
REASONS
ÀPoor condensation, incomplete fill
ÀInadequate disinfection
À The most frequent cause of failure in
endodontics is
1. split roots.
2. root perforation.
3. Incomplete obturation.
4. separated instruments.
5. filling beyond the apex.
TRAUMA – FRACTURES
23
TRAUMA
À AVULSION: Milk, replant ASAP, open apex,
splint 7-10 days, endo tx 1wk, Ca(OH)2 ,
resorption, replacement, inflammatory
À CONCUSSION: least damaging
À LUXATION: pulp necrosis likely, 60%
immature apex teeth become nonvital
Intrusive luxation, necrosis, ankylosis
À FRACTURES
TRAUMA
À An 8-year-old boy received a traumatic injury
to a maxillary central incisor. One day later,
the tooth failed to respond to electric and
thermal vitality tests. This finding dictates
1. pulpectomy.
2. apexification.
3. calcium hydroxide pulpotomy.
4. delay for the purpose of re-evaluation.
One year ago, a 9-year-old boy fractured a
central incisor. A current radiograph of the
tooth is adjacent. There are no symptoms. The
tooth does not respond to pulp testing;
however, control teeth do respond. What is the
preferred treatment?
1. Pulpotomy with Ca(OH)2
2. Pulpotomy with formocresol
3. Conventional root canal treatment
4. Debridement of the pulp space and
apexification
TRAUMA INTRUSION
Management
À Immature teeth
– A tooth with an open apex is likely to re-erupt spontaneously
– Monitor the progress of re-eruption
– No treatment is needed if tooth re-erupts into normal position
and there is no evidence of pulpal involvement
À Mature teeth
– Intruded mature teeth need to be repositioned immediately
– Initial extrusion will be made orthodontically or surgically
depending on degree of intrusion
Prognosis
À High risk of pulp necrosis; Endodontic therapy is often indicated;
possibility of resorption shows the need to follow up
Recalls
À Evaluate 4-6 weeks after trauma and after 6 months; after that
yearly recall are indicated
Tavitian/USC Endo
Root Fractures
Limited to fractures involving roots only;
cementum, dentin, and pulp
FRACTURED ROOTS
À CORONAL THIRD:
ENDO AND ORTHO
EXTRUSION
À MIDDLE THIRD: SPLINT
AND OBSERVE
À APICAL THIRD: ENDO
TO THE FRACTURE LINE
IF NECROTIC, APEX
USUALLY REMAINS
VITAL
24
FRACTURED ROOTS
À There is a root fracture in the apical third of the root
of a mandibular tooth. What will be the most likely
result?
1) Root resorption
2) Ankylosis
3) Vitality will be preserved
4) Teeth will show internal resorption
À There is a root fracture in the middle third of the
root in an 11 year old patient. The tooth is mobile
and vital. What will you do?
1) Extract
2) Pulpectomy
3) Splint and observe
4) Do nothing
VERTICAL ROOT FRACTURES
À Failure of tooth with recently placed post and core :
Vertical root fracture
À Majority of vertical root fractures of endo tx teeth
result from: Condensation forces during gutta-percha
filling
À Diagnose with perio probe, narrow periodontal pocket
width
À Tx is extraction
SEPARATED INSTRUMENTS
SEPERATED
INSTRUMENTS
À APICAL 3RD & VITAL – fill and
observe, temporize, no permanent
restoration for 3-6 months
À NON-VITAL – refer to endodontist
À MIDROOT – refer to endodontist
À In all cases inform patient
SURGERY AND HEALING
INDICATIONS FOR
SURGICAL ENDODONTIC
TREATMENT
À Failing RCT where it is not possible (or
practical) to retreat
À Disassemble?
À Post ? Is it practical???
25
SURGICAL ENDODONTIC
TREATMENT
À A patient has a draining sinus tract apical to a
maxillary lateral incisor. The tooth, which is restored
with a post and crown, received a root canal filling and
apicoectomy one year ago. Radiographically, the tooth
measures 19 mm. in length. Adjacent teeth respond
normally to pulp testing. The patient is asymptomatic.
Which of the following is the most acceptable
treatment?
1. Retreat and refill the canal with gutta-percha.
2. Retreat and refill the canal, then perform an
apicoectomy.
3. Retreat by surgery using a retrofill amalgam.
4. No treatment is necessary unless the patient develops
symptoms.
APICOECTOMY
À REVERSE FILL
À CURETTAGE
APICOECTOMY
EXPECTED HEALING TIME
À3-6 months for radiographic evidence
ÀAsymptomatic
À2-4 weeks sinus tract gone
À Prognosis of a tooth with a broken instrument located 3
mm. from the apex is probably best if the tooth has a
1) vital pulp with a periapical lesion.
2) vital pulp without a periapical lesion.
3) necrotic pulp with a periapical lesion.
4) necrotic pulp without a periapical lesion.
HEALING
ÀBONE – yes
ÀPDL – yes
ÀDENTIN – no
ÀCEMENTUM – yes
ÀENAMEL – no
HEALING
À Severity of the course of a periapical infection
depends upon the :
1) Resistance of the host
2) Virulence of the organism
3) Number of organism present
4) All of the above
5) Only 1 and 2
À What is the radiographic sign of successful
pulpotomy in a permanent tooth?
1) Open apex
2) That the apex has formed
3) Loss of periapical lucency
4) No internal resorption
HEALING
À Once the root canal is obturated, what
usually happens to the organism that had
previously entered periapical tissues from the
canal:
a) They persist and stimulate formulation of
granuloma
b) They are eliminated by the natural defenses
of the body
c) They re-enter and re-infect the sterile canal
unless periapical surgery is performed
d) They will have been eliminated by various
medicaments that were used in the root canal
26
BLEACHING
TOOTH DISCOLORATION
À PULP NECROSIS
À RESTORATIVE MATERIALS
À SYSTEMIC MEDICATIONS
– FLOURIDE
– TETRACYCLINE
À GENETIC
À ENVIRONMENTAL
BLEACHING
À INTERNAL BLEACHING
À WALKING BLEACH
À DO NOT USE STRONG, 30%, H2O2
(Superoxol) – RESORPTION
À SODIUM PERBORATE
À Need to put cement barrier between
gutta percha and bleaching material
MISCELLANEOUS
PULP TESTING
ÀDUPLICATE SYMPTOMS
ÀADJACENT AND CONTRALATERAL
TEETH
ÀCOLD
ÀHEAT
ÀCAVITY TEST PREP
EMERGENCY TX
À SEE PATIENT
À DIAGNOSE
À TREAT
APPROPRIATELY
27
EMERGENCY TX
À A patient of record calls late Saturday night because
of severe, throbbing pain aggravated by “heat, biting
and touching” in a mandibular premolar. What
procedure is recommended?
1. Instruct the patient to apply ice intermittently, take
aspirin, and call Monday for an appointment.
2. See the patient at the office and initiate endodontic treatment.
3. See the patient at the office, remove the carious dentin
and place a sedative zinc oxide-eugenol cement.
4. Prescribe an analgesic and refer the patient to an
endodontist.
5. Refer the patient to the hospital oral surgery
department for extraction.
PERFORATIONS
À MESIAL ROOT OF MANDIBULAR
1ST MOLAR
– DISTAL OF MESIAL ROOT
CORONAL
PRETREATMENT
À REMOVE CARIES
À PREVENT LEAKAGE
À SECURE POSITION FOR CLAMP
ROOT SENSITIVITY
ÀEXPOSED DENTIN
ÀRECESSION
ÀSURGERY
ÀDESENSITISE
SYSTEMIC DISEASES
À Premedication- RHEUMATIC FEVER
À AHA Guidelines
OSTEOMYELITIS
À Pt has large carious lesion, toothache,
submandibular facial swelling, fever of
102F. Continuous exudate through
gingival sulcus, moth eaten radiolucent
appearance.
Most probable diagnosis: Acute
osteomyelitis
28
À Endodontically treated posterior teeth are
more susceptible to fracture than untreated
posterior teeth. The best explanation for
this is
1. moisture loss.
2. loss of root vitality.
3. plastic deformation of dentin.
4. destruction of the coronal architecture.
5. increased susceptibility of the enamel to
fracture.
MISCELLANEOUS TEMPORARY
RESTORATION
À ZOE is a good temporary restoration
because :
1) less irritant
2) Increased strength
3) Good seal
4) Antibacterial
PULP TEST
À Which of the following is lest useful
in children
1) Percussion
2) Palpation
3) Electric pulp test
4) Thermal test
SLOB Rule
À On a radiograph, the facial root of a
maxillary first premolar would appear distal
to the lingual root if the
1) vertical angle of the cone were increased.
2) vertical angle of the cone were decreased.
3) x-ray head were angled from a distal position
relative to the premolar.
4) x-ray head were angled from a mesial
position relative to the premolar.
SLOB Rule
ÀA radiograph shows a lucency that
does not appear to move with
application of the Clarke’s Principle/
Rule. Where is the lucency situated?
1)No way of telling
2)Lingual
3)In the canal
4)Buccally
29
CONCLUSIONS
À Try and maintain pulp vitality
À Young pulps respond better than old
pulps to trauma
À Disinfect
À Seal
1
Gingivitis and Periodontal Disease
• Gingiva is normally light pink
• Surface has stippled appearance
• During eruption, gingiva is thick with
rounded margins
• Severe gingivitis is uncommon is children
– Trx: good home care, frequent check-ups,
prophys, Fl trx
Herpes Simplex Virus
– occur in children 2 – 6 yrs
– Oral findings: yellow or
white liquid filled vesicles,
which rupture to form
ulcers in a few days
– After initial attack, virus is
inactive but reappears as
cold sores. Sores appear
on gingiva and attached
mucous membranes
– Trx: palliative, sores heal
in 7 – 10 days
Recurrent Aphthous Ulcer
• Ulceration on mucous
membrane
• Can occur in schoolage children and in
adults
• Lesions persist for 4 –
12 days
• Found more
commonly on loose
mucosa
Candidiasis
• Caused by Candida
albicans
• Normal inhabitant,
pathogenic state when
resistance is lowered
• Can be a sign of
compromised immune
system (i.e. AIDS)
• Trx: Nystatin topically or
ketoconazole
systemically
Dilantin Gingivits
• Occurs in children
receiving Dilantin over
a prolonged period of
time
• Painless hyperplasia
of gingiva
Hyperplasia is
generalized
– Trx: surgical removal
most effective
Scarlet Fever
• Caused by Group A beta
hemolytic streptococci
• After 5 day incubation period,
patient develops pharyngitis,
tonsillitis, headache, fever,
chills, nausea, and vomiting
• Within 2- 3 days, typical bright
red skin rash develops
• Oral manifestation: “strawberry
tongue” and then a “raspberry
tongue”
• Disease ends in 7 – 10 days
2
Measles
• Caused by rubeola virus (paramyxovirus
family)
• Portal of entry is respiratory tract
• Oral manifestations: “koplik’s spots”
– develop on buccal mucosa and appear as
small bluish white macules, surrounded by
red margin
• Trx: pallitative
Erythema Multiforme
• Oral manifestations: macules, papules,
vesicles that become ulcerated and
covered by exudate
• Trx: Corticosteroids and antibiotics
Page 1
Goals
• Stages in evaluating an oral lesion
• Process to develop a differential diagnosis
based on the normal anatomy of the site
• Procedures that can be used to refine the
differential diagnosis and establish a
definitive diagnosis
• Approaches to treat common oral lesions
• Clinical course of some common oral
lesions with and without treatment
Stages for Evaluation of Oral Lesions
• Recognition of Tissue Alteration
• Generation of Differential Diagnosis
• Definitive Diagnostic Procedures
• Recommendation for Treatment
• Clinical Follow-up
Step 1. Recognition of Oral Lesions:
The Process
• History of the condition
• Observation of lesion parameters
– location
– color
– size
– shape
– texture or consistency
– growth pattern Which one of these two lesions would cause you to be most concerned?
A ___________________ B ___________________
Which one of these two lesions would cause you to be most concerned?
A ___________________ B ___________________
Which one of these two lesions would cause you to be most concerned?
A ___________________ B ___________________
Page 2
Which one of these two lesions would cause you to be most concerned?
A ___________________ B ___________________
Which one of these two lesions would cause you to be most concerned?
A ___________________ B ___________________
Which one of these two lesions would cause you to be most concerned?
B __________________ A ___________________
Stages for Evaluation of Oral Lesions
• Recognition of tissue alteration
• Generation of Differential Diagnosis
• Definitive Diagnostic Procedures
• Recommendation for Treatment
• Clinical Follow-up
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
How long have you had this on the palate? DX – Blue Nevus
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
Are you taking medications for hypertension? DX – Gingival Hyperplasia
2
o
to Ca++ Channel Blocker
Page 3
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
What kind of gum do you chew? DX – Cinnamon Chewing
Gum reaction
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
Do you put anything beneath your tongue? DX – Aspirin Burn
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
Are you in a risk group for HIV infection? DX – HIV Gingivitis
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
Do you habitually chew or bite your lip? DX – Lip chewing
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
What toothpaste or rinse do you use?
DX – Moderate Epithelial Dysplasia
Viadent Leukoplakia
Stages for Evaluation of Oral Lesions
• Recognition of Tissue Alteration
• Generation of Differential Diagnosis
• Definitive Diagnostic Procedures
• Recommendation for Treatment
• Clinical Follow-up
Page 4
Differential Diagnosis:
The Objective
The objective of developing a list of
differential diagnoses is to make sure that
all significant conditions that could present
in a specific manner are considered. The
initial differential diagnosis should include
ALL the potential lesions so that an
important condition will not be missed.
Step 2. Differential Diagnosis:
The Process (Pindborg Paradigm)
Impression of the etiology of the condition
• Developmental or Congenital
• Reactive – Inflammatory/Infectious
• Neoplastic
• Traumatic
• Local Manifestation of a Systemic Disease
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Developmental DX – Varix
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Reactive -Inflammatory? DX – Erosive Lichen Planus
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Reactive -Infectious DX – Hairy Leukoplakia
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Neoplastic DX – Lymphoma
Page 5
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Reactive-Inflammatory & Trauma DX – Pyogenic Granuloma
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Reactive -Infectious DX – Recurrent Herpes
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Developmental DX – Amelogenesis Imperfecta
Step 2. Differential Diagnosis:
The Process
• Normal Anatomy at the Site
• Tissue types contributing to the normal
anatomy
• Lesions that could develop from the different
tissues
Normal Anatomy/Histology as a
prompt for Differential Diagnosis
The delivery of oral healthcare is continuously
involved with the normal head, neck and
intraoral anatomy and histology. Frequent
encounters with normal soft and hard tissues
provides a ready framework for approaching
differential diagnosis.
Step 2. Differential Diagnosis Phase
What is the normal anatomy/histology at the site?
Mucosa, Connective Tissue,
Minor Salivary Glands
DX – Fibroma with
Pigmentation
Page 6
Step 2. Differential Diagnosis Phase
What is the normal anatomy/histology at the site?
Mucosa, Minor Salivary Glands,
Periosteum , Bone, Nerves DX – Fibrous Hyperplasia
Step 2. Differential Diagnosis Phase
What is the normal anatomy/histology at the site?
Mucosa, Connective tissue DX – Speckled Leukoplakia
Step 2. Differential Diagnosis Phase
What is the normal anatomy/histology at the site?
Mucosa, PDL, Periosteum DX – Peripheral Ossifying Fibroma
Step 2. Differential Diagnosis Phase
What is the normal anatomy/histology at the site?
Epithelium, Connective tissue,
Muscle, Nerve, Blood Vessel DX – Chronic Ulcer
Stages for Evaluation of Oral Lesions
• Recognition of tissue alteration
• Generation of Differential Diagnosis
• Definitive Diagnostic Procedures
• Recommendation for Treatment
• Clinical Follow-up
Step 3. Definitive Diagnosis:
The Procedures
NON-INVASIVE
• Diascopy
• Culture
• Exfoliative Cytology
– scrapings, touch preps, Brush Biopsy®
INVASIVE
• Aspiration / Sounding
• FNA biopsy (cytology)
• Biopsy (surgical, punch)
Page 7
NON-INVASIVE MODALITIES
62 yo White Female with a Vascular Anomaly on the Alveolar Mucosa
Non-Invasive Diagnostic Procedures
Occlusion of the blood vessel filling the lesion blanches the site and proves that
the pigmented lesion is the result of blood pooling.
Brush biopsy kit
Description
The harvested cells are smeared on a
glass slide and immediately fixed
with alcohol
They are then mailed to the OralCDx®
laboratory
There, the slide is stained and
examined by computer-interfaced
microscopy
Page 8
Computer Analysis Description
Computer identifies the worst cells and
photographs them
Pathologist then examines the images
of the most atypical cells and
determines whether the changes
observed are significant or not
(quality control issue similar to PAP
smear diagnosis years ago)
Description
Reading of “normal”, “atypical”, “positive”
or “inadequate sample” is returned
“Inadequate sample” is repeated at no
additional charge
Atypical or positive – scalpel biopsy is
recommended
Normal still requires follow -up, with scalpel
biopsy if it appears suspicious
INVASIVE MODALITIES
FINE NEEDLE ASPIRATION BIOPSY –
ACTUALLY CYTOLOGY CYTOLOGY
FNA
Fluids
– peripheral blood,
marrow, urine, sputum,
discharge…
Pap smears
Page 9
Surgical Biopsy – Considerations
• Obtain a sample of tissue that has a representation
of the pathologic process under investigation
• Biopsy of ulcerative or erosive conditions requires
sampling of surrounding clinically uninvolved
tissues
• If there is a suspicion of a neoplastic/malignant
process an incisional biopsy should leave sufficient
original tissue to allow the ultimate treating doctor
to assess the extent of the lesion
• Biopsies can be done by all dentists and generally do
not require any special equipment or instruments
Invasive Diagnostic Procedure
21 yo white male with asymptomatic white lesion of dorsum of tongue for weeks-months duration
Invasive Diagnostic Procedure
Infiltration of local anesthetic at the biopsy site
Invasive Diagnostic Procedure
Elliptical incision circumscribing the lesion region of interest
Invasive Diagnostic Procedure
Dissection of specimen below the mucosal junction
Invasive Diagnostic Procedure
Mucosal specimen fixed extended to prevent distortion in subsequent processing
Page 10
Invasive Diagnostic Procedure
Fixation of specimen in neutral buffered formalin supplied by Oral Pathology Lab
Invasive Diagnostic Procedure
Biopsy site closed with sutures to be removed at follow-up appointment with diagnosis
Diagnosis – Lichen Planus
21 yo white male with asymptomatic white lesion of dorsum of tongue for weeks-months duration
Invasive Diagnostic Procedure
31 African-American male with asymptomatic rubbery firm lump in upper lip of months-years
duration
Invasive Diagnostic Procedure
Incision to expose nodule embedded deep in the structure of the lip
Invasive Diagnostic Procedure
Nodule exposed and released by blunt dissection through originalincision site
Page 11
Invasive Diagnostic Procedure
Nodule removed for submission to oral pathologists with capsule intact
Diagnosis – Pleomorphic Adenoma
You judge the case?
Page 12
Stages for Evaluation of Oral Lesions
• Recognition of tissue alteration
• Generation of Differential Diagnosis
• Definitive Diagnostic Procedures
• Recommendation for Treatment
• Clinical Follow-up
Page 13
Treatment
Treatment will be based on the
definitive diagnosis of the oral lesion
and correlated with the etiology of the
lesion: Developmental, Reactive or
Neoplastic
Common Oral Lesion
Candidiasis
• Recognition – Red or white
change of mucosa
• Differential Diagnosis – Other
red or white lesions
• Definitive Diagnosis – Culture,
Exfoliative cytology
• Treatment – Topical antifungals,
Mycelex troches 5x/day for 14
days, dissolve in mouth with
dentures out, treat dentures with
dilute bleach to remove the
microorganisms
• Follow-up – Recurrence common
Prescription
Name: __________________ Date:_________
______________________________________________
License #_______
Doctor:__________________________________
DEA #:__________________
Sig: Dissolve one tablet in mouth
five times per day with dentures
out, for 14 days
Disp: 70 (seventy)
RX:Mycelex troches (clotrimazole )
______________________________________________
Address:________________________________
After Anti-Fungal Therapy
______________________________________________
License #_______
______________________________________________
Prescription
Name: __________________ Date:_________
Doctor:__________________________________
DEA #:__________________
Sig: Soak partial dentures nightly
Disp: 500 ml
RX: Nystatin suspension
100,000 U/ml
Address:________________________________
Common Oral Lesion
Aphthous Ulcer
• Recognition – Soft Ulceration on
mucosa not bound to bone
• Differential Diagnosis – Other
oral ulcerations
• Definitive Diagnosis – History,
Observation, Palpation
• Treatment – Tincture of time,
Zilactin, Aphthasol, topical
steroid may have a prophylactic
role in recurrent aphthae
• Follow-up – Recurrences are
common with a typical
presentation pattern
Page 14
Prescription
Name: __________________ Date:_________
______________________________________________
License #_______
Doctor:__________________________________
DEA #:__________________
Sig: Apply topical to oral mucosal
ulcers qid until ulcers are
healed
Disp: One tube
RX: Aphthasol
______________________________________________
Address:________________________________
Common Oral Lesion
Amalgam Tattoo
• Recognition – Black macule
in mucosa near region in
which amalgam has been
used
• Differential Diagnosis –
Pigmented oral lesions
• Definitive Diagnosis –
Clinical examination
• Treatment – None required
• Follow-up – Periodic
intraoral examination
Common Oral Lesion
Irritation Fibroma
• Recognition – Firm, raised nodule,
freely moveable
• Differential Diagnosis – Nodular
lesions
• Definitive Diagnosis – History,
Palpation, Biopsy
• Treatment – Excisional biopsy
• Follow-up – Very low recurrence rate
Common Oral Lesion
Mucocele
• Recognition – Soft, raised,
sensitive nodule in region of
minor salivary gland
• Differential Diagnosis – Mucosal
cystic conditions
• Definitive Diagnosis – History,
Palpation, Biopsy
• Treatment – Excisional Biopsy
with removal of all minor
salivary glands in region of
excision
• Follow-up – Very low rate of
recurrence
Common Oral Lesion
Pyogenic Granuloma
• Recognition – Red
enlargement of gingival
papilla
• Differential Diagnosis – Other
gingival bumps
– The 4 P’s
• Pyogenic Granuloma
• Peripheral Giant Cell
Granuloma
• Parulis
• Peripheral Ossifying
Fibroma
• Definitive Diagnosis – Biopsy
• Treatment – Excisional
biopsy
• Follow-up – Recurrence
common if etiology remains
Common Oral Lesion
Varix
• Recognition – Soft, blueblack nodule or macule
• Differential Diagnosis –
Pigmented oral lesions
• Definitive Diagnosis –
Diascopy
• Treatment – None, unless
patient concerned for
esthetics
• Follow-up – Periodic
evaluation
Page 15
Common Oral Lesion
Leukoplakia
• Recognition – White, plaque-like
change of mucosa, well defined
usually not sensitive
• Differential Diagnosis – White
lesions and squamous cell
carcinoma
• Definitive Diagnosis –
Incisional/Excisional biopsy
• Treatment – Excisional biopsy
• Follow-up – Depending on the
histopathology of the lesion
variable recurrence and/or
progression potential
Common Oral Lesion
Herpetic
Gingivostomatitis
• Recognition – Painful, 1-2 mm
ulcers on multiple oral
mucosae including those
bound to bone
• Differential Diagnosis – Other
oral ulcerations
• Definitive Diagnosis – History,
Observation, Exfoliative
Cytology
• Treatment – Supportive and
topical analgesics,
Valtrex/Valacyclovir
• Follow-up – Recurrent herpes
limited to a particular nerve
track
Common Oral Lesion
Lichen Planus
• Recognition – White striae,
erythema, erosion, history
• Differential Diagnosis –
Vesiculo-bullous conditions,
erythematous lesions
• Definitive Diagnosis –
History, Clinical Exam,
Biopsy
• Treatment – Topical steroids
• Follow-up – Chronic
condition, no known etiology,
frequent symptomatic
recurrences
65 yo white female with non-healing ulcer on ventral tongue of several months duration
Treatment
65 yo white female with non-healing ulcer on ventral tongue of several months duration
Diagnosis – Traumatic Ulcerative Granuloma Treatment
Topical application of corticosteroid gel on blotted dry mucosa that has no superimposed infections
Page 16
Cinnamon reaction
before treatment and after treatment
Treatment may just mean removing the offending agent to which th e tissue is reacting
Stages for Evaluation of Oral Lesions
• Recognition of tissue alteration
• Generation of Differential Diagnosis
• Definitive Diagnostic Procedures
• Recommendation for Treatment
• Clinical Follow-up
Value of Follow-up
• Recurrence risk varies for different
diagnoses
• Many oral lesions are by nature a
chronic process
• Avoid missing diagnosis of a more
critically important condition
• Rapid treatment intervention
Seminar Goals
• Stages in evaluating an oral lesion
• Process to develop a differential diagnosis
based on the normal anatomy of the site
• Procedures that can be used to refine the
differential diagnosis and establish a
definitive diagnosis
• Approaches to treat common oral lesions
• Clinical course of some common oral
lesions with and without treatment
Normal Anatomy/Histology as a
prompt for Differential Diagnosis
The delivery of oral healthcare is continuously
involved with the normal head, neck and
intraoral anatomy and histology. Frequent
encounters with normal soft and hard tissues
provides a ready framework for approaching
differential diagnosis.
Differential Diagnosis:
The Objective
The objective of developing a list of
differential diagnoses is to make sure that
all significant conditions that could present
in a specific manner are considered. The
initial differential diagnosis should include
ALL the potential lesions so that an
important condition will not be missed.
Page 17
How were your impressions of
the matched lesions presented at
the beginning of the session?
How frequently were the most severe lesions
identified on first impression?
Which features led you to select a particular
lesion as more severe?
What are the consequences of missing the
critical lesions? Which one of these two lesions would cause you to be most concerned?
A. BC Powder Burn B. Moderate Epithelial Dysplasia
Cancer
Cancer Cancer
Which one of these two lesions would cause you to be most concerned?
A. Major Aphthous Ulcer B. Squamous Cell Carcinoma
Which one of these two lesions would cause you to be most concerned?
A. Lichen Planus B. Erythroleukoplakia, CA in situ
Page 18
Which one of these two lesions would cause you to be most concerned?
A. MucoepidermoidCarcinoma B. Fibroma
Which one of these two lesions would cause you to be most concerned?
A. Hairy Leukoplakia B. Fibroma
Which one of these two lesions would cause you to be most concerned?
A. FactitialInjury B. Leukemia
Differential Diagnosis:
The Objective
The initial differential diagnosis should
include ALL the potential lesions so that an
important condition will not be missed.
It is not necessary to achieve the correct
diagnosis at first glimpse, but it is necessary
to consider all the critical diagnoses.
Remember
1
KEY CONCEPTS IN 0MFS
Mgt. of patients with Adrenal Suppression
A. If pt. currently on steroids
1. Day before
2. Day of Surgery Double the dose
3. Day after
4. 2 days after – Return to normal dose
B. If pt. not now on steroids but received at least 20 mg. for more than 2 wks in the past
year
1. Day before
2. Morning of Surgery
3. First 2 postsurgical days – 40 mg.
4. Next 3 days – 20 mg.
5. 6 days after surgery – discontinue steroids
Mgt of patients receiving Coumadin
1. Obtain a PT –
a. If INR between 1-1.5, precede wth surgery
b. If INR greater than 1.5 – stop Coumadin for 2 days
When INR FALLS TO 1.5 – precede with surgery
Restart coumadin on day of surgery
Classification of physical status
ASA 1 – Normal healthy person
ASA II – A pt. with mild systemic disease
ASA III – A pt. with severe systemic disease
3 types of nerve injuries
1. Neuropraxia – contusion of a nerve (continuity of epineural sheath & axons)
2. Axontmesis – a. Continuity of axon but lost
b.Continuity of sheath
3. Neurotmesis – Complete loss of nerve continuity
Hepatitis viruses
1. Hep A – spread through contact with feces
2. Hep B – spread through contact with secretions
has the most serious risk of transmission
3. Hep C- spread through contaminated feces or blood
4. Hep D- spread through contact with secreti
2
Definitions used in preventing infection
1. Sepsis – The breakdown of living tissue by microorganisms
2. Antiseptic – prevents multiplication of microorganisms (applied to living
tissue)
3. Disinfectant – prevents multiplication of microorganisms (applied to inanimate
objects)
4. Sterility – Freedom from viable organisms
5. Sanitization – Reduction of the number of organisms to a safe level
6. Decontamination – similar to sanitization
Local Anesthesia
Typical anesthesia molecule has 3 parts
1. Aromatic group – Confers lipophilic properties
Lipid solubility essential for penetration of various anatomic barriers
between the drug and its site of action
2. Intermediate chain has 2 purposes
a. Separates the lipophilic from hydrophilic ends
b. Classification
Ester COO—-
Amide NHCO —
3. Tertiary Amino terminus – Furnishes H2O solubility – ensures once injected,
the drug will not precipitate in the interstitial fluids
Gow-Gates Technique
1. With a single injection, anesthetizes inferior alveolar, lingual &
buccal nerves
2. Advantage – 98% complete anesthesia as opposed to 84%
3. Disadvantage – technique more difficult to learn; slightly longer
induction time; may require greater quantity of solution
4. Differs from other injection techniques
a. Relies on extra oral landmarks
b. Not adjacent to the nerve to be anesthitized but 10mm away
from condylar neck just below insertion of the lateral pterygoid
muscle
3
ACE inhibitor – Angiotensin Converting Enzyme
1. Blocks the conversion of angiotensin to a substance that increases salt
and H2O retention, ie. – treats high blood pressure
Osteoradionecrosis
1. A devitalization of bone secondary to radiotherapy and due to an endarteritis
2. Is not an infection
Why antibiotics fail
1. Lack of pt. compliance
2. Failure to treat the infection locally
3. Inadequate dose or length of treatment
4. Presence of resistant organisms
5. Nonbacterial infection
Signs of a Mandibular Fracture
1. Alteration in occlusion
2. Lower lip numbness
3. Pain or submucosal hemorrhage at fracture site
Stages of wound healing
1. Inflammatory
2. Fibroplastic
3. Remodeling
Trigeminal neuralgia (aka Tic douloureux)
1. Severe paroxysmal pain
2. Usually unilateral
3. V2 & V3 most affected
4. An anticonvulsant such as Tegretol
Classification of TMJ Disorders
1. Myofascial pain – the source of the pain is muscular
2. Disk Displacement – aka internal derangement
3. Degenerative joint disease
4. Chronic recurrent dislocation
4. Ankylosis
Technique of administration of N2O – 02 anesthesia
1. Place nasal mask and start 6 L. of 100% O2
2. Start N2O (approx. 20 %)
3. Increase flow of N2O 10% q. 1 min. until sedation is adequate
4. After procedure – terminate N2O but continue O2 for 3-5 min.
4
Preprosthetic Surgery
A. Simple Alveoplasty
1. Establish an envelope flap (add a vertical releasing if site is not
adequate)
2. Use rongeur & bone file
3. Suture
B. Intraseptal Alveoplasty
1. Reflect mucoperiosteum (minimally)
2. With arongeur remove intraseptal bone
3. Fracture the labio cortical plate inward
Advantages
1. Height of ridge maintained
2. Periosteum to underlying bone is maintained
Minimal dimensions of bone for endosteal implants
1. Vertical dimension – 8mm.( 2mm of bone from apex to inf. alv. canal)
2. Bone width – 1 mm on buccal and 1mm lingual to implant
Two main types of Implants
1. Endosteal
2. Trans mandibular
Midface fractures and osteotomies – Classification
1. LeFort I – Separates inferior portion of maxilla in a horizontal fashion
2. LeFort II – Separates maxilla & nasal complex from cranial base
3. LeFort III – Craniofacial separation (extends through orbits)
1
Behavior Guidance in Dental Office
n Parental input (positive or negative) is by far
the most important predictor of pediatric
patient behavior
n Fear is one of the most frequently
experienced childhood emotion.
n In managing the fearful child, the dentist
should first attempt to determine the degree
of fear and the factors responsible for it.
Common Pediatric Behavior
Management Techniques
n Modeling: The pedo patient views another pedo patient who is cooperative, and
is used as a “model.”
n Tell/Show/Do: The dentist tells the patient what will happen (“I will look at your
teeth with my mirror”), then show the patient the mirror, then does the procedure
(looking at the teeth). Tell/Show/Do is not useful for injections, extractions, etc.
n Wording Choices: Using simple, pleasant words for actions and instruments can
help. The acid etch “taste like lemon juice,” the cotton roll c an be a “tooth
pillow,” the handpiece can be a “water sprayer.” Even the injections can be a
“mosquito bite.” These language choices can reduce fear and anxiety.
n Voice Control: The use of a loud authoritarian voice tone is useful for limitsetting and for stopping dangerous behavior.
n HOME(Hand over Mouth Exercise): May return the patient to a calmer state. The
hand is placed over the mouth, and the patient is told in a stern voice, that the
hand will be removed when the undesirable behavior stops.
The First-Time Dental Patient
n Time of the Appointment: Time may influence the
behavior. Early morning hours are reserved for young
children.
n Length of Appointment: The apprehensive or fearful child
should have relatively short appointments (less than 45
minutes) until the child becomes fully indoctrinated and
gains confidence in himself or herself and the dentist.
n First Visit Procedures: If active pain or infection does not
exist, a first visit is often limited to procedures that are
reasonably comfortable of the child (exam, prophy,
fluoride, x-ray, and possible sealants).
Premedication
n Often useful for long surgical and operative procedures and for fearful,
nervous, and apprehensive children.
n May be indicated for children with behavioral problems
n Ataraxic drugs have proved to be effective in reducing anxiety and tension
without putting the patient in a hypnotic state.
n The drug acts indirectly on the autonomic nervous system by upsetting the
balance of the sympathetic and parasympathetic mechanisms.
n Many dentist have found it effective to prescribe ataraxic drugs the night
before the appointment and repeat the dose 30-45 min. prior to the appt.
n Ataraxic drugs (promethazine-Phenergan, chlorpromazine –Thorazine).
Both are phenothiazine derivatives, and hydroxyzine (Atarax), a cortical
depressant chemically unrelated to most others.
Indications for use of General
Anesthesia
n Children with developmental disability to the
degree that communication is impossible
n Children in whom all other methods have
proven unsuccessful
n Patients allergic to other anesthetics
n Patients who suffer from hemophilia
n Patients with involuntary movement
n Patients with systemic disorders and/or
congenital anomalies
1
1
Clinical Pedodontics
Cavity Preparation Principles in
Primary Teeth
• In general – Primary teeth preparations are
smaller, more delicate, and more rounded than
their permanent counterparts
• Specifics (Class II preparation)
– Axial-pulpal line angle should be rounded to reduce
the stresses and the buccal and lingual walls should
parallel the external crown outline form of the tooth
– Rounded internal line angles will result in…
• Less concentration of stresses
• Reduced restoration fracture
• Permit more complete condensation of the amalgam
Cavity Preparations (cont.)
• Specifics (Class III preparation)
– Dovetail placed on lingual or labial of prep will
allow for additional retention and necessary
access to insert the restorative material
– Greater strength composite bonding systems
can reduce the need for the mechanical
retention
Cavity Bases and Liners
• Important Points
– Purpose of base prior to condensation is to
provide thermal insulation for the pulp.
– Use of calcium hydroxide influences formation
of secondary dentin.
• Initiates local inflammatory response at site of
contact between pulp and calcium hydroxide
Stainless Steel Crowns
• MOD preparations are difficult on primary first
molars due to small tooth size and loss of tooth
structure. SSC’s are often indicated instead.
• Indications for use:
1) Extensive carious lesions
2) Hypoplastic Teeth
3) Teeth showing dentinogenesis or amelogenesis imperfecta
4) Restoration after pulpotomyin which there is an increased
danger of fracture
5) For crown and loop space maintainer
6) For habit-breaking appliances
7) Restoration of fractured teeth
Indirect Pulp Cap
• Only those teeth with deep caries that are
free of symptoms should be selected.
• Procedure should include:
– Removal of gross caries
– Allowing some caries to remain, if its removal would result in an
exposure
– Calcium hydroxide or zinc oxide eugenol placed and covered by
temporary filling
– Allow process to arrest and secondary dentin to form for 6-8
weeks
– After time has elapsed, remove arrested carious dentin, place
calcium hydroxide if sound dentin found, and restore
conventionally.
2
2
Pulpotomy
• Indication – coronal pulp shows evidence of
inflammation or degenerative change, but radicular pulp
is still healthy.
• Two common techniques:
1)Calcium hydroxide technique – recommended for permanent
teeth with incomplete root formation. Coronal pulp is removed
and calcium hydroxide is placed. RCT should be completed
once root formation has completed
2)Formocresol technique – recommended for primary teeth with
carious exposure. Coronal pulp is removed, cotton pellet
moistened with formocresol is placed in contact with the pulp
stumps and remains for 5 minutes. Zinc oxide eugenol is placed
over exposure site and the tooth is restored.
*fistulas, PAPs in the furcation, and abscess are contraindications
to both pulpcaps and pulpotomy*
Internal Resorption
• Most frequently seen evidence of
abnormal response to pulpotomy.
• A destructive process believed to be
caused by osteoclastic activity.
• No reason for occurrence
Alveolar Abscess
• Occasionally develop a few months after
pulp therapy has been completed.
• Tooth is asymptomatic.
• Fistulous opening may be present –
indicates chronic infection.
• Will appear as radiolucency
radiographically.
• Primary teeth with evidence of abscess
should be removed.
3
1
COMMON
PATHOLOGIC LESIONS
&
NBDE II
PATHOLOGY REVIEW
Dr. Parish P. Sedghizadeh
Test Logistics
• 2 days
–Multiple Choice questions (200 a.m. + 200 p.m.)
