Abe oral Board Study Guide Topic List



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Newton – demonstrated 6m & 1 yr cytotoxicity


Procedural Errors Overview
How are perforations classified?

Trope & Fuss – Old or Fresh (better prognosis; Large or small (How can they be detected?

Fuss – apex locators

Also: radiographs, blood on paper points, microscope, perio probings


What criteria are important for successful management?

Time, size & location



Beavers – monkey study showed best repair when immediate; acute inflammation, then formation of new PDL

Benenatidelay ok if aseptic
How would you manage a perforation?

If larger, consider an internal matrix as proposed by Lemon:



Rosenberg – Collacote

Alhadainey – Calcium sulfate (Capset)

Frank – Ca(OH)2

Also: hydroxyapatite, DFDBA, Gelfoam, Calcium phosphate


Repair with MTA as proposed by Torabinejad (no matrix required) – 16/16 success X1 yr; Biocompatible and caused cementum formation; less leakage than amal & IRM

Baumgartner – less bacterial leakage than amal

Daoudi – less dye leakage than Vitrebond
What’s the prognosis of perforation repairs?

Kvinnsland – 92% using ortho grade and surgical repair
What’s the incidence of separated instruments & does it affect prognosis?

Messer – 3% prevalence of retained fractured instruments; NSD in healing - 92% with fx inst & 95% without; lower success (87% & 93%) with preop PARL

Crump & NatkinNSD in failure rate
How would you manage a separated instrument?

Attempt removal, bypass or obturate to fx



Ruddle – staging platform with modified gates; ultrasonic with DOM; IRS

Other methods: Endo extractor tubs with cyanoacrylate; braiding headstroms; wire loop and tube


How do you manage a sodium hypochlorite accident?

Gluskin – long acting anesthetics, irrigation with saline to dilute, Amoxicillin, analgesics, steroids, cold compresses & recalls

Kleier – diplomate survey – did not affect prognosis; more women than men, necrotic with PARL more common
Emergency / Flare-up Overview
What is the incidence of a Flare-up and are there any predictable indicators?

Walton – 3%; Female 2X more than males; Pre-op pain or swelling before initial appt are at greater risk

Torabinejad – Pre-op pain was an excellent predictor; Females age 40-59; no or small PA lesions increased the frequency of interappointment emergency
What causes flare-ups?

Seltzer & Naidorf – Overinstrumentation, overmedication, extruded debris, incomplete pulp removal, over-irrigation, hyperocclusion, root fx, or another tooth
Is it ok to close a tooth previously left open?

August – only minimal flare-ups seen – 5%
Do prophylactic antibiotics help decrease flare-up rate?

Reader – Pen VK did not decrease flare-ups with IP

Amox did not help decrease flare-ups with necrotic, asymptomatic teeth

Pen VK did not decrease flare-ups with necrotic, symptomatic teeth
When are Antibiotics indicated?

Pathways – Antibiotics are recommended in conjunction with appropriate endo tx for progressive infections with systemic signs and symptoms such as fever (100 deg F), malaise, cellulits, unexplained trismus, and progressive or persistent swelling. I & D is indicated for any infection marked by cellulites (fluctuant or indurated).
What are other tx considerations for a flare-up?

Occlusal Adjustment – Rosenberg – works for IP pre-op pain (perc. sens)

Re-enter for complete debridement

Establish Drainage – I & D; Trephination is ineffective (Moos, Reader)

Evaluate for Analgesics – Hargreaves – 3D pain control (diagnosis, definitive tx, drugs )

Flexible prescription plan – 1) max nonnarcotic (aceto or NSAID) or 2) add aceto (w or w/out opiod) to NSAID –

Match the pts needs

Evaluate for Antibiotics – systemic involvement or immunocompromised



Evaluate for Steroids – Reader – Oral (48mg methylprednisilone) or IO

Marshall & Walton – IM dexamethasone


Infections Overview
Discuss the infections of the Mandibular area:


Fascial Space

Source

Borders

Buccal Vestibule

Any Mand tooth – exudates breaks through B cort. plate and apicies lie above attachment of Buccinator or Mentalis muscle

  • Buccal cortical plate

  • Alveolar mucosa

  • Buccinator (post)

  • Mentalis (ant)

Body of the Mandible

Any Mand tooth – exudate has not perforated the periosteum

  • Buccal or lingual cortical plate

  • Periosteum

Mental Space

Mand anterior tooth – exudate breaks through the B cort. plate and apex lies below attachment of Mentalis

  • Mentalis (superiorly)

  • Platysma (inferiorly)

