3. Using appropriate headings design a short patient history and examination form that could be used as an aid to your patient management? A full history should include



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3. Using appropriate headings design a short patient history and examination form that could be used as an aid to your patient management?


A full history should include:

- Presenting complaint (PC) or complaining of (CO)

- History of the present complaint (HPC)

- Relevant or past medical history (RMH or PMH)

- Past dental history (PDH)

- Drug history (DH) and allergies

- Family history (FH)

- Social history (SH)


-oral hygiene and habits


Take signature of the patient (if under 18years of age take from parent or guardian).CONSENT

CASE HISTORY AND EXAMINATION FORM
Patients full name
Date of birth
Address and telephone number
Occupation of the patient
Emergency Contact


1)Chief Complaint of patient:
-Should be taken in patient own words
-“How can I help you or what is your main concern”.
- If there is another complaint, then a list should be drawn with the most important one coming first.

2)History of presenting illness

the patient should be asked to elaborate on

their presenting complaint and give as much detail as they can.
Date of onset (and duration)

- Mode of onset (speed and circumstances)

- Course (continuous, periodic or following a pattern)

- Site (main location, or area if diffuse, including any extraoral sites involved)

- Radiation of pain to other areas

- Severity of pain (1–10; where 1 stands for no pain and 10 for worse possible pain one can imagine)

- Character of pain (sharp, shooting, stabbing, crushing, dull, boring, burning)

- Aggravating and relieving factors

- Associated problems

- Any previous management and its effects



3)Past medical history
- Serious past and present illnesses

- Hospitalizations

- Operations

- Specific relevant conditions, especially cardiorespiratory and bleeding problems

- Medications
-Allergies

Ask about these:


- Anaemia

- Bleeding tendency

- Cardiovascular disease, such as myocardial infarction (MI), angina, hypertension, heart valve defects and history of infective endocarditis, rheumatic carditis or cardiac surgery

- Diabetes or other endocrine disease

- Epilepsy

- Jaundice and liver disease

- Lung disease, such as asthma, chronic obstructive airways disease or tuberculosis

- Mental health

- Neurological disease, including cerebrovascular accidents (CVAs)

- Oral diseases

- Pregnancy

-even negative answers are important and should be recorded in the case notes



Drug history (DH)

-Before patients attend a clinic for the first time, they should be asked to bring with them all their medicines and/or their prescription scripts.


-In the case of an emergency, the patient’s GMP should be contacted in order to obtain any missing information.
patient’s compliance with their drug regimen

4) Relevant dental history (RDH)

establish an accurate concept of:

- Past and present oral care

- Trauma to the oro-facial structures

- Recent dental and oral disease, treatment, attitude and expectations

- Regularity of oral hygiene and attendance at the GDP

- Expectations of the referring dentist


-teeth lost due to trauma

5) Family history (FH)

If a condition with a genetic influence is suspected, it is useful to go through a family history.

Cleft palate and other developmental abnormalities

Cardiovascular disorders (hypertension and ischaemic heart disease)

Diabetes


Asthma

Mental disorders

Some types of cancer
6)Social history (SH)

The patient’s social circumstances may explain their

presenting condition and will often affect their management.

- Use of tobacco, alcohol or betel, or other drugs of abuse


(frequency, duration)

- Parafunctional habits


-Bruxism
-History of drug use
-Partners, friends and family

Dictate practical decisions, such as whether they can be discharged immediately following a procedure under GA or need to be kept in hospital.

-Financial circumstances

-Education and occupation

These may suggest the patient’s intellectual status or liability to some occupational diseases.

-Diet


-Contact with animals

-Sexual history

-Culture and religion
7) Oral Hygiene habits:

-Brushing habits


-Type of brush used (electrical or manual and soft, medium or hard)
-Frequency of brushing
-Frequency of new tooth brush
-Method of brushing
-Frequency of mouth washes if using
-Frequency of dental floss usage if flossing

Other Notes
General appraisal
Compliance
Mental and Physical state
Attitude
Ability to Understanding

8)Clinical Examination


Extra oral:
Facial Shape (Dolico, Meso, Brachi facial)
Facial Symmetry
Facial Profile (Convex, Concave, Flat)
Lips Competence
Nose breather
Smile line
Lymph nodes
TMJ (Tenderness, deviation, and clicking)
Muscle tenderness (Especially in bruxers)

Intra oral:


 Soft Tissues
Buccal and labial and lingual and palatal areas
Tongue (all surfaces, lateral, ventral and dorsal)
Floor of mouth
Soft palate
Oropharynx
Fauces
Bone
Tori
Resorbed ridges
Asymmetry
Hard palate U or V shaped, shallow or deep
Dental Arches Shape

 Teeth


General characteristics
Attrition, erosion and abrasion
Fractured chips
Plaque and calculus
Fillings, caries and mobility (general)
 Saliva
Quantity
Quality
OCCLUSION
Opening (Any deviation on opening and closing)
Midline
Angles class of occlusion (incisors, canines, and molar relation)
Over jet and overbite
Canine guidance
Group function
Occlusal interferences
TFO
Open bites and cross bites
Fremitus
Supraeruptions
Mesial tipping
Crowding
 If Appliances present
 Gingival Examination
Colour,contour, bop,stippling
Biotype
For any inflammation, pus discharge and condition of gingival
Periodontal Charting
Probing Depth (also bleeding)
Recession
Furcation involvement
Discharge
Mobility
Vitality