• Dental and Specialty topics admixed
• Pathology/Radiology questions have
images supplement – quality suboptimal
–Cases with questions (10-13 cases/9-14
questions each ‡ 200 questions a.m. then out)
• Pathology and other specialty questions are
distributed throughout the exam, including the
case section. Also 1-3 histology and 4-8
general pathology questions.
– Diagnosis and Treatment planning emphasis
A
Vesiculo-Ulcerative
Differential Dx:
• Lichen Planus
• Pemphigoid
• Pemphigus
Vulgaris
– May present as: Desquamative
Gingivitis!
– Immune-mediated conditions
– Immunofluorescent studies
———————-‡
4
2
B
C
5
3
D E
F G
H I
6
4
J
K
L
7
5
8
6
9
7
10
8
11
1
DISEASES OF THE
TEETH AND JAWS
Enamel Hypoplasia
• Local or systemic factors that interfere with the
normal matrix formation.
• Presents enamel surface defects and irregularities.
• Causes:
• Nutritional deficiency
• Neurologic defects (eg, cerebral palsy)
• Nephrotic disorders
• Allergies
• Local infection and trauma
• X-rays
• Rubella
Dentinogenesis Imperfecta
• Hereditary developmental
disturbance of the dentin in
the absence of any systemic
disorder.
• Similar dental changes may
be seen in conjunction with
systemic hereditary disorder
of bone, osteogenesis
imperfecta.
• After the primary dentition is
complete, enamel breaks
away from the incisal edge
and the occlusal surface.
• Characteristics:
• grayish/brownish
opalescent color
Dentinogenesis Imperfecta (Con’t)
• Characteristics (Con’t)
• Bulbous crowns
• Cervical constriction
• Obliterated pulp chambers and canals
• Tx: Full coverage. Enhance esthetics and to prevent
gross abrasion of the tooth structure.
Amelogenesis Imperfecta
• Group of conditions that
demonstrate developmental
alterations in the structure
of the enamel in the
absence of a systemic
disorder.
• Defective tooth structure is
limited to the enamel.
• Teeth are
yellowish/brownish in color.
• The enamel becomes
stained due to the
roughness of the surface
and the increased
permeability.
• Tx: Depends on the severity.
Mostly full coverage (since the
dentin structure is normal, the
teeth can be prepared for standard
crowns).
• Decrease hypersensitivity
• Improve esthetics
• Prevent gross abrasion of
the tooth structure.
Anodontia
• Implies the complete failure of the teeth to
develop.
• It is one of the manifestations of
ectodermal dysplasia.
• Since the absence of teeth predisposes to
a lack of growth of the alveolar process,
the construction of dentures is complicated.
12
2
Oligodontia (Partial Anodontia)
• When a number of the primary teeth fail to develop.
• Other ectodermal deficiencies are usually evident.
• The size of the primary teeth that are present may be
normal or reduced.
• The anterior teeth often have a conical shape, which is
characteristic of oligodontia associated with an
ectodermal dysplasia.
• The teeth most frequently missing are the mandibular
second bicuspids, the maxillary lateral incisors, and the
maxillary second bicuspids.
Additional Definitions
• Hypodontia
• Hyperdontia
• Microdontia
• Macrodontia
13
1
Part II COMPONENTSENDO
ÀClinical Diagnosis, Case Selection,
Treatment Planning, and Pt management 14
ÀBasic Endodontic Treatment Procedures 8
ÀProcedural Complications 3
ÀTraumatic Injuries 2
ÀAdjunctive Endodontic Therapy 1
ÀPost- Treatment Evaluation 2
ÀApproximately 60% of the
questions are repeats from
previous exams
BOARD REVIEW
À PULP BIOLOGY
À TOOTH ANATOMY
À PULP DIAGNOSIS
À ROOT CANAL THERAPY
À ENDODONTIC SUCCESS-FAILURE
À MISCELLANEOUS PULP BIOLOGY
PULP COMPOSITION
À In the normal dental pulp, which of the
following histologic features is (are) the lest
likely to appear:
A) Cell-free zone of Weil
B) Palisade odontoblastic layer
C) Lymphocytes and plasma cells
D) Undiffentiated mesenchymal cells
PULP COMPOSITION
À Which of the following cells are
characteristic of chronic inflammation of the
dental pulp:
a) Neutrophils
b) Eosinophils
c) Lymphocytes
d) Macrophages
e) Plasma cells
1) a,b,c & d 2) a,b, & d only 3) a,b, & e only
4) a, c & e 5) c, d & e only
14
2
AGING OF PULP
ÀAging of the pulp is
evidenced by an
increase in fibrous
elements
PULPAL NERVOUS
SYSTEM
ÀEfferent nerves found in the dental pulp
are:
– sympathetic post ganglionic fibres
HYDRODAMIC THEORY TYPES OF DENTIN
À PRIMARY
À SECONDARY
À TERTIARY
– REACTIONARY
– REPARATIVE
À TUBULAR
À PERITUBULAR
À INTERTUBULAR
À GLOBULAR
À INTERGLOBULAR
À SCLEROTIC
ACCESSORY CANALS
À Studies indicated that patent blood vessels
course in lateral or accessory canals connecting
the coronal and/or radicular pulp with the PDL.
À They appear to be distributed at any level of
the root as well as on the floor of the pulp
chamber.
À Distribution of lateral canals
– 17% in the apical third
– 8.8% in the middle third
– 1.6% at the coronal portion
ACCESSORY CANALS
À A non-carious tooth with deep periodontal
pockets that do not involve the apical third of
the root has developed an acute pulpitis. There
is no history of trauma other than a mild
prematurity in lateral excursion. What is the
most likely explanation for the pulpitis?
1) Normal mastication plus toothbrushing has driven
microorganisms deep into tissues with subsequent pulp
involvement at the apex.
2) During a general bacteremia, bacteria settled in this
aggravated pulp and produced an acute pulpitis.
3) Repeated thermal shock from air and fluids getting into
the deep pockets caused the pulpitis.
4) An accessory pulp canal in the gingival or the middle
third of the root was in contact with the pockets.
15
3
APICAL FORAMEN
APICAL FORAMEN
À Initial instrumentation in endodontic
tx is done to:
a) Radiographic apex
b) Dentino-enamel junction
c) Cemento-dentinal junction
d) Cemento-pulpal junction
CEMENTUM
ÀCELLULAR – APICAL THIRD OF
ROOT
ÀACELLULAR
TOOTH ANATOMY
MANDIBULAR 1st MOLAR
À Approximately what per cent of
mandibular first molars exhibit two
distal canals?
1) 0
2) 0.1
3) 0.3
4) 0.6
5) 0.75
16
4
MAX 1ST MOLAR
À BUCCAL HOOK PALATAL ROOT
À 4 CANALS
À MB1 (MB); MB2 (ML)
À 74% 2nd canal
– Half have a separate foramen
À The most common curvature of the palatal root of the
maxillary first molar is to the
1) facial.
2) mesial
3) distal
4) lingual
MAX FIRST BICUSPID
À EASIEST TOOTH TO PERFORATE
À MESIAL CONCAVITY
À CANAL NUMBER: 90% 2, 10% 1
À RADIOGRAPH
À SLOB / Clark’s Rule/BUCCAL OBJECT
RULE
À CONE SHIFT
The teeth that are easiest to perforate by slight mesial or
distal deviation from proper angulations of a bur are
mandibular incisors and maxillary first premolars
MAX LATERAL INCISOR
ÀPOSSIBLE SEVERE
DISTAL
CURVATURE
IN APICAL 1/3
ÀCURVE MAY HAVE
A PALATAL ASPECT
TO IT
MAX LATERAL INCISOR
À Which of the following teeth are the
least likely to have more than 1 canal
1) Maxillary lateral incisors
2) Mandibular lateral incisors
3) Mandibular first premolars
4) Maxillary second premolars
5) Maxillary second molars
MOST CONSISTENT ROOT
CANAL ANATOMY
À MAXILLARY CUSPID
DIAGNOSIS
17
5
DIAGNOSIS
¾ PULP
¾ PERIRADICULAR
¾ ENDO- PERIO
¾ REFERRED PAIN
¾ SINUS TRACTS
¾ CYST AND GRANULOMA
¾ RESORPTION
¾ NON-ODONTOGENIC
¾ ANKYLOSIS
PULP DIAGNOSIS
À NORMAL
À REVERSABLE PULPITIS
À IRREVERSABLE PULPITIS
À NECROTIC
PULP DIAGNOSIS
À Which is most likely to cause pulp necrosis:
1) Intrusion
2) Extrusion
3) Lateral displacement
4) Concussion
À Prolonged, unstimulated night pain suggests which of
the following conditions of the pulp?
1) Pulp Necrosis
2) Mild hyperemia
3) Reversible pulpitis
4) No specific condition
PERIRADICULAR
DIAGNOSIS
À ACUTE PERIRADICULAR
PERIODONTITIS
À ACUTE APICAL ABSCESS
À CHRONIC PERIRADICULAR
PERIODONTITIS
À CHRONIC PERIRADICULAR ABSCESS
– SUPPURATIVE PERIRADICULAR
PERIODONTITIS
À SUBACUTE PERIRADICULAR
PERIODONTITIS
À NORMAL
PERIRADICULAR
DIAGNOSIS (contd) À How to differentiate between acute apical abscess and acute
periodontal abscess:
– Pulp vitality test
À Percussion is a dental diagnostic procedure used in
determining whether periodontitis exists!
À The pathognomic symptom of chronic apical periodontitis
is:
1) Swelling
2) Intermittent pain
3) Tenderness to palpation
4) Tenderness of percussion
5) None of the above
À Radiographs reveal a deep, distal carious lesion
on the suspect tooth. The apical periodontal
ligament appears normal most probable
diagnosis for the condition of the pulp and the
apical periodontal ligament is
1) Vital pulp
2) Necrotic pulp
3) Irreversibly inflamed pulp
4) Inflamed apical periodontal ligament
5) Uninflamed apical periodontal ligament
a) 1& 4
b) 1 & 5
c) 3 & 4
d) 3 & 4
e) 3 & 5
18
6
ENDO PERIO
À PRIMARY ENDO
À PRIMARY PERIO
À PRIMARY ENDO – SECONDARY PERIO
À PRIMARY PERIO – SECONDARY ENDO
À TRUE COMBINED LESION
À PULP TEST – PROBE
ENDO PERIO
ENDO PERIO ENDO PERIO
ENDO PERIO REFERRED PAIN
ÀSITE OF PAIN – WHERE IT IS FELT
– LOCATION
ÀSOURCE OF PAIN – ORIGIN
ÀREFERED PAIN – THE SITE AND
SOURCE ARE NOT THE SAME
19
7
SINUS TRACT
• The cone should The cone should
track back to the track back to the
source of infection
• This will This will
demonstrate which demonstrate which
root of the molar is root of the molar is
affected
Presence of sinus tract Presence of sinus tract
SINUS TRACT
1. Conventional RCT, Conventional RCT,
antibiotics not needed. antibiotics not needed.
2. Will heal in 2 Will heal in 2-4 weeks after 4 weeks after
conventional RCT
3. If present, post RCT do If present, post RCT do
apical surgery with apical surgery with retrofill retrofill
(answer for the board) (answer for the board)
LATERAL PERIODONTAL
CYST
ÀVitality test
ÀNot of pulpal origin
GLOBULOMAXILLARY
CYST
ÀMythical lesion allegedly located
between maxillary lateral incisor and
cuspid
ÀVitality test
GRANULOMA
Periapical Inflammation
• An extension of pulpal An extension of pulpal
inflammation inflammation
• Periapical tissues will Periapical tissues will
become involved before become involved before
total pulpal necrosis total pulpal necrosis
• Bacteria and Bacteria and
inflammation by inflammation by
products leak through AF products leak through AF
and start inflammation
Apex
Granuloma
APICAL CYST
20
8
NON-ODONTOGENIC
CONDENSING OSTEITIS
À Confirm vitality
ÀHistory of tooth
or restoration
ÀRCT vs No RCT
CEMENTOMA
ÀVitality test
ÀRadiolucent/opaque lesion
ÀCalcifying fibroma
ÀPredominant location lower anteriors
ÀEthnic link observed (Predominantly
among African-American)
CEMENTOMA
ANKYOLOSIS
À Which is the most important sign of
Ankylosis:
1) Dull sounding
2) Resonant
3) Cessation of eruption
4) Cross bite INFECTION
21
9
BACTERIA
ÀKakehashi, Stanley, Fitzgerald
À1965
ÀBacteria are the problem
INFECTION SEVERITY
ÀRESISTANCE OF HOST
ÀVIRULENCE
ÀPOPULATION/NUMBER
CHRONIC
INFLAMMATION OF THE
PULP
ÀLYMPHOCYTES
ÀMACROPHAGES
ÀPLASMA CELLS
FATE OF
EXTRARADICULAR
INFECTION
ÀSOME PROBLEMS SUCH AS
ACTINOMYCOSES ARE
EXTRARADICULAR AND MAY
REQUIRE SURGERY TO RESOLVE
THE INFECTION.
ÀTRUE CYSTS
ÀOSTEOMYELITIS
ÀBIOPSY AND CULTURE
WHY DO WE HAVE A
PROBLEM
BACTERIA!!!
CRITERIA for SUCCESS
ÀELIMINATE BACTERIA
ÀPROTECT AGAINST BACTERIA
¾ Severity of the course of a periapical
infection depends upon the :
1) Resistance of the host
2) Virulence of the organism
3) Number of organism present
4) All of the above
5) Only 1 and 2
22
10
CRITERIA for SUCCESS
ÀWhat is the radiographic sign of
successful pulpotomy in a permanent
tooth?
1)Open apex
2)That the apex has formed
3)Loss of periapical lucency
4)No internal resorption
RESORPTION
PHYSIOLOGIC OR PATHOLOGIC
LOSS OF TOOTH STRUCTURE
SURFACE RESORPTION
ÀA PHYSIOLOGIC PROCESS
CAUSING SMALL SUPERFICIAL
DEFECTS IN THE CEMENTUM AND
DENTIN THAT UNDERGO REPAIR
BY DEPOSITION OF NEW
CEMENTUM
ÀUSUALLY NOT DETECTABLE ON A
RADIOGRAPH
SURFACE RESORPTION
PRESSURE RESORPTION
ÀORTHODONTIC TOOTH MOVEMENT
ÀTOOTH ERUPTION
ÀTUMORS
Pressure ResorptionOrthodontics
23
11
Pressure Resorption-Eruption Pressure Resorption-Eruption
INFLAMMATIORY
RESORPTION
ÀBACTERIA
ÀEXTERNAL
ÀINTERNAL
ÀPATHOLOGIC LOSS OF TOOTH
STRUCTURE RESULTING IN A
DEFECT IN THE ROOT AND
ADJACENT BONE
INFLAMMATORY
RESORPTION
INFLAMMATORY
RESORPTION
REPLACEMENT
RESORPTION
À ANKYLOSIS
À TRAUMA
À IDIOPATHIC
À PATHOLOGIC LOSS OF TOOTH
STRUCTURE WITH THE INGROWTH OF
BONE INTO THE DEFECT
À FUSION OF BONE TO CEMENTUM OR
DENTIN
24
12
External Replacement
Resorption
ÀIdiopathic
ÀExtracanal invasive resorption
ÀCervical resorption-most common name
ÀExternal invasive resorption
ETIOLOGY OF RESORPTION
ÀUNKNOWN
ÀTRAUMA
ÀORTHODONTICS
ÀINTERNAL BLEACHING
ÀBACTERIA
EXTERNAL RESORPTION
ÀSURFACE
ÀPRESSURE
ÀINFLAMMATORY
ÀREPLACEMENT
ÀINFLAMMATORY PERIRADICULAR
LESIONS ALWAYS RESULT IN
RESORPTION OF BOTH BONE AND
TOOTH
EXTERNAL INVASIVE
RESORPTION
External
Invasive
Resorption
CERVICAL
RESORPTION
INTERNAL RESORPTION
25
13
INTERNAL RESORPTION
ÀSURFACE
ÀINFLAMMATORY
ÀNECROTIC TEETH ALWAYS HAVE
INTERNAL INFLAMMATORY
RESOPRPTION
ÀPERFORATION
INTERNAL RESORPTION
INTERNAL RESORPTION
DIFFERENTIATION OF
INTERNAL AND
EXTERNAL RESORPTION
ÀINTERNAL
– REGULAR
– ROUND
– CENTERED, USE SLOB RULE
ÀEXTERNAL
– IRREGULAR, MOTH EATEN
– OFF CENTER, USE SLOB RULE
INTERNAL RESORPTION EXTERNAL RESORPTION
26
14
TREATMENT
ÀINTERNAL RESORPTION
9 ENDODONTIC TREATMENT
9 MAY BE DIFFICULT
– PERFORATION
– APICAL
TREATMENT CONTINUED
ÀEXTERNAL INFLAMMATORY
9 CALCIUM HYDROXIDE
9 CONTROL INFECTION
9 FILL CANALS
EXTERNAL
INFLAMMATORY
RESORPTION
TREATMENT CONTINUED
À EXTERNAL REPLACEMENT
– CALCIUM HYDROXIDE
– CONTROL INFECTION
– FILL CANALS
À AVULSION
– GUARDED TO HOPELESS
À IDIOPATHIC
– PROGNOSIS DEPENDS ON EXTENT AND
LOCATION
27
15
ROOT CANAL THERAPY
ROOT CANAL THERAPY
À Access
À Irrigants
À Files
À Sealers
À Gutta Percha
ACCESS
The objectives of the access
preparation are to:
À 1. Provide unobstructed visibility into all canals.
À 2. Allow files to be passed into each canal without binding
on the walls of the access preparation (straight line access to
avoid ledge).
À 3. Allow obturation instruments to fully enter each canal
without binding on the walls of the access preparation.
À 4. Include removal of all caries and defective restorations.
À 5. Make possible the removal of all pulp tissue.
À 6. Removal of the roof of the pulp chamber.
ACCESS
ÀOVAL
ÀTRIANGULAR
ÀTRAPEZOIDAL- Mandibular molar
with 4 canals.
ACCESS
À Which of the following can cause a ledge
formation:
1) Infection
2) Remaining debris within the canal
3) No straight line access
À A mandibular molar has 4 canals. How
should the access opening be:
1) Round
2) Oval
3) Trapezoidal
4) Triangular
28
16
IRRIGANTS
IRRIGANTS
À EDTA
À SODIUM HYPOCHLORIDE
EDTA
ÀEDTA- 16-20% solution
ÀChelating agent
ÀDecalcifies dentin
ÀRemoves smear layer
SODIUM HYPOCHLORITE
À5.25% NaOCl
ÀDissolves organic material
ÀKills bacteria
ÀSterilize GP, (wipe with alcohol
afterwards)
FILES
PRECURVE FILES
À Precurve all stainless steel files prior to
placement in a canal
À Precurving files is indicated
1 for files sizes #35 and over.
2 in canals that are even slightly curved.
3 as a way to negotiate past canal obstructions.
4 All of the above
5 Only (1) and (2) above
6 Only (2) and (3) above
29
17
SEALERS
SEALERS
Zinc oxide eugenol – Kerr Sealer
Resin – AH26
Paste fill
Which of the following represents the
basic constituents of most root canal
sealers:
Answer: Zinc oxide
Other Root Canal Therapies
ÀApexification
ÀPulpotomy
ÀApexogenesis
ÀApicoectomy
ÀPulp Cap
APEXIFICATION
APEXIFICATION
À NECROTIC IMMATURE TOOTH
À CONFIRM DIAGNOSIS
À ACCESS – DEBRIDMENT
À SODIUM HYPOCHLORITE – INSTRUMENTATION
À PLACE CALCIUM HYDROXIDE
À PLUGGER, LENTULO SPIRAL, COMPACTOR,
MESSING GUN
À What kind of procedure should be performed on a
tooth with necrotic pulp and unfinished root tip
– apexification
DIAGNOSE
ACCESS
DEBRID
INSTRUMENT
DISSOLVE
30
18
APEXIFICATION APEXIFICATION
APEXIFICATION
APEXOGENESIS
A vital pulp therapy procedure
performed to encourage continued
physiological development and
formation of the root end. This term is
frequently used to describe vital pulp
therapy performed to encourage the
continuation of this process.
31
19
APEXOGENESIS
À What is best sign for success of
apexogenesis
– Continuous completion of apex
APEXOGENESIS
APEXOGENESIS MTA – Mineral Trioxide
Aggregate
ÀDr Mahmoud Torabinejad, Loma Linda
ÀModified Portland Cement
ÀBismuth oxide
ÀVery good seal
ÀExpands slightly when sets with moisture
ÀLong setting time
Uses for MTA
ÀPulp cap
ÀPerforation repair
ÀPulpotomy
ÀApexification
ÀApical barrier
Other products
ÀWhite MTA
ÀSOC – Silicate Oxide Compound
ÀUSC – Universal Silicate Cement
32
20
PULPOTOMY
PULPOTOMY
ÀPulp cap
ÀPartial/Cvek
pulpotomy
ÀPulpotomy
ÀDeep pulpotomy
ÀPulpectomy
PULP CAP
WHY PULP CAP ???
ÀMAINTAIN NORMAL PULP VITALITY
ÀRETURN PULP TO NORMAL
ÀAVOID ENDODONTIC TREATMENT
ÀAVOID EXTRACTION
ÀAVOID EXTENSIVE TREATMENT
ÀPOSTPONE ENDODONTIC
TREATMENT
PULP CAP
DIRECT
À Pulp capping and pupotomy
can be more successful in newly
erupted teeth than in adult teeth
because :
1. a greater number of
odontoblast are present
2. incomplete development
of nerve endings
3. open apex allows for
greater circulation
PULP CAP
DIRECT
À Calcium hydroxide is generally
the material of choice in vital
pulp capping because :
1) Encourages dentin bridge
formation
2) Is less irritating to the pulp
3) Seals the cavity better
4) Adheres well to dentin
33
21
To ensure better thermal
and protective insulation
of the pulp during a
capping procedure ,CaOH
should be covered with
stronger base
Pulp cap
traumatic exposure
INDIRECT PULP CAP INDIRECT PULP CAP
INDIRECT PULP CAP INDIRECT PULP CAP
34
22
INDIRECT PULP CAP INDIRECT PULP CAP
REPLANTATION
ÀWHEN BOTH SURGERY AND
RETREATMENT ARE DIFFICULT
THEN EXTRACTION AND
REPLANTATION MAY BE THE
TREATMENT OF CHOICE
ENDODONTIC SUCCESS – FAILURES
FAILURE – SUCCESS
REASONS
ÀPoor condensation, incomplete fill
ÀInadequate disinfection
À The most frequent cause of failure in
endodontics is
1. split roots.
2. root perforation.
3. Incomplete obturation.
4. separated instruments.
5. filling beyond the apex.
TRAUMA – FRACTURES
35
23
TRAUMA
À AVULSION: Milk, replant ASAP, open apex,
splint 7-10 days, endo tx 1wk, Ca(OH)2 ,
resorption, replacement, inflammatory
À CONCUSSION: least damaging
À LUXATION: pulp necrosis likely, 60%
immature apex teeth become nonvital
Intrusive luxation, necrosis, ankylosis
À FRACTURES
TRAUMA
À An 8-year-old boy received a traumatic injury
to a maxillary central incisor. One day later,
the tooth failed to respond to electric and
thermal vitality tests. This finding dictates
1. pulpectomy.
2. apexification.
3. calcium hydroxide pulpotomy.
4. delay for the purpose of re-evaluation.
One year ago, a 9-year-old boy fractured a
central incisor. A current radiograph of the
tooth is adjacent. There are no symptoms. The
tooth does not respond to pulp testing;
however, control teeth do respond. What is the
preferred treatment?
1. Pulpotomy with Ca(OH)2
2. Pulpotomy with formocresol
3. Conventional root canal treatment
4. Debridement of the pulp space and
apexification
TRAUMA INTRUSION
Management
À Immature teeth
– A tooth with an open apex is likely to re-erupt spontaneously
– Monitor the progress of re-eruption
– No treatment is needed if tooth re-erupts into normal position
and there is no evidence of pulpal involvement
À Mature teeth
– Intruded mature teeth need to be repositioned immediately
– Initial extrusion will be made orthodontically or surgically
depending on degree of intrusion
Prognosis
À High risk of pulp necrosis; Endodontic therapy is often indicated;
possibility of resorption shows the need to follow up
Recalls
À Evaluate 4-6 weeks after trauma and after 6 months; after that
yearly recall are indicated
Tavitian/USC Endo
Root Fractures
Limited to fractures involving roots only;
cementum, dentin, and pulp
FRACTURED ROOTS
À CORONAL THIRD:
ENDO AND ORTHO
EXTRUSION
À MIDDLE THIRD: SPLINT
AND OBSERVE
À APICAL THIRD: ENDO
TO THE FRACTURE LINE
IF NECROTIC, APEX
USUALLY REMAINS
VITAL
36
24
FRACTURED ROOTS
À There is a root fracture in the apical third of the root
of a mandibular tooth. What will be the most likely
result?
1) Root resorption
2) Ankylosis
3) Vitality will be preserved
4) Teeth will show internal resorption
À There is a root fracture in the middle third of the
root in an 11 year old patient. The tooth is mobile
and vital. What will you do?
1) Extract
2) Pulpectomy
3) Splint and observe
4) Do nothing
VERTICAL ROOT FRACTURES
À Failure of tooth with recently placed post and core :
Vertical root fracture
À Majority of vertical root fractures of endo tx teeth
result from: Condensation forces during gutta-percha
filling
À Diagnose with perio probe, narrow periodontal pocket
width
À Tx is extraction
SEPARATED INSTRUMENTS
SEPERATED
INSTRUMENTS
À APICAL 3RD & VITAL – fill and
observe, temporize, no permanent
restoration for 3-6 months
À NON-VITAL – refer to endodontist
À MIDROOT – refer to endodontist
À In all cases inform patient
SURGERY AND HEALING
INDICATIONS FOR
SURGICAL ENDODONTIC
TREATMENT
À Failing RCT where it is not possible (or
practical) to retreat
À Disassemble?
À Post ? Is it practical???
37
25
SURGICAL ENDODONTIC
TREATMENT
À A patient has a draining sinus tract apical to a
maxillary lateral incisor. The tooth, which is restored
with a post and crown, received a root canal filling and
apicoectomy one year ago. Radiographically, the tooth
measures 19 mm. in length. Adjacent teeth respond
normally to pulp testing. The patient is asymptomatic.
Which of the following is the most acceptable
treatment?
1. Retreat and refill the canal with gutta-percha.
2. Retreat and refill the canal, then perform an
apicoectomy.
3. Retreat by surgery using a retrofill amalgam.
4. No treatment is necessary unless the patient develops
symptoms.
APICOECTOMY
À REVERSE FILL
À CURETTAGE
APICOECTOMY
EXPECTED HEALING TIME
À3-6 months for radiographic evidence
ÀAsymptomatic
À2-4 weeks sinus tract gone
À Prognosis of a tooth with a broken instrument located 3
mm. from the apex is probably best if the tooth has a
1) vital pulp with a periapical lesion.
2) vital pulp without a periapical lesion.
3) necrotic pulp with a periapical lesion.
4) necrotic pulp without a periapical lesion.
HEALING
ÀBONE – yes
ÀPDL – yes
ÀDENTIN – no
ÀCEMENTUM – yes
ÀENAMEL – no
HEALING
À Severity of the course of a periapical infection
depends upon the :
1) Resistance of the host
2) Virulence of the organism
3) Number of organism present
4) All of the above
5) Only 1 and 2
À What is the radiographic sign of successful
pulpotomy in a permanent tooth?
1) Open apex
2) That the apex has formed
3) Loss of periapical lucency
4) No internal resorption
HEALING
À Once the root canal is obturated, what
usually happens to the organism that had
previously entered periapical tissues from the
canal:
a) They persist and stimulate formulation of
granuloma
b) They are eliminated by the natural defenses
of the body
c) They re-enter and re-infect the sterile canal
unless periapical surgery is performed
d) They will have been eliminated by various
medicaments that were used in the root canal
38
26
BLEACHING
TOOTH DISCOLORATION
À PULP NECROSIS
À RESTORATIVE MATERIALS
À SYSTEMIC MEDICATIONS
– FLOURIDE
– TETRACYCLINE
À GENETIC
À ENVIRONMENTAL
BLEACHING
À INTERNAL BLEACHING
À WALKING BLEACH
À DO NOT USE STRONG, 30%, H2O2
(Superoxol) – RESORPTION
À SODIUM PERBORATE
À Need to put cement barrier between
gutta percha and bleaching material
MISCELLANEOUS
PULP TESTING
ÀDUPLICATE SYMPTOMS
ÀADJACENT AND CONTRALATERAL
TEETH
ÀCOLD
ÀHEAT
ÀCAVITY TEST PREP
EMERGENCY TX
À SEE PATIENT
À DIAGNOSE
À TREAT
APPROPRIATELY
39
27
EMERGENCY TX
À A patient of record calls late Saturday night because
of severe, throbbing pain aggravated by “heat, biting
and touching” in a mandibular premolar. What
procedure is recommended?
1. Instruct the patient to apply ice intermittently, take
aspirin, and call Monday for an appointment.
2. See the patient at the office and initiate endodontic treatment.
3. See the patient at the office, remove the carious dentin
and place a sedative zinc oxide-eugenol cement.
4. Prescribe an analgesic and refer the patient to an
endodontist.
5. Refer the patient to the hospital oral surgery
department for extraction.
PERFORATIONS
À MESIAL ROOT OF MANDIBULAR
1ST MOLAR
– DISTAL OF MESIAL ROOT
CORONAL
PRETREATMENT
À REMOVE CARIES
À PREVENT LEAKAGE
À SECURE POSITION FOR CLAMP
ROOT SENSITIVITY
ÀEXPOSED DENTIN
ÀRECESSION
ÀSURGERY
ÀDESENSITISE
SYSTEMIC DISEASES
À Premedication- RHEUMATIC FEVER
À AHA Guidelines
OSTEOMYELITIS
À Pt has large carious lesion, toothache,
submandibular facial swelling, fever of
102F. Continuous exudate through
gingival sulcus, moth eaten radiolucent
appearance.
Most probable diagnosis: Acute
osteomyelitis
40
28
À Endodontically treated posterior teeth are
more susceptible to fracture than untreated
posterior teeth. The best explanation for
this is
1. moisture loss.
2. loss of root vitality.
3. plastic deformation of dentin.
4. destruction of the coronal architecture.
5. increased susceptibility of the enamel to
fracture.
MISCELLANEOUS TEMPORARY
RESTORATION
À ZOE is a good temporary restoration
because :
1) less irritant
2) Increased strength
3) Good seal
4) Antibacterial
PULP TEST
À Which of the following is lest useful
in children
1) Percussion
2) Palpation
3) Electric pulp test
4) Thermal test
SLOB Rule
À On a radiograph, the facial root of a
maxillary first premolar would appear distal
to the lingual root if the
1) vertical angle of the cone were increased.
2) vertical angle of the cone were decreased.
3) x-ray head were angled from a distal position
relative to the premolar.
4) x-ray head were angled from a mesial
position relative to the premolar.
SLOB Rule
ÀA radiograph shows a lucency that
does not appear to move with
application of the Clarke’s Principle/
Rule. Where is the lucency situated?
1)No way of telling
2)Lingual
3)In the canal
4)Buccally
41
29
CONCLUSIONS
À Try and maintain pulp vitality
À Young pulps respond better than old
pulps to trauma
À Disinfect
À Seal
42
1
Gingivitis and Periodontal Disease
• Gingiva is normally light pink
• Surface has stippled appearance
• During eruption, gingiva is thick with
rounded margins
• Severe gingivitis is uncommon is children
– Trx: good home care, frequent check-ups,
prophys, Fl trx
Herpes Simplex Virus
– occur in children 2 – 6 yrs
– Oral findings: yellow or
white liquid filled vesicles,
which rupture to form
ulcers in a few days
– After initial attack, virus is
inactive but reappears as
cold sores. Sores appear
on gingiva and attached
mucous membranes
– Trx: palliative, sores heal
in 7 – 10 days
Recurrent Aphthous Ulcer
• Ulceration on mucous
membrane
• Can occur in schoolage children and in
adults
• Lesions persist for 4 –
12 days
• Found more
commonly on loose
mucosa
Candidiasis
• Caused by Candida
albicans
• Normal inhabitant,
pathogenic state when
resistance is lowered
• Can be a sign of
compromised immune
system (i.e. AIDS)
• Trx: Nystatin topically or
ketoconazole
systemically
Dilantin Gingivits
• Occurs in children
receiving Dilantin over
a prolonged period of
time
• Painless hyperplasia
of gingiva
Hyperplasia is
generalized
– Trx: surgical removal
most effective
Scarlet Fever
• Caused by Group A beta
hemolytic streptococci
• After 5 day incubation period,
patient develops pharyngitis,
tonsillitis, headache, fever,
chills, nausea, and vomiting
• Within 2- 3 days, typical bright
red skin rash develops
• Oral manifestation: “strawberry
tongue” and then a “raspberry
tongue”
• Disease ends in 7 – 10 days
43
2
Measles
• Caused by rubeola virus (paramyxovirus
family)
• Portal of entry is respiratory tract
• Oral manifestations: “koplik’s spots”
– develop on buccal mucosa and appear as
small bluish white macules, surrounded by
red margin
• Trx: pallitative
Erythema Multiforme
• Oral manifestations: macules, papules,
vesicles that become ulcerated and
covered by exudate
• Trx: Corticosteroids and antibiotics
44
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Goals
• Stages in evaluating an oral lesion
• Process to develop a differential diagnosis
based on the normal anatomy of the site
• Procedures that can be used to refine the
differential diagnosis and establish a
definitive diagnosis
• Approaches to treat common oral lesions
• Clinical course of some common oral
lesions with and without treatment
Stages for Evaluation of Oral Lesions
• Recognition of Tissue Alteration
• Generation of Differential Diagnosis
• Definitive Diagnostic Procedures
• Recommendation for Treatment
• Clinical Follow-up
Step 1. Recognition of Oral Lesions:
The Process
• History of the condition
• Observation of lesion parameters
– location
– color
– size
– shape
– texture or consistency
– growth pattern Which one of these two lesions would cause you to be most concerned?
A ___________________ B ___________________
Which one of these two lesions would cause you to be most concerned?
A ___________________ B ___________________
Which one of these two lesions would cause you to be most concerned?
A ___________________ B ___________________
45
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Which one of these two lesions would cause you to be most concerned?
A ___________________ B ___________________
Which one of these two lesions would cause you to be most concerned?
A ___________________ B ___________________
Which one of these two lesions would cause you to be most concerned?
B __________________ A ___________________
Stages for Evaluation of Oral Lesions
• Recognition of tissue alteration
• Generation of Differential Diagnosis
• Definitive Diagnostic Procedures
• Recommendation for Treatment
• Clinical Follow-up
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
How long have you had this on the palate? DX – Blue Nevus
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
Are you taking medications for hypertension? DX – Gingival Hyperplasia
2
o
to Ca++ Channel Blocker
46
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Step 1. Recognition Phase
What is the one best question that you could ask this patient?
What kind of gum do you chew? DX – Cinnamon Chewing
Gum reaction
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
Do you put anything beneath your tongue? DX – Aspirin Burn
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
Are you in a risk group for HIV infection? DX – HIV Gingivitis
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
Do you habitually chew or bite your lip? DX – Lip chewing
Step 1. Recognition Phase
What is the one best question that you could ask this patient?
What toothpaste or rinse do you use?
DX – Moderate Epithelial Dysplasia
Viadent Leukoplakia
Stages for Evaluation of Oral Lesions
• Recognition of Tissue Alteration
• Generation of Differential Diagnosis
• Definitive Diagnostic Procedures
• Recommendation for Treatment
• Clinical Follow-up
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Differential Diagnosis:
The Objective
The objective of developing a list of
differential diagnoses is to make sure that
all significant conditions that could present
in a specific manner are considered. The
initial differential diagnosis should include
ALL the potential lesions so that an
important condition will not be missed.
Step 2. Differential Diagnosis:
The Process (Pindborg Paradigm)
Impression of the etiology of the condition
• Developmental or Congenital
• Reactive – Inflammatory/Infectious
• Neoplastic
• Traumatic
• Local Manifestation of a Systemic Disease
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Developmental DX – Varix
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Reactive -Inflammatory? DX – Erosive Lichen Planus
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Reactive -Infectious DX – Hairy Leukoplakia
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Neoplastic DX – Lymphoma
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Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Reactive-Inflammatory & Trauma DX – Pyogenic Granuloma
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Reactive -Infectious DX – Recurrent Herpes
Step 2. Differential Diagnosis Phase
What is your impression of the etiology of this lesion?
Developmental DX – Amelogenesis Imperfecta
Step 2. Differential Diagnosis:
The Process
• Normal Anatomy at the Site
• Tissue types contributing to the normal
anatomy
• Lesions that could develop from the different
tissues
Normal Anatomy/Histology as a
prompt for Differential Diagnosis
The delivery of oral healthcare is continuously
involved with the normal head, neck and
intraoral anatomy and histology. Frequent
encounters with normal soft and hard tissues
provides a ready framework for approaching
differential diagnosis.
Step 2. Differential Diagnosis Phase
What is the normal anatomy/histology at the site?
Mucosa, Connective Tissue,
Minor Salivary Glands
DX – Fibroma with
Pigmentation
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Step 2. Differential Diagnosis Phase
What is the normal anatomy/histology at the site?
Mucosa, Minor Salivary Glands,
Periosteum , Bone, Nerves DX – Fibrous Hyperplasia
Step 2. Differential Diagnosis Phase
What is the normal anatomy/histology at the site?
Mucosa, Connective tissue DX – Speckled Leukoplakia
Step 2. Differential Diagnosis Phase
What is the normal anatomy/histology at the site?
