SUBJECTIVE ANSWER QUESTIONS SEPTEMBER 2006

Answer 1-

1. The risk of bleeding in anticoagulated patients undergoing oral

surgery Dental surgery in anticoagulated patients is common
and historically their management has been controversial
following early reports of major bleeding in such individuals .
Many of the early reports of haemorrhage associated with

dental surgery during this period predated the standardisation

of oral anticoagulant control by means of the INR. In 1954, the
American Heart Association recommended a therapeutic
range for oral anticoagulant therapy of a prothrombin time
ratio (PTR) of 2 2.5 using human brain reagents . Later, the
use of less sensitive commercial thromboplastins was not
accompanied by a change in the target PTR ratio. Clinicians,
therefore, administered larger doses of oral anticoagulants to
achieve the target ratio, resulting in an increased incidence of
haemorrhage. The development and introduction of the INR did
not take place until 1983. The risks of bleeding associated
with dental extraction in individuals not receiving oral
anticoagulants is approximately 1%. In a review of 10 studies
of patients undergoing dental surgery and in whom oral
anticoagulants were continued, 9% (89/990) had delayed
postoperative bleeding and in 3.5% of cases this was
classified as serious i.e. not controlled by local measures.
Other studies have reported the incidence of minor bleeding as
higher and in some cases up to 50%. However, the
interpretation and comparison of bleeding rates in patients
undergoing oral surgery is difficult as rates for different
procedures are not analysed separately, the definitions used
to describe serious bleeding vary and surgery can involve the
use of differing treatments to secure haemostasis.
2. What constitutes dental treatment? Many procedures
performed in the primary care setting are relatively non-invasive
and would not, therefore, require measurement of the INR. Such
procedures would include prosthodontics [construction of
dentures], scaling/polishing and some conservation work [fillings,
crowns, bridges].
Potentially invasive procedures performed in primary care
would include:
Endodontics [root canal treatment]
Local anaesthesia [infiltrations, inferior alveolar nerve block,
mandibular blocks]
Extractions [single and multiple]
Minor oral surgery

 Periodontal surgery
Biopsies
Subgingival scaling
2. Which patients on warfarin should NOT have a surgical dental
procedure in the primary care setting?
Patients on oral anticoagulants with co-existing medical problems e.g. liver disease, renal
disease, thrombocytopenia or who are taking anti-platelet drugs. Such patients may have an
increased risk of bleeding.
Patients requiring surgical procedures not listed above. Such patients should be referred to
a dental hospital or hospital-based oral and maxillofacial surgery department. Surgical
dentists in the primary care setting often have the skills to undertake any of the procedures
listed above in the context of the anticoagulated patient. The skill and experience of the
primary care dentist, together with the difficulty of the procedure all need consideration.

REFERENCE: http://onlinelibrary.wiley.com/doi/10.1111/j.1834-7819.2003.tb00015.x/epdf

ANSWER 2- MISSING LATERAL INCISORS

Advantages and Disadvantages of

Treatment Options for Congenitally
Missing Lateral Incisors
Thomas E. Dudney, DMD
The treatment of congenitally missing maxillary lateral incisors presents unique
challenges to the dental profession and often requires a coordinated
interdisciplinary approach involving orthodontists, oral surgeons, periodontists,
and restorative dentists to achieve optimal esthetic and functional results. Careful
diagnosis and information gathering as well as communication with the patient
and often, depending on age, their parentsis necessary to formulate a treatment
plan that will accomplish the desired results and satisfy patient expectations. There
are many factors that affect treatment options, such as occlusion; alignment of
teeth; patient age; available space; alveolar bone thickness; facial profile; shape,
color, and size of the canines; lip position; gingival display; and condition of
adjacent teeth. An ideal treatment plan should take into account all of these factors
to achieve the esthetic and functional goals with the least-invasive option
available. This article will not recommend a particular treatment modality, but
identify the available options and discuss their advantages and disadvantages.

