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CRE Revision

Therapeutics
Prescribing
BNF - dosage, frequency, route, forms, interactions / cautions / side effects
- dose varies with age, renal / liver disease, pregnancy, terminal care
Analgesics
Dental - Aspirin 600-900mg 4-hourly antipyretic X (<12, bleeding, GI, asthma, liver)
- Ibuprofen 400-600mg TDS antipyretic X (GI, asthma, liver disease)
- Paracetamol 1g QDS no anti-inflammatory, antipyretic, effective with codeine
- Carbamazepine
Hospital - Diclofenac Sodium 50mg TDS - Naproxen
- Opioids CNS depressant (addiction, respiratory, pupillary, urinary, nausea, GI)
- Codeine Phosphate 30-60mg every 4-hourly, moderate, short-term
- Morphine 10mg every 4-hourly / 30mg BD, requires laxative
- Buprenorphine sub-lingual 200-400ug TDS
- Diamorphine (heroin) 1-2mg IV
- Tramadol 50-100mg 4-hourly
- Gabapentin 300mg 3.6g / day, used in epilepsy and neuropathic pain
- Pregabalin 150-600mg / day, used in epilepsy, neuropathic pain and GAD
- PCA - computer system delivering micro-doses

Anti-Inflammatory (Steroids)
Topical - Hydrocortisone Mucoadhesive Buccal tablets
- Benzydamine
- Betamethasone Phosphate tablets
- Hydrocortisone 1% and Oxytetracycline 3%
- Hydrocortisone 1% and Miconazole 2%

Systemic - Hydrocortisone Sodium Succinate 100mg IM (prophylaxis)


- Prednisilone 10-20mg
- Methylprednisolone 40mg/mL
- Dexamethasone 4mg/mL

Steroid-Sparing Agent - Azathioprine


- Thalidomide

Antidepressants (co-analgesics, helpful with facial pain)


Amitriptyline (also for neuropathic pain) 50-200mg OD multiple side effects
Dosulepin (good for facial arthromyalgia) 75-150mg OD multiple side effects
Nortiptyline 10-30mg
Tranylcypromine (a MAOI / monoamine oxidase inhibitor) 10mg TDS
Citalopram / Sertraline / Fluoxetine / Paroxetine (all SSRIs)

Antiemetics Prochlorperazine / Metocloptamide / Domperidone / Ondansetron / Cyclizine

Anxiolytics / Sedatives / Hypnotics / Tranquillisers benzodiazepines for anxiety


Diazepam
Midazolam
Nitrazepam
Temazepam

Chlordiazepoxide
Lorazepam
Clomethiazole

Antibiotics
Amoxicillin 250-500mg TDS 5 days
Metronidazole 200-400mg TDS 5 days (effective with anaerobic bacteria, no alcohol)
Erythromycin 250-500mg QDS
Clindamycin
Tetracycline

Antivirals (herpes)
Acyclovir 200mg 5x / day
Penciclovir
Idoxuridine

Antifungals (candidiasis)
Nystatin
Miconazole (angular cheilitis)
Fluconazole 50mg OD

Antihistamines (allergy)
Chlorphenamine 4mg QDS
Promethazine 10-20mg BD / TDS
Alimemazine 10mg BD / TDS

Decongestants (sinusitis)
Ephedrine nasal drops
Xylometazoline and oxymetazoline nasal drops

Miscellaneous
Carbamazepine (antiepileptic) 100-200mg BD/TDS/QDS
Vitamins B, C, Folate, Iron
Artificial Saliva
Topical Anaesthetics 5% lidocaine (before LA) / EMLA & tetracaine (for oral lesions)
Fluorides
Retinoids

Drugs Affecting Dental Treatment


Warfarin <4 INR risk of bleeding with XLA / RSD / surgical
Bisphosphonates risk of MRONJ