Mucosa, PDL, Periosteum DX – Peripheral Ossifying Fibroma
Step 2. Differential Diagnosis Phase
What is the normal anatomy/histology at the site?
Epithelium, Connective tissue,
Muscle, Nerve, Blood Vessel DX – Chronic Ulcer
Stages for Evaluation of Oral Lesions
• Recognition of tissue alteration
• Generation of Differential Diagnosis
• Definitive Diagnostic Procedures
• Recommendation for Treatment
• Clinical Follow-up
Step 3. Definitive Diagnosis:
The Procedures
NON-INVASIVE
• Diascopy
• Culture
• Exfoliative Cytology
– scrapings, touch preps, Brush Biopsy®
INVASIVE
• Aspiration / Sounding
• FNA biopsy (cytology)
• Biopsy (surgical, punch)
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NON-INVASIVE MODALITIES
62 yo White Female with a Vascular Anomaly on the Alveolar Mucosa
Non-Invasive Diagnostic Procedures
Occlusion of the blood vessel filling the lesion blanches the site and proves that
the pigmented lesion is the result of blood pooling.
Brush biopsy kit
Description
The harvested cells are smeared on a
glass slide and immediately fixed
with alcohol
They are then mailed to the OralCDx®
laboratory
There, the slide is stained and
examined by computer-interfaced
microscopy
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Computer Analysis Description
Computer identifies the worst cells and
photographs them
Pathologist then examines the images
of the most atypical cells and
determines whether the changes
observed are significant or not
(quality control issue similar to PAP
smear diagnosis years ago)
Description
Reading of “normal”, “atypical”, “positive”
or “inadequate sample” is returned
“Inadequate sample” is repeated at no
additional charge
Atypical or positive – scalpel biopsy is
recommended
Normal still requires follow -up, with scalpel
biopsy if it appears suspicious
INVASIVE MODALITIES
FINE NEEDLE ASPIRATION BIOPSY –
ACTUALLY CYTOLOGY CYTOLOGY
FNA
Fluids
– peripheral blood,
marrow, urine, sputum,
discharge…
Pap smears
52
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Surgical Biopsy – Considerations
• Obtain a sample of tissue that has a representation
of the pathologic process under investigation
• Biopsy of ulcerative or erosive conditions requires
sampling of surrounding clinically uninvolved
tissues
• If there is a suspicion of a neoplastic/malignant
process an incisional biopsy should leave sufficient
original tissue to allow the ultimate treating doctor
to assess the extent of the lesion
• Biopsies can be done by all dentists and generally do
not require any special equipment or instruments
Invasive Diagnostic Procedure
21 yo white male with asymptomatic white lesion of dorsum of tongue for weeks-months duration
Invasive Diagnostic Procedure
Infiltration of local anesthetic at the biopsy site
Invasive Diagnostic Procedure
Elliptical incision circumscribing the lesion region of interest
Invasive Diagnostic Procedure
Dissection of specimen below the mucosal junction
Invasive Diagnostic Procedure
Mucosal specimen fixed extended to prevent distortion in subsequent processing
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Invasive Diagnostic Procedure
Fixation of specimen in neutral buffered formalin supplied by Oral Pathology Lab
Invasive Diagnostic Procedure
Biopsy site closed with sutures to be removed at follow-up appointment with diagnosis
Diagnosis – Lichen Planus
21 yo white male with asymptomatic white lesion of dorsum of tongue for weeks-months duration
Invasive Diagnostic Procedure
31 African-American male with asymptomatic rubbery firm lump in upper lip of months-years
duration
Invasive Diagnostic Procedure
Incision to expose nodule embedded deep in the structure of the lip
Invasive Diagnostic Procedure
Nodule exposed and released by blunt dissection through originalincision site
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Invasive Diagnostic Procedure
Nodule removed for submission to oral pathologists with capsule intact
Diagnosis – Pleomorphic Adenoma
You judge the case?
55
Page 12
Stages for Evaluation of Oral Lesions
• Recognition of tissue alteration
• Generation of Differential Diagnosis
• Definitive Diagnostic Procedures
• Recommendation for Treatment
• Clinical Follow-up
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Page 13
Treatment
Treatment will be based on the
definitive diagnosis of the oral lesion
and correlated with the etiology of the
lesion: Developmental, Reactive or
Neoplastic
Common Oral Lesion
Candidiasis
• Recognition – Red or white
change of mucosa
• Differential Diagnosis – Other
red or white lesions
• Definitive Diagnosis – Culture,
Exfoliative cytology
• Treatment – Topical antifungals,
Mycelex troches 5x/day for 14
days, dissolve in mouth with
dentures out, treat dentures with
dilute bleach to remove the
microorganisms
• Follow-up – Recurrence common
Prescription
Name: __________________ Date:_________
______________________________________________
License #_______
Doctor:__________________________________
DEA #:__________________
Sig: Dissolve one tablet in mouth
five times per day with dentures
out, for 14 days
Disp: 70 (seventy)
RX:Mycelex troches (clotrimazole )
______________________________________________
Address:________________________________
After Anti-Fungal Therapy
______________________________________________
License #_______
______________________________________________
Prescription
Name: __________________ Date:_________
Doctor:__________________________________
DEA #:__________________
Sig: Soak partial dentures nightly
Disp: 500 ml
RX: Nystatin suspension
100,000 U/ml
Address:________________________________
Common Oral Lesion
Aphthous Ulcer
• Recognition – Soft Ulceration on
mucosa not bound to bone
• Differential Diagnosis – Other
oral ulcerations
• Definitive Diagnosis – History,
Observation, Palpation
• Treatment – Tincture of time,
Zilactin, Aphthasol, topical
steroid may have a prophylactic
role in recurrent aphthae
• Follow-up – Recurrences are
common with a typical
presentation pattern
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Prescription
Name: __________________ Date:_________
______________________________________________
License #_______
Doctor:__________________________________
DEA #:__________________
Sig: Apply topical to oral mucosal
ulcers qid until ulcers are
healed
Disp: One tube
RX: Aphthasol
______________________________________________
Address:________________________________
Common Oral Lesion
Amalgam Tattoo
• Recognition – Black macule
in mucosa near region in
which amalgam has been
used
• Differential Diagnosis –
Pigmented oral lesions
• Definitive Diagnosis –
Clinical examination
• Treatment – None required
• Follow-up – Periodic
intraoral examination
Common Oral Lesion
Irritation Fibroma
• Recognition – Firm, raised nodule,
freely moveable
• Differential Diagnosis – Nodular
lesions
• Definitive Diagnosis – History,
Palpation, Biopsy
• Treatment – Excisional biopsy
• Follow-up – Very low recurrence rate
Common Oral Lesion
Mucocele
• Recognition – Soft, raised,
sensitive nodule in region of
minor salivary gland
• Differential Diagnosis – Mucosal
cystic conditions
• Definitive Diagnosis – History,
Palpation, Biopsy
• Treatment – Excisional Biopsy
with removal of all minor
salivary glands in region of
excision
• Follow-up – Very low rate of
recurrence
Common Oral Lesion
Pyogenic Granuloma
• Recognition – Red
enlargement of gingival
papilla
• Differential Diagnosis – Other
gingival bumps
– The 4 P’s
• Pyogenic Granuloma
• Peripheral Giant Cell
Granuloma
• Parulis
• Peripheral Ossifying
Fibroma
• Definitive Diagnosis – Biopsy
• Treatment – Excisional
biopsy
• Follow-up – Recurrence
common if etiology remains
Common Oral Lesion
Varix
• Recognition – Soft, blueblack nodule or macule
• Differential Diagnosis –
Pigmented oral lesions
• Definitive Diagnosis –
Diascopy
• Treatment – None, unless
patient concerned for
esthetics
• Follow-up – Periodic
evaluation
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Common Oral Lesion
Leukoplakia
• Recognition – White, plaque-like
change of mucosa, well defined
usually not sensitive
• Differential Diagnosis – White
lesions and squamous cell
carcinoma
• Definitive Diagnosis –
Incisional/Excisional biopsy
• Treatment – Excisional biopsy
• Follow-up – Depending on the
histopathology of the lesion
variable recurrence and/or
progression potential
Common Oral Lesion
Herpetic
Gingivostomatitis
• Recognition – Painful, 1-2 mm
ulcers on multiple oral
mucosae including those
bound to bone
• Differential Diagnosis – Other
oral ulcerations
• Definitive Diagnosis – History,
Observation, Exfoliative
Cytology
• Treatment – Supportive and
topical analgesics,
Valtrex/Valacyclovir
• Follow-up – Recurrent herpes
limited to a particular nerve
track
Common Oral Lesion
Lichen Planus
• Recognition – White striae,
erythema, erosion, history
• Differential Diagnosis –
Vesiculo-bullous conditions,
erythematous lesions
• Definitive Diagnosis –
History, Clinical Exam,
Biopsy
• Treatment – Topical steroids
• Follow-up – Chronic
condition, no known etiology,
frequent symptomatic
recurrences
65 yo white female with non-healing ulcer on ventral tongue of several months duration
Treatment
65 yo white female with non-healing ulcer on ventral tongue of several months duration
Diagnosis – Traumatic Ulcerative Granuloma Treatment
Topical application of corticosteroid gel on blotted dry mucosa that has no superimposed infections
59
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Cinnamon reaction
before treatment and after treatment
Treatment may just mean removing the offending agent to which th e tissue is reacting
Stages for Evaluation of Oral Lesions
• Recognition of tissue alteration
• Generation of Differential Diagnosis
• Definitive Diagnostic Procedures
• Recommendation for Treatment
• Clinical Follow-up
Value of Follow-up
• Recurrence risk varies for different
diagnoses
• Many oral lesions are by nature a
chronic process
• Avoid missing diagnosis of a more
critically important condition
• Rapid treatment intervention
Seminar Goals
• Stages in evaluating an oral lesion
• Process to develop a differential diagnosis
based on the normal anatomy of the site
• Procedures that can be used to refine the
differential diagnosis and establish a
definitive diagnosis
• Approaches to treat common oral lesions
• Clinical course of some common oral
lesions with and without treatment
Normal Anatomy/Histology as a
prompt for Differential Diagnosis
The delivery of oral healthcare is continuously
involved with the normal head, neck and
intraoral anatomy and histology. Frequent
encounters with normal soft and hard tissues
provides a ready framework for approaching
differential diagnosis.
Differential Diagnosis:
The Objective
The objective of developing a list of
differential diagnoses is to make sure that
all significant conditions that could present
in a specific manner are considered. The
initial differential diagnosis should include
ALL the potential lesions so that an
important condition will not be missed.
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Page 17
How were your impressions of
the matched lesions presented at
the beginning of the session?
How frequently were the most severe lesions
identified on first impression?
Which features led you to select a particular
lesion as more severe?
What are the consequences of missing the
critical lesions? Which one of these two lesions would cause you to be most concerned?
A. BC Powder Burn B. Moderate Epithelial Dysplasia
Cancer
Cancer Cancer
Which one of these two lesions would cause you to be most concerned?
A. Major Aphthous Ulcer B. Squamous Cell Carcinoma
Which one of these two lesions would cause you to be most concerned?
A. Lichen Planus B. Erythroleukoplakia, CA in situ
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Which one of these two lesions would cause you to be most concerned?
A. MucoepidermoidCarcinoma B. Fibroma
Which one of these two lesions would cause you to be most concerned?
A. Hairy Leukoplakia B. Fibroma
Which one of these two lesions would cause you to be most concerned?
A. FactitialInjury B. Leukemia
Differential Diagnosis:
The Objective
The initial differential diagnosis should
include ALL the potential lesions so that an
important condition will not be missed.
It is not necessary to achieve the correct
diagnosis at first glimpse, but it is necessary
to consider all the critical diagnoses.
Remember
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1
KEY CONCEPTS IN 0MFS
Mgt. of patients with Adrenal Suppression
A. If pt. currently on steroids
1. Day before
2. Day of Surgery Double the dose
3. Day after
4. 2 days after – Return to normal dose
B. If pt. not now on steroids but received at least 20 mg. for more than 2 wks in the past
year
1. Day before
2. Morning of Surgery
3. First 2 postsurgical days – 40 mg.
4. Next 3 days – 20 mg.
5. 6 days after surgery – discontinue steroids
Mgt of patients receiving Coumadin
1. Obtain a PT –
a. If INR between 1-1.5, precede wth surgery
b. If INR greater than 1.5 – stop Coumadin for 2 days
When INR FALLS TO 1.5 – precede with surgery
Restart coumadin on day of surgery
Classification of physical status
ASA 1 – Normal healthy person
ASA II – A pt. with mild systemic disease
ASA III – A pt. with severe systemic disease
3 types of nerve injuries
1. Neuropraxia – contusion of a nerve (continuity of epineural sheath & axons)
2. Axontmesis – a. Continuity of axon but lost
b.Continuity of sheath
3. Neurotmesis – Complete loss of nerve continuity
Hepatitis viruses
1. Hep A – spread through contact with feces
2. Hep B – spread through contact with secretions
has the most serious risk of transmission
3. Hep C- spread through contaminated feces or blood
4. Hep D- spread through contact with secreti
63
2
Definitions used in preventing infection
1. Sepsis – The breakdown of living tissue by microorganisms
2. Antiseptic – prevents multiplication of microorganisms (applied to living
tissue)
3. Disinfectant – prevents multiplication of microorganisms (applied to inanimate
objects)
4. Sterility – Freedom from viable organisms
5. Sanitization – Reduction of the number of organisms to a safe level
6. Decontamination – similar to sanitization
Local Anesthesia
Typical anesthesia molecule has 3 parts
1. Aromatic group – Confers lipophilic properties
Lipid solubility essential for penetration of various anatomic barriers
between the drug and its site of action
2. Intermediate chain has 2 purposes
a. Separates the lipophilic from hydrophilic ends
b. Classification
Ester COO—-
Amide NHCO —
3. Tertiary Amino terminus – Furnishes H2O solubility – ensures once injected,
the drug will not precipitate in the interstitial fluids
Gow-Gates Technique
1. With a single injection, anesthetizes inferior alveolar, lingual &
buccal nerves
2. Advantage – 98% complete anesthesia as opposed to 84%
3. Disadvantage – technique more difficult to learn; slightly longer
induction time; may require greater quantity of solution
4. Differs from other injection techniques
a. Relies on extra oral landmarks
b. Not adjacent to the nerve to be anesthitized but 10mm away
from condylar neck just below insertion of the lateral pterygoid
muscle
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3
ACE inhibitor – Angiotensin Converting Enzyme
1. Blocks the conversion of angiotensin to a substance that increases salt
and H2O retention, ie. – treats high blood pressure
Osteoradionecrosis
1. A devitalization of bone secondary to radiotherapy and due to an endarteritis
2. Is not an infection
Why antibiotics fail
1. Lack of pt. compliance
2. Failure to treat the infection locally
3. Inadequate dose or length of treatment
4. Presence of resistant organisms
5. Nonbacterial infection
Signs of a Mandibular Fracture
1. Alteration in occlusion
2. Lower lip numbness
3. Pain or submucosal hemorrhage at fracture site
Stages of wound healing
1. Inflammatory
2. Fibroplastic
3. Remodeling
Trigeminal neuralgia (aka Tic douloureux)
1. Severe paroxysmal pain
2. Usually unilateral
3. V2 & V3 most affected
4. An anticonvulsant such as Tegretol
Classification of TMJ Disorders
1. Myofascial pain – the source of the pain is muscular
2. Disk Displacement – aka internal derangement
3. Degenerative joint disease
4. Chronic recurrent dislocation
4. Ankylosis
Technique of administration of N2O – 02 anesthesia
1. Place nasal mask and start 6 L. of 100% O2
2. Start N2O (approx. 20 %)
3. Increase flow of N2O 10% q. 1 min. until sedation is adequate
4. After procedure – terminate N2O but continue O2 for 3-5 min.
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4
Preprosthetic Surgery
A. Simple Alveoplasty
1. Establish an envelope flap (add a vertical releasing if site is not
adequate)
2. Use rongeur & bone file
3. Suture
B. Intraseptal Alveoplasty
1. Reflect mucoperiosteum (minimally)
2. With arongeur remove intraseptal bone
3. Fracture the labio cortical plate inward
Advantages
1. Height of ridge maintained
2. Periosteum to underlying bone is maintained
Minimal dimensions of bone for endosteal implants
1. Vertical dimension – 8mm.( 2mm of bone from apex to inf. alv. canal)
2. Bone width – 1 mm on buccal and 1mm lingual to implant
Two main types of Implants
1. Endosteal
2. Trans mandibular
Midface fractures and osteotomies – Classification
1. LeFort I – Separates inferior portion of maxilla in a horizontal fashion
2. LeFort II – Separates maxilla & nasal complex from cranial base
3. LeFort III – Craniofacial separation (extends through orbits)
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1
Operative Dentistry
DEND 427 Review for NDBE II
CARIOLOGY
Santiago Moncayo, D.D.S.
Case School Of Dental Medicine 06-23-2006
Risk Factors Associated With
Dental Caries
„ Susceptible tooth surface
„ Acidogenic Bacteria
„ Fermentable Carbohydrates (sucrose)
„ Inadequate salivary flow or buffering capacity
„ Low exposure to fluoride
Caries Susceptibility of Teeth
„ Maxillary> mandibular arch
„ First molars (upper and lower) > second molars (upper and
lower) > second bi-cuspids (upper) > first bicuspids (upper) and
second bicuspids (lower) > central and lateral incisors (upper) >
canine (upper) and first bicuspids (lower) > lower anteriors
„ Tooth surface: occlusal > mesial > distal > buccal > lingual
Dental Caries Classification
„ Pit and fissure: class I
„ Smooth surface:
proximal: class II, III;
cervical, root surface:
class V
Dental Caries Classification
„ Rate of progression:
incipient, acute,
chronic, arrested
„ Hard tissue involved:
enamel, dentin,
cementum
„ Etiology: radiation,
baby bottle, rampant
Organisms Responsible for Caries
„ Streptococcus
Mutans
„ S. sanguis
„ S. salivarius
„ Lactobacillus
„ Actinomyces viscus
(Root caries)
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2
Properties of Cariogenic
Bacteria
„ Survive at low pH and
metabolize sugars to form
acids.
„ Can produce glucans from
dietary sucrose. (sticky
matrix).
„ Glucans are sticky Glucans
carbohydrates that act as
a matrix for the bacteria
on the enamel surface.
Role of Saliva
„ Adequate flow reduces plaque accumulation.
„ Calcium, phosphate, hydroxyl, and fluoride ions reduce enamel
solubility and remineralize early decay.
„ Bicarbonate buffering capacity of saliva reduces ph fall.
„ Salivary proteins form the protective acquired pellicle
„ IgA, lysosomes, lactoperoxidase, and lactoferrin have
antibacterial activity.
Role of Fluoride
„ Anticaries effects are topical
„ Inhibits enamel demineralization
„ Enhances remineralization of the enamel after
demineralization and increases acid resistance.
„ The systemic benefits of fluoride are minimal.
Tooth Mineral Complexes
„ During tooth germination is a carbonated apatite.
(most soluble)
„ Hydroxy apatite (less soluble)
„ Fluorapatite (least soluble)
„ Carbonated apatite is more acid soluble than hydroxyapatite
and calcium-deficient (replaced by sodium, magnesium, and
zinc)
maturation cycle
De – Remineralization
„ During demineralization
carbonate is lost
„ During remineralization
it is replaced by OH or F
ions, thereby decreasing
the acid solubility.
REMINERALIZATION
DEMINERALIZATION
Stephan Plot
„ Experimental measurement of pH changes on enamel surfaces
during exposure to fermentable carbohydrates in the presence
of acidogenic bacteria (in plaque) over time
„ It demonstrates the acid production of bacteria (pH decrease)
with a glucose swallow and the gradual rise due to salivary
buffering
68
3
Critical pH for Enamel
Dissociation
„ Hydroxyapatite is 5.3 – 5.5
„ Fluoroapatite 4.5
„ Carbonated beverages (Coke, Pepsi) have a pH at
about 3.5.
„ Earliest visually observable macroscopic lesion is the
White spot lesion.
Differences of Enamel and
Dentinal Caries
„ Enamel caries is an acidogenic progression of
tooth mineral dissolution
„ Dentinal caries involves acid decalcification
followed by proteolytic or enzymatic
degeneration of the organic matrix.
Incipient Lesion Treatment
„ Most early enamel lesions are capable
of remineralization, or arresting, if risk
factors are reduced. (diet, bacterial,
and salivary analysis) followed by
fluoride supplements.
Clinical Tests for Caries
Susceptibility
„ Ivoclar and Vivadent provide the essential
components to culture and grade levels of S.
mutans and lactobacilli in saliva as well as to
measure salivary pH, flow rates, and
buffering capacity.
Progression of Caries in Dentin
1. Infected
2. Affected
3. Translucent
4. Reparative
1
2
3
4
4
Progression of Caries in Dentin
69
4
Caries Diagnosis
„ Criteria for identification
1. discolored softened tooth structure
2. frank cavitation
3. areas of radiolucency on radiographs
■ Direct visual inspection with a sharp
explorer and air-drying with use of
magnification are the first steps of
examination.
■ Bitewings and periapical radiographs
■ Transillumination
High-tech Diagnosis of Caries
„ Quantitative light-induced fluorescence (QFL)
KaVo’s DIAGNOdent probe uses red laser light to
assess pit and fissure lesions (www.kavousa.com).
„ Digital imaging fiberoptic transillumination
(DIFOTI) (www.difoti.com). Images of
transilluminated visible light are captured by a digital
camera and computer processed.
Stabilization of Multiple Caries
1. Medical and dental history and assess risk factors.
2. Preventive measures.
3. Extraction of nonsalvageable teeth
4. Remove caries in vital teeth and Ca(OH)2 sealed with resins or
resin-reinforced glass ionomers.
5. If frank pulpal exposures, remove pulp followed by
temporization. With a suitable glass ionomer material and
endodontic treatment.
Stabilization of Multiple Caries
6. In very deep carious lesions, whether symptomatic or not,
where pulpal exposure is to be expected, it is probably best
to go directly to endodontic treatment rather than try an
intermediate step of excavation and temporary stabilization.
7. Finalize a treatment plan with permanent restorations for the
existing teeth and suitable provisionals for replacement of
missing teeth.
Caries Detector Solutions
„ Colored dye in propylene glycol base
„ Differentiate infected and affected dentine
„ It bonds to the denatured collagen in the infected dentin
„ It is applied for 10 seconds and then rinsed
„ Seek (Ultradent) and Snoop (Pulpdent)
„ Green, Red
Cavity Disinfectants
„ Bactericidal agent to reduce sensitivity and bacterial
growth under a restoration
„ Current products contain either benzalkonium
chloride and EDTA or 2% chlorhexidine gluconate
70
5
Supplemental Sources of
Topical Fluoride
„ Public water supplies: 1ppm sodium fluoride (NaF)
„ Toothpaste: regular brands contain 0.10-0.15% NaF
„ Prescription: PreviDent 5000 Plus, 1.1% NaF
„ Mouth rinses: Act, FluoriGuard, Prevident Rinse, 0.2-0.5% NaF
„ Brush-on gels/fluoride trays: Prevident, 1.1% NaF neutral pH
Contraindication of Acidulated
or Stannous Fluoride
„ 0.4% stannous fluoride (pH of 3.0)
„ 0.2% sodium fluoride (pH of 7.0)
„ Acidulated fluoride (APF) solutions
„ Topical 0.4% stannous gels (Gel-Kam, Colgate)
„ Remove the glaze from porcelain, glass ionomer, and
composite restorations.
Indications for Fluoride Gel
Applications
„ High consumption of carbonated beverages
„ Bulimic patients (10% female adolescents)
„ Elderly and nursing home patients
„ Gastric reflux patients
„ Chemotherapy and radiation-treated patients
Loss of Tooth Structure
„ Attrition
„ physiologic wear
„ Erosion
„ loss of tooth structure by a chemical process
„ Abfraction
„ loss of tooth substance by biomechanical forces
Principles for Cavity
Preparation
1. Tooth anatomy, the tooth position, extent of
caries, and properties of the filling material.
2. Gingival margins should end on enamel.
3. Supragingival margins.
4. Occlusal contact not in interface.
5. Unsupported enamel should be removed.
6. Dry work field
Principles for Composite and
Amalgam Preparations
„ The classic cavity preparations,
according to Black’s principles, are not
needed for contemporary bonded
retained composite and amalgam
restorations
71
6
Fissurotomy
„ Conservative
preparation of occlusal
pits and fissures using
either air abrasion or
special burs
„ Flowable composites.
„ Hybrid composites, are
more difficult to place
without the
incorporation of voids.
Tunnel Preparation
„ Conservative approach to restore class
II caries
„ It conserves the proximal marginal
ridge
„ Matrix band beforehand protects the
adjacent tooth wall.
Slot Preparation
„ Any narrow access to reach interproximal
caries can be called a slot preparation.
„ Access may be from the buccal or lingual as
in a class III lesion, or from the occlusal
aspect.
„ The ideal is to conserve tooth structure
by removing only caries and a minimal
amount of tooth structure. !!!!!!!!!
Micro-air Abrasion
„ Pressurized abrasive powders (27-50 micron
aluminum oxide) propelled at high velocity to
remove tooth structure (compressed air or
nitrogen tanks). The claimed advantages are
less trauma and a less invasive.
„ Often not requires local anesthesia.
„ Conservative class I and V preparations
„ Disadvantages: special high speed evacuation
equipment and high cost of the units.
Air Abrasion Systems
MAXIMUM
PROPELLAN
T
PRESSURE
Air Techniques -Air Dent II CS Chairside 27 and 50
micron
Aluminum
oxide
High-pressure
compressor
160 psi No
Bisco, Inc. Accu-prep
Deluxe
Chairside 50 micron Aluminum
oxide
Air 40 psi No
Danville
Enginering
PrepStart Tabletop 27 and 50
micron
Aluminum
oxide
Air or bottled
gas
145 psi No
Carbon
dioxide,
com-pressed
air
J.Morita
USA, Inc
AdAbrader
Plus
Tabletop. 50 micron Aluminum
oxide
Compressed air 100 psi No
Lares Research MicroPrep
Director
Cart 27 micron Aluminum
oxide
Compressed air 120 psi Yes
COMPANY PRODUCT
NAME
MODEL
TYPE
ABRASIVE
PARTICLE
SIZE
TYPE OF
ABRASIVE
PROPELLAN
T
BUILT-IN
COMPRESSO
R
Dentsply
Gendex
AirTouch Tower,
Desktop
27 and 50
micron
Aluminum
oxide
120 psi No
Operative Dentistry
DEND 427 Review for NDBE II
Dental Adhesives
Santiago Moncayo, D.D.S.
Case School Of Dental Medicine 06-23-2006
72
7
Goals of Dental Bonding
„ Eliminate or minimize the contraction gap of
composite polymerization
„ Sustain thermal expansion and contraction cycles
„ Create 20-30 MPa bond strengths to enamel and
dentin
„ Eliminate microleakage (Stains, sensitivity and pulpal
symptoms, recurrent caries, and bond failures)
Adhesive Systems
Components
„ acid etchant solution,
„ hydrophilic primer,
„ resin.
Types of Adhesive Systems
Currently Available
„ Type 1. Etchant; primer and adhesive resin applied
separately as two solutions. are “all-purpose” types.
They generally bond to light, dual, and self-cured
composites.
„ Type 2. Etchant; primer and adhesive applied as a
single solution. Type 2 systems have nearly allpurpose capability.
Types of Adhesive Systems
Currently Available
„ Type 3. Self-etching primer (SEP) applied to dissolve
smear layer and not washed off; adhesive applied
separately.
„ Type 4. Self-etching primer and adhesive applied as
a single solution to dissolve and treat the smear layer
simultaneously.
Dental Adhesives
BRAND NAME COMPANY NUMBER OF
COMPONENTS
SHEAR BOND
STRENGTHMPA.
DENTIN
SHEAR BOND
STRENGTH MPA.
ENAMEL
Type 1
All Bond 2
Amalgambond Plus
Scotchbond
Multipurpose
Optibond FL
Bisco
Parkell
3M
Kerr
4
4
3
3
13.9
17.6
19.4
20.3
12.3
20.5
18.0
34.1
Type2
Excite
Fuji Bond LC
One-Step
Prime & Bond NT
Optibond Solo plus
Single Bond
Ivoclar
GC America
Bisco
Dentsply/Caulk
Kerr
3M
2
3
2
2
2
2
16.6
10.8
10.2
10.3
15.3
16.3
15.1
14.3
24.7
20.0
19.8
17.8
Type3
ClearFill SE Bond
ClearFill liner Bond
Kuraray
Kuraray
2
3
21.3
21.1
24.0
22.8
Type 4
One-Up Bond
Prompt L-Pop
J Morita
ESP
2
1
17.8
8.8
16.6
22.2
Smear Layer
73
8
Hybrid Layer
„ Multilayered zone of
composite resin, and
dentin, and collagen
Etching Patterns
35% orthophosphoric Acid
„ Type I: The head of
the rod gets dissolved.
(15 sec.).
„ Type II: Interprismatic
areas.
(25 sec.).
„ Type III: Surface
enamel lost.
(More than 25 sec.)
2 – 8 μm.
Etching Patterns
I
II
III
Recommended
etching time:
15 seconds !!!!
Bonding To Enamel
Pulpal Sensitivity
„ Incomplete placement of the bonding agents
„ Incomplete wetting in application of the primer agent
„ Incomplete curing of the bonding agent
„ Place incremental layers of wetting agent until a
glossy appearance is observed
„ Dentin is dried too completely
Adhesive Application Time
„ In general, after applying the adhesive, 15-20
seconds should be allowed for penetration.
„ Then air evaporation of the solvent (acetone or
alcohol) is followed by curing (visible light-cured
generally).
„ This should leave a shiny dentin surface.
„ If this goal is not achieved, reapplication of the
adhesive should be reapplication until a shiny layer
appears.
74
9
Composition of Primers
„ Primers are bifunctional molecules.
„ One end is hydrophobic to bind to the adhesive
„ The hydrophilic end permeates conditioned dentin
and chases the water of the moist surface,
assisted by solvents (acetone or alcohol).
„ Solvents evaporation need to be by air
drying.
„ Do not light-cureExamples of primers are
HEMA, 4-Meta, and PENTA.
Bonding Agents
„ Bonding resins are unfilled BIS-GMA or UDMA
„ Visible light-cured (VLC), auto-cured or dual-cured
„ The latest generation (fifth generation) mixes the
primer and adhesive for time savings.
„ Prime and Bond NT (Dentsply/Caulk), 3M Single
Bond; and OptiBond Solo (Kerr).
„ There is a trend to add fillers to the adhesive bonding
agents to enhance their physical properties
How Fillers Enhance Adhesives
„ Increase the bond strength at the hybrid layer.
„ Improve stress absorption at the tooth restoration
interface, enabling better retention. Lower modulus
of elasticity to impart added flexibility and thus
relieve contraction stress due to polymerization
shrinkage. The adhesive absorbs within itself some of
the contraction stress.
„ Help adhesive cover the dentin in one application
rather than multiple applications.
Sixth Generation Systems
„ This system combine the etchant and primer and
adhesive into one step.
„ Advantages are even depth of penetration into the
dentin, minimal postoperative sensitivity, and saving
time.
„ Are highly technique-sensitive and use only VLC.
Sixth Generation Systems
„ They are not shown enough strength to bond enamel
and therefore should be considered mainly as dentinbonding agents.
„ Prompt L-Pop (3M ESPE), Panavia F. Touch and Bond
(Parkell), and Clearfil SE Bond (Kuraray).
Adhesive Procedures
„ To enamel: pumice surface; wash; etch 15”; wash; air dry;
apply unfilled VLC resin only.
„ To dentin and enamel: Clean surface; etch 15”; wash; leave
moist; use VLC adhesive components in layers before
composite; consider filled adhesives.
„ For amalgam (dentin only) : Clean surface; etch 15 seconds;
wash; use VLC primer to seal tubules; self-cure resin adhesive
(two-component system): pack amalgam before resin sets.
75
Common Clinical Pathology Lesions & NBDEII Review Questions
Dr. Parish P. Sedghizadeh
1. The condition depicted in A was discovered by the patient’s hygienist. The
patient is a moderate smoker. The most likely possibility to include in a differential
diagnosis is:
A. nicotinic stomatitis
B. lichen planus
C. mucosal dysplasia
D. carcinoma in-situ
2. A patient states that for almost a year now she has had a rubbery, firm, painless
nodule within the substance of the parotid gland that has increased in size over several
months. The condition described is MOST likely a:
A. mucocele
B. lymph node
C. benign mixed tumor
D. sialolith
3. The MOST common location for a mucous retention swelling is the:
A. tongue
B. gingiva
C. lower lip
D. upper lip
4. A young boy has ulcers in his mouth, general malaise, and an oral temperature of
102°F. The MOST probable diagnosis is which of the following?
A. candidiasis
B. iron deficiency
C. herpetic stomatitis
D. vitamin B deficiency
5. The virus that causes acute herpetic gingivostomatitis is closely related to the
virus that causes:
A. measles
B. chickenpox
C. mumps
D. rubella
76
6. The patient shown in B presents with these asymptomatic lesions on the face
which have been present for years. This most likely represents which of the following
conditions?
A. shingles
B. neurofibromatosis
C. dermatosis papulosa nigra
D. lupus erythematosus
7. Which of the following lesions has the greatest malignant potential?
A. leukoedema
B. lichen planus
C. actinic keratosis
D. white sponge nevus
8. The condition pictured in C is accompanied by a photomicrograph
showing the histopathologic features of the lesion. What combination from below BEST
describes the lesion clinically and histologically, respectively?
A. lichen planus and mucosal dysplasia
B. hairy leukoplakia and mucositis
C. leukoplakia and mucosal dysplasia
D. squamous cell carcinoma and mucosal dysplasia
9. Carcinoma in situ, or severe epithelial dysplasia, may exhibit each of the
following EXCEPT one. Which one is the EXCEPTION?
A. pleomorphism
B. invasion
C. hyperchromatism
D. abnormal mitosis
10. Radiographic examination of a healthy 20-year-old woman discloses the
asymptomatic lesion shown in D. The etiology of this lesion is most likely:
A. inflammatory
B. traumatic
C. neoplastic
D. developmental
77
11. The lesion depicted in E was discovered on routine examination by the patient’s
dentist. The most likely diagnosis is:
A. squamous papilloma
B. lingual tonsil
C. traumatic ulcer
D. irritation fibroma
12. The patient shown in F was unaware of this palatal lesion until it was noticed by
her dentist. Which of the following is the correct diagnosis?
A. squamous cell carcinoma
B. verrucous carcinoma
C. squamous papilloma
D. mucous extravasation phenomena
13. The lesion shown in G was first noticed years ago by this retired lifeguard. Since
then, he reports it has slightly increased in size. Upon clinical examination, the lesion is
soft and blanches slightly upon diascopy. The most likely diagnosis is:
A. melanotic macule
B. amalgam tattoo
C. focal melanosis
D. varix
14. Which of the following cysts is the LEAST likely to be visible radiographically?
A. nasopalatine
B. lateral periodontal
C. dentigerous
D. nasolabial
15. The 46-year-old man depicted in H complains of ‘cracked’ lips that do not resolve
with use of chapstick and have become more sensitive recently. Which of the following
pharmacologic therapies would you recommend to help improve his condition?
A. corticosteroid
B. antihistamine
C. antifungal
D. antiviral
78
16. The gingival lesions shown in I were noticed by this immunocompromised patient
a few days ago because of increasing pain in the area and ‘bad breath’ more recently.
This likely represents which of the following conditions?
A. cicatricial pemphigoid
B. pemphigus vulgaris
C. acute necrotizing ulcerative gingivitis
D. chronic periodontitis
17. What is the most likely diagnosis for the asymptomatic lesion depicted in J?
A. osteoma
B. torus palatinus
C. pleomorphic adenoma
D. fibroma
18. The 18-year-old female shown in K complains of pain upon mastication that has
increased over the past few days. She is likely experiencing which of the following
conditions?
A. pericoronitis
B. acute necrotizing ulcerative gingivitis
C. cicatricial pemphigoid
D. erosive lichen planus
19. The successful treatment of the asymptomatic radiographic findings shown in L
should involve the administration of antibiotics and endodontic therapy. This patient’s
periapical x-ray strongly suggests the presence of infection.
A. Both statements are TRUE
B. Both statements are FALSE
C. The first statement is TRUE, the second is FALSE
D. The first statement is FALSE, the second is TRUE
20. The highest incidence of fibrous gingival hyperplasia is related to:
A. puberty
B. diabetes
C. leukemia
D. medications
79
List of Common Clinical Pathology Lesions:
(Diagnoses from Powerpoint® presentation):
Powerpoint Slide #
3. Desquamative Gingivitis
4. Lichen Planus (reticular)
6. Pleomorphic Adenoma (benign mixed tumor)
7. Nasolabial Cyst
8. Mucocele (mucous extravasation phenomena)
9. Herpes Labialis
10. Actinic Keratosis (solar keratosis)
11. Dermatosis Papulosa Nigra
12. Leukoplakia/Squamous Cell Carcinoma
13. Nasopalatine Duct Cyst (Incisive Canal Cyst)
14. Lingual Tonsils (normal anatomy)
15. Squamous Papilloma
16. Varix (varicose vein)
17. Angular Cheilitis (Candida infection)
18. ANUG
19. Palatal Torus
20. Pericoronitis
21. Periapical Cemento-Osseous Dysplasia
22. Denture Stomatitis
23. Nevus (mole)
24. Fordyce Granules (sebaceous glands)
25. Traumatic Ulcer
26. Idiopathic Osteosclerosis
27. Ephelides (freckles)
28. Dentigerous Cyst
29. Odontogenic Keratocyst histology
30. Ameloblastoma histology
31. Basal Cell Carcinoma with Linear Telangiectasia
32. Geographic Tongue (benign migratory glossitis)
33. Amalgam Tattoo
34. Seborrheic Keratosis
35. Inflammatory Papillary Hyperplasia
36. Actinic Lentigo (solar lentigo, age spot, liver spot)
37. Morsicatio Buccarum (cheek chewing, frictional keratosis)
38. Fibroma (traumatic)
39. Black Hairy Tongue
40. Melanotic Macule
41. Parulis (sinus tract)
42. Antral Pseudocyst (sinus mucocele)
43. Leukoedema
44. Aphthous Ulcer (canker sore)
45. Nicotinic Stomatitis (smoker’s palate)
46. Fissured Tongue
80
1
NBDE II Review
The Exam: Test logistics
• 2 days
– Day 1: 400 Multiple Choice Questions
(200 a.m. + 200 p.m.)
