Racds Osce - General Dentistry (1)

Question 1:

The patient is an 8 year-old girl. What advice would you give the patient and parents on the future closure of the upper diastema? What are the indications for a frenectomy

Question 1: Answer A differential diagnosis should be made to ascertain the factors responsible for the diastema, such as unerupted supernumerary teeth (mesiodens), small size of teeth or deep insertion of a fibrous labial fraenum. Diastema usually reduce as the permanent canines erupt. Complete closure often requires orthodontic intervention. A frenectomy is then indicated after orthodontic closure to reduce the excess soft tissues. Surgical scarring assists in retention of the space closure as the tissues contract.

Question 2:

This male patient in his mid-twenties presented with an asymptomatic area on the lateral surface of tongue. This did not rub off and did not respond to antifungal therapy.

What is your differential diagnosis? Differential diagnosis

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Hairy leukoplakia, indicative of mid-to-late stage human immunodeficiency virus infection (HIV). Frictional keratosis. Idiopathic keratosis.

Question 3:

Both of these lesions occurred on the lips of men who had spent much of their time out of doors. From the appearance of each lesion and from its position, decide which of the following statements is most likely to be true. a. b. c. d.

Both lesions are squamous cell carcinomas. The lesion on the upper lip is a squamous cell carcinoma—that on the lower lip is a basal cell carcinoma. Both lesions are basal cell carcinomas. The lesion on the upper lip is a basal cell carcinoma, that on the lower a squamous cell carcinoma.

(d) It is most likely that : The lesion on the upper lip is a basal cell carcinoma; that on the lower lip, a squamous cell carcinoma. However, BCC on the vermillion border cannot be excluded.

Question 4:

This upper right central incisor and lateral incisor were traumatised by a blow three days ago. Patient's age is twelve years. There is no response to pulp testing, yet neighbouring teeth test normally. Would you proceed with pulp extirpation?

Question 4: Answer No. Traumatised teeth will frequently yield a negative pulp test for some time after trauma, then later test vital.

Question 5:

Slide shows the anterior teeth of a 10 year old boy. One of the upper central incisors is in torsiversion. What are the common causes of this problem?

Question 5: Answer Causes of displacement

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Presence of an unerupted supernumerary tooth Tooth size—basal bone discrepancy Tooth developed in ectopic position Previous trauma.

Question 6:

This slide shows fracture of both maxillary central incisors in a 25 year old patient. One tooth exhibits an Ellis Class III fracture and associated pulp exposure. The teeth are vital and the dentition is otherwise excellent.

What are the options for treatment?

Question 6: Answer Treatment Options : a. b. c. d.

A periapical X-ray to verify that there is no root fracture. Pulp extirpation and root canal treatment. Aesthetic restoration of the lost tooth structure depending on patient's requirement and circumstances. A partial (Cvek) pulpotomy in a previously minimally restored and symptomless tooth may provide success in a high percentage of cases. Long term success is difficult to predict, but decreases with increasing age.

Question 7:

This female aged 22 presented with gross loss of attached gingiva in all quadrants. What are the likely causes, and how would you manage this condition?

Question 8: Answer  

Acid erosion in combination with toothbrush abrasion. Management

Erosion

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Determine aetiology if possible Acids come from three main sources: o Dietary o Regurgitated hydrochloric acid (as in anorexia, bulimia nervosa, hiatus hernia, peptic and duodenal ulcers, mild chronic indigestion etc) o Industrial or occupational (less common today). Removal of cause or treatment of underlying medical condition may be sufficient to halt or slow progress. Long term review and management is essential.

Toothbrush abrasion: Advice on toothbrushing technique and abrasive nature of some dentifrices.

Question 8:

This patient has undergone radiotherapy for a salivary gland tumour. What supportive measures can be offered?

Question 8: Answer Topical fluoride therapy (rinse or gel in a custom-made stent), artificial saliva, dilute chlorhexidine rinses, instruction in meticulous oral hygiene measures, dietary advice to minimise root surface caries.

Question 9:

This bitewing radiograph of a fifteen year old patient reveals interproximal carious lesions confined to enamel. Visually there is no cavitation present. What treatment do you propose?

Question 9: Answer Detailed diet history; assessment of patient motivation to follow a rigorous preventive regimen involving dietary change, meticulous plaque control and home fluoride application until stability achieved. Regular review required. Operative intervention is necessary only in the presence of enamel cavitation.