Submental Space

Mand anterior tooth – exudate breaks through L cort. plate and apex lies below attachment of Mylohyoid

  • Mylohyoid (superiorly)

  • Platysma (inferiorly)

Sublingual Space

Any Mand tooth – exudates breaks through L cort. plate and apex lies above attachment of Mylohyoid

  • Mucosa of floor of the mouth (superiorly)

  • Mylohyoid (inferiorly)

  • Mandible (lateral)

Submandibular Space

Mand posterior tooth – exudates breaks through the L cort. plate and apicies lie below attachment of the Mylohyoid

  • Mylohyoid (superiorly)

  • Platysma (inferiorly)

  • Mandible (lateral)

Pterygomandibular Space

Mand second or third Molars – exudates drains directly into the space or contaminated IAN block

  • Medial Pterygoid (medial)

  • Ramus (lateral)

  • Lateral Pterygoid (superior)



What 3 spaces are involved in Ludwigs angina?

Submental, Submandibular & Sublingual - life threatening cellulites which can advance to the pharyngeal and cervical spaces, resulting in airway obstruction

Discuss the infections of the lateral face and cheek:


Fascial Space

Source

Borders

Buccal Vestibule

Max posterior tooth – exudates breaks through the B cort plate and apicies lie below attachment of the Buccinator

  • Buccal cortical plate

  • Alveolar mucosa

  • Buccinator (superiorly)

Buccal Space

Any Mand or Max posterior tooth – exudates breaks through B cort plate and apicies lie above/below the attachment of the Buccinator respectively

  • Buccinator (medial)

  • Skin of Cheek (lateral)

  • Zygomatic arch/Buccinator attachment (superiorly)

  • Mandible/Masseter attachment (inferiorly)

Submasseteric Space

Impacted 3rd Molar

  • Ramus (medial)

  • Masseter (lateral)

Temporal Space

Involved indirectly if an infection spreads superiorly from the inferior pterygomandibular or submasseteric spaces

Deep Temporal:

  • Skull (medial)

  • Temporalis (lateral)

Superficial Temporal:

  • Temporalis (medial)

  • Fascia

Discuss the infections of the midface:


Fascial Space

Source

Borders

Palate

Any Maxillary tooth with apex near palate

  • Palate (superiorly)

  • Periosteum (inferior)

Base of the Upper Lip

Maxillary Central Incisor with apex close to B cort plate & above attachment of Obicularis Oris

  • Mucosa of the Base of the Upper Lip

  • Obicularis Oris (inferior)

Canine Space (Infraorbital)

Maxillary Canine or 1st Premolar – exudates breaks through B cort plate and apex lies above the attachment of the Levator Anguli Oris

  • Levator Anguli Oris (inferior)

  • Levator Labii Superioris (superiorly)

Periorbital Space

Spread of infection from the Canine or Buccal Spaces

  • Lies deep to the Orbicularis Oculi


Why are infections of the midface dangerous?

Cavernous sinus thrombosis – life threatening infection in which a thrombus formed in the cavernous sinus breaks free, resulting in a blockage of an artery or the spread of infection. Infections in the midface initiate an inflammatory response. Increased pressure can reverse the direction of venous blood flow (due to lace of valves) causing stasis in the cavernous sinus – this may initiate thrombus formation.

Retreatment Overview
Are Silver points a concern?

Seltzer – corrosion products of silver sulfides, silver sulfates, silver carbonates, and silver amine sulfate amide hydrates which are cytotoxic
What are some techniques to remove Silver points?

Krell – ultrasonics with hedstroms

Ruddle – ultrasonics with IRS
How do you remove posts?

Johnson – 16 min ultrasonic vibration

Baumgartner – Gonan produced less cracks than ultrasonics and was quicker
Can ultrasonic post removal cause any problems?

Eleazer - > 15 sec caused high root surface temps

Huttula & McClanahan – irrigate with ultrasonics reduced temps
What solvent is most effective at gutta percha removal?

Kaplowitz – tested 5 solvents; only chloroform dissolved GP completely
Is chloroform safe for the patient and the dental staff?

Chutich no health risk to the pt; .32mg extruded – 49mg is permissible toxic dose

McDondald – safe for staff; air vapors well below OSHA standards
How are Thermafil carriers removed?

Bertrand – chloroform and endo files

Baratto – Profiles at 300 rpm

Wolcott & Hicks – System B 225 deg & hand instruments
What is Red Russian paste and how do you remove it?

Gound – Resorcinol-formaldehyde resin; 10% sodium hydroxide causes polymerization

Krell – use ultrasonics

Hartwell – no solvent works; NaOCl works best

Surgery Overview
What are the anatomical concerns during periapical surgery?