• General dental and specialty topics admixed
• Diagnosis, treatment planning and management
emphasis
• Image booklet to supplement some of the questions
The Exam: Test logistics
– Day 2: 200 multiple choice questions a.m.
• 10-13 cases with 9-14 multiple choice questions each
– Scores are shown as low, average, or high for each
section ‡ but only one overall percentile is given at the
end
– Study with the dental decks, supplemental review
material, and old exams…but learn the concepts behind
the questions! Questions change, but the concepts they
test are similar over the years. The more you look over
the material, the more comfortable you will be.
Pharmacology I
Why or When do we use drugs (clinically)?
• To control, cure, or prevent disease
Who can prescribe drugs, and Where?
• Licensed doctors, requires DEA registration and
is state specific
• DEA regulates drug laws (legal Rx and illegal) in
this country
What can you Rx?
• Drugs within the scope of your practice
• Must be cognizant of Controlled Substances Act
– Drug Schedules I-V
DEA Schedules
• Schedule I
[Use illegal/restricted to research; high abuse potential; no accepted
medicinal use in US]
Examples: hallucinogens, heroin, marijuana
Schedule II
[Requires prescription; high abuse potential; no refills or verbal orders
allowed; some states require triplicate Rx]
Examples: amphetamines, barbiturates, opiates (single entity, some combos)
Schedule III
[Requires prescription; moderate abuse potential; max 5 refills/6mo;
verbal orders allowed]
Examples: anabolic steroids, dronabinol, ketamine, opiates (some combos)
Schedule IV
[Requires prescription; low/moderate abuse potential; max 5
refills/6mo; verbal orders allowed]
Examples: appetite suppressants, benzodiazepines, sedative/hypnotics
Schedule V
[Requires prescription or may be OTC with restrictions in some states;
limited abuse potential; max 5 refills/6mo; verbal orders allowed]
Examples: opiate or opiate-derivative antidiarrheals and antitussives
81
2
How do we use drugs?
• Enteral – GI tract route of administration
»Oral ‡ stomach ‡ intestines ‡ liver
(portal circulation) ‡ heart ‡ general
circulation‡ target tissues
»Sublingual or Rectal ‡ straight into general
circulation and bypasses first-pass liver
metabolism
• Parenteral – Non-GI route of administration
»Intravascular, intramuscular, subcutaneous
‡ straight into general circulation and
bypasses first-pass liver metabolism
How else do we use drugs?
• Other –
Inhalation
i.e. anesthetics, sterols for asthma
Intra-nasal
i.e. calcitonin for osteoporosis, cocaine
Intra-thecal
i.e. analgesics, anti-neoplastics
Topical
i.e. anesthetics, antibiotics, antifungals
Key Concepts of Drug Activity
• Pharmacokinetics
– The body’s effect on a drug
• Pharmacodynamics
– The drug’s effect on the body
Pharmacokinetics
Dose and Route of Administration (Input)
Circulatory System / Plasma
1. Absorption
Target Tissues
Excretion in urine, feces, bile (Output)
2. Distribution
3. Metabolism
4. Elimination
– The body’s effect on a drug
1. Absorption
• The onset of action of a drug is primarily
determined by the rate of absorption
• 4 factors that affect the absorption of drugs into
the bloodstream:
1. Bioavailability
• The amount (quantity or %) that reaches the blood
or plasma. Usually, a drug’s major effect is
produced by the amount of drug that is free in
plasma.
2. Stability
• Insulin is unstable in the GI tract, hence the
injections for Diabetics to bypass the enteral route
3. Permeability
• pH (acid-base interactions, protonation, pKa, HenderssonHasselbach)
– Coated tabs (buffered)
• Gastric Emptying
– Parasympathetic vs. Sympathetic
– Food in the stomach delays gastric emptying and increases acid
production to allow for proper digestion; drugs destroyed by acid
should be taken without food when possible
• Lipid solubility (hydrophobic, non-ionized, i.e. sterols)
• Water solubility (hydrophilic, ionized or charged)
• Transport mechanisms (passive, active, or facilitated)
• Contact time, surface area, blood supply
1. Absorption
82
3
4. First-pass hepatic metabolism
• For enteral drugs, some are inactivated by the liver
before reaching systemic circulation, thus
decreasing bioavailability; others drugs are
activated by the liver, increasing bioavailability
• IV (intravenous) route of administration bypasses
first-pass liver metabolism, also increasing
bioavailability
1. Absorption
Can stress effect drug absorption
from an enteral route?
Would you tell your patients to take
Penicillin on an empty or full
stomach?
Hint: Penicillin is inactivated by stomach acid. What if patient
has nausea when taking it on an empty stomach?
Pharmacokinetics
Dose and Route of Administration (Input)
Circulatory System / Plasma
1. Absorption
Target Tissues
Excretion in urine, feces, bile (Output)
2. Distribution
3. Metabolism
4. Elimination
– The body’s effect on a drug
2. Distribution
• In circulation, drugs bind to plasma proteins
(mainly albumin) relatively non-specifically
• Competition for plasma protein binding sites
(affinity) explains some drug-drug interactions
– i.e. sulfonamide antibiotics and warfarin anticoagulants are highly bound to plasma proteins, so if
you give a sulfonamide to a patient on chronic
warfarin therapy, the sulfonamide can displace
warfarin and cause dangerously high free warfarin
concentrations in the blood
A patient is treated with drug A, which has a high affinity for
albumin and is administered in amounts that do not
exceed the binding capacity of albumin. A second
drug, drug B, is added to the treatment regimen. Drug
B also has a high affinity for albumin and is
administered in amounts that are 100 times the binding
capacity of albumin. Which of the following might
occur after administration of drug B?
A. An decrease in tissue concentration of drug A
B. An increase in tissue concentration of drug A
C. A decrease in the half -life of drug A
D. A decrease in the volume of distribution (Vd) of Drug A
Test Question? 2. Distribution
• Other factors affecting drug distribution:
– Blood flow
– Capillary permeability
– Drug structure
– Affinity
– Half-life of drug (t1/2)
– Drug volume of distribution (Vd
)
– Hydrophobic or Hydrophilic nature of drug…
83
4
Example:Blood-Brain Barrier
–Water-soluble molecules require carrier or
transport mechanisms, or they must travel
through gap junctions of cells if possible
–Lipid-soluble molecules pass more readily
through cell membranes, but are also more
likely to be distributed to fat cells
Can obesity be a factor in causing unequal
drug distribution?
2. Distribution Pharmacokinetics
Dose and Route of Administration (Input)
Circulatory System / Plasma
1. Absorption
Target Tissues
Excretion in urine, feces, bile (Output)
2. Distribution
3. Metabolism
4. Elimination
– The body’s effect on a drug
3. Metabolism
• Most drugs are metabolized in the liver or other tissues in
a process called biotransformation, which occurs for two
main reasons:
– Inactivation of the drug for future excretion or elimination
– Activation of the drug for desired effect
• The liver does this through:
– Phase I reactions (cytochrome p450 red-ox, hydrolysis…) mainly
activate
– Phase II reactions (conjugation) mainly inactivate
Note: Neonates are deficient in conjugating enzymes.
What implications does this have with respect to drug
metabolism?
The conjugation of glucuronic acid to a drug
by the liver is an example of a:
A. Cytochrome P450 reaction
B. Amination reaction
C. Phase I activation reaction
D. Phase II inactivation reaction
Test Question?
Drug Metabolism – Pharmacokinetics
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9
Drug Dosage (quantity)
Drug Metabolism Rate
(kinetics)
3. Metabolism
1
st-order (proportional to drug
dose or concentration)
Zero-order (constant and
independent of drug dose)
By what mechanisms?
Test Question?
Drugs showing zero-order kinetics of elimination:
A. Are more common than those showing first-order kinetics
B. Decrease in concentration exponentially in time
C. Have a half-life that is independent of dose
D. Show a plot of drug concentration versus time that is linear
Drug Metabolism – Pharmacokinetics
0
5
1 0
1 5
2 0
2 5
3 0
3 5
4 0
1 2 3 4 5 6 7 8 9
Drug Dosage (quantity)
Drug Metabolism Rate
(kinetics)
84
5
Test Question?
Which one of the following is TRUE for a drug whose
metabolism or elimination from plasma shows first-order
kinetics?
A. The half-life of the drug is proportional to drug concentration in
plasma
B. The amount eliminated per unit time is constant
C. The amount eliminated per unit time is proportional to the plasma
concentration
D. A plot of drug concentration versus time is sigmoidal
Drug Metabolism – Pharmacokinetics
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9
Drug Dosage (quantity)
Drug Metabolism Rate
(kinetics)
Pharmacokinetics
Dose and Route of Administration (Input)
Circulatory System / Plasma
1. Absorption
Target Tissues
Excretion in urine, feces, bile (Output)
2. Distribution
3. Metabolism
4. Elimination
– The body’s effect on a drug
4. Elimination
• Excretion of drug
– Changed (metabolized by liver)
– Unchanged (not metabolized by liver)
• The Kidney is the primary site of drug excretion
and clearance through the urine
• Lungs
– Gases
– Garlic
• GI
– Emesis (i.e. alcohol), Bile, Feces
• Body fluids
– Sweat, Saliva, Tears and Breast Milk
Which of the following combination of diseases
would have the most deleterious effects on
drug metabolism and excretion?
A. CNS degeneration and Cerebral Palsy
B. Hepatic failure and adrenal insufficiency
C. Renal failure and hepatic insufficiency
D. Hepatic insufficiency and GI malabsorption
Test Question?
What lab tests or values could you use to help you
clinically if prescribing medications to this population?
For kidney, creatinine clearance is a good measure of
excretory function, or lack thereof. For liver, AST/ALT,
although not really reliable clinically.
Pharmacodynamics
• The drug’s effect on the body
• Drug-receptor interactions (forces) and
biochemical cascades (G-protein, cAMP)
• Non-receptor acting drugs
– i.e. Antacids are bases that just neutralize
stomach acid (what can you treat with these?)
– i.e. Chelating drugs just bind metallic ions
(what can you treat with these?)
Pharmacodynamics
Receptor Interactions:
• Agonists (inducers)
– Efficacy
• The maximum response that an agonistic drug can
produce
– Potency
• The measure of how much drug is required to produce
a desired effect
85
6
Receptor Interactions:
• Antagonists (competitors)
– Competitive antagonists are reversible
– Non-competitive antagonists are irreversible
Pharmacodynamics
Receptor interactions are key to understanding
drug effects on the systems of the body!
Pharmacodynamics
• Dose-response curves give us an idea of what minimum
drug dose or quantity will produce a predetermined
response in a population:
– ED50 (Effective Dose) is the dose of drug that will produce the
desired effect in 50% of the population
– TD50 (Toxic Dose) is the minimum dose that produces a specific
toxic effect in 50% of the population
– LD50 (Lethal Dose) is the minimum dose that kills 50% of the
population
– TI (Therapeutic Index) is a measure of drug safety and is expressed
as the following ratio:
• TI = TD50/ED50 or LD50/ED50
• Higher TI is better, lower is worse
(value >2 is okay, less requires patient monitoring)
Test Question?
Which of the following combinations derived
from dose-response curves makes for
the safest drug, or the best Therapeutic
Index?
A. Low ED50 and Low TD50
B. High ED50 and High LD50
C. Low LD50 and High ED50
D. Low ED50 and High LD50
THE DRUGS!
Autonomic Nervous System Drugs
Autonomic Nervous System
Central and Peripheral
Sympathetic Parasympathetic
Preganglionic: cholinergic
Postganglionic: adrenergic
(except sweat glands:
cholinergic)
Preganglionic: cholinergic
Postganglionic: cholinergic
Fight and flight Rest and ruminate
CHOLINERGIC RECEPTOR AGONISTS
Direct Acting Indirect Acting
Acetylcholine Neostigmine
Pilocarpine Physostigmine
Carbachol Edrophonium
Many of these drugs are used to treat glaucoma. Anti-cholinergic drugs are
contraindicatedin patients with glaucoma.
Sweat glands are innervated by acetylcholine (cholinergic), but uniquely by
sympathetic post-ganglionic cholinergic receptors as opposed to
parasympathetic post-ganglionic cholinergic receptors.
86
7
CHOLINERGIC RECEPTOR ANTAGONISTS
Anti-muscarinic agents Ganglionic blockers
Atropine Nicotine
Scopolamine Trimethaphan
Neuromuscular blockers
Succinylcholine
(depolarizes motor end-plate)
Tubocurarine
Doxacurium
Pancuronium
Pipercuronium
Atropine reduces salivary gland secretions. During what type of
procedures would this be helpful clinically?
Pilocarpine, on the other hand, increases salivary secretions. This
could be used to treat what common oral condition?
Test Question?
Which ONE of the following drugs most
closely resembles atropine in its
pharmacologic actions?
A. Trimethaphan
B. Scopolamine
C. Physostigmine
D. Acetylcholine
Which of the following drugs would be the
most effective in treating Myasthenia
Gravis?
A. Atropine
B. Scopolamine
C. Neostigmine
D. Nifedipine
Test Question? ADRENERGIC RECEPTOR AGONISTS
Direct Acting Indirect Acting
Albuterol Amphetamine
Dobutamine Tyramine
Epi/Norepi
Mixed
Ephedrine
Dopamine
Metaraminol
Clonidine
Isoproterenol
Metaproterenol
Cocaine
Alpha, Beta or both agonistic actions exist. Review these in detail
before the exam with respect to bronchodilation, vasodilation,
bronchoconstriction, bronchodilation, etc…
How do most of these drugs effect blood pressure or hypertension?
ADRENERGIC RECEPTOR ANTAGONISTS
Alpha blockers Beta blockers
Propanolol
Timolol
Nadolol
Acebutolol
Metoprolol
Atenolol
Phenoxybenzamine
Phentolamine
Doxazosin
Prazosin
Terazosin
Neurotransmitter
level
Guanethidine
Reserpine
How do most of these drugs effect blood
pressure or hypertension?
Test Question?
Which one of the following drugs is useful in
treating tachycardia?
A. Clonidine
B. Tyramine
C. Propanolol
D. Reserpine
87
8
Test Question?
Systolic blood pressure is decreased after
the injection of which of the following
drugs?
A. Reserpine
B. Tyramine
C. Dopamine
D. Clonidine
CNS STIMULANTS
Psychomotor Psychomimetic
Caffeine
Nicotine
Cocaine
LSD
PCP
THC
Methylphenidate
Theophylline
Theobromine
CNS Stimulants
CNS Depressants
To treat Anxiety (sympathetic overflow)
– Benzodiazepines (GABA receptor-like activity,
RAS) have largely replaced barbiturates
• Clonazepam
• Diazepam (Valium®)
• Lorazepam
• Midazolam
• Triazolam
• Alprazolam
• Buspirone
• Hydroxyzine
• Zolpidem
CNS Depressants
To treat Epilepsy (over-activity)
– Antiepileptic drugs:
• Carbamazepine
• Clonazepam
• Diazepam
• Gabapentin
• Phenobarbitol
• Phenytoin (Gingival Hyperplasia side-effect)
• Primidone
• Valproic Acid
CNS Depressants
• To treat Schizophrenia and some
Psychoses
– Neuroleptic drugs
– Block dopamine and serotonin receptors
• Butyrophenones
– Haloperidol
• Benzisoxazoles
– Resperidone
• Phenothiazines
– Chlorpromazine
– Promethazine
Test Question?
Besides being a good anxiolytic,
benzodiazepines are also very useful for:
A. Myasthenia gravis
B. General anesthesia
C. Parkinson’s disease
D. Hypothermia
88
9
Anti-depressants
Anti-depressants
Tricyclics SSRI’s MAO inhib’s Mania Drugs
Amitriptlyine
Nortryptiline
Protryptiline
Amoxapine
Desipramine
Imipramine
Trimipramine
Fluoxetine
Paroxetine
Trazodone
Nefazodone
Venlafaxine
Isocarboxazid
Phenelzine
Tranylcypromine
Lithium Salts
Test Question?
The tricyclic anti-depressants work by which
of the following mechanisms?
A. GABA agonist
B. GABA antagonist
C. releasing norepinephrine
D. blocking norepinephrine reuptake
CNS
Parkinson’s disease
– Levodopa (dopamine) and carbidopa are used
to treat Parkinson’s to compensate for lack of
endogenous dopamine in the substantia nigra
• Dopamine alone does not cross the BloodBrain Barrier, but it can as Levodopa
Pharmacology II
Cardiovascular System Drugs
• Congestive Heart Failure (CHF)
– Heart is unable to meet the needs of the body
– Starling’s law: CO=CR, in CHF either output
or return is impaired
– “Congestive” because symptoms include
pulmonary edema with left sided heart failure,
and peripheral edema with right sided heart
failure
– Therapeutic goal is to increase cardiac output
Drugs used to treat CHF
CHF
Vasodilators Diuretics Inotropic(Ca++) Agents
ACE Inhibitors
Enalapril
Captopril
Fosinopril
Benazepril
Furosemide Cardiac Glycosides
Digoxin
Digitoxin
Beta-adrenergic agonists
Epi/Norepi
Dobutamine
Spironolactone
Hydrochlorothiazide
89
10
Test Question?
All of the following classes of drugs are used
to treat CHF except the following:
A. Beta-adrenergic antagonists
B. Beta-adrenergic agonists
C. Vasodilators
D. Diuretics
Anti-arrhythmic Drugs
• In arrhythmia, the heart beats too rapidly
(tachycardia), too slowly (bradycardia), or
responds to impulses originating from sites
or pathways other than the SA node
(pacemaker)
• Therapeutic goal is to normalize impulse
conduction
Anti-arrhythmics
Class I
(Na+ channel blockers)
Class II
(Beta -adrenergic blockers)
Class III
(K+ channel blockers)
Class IV
(Ca++ channel blockers)
Lidocaine
Mexiletine
Quinidine
Disopyramide
Procainamide
Metoprolol
Propranolol Amiodarone
Sotalol
Bretylium
Diltiazem
Verapamil
Amlodipine
Nifedipine
Anti-arrhythmic Drugs Anti-anginal Drugs
• Angina pectoris results from coronary
blood flow that is insufficient to meet the
oxygen demands of the body
• Therapeutic goal is to increase perfusion
to the heart (vasodilating nitrates and
Ca++ channel blockers) or decrease the
demand (Beta-blockers)
• Significant first-pass hepatic metabolism
occurs with the nitrates
Anti-anginal Drugs
Anti-anginals
Organic Nitrates Beta-blockers Ca++ channel blockers
Isosorbide dinitrate
Nitroglycerin Propranolol…
Nifedipine
(Gingival Hyperplasia side-effect)
Amlodipine
Diltiazem
Verapamil
Anti-hypertensive Drugs
• HTN defined as >140/90 mmHg, affects 15%
of the US population (60 million)
• Therapeutic goal is to lower BP and prevent
disease sequelae, being cognizant of
concomitant disease
• Multi-drug regimen may be warranted
• Compliance is the most common reason for
therapy failure
– Dentists can play an important role here
90
11
Anti-hypertensive Drugs
Anti-hypertensives
Diuretics
Alpha and Beta Blockers
Ca++ channel blockers
ACE Inhibitors
Angiotensin II Antagonists
Losartan
Test Question?
Which of the following class of drugs is NOT
used to treat hypertension?
A. Diuretics
B. ACE inhibitors
C. Alpha agonists
D. Beta antagonists
Drugs affecting Blood
• The drugs useful in treating blood
dyscrasias cover 3 important dysfunctions:
– Thrombosis
– Bleeding
– Anemia
What could you use to treat each of these abnormalities
based on your knowledge of physiology?
Drugs affecting Blood
Thrombosis Tx
Platelet Inhibitors Anti-coagulants Thrombolytic Agents
Aspirin (Salicyclic Acid)
Dipyridamole
Heparin
Warfarin
Streptokinase
Urokinase
Drugs affecting Blood
Drugs affecting blood
Bleeding Tx Anemia Tx
Vitamin K
Protamine Sulfate
Aminocaproic Acid
Iron
Folic Acid
Vitamin B12
Erythropoietin
Note: Hydroxyurea is used to treat Sickle Cell Anemia!
• What do the lungs do?
• What type of drugs can affect that?
Drugs affecting the
Respiratory System
91
12
Drugs affecting the
Respiratory System
• Drugs used to treat Allergic Rhinitis
– Anti-histamines (H1
)
– Corticosteroids
– Alpha-adrenergic agonists (vasoconstricts)
• Drugs used to treat Asthma:
– Beta-adrenergic agonists (bronchodilates)
– Corticosteroids
– Theophylline (coffee, tea)
• Drugs used to treat COPD:
– Corticosteroids
– Beta-adrenergic agonists
• Drugs used to treat Cough:
– Opiates (suppress CNS cough centers)
Drugs affecting the
Respiratory System
• What do the kidneys do?
• What type of drugs can affect that?
Drugs affecting the Kidney Drugs affecting the Kidney
Diuretics
Carbonic
Anhydrase
Inhibitors
Loop Thiazide Potassium-sparing Osmotic
Acetazolamide
Furosemide
Torsemide
Bumetanide
Chlorothiazide
Hydrochlorothiazide
Sprionolactone
Amiloride
Mannitol
Urea
Drugs affecting the GI System
• Drugs used to treat Peptic Ulcer
– Proton pump inhibitors
• Omeprazole
• Lansoprazole
– H2
-receptor antagonists
• Cimetidine
• Ranitidine
• Famotidine
– Antimicrobial
• Amoxicillin
• Tetracycline
• Metronidazole
• Drugs used to treat Peptic Ulcer
– Antacids
• Magnesium hydroxide (milk of magnesia)
• Calcium carbonate (Tums®, Rolaids®)
• Aluminum hydroxide
• Sodium bicarbonate
– Anti-muscarinic agents
• Hyoscyamine
• Pirenzepine
Drugs affecting the GI System
92
13
• Drugs used to treat Diarrhea:
– Anti-diarrheals
• Kaolin
• Pectin
• Methylcellulose
• Drugs used to treat Constipation:
– Laxatives
• Castor oil
• Senna
• Aloe
• Glycerine
Drugs affecting the GI System Compensatory Drugs
Normal physiology is key to understanding
these drug effects:
• Thyroid?
• Pancreas?
• Pituitary?
• Adrenals? (all 3 layers)
Anti-inflammatory Drugs
NSAID’s are less dangerous than chronic
steroidal anti-inflammatory drugs:
• Aspirin (Bayer®)
• Diclofenac
• Etodolac
• Fenoprofen
• Ibuprofen (Advil®)
• Indomethacin
• Naproxin
• Sulindac
• Tolmetin
Non-narcotic analgesics:
•Acetaminophen (Tylenol®)
•Phenacetin
Test Question?
Which of the following NSAID’s is not antiinflammatory?
A. ASA (salicyclic acid)
B. Ibuprofen
C. Naproxen
D. Acetaminophen
Anti-microbial Drugs
• Antimycobacterials
– INH, Rifampin, Ethambutol, Dapsone
• Antivirals
– Acyclovir, Famciclovir, Ganciclovir
– Vidarabine, Rimantadine, Amantadine, Ribavirin
– Interferon (Hepatitis)
– Zidovudine, Zalcitabine, Stavudine, Didanosine
(HIV)
• Antiprotozoals
– Quinolones, Metronidazole
Test Question?
Which of the following drugs is useful for
treating Hepatitis C?
A. Ganciclovir
B. Interferon
C. Acyclovir
D. Famciclovir
93
14
• Antifungals
– Polyenes:
• Amphotericin B (systemic)
• Nystatin (topical)
– Imidazoles:
• Ketoconazole (systemic)
• Clotrimazole (systemic or topical, Mycelex®)
• Miconazole
• Itraconazole
• Fluconazole
– Griseofulvin
• Disrupts fungal mitotic spindle formation
• Used to treat dermatophytic infections
Anti-microbial Drugs Test Question?
A significant difference between nystatin and
amphotericin B is that:
A. They are different types of antifungals
B. One is effective against candidiasis and one is not
C. One is administered topically and the other
systemically
D. Only one of them acts on the fungal cell membrane
Antibiotics
‡ RNA ‡ PROTEIN
ENZYMES
Inhibition of DNA Replication or
Transcription:
Quinolones, Rifampin, Doxorubicin
Inhibition of Translation or Protein Synthesis:
Clindamycin, Chloramphenicol, Erythromycin, Tetracyclines
Aminoglycosides: Streptomycin, Neomycin, Gentamycin
Inhibition of synthesis of essential
metabolites: Sulfa drugs, Trimethoprim
Inhibition of cell wall synthesis:
Penicillins, Ampicillin, Cephalosporins,
Bacitracin, Vancomycin
Injury to cell
membrane:
Polymyxin B
flCidal Static‡
DNA
50S 30S
Bacterial Cell
Local Anesthetics
Amides:
[aniline derivatives]
articaine, bupivacaine, dibucaine, levobupivacaine,
lidocaine, mepivacaine, prilocaine, ropivacaine
Esters:
[PABA derivatives]
benzocaine, butamben, chloroprocaine, cocaine,
procaine, proparacaine, tetracaine
• Hypersensitivity info:
Ester allergy more common; cross-sensitivity between
classes rare; consider paraben or bisulfite sensitivity if
apparent allergy to both classes
General Anesthetics
• 3 stages:
– Induction, Maintenance, Recovery
– Induction and Pre-anesthetic medication
regimens can use:
• Benzodiazepines
• Opioids
• Anticholinergics
• Antiemetics
• Antihistamines
• Maintenance:
– Today mainly volatile inhalation gases
• Enflurane
• Halothane
• Isoflurane
• Methoxyflurane
• NO
• Recovery:
– Reverse of induction, withdrawal of drugs for
redistribution, counter-acting med’s prn
General Anesthetics
94
15
Antibiotic Premedication
(Endocarditis Prophylaxis-Adult)
[timing of administration]
unless otherwise noted, give all PO doses 1h before procedure; a ll IM/IV doses within 30min of
procedure
for orodental , resp , esoph
[standard regimen]
Dose: amoxicillin 2 g PO; Alt: ampicillin 2 g IM/IV
[PCN allergy]
Dose: clindamycin 600 mg PO/IV; Alt: cephalexin 2 g PO; cefazolin 1 g IM/IV; azithromycin 500 mg
PO; clarithromycin 500 mg PO
for GU, GI (not esoph)
[high risk]
Dose: ampicillin 2 g IM/IV and gentamicin 1.5 mg/kg within 30min before procedure, then ampicillin 1
g IM/IV or amoxicillin 1 g PO 6h later
Info: prosthetic, bioprosthetic , homograft valves; previous endocarditis ; complex cyanotic congenital
heart disease; surgical pulmonary shunts
[high risk, PCN allergy]
Dose: vancomycin 1 g IV and gentamicin 1.5 mg/kg IM/IV
[moderate risk]
Dose: amoxicillin 2 g PO; Alt: ampicillin 2 g IM/IV
Info: other congenital cardiac malformation; acquired defects, r heumatic heart disease; hypertrophic
cardiomyopathy; MVP with regurgitation and/or thickened leaflets
[moderate risk, PCN allergy]
Dose: vancomycin 1 g IV
[timing of administration]
unless otherwise noted, give all PO doses 1h before procedure; a ll IM/IV doses within 30min of procedure
for orodental , resp , esoph
[standard regimen]
Dose: amoxicillin 50 mg/kg (max 2 g) PO; Alt: ampicillin 50 mg/kg (max 2 g) IM/IV
[PCN allergy]
Dose: clindamycin 20 mg/kg (max 600 mg) PO/IV; Alt: cephalexin 50 mg/kg (max 2 g) PO; cefazolin 25 mg/kg
(max 1 g) IM/IV; azithromycin 15 mg/kg (max 500 mg) PO; clarithromycin 15 mg/kg (max 500 mg) PO
for GU, GI (not esoph)
[high risk]
Dose: ampicillin 50 mg/kg (max 2 g) IM/IV and gentamicin 1.5 mg/kg (max 120 mg) within 30min before
procedure, then ampicillin 25 mg/kg (max 2 g) IM/IV or amoxicillin 25 mg/kg (max 2 g) PO 6 h later
Info: prosthetic, bioprosthetic , homograft valves; previous endocarditis ; complex cyanotic congenital heart
disease; surgical pulmonary shunts
[high risk, PCN allergy]
Dose: vancomycin 20 mg/kg (max 1 g) IV and gentamicin 1.5 mg/kg (max 120 mg) IM/IV
[moderate risk]
Dose: amoxicillin 50 mg/kg (max 2 g) PO; Alt: ampicillin 50 mg/kg (max 2 g) IM/IV
Info: other congenital cardiac malformation; acquired defects, r heumatic heart disease; hypertrophic
cardiomyopathy; MVP with regurgitation and/or thickened leaflets
[moderate risk, PCN allergy]
Dose: vancomycin 20 mg/kg (max 1 g) IV`
Antibiotic Premedication
(Endocarditis Prophylaxis-Child)
GOOD LUCK!
95
1
PROSTHODONTICS
George Bryon Craig DDS
General Considerations (21)
n Diagnosis and treatment planning
n Preprosthodontic treatment
n Maxillomandibular relations
n Impressions and casts
n Esthetics and Phonetics
n Restorative implantology
Complete and Removable Partial
Denture Prosthodontics (8)
n Design of prosthesis and mouth
preparation
n Occlusion
n Dental Materials
n Insertion and postinsertion
Fixed Partial Prosthodontics (16)
n Design of Prosthesis and mouth
preparation
n Occlusion
n Ceramic techniques
n Dental Materials
n Insertion and postinsertion
n Complete Denture
n Crown & Bridge
n Impression Materials
n Miscellaneous
n Occlusion/Temporomandibular Joint
n Porcelain
n Removable Partial Denture
Complete Denture
96
2
83/11
Excessive vertical dimension may
result in
n poor denture retention.
n Drooping of the corners of the
mouth.
n Creases and wrinkles around the lips.
n Trauma to the underlying supporting
tissues. CORRECT
83/21
Overextension of a mandibular denture base
in the distofacial area will cause
dislodgment of the denture during function
as the result of the action of the
n masseter muscle. CORRECT
n buccinator muscle.
n Pterygomandibular raphe.
n Superior pharyngeal constrictor muscle.
83/25
The distal palatal termination of the
maxillary complete denture base is
dictated by the
n tuberosity.
n fovea palatinae.
n Maxillary tori.
n Vibrating line. CORRECT
n Posterior palatal seal.
83/32
An excessive vertical dimension of
occlusion in a patient with complete
dentures will adversely affect
n retention.
n Protrusion.
n Centric relation.
n Balanced occlusion.
n Interocclusal clearance. CORRECT
83/43
Placement of maxillary anterior teeth
in complete dentures too far
Superiorly and anteriorly might
result in difficulty in pronouncing
n “f” and “v” sounds. CORRECT
n “d” and “t” sounds.
n “s” and “th” sounds.
n Most vowels.
83/52
Papillary hyperplasia in a denture-wearing
patient results primarily from
n overextension of the lingual flange.
n Inadequate eccentric occlusal contact.
n An inappropriate relief chamber on the
maxillary denture. CORRECT
n Invasion of soft tissue by Candida
albicans.
n An unpolished tissue surface on the
maxillary denture.
97
3
83/64
The bearing area of the maxillary denture of an
elderly patient shows hyperplastic tissue over the
entire ridge. Treatment for this condition is to
n remove surgically all the hyperplastic tissue.
n Make an impression immediately in order to
compress the entire area.
n Instruct the patient to leave the denture out of
the mouth for several months.
n Use tissue treatment material for several weeks
before making an impression. CORRECT
83/73
A generalized inflammatory condition in the
stressbearing mucosa may be caused by
(a) faulty occlusion; (b) ill-fitting
dentures; (c) wearing the dentures for 24
hours consecutively; (d) an overclosed
occlusal vertical dimension.
n (a) and (b) only
n (a), (b) and (c) CORRECT
n (a) and (c) only
n (b), (c) and (d)
n All of the above
86/29
Proper lip support for a patient with
complete dentures is provided primarily by
the
n convex surface of the labial flange.
n Festooned carvings on the facial surface.
n Thickness of the border in the vestibule.
n Facial surfaces of teeth and simulated
attached gingiva. CORRECT
86/41
A balanced occlusion in maxillary and
mandibular complete dentures exists when
n opposing teeth contact in centric
occlusion.
n Opposing teeth contact in centric
occlusion, working, balancing and
protrusive positions. CORRECT
n Incisors contact without contact of
posterior teeth in a protrusive position.
n Facial cusps touch in working position
without contact on balancing cusps.
86/45
When testing the arrangement of teeth
at the trial insertion of complete
dentures, the lower lip should, when
pronouncing the letter “f” as in fifty,
n be anterior to maxillary incisors.
n Be posterior to maxillary incisors.
n Not come near maxillary incisors.
n Contact lightly the incisal edges of
maxillary incisors. CORRECT
88/04
The usual cause of contacting or
clicking of posterior teeth when a
patient speaks is
n decreased vertical dimension of
occlusion
n increased vertical dimension of
occlusion. CORRECT
n posterior teeth set too far lingually.
n Posterior teeth set too far facially.
98
4
88/16
Excessive vertical dimension of
occlusion may result in
n poor denture retention.
n Increased interocclusal distance.
n Drooping of the corners of the
mouth.
n Creases and wrinkles around the lip.
n Trauma to underlying supporting
tissues. CORRECT
88/18
A patient who wears complete dentures is
having trouble pronouncing the letter “C”.
This is probably caused by
n too thick a palatal seal area.
n Too thick a base in the mandibular
denture.
n Incorrect positioning of maxillary incisors.
CORRECT
n Imporoper positioning of mandibular
incisors.
88/25
Proper lip support for a patient with
complete dentures is provided primarily by
the
n convex surface of the labial flange.
n Rounded contours of interdental papillae.
n Proper pronouncement of sibilant sounds.
n Thickness of the border in the vestibule.
n Facial surfaces of teeth and simulated
attached gingiva. CORRECT
88/31
In determining the posterior limit of a
maxillary denture base, which of the
following is on the posterior border?
n Hamular notch. CORRECT
n Hamular process
n Fovea palatine
n Vibrating line
n Pterygomandibular raphe
88/38
Treatment of choice for a patient with a
maxillary complete denture with severe
bilateral tuberosity undercuts is to
n remove both tuberosity undercuts.
n Reduce the tissue bilaterally.
n Reduce the tissue on one side only, if
possible. CORRECT
n None of the above. No treatment is
necessary
88/41
During postinsertion adjustment, errors in occlusion
may be checked most accurately by
n having the patient leave the dentures out of the
mouth for 24 hours.
n Directing the patient to close the jaws, bringing
the teeth into occlusion.
n Having the patient close in occlusion and making
a transfer record to the articulator.
n Remounting the dentures on the articulator using
remount casts and new interocclusal records.
CORRECT
99
5
88/53
The error that most frequently contributes
to poor esthetics of dentures is the
practice of placing maxillary anterior teeth
n following the smile line.
n Too far below the lip line.
n Directly over the edentulous ridge.
CORRECT
n Too far to the facial of the edentulous
ridge.
n Too far to the lingual of the edentulous
ridge.
97/239
When construction complete dentures,
the ala tragus line must be parallel to
n Frankfort horizontal plane
n The maxillary posterior occlusal rims.
CORRECT
n The mandibular posterior occlusal
rims.