9)Investigations


 •Pulpal response tests
•Study casts
•Clinical photographs
•Dietary analysis
•Medical investigations

10.CASE ASSESSMENT

•Diagnosis–Aetiology,Risk factors


•Prognosis
•Treatment goals–Treatment risk factors
•Treatment options
•Provisional treatment plan

11.TREATMENT PLANNING

•Phase 1 (Preliminary phase)


•Phase 2 (Interim phase)

•Phase 3 (Restorative/prosthetic phase)


•Phase 4 (Recall/review/maintenance)

 PATIENT CONSULTATION

•Presentation & discussion of treatment plan
•Patient consent
•Appointments, fees, financial arrangements
•Confirmation of treatment plan
-OHI
-Education
-habits

1. Design a brief list of medical history questions to be used a part of a patient's overall history - taking procedure?

Medical History:

 1)      Have you been admitted to the hospital any time for major illnesses, and have undergone any surgeries under general anesthesia.

2)      Have you or any of your family members had a reaction of any kind or nature to general anesthetics?

3)      Have you ever had any kind of severe bleeding problems or did you have any serious problems after dental treatments?

4)      Are you currently taking any medications including your routine medications, or have u taken any medications in the last three months?

5)      Are you allergic to any medications, foods or latex?

6)      Do you have high blood pressure?

7)      Have you ever had any type of heart disease, heart murmur, or rheumatic fever?

8)      Do you have pacemaker?

9)      Have you ever had heart valve or open heart surgery?

10)  Have you ever had asthma, tuberculosis or any other lung disease or any kind of breathing problems or problems related to lungs?

11)  Do you have any gastric problems (such as ulcers, digestion problems, bleeding through feaces, etc

12)  Do you have diabetes?

13)  Have you ever had hepatitis or any other liver disease?

14)  Have you ever had a stroke, fits or epilepsy?

15)  Are you undertaking psychiatric treatment?

16)  Have you ever had kidney problems?

17)  Do you have any thyroid problems?

18)  Do you have any joint problems, arthritis or history of joint replacement surgery?

19)  Do you smoke or drink.

20)  Do you use any kind of recreation drugs?

21)  Do you currently have or have you recently been exposed to an infectious disease?

22)  Do you currently have, or have you recently been exposed to the virus HIV? (AIDS VIRUS) and have you recently undergone any test for HIV.

23)  Have you ever undergone neurosurgery or growth hormone treatment

24)  For women only: Are u pregnant?

25)  Do you have any other medical or disability problems, other than I have asked you?

28)  Any family history of medical problems (diabetes, heart problems, epilepsy, psychiatric, kidney or liver problems)

29)  Do you require an interpreter?

30)  Who to contact in case of emergency?


117. What is the importance of medical history.


A
A health questionnaire (“yes or no” format) is useful in

making the patient responsible for the accuracy of the

medical history. This is a guideline in questioning the patient further
B The new patient’s age is important in developing a treatment plan and as a guide to certain age-related diseases.

Note the date and findings of the patient’s last physical

examination. List the names and addresses of any physicians treating the patient, as well as medications the patient is currently taking and reasons for their use.
C Note heart attacks, rheumatic heart disease, heart surgery, and replacement parts in the heart so that precautions such as antibiotic prophylaxis for patients with rheumatic heart disease or artificial valves can be taken.
The patient may even require medication before periodontal probing.
Many dentists obtain a baseline blood pressure

reading at this time.



D Diabetes is a major problem in successful management of periodontal diseases. For a known diabetic, determine

whether (1) the disease is controlled and (2) the patient has

visited a physician within the past 3 to 6 months. If the

patient is unaware of having diabetes, questions regarding

a personal history of periodontal abscesses and blood relatives with diabetes may suggest a problem requiring medical evaluation.

E Infectious diseases such as hepatitis, acquired immunodeficiency syndrome (AIDS), and tuberculosis (TB) should be included in the questionnaire. Establish whether a patient who has had hepatitis B is a carrier. Encourage the patient to be tested, for family safety if for no other reason.
HIV+ often has

an associated periodontal problem

.

F Hepatitis (see E) and cirrhosis are common problems that

affect dental care. Cirrhosis may impair a patient’s healing

potential. Recurrent kidney infections may require

antibiotic prophylaxis before periodontal treatment.


G Patients with seizure disorders may require additional medication before periodontal treatment. Those taking diphenylhydantoin sodium (Dilantin) often develop a “hyperplastic” gingival response

H Asthma can complicate periodontal treatment, especially

when anesthetics containing epinephrine are used. Sinusitis

can complicate the differential diagnosis of periodontal

pain in the maxillary posterior area.


I Avoid nonemergency periodontal treatment of any complexity throughout pregnancy but especially in the first and third trimesters. Pregnancy can modify gingivitis. Such

“pregnancy gingivitis” often does not respond to treatment

until several months after gestation.


J
Gastric or duodenal ulcers may complicate periodontal

healing because of dietary restrictions. Gingival changes

may accompany colitis.


K
Various types of cancer present complications in periodontal treatment. Leukemia may be accompanied by gingival enlargement. The prognosis for the more severe or

advanced types of cancer can force modification of usual

treatment plans.
Radiation therapy may make surgical

treatment inadvisable. The treating physician should be

contacted if chemotherapy is being used or has been used

recently.