Alarm Bells
Liver Failure
Renal Disease
Pregnancy
Breast-Feeding

Materials

CERAMICS = aesthetics [translucent], minimally invasive [PJC/Veneer], wear resistant


(hard)
= brittle (crack propagation), can be opaque (veneered), wears opposing tooth,
expensive

Glass-Matrix Ceramics (translucent, etchable (HF), resin bonding cement)


[Glass - most brittle]
Feldspar - SiO2-Al2O3 (inclusion increases strength slightly, translucent)
Leucite - +K2O (leucite reinforced dispersion strengthening)
Lithium Disilicate - SiO2-Li2O (stronger, pressable [in mould], but more opaque)
[Glass-Infiltrated - inclusions of Mg-Al / Al / Zirconia]
Oxide / Polycrystalline Ceramics (glass-free, opaque veneer, non-etchable sandblast +
adhesive)
[Alumina Oxide - first glass-free ceramic]
Y-TZP (Yittria-stabilised Tetragonal Zirconia Polycrystal) - transformation toughened

Strengthening Brittle Ceramics

Reducing Fusion Temperature:


- repeated firing/fritting
- more Feldspar inclusions (Na/K/Al) in dental ceramic
- Large Metal Ion inclusions (Boron/Calcium/Lithium)
- Silica Network Modifiers

Reduce/Distribute/Localise Porosities within Grain during fabrication:


- Compaction (condensation whilst mixing powder and liquid)
- Firing (condensation, Hot Isostatic Pressing [HIP], vacuum)
- Glazing (final firing for surface porosities)

Interrupting Crack Propagation:


- Inclusions (Alumina/Large Metal Ions)
- Transformation Toughening (tetragonal to monoclinic phase in Y-TZP increases fracture
toughness)

Ion Exchange (swap small Na for larger K compressive stresses)

Metal Bonding (via Contraction [CTE mismatch], Micromechanical [sandblast/burr], Chemical


[oxide layer])

ADVERSE REACTIONS
Amalgam / Metals Lichenoid Reactions / Burning Sensation / Swelling
Acrylic Resin / Latex / Nickel / Acrylates (HEMA/resin) Allergic Contact Dermatitis (Type IV)

ALLOYS (Substitutional, Interstitial, Intermetallic)


- Substitutional solute replaces similar sized solvent (Gold replaces
Copper/Platinum/Palladium/Silver)
- Interstitial solute in between solvent atoms (Carbon [small solute] + Iron [big solvent] = Steel
Alloys)
- Intermetallic Compounds specific metallic lattice structure, hardness/brittle/Tm, [Amalgam])
CEMENTS
Temporary Liners (direct/indirect pulpal cap)
- Dycal (Calcium Hydroxide + Zinc Oxide) - alkaline (helps tertiary dentine)
- MTA (Mineral Trioxide Aggregate) - sets with water Calcium Hydroxide (good seal), long
setting time
- Biodentine (calcium-silicate) releases calcium HA formation, dentine replacement, faster
set
Luting Cements (thin, long working time, rapid set, adhesive, radiopaque)
- ZOE neutral pH, bactericide, mild pulp irritant, inhibits/discolours composite resin
- Zinc Phosphate 15 min set (accelerated by moisute/heat/more powder), pH 2 6
- Zinc Polycarboxylate adhesive to tooth, higher initial pH
- EBA Cement modified ZOE (lower solubility, higher strength)
- GIC
DBA - TYPES & IDEAL PROPERTIES
HEMA (bi-functional coupling agent) - Hybrid Layer between dentine (hydrophilic) / resin
(hydrophobic)
BBC DMs - Biocompatible, Bond Strength, Compatible, Dimensionally Stable, Microleakage,
Shelf-Life

ETCH PATTERNS
Type 1 (rod centre removed [honeycomb]) | Type 2 (rod sheath removed [cobblestone]) | Type 3
(mixture)