Space Closure with Canine Substitution

The two main treatment options include either space opening with prosthetic
replacement or space closure with canine substitution. In ideal situations where
patients have a balanced or slightly convex facial profile; an angle class II
malocclusion with no mandibular crowding or an angle class I malocclusion with
mandibular crowding necessitating extractions; and small canines that are lighter in
color, space closure may be a viable alternative. The advantages of canine
substitution are that natural teeth are biocompatible and preferable long term and
the finished result is permanent, negating the need for future prosthetic
replacement. Furthermore, even though canine-protected occlusion is not possible,
long-term studies have shown that space closure using a premolar is equally sound
occlusally and preferable periodontally to space opening. The disadvantages of
canine substitution are the need for certain conditions to exist as previously stated,
adverse effects on dentoalveolar and facial esthetics as a result of the canine
prominence being moved mesially, the tendency for space to sometimes reopen,
and very large or dark canines that are difficult to reshape or bleach to an
acceptable shade and may require a restoration (ie, porcelain veneer) to achieve the
desired esthetic result (Figure 1A and Figure 1B).
Space Opening with Prosthetic Replacement
Historically, options for space opening with prosthetic replacement were limited to
removable partial dentures and conventional fixed bridges. Neither option was very
appealing and in the past made space closure with canine substitution a more
attractive alternative. The only advantage of removable partial dentures was that
they were far more conservative than fixed bridges. However, their disadvantages
included their bulky and cumbersome design, which made it difficult to achieve
esthetic results, and the fact that patients disliked wearing them.
Although conventional fixed bridges were more comfortable and esthetic than
removable partial dentures, they required gross reduction of healthy tooth
structure, which is generally contraindicated in young patients. With todays
materials, fixed bridges offer excellent results from esthetic and functional
perspectives, but because they still require an amount of tooth reduction their use
should be limited to situations where a conventional bridge already exists or the
condition of the abutment teeth (ie, wear, caries, fracture, etc) would dictate a more
aggressive preparation.
The first attempt at a conservative fixed restorative option was the Maryland
bridge, which had metal wings that bonded to the lingual surface of the central and
canine. The advantage of a Maryland bridge was that it was minimally invasive,
but the disadvantages included compromised esthetics from the metal wings
showing through translucent enamel and the inability of the rigid metal wings to
flex with the slight mobility of the anterior teeth, often leading to debonding. In
recent years two more options for prosthetic replacement have gained favor. One is
the fiber-reinforced resin-bonded bridge and the other is the single-tooth implant.

Both options offer a conservative approach with acceptable esthetics and, although
each option has certain advantages, each also has disadvantages.
The Fiber-Reinforced Resin-Bonded Bridge
The fiber-reinforced resin-bonded bridge, sometimes referred to as the Encore
bridge, is based on the same principle as the Maryland bridge. Instead of metal
wings, this type of bridge incorporates laboratory-processed composite resin with
fiber reinforcement in the form of a lingual framework with a ceramic veneer
bonded to the facial of the pontic. This design ensures long-term esthetics and
vitality of the restoration. Unlike metal, the fiber-reinforced resin framework
readily bonds to enamel and dentin and has the strength and elasticity to resist
fracture and debonding, even in the presence of slight mobility of the anterior
teeth.
Furthermore, because the material is tooth-colored, the problem of discoloration
and graying of enamel caused by metal show-through is eliminated (Figure 2A and
Figure 2B). In cases where patients desire a more comprehensive smile
enhancement procedure in addition to replacing the congenitally missing lateral
incisors, this technique works well because porcelain veneers can be placed on the
natural teeth as well as the pontics of the resin frameworks, thus giving the
restorative team control of the size, shape, position, and color of the restorations in
the final smile (Figure 3A; Figure 3B; Figure 3C).
Fiber-reinforced resin-bonded bridges with ceramic overlays on the pontics can be
an excellent treatment option, but there are some disadvantages of this procedure
as well. While they are much less invasive than conventional three-unit or even
two-unit canine cantilevered fixed bridges, these bridges do require some tooth
preparation on the lingual and interproximal surfaces of the abutment teeth. Also,
because of their high failure rate when subjected to excessive lateral forces, these
bridges are not recommended for pa- tients with a deep overbite
relationship.5 Although different preparation designs exist, the one that
incorporates as much of the lingual surface as possible (a depth of about 1 mm)
and has a horizontal central groove for strength and a proximal box design for
increased thickness and fiber concentration in the connector sites seems to achieve
the best long-term results, but also requires the most preparation of healthy tooth
structure. Furthermore, this type of fixed restorative option likely would have to be
remade several times over the lifetime of a young patient, and the possibility of
connector site fractures, material delamination, or debonding still exists. However,
in cases where canine substitution or single-tooth implant replacement are
contraindicated or the patient chooses not to go through the necessary protocol for
implant placement, the fiber-reinforced resin-bonded bridge may be the best
restorative option.
The Single-Tooth Implant
A more recent option for treating congenitally missing lateral incisors, and one that
currently is recommended often, is the single-tooth implant. Over the past several
years, the predictability and long-term success rates of implants have made them