L
Many medicaments and drugs used in periodontal treatment are significant allergens that may have to be avoided with sensitized patients.


M
Some dermatologic diseases, such as lichen planus, pemphigus, and pemphigoid, have periodontal components.


N
Some types of arthritis can restrict dexterity required for

plaque removal. Corticosteroid therapy often delays healing

after periodontal treatment.


O
Physical or medical disabilities may help explain the etiology of inflammatory periodontal disease if the patient is unable to perform adequate oral hygiene procedures. Disabilities may also influence the prognosis and treatment

planning.



P Heavy smoking, excessive alcohol consumption or drug use influence the periodontal diagnosis, prognosis, and treatment planning.
Vigorous tooth brushing, especially with a

hard brush, may explain root exposure. Self-mutilating

habits may alter gingival appearance.


Q
Medications used for the treatment or management of any medical problem may affect periodontal treatment. Some medications, such as β-blockers, may require changes in anesthetics. Others, such as antibiotics, may produce temporary improvements in periodontitis.

R Update the medical history of a recall or continuing patient at every visit. New medical problems, altered status of previously diagnosed medical problems, and changes in medications can affect periodontal treatment. 

 

 



 





37. Prescription writing?.


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  • Written in indelible ink

  • Name & address of the dentist

  • Provider number of the dentist

  • Name & address of the patient

  • Details of the drug including amount and directions for use

  • Be signed and dated by the dentist

  • Have the words dental treatment only written on the prescription

  • Can be written on plain paper


  • Check medical history

  • For children calculate the correct dosage based on weight

  • Use generic drug names where possible

  • Document the prescription in the patients history

  • Do not write prescription for more than one pt on the same form
    Write drug names in full
    Do not use latin terms, abbreviations
    If decimals are used, put0. In front
    Do not abbreviate units
    Avoid more than 2 medications on one prescription
    Draw a line across the space to prevent fraudulent use

Sig - Meaning directions to pt


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64.. the role of saliva in oral tissue health, protective role in caries control and erosion?









Iatrogenic-Medications, chemotherapy, radiation therapy of head and neck tumors, surgical trauma, graft-versus-host-disease

-Chronic inflammatory autoimmune diseases



-Endocrine diseases

Diabetes mellitus (labile), hyper- and hypothyroidism, Cushing’s syndrome, Addison’s disease



-Neurological disorders

Mental depression, narcolepsy, Parkinson’s disease, Bell’s palsy, Alzheimer’s disease, Holme’s–Adie syndrome

-Genetic disorders and congenital anomalies

Ectodermal dysplasia, cystic fibrosis, Prader–Willi’s syndrome

-Malnutrition

-Infections

HIV/AIDS, epidemic parotitis, Epstein–Barr virus, bacterial sialoadenitis, tuberculosis



-Other conditions

Hypertension, fibromyalgia, chronic fatigue syndrome, burning mouth syndrome, compromised masticatory performance


-Saliva is a complex secretion. 93% by volume is secreted by the major salivary glands and the remaining 7% by the minor glands.

Function:

* The part that saliva plays in protecting against caries can be summarised under four aspects: -


1)Mechanical cleansing of food and bacteria
-diluting and eliminating sugars and other substances: a high volume of saliva at rest increases the speed of sugar removal. faster in the areas that are closest to the places where the salivary gland ducts drain into the mouth
2)Oral acid neutralization and dilution of detritus - buffer capacity: contains specific buffer mechanisms such as bicarbonate, phosphate and some protein systems which have a buffer effect and provide ideal conditions for automatically eliminating certain bacterial components that require a very low pH to survive.
3)balancing demineralisation -remineralisation:The factors that regulate the hydroxyapatite (HA) balance are the pH and the concentration of free calcium, phosphate and fluoride ions In the dynamic balance of the caries process, supersaturation of the saliva provides a barrier to demineralisation and tips the balance towards remineralisation. The presence of fluoride assists this balance.

4)antimicrobial action:
The most important proteins involved in oral ecosystem maintenance are proline-rich proteins, lysozyme, lactoferrin, peroxidases, agglutinins and histidine, as well as secretory immunoglobulin A and immunoglobulins G and M

Other functions are




5)Lubrication of oral surfaces:

Lubrication of the oral, oropharyngeal and esophageal mucosa is to a large extent mediated by the high-molecular-weight glycoproteins, i.e. mucins, secreted

from the submandibular, sublingual and minor

salivary glands.
6)Protection of oro-esophageal mucosa: Salivary Epidermal growth factorplays an important physiological role in the maintenance of oro-esophageal and gastric tissue integrity.
effects of salivary EGF, and also esophageal

derived EGF, include healing of ulcers, inhibition of gastric acid secretion, stimulation of DNA synthesis as well as mucosal protection from intraluminal injurious factors such as gastric acid, bile acids, pepsin, and trypsin and to physical, chemical and bacterial agents



7)Dissolution of taste compounds:
food particles need to be in solution in order to

stimulate taste receptor cells in the taste buds within the lingual papillae (fungiform, foliate, and vallate papillae).


Taste sensitivity is related to saliva composition as each receptor cells upper surface is bathed by the oral fluids.