Ala Tragus 97/140
A plaster index is used to
n preserve face bow transfer CORRECT
n maintain vertical dimension of
occlusion
n maintain bite registration
2004/161
Which on of the following is the most
important factor for providing
retention for complete dentures?
n cohesion
n adhesion
n peripheral seal CORRECT
Crown & Bridge
100
6
88/83
The retentive characteristics of a full crown may be
enhanced by (a) using glass ionomer cement; (b)
using zinc phosphate cement; (c) adding pinholes
in the preparation; (d) adding grooves parallel to
the path of draw; (e) maximizing the parallelism
of the axial walls.
n (a), (c) and (d)
n (a), (d) and (e)
n (b), (c) and (d)
n (b), (c) and (e)
n (c), (d) and (e) CORRECT
n All of the above
97/54
What is the most accurate way of
checking the occlusion for a fixed
prosthesis?
n articulating paper
n shimstockCORRECT
n patient information
97/70
How far should implants be placed
from one another?
n 3mm CORRECT
n 4mm
n 5mm
n 7mm
97/189
The ideal time to wait for
osseointergration of an implant to
take place is
n 3 months
n 6 months CORRECT
n 9 months
n 12 months
Impression Materials
97/133
Impression material with least tear
resistance
n rubber base
n irreversible hydrocolloid
n reversible hydrocolloid CORRECT
101
7
97/179
What is the impression material with
the best dimensional stability 24
hours after taking the impression?
n polyvinyl siloxane CORRECT
n reversible colloid
n irreversible colloid
Miscellaneous
86/28
At which of the following positions is
sibilant sound usually produced?
n rest position
n occluding position
n open form rest position
n between rest and occluding
positions. CORRECT
88/76
The lateral pterygoid muscle functions to (a)
elevate the mandible; (b) protrude the
mandible; (c) lift the mandible from the
pterygoid plate; (d) move the mandible to
the opposite side.
n (a) and (b)
n (a) and (c)
n (a) and (d)
n (b) and (c)
n (b) and (d) CORRECT
n (c) and (d)
n GOLD CASTING ALLOYS
• Type I – soft gold-for inlays
• Type II – medium- inlays
• Type III – hard – onlays and crowns
• Type IV – extra hard w/low fusing temp
– partial dentures
• Ceramic-metal restorations (contain
iron, tin, indium)
98/63
When do you clean zinc phosphate
cement from crown margins?
n immediately
n 4 hours after the cement has set
n after the cement has set completely
CORRECT
n the next day
102
8
88/11
The proper zone of a gas-air blowpipe
flame used for melting casting gold
alloys is
n the reducing zone CORRECT
n the oxidizing zone
n the zone closest to the nozzle
n a combination of oxidizing and
reducing zones
88/16
The property that most closely
describes the ability of a cast gold
inlay to be burnished is
n elastic limit
n ultimate strength
n percentage elongation. CORRECT
n modulus of resilience
n modulus of elasticity
88/31
In mixing zinc phosphate cement,
which clinical variable has the
greatest effect on the strength of the
cement?
n spatulation time.
n Liquid-powder ratio CORRECT
n Temperature of the mixing slab
n Number and size of powder
increments
Occlusion
Temporomandibular
Joint
83/68
Group function occlusion in an existing dentition is
characterized by having (a) no balancing side
contacts; (b) working side contacts from canine
to third molar; (c) a long centric from centric
relation to centric occlusion; (d) canine rise in
protrusion; (e) total balance in lateral excursion.
n (a) and (b) only CORRECT
n (a), (b), (c), and (d)
n (a), (b), and (d) only
n (b), and (d) only
n (c), (d) and (e)
n (c), and (e) only
88/29
In a restorative problem involving all teeth
in the mouth, the protrusive condylar path
inclination has its primary influence on
n incisal guidance.
n Anterior teeth only.
n Mesial inclines of mandibular cusps and
distal inclines of maxillary cusps.
CORRECT
n Mesial inclines of maxillary cusps and
distal inclines of mandibular cusps.
103
9
97/91
Best way to image TMJ
n CT
n MRI CORRECT
n High pan
n Lateral oblique
Class II maloccllusion
n Division I: is when the maxillary
anterior teeth are proclined and a
large overjet is present
n Division II: is where the maxillary
anterior teeth are retreclined and a
deep overbite exists.
Classification of malocclusion
June 2, 2004
Dr. Robert Gallois
n http://www.columbia.edu/itc/hs/dental/ort
ho/ClassificationMalocclusion.pdf
n The overlap of the cusps helps to
keep the soft tissue of the tongue
and cheeks out from the occlusal
tables, preventing self-injury during
chewing
n The amount of horizontal (overjet )
and vertical (overbite) can
significantly influence mandibular
movement and thus influence the
cusp design of restorations.
Overjet
104
10
Overbite The TMJ and it influence
TMJ
n Condyle
n Articular Disk (superior and inferior
joint spaces)
n Articular eminences
Mandibular Movements
n Rotation (superior joint space)
n Translation (inferior joint space)
n Immediate side shift (working side in
lateral excursion)
Rotation and Translation Side Shift
105
11
Planes of Motion
n Sagital
n Frontal
n Horizontal
Sagital (Posselt’s diagram)
Frontal Horizontal
Types of Occlusion we use
n Canine guidance
n Group function
n Balanced occlusion
Canine Guidance
106
12
Canine Guidance Group Function
Balanced Occlusion
n Used in denture patients
n A minimum of three point bilateral
supporting contact occurs between
the maxillary and mandibular teeth
at all times in lateral and protrusive
excursions (compensating curve)
Compensating Curve
Porcelain
86/11
The phenomenon where porcelain
appears different under varying light
conditions is
n metamerism. CORRECT
n translucency.
n Transmittance
n Opacification
n Refractive optics
107
13
86/77
Which of the following are causes of
separation or fracture of the porcelain
from the metal in the metal-ceramic
technique? (a) Poor metal framework
design; (b) Excessive porcelain
condensation; (c) Centric occlusal contacts
entirely on porcelain; (d) Contamination of
metal prior to opaque application
n (a), (b) and (d)
n (a) and (c)
n (a) and (d) only
n (b) and (d) only CORRECT
Removable Partial
Dentures
83/18
A properly designed rest on the lingual
surface of a canine is proferred to a
properly designed rest on the incisal
surface because
n less leverage is exerted against the tooth
by the lingual rest. CORRECT
n The enamel is thicker on the lingual
surface.
n Visibility of as well as access to the lingual
surface is better.
n The cingulum of the canine provides a
natural surface for the recess.
83/57
The most important function of an indirect
retainer is to prevent
n tissue resorption.
n Occlusal interferences.
n Movement of the denture base toward the
tissue.
n Movement of the teeth after orthodontic
treatment.
n Movement of a distal extension base away
from the tissues. CORRECT
83/45
Clasps should be so designed that, upon
insertion or removal of a removable partial
denture, the reciprocal arms contact the
abutment teeth when the retentive arms
engage the height of contour in order to
n permit insertion and removal without
applying excessive force. CORRECT
n assure complete seating of the framework
n prevent distortion of the clasps.
n All of the above.
83/85
Which of the following problems may occur
in a patient with a maxillary removable
partial denture if the palatal bar is made
too thick?
n Difficulty in pressing food backward for
swallowing. CORRECT
n Poor dissipation of force because of
excessive rigidity
n Irritation of the palatal tissues
n Distortion under occlusal stress
n Injury to the abutment teeth
108
14
83/90
In designing a retainer on a
noncarious mandibular first premolar
abutment with a short clinical crown,
which of the following restorations is
most appropriate?
n An inlay
n A full crown CORRECT
n An MOD onlay
n A reverse ¾ crown
86/26
The most frequent cause of tissue soreness
along the mucobuccal area of a removable
partial denture is
n use of anatomic teeth.
n A centric prematurity .
n Heavy balancing contact.
n Extension of the denture border.
CORRECT
n Lack of rigidity of the major connector.
88/20
When a removable partial denture is completely
seated, the retentive terminals of the retentive
clasp arms should be
n passive and applying no pressure on the teeth.
CORRECT
n contacting the abutment teeth only in the
suprabulge areas.
n Resting lightly on the height of contour line on
the abutment teeth.
n Applying a definite, positive force on the
abutment teeth in order to prevent dislodgment
of the removable partial denture.
88/34
Which of the following is likely to occur under the
distal extension maxillary partial denture of a
patient with Paget’s disease?
n The bone will tend to expand and the partial
denture will have to be remade periodically.
CORRECT
n The bone is like “cottonwool” and will be resorbed
rapidly, thus, making frequent rebasing
necessary.
n The bone will become very dense and hard, thus,
soreness of the basal seat is likely to occur.
n Nothing will occur because maxillary bone is not
usually affected.
88/46
Indirect retention is designed to
n stabilize tooth-borne removable partial
dentures.
n Engage an undercut area of an abutment
tooth.
n Help resist tissueward movement of an
extension base partial denture.
n Help resist dislodgment of an extension
base partial denture in an occlusal
direction. CORRECT
n KENNEDY CLASSIFICATIONS
• Class I – bilateral distal extension
• Class II – unilateral distal extension
• Class III – unilateral tooth borne
edentulous area
• Class IV – bilateral (crossing midline)
edentulous area (tooth borne)
109
15
97/108
When placing an I-clasp on a premolar
for a distal extension RPD, the I-bar
moves_____ and ______ under
occlusal forces.
n occlusally and distally
n occlusally and mesially
n apical and distal
n apical and mesial CORRECT
97/139
A patient wearing a new bilateral RPD
complains of soreness in tissue
bearing areas 24 hours after
insertion. The most likely cause
would be
n occlusal discrepancies CORRECT
n over extended denture
n under extended denture
n allergy
110
RADIOGRAPHIC PATHOLOGY
I. DEFINITIONS
– “Radiographic appearances are governed by anatomic or physiologic
changes in the presence of disease processes. Radiologic ‘diagnosis’ is
founded on knowledge of these alterations, the prerequisite being
awareness of disease mechanisms.” H.M. Worth
II. THE RADIOGRAPHIC REPORT
– Patient name, age, ethnicity, referring physician, and date of radiographs
– Radiographic Procedure (brief but more descriptive for invasive procedures)
– Radiographic Findings (objective info: location/anatomy/structural effects)
a. Anatomy: epicenter (above/below/in the canal), local/generalized,
monostotic/polyostotic
b. Shape: hydraulic (cysts), scalloping, regular/irregular
c. Internal: density (opaque/lucent/mixed), trabeculation, septation,
mineralization/calcification (amorphous/discrete/grainy), geographic
radiolucency or hydraulic/cystic radiolucency
d. Periphery: borders discrete or well-defined vs. blending or
permeative, cortication, sclerosis, capsule
e. Behavior: space occupying, displacing, destroying, expanding, or
osteo-inducing such as in new periosteal bone formation
– Interpretation/Impression (subjective DDx: may include clinical or
surgical findings, histologic findings, or other diagnostic procedures)
III. IMAGING MODALITIES (pre-biopsy preferred)
A. Panoramic and Occlusal Radiographs
i. Together help simulate CT coronal and axial sections,
especially in cases of cortical expansion/periosteal reaction.
ii. Useful when cost or access to more advanced imaging a factor,
or follow-up cases…aka: “poor man’s CT”
B. Computerized Tomography (standard)
i. Acquired Coronal (not corrected), Axial, and Sagittal.
ii. Contrast (ie: Gadolinium) can enhance lesional features and is
essential for neoplastic lesions
111
C. Magnetic Resonance Imaging (MRI)
i. Soft tissue imaging modality based on proton spin and
magnetic moments of hydrogen ions (T1 and T2 weighted)
ii. Not good for bone pathology because hydrogen ions in bone
are bound and not free to spin and relax.
D. Nuclear Medicine (adjunct, still evolving)
i. Radiopharmaceutical (technetium) gamma photon detection
system which is utilized for identifying areas of increased
metabolic activity – such as in neoplasia, septic arthritis,
metabolic bone disease, active condylar hyperplasia, and
osteomyelitis (except in chronic sclerosing phase in which
CT’s are more ideal)
E. Positron Emission Tomography (adjunct, still evolving)
i. FDG (glucose analogue) shows increased activity in areas with
high metabolic (glycolytic) activity – such as in osteomyelitis,
hyperparathyroidism, or neoplasia metastases or follow-up.
F. TMJ Tomography
i. Imaging modality for various joint conditions ranging from
reactive to neoplastic.
IV. CONDITIONS
-Correlate with clinical and histopathologic findings
A. Developmental
i. Symmetry, often asymptomatic, long history, little or no change
over time
B. Neoplastic
i. Malignant: Infiltrative growth pattern, ragged, poorly
demarcated or ill-defined, paresthesia
ii. Benign: Slow growth, uniform, well-demarcated or welldefined
C. Reactive/Inflammatory
i. Inflammatory symptomatology if any, shorter history, more
common
112
1
RADIOGRAPHIC
PATHOLOGY OF THE
HEAD AND NECK
Dr. Parish P. Sedghizadeh
Diplomate, American Board of Oral & Maxillofacial Pathology
Assistant Professor, University of Southern California –
School of Dentistry and Center for Craniofacial Molecular Biology
Division of Diagnostic Sciences; Orofacial Pain & Oral Medicine Center
Looking for abnormalities: Requires knowledge of normal
anatomy first, what constitutes a good film or image, and
why the imaging study is being done clinically.
Radiolucency , Opacity, or mixed…
xxxxxxxxxxxx
Differential Diagnostic process:
Based on normal anatomy, then
identifying abnormality as possibly
an Odontogenic Cyst/Tumor,
Neurovascular lesion, NonOdontogenic Cyst/Tumor, or other
condition…depending on the
epicenter relationship to anatomic
structures like the IA Canal.
Neurovascular Lesion
• Benign:
– Neurofibroma
– Neuroma
– Hemangioma
• Malignant:
– Neurofibrosarcoma
– Neurogenic Sarcoma
– Angiosarcoma
Differential Diagnosis:
Mandibular Radiolucencies
Within the IA Canal
Differential Diagnosis:
Mandibular Radiolucencies
Above the IA Canal (excludes infections
• Odontogenic Cysts causing apical lesion)
– Dentigerous Cyst (often contains crown of impacted tooth)
– Odontogenic Keratocyst (OKC)
– Lateral Periodontal Cyst
– Periapical Cyst
– Calcifying Odontogenic Cyst (COC)
• Odontogenic Tumors
– Ameloblastoma
– Adenomatoid Odontogenic Tumor
– Calcifying Epithelial Odontogenic Tumor (mixed lucencyopacity)
– Odontoma (central opacification with peripheral lucency)
– Odontogenic Myxoma (multi-locular lucency)
Dentigerous (Developmental)
Cyst
113
2
Dentigerous (Developmental) Cyst
Dentigerous (Developmental) Cyst
Odontogenic Myxoma
Lateral Periodontal Cyst Odontogenic Keratocyst
Residual Cyst Calcifying Odontogenic Cyst
Odontomas (compound)
114
3
Odontoma (complex)
Periapical Cemento-Osseous Dysplasia
Differential Diagnosis:
Mandibular Radiolucencies
Below the IA Canal
• Bone Tumors
– Metastatic Carcinoma
– Osteosarcoma
• Bone Cysts
– Stafne bone defect (not a true cyst, but actually a salivary gland
depression in the bone – no Tx, follow)
– Traumatic Bone Cyst
– Aneurysmal Bone Cyst (ABC)
• Bone Reactive / Inflammatory
– Osteomyelitis
– Giant Cell Reaction
* Except for the Stafne defect, most of the lesions above often
appear above the IA canal also, highlighting the fact that most
lesions in the lower jaw occur above the IA canal.
Size Difference?
Size Difference?
Stafne Defect
NO! CT scan or periodic radiographic evaluation
Some small but important opacities…
115
4
Idiopathic Osteosclerosis
(formerly Condensing Osteitis)
Sialolith
Calcified (mineralized) Lymph Nodes (tuberculosis)
Calcified (mineralized) Atherosclerotic Plaques of Carotid Artery
THE ROLE OF
ADVANCED IMAGING
IN DIFFERENTIATING BONE PATHOSES
WITH OSTEOGENIC POTENTIAL,
such as in cases demonstrating new
periosteal bone formation
PERIOSTEAL REACTIONS
IN THE FORM OF NEW BONE
FORMATION
– Osteomyelitis
– (proliferative periostitis)
– Osteosarcoma
– Metastatic Carcinoma
– Langerhans Cell Disease
116
5
Periosteal Reactions
• Varying etiopathogenesis
– Ranging from reactive to
neoplastic
• Result is varying
osteoblastic (forming) and
osteoclastic (resorbing)
activity
physiologically/molecularly
that is evident
histopathologically also
• Demonstrates radiographic
appearance likened to an
“onion-skin” or “hair-on-end”
pattern
Periosteal Reactions
• Varying etiopathogenesis
– Ranging from reactive to
neoplastic
• Result is varying
osteoblastic (forming) and
osteoclastic (resorbing)
activity
physiologically/molecularly
that is evident
histopathologically also
• Demonstrates radiographic
appearance likened to an
“onion-skin” or “hair-on-end”
pattern
• Clinically may demonstrate cortical
osseous expansion, with or without
tenderness depending on factors
such as etiology and patients’ pain
perceptions
• Definitive diagnosis may require
clinical, radiographic, and
histologic/ immunohistochemical
correlation in many cases
Periosteal Reactions Conditions in which new
periosteal bone formation
may be a feature
• Osteomyelitis
– Proliferative Periostitis (Garrè’s)
• Osteosarcoma
• Metastatic Carcinoma
• Langerhans Cell Disease
Osteomyelitis –
Proliferative Periostitis
• Hypothesized that acute osteomyelitis, or
inflammation of medullary bone, which is
mainly lytic in nature, (from infection, trauma,
etc…) spreads to the periosteum
• Inflammatory cytokines then stimulate cortical
resorption, while inflammatory exudate also
lifts the periosteum and induces new bone
formation which occurs parallel/lamellar to
cortex, accounting for unique presentation
117
6
Osteosarcoma
• Periosteal, Parosteal, and Gnathic in H&N
• Rare cases associated with Paget’s
disease and Cemento-Osseous dysplasia
• Radiolucent, radiopaque, or mixed
radiographic appearance
• Lytic, loss of lamina dura, widening of
PDL, destruction of adjacent structures,
and ragged and ill-defined margins may
be seen classically
• Disrupted and disorganized periosteum
may appear “hair-on-end” or “sunburst”
• Intact periosteum, more rarely, may
show an “onion-skin” pattern,
presumably mediated by molecular and
chemical factors released from tumor
cells and immune cells
• Bone Morphogenic Protein, Alkaline
Phosphatase, Osteocalcin, Endothelin,
and various growth factors
118
7
Metastatic Carcinoma
• Variable radiographic appearance, with
polymorphous shape and irregular, illdefined margins usually
• However, similar to previous conditions,
metastatic carcinoma can also produce a
periosteal reaction in the form of new bone
formation, particularly prostate and breast
cancers
• In vitro cell culture studies have shown
prostatic acid phosphatase and its substrate
a-glycerophosphate stimulate calcification
and osteogenesis in prostatic cases
Langerhans Cell Disease
• Growing evidence indicates this is a
neoplastic process, and many investigators
favor malignancy of Langerhans cells as
opposed to histiocytes (CD1a vs.CD68)
• Intraosseous lesions may result in
radiographic appearance of teeth with
unsupported bone, often termed “teeth
floating in space”
• New periosteal bone formation similar to
aforementioned inflammatory (cytokine)
neoperiostosis may be a feature
• Mainly children and young adults affected

CD1a stain
Langerhans cell disease
Copyright © 2003, Elsevier Science (USA). All rights reserved.
THE ROLE OF
ADVANCED IMAGING IN
DIFFERENTIATING BETWEEN
BONE PATHOSES
119
8
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120
1
Management of Traumatic
Injuries
Ellis’ classification:
• Class I: Simple fracture of
the crown involving little
or no dentin
• Class II: Extensive
fracture of the crown
involving considerable
dentin but not the pulp
• Class III: Extensive
fracture of the crown with
a pulpal exposure
• Class IV: A fracture in
which the entire crown
has been lost
Vitality tests after trauma
• Thermal test- most reliable, especially in primary
incisors, failure to respond to heat is indicative of pulpal
necrosis
• EPT- often unreliable
• Failure of a recently traumatized tooth to respond to the
pulp test is common.
• Emergency tx should be completed and the tooth
should be retested in 10-14 days.
• Darkening of the tooth is a good indication of loss of
vitality of the pulp.
Types of Injuries
• Ankylosis
– This is caused by injury to the
periodontal membrane and
subsequent inflammation
– The ankylosed primary tooth
in the anterior segment should
be removed if there is
evidence of it causing delayed
or ectopic eruption of the
permanent successor
– It is often detected by a “step”
with the ankylosed tooth
below the plane of occlusion.
• Luxation/Intrusion
– Displaced but not intruded primary teeth should be
repositioned as soon as possible to prevent
interference of occlusion
– They can be stabilized with wire and composite
splint
– Intruded teeth are left to spontaneously re-erupt
– Severely loosened primary teeth should be
removed
• Dilaceration
– This occasionally occurs
after intrusion or
displacement injuries
– The developed portion of
the tooth is twisted or
bent on it self, and on
this new position growth
progresses
– The resulting tooth has
the crown in a
significantly different
position from the root
121
2
• Root Fractures
– Root fractures at the apical half of the tooth are
more likely to undergo repair often without
treatment
– In order for repair to take place, the fragments must
be maintained in apposition
– Healing should take place in 3-4 weeks
• Avulsion
– The best prognosis is for teeth replanted within a
short period of time
– Teeth should not be cleaned, disinfected, rinsed, or
scaled
– The pt or parent can be instructed to replant the
tooth, or the tooth can be stored in milk or saliva
– Reimplanted teeth are treated endodontically later
122
1
Operative Dentistry
DEND 427 Review for NDBE II
CARIOLOGY
Santiago Moncayo, D.D.S.
Case School Of Dental Medicine 06-23-2006
Risk Factors Associated With
Dental Caries
„ Susceptible tooth surface
„ Acidogenic Bacteria
„ Fermentable Carbohydrates (sucrose)
„ Inadequate salivary flow or buffering capacity
„ Low exposure to fluoride
Caries Susceptibility of Teeth
„ Maxillary> mandibular arch
„ First molars (upper and lower) > second molars (upper and
lower) > second bi-cuspids (upper) > first bicuspids (upper) and
second bicuspids (lower) > central and lateral incisors (upper) >
canine (upper) and first bicuspids (lower) > lower anteriors
„ Tooth surface: occlusal > mesial > distal > buccal > lingual
Dental Caries Classification
„ Pit and fissure: class I
„ Smooth surface:
proximal: class II, III;
cervical, root surface:
class V
Dental Caries Classification
„ Rate of progression:
incipient, acute,
chronic, arrested
„ Hard tissue involved:
enamel, dentin,
cementum
„ Etiology: radiation,
baby bottle, rampant
Organisms Responsible for Caries
„ Streptococcus
Mutans
„ S. sanguis
„ S. salivarius
„ Lactobacillus
„ Actinomyces viscus
(Root caries)
2
Properties of Cariogenic
Bacteria
„ Survive at low pH and
metabolize sugars to form
acids.
„ Can produce glucans from
dietary sucrose. (sticky
matrix).
„ Glucans are sticky Glucans
carbohydrates that act as
a matrix for the bacteria
on the enamel surface.
Role of Saliva
„ Adequate flow reduces plaque accumulation.
„ Calcium, phosphate, hydroxyl, and fluoride ions reduce enamel
solubility and remineralize early decay.
„ Bicarbonate buffering capacity of saliva reduces ph fall.
„ Salivary proteins form the protective acquired pellicle
„ IgA, lysosomes, lactoperoxidase, and lactoferrin have
antibacterial activity.
Role of Fluoride
„ Anticaries effects are topical
„ Inhibits enamel demineralization
„ Enhances remineralization of the enamel after
demineralization and increases acid resistance.
„ The systemic benefits of fluoride are minimal.
Tooth Mineral Complexes
„ During tooth germination is a carbonated apatite.
(most soluble)
„ Hydroxy apatite (less soluble)
„ Fluorapatite (least soluble)
„ Carbonated apatite is more acid soluble than hydroxyapatite
and calcium-deficient (replaced by sodium, magnesium, and
zinc)
maturation cycle
De – Remineralization
„ During demineralization
carbonate is lost
„ During remineralization
it is replaced by OH or F
ions, thereby decreasing
the acid solubility.
REMINERALIZATION
DEMINERALIZATION
Stephan Plot
„ Experimental measurement of pH changes on enamel surfaces
during exposure to fermentable carbohydrates in the presence
of acidogenic bacteria (in plaque) over time
„ It demonstrates the acid production of bacteria (pH decrease)
with a glucose swallow and the gradual rise due to salivary
buffering
3
Critical pH for Enamel
Dissociation
„ Hydroxyapatite is 5.3 – 5.5
„ Fluoroapatite 4.5
„ Carbonated beverages (Coke, Pepsi) have a pH at
about 3.5.
„ Earliest visually observable macroscopic lesion is the
White spot lesion.
Differences of Enamel and
Dentinal Caries
„ Enamel caries is an acidogenic progression of
tooth mineral dissolution
„ Dentinal caries involves acid decalcification
followed by proteolytic or enzymatic
degeneration of the organic matrix.
Incipient Lesion Treatment
„ Most early enamel lesions are capable
of remineralization, or arresting, if risk
factors are reduced. (diet, bacterial,
and salivary analysis) followed by
fluoride supplements.
Clinical Tests for Caries
Susceptibility
„ Ivoclar and Vivadent provide the essential
components to culture and grade levels of S.
mutans and lactobacilli in saliva as well as to
measure salivary pH, flow rates, and
buffering capacity.
Progression of Caries in Dentin
1. Infected
2. Affected
3. Translucent
4. Reparative
1
2
3
4
4
Progression of Caries in Dentin
4
Caries Diagnosis
„ Criteria for identification
1. discolored softened tooth structure
2. frank cavitation
3. areas of radiolucency on radiographs
■ Direct visual inspection with a sharp
explorer and air-drying with use of
magnification are the first steps of
examination.
■ Bitewings and periapical radiographs
■ Transillumination
High-tech Diagnosis of Caries
„ Quantitative light-induced fluorescence (QFL)
KaVo’s DIAGNOdent probe uses red laser light to
assess pit and fissure lesions (www.kavousa.com).
„ Digital imaging fiberoptic transillumination
(DIFOTI) (www.difoti.com). Images of
transilluminated visible light are captured by a digital
camera and computer processed.
Stabilization of Multiple Caries
1. Medical and dental history and assess risk factors.
2. Preventive measures.
3. Extraction of nonsalvageable teeth
4. Remove caries in vital teeth and Ca(OH)2 sealed with resins or
resin-reinforced glass ionomers.
5. If frank pulpal exposures, remove pulp followed by
temporization. With a suitable glass ionomer material and
endodontic treatment.
Stabilization of Multiple Caries
6. In very deep carious lesions, whether symptomatic or not,
where pulpal exposure is to be expected, it is probably best
to go directly to endodontic treatment rather than try an
intermediate step of excavation and temporary stabilization.
7. Finalize a treatment plan with permanent restorations for the
existing teeth and suitable provisionals for replacement of
missing teeth.
Caries Detector Solutions
„ Colored dye in propylene glycol base
„ Differentiate infected and affected dentine
„ It bonds to the denatured collagen in the infected dentin
„ It is applied for 10 seconds and then rinsed
„ Seek (Ultradent) and Snoop (Pulpdent)
„ Green, Red
Cavity Disinfectants
„ Bactericidal agent to reduce sensitivity and bacterial
growth under a restoration
„ Current products contain either benzalkonium
chloride and EDTA or 2% chlorhexidine gluconate
5
Supplemental Sources of
Topical Fluoride
„ Public water supplies: 1ppm sodium fluoride (NaF)
„ Toothpaste: regular brands contain 0.10-0.15% NaF
„ Prescription: PreviDent 5000 Plus, 1.1% NaF
„ Mouth rinses: Act, FluoriGuard, Prevident Rinse, 0.2-0.5% NaF
„ Brush-on gels/fluoride trays: Prevident, 1.1% NaF neutral pH
Contraindication of Acidulated
or Stannous Fluoride
„ 0.4% stannous fluoride (pH of 3.0)
„ 0.2% sodium fluoride (pH of 7.0)
„ Acidulated fluoride (APF) solutions
„ Topical 0.4% stannous gels (Gel-Kam, Colgate)
„ Remove the glaze from porcelain, glass ionomer, and
composite restorations.
Indications for Fluoride Gel
Applications
„ High consumption of carbonated beverages
„ Bulimic patients (10% female adolescents)
„ Elderly and nursing home patients
„ Gastric reflux patients
„ Chemotherapy and radiation-treated patients
Loss of Tooth Structure
„ Attrition
„ physiologic wear
„ Erosion
„ loss of tooth structure by a chemical process
„ Abfraction
„ loss of tooth substance by biomechanical forces
Principles for Cavity
Preparation
1. Tooth anatomy, the tooth position, extent of
caries, and properties of the filling material.
2. Gingival margins should end on enamel.
3. Supragingival margins.
4. Occlusal contact not in interface.
5. Unsupported enamel should be removed.
6. Dry work field
Principles for Composite and
Amalgam Preparations
„ The classic cavity preparations,
according to Black’s principles, are not
needed for contemporary bonded
retained composite and amalgam
restorations
6
Fissurotomy
„ Conservative
preparation of occlusal
pits and fissures using
either air abrasion or
special burs
„ Flowable composites.
„ Hybrid composites, are
more difficult to place
without the
incorporation of voids.
Tunnel Preparation
„ Conservative approach to restore class
II caries
„ It conserves the proximal marginal
ridge
„ Matrix band beforehand protects the
adjacent tooth wall.
Slot Preparation
„ Any narrow access to reach interproximal
caries can be called a slot preparation.
„ Access may be from the buccal or lingual as
in a class III lesion, or from the occlusal
aspect.
„ The ideal is to conserve tooth structure
by removing only caries and a minimal
amount of tooth structure. !!!!!!!!!
Micro-air Abrasion
„ Pressurized abrasive powders (27-50 micron
aluminum oxide) propelled at high velocity to
remove tooth structure (compressed air or
nitrogen tanks). The claimed advantages are
less trauma and a less invasive.
„ Often not requires local anesthesia.
„ Conservative class I and V preparations
„ Disadvantages: special high speed evacuation
equipment and high cost of the units.
Air Abrasion Systems
MAXIMUM
PROPELLAN
T
PRESSURE
Air Techniques -Air Dent II CS Chairside 27 and 50
micron
Aluminum
oxide
High-pressure
compressor
160 psi No
Bisco, Inc. Accu-prep
Deluxe
Chairside 50 micron Aluminum
oxide
Air 40 psi No
Danville
Enginering
PrepStart Tabletop 27 and 50
micron
Aluminum
oxide
Air or bottled
gas
145 psi No
Carbon
dioxide,
com-pressed
air
J.Morita
USA, Inc
AdAbrader
Plus
Tabletop. 50 micron Aluminum
oxide
Compressed air 100 psi No
Lares Research MicroPrep
Director
Cart 27 micron Aluminum
oxide
Compressed air 120 psi Yes
COMPANY PRODUCT
NAME
MODEL
TYPE
ABRASIVE
PARTICLE
SIZE
TYPE OF
ABRASIVE
PROPELLAN
T
BUILT-IN
COMPRESSO
R
Dentsply
Gendex
AirTouch Tower,
Desktop
27 and 50
micron
Aluminum
oxide
120 psi No
Operative Dentistry
DEND 427 Review for NDBE II
Dental Adhesives
Santiago Moncayo, D.D.S.
Case School Of Dental Medicine 06-23-2006
7
Goals of Dental Bonding
„ Eliminate or minimize the contraction gap of
composite polymerization
„ Sustain thermal expansion and contraction cycles
„ Create 20-30 MPa bond strengths to enamel and
dentin
„ Eliminate microleakage (Stains, sensitivity and pulpal
symptoms, recurrent caries, and bond failures)
Adhesive Systems
Components
„ acid etchant solution,
„ hydrophilic primer,
„ resin.
Types of Adhesive Systems
Currently Available
„ Type 1. Etchant; primer and adhesive resin applied
separately as two solutions. are “all-purpose” types.
They generally bond to light, dual, and self-cured
composites.
„ Type 2. Etchant; primer and adhesive applied as a
single solution. Type 2 systems have nearly allpurpose capability.
Types of Adhesive Systems
Currently Available
„ Type 3. Self-etching primer (SEP) applied to dissolve
smear layer and not washed off; adhesive applied
separately.
„ Type 4. Self-etching primer and adhesive applied as
a single solution to dissolve and treat the smear layer
simultaneously.
Dental Adhesives
BRAND NAME COMPANY NUMBER OF
COMPONENTS
SHEAR BOND
STRENGTHMPA.
DENTIN
SHEAR BOND
STRENGTH MPA.
ENAMEL
Type 1
All Bond 2
Amalgambond Plus
Scotchbond
Multipurpose
Optibond FL
Bisco
Parkell
3M
Kerr
4
4
3
3
13.9
17.6
19.4
20.3
12.3
20.5
18.0
34.1
Type2
Excite
Fuji Bond LC
One-Step
Prime & Bond NT
Optibond Solo plus
Single Bond
Ivoclar
GC America
Bisco
Dentsply/Caulk
Kerr
3M
2
3
2
2
2
2
16.6
10.8
10.2
10.3
15.3
16.3
15.1
14.3
24.7
20.0
19.8
17.8
Type3
ClearFill SE Bond
ClearFill liner Bond
Kuraray
Kuraray
2
3
21.3
21.1
24.0
22.8
Type 4
One-Up Bond
Prompt L-Pop
J Morita
ESP
2
1
17.8
8.8
16.6
22.2
Smear Layer
8
Hybrid Layer
„ Multilayered zone of
composite resin, and
dentin, and collagen
Etching Patterns
35% orthophosphoric Acid
„ Type I: The head of
the rod gets dissolved.
(15 sec.).
„ Type II: Interprismatic
areas.
(25 sec.).
„ Type III: Surface
enamel lost.
(More than 25 sec.)
2 – 8 μm.
Etching Patterns
I
II
III
Recommended
etching time:
15 seconds !!!!
Bonding To Enamel
Pulpal Sensitivity
„ Incomplete placement of the bonding agents
„ Incomplete wetting in application of the primer agent
„ Incomplete curing of the bonding agent
„ Place incremental layers of wetting agent until a
glossy appearance is observed
„ Dentin is dried too completely
Adhesive Application Time
„ In general, after applying the adhesive, 15-20
seconds should be allowed for penetration.
„ Then air evaporation of the solvent (acetone or
alcohol) is followed by curing (visible light-cured
generally).
„ This should leave a shiny dentin surface.
„ If this goal is not achieved, reapplication of the
adhesive should be reapplication until a shiny layer
appears.
9
Composition of Primers
„ Primers are bifunctional molecules.
„ One end is hydrophobic to bind to the adhesive
„ The hydrophilic end permeates conditioned dentin
and chases the water of the moist surface,
assisted by solvents (acetone or alcohol).
„ Solvents evaporation need to be by air
drying.
„ Do not light-cureExamples of primers are
HEMA, 4-Meta, and PENTA.
Bonding Agents
„ Bonding resins are unfilled BIS-GMA or UDMA
„ Visible light-cured (VLC), auto-cured or dual-cured
„ The latest generation (fifth generation) mixes the
primer and adhesive for time savings.
„ Prime and Bond NT (Dentsply/Caulk), 3M Single
Bond; and OptiBond Solo (Kerr).
„ There is a trend to add fillers to the adhesive bonding
agents to enhance their physical properties
How Fillers Enhance Adhesives
„ Increase the bond strength at the hybrid layer.
„ Improve stress absorption at the tooth restoration
interface, enabling better retention. Lower modulus
of elasticity to impart added flexibility and thus
relieve contraction stress due to polymerization
shrinkage. The adhesive absorbs within itself some of
the contraction stress.
„ Help adhesive cover the dentin in one application
rather than multiple applications.
Sixth Generation Systems
„ This system combine the etchant and primer and
adhesive into one step.
„ Advantages are even depth of penetration into the
dentin, minimal postoperative sensitivity, and saving
time.
„ Are highly technique-sensitive and use only VLC.
Sixth Generation Systems
„ They are not shown enough strength to bond enamel
and therefore should be considered mainly as dentinbonding agents.
„ Prompt L-Pop (3M ESPE), Panavia F. Touch and Bond
(Parkell), and Clearfil SE Bond (Kuraray).
Adhesive Procedures
„ To enamel: pumice surface; wash; etch 15”; wash; air dry;
apply unfilled VLC resin only.
„ To dentin and enamel: Clean surface; etch 15”; wash; leave
moist; use VLC adhesive components in layers before
composite; consider filled adhesives.
„ For amalgam (dentin only) : Clean surface; etch 15 seconds;
wash; use VLC primer to seal tubules; self-cure resin adhesive
(two-component system): pack amalgam before resin sets.
Common Clinical Pathology Lesions & NBDEII Review Questions
Dr. Parish P. Sedghizadeh
1. The condition depicted in A was discovered by the patient’s hygienist. The
patient is a moderate smoker. The most likely possibility to include in a differential
diagnosis is:
A. nicotinic stomatitis
B. lichen planus
C. mucosal dysplasia
D. carcinoma in-situ
2. A patient states that for almost a year now she has had a rubbery, firm, painless
nodule within the substance of the parotid gland that has increased in size over several
months. The condition described is MOST likely a:
A. mucocele
B. lymph node
C. benign mixed tumor
D. sialolith
3. The MOST common location for a mucous retention swelling is the:
A. tongue
B. gingiva
C. lower lip
D. upper lip
4. A young boy has ulcers in his mouth, general malaise, and an oral temperature of
102°F. The MOST probable diagnosis is which of the following?
A. candidiasis
B. iron deficiency
C. herpetic stomatitis
D. vitamin B deficiency
5. The virus that causes acute herpetic gingivostomatitis is closely related to the
virus that causes:
A. measles
B. chickenpox
C. mumps
D. rubella
6. The patient shown in B presents with these asymptomatic lesions on the face
which have been present for years. This most likely represents which of the following
conditions?
A. shingles
B. neurofibromatosis
C. dermatosis papulosa nigra
D. lupus erythematosus
7. Which of the following lesions has the greatest malignant potential?
A. leukoedema
B. lichen planus
C. actinic keratosis
D. white sponge nevus
8. The condition pictured in C is accompanied by a photomicrograph
showing the histopathologic features of the lesion. What combination from below BEST
describes the lesion clinically and histologically, respectively?
A. lichen planus and mucosal dysplasia
B. hairy leukoplakia and mucositis
C. leukoplakia and mucosal dysplasia
D. squamous cell carcinoma and mucosal dysplasia
9. Carcinoma in situ, or severe epithelial dysplasia, may exhibit each of the
following EXCEPT one. Which one is the EXCEPTION?
A. pleomorphism
B. invasion
C. hyperchromatism
D. abnormal mitosis
10. Radiographic examination of a healthy 20-year-old woman discloses the
asymptomatic lesion shown in D. The etiology of this lesion is most likely:
A. inflammatory
B. traumatic
C. neoplastic
D. developmental
11. The lesion depicted in E was discovered on routine examination by the patient’s
dentist. The most likely diagnosis is:
A. squamous papilloma
B. lingual tonsil
C. traumatic ulcer
D. irritation fibroma
12. The patient shown in F was unaware of this palatal lesion until it was noticed by
her dentist. Which of the following is the correct diagnosis?