Maxillary:

Eberhardt & Torabinejad – MB root of 2nd molar is closest to the sinus (2mm) and furthest from buccal cort plate (4.5mm); buccall root of 1st premolar is closest to buccal cort plate (1.6mm) and furthest from sinus (7mm); 5% of roots protrude into the sinus
Mandibular:

Phillips & Weller – mental foramen located 60% the distance from the buccal cusp tip of the 2nd premolar to the inferior border of the mandible; exits posterior-superiorly; radiographically 3mm below and slightly mesial of apex of 2nd premolar

Torabinejad – IAN S shaped – buccal to the D root of 2nd molar; crosses to L below the M root of 2nd molar; L to 1st molar; crosses to buccal below 2nd premolar
How would you manage a sinus exposure?

Lin & Langeland – prescribe decongestants (.5% neosynephrine); antibiotic only if sinusitis develops
How do you avoid the mental foramen and nerve?

Moiseiwitsch – take vertical PA radiograph; triangular incision w/ D vert release; notch bone superiorly for retractor
Discuss hemostasis during surgery?

Kim – Recommends racellet epi pellets; other hemostasis measures include:

Bone wax – may act as foreign body if any remains

Chemical vasoconstrictors – epi pellets placed 2-4min – little systemic absorption

Ferric sulfate – must be completely curetted or healing will be delayed (Jeansonne)

Calcium sulfate – acts via tamponade effect; biocompatible and resorbs

Collagen – causes platelet aggregation


Are epi pellets a concern systemically?

Baumgartner – epi pellets produce no significant cardiovascular effects
How much blood is typically lost during endodontic surgery?

Messer – Avg 9.5mL; similar to tooth extraction; time is biggest factor

Buckley – use 1:50,000 epi – ½ the blood loss
How much of the root end should be resected? Bevel?

Kim – 3mm resection = 98% of apical ramifications and 93% of lateral canals removed

Niemczk & Kim – 4mm root resection of MB root of Max 1st molar will expose a complete or partial isthmus 100% of the time

Gilheany & Figdor – aim for 0 deg bevel for decreased leakage
Why use ultrasonics for the retro-prep? Do ultrasonics cause cracks?

Baumgartner – 3mm prep with diamond coated ultrasonics; no crack seen and minimal bony crypt required
Does the entire lesion need to be curetted and removed for healing to occur?

Lin & Langland – No, but must remove all foreign objects
Is it necessary to remove the apical smear layer?

Jeansonne – no difference in healing noted (used tetracyc. & citric acid)
Is a retro-fill required? What do you use and why?

Altonen – teeth with retrofills had greater success

Dorn – Super EBA (best) showed better success rates 95% compared to IRM or amal

Jeansonne – Washout noted with MTA
Discuss MTA as a retro-fill material?

Torabinejad – biocompatible; demonstrates the least leakage; ok with blood contamination; substrate for osseous and cementum growth
Would you consider guided tissue regeneration?

Pecora & Kim – If > 10mm; through & through; endo-perio defect

Suda – Calcium sulfate was effective in bone regeneration
What type of sutures do you use and why?

Becker – Vicryl (polyglactin) produced little inflammatory response compared to polypropylene, silk or gut
Discuss incision and wound healing following endodontic surgery?

Harrison & Jurosky

Healing of the incisional wound:

24 h – thin epithelial seal

24-48 h – multilayered epithelial seal

48-72 h – epithelial barrier; collegen fiber synthesis

Preserve root attached tissue; submarginal & intrasulcular flaps performed equally

Healing of the osseous wound:

Day 1-3 – fibrin clot

Day 4 – granulation tissue replaces clot

Day 14 – new periosteum forms; osteoblastic activity; new woven bone trabeculae occupy 80%

Day 28 – maturing new trabecular bone

Periosteum does not survive flap reflection; don’t curette cortical retained tissue; crestal bone levels will reduce following sx


When should sutures be removed?

Kim – 2-3 days
When would decompression be considered and discuss different approaches?

Large lesions in order to avoid: divitalizing adjacent teeth, damage anatomical structures, parasthesia or risky sx (elderly)



Freedland – used polyvinyl tubing and daily irrigation

Hoen – Aspiration & irrigation
Trauma Overview
How do you classify crown fractures?

Andreasen: Crown infraction (craze line); Uncomplicated crown fx (enamel and/or dentin with no pulp exposure); Complicated crown fx (pulp exposed)
What is the probability of pulp necrosis following crown fx?