8)Facilitation of speech, mastication and swallowing



9)Formation of food bolus conducive for swallowing

During mastication the food mixes with the saliva to form a bolus, which is a rounded, smooth, and lubricated portion of mechanically broken down food
slippery bolus that can easily slide through the esophagus without damaging the mucosa.

10)Initial digestion of starches and lipids:
a-amylase, or ptyalin, which breaks carbohydrates (starches) down to maltoses by cleaving the a-1-4 glycosidic bindings.
Lingual lipase, is secreted from acinar cells of the serous von Ebner’s glands.It breaks down a small fraction of dietary triglycerides in the oral cavity and stomach

11)Esophageal clearance and gastric acid buffering:

Increasing salivary flow results in increased bicarbonate concentration and therefore increased acid neutralization.
Helps in swaloowing and moving food downwards the alimentary canal

  ENAMEL EROSION.


Extrinsic:Excessive consumption of dietary acids, Ascorbic acid (vitamin C) from many sorts of drinks, sports drinks and candies, Oral administration of acid medications, Airborne acidic contaminates of the working environment or industrial acids

Intrinsic: Gastric acid contacting the teeth through recurrent vomiting, regurgitation or reflux , Eating disorders such as nervous vomiting, anorexia nervosa or bulimia, causing regurgitation , Morning sickness from pregnancy, Alcoholism

Saliva is known to have many properties that can provide a protective function against erosion:

1)Dilutes and clears potentially erosive agents from the mouth and buffers dietary acids

2)Maintains a super-saturated state next to the tooth surface, due to the presence of calcium and phosphate from saliva

3)Formation of the acquired pellicle, which has the ability to protect the enamel surface from demineralization by dietary acids providing calcium and phosphate necessary for remineralization



114. Causes of failure of LA and management
79.Patient has apical abscess in 46 and needs extraction. Already 4.4 ml. of 2% lignocaine with adrenaline 1: 80.000 is injected, but when you try to extract tooth it is still painful. Discuss the possible management options.
94.Apical abscess. After inferior block anaesthetic, numbness of lip, tongue and buccal site; however patient still feels pain. Describe the reason and how to manage it.


Operator dependent

  • Choice of technique and solution

  • Poor technique

Patient dependent

  • Anatomical

  • Pathological

  • Psychological.

Pharmacological causes are not included as modern local anaesthetic solutions, when used appropriately, are reliable.

When an initial local anaesthetic fails the best treatment is to repeat the injection; this will often lead to success.



Operator dependent variables

1)administration of insufficient solution or use of an inappropriate anaesthetic or method of administration.


2) in adult patients about 1.0 ml of solution should be deposited for infiltration injections in the maxilla; for most regional block techniques 1.5 ml should be injected

An example of an inappropriate method is the use of infiltration anaesthesia to obtain pulpal anaesthesia in permanent mandibular molars in adults.



Choice of solution

1)In some medically-compromised patients adrenaline-free solutions may be preferred, however for the majority of cases lignocaine with adrenaline is the 'gold standard'.


2)The use of plain lignocaine does not give reliable pulpal anaesthesia and in addition its effect is short-lived.

Poor technique

1)The most likely defect in technique is faulty needle placement.


2)Failure to aspirate before injection, which could lead to intravascular deposition of solution might also lead to failure of anaesthesia
3)Success may be related to the speed at which the solution is deposited. Anaesthetic might be directed away from a nerve trunk during forceful injection.
4)poor technique usually relates to mandibular anaesthesia, specifically failed inferior alveolar nerve block injections.

The success rate for inferior alveolar block injections with lignocaine and adrenaline is more than 90%.Reassess the technique.


5)The common causes of failure are touching bone too soon on the anterior ascending ramus or injecting inferior to the mandibular foramen
Rectify the problem with a repeat injection, perhaps at a slightly higher level.

In those cases where a second injection has not overcome the failure, an alternative approach to the inferior alveolar nerve should be considered. There are a number of approaches to the inferior alveolar nerve, including extra-oral techniques.



Methods of overcoming a failed inferior alveolar nerve block injection


1)The Gow-Gates technique

The method relies upon deposition of local anaesthetic adjacent to the head of the mandibular condyle


The patient has the mouth wide open and the dentist imagines a line drawn from the angle of the mouth to the inter-tragic notch.
The needle is introduced across the contralateral mandibular canine and directed across the mesio-palatal cusp of the ipsilateral upper second molar. The point of mucosal penetration is thus higher than with the conventional block and the needle is advanced until bony contact is made.
The point of bony contact is the condylar head. The needle is withdrawn slightly, and after aspirating a full cartridge is deposited.
The patient should keep the mouth open for a few minutes until the subjective signs of inferior alveolar anaesthesia are reported.

2)The Akinosi technique

This method which is also known as the Vazirani-Akinosi closed-mouth technique, is useful when conventional block anaesthesia fails


It does not rely upon contacting a bony end-point.
The patient has the mouth closed and the syringe is advanced parallel to the maxillary occlusal plane at the level of the maxillary muco-gingival junction. The needle is advanced until the hub is level with the distal surface of the maxillary second molar. At this point a cartridge of solution is deposited.

3)Infiltration anaesthesia

Buccal infiltration anaesthesia in the mandible can be effective in some areas. Indeed in children this may the preferred technique when treating the deciduous dentition.8 In adult patients buccal infiltrations may be effective in the mandibular incisor region.