A. squamous cell carcinoma
B. verrucous carcinoma
C. squamous papilloma
D. mucous extravasation phenomena
13. The lesion shown in G was first noticed years ago by this retired lifeguard. Since
then, he reports it has slightly increased in size. Upon clinical examination, the lesion is
soft and blanches slightly upon diascopy. The most likely diagnosis is:
A. melanotic macule
B. amalgam tattoo
C. focal melanosis
D. varix
14. Which of the following cysts is the LEAST likely to be visible radiographically?
A. nasopalatine
B. lateral periodontal
C. dentigerous
D. nasolabial
15. The 46-year-old man depicted in H complains of ‘cracked’ lips that do not resolve
with use of chapstick and have become more sensitive recently. Which of the following
pharmacologic therapies would you recommend to help improve his condition?
A. corticosteroid
B. antihistamine
C. antifungal
D. antiviral
16. The gingival lesions shown in I were noticed by this immunocompromised patient
a few days ago because of increasing pain in the area and ‘bad breath’ more recently.
This likely represents which of the following conditions?
A. cicatricial pemphigoid
B. pemphigus vulgaris
C. acute necrotizing ulcerative gingivitis
D. chronic periodontitis
17. What is the most likely diagnosis for the asymptomatic lesion depicted in J?
A. osteoma
B. torus palatinus
C. pleomorphic adenoma
D. fibroma
18. The 18-year-old female shown in K complains of pain upon mastication that has
increased over the past few days. She is likely experiencing which of the following
conditions?
A. pericoronitis
B. acute necrotizing ulcerative gingivitis
C. cicatricial pemphigoid
D. erosive lichen planus
19. The successful treatment of the asymptomatic radiographic findings shown in L
should involve the administration of antibiotics and endodontic therapy. This patient’s
periapical x-ray strongly suggests the presence of infection.
A. Both statements are TRUE
B. Both statements are FALSE
C. The first statement is TRUE, the second is FALSE
D. The first statement is FALSE, the second is TRUE
20. The highest incidence of fibrous gingival hyperplasia is related to:
A. puberty
B. diabetes
C. leukemia
D. medications
List of Common Clinical Pathology Lesions:
(Diagnoses from Powerpoint® presentation):
Powerpoint Slide #
3. Desquamative Gingivitis
4. Lichen Planus (reticular)
6. Pleomorphic Adenoma (benign mixed tumor)
7. Nasolabial Cyst
8. Mucocele (mucous extravasation phenomena)
9. Herpes Labialis
10. Actinic Keratosis (solar keratosis)
11. Dermatosis Papulosa Nigra
12. Leukoplakia/Squamous Cell Carcinoma
13. Nasopalatine Duct Cyst (Incisive Canal Cyst)
14. Lingual Tonsils (normal anatomy)
15. Squamous Papilloma
16. Varix (varicose vein)
17. Angular Cheilitis (Candida infection)
18. ANUG
19. Palatal Torus
20. Pericoronitis
21. Periapical Cemento-Osseous Dysplasia
22. Denture Stomatitis
23. Nevus (mole)
24. Fordyce Granules (sebaceous glands)
25. Traumatic Ulcer
26. Idiopathic Osteosclerosis
27. Ephelides (freckles)
28. Dentigerous Cyst
29. Odontogenic Keratocyst histology
30. Ameloblastoma histology
31. Basal Cell Carcinoma with Linear Telangiectasia
32. Geographic Tongue (benign migratory glossitis)
33. Amalgam Tattoo
34. Seborrheic Keratosis
35. Inflammatory Papillary Hyperplasia
36. Actinic Lentigo (solar lentigo, age spot, liver spot)
37. Morsicatio Buccarum (cheek chewing, frictional keratosis)
38. Fibroma (traumatic)
39. Black Hairy Tongue
40. Melanotic Macule
41. Parulis (sinus tract)
42. Antral Pseudocyst (sinus mucocele)
43. Leukoedema
44. Aphthous Ulcer (canker sore)
45. Nicotinic Stomatitis (smoker’s palate)
46. Fissured Tongue
1
NBDE II Review
The Exam: Test logistics
• 2 days
– Day 1: 400 Multiple Choice Questions
(200 a.m. + 200 p.m.)
• General dental and specialty topics admixed
• Diagnosis, treatment planning and management
emphasis
• Image booklet to supplement some of the questions
The Exam: Test logistics
– Day 2: 200 multiple choice questions a.m.
• 10-13 cases with 9-14 multiple choice questions each
– Scores are shown as low, average, or high for each
section ‡ but only one overall percentile is given at the
end
– Study with the dental decks, supplemental review
material, and old exams…but learn the concepts behind
the questions! Questions change, but the concepts they
test are similar over the years. The more you look over
the material, the more comfortable you will be.
Pharmacology I
Why or When do we use drugs (clinically)?
• To control, cure, or prevent disease
Who can prescribe drugs, and Where?
• Licensed doctors, requires DEA registration and
is state specific
• DEA regulates drug laws (legal Rx and illegal) in
this country
What can you Rx?
• Drugs within the scope of your practice
• Must be cognizant of Controlled Substances Act
– Drug Schedules I-V
DEA Schedules
• Schedule I
[Use illegal/restricted to research; high abuse potential; no accepted
medicinal use in US]
Examples: hallucinogens, heroin, marijuana
Schedule II
[Requires prescription; high abuse potential; no refills or verbal orders
allowed; some states require triplicate Rx]
Examples: amphetamines, barbiturates, opiates (single entity, some combos)
Schedule III
[Requires prescription; moderate abuse potential; max 5 refills/6mo;
verbal orders allowed]
Examples: anabolic steroids, dronabinol, ketamine, opiates (some combos)
Schedule IV
[Requires prescription; low/moderate abuse potential; max 5
refills/6mo; verbal orders allowed]
Examples: appetite suppressants, benzodiazepines, sedative/hypnotics
Schedule V
[Requires prescription or may be OTC with restrictions in some states;
limited abuse potential; max 5 refills/6mo; verbal orders allowed]
Examples: opiate or opiate-derivative antidiarrheals and antitussives
2
How do we use drugs?
• Enteral – GI tract route of administration
»Oral ‡ stomach ‡ intestines ‡ liver
(portal circulation) ‡ heart ‡ general
circulation‡ target tissues
»Sublingual or Rectal ‡ straight into general
circulation and bypasses first-pass liver
metabolism
• Parenteral – Non-GI route of administration
»Intravascular, intramuscular, subcutaneous
‡ straight into general circulation and
bypasses first-pass liver metabolism
How else do we use drugs?
• Other –
Inhalation
i.e. anesthetics, sterols for asthma
Intra-nasal
i.e. calcitonin for osteoporosis, cocaine
Intra-thecal
i.e. analgesics, anti-neoplastics
Topical
i.e. anesthetics, antibiotics, antifungals
Key Concepts of Drug Activity
• Pharmacokinetics
– The body’s effect on a drug
• Pharmacodynamics
– The drug’s effect on the body
Pharmacokinetics
Dose and Route of Administration (Input)
Circulatory System / Plasma
1. Absorption
Target Tissues
Excretion in urine, feces, bile (Output)
2. Distribution
3. Metabolism
4. Elimination
– The body’s effect on a drug
1. Absorption
• The onset of action of a drug is primarily
determined by the rate of absorption
• 4 factors that affect the absorption of drugs into
the bloodstream:
1. Bioavailability
• The amount (quantity or %) that reaches the blood
or plasma. Usually, a drug’s major effect is
produced by the amount of drug that is free in
plasma.
2. Stability
• Insulin is unstable in the GI tract, hence the
injections for Diabetics to bypass the enteral route
3. Permeability
• pH (acid-base interactions, protonation, pKa, HenderssonHasselbach)
– Coated tabs (buffered)
• Gastric Emptying
– Parasympathetic vs. Sympathetic
– Food in the stomach delays gastric emptying and increases acid
production to allow for proper digestion; drugs destroyed by acid
should be taken without food when possible
• Lipid solubility (hydrophobic, non-ionized, i.e. sterols)
• Water solubility (hydrophilic, ionized or charged)
• Transport mechanisms (passive, active, or facilitated)
• Contact time, surface area, blood supply
1. Absorption
3
4. First-pass hepatic metabolism
• For enteral drugs, some are inactivated by the liver
before reaching systemic circulation, thus
decreasing bioavailability; others drugs are
activated by the liver, increasing bioavailability
• IV (intravenous) route of administration bypasses
first-pass liver metabolism, also increasing
bioavailability
1. Absorption
Can stress effect drug absorption
from an enteral route?
Would you tell your patients to take
Penicillin on an empty or full
stomach?
Hint: Penicillin is inactivated by stomach acid. What if patient
has nausea when taking it on an empty stomach?
Pharmacokinetics
Dose and Route of Administration (Input)
Circulatory System / Plasma
1. Absorption
Target Tissues
Excretion in urine, feces, bile (Output)
2. Distribution
3. Metabolism
4. Elimination
– The body’s effect on a drug
2. Distribution
• In circulation, drugs bind to plasma proteins
(mainly albumin) relatively non-specifically
• Competition for plasma protein binding sites
(affinity) explains some drug-drug interactions
– i.e. sulfonamide antibiotics and warfarin anticoagulants are highly bound to plasma proteins, so if
you give a sulfonamide to a patient on chronic
warfarin therapy, the sulfonamide can displace
warfarin and cause dangerously high free warfarin
concentrations in the blood
A patient is treated with drug A, which has a high affinity for
albumin and is administered in amounts that do not
exceed the binding capacity of albumin. A second
drug, drug B, is added to the treatment regimen. Drug
B also has a high affinity for albumin and is
administered in amounts that are 100 times the binding
capacity of albumin. Which of the following might
occur after administration of drug B?
A. An decrease in tissue concentration of drug A
B. An increase in tissue concentration of drug A
C. A decrease in the half -life of drug A
D. A decrease in the volume of distribution (Vd) of Drug A
Test Question? 2. Distribution
• Other factors affecting drug distribution:
– Blood flow
– Capillary permeability
– Drug structure
– Affinity
– Half-life of drug (t1/2)
– Drug volume of distribution (Vd
)
– Hydrophobic or Hydrophilic nature of drug…
4
Example:Blood-Brain Barrier
–Water-soluble molecules require carrier or
transport mechanisms, or they must travel
through gap junctions of cells if possible
–Lipid-soluble molecules pass more readily
through cell membranes, but are also more
likely to be distributed to fat cells
Can obesity be a factor in causing unequal
drug distribution?
2. Distribution Pharmacokinetics
Dose and Route of Administration (Input)
Circulatory System / Plasma
1. Absorption
Target Tissues
Excretion in urine, feces, bile (Output)
2. Distribution
3. Metabolism
4. Elimination
– The body’s effect on a drug
3. Metabolism
• Most drugs are metabolized in the liver or other tissues in
a process called biotransformation, which occurs for two
main reasons:
– Inactivation of the drug for future excretion or elimination
– Activation of the drug for desired effect
• The liver does this through:
– Phase I reactions (cytochrome p450 red-ox, hydrolysis…) mainly
activate
– Phase II reactions (conjugation) mainly inactivate
Note: Neonates are deficient in conjugating enzymes.
What implications does this have with respect to drug
metabolism?
The conjugation of glucuronic acid to a drug
by the liver is an example of a:
A. Cytochrome P450 reaction
B. Amination reaction
C. Phase I activation reaction
D. Phase II inactivation reaction
Test Question?
Drug Metabolism – Pharmacokinetics
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9
Drug Dosage (quantity)
Drug Metabolism Rate
(kinetics)
3. Metabolism
1
st-order (proportional to drug
dose or concentration)
Zero-order (constant and
independent of drug dose)
By what mechanisms?
Test Question?
Drugs showing zero-order kinetics of elimination:
A. Are more common than those showing first-order kinetics
B. Decrease in concentration exponentially in time
C. Have a half-life that is independent of dose
D. Show a plot of drug concentration versus time that is linear
Drug Metabolism – Pharmacokinetics
0
5
1 0
1 5
2 0
2 5
3 0
3 5
4 0
1 2 3 4 5 6 7 8 9
Drug Dosage (quantity)
Drug Metabolism Rate
(kinetics)
5
Test Question?
Which one of the following is TRUE for a drug whose
metabolism or elimination from plasma shows first-order
kinetics?
A. The half-life of the drug is proportional to drug concentration in
plasma
B. The amount eliminated per unit time is constant
C. The amount eliminated per unit time is proportional to the plasma
concentration
D. A plot of drug concentration versus time is sigmoidal
Drug Metabolism – Pharmacokinetics
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9
Drug Dosage (quantity)
Drug Metabolism Rate
(kinetics)
Pharmacokinetics
Dose and Route of Administration (Input)
Circulatory System / Plasma
1. Absorption
Target Tissues
Excretion in urine, feces, bile (Output)
2. Distribution
3. Metabolism
4. Elimination
– The body’s effect on a drug
4. Elimination
• Excretion of drug
– Changed (metabolized by liver)
– Unchanged (not metabolized by liver)
• The Kidney is the primary site of drug excretion
and clearance through the urine
• Lungs
– Gases
– Garlic
• GI
– Emesis (i.e. alcohol), Bile, Feces
• Body fluids
– Sweat, Saliva, Tears and Breast Milk
Which of the following combination of diseases
would have the most deleterious effects on
drug metabolism and excretion?
A. CNS degeneration and Cerebral Palsy
B. Hepatic failure and adrenal insufficiency
C. Renal failure and hepatic insufficiency
D. Hepatic insufficiency and GI malabsorption
Test Question?
What lab tests or values could you use to help you
clinically if prescribing medications to this population?
For kidney, creatinine clearance is a good measure of
excretory function, or lack thereof. For liver, AST/ALT,
although not really reliable clinically.
Pharmacodynamics
• The drug’s effect on the body
• Drug-receptor interactions (forces) and
biochemical cascades (G-protein, cAMP)
• Non-receptor acting drugs
– i.e. Antacids are bases that just neutralize
stomach acid (what can you treat with these?)
– i.e. Chelating drugs just bind metallic ions
(what can you treat with these?)
Pharmacodynamics
Receptor Interactions:
• Agonists (inducers)
– Efficacy
• The maximum response that an agonistic drug can
produce
– Potency
• The measure of how much drug is required to produce
a desired effect
6
Receptor Interactions:
• Antagonists (competitors)
– Competitive antagonists are reversible
– Non-competitive antagonists are irreversible
Pharmacodynamics
Receptor interactions are key to understanding
drug effects on the systems of the body!
Pharmacodynamics
• Dose-response curves give us an idea of what minimum
drug dose or quantity will produce a predetermined
response in a population:
– ED50 (Effective Dose) is the dose of drug that will produce the
desired effect in 50% of the population
– TD50 (Toxic Dose) is the minimum dose that produces a specific
toxic effect in 50% of the population
– LD50 (Lethal Dose) is the minimum dose that kills 50% of the
population
– TI (Therapeutic Index) is a measure of drug safety and is expressed
as the following ratio:
• TI = TD50/ED50 or LD50/ED50
• Higher TI is better, lower is worse
(value >2 is okay, less requires patient monitoring)
Test Question?
Which of the following combinations derived
from dose-response curves makes for
the safest drug, or the best Therapeutic
Index?
A. Low ED50 and Low TD50
B. High ED50 and High LD50
C. Low LD50 and High ED50
D. Low ED50 and High LD50
THE DRUGS!
Autonomic Nervous System Drugs
Autonomic Nervous System
Central and Peripheral
Sympathetic Parasympathetic
Preganglionic: cholinergic
Postganglionic: adrenergic
(except sweat glands:
cholinergic)
Preganglionic: cholinergic
Postganglionic: cholinergic
Fight and flight Rest and ruminate
CHOLINERGIC RECEPTOR AGONISTS
Direct Acting Indirect Acting
Acetylcholine Neostigmine
Pilocarpine Physostigmine
Carbachol Edrophonium
Many of these drugs are used to treat glaucoma. Anti-cholinergic drugs are
contraindicatedin patients with glaucoma.
Sweat glands are innervated by acetylcholine (cholinergic), but uniquely by
sympathetic post-ganglionic cholinergic receptors as opposed to
parasympathetic post-ganglionic cholinergic receptors.
7
CHOLINERGIC RECEPTOR ANTAGONISTS
Anti-muscarinic agents Ganglionic blockers
Atropine Nicotine
Scopolamine Trimethaphan
Neuromuscular blockers
Succinylcholine
(depolarizes motor end-plate)
Tubocurarine
Doxacurium
Pancuronium
Pipercuronium
Atropine reduces salivary gland secretions. During what type of
procedures would this be helpful clinically?
Pilocarpine, on the other hand, increases salivary secretions. This
could be used to treat what common oral condition?
Test Question?
Which ONE of the following drugs most
closely resembles atropine in its
pharmacologic actions?
A. Trimethaphan
B. Scopolamine
C. Physostigmine
D. Acetylcholine
Which of the following drugs would be the
most effective in treating Myasthenia
Gravis?
A. Atropine
B. Scopolamine
C. Neostigmine
D. Nifedipine
Test Question? ADRENERGIC RECEPTOR AGONISTS
Direct Acting Indirect Acting
Albuterol Amphetamine
Dobutamine Tyramine
Epi/Norepi
Mixed
Ephedrine
Dopamine
Metaraminol
Clonidine
Isoproterenol
Metaproterenol
Cocaine
Alpha, Beta or both agonistic actions exist. Review these in detail
before the exam with respect to bronchodilation, vasodilation,
bronchoconstriction, bronchodilation, etc…
How do most of these drugs effect blood pressure or hypertension?
ADRENERGIC RECEPTOR ANTAGONISTS
Alpha blockers Beta blockers
Propanolol
Timolol
Nadolol
Acebutolol
Metoprolol
Atenolol
Phenoxybenzamine
Phentolamine
Doxazosin
Prazosin
Terazosin
Neurotransmitter
level
Guanethidine
Reserpine
How do most of these drugs effect blood
pressure or hypertension?
Test Question?
Which one of the following drugs is useful in
treating tachycardia?
A. Clonidine
B. Tyramine
C. Propanolol
D. Reserpine
8
Test Question?
Systolic blood pressure is decreased after
the injection of which of the following
drugs?
A. Reserpine
B. Tyramine
C. Dopamine
D. Clonidine
CNS STIMULANTS
Psychomotor Psychomimetic
Caffeine
Nicotine
Cocaine
LSD
PCP
THC
Methylphenidate
Theophylline
Theobromine
CNS Stimulants
CNS Depressants
To treat Anxiety (sympathetic overflow)
– Benzodiazepines (GABA receptor-like activity,
RAS) have largely replaced barbiturates
• Clonazepam
• Diazepam (Valium®)
• Lorazepam
• Midazolam
• Triazolam
• Alprazolam
• Buspirone
• Hydroxyzine
• Zolpidem
CNS Depressants
To treat Epilepsy (over-activity)
– Antiepileptic drugs:
• Carbamazepine
• Clonazepam
• Diazepam
• Gabapentin
• Phenobarbitol
• Phenytoin (Gingival Hyperplasia side-effect)
• Primidone
• Valproic Acid
CNS Depressants
• To treat Schizophrenia and some
Psychoses
– Neuroleptic drugs
– Block dopamine and serotonin receptors
• Butyrophenones
– Haloperidol
• Benzisoxazoles
– Resperidone
• Phenothiazines
– Chlorpromazine
– Promethazine
Test Question?
Besides being a good anxiolytic,
benzodiazepines are also very useful for:
A. Myasthenia gravis
B. General anesthesia
C. Parkinson’s disease
D. Hypothermia
9
Anti-depressants
Anti-depressants
Tricyclics SSRI’s MAO inhib’s Mania Drugs
Amitriptlyine
Nortryptiline
Protryptiline
Amoxapine
Desipramine
Imipramine
Trimipramine
Fluoxetine
Paroxetine
Trazodone
Nefazodone
Venlafaxine
Isocarboxazid
Phenelzine
Tranylcypromine
Lithium Salts
Test Question?
The tricyclic anti-depressants work by which
of the following mechanisms?
A. GABA agonist
B. GABA antagonist
C. releasing norepinephrine
D. blocking norepinephrine reuptake
CNS
Parkinson’s disease
– Levodopa (dopamine) and carbidopa are used
to treat Parkinson’s to compensate for lack of
endogenous dopamine in the substantia nigra
• Dopamine alone does not cross the BloodBrain Barrier, but it can as Levodopa
Pharmacology II
Cardiovascular System Drugs
• Congestive Heart Failure (CHF)
– Heart is unable to meet the needs of the body
– Starling’s law: CO=CR, in CHF either output
or return is impaired
– “Congestive” because symptoms include
pulmonary edema with left sided heart failure,
and peripheral edema with right sided heart
failure
– Therapeutic goal is to increase cardiac output
Drugs used to treat CHF
CHF
Vasodilators Diuretics Inotropic(Ca++) Agents
ACE Inhibitors
Enalapril
Captopril
Fosinopril
Benazepril
Furosemide Cardiac Glycosides
Digoxin
Digitoxin
Beta-adrenergic agonists
Epi/Norepi
Dobutamine
Spironolactone
Hydrochlorothiazide
10
Test Question?
All of the following classes of drugs are used
to treat CHF except the following:
A. Beta-adrenergic antagonists
B. Beta-adrenergic agonists
C. Vasodilators
D. Diuretics
Anti-arrhythmic Drugs
• In arrhythmia, the heart beats too rapidly
(tachycardia), too slowly (bradycardia), or
responds to impulses originating from sites
or pathways other than the SA node
(pacemaker)
• Therapeutic goal is to normalize impulse
conduction
Anti-arrhythmics
Class I
(Na+ channel blockers)
Class II
(Beta -adrenergic blockers)
Class III
(K+ channel blockers)
Class IV
(Ca++ channel blockers)
Lidocaine
Mexiletine
Quinidine
Disopyramide
Procainamide
Metoprolol
Propranolol Amiodarone
Sotalol
Bretylium
Diltiazem
Verapamil
Amlodipine
Nifedipine
Anti-arrhythmic Drugs Anti-anginal Drugs
• Angina pectoris results from coronary
blood flow that is insufficient to meet the
oxygen demands of the body
• Therapeutic goal is to increase perfusion
to the heart (vasodilating nitrates and
Ca++ channel blockers) or decrease the
demand (Beta-blockers)
• Significant first-pass hepatic metabolism
occurs with the nitrates
Anti-anginal Drugs
Anti-anginals
Organic Nitrates Beta-blockers Ca++ channel blockers
Isosorbide dinitrate
Nitroglycerin Propranolol…
Nifedipine
(Gingival Hyperplasia side-effect)
Amlodipine
Diltiazem
Verapamil
Anti-hypertensive Drugs
• HTN defined as >140/90 mmHg, affects 15%
of the US population (60 million)
• Therapeutic goal is to lower BP and prevent
disease sequelae, being cognizant of
concomitant disease
• Multi-drug regimen may be warranted
• Compliance is the most common reason for
therapy failure
– Dentists can play an important role here
11
Anti-hypertensive Drugs
Anti-hypertensives
Diuretics
Alpha and Beta Blockers
Ca++ channel blockers
ACE Inhibitors
Angiotensin II Antagonists
Losartan
Test Question?
Which of the following class of drugs is NOT
used to treat hypertension?
A. Diuretics
B. ACE inhibitors
C. Alpha agonists
D. Beta antagonists
Drugs affecting Blood
• The drugs useful in treating blood
dyscrasias cover 3 important dysfunctions:
– Thrombosis
– Bleeding
– Anemia
What could you use to treat each of these abnormalities
based on your knowledge of physiology?
Drugs affecting Blood
Thrombosis Tx
Platelet Inhibitors Anti-coagulants Thrombolytic Agents
Aspirin (Salicyclic Acid)
Dipyridamole
Heparin
Warfarin
Streptokinase
Urokinase
Drugs affecting Blood
Drugs affecting blood
Bleeding Tx Anemia Tx
Vitamin K
Protamine Sulfate
Aminocaproic Acid
Iron
Folic Acid
Vitamin B12
Erythropoietin
Note: Hydroxyurea is used to treat Sickle Cell Anemia!
• What do the lungs do?
• What type of drugs can affect that?
Drugs affecting the
Respiratory System
12
Drugs affecting the
Respiratory System
• Drugs used to treat Allergic Rhinitis
– Anti-histamines (H1
)
– Corticosteroids
– Alpha-adrenergic agonists (vasoconstricts)
• Drugs used to treat Asthma:
– Beta-adrenergic agonists (bronchodilates)
– Corticosteroids
– Theophylline (coffee, tea)
• Drugs used to treat COPD:
– Corticosteroids
– Beta-adrenergic agonists
• Drugs used to treat Cough:
– Opiates (suppress CNS cough centers)
Drugs affecting the
Respiratory System
• What do the kidneys do?
• What type of drugs can affect that?
Drugs affecting the Kidney Drugs affecting the Kidney
Diuretics
Carbonic
Anhydrase
Inhibitors
Loop Thiazide Potassium-sparing Osmotic
Acetazolamide
Furosemide
Torsemide
Bumetanide
Chlorothiazide
Hydrochlorothiazide
Sprionolactone
Amiloride
Mannitol
Urea
Drugs affecting the GI System
• Drugs used to treat Peptic Ulcer
– Proton pump inhibitors
• Omeprazole
• Lansoprazole
– H2
-receptor antagonists
• Cimetidine
• Ranitidine
• Famotidine
– Antimicrobial
• Amoxicillin
• Tetracycline
• Metronidazole
• Drugs used to treat Peptic Ulcer
– Antacids
• Magnesium hydroxide (milk of magnesia)
• Calcium carbonate (Tums®, Rolaids®)
• Aluminum hydroxide
• Sodium bicarbonate
– Anti-muscarinic agents
• Hyoscyamine
• Pirenzepine
Drugs affecting the GI System
13
• Drugs used to treat Diarrhea:
– Anti-diarrheals
• Kaolin
• Pectin
• Methylcellulose
• Drugs used to treat Constipation:
– Laxatives
• Castor oil
• Senna
• Aloe
• Glycerine
Drugs affecting the GI System Compensatory Drugs
Normal physiology is key to understanding
these drug effects:
• Thyroid?
• Pancreas?
• Pituitary?
• Adrenals? (all 3 layers)
Anti-inflammatory Drugs
NSAID’s are less dangerous than chronic
steroidal anti-inflammatory drugs:
• Aspirin (Bayer®)
• Diclofenac
• Etodolac
• Fenoprofen
• Ibuprofen (Advil®)
• Indomethacin
• Naproxin
• Sulindac
• Tolmetin
Non-narcotic analgesics:
•Acetaminophen (Tylenol®)
•Phenacetin
Test Question?
Which of the following NSAID’s is not antiinflammatory?
A. ASA (salicyclic acid)
B. Ibuprofen
C. Naproxen
D. Acetaminophen
Anti-microbial Drugs
• Antimycobacterials
– INH, Rifampin, Ethambutol, Dapsone
• Antivirals
– Acyclovir, Famciclovir, Ganciclovir
– Vidarabine, Rimantadine, Amantadine, Ribavirin
– Interferon (Hepatitis)
– Zidovudine, Zalcitabine, Stavudine, Didanosine
(HIV)
• Antiprotozoals
– Quinolones, Metronidazole
Test Question?
Which of the following drugs is useful for
treating Hepatitis C?
A. Ganciclovir
B. Interferon
C. Acyclovir
D. Famciclovir
14
• Antifungals
– Polyenes:
• Amphotericin B (systemic)
• Nystatin (topical)
– Imidazoles:
• Ketoconazole (systemic)
• Clotrimazole (systemic or topical, Mycelex®)
• Miconazole
• Itraconazole
• Fluconazole
– Griseofulvin
• Disrupts fungal mitotic spindle formation
• Used to treat dermatophytic infections
Anti-microbial Drugs Test Question?
A significant difference between nystatin and
amphotericin B is that:
A. They are different types of antifungals
B. One is effective against candidiasis and one is not
C. One is administered topically and the other
systemically
D. Only one of them acts on the fungal cell membrane
Antibiotics
‡ RNA ‡ PROTEIN
ENZYMES
Inhibition of DNA Replication or
Transcription:
Quinolones, Rifampin, Doxorubicin
Inhibition of Translation or Protein Synthesis:
Clindamycin, Chloramphenicol, Erythromycin, Tetracyclines
Aminoglycosides: Streptomycin, Neomycin, Gentamycin
Inhibition of synthesis of essential
metabolites: Sulfa drugs, Trimethoprim
Inhibition of cell wall synthesis:
Penicillins, Ampicillin, Cephalosporins,
Bacitracin, Vancomycin
Injury to cell
membrane:
Polymyxin B
flCidal Static‡
DNA
50S 30S
Bacterial Cell
Local Anesthetics
Amides:
[aniline derivatives]
articaine, bupivacaine, dibucaine, levobupivacaine,
lidocaine, mepivacaine, prilocaine, ropivacaine
Esters:
[PABA derivatives]
benzocaine, butamben, chloroprocaine, cocaine,
procaine, proparacaine, tetracaine
• Hypersensitivity info:
Ester allergy more common; cross-sensitivity between
classes rare; consider paraben or bisulfite sensitivity if
apparent allergy to both classes
General Anesthetics
• 3 stages:
– Induction, Maintenance, Recovery
– Induction and Pre-anesthetic medication
regimens can use:
• Benzodiazepines
• Opioids
• Anticholinergics
• Antiemetics
• Antihistamines
• Maintenance:
– Today mainly volatile inhalation gases
• Enflurane
• Halothane
• Isoflurane
• Methoxyflurane
• NO
• Recovery:
– Reverse of induction, withdrawal of drugs for
redistribution, counter-acting med’s prn
General Anesthetics
15
Antibiotic Premedication
(Endocarditis Prophylaxis-Adult)
[timing of administration]
unless otherwise noted, give all PO doses 1h before procedure; a ll IM/IV doses within 30min of
procedure
for orodental , resp , esoph
[standard regimen]
Dose: amoxicillin 2 g PO; Alt: ampicillin 2 g IM/IV
[PCN allergy]
Dose: clindamycin 600 mg PO/IV; Alt: cephalexin 2 g PO; cefazolin 1 g IM/IV; azithromycin 500 mg
PO; clarithromycin 500 mg PO
for GU, GI (not esoph)
[high risk]
Dose: ampicillin 2 g IM/IV and gentamicin 1.5 mg/kg within 30min before procedure, then ampicillin 1
g IM/IV or amoxicillin 1 g PO 6h later
Info: prosthetic, bioprosthetic , homograft valves; previous endocarditis ; complex cyanotic congenital
heart disease; surgical pulmonary shunts
[high risk, PCN allergy]
Dose: vancomycin 1 g IV and gentamicin 1.5 mg/kg IM/IV
[moderate risk]
Dose: amoxicillin 2 g PO; Alt: ampicillin 2 g IM/IV
Info: other congenital cardiac malformation; acquired defects, r heumatic heart disease; hypertrophic
cardiomyopathy; MVP with regurgitation and/or thickened leaflets
[moderate risk, PCN allergy]
Dose: vancomycin 1 g IV
[timing of administration]
unless otherwise noted, give all PO doses 1h before procedure; a ll IM/IV doses within 30min of procedure
for orodental , resp , esoph
[standard regimen]
Dose: amoxicillin 50 mg/kg (max 2 g) PO; Alt: ampicillin 50 mg/kg (max 2 g) IM/IV
[PCN allergy]
Dose: clindamycin 20 mg/kg (max 600 mg) PO/IV; Alt: cephalexin 50 mg/kg (max 2 g) PO; cefazolin 25 mg/kg
(max 1 g) IM/IV; azithromycin 15 mg/kg (max 500 mg) PO; clarithromycin 15 mg/kg (max 500 mg) PO
for GU, GI (not esoph)
[high risk]
Dose: ampicillin 50 mg/kg (max 2 g) IM/IV and gentamicin 1.5 mg/kg (max 120 mg) within 30min before
procedure, then ampicillin 25 mg/kg (max 2 g) IM/IV or amoxicillin 25 mg/kg (max 2 g) PO 6 h later
Info: prosthetic, bioprosthetic , homograft valves; previous endocarditis ; complex cyanotic congenital heart
disease; surgical pulmonary shunts
[high risk, PCN allergy]
Dose: vancomycin 20 mg/kg (max 1 g) IV and gentamicin 1.5 mg/kg (max 120 mg) IM/IV
[moderate risk]
Dose: amoxicillin 50 mg/kg (max 2 g) PO; Alt: ampicillin 50 mg/kg (max 2 g) IM/IV
Info: other congenital cardiac malformation; acquired defects, r heumatic heart disease; hypertrophic
cardiomyopathy; MVP with regurgitation and/or thickened leaflets
[moderate risk, PCN allergy]
Dose: vancomycin 20 mg/kg (max 1 g) IV`
Antibiotic Premedication
(Endocarditis Prophylaxis-Child)
GOOD LUCK!
1
PROSTHODONTICS
George Bryon Craig DDS
General Considerations (21)
n Diagnosis and treatment planning
n Preprosthodontic treatment
n Maxillomandibular relations
n Impressions and casts
n Esthetics and Phonetics
n Restorative implantology
Complete and Removable Partial
Denture Prosthodontics (8)
n Design of prosthesis and mouth
preparation
n Occlusion
n Dental Materials
n Insertion and postinsertion
Fixed Partial Prosthodontics (16)
n Design of Prosthesis and mouth
preparation
n Occlusion
n Ceramic techniques
n Dental Materials
n Insertion and postinsertion
n Complete Denture
n Crown & Bridge
n Impression Materials
n Miscellaneous
n Occlusion/Temporomandibular Joint
n Porcelain
n Removable Partial Denture
Complete Denture
2
83/11
Excessive vertical dimension may
result in
n poor denture retention.
n Drooping of the corners of the
mouth.
n Creases and wrinkles around the lips.
n Trauma to the underlying supporting
tissues. CORRECT
83/21
Overextension of a mandibular denture base
in the distofacial area will cause
dislodgment of the denture during function
as the result of the action of the
n masseter muscle. CORRECT
n buccinator muscle.
n Pterygomandibular raphe.
n Superior pharyngeal constrictor muscle.
83/25
The distal palatal termination of the
maxillary complete denture base is
dictated by the
n tuberosity.
n fovea palatinae.
n Maxillary tori.
n Vibrating line. CORRECT
n Posterior palatal seal.
83/32
An excessive vertical dimension of
occlusion in a patient with complete
dentures will adversely affect
n retention.
n Protrusion.
n Centric relation.
n Balanced occlusion.
n Interocclusal clearance. CORRECT
83/43
Placement of maxillary anterior teeth
in complete dentures too far
Superiorly and anteriorly might
result in difficulty in pronouncing
n “f” and “v” sounds. CORRECT
n “d” and “t” sounds.
n “s” and “th” sounds.
n Most vowels.
83/52
Papillary hyperplasia in a denture-wearing
patient results primarily from
n overextension of the lingual flange.
n Inadequate eccentric occlusal contact.
n An inappropriate relief chamber on the
maxillary denture. CORRECT
n Invasion of soft tissue by Candida
albicans.
n An unpolished tissue surface on the
maxillary denture.
3
83/64
The bearing area of the maxillary denture of an
elderly patient shows hyperplastic tissue over the
entire ridge. Treatment for this condition is to
n remove surgically all the hyperplastic tissue.
n Make an impression immediately in order to
compress the entire area.
n Instruct the patient to leave the denture out of
the mouth for several months.
n Use tissue treatment material for several weeks
before making an impression. CORRECT
83/73
A generalized inflammatory condition in the
stressbearing mucosa may be caused by
(a) faulty occlusion; (b) ill-fitting
dentures; (c) wearing the dentures for 24
hours consecutively; (d) an overclosed
occlusal vertical dimension.
n (a) and (b) only
n (a), (b) and (c) CORRECT
n (a) and (c) only
n (b), (c) and (d)
n All of the above
86/29
Proper lip support for a patient with
complete dentures is provided primarily by
the
n convex surface of the labial flange.
n Festooned carvings on the facial surface.
n Thickness of the border in the vestibule.
n Facial surfaces of teeth and simulated
attached gingiva. CORRECT
86/41
A balanced occlusion in maxillary and
mandibular complete dentures exists when
n opposing teeth contact in centric
occlusion.
n Opposing teeth contact in centric
occlusion, working, balancing and
protrusive positions. CORRECT
n Incisors contact without contact of
posterior teeth in a protrusive position.
n Facial cusps touch in working position
without contact on balancing cusps.
86/45
When testing the arrangement of teeth
at the trial insertion of complete
dentures, the lower lip should, when
pronouncing the letter “f” as in fifty,
n be anterior to maxillary incisors.
n Be posterior to maxillary incisors.
n Not come near maxillary incisors.
n Contact lightly the incisal edges of
maxillary incisors. CORRECT
88/04
The usual cause of contacting or
clicking of posterior teeth when a
patient speaks is
n decreased vertical dimension of
occlusion
n increased vertical dimension of
occlusion. CORRECT
n posterior teeth set too far lingually.
n Posterior teeth set too far facially.
4
88/16
Excessive vertical dimension of
occlusion may result in
n poor denture retention.
n Increased interocclusal distance.
n Drooping of the corners of the
mouth.
n Creases and wrinkles around the lip.
n Trauma to underlying supporting
tissues. CORRECT
88/18
A patient who wears complete dentures is
having trouble pronouncing the letter “C”.
This is probably caused by
n too thick a palatal seal area.
n Too thick a base in the mandibular
denture.
n Incorrect positioning of maxillary incisors.
CORRECT
n Imporoper positioning of mandibular
incisors.