COMPOSITE RESIN free-radical addition polymerization with 470nm blue light


Resin (Teg-DMA [diluent] / Bis-GMA / UDMA) increases fluidity/shrinkage
Filler (Silica/Quartz) Micro (less wear) / Nano (more polished) decreases fluidity/shrinkage
Silane-Coupling Agent enhances bond
Photoinitiators camphaquinone (a-diketone)

Adv - aesthetics, minimally invasive (micromechanical retention / adhesive), durable


Dis shrinkage (microleakage), technique sensitive (moisture/adhesive/incremental), soggy
bottom (toxic)
Biocompatability incomplete polymerisation soggy bottom / leaching, plaque retentive
caries

GLASS IONOMER CEMENT acid-base reaction chemical bond


Calcium Fluoro-Aluminosilicate glass particles + Strontium (radio-opacity)
Itaconic Acid + Tartaric Acid (polyacids)

1) Dissolution polyacid attack glass particles ion release


2) Gelation + Hardening - Siliceous Hydrogel (Ca2+ bind to carboxylate groups Al3+ cross-links)
(shrinkage)
3) Hydration 4-6 months water uptake (expansion)

Adv chemical bond, fluoride release, no significant overall shrinkage, little moisture control,
white filling
Dis - wear resistant, aesthetics (not tooth coloured), Early Water Contamination solubility /
hardness
Biocompatability minimal pulp irritation rapid recovery

AMALGAM
Trituration (Mercury + Silver, Tin, Copper) undertriturated (crumbles, hard) / overtriturated
(soupy, soft)
Condensation compact to achieve continuous matrix phase, prevent voids
Setting finishes when all the mercury has reacted and formed gamma-1

Low Cu: + Hg 1 + 2 + (gamma-2 increases creep, increases corrosion,


contains voids)
High Cu: + Cu + Hg 1 + + + (engma/epsilon phases replace gamma-2 phase)

Adv high strength, rigid, little moisture control, cheap, easy to handle
Dis aesthetics, not minimally invasive, mercury, corrosion/creep failure, thermoelectric
conductivity
Biocompatability corrosion, thermal conduction to pulp, lichenoid reactions

BIOCOMPATABILITY - non-toxic to living tissues (effects of material on tissue and vice


versa)
Testing - in vitro (predicts in vivo), specificity (teeth), sensitivity (suitable), controls
(positive/negative)
- clinical trials follow (expensive, consent, ethical)
- as per ISO Part 5 (cytotoxicity) + ECVAM guidelines
Biosafety (exclusion of harmful effects)
Biofunctionality (+ beneficial host response)

THERMAL DEFINITIONS
Thermal Conductivity, K = [(heat X distance) / (area X temp. gradient)] = constant of a material
Thermal Diffusivity, H = [Thermal Conductivity/(Specific Heat X Density)] = rate of temperature
disturbance
Co-efficient of Thermal Expansion, CTE = increase in length per degree rise in temperature
Glass Transition Temperature, Tg = glassy brittle rubbery (for denture base / restorative
materials)
FRACTURE TOUGHNESS (KC)
Energy required for a crack to form (ability to resist crack propagation) (metals>composite>GIC)
Kc = Ya (k = Stress Intensity Factor, Y material / crack shape, = stress, a = crack length)
[MNm-1.5]
HARDNESS resistance to indentation (wear), tests (Knoop, Vickers)
FATIGUE LIMIT stress value where failure occurs, after a specific number of loading cycles
ENDURANCE LIMIT the stress below which failure never occurs, for infinite loading cycles

RCT MATERIALS (long term seal, bactericidal, compatible with bone/tooth, good
mechanically)
Filler - GP (polymeric) - rubber, semi-plastic, pre-formed isomer (ZnO, GP, radio-opacifiers)
- Adv: shape adapts to canal, removable Dis: not rigid (difficult
to place)
- Amalgam (metallic) - Adv: cheap, plastic on insertion, radiopaque Dis: difficult to
condense, leaks
- Titanium (metallic) - Adv: new, bone integration, rigid Dis: expensive
Sealant - ZOE (used with GP, neutral pH, bactericide, biocompatible, inhibits/discolours composite
resin)