4)Mental and incisive nerve block

When treating the lower premolar and anterior teeth a mental and incisive nerve block may overcome a failed inferior alveolar nerve block.


injected in the region of the mental foramen which is often located between the apices of the lower premolars

5)Intraligamentary and intra-osseous anaesthesia

These techniques rely on the deposition of solution in the cancellous bone of the alveolus.



6)Intra-pulpal anaesthesia
Unlike intra- ligamentary and intra-osseous techniques this method achieves anaesthesia as a result of pressure.
When a small access cavity is available into the pulp a needle which fits snugly into the pulp should be chosen.
A small amount (about 0.1 ml) of solution is injected under pressure.

Anatomical causes of failure of anaesthesia

1)Individual variations in the position of nerves and foramina

The foramina of importance in regional block anaesthesia in dentistry do not have a consistent location between patients. Available radiographs may be helpful in anticipating this situation.



2)Accessory nerve supply
Teeth may receive innervation from more than one nerve trunk.
Techniques of Gow-Gates and Akinosi. Alternatively, a lingual infiltration adjacent to the tooth of interest may be effective.

3)Barriers to anaesthetic diffusion


The most obvious barrier to anaesthetic diffusion is the thick cortical plate of the mandibular alveolus
Inject mesial and distal to the first molar away from the buttress

Pathological causes of failure of anaesthesia

1)Factors precluding access

Factors which can preclude access include trismus and anatomical changes because of trauma or surgery.


Use the Akinosi closed-mouth technique described above. There are extra-oral approaches but these are not recommended in practice.

2)Inflammation

The practitioner therefore has to decide on the maximum volume of local anaesthetic be prepared to use up to that maximum to anaesthetise that tooth.


Limit treatment to only one tooth
Inject more solution. This does not have to be at the same site.
Can be supplemented with intraligamentary or intra-osseous injections if required.

Psychological causes of failure

This may be because of fear and apprehension. In such patients the use of sedative techniques can be helpful Benzodiazepines reduces local anaesthetic toxicity

A technique suggested for patients who have experienced local anaesthetic failure in the mandible is this:


  1. Conventional inferior alveolar and lingual block with lignocaine and adrenaline (1.5 ml), followed by long buccal nerve block with remainder of cartridge.

  2. After subjective soft tissue signs of first block have taken effect a repeat inferior alveolar and lingual block injection using 3% prilocaine with 0.03 IU/ml felypressin
    If subjective signs of inferior alveolar nerve block anaesthesia are not apparent after a second block then an Akinosi block is recommended with lignocaine and adrenaline.

  3. Buccal and lingual infiltrations adjacent to the tooth of interest using around 1.0 ml of lignocaine and adrenaline in total (this to eliminate any accessory supply).

  4. Intraligamentary injection of 0.2 ml lignocaine with adrenaline per root.

In the severely medically-compromised adrenaline-free solution such as 3% prilocaine with felypressin should be used.

51. Radiation hazards?
55. What are the factors which will reduce the exposure of the patient to radiation in a dental surgery list factors and describe how each effects the reduction of patient exposure?

-Justification
-Limitation
-Optimisation
(effects from book)
ALARP, is an acronym for an important principle in exposure to radiation and other occupational health risks and stands for "As Low As Reasonably Practicable
There are four major ways to reduce radiation exposure to workers or to population:

  • Shielding. Use proper barriers to block or reduce ionizing radiation.

  • Time. Spend less time in radiation fields.

  • Distance. Increase distance between radioactive sources and workers or population.

  • Amount. Reduce the quantity of radioactive material for a practice

Chronic or long-term effects




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14. Discuss the procedures involved in surgery preparation between patients?

1) Surface management

1)remove the barrier drapes used in an aseptic

technique and disposing of them appropriately. Unless these areas are contaminated it is not necessary to wipe the regions which have been covered by the barrier drapes.


2)Wash hands with antiseptic rinse and dry
2) Suction units
-Intermittent thorough flushing of suction lines with water during treatment is carried out to prevent blood and saliva accumulating and coagulating in suction lines.

-At the end of each day, one litre of non-foaming detergent is prepared and sucked through the volume aspirators and flushed in the spittoon.


-The chairside assistant is responsible for flushing air and water lines for 2 minutes after treatment of each patient for 30 seconds
The ultrasonic scaler handle is also flushed for 20 seconds after use.

3) Handpiece Management

-Handpieces are flushed for 30 seconds and then removed from the couplings;

-Handpiece and handpiece covers are aseptically removed; and the handpieces are wiped with detergent


-All handpieces are to be steam sterilised between patients.
-Other reusable intraoral instruments are

cleaned, packaged and steam sterilised after each patient.

-All burs are sterilised between patients or disposed of after use



4) Sorting of items, waste management

-All sharp items are disposed into the clearly labelled, puncture resistant, approved sharps container


-Dispose all the cotton rolls and the disposable material into the trash bin

5) The chairside assistant then removes gloves, washes hands and sets up for the next patient with sterilised instruments, barrier drapes and equipment.


6)All laboratory work is cleaned prior to leaving the clinical area. Impressions, even if contaminated with blood, are cleaned immediately after removal from

the mouth by running under cold water, then spraying with detergent.


Disinfection of the impressions is done

7)Patient is brought in and draped after instruments are arranged and handpieces replaced



15. Discuss the management of blood - contaminated instruments following dental surgical procedures?

1) Dental instruments and devices that are contaminated with blood and body solutions and other contaminants must be cleaned immediately to prevent the substances drying on them.