an obvious restorative choice, especially when teeth adjacent to the space are
healthy, of normal size and shape, and unrestored. Furthermore, placement of an
implant may provide a functional stimulus to help preserve bone and prevent
resorption. However, when choosing the single-tooth implant as a restorative option, several factors must be taken into ac- count such as growth considerations,
space requirements, and site development.
Because an implant acts essentially like an ankylosed tooth, any vertical alveolar
growth and eruption of teeth would cause a discrepancy between the gingival
margin of the natural tooth and the implant. Therefore, implant placement should
occur only after growth has been completed, and it has been suggested that neither
chronological age nor hand-wrist radiographs are reliable enough to make that
determination. Instead it would be best to compare superimposed cephalometric
radiographs taken at 1-year intervals until no growth changes are detected. Also,
the amount of space between the roots is critical to successful implant placement,
and orthodontic intervention usually is necessary to achieve not only the amount of
interradicular space needed, but also the proper root angulation. Because
orthodontic treatment usually occurs at an early age, several years of maintenance
therapy may be required until the appropriate age for implant placement. It is also
important to maintain proper spacing for ideal tooth proportions of the final
restoration.
In addition to the tooth width requirements for mesiodistal spacing, the alveolar
width in a buccolingual direction must be adequate for implant placement. Often
an additional surgical appointment is necessary to graft or augment the alveolar
ridge before an implant can be placed. It has been suggested in the literature that
by allowing or guiding the eruption of the canines into the lateral position and
orthodontically moving them to their natural position, the necessary amount of
buccolingual alveolar thickness for implant placement can be achieved naturally,
without the need to perform any ridge augmentation. Although not completely
understood, it has been shown that very little, if any, resorptive change in alveolar
bone width is observed when space is opened orthodontically compared with the
decrease in alveolar ridge width after extraction of maxillary anterior teeth.
However, a disadvantage of orthodontic canine distalization for implant site
development is the potential for loss of arch length when the canines are allowed to
erupt mesially.
While single-tooth implants as a prosthetic replacement for congenitally missing
lateral incisors can conservatively satisfy the esthetic, functional, and biologic
goals of treatment, they are not without disadvantages and often require very
careful case selection and a diligent and well-coordinated interdisciplinary
approach. In addition to site development, space requirements, and age restrictions
because of the necessity for growth completion as conditions that must be met for
successful treatment, implants as a restorative option have the potential for esthetic
failure as a result of gingival darkening, exposure at the margin from gingival
recession, incisal edge and gingival discrepancies from long-term facial growth
and vertical movement of teeth, and the difficulty of matching natural tooth color

and translucency with an implant crown. When restoring congenitally missing

lateral incisors with implants, or any type of restorative option, the patient should
be committed to a lifetime of wearing a prosthesis in the area of the mouth where
esthetics are critical and not always easy to control.

Another answer from ODELL

Answer 3- Differential diagnosis is linked to periodontitis which is local and can

be caused by

Management : It is basically to find out the cause, design a

prosthesis and follow precautions to get rid of relapse process.

ANSWER 4- possible management option is incision and drain

because LA does not work properly in infection cases.

ANSWER 5- Management of the child on his/her first dental visit.

Please follow recommendations mentioned below:

Discussion with the parents

ANOTHER SAQS
Answer 1.

Answer 2- smoking and its effects on dental health

http://onlinelibrary.wiley.com/doi/10.1111/j.18347819.2009.01142.x/epdf

Answer 3Short term management:

Long term management:

Answer 4- http://www.endoexperience.com/documents/Joiner2.pdf

Answer 5http://onlinelibrary.wiley.com/doi/10.1002/9781118702895.app6/pdf

Finally thank god its mcqs now

1- B
Option A- erosion
Option b- abrasion
Option c- attrition
Option d- abfraction

2- c

3- A repeated question
4- A
5-A
6- both as they are resin bonded fixed bridges
7- A Antes Law

8-A
9-A
10-B
11-B

12- E
13-A

14-C
15-A
16-B
17-

18- B

19- A
D- poorest prognosis
20-a
21-c
22-B
23-A
24-b
25-d
26- A
27-C
28-A

29-A
30-D
31-B
32-E
33-B
34-C

35-D

36-B
37-A
38- B

39-A
40-B
41-A
42-C
44-B

45-c

46-C
47-A
48-B
49-B
50-C BEST IS C IF C IS NOT PRESENT THEN A IS THE BEST
OPTION.
51-B
52-B
53-A

54-B
55-A
56- C
57- b
58-E
59-B
60-B
61-B
62-C
63-B
64-A
65-B

66-

67-D
68-A
69-B
70-A
71-B

72- NEED MORE OPTIONS

73- A
https://books.google.co.nz/books?id=tclpAAAAMAAJ&q=THIRD+MOL
AR+SURGERY-+MAXIMUM+SWELLING+AFTER+2448+HOURS&dq=THIRD+MOLAR+SURGERY+MAXIMUM+SWELLING+AFTER+2448+HOURS&hl=en&sa=X&ved=0ahUKEwiExLyn3pHOAhVLoJQKHRQ
cBtYQ6AEIJTAA