88/25
Proper lip support for a patient with
complete dentures is provided primarily by
the
n convex surface of the labial flange.
n Rounded contours of interdental papillae.
n Proper pronouncement of sibilant sounds.
n Thickness of the border in the vestibule.
n Facial surfaces of teeth and simulated
attached gingiva. CORRECT
88/31
In determining the posterior limit of a
maxillary denture base, which of the
following is on the posterior border?
n Hamular notch. CORRECT
n Hamular process
n Fovea palatine
n Vibrating line
n Pterygomandibular raphe
88/38
Treatment of choice for a patient with a
maxillary complete denture with severe
bilateral tuberosity undercuts is to
n remove both tuberosity undercuts.
n Reduce the tissue bilaterally.
n Reduce the tissue on one side only, if
possible. CORRECT
n None of the above. No treatment is
necessary
88/41
During postinsertion adjustment, errors in occlusion
may be checked most accurately by
n having the patient leave the dentures out of the
mouth for 24 hours.
n Directing the patient to close the jaws, bringing
the teeth into occlusion.
n Having the patient close in occlusion and making
a transfer record to the articulator.
n Remounting the dentures on the articulator using
remount casts and new interocclusal records.
CORRECT
5
88/53
The error that most frequently contributes
to poor esthetics of dentures is the
practice of placing maxillary anterior teeth
n following the smile line.
n Too far below the lip line.
n Directly over the edentulous ridge.
CORRECT
n Too far to the facial of the edentulous
ridge.
n Too far to the lingual of the edentulous
ridge.
97/239
When construction complete dentures,
the ala tragus line must be parallel to
n Frankfort horizontal plane
n The maxillary posterior occlusal rims.
CORRECT
n The mandibular posterior occlusal
rims.
Ala Tragus 97/140
A plaster index is used to
n preserve face bow transfer CORRECT
n maintain vertical dimension of
occlusion
n maintain bite registration
2004/161
Which on of the following is the most
important factor for providing
retention for complete dentures?
n cohesion
n adhesion
n peripheral seal CORRECT
Crown & Bridge
6
88/83
The retentive characteristics of a full crown may be
enhanced by (a) using glass ionomer cement; (b)
using zinc phosphate cement; (c) adding pinholes
in the preparation; (d) adding grooves parallel to
the path of draw; (e) maximizing the parallelism
of the axial walls.
n (a), (c) and (d)
n (a), (d) and (e)
n (b), (c) and (d)
n (b), (c) and (e)
n (c), (d) and (e) CORRECT
n All of the above
97/54
What is the most accurate way of
checking the occlusion for a fixed
prosthesis?
n articulating paper
n shimstockCORRECT
n patient information
97/70
How far should implants be placed
from one another?
n 3mm CORRECT
n 4mm
n 5mm
n 7mm
97/189
The ideal time to wait for
osseointergration of an implant to
take place is
n 3 months
n 6 months CORRECT
n 9 months
n 12 months
Impression Materials
97/133
Impression material with least tear
resistance
n rubber base
n irreversible hydrocolloid
n reversible hydrocolloid CORRECT
7
97/179
What is the impression material with
the best dimensional stability 24
hours after taking the impression?
n polyvinyl siloxane CORRECT
n reversible colloid
n irreversible colloid
Miscellaneous
86/28
At which of the following positions is
sibilant sound usually produced?
n rest position
n occluding position
n open form rest position
n between rest and occluding
positions. CORRECT
88/76
The lateral pterygoid muscle functions to (a)
elevate the mandible; (b) protrude the
mandible; (c) lift the mandible from the
pterygoid plate; (d) move the mandible to
the opposite side.
n (a) and (b)
n (a) and (c)
n (a) and (d)
n (b) and (c)
n (b) and (d) CORRECT
n (c) and (d)
n GOLD CASTING ALLOYS
• Type I – soft gold-for inlays
• Type II – medium- inlays
• Type III – hard – onlays and crowns
• Type IV – extra hard w/low fusing temp
– partial dentures
• Ceramic-metal restorations (contain
iron, tin, indium)
98/63
When do you clean zinc phosphate
cement from crown margins?
n immediately
n 4 hours after the cement has set
n after the cement has set completely
CORRECT
n the next day
8
88/11
The proper zone of a gas-air blowpipe
flame used for melting casting gold
alloys is
n the reducing zone CORRECT
n the oxidizing zone
n the zone closest to the nozzle
n a combination of oxidizing and
reducing zones
88/16
The property that most closely
describes the ability of a cast gold
inlay to be burnished is
n elastic limit
n ultimate strength
n percentage elongation. CORRECT
n modulus of resilience
n modulus of elasticity
88/31
In mixing zinc phosphate cement,
which clinical variable has the
greatest effect on the strength of the
cement?
n spatulation time.
n Liquid-powder ratio CORRECT
n Temperature of the mixing slab
n Number and size of powder
increments
Occlusion
Temporomandibular
Joint
83/68
Group function occlusion in an existing dentition is
characterized by having (a) no balancing side
contacts; (b) working side contacts from canine
to third molar; (c) a long centric from centric
relation to centric occlusion; (d) canine rise in
protrusion; (e) total balance in lateral excursion.
n (a) and (b) only CORRECT
n (a), (b), (c), and (d)
n (a), (b), and (d) only
n (b), and (d) only
n (c), (d) and (e)
n (c), and (e) only
88/29
In a restorative problem involving all teeth
in the mouth, the protrusive condylar path
inclination has its primary influence on
n incisal guidance.
n Anterior teeth only.
n Mesial inclines of mandibular cusps and
distal inclines of maxillary cusps.
CORRECT
n Mesial inclines of maxillary cusps and
distal inclines of mandibular cusps.
9
97/91
Best way to image TMJ
n CT
n MRI CORRECT
n High pan
n Lateral oblique
Class II maloccllusion
n Division I: is when the maxillary
anterior teeth are proclined and a
large overjet is present
n Division II: is where the maxillary
anterior teeth are retreclined and a
deep overbite exists.
Classification of malocclusion
June 2, 2004
Dr. Robert Gallois
n http://www.columbia.edu/itc/hs/dental/ort
ho/ClassificationMalocclusion.pdf
n The overlap of the cusps helps to
keep the soft tissue of the tongue
and cheeks out from the occlusal
tables, preventing self-injury during
chewing
n The amount of horizontal (overjet )
and vertical (overbite) can
significantly influence mandibular
movement and thus influence the
cusp design of restorations.
Overjet
10
Overbite The TMJ and it influence
TMJ
n Condyle
n Articular Disk (superior and inferior
joint spaces)
n Articular eminences
Mandibular Movements
n Rotation (superior joint space)
n Translation (inferior joint space)
n Immediate side shift (working side in
lateral excursion)
Rotation and Translation Side Shift
11
Planes of Motion
n Sagital
n Frontal
n Horizontal
Sagital (Posselt’s diagram)
Frontal Horizontal
Types of Occlusion we use
n Canine guidance
n Group function
n Balanced occlusion
Canine Guidance
12
Canine Guidance Group Function
Balanced Occlusion
n Used in denture patients
n A minimum of three point bilateral
supporting contact occurs between
the maxillary and mandibular teeth
at all times in lateral and protrusive
excursions (compensating curve)
Compensating Curve
Porcelain
86/11
The phenomenon where porcelain
appears different under varying light
conditions is
n metamerism. CORRECT
n translucency.
n Transmittance
n Opacification
n Refractive optics
13
86/77
Which of the following are causes of
separation or fracture of the porcelain
from the metal in the metal-ceramic
technique? (a) Poor metal framework
design; (b) Excessive porcelain
condensation; (c) Centric occlusal contacts
entirely on porcelain; (d) Contamination of
metal prior to opaque application
n (a), (b) and (d)
n (a) and (c)
n (a) and (d) only
n (b) and (d) only CORRECT
Removable Partial
Dentures
83/18
A properly designed rest on the lingual
surface of a canine is proferred to a
properly designed rest on the incisal
surface because
n less leverage is exerted against the tooth
by the lingual rest. CORRECT
n The enamel is thicker on the lingual
surface.
n Visibility of as well as access to the lingual
surface is better.
n The cingulum of the canine provides a
natural surface for the recess.
83/57
The most important function of an indirect
retainer is to prevent
n tissue resorption.
n Occlusal interferences.
n Movement of the denture base toward the
tissue.
n Movement of the teeth after orthodontic
treatment.
n Movement of a distal extension base away
from the tissues. CORRECT
83/45
Clasps should be so designed that, upon
insertion or removal of a removable partial
denture, the reciprocal arms contact the
abutment teeth when the retentive arms
engage the height of contour in order to
n permit insertion and removal without
applying excessive force. CORRECT
n assure complete seating of the framework
n prevent distortion of the clasps.
n All of the above.
83/85
Which of the following problems may occur
in a patient with a maxillary removable
partial denture if the palatal bar is made
too thick?
n Difficulty in pressing food backward for
swallowing. CORRECT
n Poor dissipation of force because of
excessive rigidity
n Irritation of the palatal tissues
n Distortion under occlusal stress
n Injury to the abutment teeth
14
83/90
In designing a retainer on a
noncarious mandibular first premolar
abutment with a short clinical crown,
which of the following restorations is
most appropriate?
n An inlay
n A full crown CORRECT
n An MOD onlay
n A reverse ¾ crown
86/26
The most frequent cause of tissue soreness
along the mucobuccal area of a removable
partial denture is
n use of anatomic teeth.
n A centric prematurity .
n Heavy balancing contact.
n Extension of the denture border.
CORRECT
n Lack of rigidity of the major connector.
88/20
When a removable partial denture is completely
seated, the retentive terminals of the retentive
clasp arms should be
n passive and applying no pressure on the teeth.
CORRECT
n contacting the abutment teeth only in the
suprabulge areas.
n Resting lightly on the height of contour line on
the abutment teeth.
n Applying a definite, positive force on the
abutment teeth in order to prevent dislodgment
of the removable partial denture.
88/34
Which of the following is likely to occur under the
distal extension maxillary partial denture of a
patient with Paget’s disease?
n The bone will tend to expand and the partial
denture will have to be remade periodically.
CORRECT
n The bone is like “cottonwool” and will be resorbed
rapidly, thus, making frequent rebasing
necessary.
n The bone will become very dense and hard, thus,
soreness of the basal seat is likely to occur.
n Nothing will occur because maxillary bone is not
usually affected.
88/46
Indirect retention is designed to
n stabilize tooth-borne removable partial
dentures.
n Engage an undercut area of an abutment
tooth.
n Help resist tissueward movement of an
extension base partial denture.
n Help resist dislodgment of an extension
base partial denture in an occlusal
direction. CORRECT
n KENNEDY CLASSIFICATIONS
• Class I – bilateral distal extension
• Class II – unilateral distal extension
• Class III – unilateral tooth borne
edentulous area
• Class IV – bilateral (crossing midline)
edentulous area (tooth borne)
15
97/108
When placing an I-clasp on a premolar
for a distal extension RPD, the I-bar
moves_____ and ______ under
occlusal forces.
n occlusally and distally
n occlusally and mesially
n apical and distal
n apical and mesial CORRECT
97/139
A patient wearing a new bilateral RPD
complains of soreness in tissue
bearing areas 24 hours after
insertion. The most likely cause
would be
n occlusal discrepancies CORRECT
n over extended denture
n under extended denture
n allergy
RADIOGRAPHIC PATHOLOGY
I. DEFINITIONS
– “Radiographic appearances are governed by anatomic or physiologic
changes in the presence of disease processes. Radiologic ‘diagnosis’ is
founded on knowledge of these alterations, the prerequisite being
awareness of disease mechanisms.” H.M. Worth
II. THE RADIOGRAPHIC REPORT
– Patient name, age, ethnicity, referring physician, and date of radiographs
– Radiographic Procedure (brief but more descriptive for invasive procedures)
– Radiographic Findings (objective info: location/anatomy/structural effects)
a. Anatomy: epicenter (above/below/in the canal), local/generalized,
monostotic/polyostotic
b. Shape: hydraulic (cysts), scalloping, regular/irregular
c. Internal: density (opaque/lucent/mixed), trabeculation, septation,
mineralization/calcification (amorphous/discrete/grainy), geographic
radiolucency or hydraulic/cystic radiolucency
d. Periphery: borders discrete or well-defined vs. blending or
permeative, cortication, sclerosis, capsule
e. Behavior: space occupying, displacing, destroying, expanding, or
osteo-inducing such as in new periosteal bone formation
– Interpretation/Impression (subjective DDx: may include clinical or
surgical findings, histologic findings, or other diagnostic procedures)
III. IMAGING MODALITIES (pre-biopsy preferred)
A. Panoramic and Occlusal Radiographs
i. Together help simulate CT coronal and axial sections,
especially in cases of cortical expansion/periosteal reaction.
ii. Useful when cost or access to more advanced imaging a factor,
or follow-up cases…aka: “poor man’s CT”
B. Computerized Tomography (standard)
i. Acquired Coronal (not corrected), Axial, and Sagittal.
ii. Contrast (ie: Gadolinium) can enhance lesional features and is
essential for neoplastic lesions
C. Magnetic Resonance Imaging (MRI)
i. Soft tissue imaging modality based on proton spin and
magnetic moments of hydrogen ions (T1 and T2 weighted)
ii. Not good for bone pathology because hydrogen ions in bone
are bound and not free to spin and relax.
D. Nuclear Medicine (adjunct, still evolving)
i. Radiopharmaceutical (technetium) gamma photon detection
system which is utilized for identifying areas of increased
metabolic activity – such as in neoplasia, septic arthritis,
metabolic bone disease, active condylar hyperplasia, and
osteomyelitis (except in chronic sclerosing phase in which
CT’s are more ideal)
E. Positron Emission Tomography (adjunct, still evolving)
i. FDG (glucose analogue) shows increased activity in areas with
high metabolic (glycolytic) activity – such as in osteomyelitis,
hyperparathyroidism, or neoplasia metastases or follow-up.
F. TMJ Tomography
i. Imaging modality for various joint conditions ranging from
reactive to neoplastic.
IV. CONDITIONS
-Correlate with clinical and histopathologic findings
A. Developmental
i. Symmetry, often asymptomatic, long history, little or no change
over time
B. Neoplastic
i. Malignant: Infiltrative growth pattern, ragged, poorly
demarcated or ill-defined, paresthesia
ii. Benign: Slow growth, uniform, well-demarcated or welldefined
C. Reactive/Inflammatory
i. Inflammatory symptomatology if any, shorter history, more
common
1
RADIOGRAPHIC
PATHOLOGY OF THE
HEAD AND NECK
Dr. Parish P. Sedghizadeh
Diplomate, American Board of Oral & Maxillofacial Pathology
Assistant Professor, University of Southern California –
School of Dentistry and Center for Craniofacial Molecular Biology
Division of Diagnostic Sciences; Orofacial Pain & Oral Medicine Center
Looking for abnormalities: Requires knowledge of normal
anatomy first, what constitutes a good film or image, and
why the imaging study is being done clinically.
Radiolucency , Opacity, or mixed…
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Differential Diagnostic process:
Based on normal anatomy, then
identifying abnormality as possibly
an Odontogenic Cyst/Tumor,
Neurovascular lesion, NonOdontogenic Cyst/Tumor, or other
condition…depending on the
epicenter relationship to anatomic
structures like the IA Canal.
Neurovascular Lesion
• Benign:
– Neurofibroma
– Neuroma
– Hemangioma
• Malignant:
– Neurofibrosarcoma
– Neurogenic Sarcoma
– Angiosarcoma
Differential Diagnosis:
Mandibular Radiolucencies
Within the IA Canal
Differential Diagnosis:
Mandibular Radiolucencies
Above the IA Canal (excludes infections
• Odontogenic Cysts causing apical lesion)
– Dentigerous Cyst (often contains crown of impacted tooth)
– Odontogenic Keratocyst (OKC)
– Lateral Periodontal Cyst
– Periapical Cyst
– Calcifying Odontogenic Cyst (COC)
• Odontogenic Tumors
– Ameloblastoma
– Adenomatoid Odontogenic Tumor
– Calcifying Epithelial Odontogenic Tumor (mixed lucencyopacity)
– Odontoma (central opacification with peripheral lucency)
– Odontogenic Myxoma (multi-locular lucency)
Dentigerous (Developmental)
Cyst
2
Dentigerous (Developmental) Cyst
Dentigerous (Developmental) Cyst
Odontogenic Myxoma
Lateral Periodontal Cyst Odontogenic Keratocyst
Residual Cyst Calcifying Odontogenic Cyst
Odontomas (compound)
3
Odontoma (complex)
Periapical Cemento-Osseous Dysplasia
Differential Diagnosis:
Mandibular Radiolucencies
Below the IA Canal
• Bone Tumors
– Metastatic Carcinoma
– Osteosarcoma
• Bone Cysts
– Stafne bone defect (not a true cyst, but actually a salivary gland
depression in the bone – no Tx, follow)
– Traumatic Bone Cyst
– Aneurysmal Bone Cyst (ABC)
• Bone Reactive / Inflammatory
– Osteomyelitis
– Giant Cell Reaction
* Except for the Stafne defect, most of the lesions above often
appear above the IA canal also, highlighting the fact that most
lesions in the lower jaw occur above the IA canal.
Size Difference?
Size Difference?
Stafne Defect
NO! CT scan or periodic radiographic evaluation
Some small but important opacities…
4
Idiopathic Osteosclerosis
(formerly Condensing Osteitis)
Sialolith
Calcified (mineralized) Lymph Nodes (tuberculosis)
Calcified (mineralized) Atherosclerotic Plaques of Carotid Artery
THE ROLE OF
ADVANCED IMAGING
IN DIFFERENTIATING BONE PATHOSES
WITH OSTEOGENIC POTENTIAL,
such as in cases demonstrating new
periosteal bone formation
PERIOSTEAL REACTIONS
IN THE FORM OF NEW BONE
FORMATION
– Osteomyelitis
– (proliferative periostitis)
– Osteosarcoma
– Metastatic Carcinoma
– Langerhans Cell Disease
5
Periosteal Reactions
• Varying etiopathogenesis
– Ranging from reactive to
neoplastic
• Result is varying
osteoblastic (forming) and
osteoclastic (resorbing)
activity
physiologically/molecularly
that is evident
histopathologically also
• Demonstrates radiographic
appearance likened to an
“onion-skin” or “hair-on-end”
pattern
Periosteal Reactions
• Varying etiopathogenesis
– Ranging from reactive to
neoplastic
• Result is varying
osteoblastic (forming) and
osteoclastic (resorbing)
activity
physiologically/molecularly
that is evident
histopathologically also
• Demonstrates radiographic
appearance likened to an
“onion-skin” or “hair-on-end”
pattern
• Clinically may demonstrate cortical
osseous expansion, with or without
tenderness depending on factors
such as etiology and patients’ pain
perceptions
• Definitive diagnosis may require
clinical, radiographic, and
histologic/ immunohistochemical
correlation in many cases
Periosteal Reactions Conditions in which new
periosteal bone formation
may be a feature
• Osteomyelitis
– Proliferative Periostitis (Garrè’s)
• Osteosarcoma
• Metastatic Carcinoma
• Langerhans Cell Disease
Osteomyelitis –
Proliferative Periostitis
• Hypothesized that acute osteomyelitis, or
inflammation of medullary bone, which is
mainly lytic in nature, (from infection, trauma,
etc…) spreads to the periosteum
• Inflammatory cytokines then stimulate cortical
resorption, while inflammatory exudate also
lifts the periosteum and induces new bone
formation which occurs parallel/lamellar to
cortex, accounting for unique presentation
6
Osteosarcoma
• Periosteal, Parosteal, and Gnathic in H&N
• Rare cases associated with Paget’s
disease and Cemento-Osseous dysplasia
• Radiolucent, radiopaque, or mixed
radiographic appearance
• Lytic, loss of lamina dura, widening of
PDL, destruction of adjacent structures,
and ragged and ill-defined margins may
be seen classically
• Disrupted and disorganized periosteum
may appear “hair-on-end” or “sunburst”
• Intact periosteum, more rarely, may
show an “onion-skin” pattern,
presumably mediated by molecular and
chemical factors released from tumor
cells and immune cells
• Bone Morphogenic Protein, Alkaline
Phosphatase, Osteocalcin, Endothelin,
and various growth factors
7
Metastatic Carcinoma
• Variable radiographic appearance, with
polymorphous shape and irregular, illdefined margins usually
• However, similar to previous conditions,
metastatic carcinoma can also produce a
periosteal reaction in the form of new bone
formation, particularly prostate and breast
cancers
• In vitro cell culture studies have shown
prostatic acid phosphatase and its substrate
a-glycerophosphate stimulate calcification
and osteogenesis in prostatic cases
Langerhans Cell Disease
• Growing evidence indicates this is a
neoplastic process, and many investigators
favor malignancy of Langerhans cells as
opposed to histiocytes (CD1a vs.CD68)
• Intraosseous lesions may result in
radiographic appearance of teeth with
unsupported bone, often termed “teeth
floating in space”
• New periosteal bone formation similar to
aforementioned inflammatory (cytokine)
neoperiostosis may be a feature
• Mainly children and young adults affected

CD1a stain
Langerhans cell disease
Copyright © 2003, Elsevier Science (USA). All rights reserved.
THE ROLE OF
ADVANCED IMAGING IN
DIFFERENTIATING BETWEEN
BONE PATHOSES
8
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1
Management of Traumatic
Injuries
Ellis’ classification:
• Class I: Simple fracture of
the crown involving little
or no dentin
• Class II: Extensive
fracture of the crown
involving considerable
dentin but not the pulp
• Class III: Extensive
fracture of the crown with
a pulpal exposure
• Class IV: A fracture in
which the entire crown
has been lost
Vitality tests after trauma
• Thermal test- most reliable, especially in primary
incisors, failure to respond to heat is indicative of pulpal
necrosis
• EPT- often unreliable
• Failure of a recently traumatized tooth to respond to the
pulp test is common.
• Emergency tx should be completed and the tooth
should be retested in 10-14 days.
• Darkening of the tooth is a good indication of loss of
vitality of the pulp.
Types of Injuries
• Ankylosis
– This is caused by injury to the
periodontal membrane and
subsequent inflammation
– The ankylosed primary tooth
in the anterior segment should
be removed if there is
evidence of it causing delayed
or ectopic eruption of the
permanent successor
– It is often detected by a “step”
with the ankylosed tooth
below the plane of occlusion.
• Luxation/Intrusion
– Displaced but not intruded primary teeth should be
repositioned as soon as possible to prevent
interference of occlusion
– They can be stabilized with wire and composite
splint
– Intruded teeth are left to spontaneously re-erupt
– Severely loosened primary teeth should be
removed
• Dilaceration
– This occasionally occurs
after intrusion or
displacement injuries
– The developed portion of
the tooth is twisted or
bent on it self, and on
this new position growth
progresses
– The resulting tooth has
the crown in a
significantly different
position from the root
2
• Root Fractures
– Root fractures at the apical half of the tooth are
more likely to undergo repair often without
treatment
– In order for repair to take place, the fragments must
be maintained in apposition
– Healing should take place in 3-4 weeks
• Avulsion
– The best prognosis is for teeth replanted within a
short period of time
– Teeth should not be cleaned, disinfected, rinsed, or
scaled
– The pt or parent can be instructed to replant the
tooth, or the tooth can be stored in milk or saliva
– Reimplanted teeth are treated endodontically later
111
DIAGNOSIS
1. What is the proper role of the pulp tester in clinical diagnosis?
The pulp tester excites the nervous system of the pulp through electrical stimulation. However,
the pulp tester suggests only whether the tooth is vital or nonvital: the crucial factor is the vascularity of
the tooth. The pulp test alone is not sufficient to allow a diagnosis and must be combined with other tests.
2. What is the importance of percussion sensitivity in endodontic diagnosis?
Percussion sensitivity is a valuable diagnostic tool. Once the infection or inflammatory process
has extended through the apical foremen into the periodontal ligament (PDL) space and apical tissues,
pain is localizable with a percussion test. The PDL space is richly innervated by proprioceptive fibers,
which make the percussion test a valuable tool.
3. Listening to a patient’s complaint of pain is a valuable diagnostic aid. What differentiates
reversible from irreversible pulpitis?
In general, with reversible pulpitis pain is elicited only on application of a stimulus (i.e., cold,
sweets). The pain is sharp and quick but disappears on removal of the stimulus. Spontaneous pain is
absent. The pulp is general noninflamed. Treatment usually is a sedative dressing or a new restoration
with a base. Irreversible pulpitis is generally characterized by pain that is spontaneous and lingers for
some time after stimulus removal. There are various forms of irreversible pulpitis, but all require
endodontic intervention.
4. What are the clinical and radiographic signs of an acute apical abscess?
Clinically an acute apical abscess is characterized by acute pain of rapid onset. The affected
tooth is exquisitely sensitive to percussion and may feel “elevated” because of apical suppuration.
Radiographic examination may show a totally normal periapical complex or a slightly widened PDL space,
because the infection has not had enough time to demineralize the cortical bone and reveal a
radiolucency. Electric and thermal tests are negative.
5. Discuss the importance of inflammatory resorption.
Resorption after avulsion injuries depends on the thickness of cementum. When the PDL does
not repair and the cementum is shallow, resorption penetrates to the dentinal tubules. If the tubules
contain infected tissue, the toxic products pass into the surrounding alveolus to cause severe
inflammatory resorption and potential loss of the tooth.
112
6. A patient presents with a “gumboil” or fistula. What steps do you take to diagnose the
cause or to determine which tooth is involved?
All fistulas should be traced with a gutta percha cone, because the originating tooth may not be
directly next to the fistula. Fistulas positioned high on the marginal gingiva, with concomitant deep probing
and normal response of teeth to vitality testing, may have a periodontal etiology.
7. Why is it often quite difficult to find the source of pain in endodontic diagnosis when a
patient complains of radiating pain without sensitivity to percussion or palpation?
Teeth are quite often the source of referred pain. Percussion or palpation pain may be lacking in
a tooth in which the inflammatory process has not reached the proprioceptive fibers of the periodontal
ligament. The pulp contains no proprioceptive fibers.
8. What is the anatomic reason that pain from pulpitis can be referred to all parts of the head
and neck?
In brief, nerve endings of cranial nerves VII (facial), IX (glossopharyngeal), and X (vagus) are
profusely and diffusely distributed within the subnucleus caudalis of the trigeminal cranial nerve (V). A
profuse intermingling of nerve fibers creates the potential for referral of dental pain to many sites.
9. Is there any correlation between the presence of symptoms and the histologic condition of
the pulp?
No. Several studies have shown that the pulp may actually degenerate and necrose over a period
of time without symptoms. Microabscess formation in the pulp may be totally asymptomatic.
10. Describe the process of internal resorption and the necessary treatment.
Internal resorption begins on the internal dentin surface and spreads laterally. It may or may not
reach the external tooth surface. The process is often asymptomatic and becomes identifiable only after it
has progressed enough to be seen radiographically. The etiology is unknown. Trauma is often but not
always implicated. Resorption that occurs in inflamed pulps is characterized histologically by
dentinoclasts, which are specialized, multinucleated giant cells similar to osteoclasts. Treatment is prompt
endodontic therapy. However, once external perforation has caused a periodontal defect, the tooth is
often lost.
11. Describe the process of internal resorption and the necessary treatment.
Internal resorption begins on the internal dentin surface and spreads laterally. It may or may not
reach the external tooth surface. The process is often asymptomatic and becomes identifiable only after it
has progressed enough to be seen radiographically. The etiology is unknown. Trauma is often but not
always implicated. Resorption that occurs in inflamed pulps is characterized histologically by
dentinoclasts, which are specialized, multinucleated giant cells similar to osteoclasts. Treatment is prompt
endodontic therapy. However, once external perforation has caused a periodontal defect, the tooth is
113
often lost.
12. What is the significance of the intact lamina aura in radiographic diagnosis?
The lamina aura is the cribiform plate or alveolar bone proper, a layer of compact bone lining the
socket. Because of its thickness, an x-ray beam passing through it produces a white line around the root
on the radiograph. Byproducts of pulpal disease, passing from the apex or lateral canals, may degenerate
the compact bone; its loss can be seen on a radiograph. However, this finding is not always diagnostic,
because teeth with normal pulps may have no lamina aura.
13. Which radiographic technique produces the most accurate radiograph of the root and
surrounding tissues?
The paralleling or right-angle technique is best for endodontics. The film is placed parallel to the
long axis of the tooth and the beam at a right angle to the film. The technique allows the most accurate
representation of tooth size.
14. What is the definition of a true combined lesion?
A true combined lesion is due to both endodontic and periodontal disorders that progress
independently. The lesions may join as the periodontal lesion progresses apically. Such lesions, if any
chance of healing is to occur, require both endodontic therapy and aggressive periodontal therapy.
Usually, the prognosis is determined more by the extent of the periodontal lesion.
15. What is the reason that radiographic examination does not show periapical radiolucencies
in certain teeth with acute abscesses?
One study showed that 30-50% of bone calcium must be altered before radiographic evidence of
periapical breakdown appears. Therefore, in acute infection apical radiolucencies may not appear until
later, as treatment progresses.
16. Why do pulpal-periapical infections of mandibular second and third molars often involve
the submandibular space?
Extension of any infection is closely tied to bone density, the proximity of root apices to cortical
bone, and muscle attachments. The apices of the mandibular second and third molars are usually below
the mylohyoid attachment; therefore infection usually spreads to the lingual and submandibular spaces;
often the masticator space is also involved.
114
17. A patient presents with a large swelling involving her chin. Diagnostic tests reveal that the
culprit is the lower right lateral incisor. What factor determines whether the swelling
extends into the buccal fold or points facially?
A major determining factor in the spread of an apical abscess is the position of the root apex in
relation to local muscle attachments. In this particular case, the apex of the lateral incisor is below the
level of the attachment of the mentalis muscle; therefore, the abscess extends into the soft tissues of the
chin.
18. A middle-aged woman has been referred for diagnosis of multiple radiolucent lesions
around the apices of her mandibular incisor. The patient is asymptomatic, the teeth are
normal on vitality tests, no cortical expansion is noted, and the periodontium is normal.
Medical history and blood tests are normal. What is your diagnosis?
The most likely diagnosis is periradicular cemental dysplasia or cementoma. This benign
condition of unknown etiology is characterized by an initial osteolytic phase in which fibroblasts and
collagen proliferate in the apical region of the mandibular incisors, replacing medullary bone. The teeth
remain normal to all testing. Eventually, cementoblasts differentiate to cause reossification of the area.
Treatment is to monitor over time.
Torabinejad M, Walton R: Periradicular lesions. In Ingle JI (ed): Endodontics, 4th ed. Baltimore, Williams &
Wilkins, 1994, pp 434-457.
CLINICAL ENDODONTICS (TREATMENT)
19. What is the current thinking on use of the rubber dam?
The dam is an absolute necessity for treatment. It ensures a surgically clean operating field that
reduces chance of cross-contamination of the root canal, retracts tissues, improves visibility, and
improves efficiency. It protects the patient from aspiration of files, debris, irrigating solutions, and
medicaments. From a medicolegal standpoint, use of the dam is considered the standard of care.
20. What basic principles should be kept in mind for proper access opening?
Proper access is a crucial and overlooked aspect of endodontic practice. The root canal system is
usually a multicanaled configuration with fins, loops, and accessory foramina. When possible, the opening
must be of sufficient size, position, and shape to allow straight-line access into the canals. Access of
inadequate size and position invites inadequate removal of caries, compromises proper instrumentation,
and inhibits proper obturation, However, overzealous access leads to perforation, weakening of tooth
structure, and potential fracture.
21. What are the current concepts on irrigating solutions in endodontics?
The type of irrigant is of minor importance in relation to the volume and frequency. The crucial
factor is constant irrigation to remove dentinal debris, to prevent blockage, and to lessen the chance of
apical introduction of debris. Several studies have shown the efficacy of saline, distilled water, sodium
hypochlorite, hydrogen peroxide, combinations of the above, and many other agents. The results show no
advantage to chemomechanical preparation of the root canal system.
22. Of what material are endodontic files currently made?
Hand-operated instruments, including broaches, H-files, K-files, reamers, K-flex files, and S-files,
are made of stainless steel as opposed to carbon steel, which was used in the past. Stainless steel bends
more easily, is not as brittle, is less likely to break compared with carbon steel, and can be autoclaved
without dulling. In addition, hand and rotary files are now being made of nickel-titanium.
23. What are the characteristics of a K-file?
The K-file is made by machine grinding of stainless steel wire into a square shape (some
companies produce a triangular shape). The square wire is then twisted by machines in a
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counterclockwise direction to produce a tightly spiraled file.
24. What are the characteristics of a reamer?
The reamer is made by machine twisting of a triangular stainless steel stock wire in a
counterclockwise direction but into a less tightly spiraled instrument than the K-file.
25. How does the K-flex file differ?
The K-flex file is produced from a rhomboid or a diamond-shaped stainless steel stock wire
twisted to produce a file. However, the two acute angles of the rhombus produce a cutting edge of
increased sharpness and cutting efficiency. The low flutes made from the obtuse angles form an area for
debris removal.
26. How does filing differ from reaming?
Filing establishes its cutting action upon withdrawal of the instrument. The instrument is removed
from the canal without turning. Thus it uses basically a push-pull motion. Reaming is done by placing the
instrument in the canal, rotating, and withdrawing.
27. What is the recommended use for Gates-Glidden and Reeso drills?
These two types of engine-driven instruments, especially the Gates-Glidden drills, are useful in
the new recommended instrumentation technique of step-down preparation. They are efficient in initial
coronal preparation of the canal, thereby allowing easier, more efficient, and less traumatic apical
preparation.
28. What is RC-prep? How is it used?
RC-prep is composed of ethylene diamine tetraacetic acid (EDTA) and urea peroxide in a
carbwax base. Its use as a canal lubricant is also enhanced by combination with sodium hypochlorite,
which produces much bubbling action, allowing enhanced removal of dentinal debris and permeability into
the tubules.
29. Why is nickel-titanium becoming a material of choice for endodontic hand and rotary
instruments?
The newer hand and rotary instruments made from nickel-titanium have excellent flexibility and
strength after repeated sterilization, are quite anticorrosive, and resist fracture quite well.
30. What types of hand-operated implements for root canal instrumentation are currently
available?
A detailed discussion of the various properties and differences in file-reamer types is beyond the
scope of this chapter. K-type files and reamers are still widely used because of their strength and
flexibility. H-type Hedstrom files are quite popular because of their aggressive ability to cut dentin. S-files
are highly efficient for cutting dentin on the withdrawal stroke and for filing and reaming. Flex-it files are a
new modification with a noncutting tip design. This design allows guidance of the tip through curvatures
and reduces the risk of ledging, perforation, and transportation of the apex. For an excellent discussion of
instrumentation devices and techniques, the reader is referred to Cohen S. Burns RC (eds): Pathways of
the Pulp, 6th ed. St. Louis, Mosby, 1994.
31. What is the current status on acceptability of root canal obturation materials?
Gutta percha remains the most popular and accepted filling material for root canals. Numerous
studies have demonstrated that it is the least tissue-irritating and most biocompatible material available.
Although differences occur among manufacturers, gutta percha contains transpolyisoprene, barium
sulfate, and zinc oxide, which provide an inert, compactible, dimensionally stable material that can adapt
to the root canal walls.
N-2 pastes and other paraformaldehyde-containing pastes are not approved by the Food and
Drug Administration (FDA). Several studies have shown conclusively that such root-filling pastes are
highly cytotoxic in tissue culture; reactions to bone include chronic inflammation, necrosis, and bone
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sequestration. Compared with gutta percha, the pastes are highly antigenic and perpetuate inflammatory
lesions. For these reasons they are not considered the standard of endodontic care.
32. What is the proper apical extension of a root canal filling?
The proper apical extension of a root canal filling has been discussed extensively for years, and
the debate continues. In the past recommendations were made to fill a root canal to the radiographic
apex in teeth that exhibited necrosis or areas of periapical breakdown and to stop slightly short of this
point in vital teeth. Currently, however, it is generally recommended that a root canal be filled to the
dentinocementum junction, which is 0.5-2 mm from the radiographic apex. Filling to the radiographic apex
is usually overfilling or overextending and increases the chance of chronic irritation of periapical tissues.
33. Describe the walking bleach technique.
The walking bleach technique is used to bleach nonvital teeth with roots that have been
obturated. The technique involves the placement of a thick white paste composed of sodium perborate
and Superoxol in the tooth chamber with a temporary restoration. Several repetitions of this procedure,
along with the in-office application of heat to Superoxol-saturated cotton pellets in the tooth chamber,
work quite well.
34. Several authors report extensive cervical resorption after bleaching of pulpless teeth with
the walking bleach technique using Superoxol, sodium perborate, and heat. What is the
cause?
In approximately 10% of all teeth, defects at the cementoenamel junction allow dentinal tubules to
communicate from the root canal system to the PDL. These tubules remain open, without sclerosis, if the
tooth becomes pulpless at a young age. It is thought that the bleaching agents may leach through the
open tubules to cause the resorption. Therefore, a barrier of some type is recommended, such as zinc,
phosphate cement, or some type of light canal bonding agent.
Rothstein CD: Bleaching and vital discolored teeth. In Cohen S. Burns RC (eds): Pathways of the Pulp, 7th
ed. St. Louis, Mosby, 1998, pp 674-691.
35. List four useful tools in the diagnosis of a vertical crown-root fracture.
1. Transillumination with fiberoptic light
2. Persistent periodontal defects in otherwise healthy teeth
3. Wedging and staining of defects
4. Radiographs rarely show vertical fractures but do show a radiolucent defect laterally from
sulcus to apex (which can be probed).
36. Describe the crown-down pressureless technique of root canal instrumentation.
With the crown-down pressureless technique the canal is prepared in a coronal to apical direction
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by initially instrumenting the coronal two-thirds of the canal before any apical preparation. This technique,
popularized by Marshall-Pappin, minimizes apically extruded debris and eliminates binding of instruments
coronally, thereby making apical preparation more difficult.