2) This will reduce the need for intensive cleaning by hand at a later stage.

3) Remove the gross soil from instruments by wiping them at the chairside on to an adhesive backed sponge or dampened gauze.

4) Alternatively, if they are unable to be cleaned immediately, the instruments may be soaked in detergent or an enzymatic cleaner to prevent hardening of residue.

5) Enzymatic cleaner should not be used ,however for routine cleaning of instruments and should not be sprayed as they cause lung irritation.

6) The presence of organic material left on instruments/equipment may prevent the penetration of steam during sterilization ,therefore instruments must be completely cleaned before they are disinfected or sterilised.

7) Staff cleaning contaminated instruments must use heavy duty (puncture and chemical resistant) gloves, wear eye protection/face shield/mask and a waterproof/fluid resistant gown/apron.

8) Cleaning techniques should aim to avoid spraying liquid into the air.

9) Splashes of cleaning agents on a person's skin must be washed quickly with clean water and then treated in accordance with the manufacturer's instructions.

10) Dental staff who clean and reprocess instruments must be given formal training in the relevant procedures.

11) Instruments can be cleaned either by hand or mechanically (in either an ultrasonic bath or instrument washer /disinfector)

12) Automated mechanical cleaning is preferred to manual cleaning as it is more efficient, reduces the risk of exposure to blood and reduces the penetrating skin injuries from sharp or pointed instruments.

13) After either manual or mechanical cleaning, instruments should be checked visually under good lighting to ensure all soil /contaminant is removed.

14) Damaged or rusted instruments must be repaired or discarded and those with visible residue soil /contamination must be recleaned.

15)Sterilisation by steam under pressure, or a

Chemical sterilant system

Sterility must be maintained:

• packaged items must be allowed to dry before

removal from the steriliser

• the integrity of the wrap must be maintained

• wraps should act as an effective biobarrier

during storage

• store to protect from environmental

contamination

• unpackaged sterile items must be used

immediately





13. Discuss the principles of infection control in dental practice?
1) TAKE ACTIONS TO STAY HEALTHY
I.Immunizations
1.Hepatitis B Vaccine:compulsory vaccination of all the dental health care professionals and periodic booster doses.
2. Preventable Annual Influenza Vaccine.

II.Hand hygiene: through had scrubbing with soap and water after every procedure or if hands are soiled with blood,bodyfuid or proteinaceous material


-decontamination of hands by rubbing with alcohol-based solutions or gels has been advocated for use

2) AVOID CONTACT WITH BLOOD & OTHER INFECTIOUS MATTER

1.Avoid Contact with Blood and Body Fluids
Gloves should be worn by dental personnel for all procedures where contact with patient secretions or tissue is possible

2.Avoid injuries all the sharp objects should be immediately capped or disposed after the use.


If injuries occur follow standard protocols for sharps injury.

3.Personal Protective Equipment Health care workers should wear personal protective equipment, including eye and face protection, where aerosols are likely to be generated. Patients should be provided with protective eye equipment.


Facemasks are used to protect the mucous membranes of the mouth and nose from spray, splashes, spatter and

aerosols.


The wearing of open-toed sandals and shoes made from

fabric is to be discouraged in the dental clinical environment to minimise the potential for cross-infection or physical injury from dropped instruments

4. Surgical gowns: Clean gowns should be worn to prevent crosscontamination of the clothes of dental healthcare staff during dental procedures.

3) MAKE OBJECTS SAFE FOR USE

- Intraoral X-ray films should always be barrier protected prior to insertion into the oral cavity

-Clean, heat sterilize or disinfect instruments and reusable patient care


-Dental surgeries should have dedicated space allocated

for instrument decontamination and processing


- dental instruments and equipment may be

divided into three risk categories: high, medium and

low risk,and sterilized or disinfected according to the risk of infection associated with the subsequent use of each item of equipment
-All instruments and equipment (including air rotor, air syringe,dental burs, reamers and files) used in the mouths of patients should either be disposable (single use) or sterilised between cases.

-Materials, equipment and instruments must be covered with an impermeable material in closed drawers, covered containers, to protect them from contamination by aerosols. -Instruments must be sterile at the time of use and must be kept bagged until use.

2.Monitor processes the sterilisation procedure should be monitored on regular basis with the help of colour changing strips for autoclaves, which indicate the successful sterilization.

3.Contain and dispose of single use items all the used items should be disposed according to disposal norms.

4) LIMIT THE SPREAD OF CONTAMINATION
1.use evacuation to control spatter The formation of droplets, splatter and aerosols should be minimised during treatment by use of rubber dam and high vacuum suction

2.dental impressions and casts. All materials transported to and from dental laboratories should first be cleaned, disinfected as appropriate and placed in a sealed container.

3.surface barriers Barrier draping, using either plastic wrap, sterile drape or preformed plastic covers, should be used where appropriate. Sterile drapes should be used for surgical procedures.

Wiped down or sterilized


• any hand-operated control in the operating field, the operating light handle,the X-ray head, the suction tubing and the cradles they rest in;

• any intraoral light source


• the bracket table and its handle.