PAPER II
1-incorrect question during swallowing suprahyoid muscles
contracts, tongue touches anterior hard palate, contact of upper
and lower teeth, masseter contracts..
2- a
3- B

4-A
5-B
6-A

7-C
8- B

9-B

10- c
11-D

12-c infection control guidelines

13- c
14- D

15 -A
https://books.google.co.nz/books?id=hpc60yCsTPcC&pg=RA7PA176&dq=bond+between+implant+and+bone+is&hl=en&sa=X&ved
=0ahUKEwi5qtOK05bOAhXCnpQKHRWXDQoQ6AEIHDAA#v=onepage
&q=bond%20between%20implant%20and%20bone%20is&f=true

16-D

17-c
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3895311/

18- b

LINGUAL ERUPTION OF MANDIBULAR PERMANENT INCISORS

The eruption of mandibular permanent incisors lingual to retained primary incisors
is often a source of concern for parents. The primary teeth may have undergone
extensive root resorption and may be held only by soft tissues. In other instances
the roots may not have undergone normal resorption and the teeth remain solidly in

place. It is common for mandibular permanent incisors to erupt lingually, and this
pattern should be considered
essentially normal. It is seen both in patients with an obvious arch length
inadequacy and in those with a desirable amount of spacing of the primary
incisors.
Management:
1. In either case the tongue and continued alveolar growth seem to play an
important role in influencing the permanent incisors into a more normal position
with time. Although there may be insufficient room in the arch for the newly
erupted permanent tooth, its position will improve over several months.
2. In some cases there is justification for removal of the corresponding primary
tooth. Extraction of other primary teeth in the area is not recommended, however,
because it will only temporarily relieve the crowding and may even contribute to
the development of a more severe arch length inadequacy.

http://www.ncbi.nlm.nih.gov/pubmed/2668366

19-C

20- b
21-c
22-b
23-a
2425- E

26- B
giant cell granuloma 11-49 % Recurrence, or persistence. of a lipoma can be
the result of incomplete removal. This would be more common if the removal was done
with liposuction rather than open removal. Fibrous epulis- 10%. Haematoma- 5-30%.
PULP polyp does not show any recurrence. Reference- Burkitt oral medicine book.

27-A
28-E
29-A
30-A

31-C
32-B refer to cephalometry ppt file

33-B

34- D.. chances of systemic infection

35-C

36-A
37-a

38-b

39-A
40-c
41-c

42-a
43- D
44-a
45- NEED MORE OPTIONS
46- C
The levels of Gram-negative anaerobic bacteria, such as Prevotella intermedia,
increase as a result of the high concentration of hormones available as a nutrient
for growth.

47- b

48-A

49-B

50-E

51-A
https://books.google.co.nz/books?id=w1rbVel7Q6YC&pg=PA62&dq=T
HE+FIRST+FORMING+MICROBE+OF+PLAQUE+ARE+GRAM+POSITIVE
&hl=en&sa=X&ved=0ahUKEwizsJaLvpPOAhVGpJQKHWeOBLkQ6AEI
JTAA#v=onepage&q=THE%20FIRST%20FORMING%20MICROBE%20
OF%20PLAQUE%20ARE%20GRAM%20POSITIVE&f=true

52-B
53-A
54-B
PARAESTHESIA IS A SIGN OF MALIGNANCY PLEOMORPHIC
ADENOMA IS BENIGN TUMOR.
55-A

56-b
57-D
58-A

59-B
60-C
61-C
62-B
63-B
64-B

65-B
66-B
67-D
68-c
69-B

70-B
71-A
72- C

73-A

74-E

SCD IS NOT COMMON IN MEDITERREAN PEOPLE BU THALLASEMIA

IS.
Thalassemia is a form of inherited autosomal recessive blood disorder characterized by
abnormal formation of hemoglobin.[1] The abnormal hemoglobin formed results in
improper oxygen transport and destruction of red blood cells.[1] Thalassemia is caused by variant
or missing genes that affect how the body makes hemoglobin, the protein in red blood cells that
carries oxygen. People with thalassemia make less hemoglobin and have fewer circulating red
blood cells than normal, which results in mild to severe microcytic anemia.

Thalassaemias are the most common in Asia, the Mediterranean basin, and the Middle East.
Sickle-cell disease predominates in Africa.

75-C

76-B

77-D

78- A..
AGE 9 YEARS= CI, LI, 1ST MOLAR BOTH UPPER AND LOWER

79-B
80-C
81-C
82-A

83-D

84-A
85-A
86-A
87-d
88-A