37. What is the balanced-force concept of root canal instrumentation and preparation?
The balanced-force concept, proposed by Roane and Sabala, is based on the idea of balancing
the cutting forces over a greater area of the canal and focusing less force on the area where the file tip
engages the dentin. The technique is done with the Flex-it file with a noncutting tip and a triangular crosssection. By using this type of file in a counterclockwise reaming motion, ledging is minimized, more inner
canal curvature is accomplished, and less zipping of the apex occurs.
Roane JB, Sabala C, Duncanson M: The “balanced force” concept for instrumentation of curved canals. J
Endod 11:203, 1985.
38. What is the frequency of fourth canals in mesial roots of maxillary first molars?
In an extensive study of maxillary first molars, 59% of the mesiobuccal roots contained either a
larger buccal and smaller lingual canal or two separate canals and foramina. This finding shows the
importance of searching for a fourth canal to ensure clinical success.
39. What is the current thinking about the manner of storage of an avulsed permanent tooth
and its relationship to post-replantation success?
After 15-12 minutes of extraoral exposure, the cell metabolites in the periodontal ligament have
been depleted and need to be reconstituted before replantation. Research by Cvek has shown that
soaking the tooth in a physiologic solution for 30 minutes before replanting reduces the chance of postreplant resorption. The media of choice are Hank’s balanced salt solution (found in Save-A-Tooth) and
Visapan (used for storage of transplant organs). If neither is available, milk or saline may be used, but not
as successfully.
40. What is the current guideline for the length of time to splint an avulsed tooth, with and
without alveolar fracture?
The current recommendation is to splint an avulsed tooth for 7-14 days (3-5 weeks with alveolar
fracture). If an avulsed tooth is replanted fairly quickly (within 1 hour) and some of the fibroblasts of the
periodontal ligament (PDL) and cementoblasts of the root surface remain viable, initial PDL repair may
occur in 7-14 days.
41. When an avulsed tooth is replanted, what are the current recommendations concerning
rigid or functional splinting?
Recent studies show that early functional stimulus may improve the healing of luxated teeth. It is
advantageous to reduce the time of fixation to the time necessary for clinical healing of the periodontium,
which may take place in a few weeks. Andreasen has shown that prolonged rigid immobilization
increases the risk of ankylosis; thus the splint should allow some vertical movement of the involved teeth.
Andreasen J: Effect of masticatory stimulation on dentoalveolar ankylosis after experimental tooth
replantation. Endod Dent Traumatol 1;13-16, 1985.
Andreasen J: Periodontal healing after replantation of traumatically avulsed human teeth: Assessment by
mobility testing and radiography. Acta Odontol scan 33;325-335,1975.
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42. What is the physiologic basis for the use of calcium hydroxide pastes for resorptive
defects or avulsed teeth?
The theory behind the use of calcium hydroxide pastes is that areas of resorption have an acidic
pH of approximately 4.5-5.0. Such areas are more acidic than normal tissue because of the effects of
inflammatory mediators and tissue breakdown products. The basic pH of calcium hydroxide neutralizes
the acidic pH, thereby inhibiting the resorptive process of osteoclastic hydrolases.
Tronstad L, et al: pH changes in dental tissues after root canal with calcium hydroxide. J Endod 7:17, 1981.
43. What is the current thinking on the use of medicaments in endodontic practice?
Formerly, medicaments were in wide use in endodontics to kill bacteria in the canal. However,
current thinking stresses thorough debridement of canals and the use of irrigating solutions to clean
canals. Medicaments are not stressed, because all have been shown to be cytotoxic in tissue culture. In
addition, several medicaments have been shown to elicit immunologic reactions in animal studies.
Mechanical canal cleaning sufficiently lowers microbial levels to allow the local defense mechanisms to
heal endodontic periapical lesions.
44. Discuss the variations of postoperative pain in one-visit vs. two-visit endodontic
procedures.
Several studies show no difference in postoperative pain in one-visit vs. two-visit endodontic
procedures. In fact, one study found that single-visit therapy resulted in postoperative pain approximately
one-half as often as multiple-visit therapy.
45. What is the treatment of choice for an intruded maxillary central incisor with a fully formed
apex?
Repositioning or surgical extrusion should be done immediately with splinting for 7-10 days.
Because pupal necrosis is the usual outcome, pulpectomy within 2 weeks and placement of calcium
hydroxide are recommended. Close observation every few months is needed.
46. What is the desired shape of the endodontic cavity (root canal) for obturation in both
lateral and vertical condensation techniques?
The canal should be instrumented and shaped so that it has a continuously tapering funnel
shape. The narrowest diameter should be at the dentinocemental junction (0.5-1.0 mm from apex) and
the widest diameter at the canal opening.
47. Are electronic measuring devices for root canal of any clinical value in everyday
endodontic practice?
Yes. Electronic measuring devices have been shown by several investigators to be quite
accurate. In general, they work by measuring gradients in electrical resistance when a file passes from
dentin (insulator) to conductive apical tissues. They are quite useful when the apex is obscured on a
radiograph by sinus superimposition, other roots, or osseous structures.
48. What is the accepted material of choice for pulp-capping procedures?
The literature has reports, of many drugs, medicaments, and anti-inflammatory agents used for
pulp capping, but the material of choice remains calcium hydroxide. Calcium hydroxide, applied to the
pulp tissue, seems to cause necrosis of the underlying tissue, but the continuous tissue often forms
calcific bridges.
49. Describe the process of apexification.
Apexification involves the placement of agents in the pulpless permanent tooth, with an
incompletely formed apex, to stimulate continued apical closure. Calcium hydroxide pastes are the
accepted agents for use in the canals.
50. What is the accepted treatment for carious exposures in primary teeth?
For carious exposures in primary teeth in which the tissue appears vital and the inflammation is
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only in the coronal pulp, the formocresol pulpotomy is still widely accepted. When a carious exposure
shows total pulpal degeneration (necrosis), full pulpectomy is indicated with placement of a resorb able
zinc oxide-eugenol (ZOE) paste.
51. What is the role of sealer-cements in root canal obturation?
Sealer-cements are still widely recommended for use with a semisolid obturating material (gutta
percha). The sealers fill discrepancies between the root filling and canal wall, act as a lubricant, help to
seat cones of gutta percha, and fill accessory canals and/or foramina apically.
52. What biologic property is shared by all sealer-cements used in endodontics?
Studies of biocompatability have shown that all sealer-cements are highly toxic when freshly
mixed, but the toxicity is reduced on setting. Chronic inflammatory responses, which usually persist for
several days, are often cited as a reason not to avoid apical overextension of the sealer. Several studies
have recommended the use of sealers that are more biocompatible, such as AH-26 and the newer
calcium hydroxide-based sealers (Sealapex and CRCS).
53. In using Cavit as an interappointment temporary seal, what precautions must be taken?
Cavit, which is a hygroscopic single paste containing zinc oxide, calcium and zinc phosphate,
polyvinyl and chloride acetate, and triethanolamine, requires placement of at least 3 mm of material to
ensure a proper seal and fracture resistance.
54. What materials or devices are of use in removing gutta percha for retreatment?
Initial removal should be done with endodontic drills (Gates-Glidden or Peezo) or by using a
heated plugger to remove the coronal portion of the gutta percha. This procedure allows space in the
canal for placement of solvents to dissolve remaining material. Solvents include chloroform, xylene,
methyl chloroform, and eucalyptol. Chloroform is the most effective, although it has been used less
because of reported carcinogenic potential. Xylene and eucalyptol are the least effective. Once the
remaining gutta percha has been softened, it often can be removed by files or reamers.
Wennberg A, Orstavik D: Evaluation of alternatives to chloroform in endodontic practice. Endod Dent
Traumatol 5;234,1989.
55. What are the cause, histologic characteristics, and treatment for internal resorption?
The exact cause is unknown, but internal resorption is often seen after trauma that results in
hemorrhage of vessels in the pulp and infiltration of chronic inflammatory cells. Macrophages have been
shown to differentiate into dentinoclastic-type cells. With this proliferation of granulation tissue, resorption
can occur. Treatment is to remove the pulpal tissues as soon as possible so that tooth structure is not
perforated.
56. Does preparation of the post immediately on obturation have a different effect on the
apical seal of a root canal filling from delayed preparation?
Dye leakage studies have shown no difference and no effect on the apical seal whether post
preparation is immediate or delayed.
Madison S, Zakariasen K: Linear and volumetric analysis of apical leakage in teeth prepared for posts. J
Endod 10:422-427, 1984.
57. What temperature and immersion time are needed to sterilize endodontic files in a bead
sterilizer?
At the proper temperature of 220ΕC (428ΕF) in the bead sterilizer, an endodontic file should be
immersed for 15 seconds. However, because of the potential for a wide variation of temperatures in the
transfer medium (beads or salt), this technique should be secondary to other, more reliable techniques of
sterilization.
58. What is the best and easiest technique for sterilization of gutta percha cones?
Immersion of the cone in a 5.25% solution of sodium hypochlorite for 1 minute is quite effective in
killing spores and vegetative organisms.
Senia SE, et al: Rapid sterilization of gutta percha cones with 5.25% sodium hypochlorite. J Endod 1;136,
1975.
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59. What simple techniques should be used to avoid apical ledging and perforation?
Overly aggressive force should not be used in the apical area. A light touch with a precurved file
to negotiate apical curvature is necessary to maintain proper canal curvature.
60. Which type of file is the strongest and cuts least aggressively?
K-files are the strongest of all files. Because they cut the least aggressively, they can be used
with quarter-turn pulling motion, rasping, or clockwise-counterclockwise motions.
61. List four criteria that must be met before obturation of a canal.
1. The patient must be asymptomatic; the tooth in question must not be sensitive to percussion
or palpation.
2. No foul odor should emanate from the tooth.
3. The canal should not produce exudate.
4. The temporary restoration should be intact, i.e., no leakage has contaminated the canal.
62. How does preparation of the canal for filling techniques that use injection of gutta percha
differ from that for conventional techniques?
All injection techniques require a more flared canal body and a definite apical construction to
prevent flow of softened gutta percha into periapical tissues.
63. What is the treatment of choice for a primary endodontic lesion in a mandibular molar with
secondary periodontal involvement (including furcation lucency) in a periodontally healthy
mouth?
Treatment generally consists solely of endodontic therapy. Necrotic pulpal tissue that causes
furcation and lateral root or apical breakdown also may cause periodontal pockets through the sulcus, but
these are actually fistulas rather than true pockets. Endodontic therapy alone often heals this secondary
periodontal involvement.
64. What is the current thinking on the prognosis of pulp capping and partial pulpectomy
procedures on traumatically exposed pulps?
In a study of traumatically exposed pulps, including both mature teeth and teeth with immature
apices, Cvek found that pulp capping or partial pulpectomy procedures were successful in 96% of cases.
In all teeth the superficial pulp in the traumatized area was carefully excised. Cvek and others agree that
such procedures are generally more successful in vital teeth with immature root formation.
Cvek M. Lundberg J: et al: Histological appearance of pulps after exposure by a crown fracture: Partial
pulpotomy and clinical diagnosis of healing. J Endod 9:8-11, 1983.
65. What is the current thinking on ideal treatment for carious exposure of a mature
permanent tooth?
There is general agreement that carious exposure of a mature permanent tooth generally
requires endodontic therapy. Carious exposure generally implies bacterial invasion of the pulp, with toxic
products involving much of the pulp. However, partial pulpotomy and pulp capping of a carious exposure
in a tooth with an immature apex have a higher chance of working.
66. You have elected to perform partial pulpotomy and to place a calcium hydroxide cap on a
maxillary permanent central incisor with blunderbuss apex in a young boy. What followup is necessary?
Close monitoring of the tooth is necessary. First, it is important to see whether any pathology
develops. If necrosis occurs with apical pathology, extirpation with apexification is needed. On the other
hand, if vitality is maintained in such teeth, root formation continues, along with dystrophic calcification.
67. What is the recommended technique for the access opening in endodontic therapy for
maxillary primary incisors?
A facial approach is generally recommended for such teeth, which need pulpectomy with a filling
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of zinc oxide-eugenol paste. Because of esthetic problems and the difficulty in bleaching, endodontic
therapy is followed by composite facial restoration.
68. Can infections of deciduous teeth cause odontogenesis of the permanent teeth?
In one study, local infections of deciduous teeth for up to 6 weeks did not influence
odontogenesis of the permanent central incisors. However, longstanding infections may have a profound
effect on permanent teeth buds because of direct communication between the pulpal and periodontal
vasculature of the deciduous tooth and the plexus surrounding the developing permanent tooth.
69. Describe the characteristics of the Profile Rotary Instrumentation Series.
This series of nickel-titanium rotary files has a rounded, guided tip and a U-shaped flute for
collecting debris. It is available in a .04 and .06 taper series; the .06 taper is used in a sequential series,
allowing for a crown-down preparation.
70. Thermafil endodontic obturators are now widely used. What is the basic methodology?
Pre-notched stainless steel files coated with alpha-phase gutta percha are used to obturate the
canal. Selection of the Thermafil device depends on the last carrier and condenser for the thermally
plasticized alpha-phase gutta percha. Alpha-phase rather than the more common beta-phase gutta
percha is used because, when heated, it has superior flow properties and adheres will to the metal
carrier.
71. What is the major difference between the two main thermoplasticized gutta percha
techniques on the market?
In the Obtura II system, gutta percha heated to 160ΕC is injected through a silver needle tip at a
temperature of about 65ΕC. The Ultrafil system is a low-temperature technique that heats the gutta
percha to 70ΕC for injection. Both techniques stress the importance of maintaining constriction at the
cementodentinal junction to prevent flow of gutta percha beyond the apex.
72. What is the “dentin-chips apical-plug filling technique”?
This technique consists of filling the last 1-2 mm of the apex of the canal with dentin chips to seal
the apical foremen. Above this is placed a seal of gutta percha. This so-called biologic seal of dentin
chips should be made only after proper debridement of the canal to avoid apical placement of infected
chips. The efficacy of this technique is controversial.
73. In treating a maxillary lateral incisor, what particular care must be taken in instrumenting
the apical portion?
The apical root portion usually curves toward the distal palatal space; this configuration must be
negotiated carefully.
74. Should the smeared layer of dentinal debris be removed from canal walls?
Yes. Removal of the smeared layer is recommended because of the possibility that it harbors
bacteria.
75. What is considered the most reliable technique to remove the smeared layer of organic
and inorganic dentinal debris from canal walls?
The recommended technique is the use of a chelating agent, such as EDTA with sodium
hypochlorite, during instrumentation.
76. What is the single most important factor in determining the degree and severity of the
pulpal response to a tooth preparation (cutting) procedure?
Research has shown that the remaining dentin thickness between the floor of the cavity
preparation and the pulp chamber is the most crucial determinant of the pulpal response. In general, a 1-
mm thickness of dentin provides a sufficient degree of protection from the trauma of high-speed drills and
restorative materials. With a thickness less than 2 mm, the inflammatory response in the pulp seems to
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increase dramatically. Neither age nor tooth size has as significant an effect.
Swerdlow H, Stanley HR: Reaction of human dental pulp to cavity preparation. J Prosthet Dent 9:121, 1959.
77. In restoring a tooth with a deep carious lesion, clinicians often excavate the caries and
place a temporary sedative restoration to allow symptoms to subside. What is the
rationale behind this procedure in relation to pulpal physiology?
A deep carious lesion produces an inflammatory response in the pulp tissue adjacent to the
dentinal tubules in the area of the caries. Removal of the irritation to the pulp and placement of a sedative
filling allow new odontoblasts to differentiate and to produce a reparative dentin in the involved area. This
process usually requires approximately 20 days for odontoplastic regeneration and 80 days for reparative
dentin formation.
Stanley HR: The rate of tertiary dentin formation in the human tooth. Oral Surg 21:100, 1966.
78. What is the most common reason for failure of root canals?
Although an endodontically treated tooth may fail for various reasons, including fracture,
periodontal disease, or prosthetic complication leading to one of the above, the most common cause of
failure is incompletely and inadequately debrided and disinfected root canals. The time-honored saying
that what you take out of the canal is not as important as what you put in has much merit. The
chemomechanical debridement of the root canal system, which is necessary to remove all irritants to the
surrounding apical and periodontal tissues, is still the crucial aspect of root canal treatment.
PULP AND PERIAPICAL BIOLOGY
79. What is the dental pulp? Describe in a brief paragraph the ultrastructural characteristics of
this remarkable tissue.
The dental pulp is a matrix composed of ground substance, connective cells and fibers, nerves, a
microcirculatory system, and a highly specialized and differentiated cell called the odontoblast. The dental
pulp is similar to other connective tissues in the body, but its ability to deal with injury and inflammatory
reactions is severely limited by the mineralized walls that surround it. Therefore, its ability to increase
blood supply during vasodilation is impaired.
80. The odontoblast is a remarkable and unique cell. Briefly describe its major characteristics.
The odontoblast is a highly differentiated cell that forms a pseudostratified layer of cells along the
periphery of the pulp chamber. It is a highly polarized cell with synthesizing activity in its cell body and
secretory activity in the odontoblastic process, which forms the predentin matrix. Because it is the main
cell for dentin formation, injury by caries or restorative procedures may affect this activity.
81. Give a brief description of the most accepted theory about the mechanism of dentin
sensitivity.
The most plausible theories are based on the fact that the dentinal tubule acts as a capillary tube.
The tubule contains fluid, or a pulpal transudate, that is displaced easily by air, heat, cold, and explorer
tips. This rapid inward or outward movement of fluid in tubules may excite odontoblastic processes, which
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have been shown to travel within the tubules, or sensory receptors in the underlying pulp.
Brannstrom M, Astrom A: The hydrodynamics of the dentine: Its possible relationship to dentinal pain. Int
Dent J 22:219-227, 1972.
82. A 45-year-old woman presents for consultation. She is asymptomatic. Radiographs reveal
a radiolucent lesion apical to teeth 24 and 25 with no swelling or buccal plate expansion.
The dentist diagnosed periapical cemental dysplasia. How is this diagnosis confirmed?
Periapical cemental dysplasia or cementoma presents as a radiolucent lesion in its early stages.
It is a fibroosseous lesion developing from cells in the periodontal ligament space. The teeth involved
respond normally to vitality testing.
83. What is the effect of orthodontic tooth movement on the pulp?
In progressive, slow orthodontic movement, the minor circulatory changes and inflammatory
reactions are reversible. However, with excessively severe orthodontic forces, disruption of pulpal
vascularity may be irreversible, leading to disruption of odontoblasts and fibroblasts and possible pulpal
necrosis. Rupture of blood vessels in the periodontal ligament also may affect pulpal vascularity. In
addition, orthodontic tooth movement is associated with excessive root resorption and blunted roots, both
of which may occur with continued vitality.
84. Inflammatory mediators cause vasodilation of blood vessels. How does vasodilation in the
pulp differ from that in other tissues?
Vasodilation in all tissues is a defense mechanism, controlled by various inflammatory mediators,
to allow tissue survival during inflammation. The pulp responds differently, with an increase in blood flow
followed by a sustained decrease. This secondary vasoconstriction often leads to the demise of the pulp.
Kim S: Regulation of blood flow of the dental pulp. J Endod 115(9):1989.
85. Is it possible to differentiate a periapical cyst from a periapical granuloma on the basis of
radiographic appearance alone?
No. radiographic appearance is not diagnostic. Often a sclerotic border may be present, but its
absence does not preclude cystic formation. An exhaustive study indicates that lesions greater than 200
mm3
are usually cystic in nature.
Natkin E, Oswald RJ, Carnes LI; Tthe relationship of lesion size to diagnosis, incidence and treatment of
periapical cysts and granulomas. Oral Surg Oral Med Oral Pathol 57:82-94, 1984.
86. A patient presents with a maxillary central incisor that has a history of trauma. The patient
is asymptomatic, and the radiograph is normal. Because the tooth gives no response to an
electric pulp tester, you elect to do endodontic therapy without anesthesia. However, with
access and instrumentation the patient feels everything. Explain the inconsistency.
The electric pulp tester excites the A8 fibers in the tooth. The pulp contains A8 and C nociceptive
fibers; the A8 fibers have a lower stimulation threshold than the C fibers. The C fibers are more resistant
to hypoxia and can function long after the A8 fibers are inactivated by injury to pulp tissue. The electric
pulp tester does not stimulate C fibers.
87. List six normal changes in pulp tissue due to age.
(1) Decrease in size and volume of pulp, (2) increase in number of collagen fibers, (3) decreased
number of odontoblasts (4) decrease in number and quality of nerves, (5) decreased vascularity, and (6)
overall increase in cellularity.
Bernick S: Effect of aging on the nerve supply to human teeth. J Dent Res 46:694, 1967.
88. What is the meaning of the term dentinal pain?
Dentinal pain is due to the outflow of fluid in dentinal tubules that stimulates free nerve endings,
most likely A8 fibers. Dentinal pain is usually associated with cracked teeth (into the dentin), defective
fillings, or hypersensitive dentin. The pain produced by such stimulation does not usually signify that the
pulp is inflamed or the tissue injured, whereas pulpal pain is due to true tissue injury associated with
stimulation of C fibers.
89. Do the odontoblastic processes extend all the way through the dentin?
This controversial topic has been studied extensively by several investigators. The process is
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basically an extension of the cell body of the odontoblast. It is the secretory portion of the odontoblast and
contains large amounts of microtubules and microfilaments. Light microscopic studies have generally
shown odontoblastic processes only in the inner one-third of dentin; this finding agrees with scanning
electron microscope studies and transmission electron microscope studies, which showed processes
mainly in the inner one-third of dentin.
Brannstrom : The dentinal tubules and the odontoblast processes. Acta Odontol Scand 30:291, 1972.
Gunji T, et al: Distribution and organization of odontoblast processes in human dentin. Arch Histol Jpn
46;213, 1983.
Sigal MJ: The odontoblast process extends to the dentinoenamel junction: An immunocytochemical study of
rat dentine. J Histochem Cytochem 32:872,1984.
Thomas HF: The extent of the odontoblast process in human dentin. J Dent Res 58:2207, 1979.
90. Describe briefly the circulatory system of the dental pulp.
The pulp contains a true microcirculatory system. The major vessels are arterioles, venules and
capillaries. The capillary network in the pulp is extensive, especially in the subodontoblastic region, where
the important functions of transporting nutrients and oxygen to pulpal cells occurs and waste products are
removed. The pulpal microcirculation is under neural control and also under the influence of chemical
agents, such as catecholamines, that exert their effects at the alpha and beta receptors found in pulpal
arterioles.
Cohen S, Burns RC (eds): Pathways of the Pulp, 6th ed. St. Louis, Mosby, 1994.
91. Have immunoglobulins and immunocompetent cells been found in the dental pulp?
Yes. Numerous studies have demonstrated that the pulp and periapical tissues are able to mount
an immune response against injury to the pulp and apical tissues. All classes of immunoglobulins have
been identified in the dental pulp, and microscopic examination of damaged pulpal tissue reveals the
presence of leukocytes, macrophages, plasma cells, lymphocytes, giant cells, and mast cells.
MICROBIOLOGY AND PHARMACOLOGY
92. What types of bacteria are the predominant pathogens in endodontic-periapical
infections?
Many well-done studies have shown definitively the predominant role of gram-negative obligate
anaerobic bacteria in endodontic-periapical infections. Earlier studies generally implicated facultative
organisms (streptococci, enterococci, lactobacilli), but improved culturing techniques established the
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predominance of obligate anaerobes. A recent study further demonstrated the important role of
Porphyromonas endodontalis (formerly Bacteroides endodontalis) in endodontic infections.
Van Winkelhoff, et al: Porphyromonas endodontalis: Its role in endodontic infections. J Endod 18:431, 1992.
93. What is considered the antibiotic of choice in treatment of orofacial infections of
endodontic origin?
In light of all the new microbiologic research implicating the predominance of obligate anaerobes,
drug sensitivity tests still show the penicillins to be the drugs of choice. Penicillin is highly effective against
most of the obligate anaerobes in endodontic infections, and because the infections are of a mixed nature
with strict substrate interrelations among various bacteria, the death of several strains has a profound
effect on the overall population of an endodontic-periapical infection.
94. What antibiotics are considered most effective in treatment of orofacial infections of
endodontic origin that do not respond to the penicillins?
For infections not responding to the penicillins, clindamycin is often recommended. It produces
high bone levels and is highly effective against anaerobic bacteria, but it must be used with caution
because of the potential for pseudomembranous colitis. A second choice is metronidazole, which also is
quite effective against gram-negative obligate anaerobes.
95. What is the current status of culturing and sensitivity testing for endodontic-periapical
infections?
Culturing and sensitivity testing have been a controversial topic in endodontic practice for years.
According to current thinking, if the proper clinical guidelines are followed, including use of rubber dam,
proper chemomechanical cleaning of the root canal system, and proper use of correct antibiotics as
indicated, culturing and sensitivity testing are not required. Proper culturing for both facultative and
anaerobic bacteria is expensive, time-consuming, and not cost-effective, given the high success rate of
properly done endodontic therapy.
96. The role of gram-negative anaerobic bacteria is an established fact in the pathogenesis of
endodontic lesions. What role does the bacterial endotoxin play?
Endotoxins are highly potent lipopolysaccharides released from the cell walls of gram-negative
bacteria. They are able to resorb bone via stimulation of osteoclastic activity, activation of complement
cascades, and stimulation of lymphocytes and macrophages. Various studies have demonstrated their
presence in pulpless teeth (with necrotic tissue) and apical lesions.
97. What roles do nonsteroidal anti-inflammatory drugs (NSAIDs) have in endodontic
practice?
NSAIDs have a significant role in endodontic practice. Many patients require postoperative
medication to control pericementitis, which can be quite painful after pulpectomy and may persist for
several days. The NSAIDs are quite effective; their mechanism of action is to inhibit synthesis of
prostaglandins. One study showed that ibuprofen, when given preoperatively to symptomatic and
asymptomatic patients, significantly reduces postoperative pericementitis.
Dionne RA, et al: Suppression of postoperative pain by preoperative administration of ibuprofen in
comparison to placebo, acetaminophen and acetaminophen plus codeine. J Clin Pharmacol 23;37-43, 1983.
98. What is the latest thinking on the role of black-pigmented anaerobic rods in the etiology of
infected root canals and periapical infection?
Black-pigmented anaerobic rods have been shown to play an essential role in the etiology of
endodontic infections when present in anaerobic mixed infections. The most strongly implicated organism
is Porphyromonas endodontalis, which, because of its need for various growth factors, is directly related
to the presence of acute periapical inflammation, pain, and exudation.
99. A patient presents with swelling, in obvious need of endodontic therapy. His medical
history is significant for penicillin allergy and asthma, for which he is taking Theo-Dur.
What precautions should you exercise?
By no means should erythromycin be used as an alternative to penicillin. Theo-Dur is a form of
theophylline used for chronic reversible bronchospasm associated with bronchial asthma and
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erythromycin has been shown to elevate significantly serum levels of theophylline.
100. For years it was taught that any bacteria left behind in an obturated canal would die and
therefore cause no problems. What are the latest findings about this controversy?
The most recent electron micrograph studies have shown persistence of bacteria in the apical
portion of roots in therapy-resistant lesions. The result is persistent periapical pathosis.
101. What efficacy do the cephalosporins have in treating acute pulpal-periapical infections?
Although the cephalosporins are broad-spectrum antibiotics, their activity is limited in pulpalperiapical infections, which are mixed infections predominantly due to obligate anaerobic bacteria. The
cephalosporins are not highly effective against such bacteria and actually have less activity against many
anaerobes than penicillin. For serious infections that are penicillin or erythromycin-resistant, clindamycin
is much more effective because of its activity against the obligate and facultative organisms in pulpalperiapical infections.
102. What precautions should be taken in prescribing antibiotics to a female patient who takes
birth control pills?
The dentist should warn the patient that oral antibiotics may decrease the effectiveness of birth
control pills and that they may be ineffective during the course of antibiotic therapy. The most often
implicated antibiotic is the penicillin class, although erythromycin, cephalosporin, tetracyclines, and
metronidazole also have been implicated.
103. The quinolone class of antibiotics, which includes ciprofloxacin, are becoming quite
popular. Do they have any role in treating alveolar infections?
Very little, if any. Most anaerobes implicated in endodontic-alveolar abscesses are resistant to the
quinolones.
ANESTHESIA
104. What is the physiologic basis of the difficulty in achieving proper pulpal anesthesia in the
presence of inflammation or infection?
Attaining effective pulpal anesthesia in the presence of pulpal-alveolar infection or inflammation is
often quite difficult because of changes in tissue pH. The normal tissue pH of 7.4 decreases to 4.5-5.5.
This change in pH due to pulpal-periapical pathology favors a shift to a cationic form of the local
anesthesia molecule, which cannot diffuse through the lipoprotein neural sheath. Therefore, anesthesia is
ineffective.
105. What is the significance of the mylohyoid nerve in successful anesthesia of the
mandibular first molar?
The mylohyoid nerve is often implicated in unsuccessful anesthesia of the first molar. This nerve
branches off the inferior alveolar nerve above its entry into the mandibular foremen. The mylohyoid nerve
then travels in the mylohyoid groove in the lingual border of the mandible to the digastric and mylohyoid
muscles. However, because it often carries sensory fibers to the mesial root of the first molar, lingual
anesthetic infiltration may be required to block it.
106. What is the method of action of injection into the periodontal ligament?
Injection into the periodontal ligament is not a pressure-dependent technique. The local
anesthetic works by traveling down the periodontal ligament space and shutting off the pulpal
microcirculation. To be effective, this technique requires the use of a local anesthetic with a
vasoconstrictor.
107. The Gow-Gates block is an effective alternative to the inferior alveolar block. When is it
indicated? Briefly describe how it works.
In patients in whom the traditional inferior alveolar block is ineffective or impossible to perform
because of infection or inflammation, the Gow-Gates block has a high success rate. It is a true
mandibular block that anesthetizes all of the sensory portions of the mandibular nerve. The injection site
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is the lateral side of the neck of the mandibular condyle; thus, it is effective when intraoral swelling
contraindicates the inferior alveolar block.
108. What is the reason for attempting to anesthetize the mylohyoid nerve for endodontic
treatment of a symptomatic lower first molar?
The mylohyoid nerve has been shown to supply sensory innervation to mandibular molars,
especially the mesial root of first molars. Infiltration of this nerve as it courses along the medial surface of
the mandible is often helpful.
109. A drug salesman has convinced you to use propoxycaine hydrochloride as a local
anesthetic. Is there any true or absolute contraindication to use of an ester anesthetic?
Yes. Patients who have a hereditary trait known as atypical pseudocholinesterase have an
inability to hydrolyze ester-type local anesthetics. Therefore, toxic reactions may result. Only amide
anesthetics should be use.
110. A patient presents with an extremely painful lower molar requiring endodontic therapy.
You have already used six cartridges of lidocaine with epinephrine to achieve anesthesia.
The patient begins to react differently. In brief, what are the signs of local anesthetic
toxicity?
Local anesthetic toxicity depends on the blood level and the patient’s status. In general, a mild
toxic reaction manifests as agitation, talkativeness, and increased vital parameters (blood pressure, heart
rate, and respiration). A massive reaction manifests as seizures, generalized collapse of the central
nervous system, and possible myocardial depression and vasodilation.
SURGICAL ENDODONTICS
111. What is the purpose of the apicoectomy procedure in surgical endodontics?
Perpetuation of apical inflammation or infection often is due to poorly obturated canals, tissue left
in the canal, or quite often an apical delta of accessory foramina containing remnants of necrotic tissue.
The removal of this apical segment via apicoectomy usually removes the nidus of infection.
112. A patient presents for apicoectomy on a maxillary central incisor with failed endodontic
therapy. A well-done porcelain-to-gold crown is present, with the gold margin placed in the
gingival sulcus for esthetic purposes. What flap design is most appropriate?
A full mucoperiosteal flap involving the marginal and interdental gingival tissues may potentially
cause loss of soft-tissue attachments and crestal bone height, thereby causing an esthetic problem with
the gold margin of the crown. Instead, a submarginal rectangular (Luebke-Ochsenbein) flap that
preserves the marginal and interdental gingiva, is recommended.
113. What is the material of choice for root end fillings in surgical endodontics?
Histologic studies have compared several materials, including amalgam, EBA cement, resins,
polycarboxylate cements, glass ionomers, and gold foils. Although no study has shown a definitive
superiority of one over another, the most commonly used today are amalgam and EBA cements. The
type of material is properly secondary in importance to the root resection technique, apical preparation,
curettage of the lesion, and technique in placement.
114. What type of scalpel is best used for intraoral incision and drainage of an endodontic
abscess?
A pointed no. 11 or no. 12 blade is preferred over a rounded no. 15 blade.
115. In performing apical surgery on the mesial root of maxillary molars, what mistake is
commonly made?
It is important to look for unfilled mesiolingual canals in such roots. Therefore, a proper long bevel
is necessary to expose this commonly unfilled fourth canal.
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116. Numerous studies have addressed the success rates of endodontic surgery. Most agree,
however, on certain basic conclusions. Can you name the most common conclusions?
All of the success studies share certain basic conclusions. First, the success of endodontic
surgery is closely related to the standard of treatment of the root canal. Second, orthograde
(conventional) root fills are preferred, if possible. Thirdly, the success rate is about 20% lower for
retrograde fills than for properly done orthograde fills.
Andreasen JO, Rud J: A multivariate analysis of various factors upon healing after endodontic surgery. Int J
Oral Surg 1;258-271, 1972.
Rud J, Andreasen JO: Radiographic criteria for the assessment of healing after endodontic surgery. Int J
Oral Surg 1;195-214, 1972.
117. What is the recommended surgical approach for apical surgery on palatal roots of
maxillary molars?
The palatal approach is recommended; with proper flap design and size, proper reflection is not a
difficult procedure. The buccal approach is potentially too damaging to supporting bone of the molar and
may actually cause more risk of postoperative sinus problems.
118. Why is a “slot preparation” often recommended in preparation of root end filling for mesial
roots of maxillary or mandibular roots?
The slot preparation is a trough-type preparation that extends from one canal orifice to another
canal orifice in the same root. This procedure is accomplished with undercuts in the adjacent walls. The
slot preparation allows not only sealing of the canal orifices but also small anastomoses between the
main canals.
119. Has the ideal retrosurgical material been developed?
No. Many research studies have been published about a myriad of materials. However, the ideal
is not yet determined. Most likely the material itself is not as important as the surgical preparation, the
depth of the preparation, and how it is placed.
120. After root end resection during endodontic surgery, many practitioners apply citric acid to
the exposed dentin surface. What is the rationale behind this practice?
A desired result of root end surgery (apicoectomy) is to achieve, if possible, a functional apical
dentoalveolar apparatus with cementum deposition on the root end. However, the resected root end is
covered with a smeared layer of dentin from the high-speed bur, which does not allow reattachment of
newly deposited cementum. Applying citric acid for 2 or 3 minutes dissolves the smear layer and causes
a small degree of demineralization of dentin. This, in turn, exposes collagen fibrils of the dentinal organic
matrix and allows a proper area for attachment of collagen fibrils from newly formed cementum.
Polson AM, et al: The production of a root surface smear layer by instrumentation and its removal by citric
acid. J Periodontol 55:443-446,1984.
121. Several studies have shown that resected mandibular molars fail twice as often as
resected maxillary molars. What are the major etiologic reasons for failure?
The most common cause of failure is root fracture, followed in order by cement washouts around
restorations, undermining caries, and recurrent periodontal pathoses around remaining roots.
Langer B, Wagenberg B: An evaluation of root resections: A ten-year study. J Periodontol 52:719-722, 1981.
Erpensten H: A 3-year study of hemisectioned molars. J Clin Periodontol 10:1-10,1983.
122. In performing apical surgery, what is the current thinking about the angle of the apical
bevel during apicoectomy and how it relates to depth of retrograde fillings?
Recent studies have shown that increasing the angle of the apical bevel increases the potential
for apical leaking due to exposure of more dentinal tubules. A level as close to zero degrees as possible
is ideal. In addition, increasing the depth of retrograde preparation and filling decreases apical leaking by
sealing more dentinal tubules.
123. Why, in the past, have the mesial roots of maxillary first molars and mandibular first
molars failed so commonly after endodontic surgery?
Before the advent of enhanced illumination and magnification with surgical loupes and the
operating microscope, the isthmus between the mesial canals was commonly not prepared. The isthmus
may contain necrotic tissue that can perpetuate the apical lesion.
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124. Why are ultrasonic techniques becoming the most popular instruments for
retropreparation during apical surgery?
The ultrasonic systems available today are a huge improvement over techniques in the past.
They allow retropreparations that align properly with the long axis of the tooth, and they can be sufficiently
deep to conform to the true shape of the apical root canal system.
125. During apical surgery in the past, teeth with extensive periodontal defects were extracted
because of the poor prognosis. Today, however, guided tissue regeneration can save
many of these teeth. How does it work?
An inert barrier is placed over the periodontal defects. These membranes allow proliferation of
undifferentiated cells of the PDL and surrounding bone to grow across the wound, potentially forming a
new attachment, and prevent the downgrowth of epithelial cells to form a junctional epithelium.
126. What is the ultimate goal of apical surgery?
The goal is to eliminate the source of periapical irritation emanating from the root canal, which
perpetuates apical infection. In addition, it is important to allow reformation of cementum around the apex,
to reestablish a functioning PDL, and to allow alveolar bone repair. If these goals are not possible, we aim
at least to allow repair scar tissue, which is less than ideal but still a form of repair.
BIBLIOGRAPHY
1. Cohen S, Burns RC (eds): Pathways of the Pulp,7th ed. St. Louis, Mosby, 1998.
2. Guttman J, Harrison J: Surgical Endodontics. Cambridge, MA, Blackwell Scientific Publications, 1991.
3. Journal of Endodontics.

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