4.proper disposal of the clinic waste in color coded bags




12. Describe the procedures that would ensure the correct sterilization of dental burs and hand pieces. Discuss types of sterilization methods and verification procedures to ensure correct sterilization?
126.a.How do you clean, package, sterilize and store instruments used in operative dentistry(OR surgical tooth extraction OR endodontics)? b.What are the methods available to monitor the sterilization process?
92.Describe the procedures that would ensure the correct sterilization of dental burs and handpieces. Discuss types of sterilization methods and verification

1)Critical items Items that enter sterile body tissues or vascular system that require sterilization.

2)Semicritical Items that contact mucous membranes

that require a high level of disinfection.

3)Noncritical Items that contact intact skin require intermediate level of disinfection, whereas items that contact environmental surfaces require low levels of disinfection.





procedures to ensure correct sterilization



1)DENTAL BURS

-Used burs should be considered as contaminated

and appropriate handling precautions should be taken

during reprocessing.

-Gloves, eye protection and a mask should be worn.


-The burs should be protected from damage to the cutting edges.
If transported wet or prolonged storage in disinfectant solutions

may result in corrosion and should be avoided.


PREPARATION FOR CLEANING

There are no special requirements unless infection controls require the use of a disinfectant

DRYING

Dry the burs using paper towelling or dry heat not exceeding 140ºC.



PACKAGING FOR STERILIZATION

If using a vacuum autoclave pack the burs in dedicated bur stands or pouches validated for sterilization.

If using a non-vacuum autoclave the burs should not be packed or wrapped but be contained in dedicated bur stands with perforated lids.

2)HANDPIECE STERILIZATION/Asepsis

-Before removing handpiece from the hose following treatment, wipe all visible debris from handpiece and briefly operate air/water system to flush water and air lines.

-Remove handpiece from hose and clean all external surfaces with gauze or scrubbing brush saturated with isopropyl alcohol.

Do not use ultrasonics. Dry thoroughly with gauze.

-Clean internal parts of handpiece to remove aspirated debris and wear products.

-Lubricate if required.

-Place handpiece in a sterilization bag


1)Instrument collecting and transportation

After use in dental procedures, contaminated dental

instruments have to be removed from the clinic and

transported to the designated processing area for cleaning,

decontamination and sterilisation.

■ Instruments should be removed from the surgery or

clinical environment using a defined procedure.

■ To prevent injuries during transportation and during

the decontamination process, instruments should be

arranged in kits or cassettes for set procedures

■ Instruments should not be transported uncovered, as

there is the likelihood of dropping the instruments

■ Depending on how long the instruments are stored

prior to cleaning, it may be necessary to store them in a

disinfectant solution.

instruments should be cleaned and disinfected immediately or shortly after use.


In the case of heavily contaminated instruments it is best to

adopt a policy of removing as much of the contamination

as possible prior to collection for transport to the

decontamination area

■ Remove all disposable items from the kit prior to dispatch
2)Hand washing of instruments

Cleaning should remove all visible dirt, dust or other foreign materials.

Hand washing of instruments is the least

preferred method of instrument decontamination and

should be strongly discouraged due to the high risk of

percutaneous injury during cleaning.

■ Instrument decontamination should take place away

from food, beverages or sterile items.

■ Wear protective clothing: goggles, facemask, water

resistant over-gown or plastic apron and heavy-duty

protective gloves.

■ Gloves should be able to withstand instrument abrasion,

should be cut, tear and puncture resistant.

■ Use a low-foaming detergent

■ A wide range of autoclavable cleaning brushes is

available for cleaning both lumened and non-lumened

instruments. Steel brushes should not be used to clean

instruments as they can scratch instrument surfaces

■ Begin by cleaning from the centre of the item using an

outward motion. Hold the instrument under the water

to avoid generation of aerosols.

■ After cleaning, the instruments should be thoroughly

rinsed and dried.
3)Ultrasonic cleaning

Ultrasonic cleaners can be used to decontaminate dental

instruments and their use is far safer than hand washing

instruments

Contaminated instruments in an open

basket or tray are immersed in an enzymatic solution

designed to digest biological material.

Ultrasonic waves are then passed through the solution by cavitation. Not suitable for plastic items


4)Packaging of instruments

-After cleaning and decontamination, dental instruments

have to be appropriately packaged prior to sterilisation

by autoclaving.

-done to prevent recontamination with dust and microorganisms from the environment.

-All instruments should be thoroughly dry before packaging and sterilisation.

-The packaging material should be compatible with the sterilization process ,should provide an effective barrier against recontamination by microorganisms

-Primary packaging consisting of sterilisation pouches or

bags


- instruments in kits or cassettes may

be packaged as required.

-should also contain clearly visible chemical indicator strips that give a colour change
5)Sterilisation of dental instruments

-

Instruments and equipment will only be sterile if one of the

Following sterilisation processes is used:

• steam under pressure (moist heat)

• dry heat;

• ethylene oxide;

• automated environmentally sealed low-temperature

peracetic acid, hydrogen peroxide plasma and
other chemical sterilant systems

• irradiation.