DENTAL IMPLANTS (OSSEOINTERGRATION)


Osseoinduction induce stem cells (osteoprogenitor osteoblast)
Osseoconduction allow adjacent bone growth by direct apposition
Osseointegration direct structural and functional connection between living bone and load
bearing implant

IMPRESSION MATERIAL IDEAL PROPERTIES


A Accuracy A
DS Dimensionally Stable Dentist Said
TS Tear Strength The Silicone
MV Medium Viscosity Mould Verifies
WT Working Time Where The
ST Setting Time Sexy Toys
H Hydrophilic Have
B Biocompatibility Been
D Disinfect-able Dislodged

IMPRESSION MATERIALS Elastomers (ACS/CCS/PE) & Hydrocolloids


(Al/Ag)
ELASTOMERS rubber, viscosity determined by body, macromolecules linked by VDWs

Addition Cured Silicone ()


Composition vinyl-terminated polydimethyl siloxanes, hydrogen (allows cross-link), platinum
(catalyst)
Properties hydrogen surface pitting
Condensation Cured Silicone ()
Composition - hydroxy-terminated polydimethyl siloxanes, alkyl silicate (allows cross-link), tin
(catalyst)
Properties hydrophobic blow holes, condensation shrinkage
Polyether ()
Polyether + Filler + Sulphonic Acid Ester (catalyst) allergic reaction, short working time, stiff set

HYDROCOLLOIDS Sol Gel state (fibrils = tear resistance), Imbibtion (uptake), Syneresis
(evaporate)

Alginate (irreversible, Modified Alginates contains silicone detail + tear resistance)


Composition Sodium Alginate (Sol) + Calcium Sulphate + some Filler Calcium Alginate
Properties dimensionally unstable
Agar (reversible)
NON-ELASTIC
- Zinc Oxide + Eugenol - Zinc Eugenolate (thin cross section, detailed, brittle, not elastic)
- Impression Plaster B calcium sulphate hemihydrate + calcium sulphate dihydrate
ACRYLIC (Denture Base) - Denture Base (aesthetic, light, strong, high modulus, non-toxic,
repairable)

PMMA (powder beads + initiator) [2.5] + MMA (liquid + activator + cross-linking agent) [1]

(excess polymer porosities | excess monomer shrinkage)

Initiation (initiator forms free radicals)


Propagation (free radicals attack double bond [MMA]) [exothermic]
Termination (two free radicals / disproportionation)

Curing - Heat - exothermic gradual temperature increase monomer evaporates


(porosities)
- Chemical - benzoyl peroxide (initiator) + tertiary amine (activator) free radicals
- Light - urethane dimethacrylate + microfine siica + camphorquinone
- Microwave - microwave radiation speeds setting, special container required, similar to heat
set

Adv:
- High molecular weight
- Light weight
- Good aesthetics

Dis: [Dentures Would Be Perfect If Patients Took Care]


- Drying completely shrinkage/distortion
- Water Uptake (dimensional changes)
- Brittle
- Porosities (gas escaping)
- Insulator (loss of thermal stimulus due to low thermal conductivity/diffusivity)
- Plasticisation (residual monomers due to inadequate curing)
- Tg = 105C (cannot be cleaned with boiling water)
- CTE must be matched with tooth and base

METALS
Cast by the Lost Wax Technique (wax-up, add sprue, investment [ceramic], burnout wax, cast up metal)
Use: crowns/bridges/denture framework (more brittle due to small grains and many grain
boundaries)

Wrought by Cold Working (squeezing/drawing/bending to deform grain structure, allow the lattice to
slip)
Use: clasps/files/wire (good strength/elastic recoil, annealing [hammer/anvil increases
ductility/softness])