Ravn – 6% with uncomplicated crown fx; if concussion & mobility, then 30%;

80% success with DPC and uninflammed pulps



Cvek – 96% success cvek pulpotomy ( remove 2mm pulp up to 7days after fx)
What is the tx for a crown fx?

Uncomplicated – Restore with GI or composite resin; attempt bonding fx’d segment

Complicated – Cvek pulpotomy with Ca(OH)2 or RCT
What is the tx for a root fx?

3 radiographs; Reposition coronal segment & physiologic splint X3 wks; relieve occl

-if fx is coronal, remove coronal segment; consider gingivectomy or ortho extrusion
What is probability of pulp necrosis with root fxs?

Andreasen – 25% of the coronal segment
What are the methods of healing for a root fx?

Andreasen – Calcified tissue; connective tissue; interproximat bone & ct; inflammatory tissue w/out healing
What is the tx for a luxation injury?

Take multiple angled radiographs to discern root fx or not;

Reposition tooth in normal position (consider ortho reposition with intrusion); physiologic splint X3 wks; relieve occlusion; monitor for pulpal necrosis/pathology

-If intrusion of fully formed root apex, initiate RCT in 2wks


What is the probability of pulp necrosis following luxation injuries?

Andreasen – Concussion 3%; Subluxation 6%; Extrusion 26%; Lateral Luxation 58%; Intrusion 85%
How do you manage an avulsed tooth with an open apex (<1 hr dry)?

Clean root and socket with saline; Soak tooth in doxycycline 1mg/20mL for 5 min (Cvek- less ankylosis or inflammation); examine for alveolar fx & replant; physiologic splint X1 wk; monitor for necrosis/PA pathology


How do you manage an avulsed tooth with an open apex (>1 hr dry)?

Replantation is not indicated



How do you manage an avulsed tooth with a closed apex (<1 hr dry)?

Clean root and socket with saline; examine for alveolar fx & replant; physiologic splint X1 wk; initiate RCT X7-10 days



How do you manage an avulsed tooth with a closed apex (>1 hr dry)?

Clean root surface and soak in 2% stannous fl- X5min; clean socket with saline; examine for alveolar fx and replant; physiologic splint X1 wk; initiate RCT X7 days


What type of healing can you expect with an avulsed tooth?

Andreasen – normal, replacement resorption, surface resorption & inflammatory resorption; <30min before replanted, 90% no resorption; >90min = resorption
Discuss storage media for avulsed teeth?

Trope: Best to worst: HBSS > Milk > Saline > Saliva > Water

Blomlof – Milk gives you 6 extra hrs
Discuss splinting of avulsed teeth?

Castilli – splinting X7 days recovered uneventfully; 30 days induced resorption & ankylosis
What are some general adjuncts for trauma tx?

Tetanus booster; chlorhexidine rinses; analgesics

Antibiotics – Pen VK or doxyclycline (Trope – anti-resorptive) X1wk for avulsions
What is the role of Ca(OH)2 in replanted teeth?

Trope – decrease incidence of inflammatory resorption; 1wk = 8wks

Dumsha – NSD in inflammatory resorption with GP or 5mo tx with Ca(OH)2; recommends obturating immediately
What is the role of fluorides in replanted teeth?

Klinge – SnF2 delays replacement resorption

Coccia – delays resorption; 2X survival time
What is the recommended follow-up for traumatic dental injuries?

Pathways – after tx 3, 6, 12 mo and yearly thereafter



Anesthesia Overview
What properties of local anesthetics determine the onset of action, potency, and duration of action?

Malmed

pKa determines the onset of action – the lower the pKa the more rapid the onset

Lipid solubility determines the potency – permits anesthetic to penetrate the membrane more easily

Protein binding is responsible for the duration of action. Duration also increased with vasoconstrictor which decreases blood flow and systemic absorption
Amide LAs are metabolized in the Liver
What is the mechanism of action for local anesthetics?

Blockage of sodium channels by partitioning into 2 types, the charged acid (RNH+) and the uncharged basic form (RN), which penetrates the nerve membrane, ionizes and blocks the influx of sodium ions preventing depolarization (-70 mV → 40 mV)


What are some explanations for anesthetic failure?

Hargreaves - 1) lower pH of inflamed tissue → reduces the amount of base form of anesthetic that penetrates the nerve membrane

2) Unsuccessful technique

3) Inflamed nerves have altered resting potentials and decreased excitability thresholds

4) TTX-R sodium channel which are resistant to LAs (increased expression in IP cases)

5) Apprehensive pts have decreased pain thresholds

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