1)Steam under pressure causes coagulation of protein structures,

thus inactivating infectious agents


2)Dry heat sterilisation by means of hot dry air

destroys infectious agents by the process

of oxidation

3)Chemical sterilisation is achieved by alkylation of the protein in the

microbial cell. Processing time depends on the temperature,

relative humidity and gas concentration,and can be effective

only if the gas can penetrate the packaging and reach all

surfaces of the articles requiring sterilisation


4) Hydrogen peroxide plasma

Low-temperature hydrogen peroxide plasma (HPP) sterilisation works by

alkylation of the protein in the microbial cell.
5) Peracetic acid

Low-temperature peracetic acid (PAA) sterilisation works by oxidation of

microbial cell proteins
Verification procedures to ensure correct sterilization:

MECHANICAL indicators for monitoring sterilization include assessing the cycle time, temperature, and pressure of sterilization equipment by observing the gauges or displays on the sterilizer.

Some tabletop sterilizers have recording devices that print out these parameters

CHEMICAL indicators, internal and external, use sensitive chemicals to assess physical conditions such as temperature during the sterilization process. Chemical indicators such as heat sensitive tape change color rapidly when a given parameter is reached.

BIOLOGICAL indicators (BIs) are the most accepted means of monitoring the sterilization process because they directly determine whether the most resistant microorganisms are present rather than merely

determine whether the physical and chemical conditions necessary for sterilization are met.



5)Storage
-Sterilised instruments, other items and disposable single use items contained in wrapped packages or pouches should be stored in a dry enclosed area, preferably in closed cupboards, cabinets or drawers. ---
-They should not be stored under sinks or adjacent to taps or other locations where they may become damp or wet.

-All sterilised packages should contain the sterilisation date and, if there are multiple autoclaves in a particular facility, the autoclave used.


-All sterilised packages should be examined.

If packaging is compromised, the instruments

should be recleaned, repackaged and resterilised.

97.A 25 year-old patient presents with abscess on tooth 36. how would you manage? 9yr old patient with dentoalveolar abscess. Write a full prescription. Short term and long term management

The term dentoalveolar abscess comprises 3 distinct processes, as follows:



  • A periapical abscess that originates in the dental pulp and is usually secondary to dental caries is the most common dental abscess in children. Pulpitis can progress to necrosis, with bacterial invasion of the alveolar bone, causing an abscess.

  • A periodontal abscess involves the supporting structures of the teeth.This is the most common dental abscess in adults

  • Pericoronitis describes the infection of the gum flap (operculum) that overlies a partially erupted or impacted third molar.

CLINICAL PRESENTATION
1) pain, swelling, and redness of the mouth and face.
2)With an advanced infection, vomiting, fever, and chills.
3)Localized pain and swelling
4) Fever
5) Decreased intake of fluid, food, or both- Signs of dehydration
6) Gingiva:
Swelling, Warmth, Erythema
Parulis or "gum boil" (a soft, solitary, reddish papule located facial and apical to a chronically abscessed tooth that occurs at the endpoint of a draining dental sinus tract)[6]
7)The signs of dental abscess typically include, but are not limited to tenderness with touch, pus drainage, and sometimes difficulty or pain upon fully opening your mouth or swallowing
8)apical abscess
-Teeth: Increased mobility
Pressure or percussion tenderness
Thermal sensitivity
Extrusion

-An acute apical abscess is characterized by rapid onset,spontaneous pain, tenderness of the tooth to pressure,pus formation and eventual swelling of associated tissues.

-A sinus tract is the typical feature of the chronic apical abscess. A chronic apical abscess is most commonly, but not always, associated with an apical radiolucency.
It is asymptomatic or only slightly symptomatic and the patient may often be unaware of its presence. This may last as long as the sinus tract is not obstructed.

9)Regional lymph node involvement

10)More severe infection

Trismus, indicating involvement of the masticator space


Difficulty swallowing (dysphagia)
Respiratory difficulty
Necrotizing fasciitis
Ludwigs angina
Systemic effects
cavernous thrombosis

INVESTIGATIONS


Depending on severity of abscess based on clinical presentation the following is recommended:

  • Periapical radiography is the first level of investigation. It provides a localized view of the tooth and its supporting structures.
    Widening of the periodontal ligament space or a poorly defined radiolucency may be noted.

  • Panoramic radiography (pantomography) is most helpful in emergency situations because it provides the most information for all teeth and supporting structures.

If swelling extends beyond local area then the following is indicated:

  • Lateral and anteroposterior neck views to rule out a soft tissue neck mass that impinges on the airway.

  • CT scanning with intravenous contrast is the most accurate method to determine the location, size, extent, and relationship of the inflammatory process to the surrounding vital structures.

Procedures

General principles for the management of infection are:

1)Rapidly start treatment: identify advanced stage, or airway obstruction/ systemic effects admitted to hospital
2)Pus drained ASAP
Confirm presence of the abscess via needle aspiration.

- Incision and drainage may be performed only if pus can be aspirated.

-If pus cannot be aspirated, manage medically until a more localized infection develops
-establish draings via I and D or pulpally
3)Remove causative factor
-if the tooth is beyond repair
-not applicable in pericoronitis

4)provide antibiotics


-if necessary for localization of the abscess
-pus collected, sent for culture

5)Supportive measures


-fluid intake, rest

6)review progress: All patients with infection must be reviewed within 48hr to 72 hrs of commencing the treatment


Noticeable change in swelling , trismus and pain should be observed in 24 hours

7) Short term management would be: pain killers


penicillin V, G
or Amoxicillin and metronidazole

Or extraction+drianage



Long term management would be: rct+drainage+antibiotics(if systemic signs are present)

Aditi Khamar This material is not to be sold. Page



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