Question 10:

This female in her mid-twenties presented with an acutely painful gingival condition, fever, lymphadenopathy, malaise and headache.

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What is the clinical diagnosis? How would you treat the condition?

Question 10: Answer  

Primary herpetic gingivo-stomatitis superimposed upon a chronic periodontitis. The condition is distinguished clinically from acute necrotising ulcerative gingivitis by the presence of ulcerative lesions visible on the mucosa and lips. Treatment of the acute stage is palliative, directed towards relief of acute symptoms, e.g., analgesics, fluids, soft diet, rest and Tetracycline mouthwash (250 mg capsule dissolved in 5 ml water, 4-6 hourly, 3 days) or dissolve contents of 25 x 250 mg capsules in 200 ml chloroform water; 5 ml as mouthwash every 4-6 hours.

Question 11:

This upper right central incisor was subjected to trauma one week previously. It tests vital and is not mobile. What immediate treatment would you suggest to help retain this tooth?

Question 11: Answer None, apart from periodic supervision. If the pulp remains vital and the tooth is not mobile, a repair of the fracture can be anticipated.

Question 12:

These slides are of a middle-aged female patient. The lesions on the cheeks and tongue are bilateral.

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What is your provisional diagnosis? How would you obtain a definitive diagnosis?

Question 12: Answer Minor erosive lichen planus. Diagnosis is based on history and clinical and histological findings (immunofluorescence). Close monitoring is required as there is a low ,but definite risk of malignant transformation.

Question 13:

This slide shows a missing incisor in an otherwise complete dentition. What factors would you consider in assessing this case for a single tooth implant?

Question 13: Answer Factors in assessment for implants

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Bony morphology. (length, width and density of bone) Soft tissue profile. (need for augmentation; relation to lipline) Angulation of maxilla in relation to chosen implant system. Implant system. (type of fixture and superstructure) Restorative materials to be utilised. Opposing occlusion.

Question 14:

Slide shows an upper right central incisor which tests non-vital and was traumatised eighteen months previously. The patient is eight years old. What treatment do you propose?

Question 14: Answer Exposed dentine should be covered or restored, then the tooth treated by a calcium hydroxide apexification procedure. Surgery is not indicated at this stage

Question 15:

A 45 year old male presented with a history of recurrent attacks of orofacial pain and concern for his appearance due to tooth wear. What factors may contribute to the aetiology of the orofacial pain? Briefly how might this problem be managed?

Question 15: Answer Factors contributing to orofacial pain

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Parafunctional clenching evoking pain in jaw muscles and T.M. joints Inadequate posterior support contributing to excessive loading of both T.M. joints Excessive wear on anterior teeth.

Management options

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Occlusal splint therapy to resolve symptoms Restoration of edentulous space and mandibular occlusal plane. Anterior restorations to restore tooth loss.

This female in her early thirties has had full mouth periodontal surgery, followed by full arch metal-ceramic crowns, which have been splinted together. What factors have contributed towards the deterioration in her periodontal condition?

Question 16: Answer Sub-gingival margins accompanied by crowns overcontoured both mesio-distally and bucco-lingually, and inadequate embrasures have all contributed towards inadequate plaque control.

Question 17:

This first permanent molar tooth exhibits a combination of hypoplasia and hypocalcification of unknown aetiology. What are the options for treatment currently available for such a condition?

Question 17: Answer Options for treatment

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Glass-ionomer cement. Smooth rough enamel and apply topical fluoride. Preventive Resin Restoration. (PRR) Amalgam restoration, if margins can be placed in areas where subsequent breakdown is unlikely. If tooth is fully erupted, and severely affected, a stainless steel crown can be placed.

Question 18:

The slide shows a periapical radiograph of an unerupted third molar. What precautions would you take in assessing this tooth for removal?

Question 18: Answer Precautions in tooth removal

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Additional radiograph to display entire tooth Surgical assessment, including possible need to section tooth Informed consent, noting possibility of transient or permanent parasthesia following surgery.

Question 19:

The slide shows a bitewing radiograph of posterior teeth restored with composite resin. What deficiencies of this form of restorative material are revealed in this radiograph?

Question 19: Answer Marginal gaps caused by contraction shrinkage of the composite, towards the curing light source.

Question 20:

This patient requests treatment to improve the colour and shape of the upper front teeth. What are the problems associated with porcelain veneers as an option in this case?

Question 20: Answer

Problems with porcelain veneers

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Past or present parafunctional habit. Thin enamel Absent enamel at gingival margins.