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AFK Mock 3 References
Book 1
2023 Prep Doctors | All rights reserved
CBCT Volume Indications

5x5 cm Limited view (single quadrant). Useful for endodontics or
placement of 1 implant.
5x8 and 8x8 Both dental arches are visible. Useful for placing implants in
cm multiple quadrants, and evaluation of bony pathology.
12x12 cm, Both jaws including the TMJs, airways, and sinuses.
14x8 cm
2
https://www.ncbi.nlm.nih.gov/pmc/articles/P
MC7578221/
• MIP, as the name suggests, affects incisors and first molars of
adolescents and young adults associated to minimal plaque and
rapid rate of progression.
4
6
Class II division 2: Normal overjet, 100%
overbite
8
Preventative regimen for moderate risk (permanent

dentition after 3rd molar eruption)
- Recall intervals: _________every 6 months______________________________
- Radiographic intervals: _______every 6-18 months________________________
- Preventive measures: diet counselling, fluoride (brush twice daily with fluoridated
toothpaste (1,200-1,500 ppm), consume water with optimal fluoride level (alternatively, take
fluoride supplement with fluoride- deficient water supplies), fluoride varnish every 6
months), sealant applied to permanent molars, xylitol 6-10 gm/day, Fl mouth rinse.
- Therapeutic measures: active surveillance for non-cavitated, restore cavitated.
10
In 1975 Hamp, Nyman and Lindhe proposed a classification system
referring to the horizontal attachment loss and based on three degrees:
• Degree I → horizontal attachment loss < 3 mm of the total width of the
furcation area.
• Degree II →horizontal attachment loss > 3 mm but not encompassing the
total width of the furcation area.
• Degree III →“through and through” destruction of the periodontal tissue in
the furcation area.
11
Cerebrovascular Accident
Cerebrovascular Accident
Signs and symptoms: Management:
• Sudden dizziness. • CAB
• Sudden vertigo. • Oxygen.
• Sudden severe headache. • Call 911
• Transient monocular blindness (Vision changes). • If patient goes into coma → head-tilt/chin-lift is
• Nausea and vomiting. added to the management.
• Transient paresthesia. • Monitor vital signs → prepare for CPR if needed.
• Unilateral weakness or paralysis.
• Convulsions.
• Loss of consciousness (Coma).
• sweating and chills
• speech defects (aphasia)
• Neurological deficits
• Severely elevated blood pressure (Malamed)
• Note: Blood pressure and pulse generally are normal. (LF)
• Raised blood pressure and raised body temperature, and lowered pulse and respiration maybe seen in
advanced cases of increased intracranial pressure
2023 Prep Doctors (LF)
| All rights reserved
12
Hargreaves, K.M., Berman, L. (2016). Cohen’s pathways of the
pulp. (11th ed.) St. Louis: Elsevier.
• External or cervical root resorption is a serious complication of
whitening procedures with peroxide compounds. Cervical root
resorptions were seen in 6% to 8% of cases when 35% hydrogen
peroxide was used, and 18% to 25% if the hydrogen peroxide was
heat activated. The etiology for external root resorption to occur is
complex. It is suggested that a combination of predisposing
factors—such as a cementum deficiency exposing dentin, a
periodontal ligament injury that is triggering an inflammatory
response, or an infection that is sustaining inflammation—has to be
present. Cervical resorptions are also often seen in patients who
had bleaching treatment at a young age or who suffered from a
traumatic injury.
13
Walton, R.E., Torabinejad, M., Fouad, A.J. (2015). Endodontics:

principles and practice. (5th ed.) New York: Elsevier.
• External root resorption is a frequent occurrence in replanted
avulsed teeth. Three types have been identified: surface,
inflammatory, and replacement.
Surface Resorption
• Also called “repair-related resorption,” surface resorption is
transient and shows as lacunae of resorption in the cementum of
replanted teeth. They are not usually visible on radiographs. If
resorption does not continue, the lacunae are repaired by
deposition of new cementum.
14
Inflammatory (Infection-Related) Resorption
• Inflammatory resorption occurs as a response to the presence of
infected necrotic pulp tissue in conjunction with injury to the
periodontal ligament. It occurs with replanted teeth in addition to
other types of luxation injuries. It is characterized by loss of tooth
structure and adjacent alveolar bone. Resorption usually subsides
after removal of the necrotic, infected pulp, so the prognosis is
good. Root canal treatment is therefore recommended routinely for
replanted teeth with closed apices to prevent the occurrence of
inflammatory resorption.
15

External Replacement (PDL-Related) Resorption
• In replacement resorption, the tooth structure is resorbed and
replaced by bone, resulting in ankylosis in which bone fuses
directly to the root surface. The characteristics of ankylosis are lack
of physiologic mobility, failure of the tooth to erupt along with
adjacent teeth (leading to infraocclusion in young individuals), and a
“solid” metallic sound on percussion. Currently no treatment is
available for replacement resorption, which tends to be continuous
until the root is replaced by bone. In teeth that have had long
extraalveolar dry periods, the resorptive process is apparently
slowed (but not halted) by immersing the tooth in fluoride before
replantation.
16
• Drainage through the soft tissue is accomplished most effectively
when the swelling is fluctuant. A fluctuant swelling is a fluid-
containing mass in which a wavelike sensation (like pushing on a
water balloon) is felt when pressure is applied. Incising a fluctuant
swelling releases purulence immediately and provides rapid relief. If
the swelling is nonfluctuant or firm, incision for drainage often
results in drainage of only blood and serous fluids. Incision and
drainage of a nonfluctuant abscess reduces pressure and facilitates
healing by reducing irritants and increasing circulation in the area.
17

• The best treatment for swelling originating from a symptomatic
apical abscess of pulpal origin is to establish drainage through the
offending tooth. When adequate drainage cannot be accomplished
through the tooth itself, drainage is obtained through soft tissue
incision. Occasionally, drainage is performed through the soft tissue
even if it has also been obtained through the tooth.
18
Soft Tissue Calcifications
19
20
Tonsilloliths
• Cluster of radiopaque structures.
• Overlap the midportion of the ramus.
• May appear inferior to the inferior alveolar canal.
21

Calcified Lymph Nodes
• Near the angle of the mandible and posterior to the ramus.
• Cauliflower shaped.
22
Carotid Artery Calcification
• Well-defined radiopacities.
• Visible in the soft tissues of the neck.
• Near C3 and C4.
• Irregular in shape.
• Vertical orientation.
23
24
25

Sialoliths
• Well-defined.
• Radiopaque.
• May be homogenous or heterogenous.
• Most commonly involves the submandibular gland.
• May be regular or irregular in shape.
26
27

Phelobliths
• Mineralization of intravascular thrombi that result from venous stagnation.
• Radiopaque and well-defined.
• May be homogenous or heterogenous.
• Most commonly seen within hemangiomas.
28
29

Calcified Stylohyoid Ligament
30
Neville, B.W. (2016). Oral & maxillofacial pathology. (4th ed.)
Philadelphia; Toronto: W.B. Saunders.
• Although no single triggering agent is responsible, the mucosal
destruction appears to represent a T cell–mediated immunologic
reaction with production of tumor necrosis factor-alpha (TNF-α).
This factor is a major inflammatory cytokine and assists in the
ultimate targeting of the surface epithelium for destruction by
cytotoxic T cells (CD8+). Evidence of the destruction of the oral
mucosa mediated by these lymphocytes is strong, but the initiating
causes are elusive and most likely highly variable.
31
Teeth Formation, Eruption and Calcification

Eruption times and calcification times:
32
Nowak, A., et al. (2019). Pediatric dentistry: infancy
through adolescence. (6th ed.) Elsevier.
• The dentist does require other radiographs to make a thorough
diagnosis or problem list in the 3- to 6-year-old child. Children in
this age range may find it difficult to cooperate with the
radiographic procedures, in which case the radiographic
examination should be deferred until behavior improves or can be
managed.
33
Upper Airway Obstruction

Signs and symptoms Management
Partial airway obstruction: coughing, • Conscious Patients: • Unconscious patients:
wheezing, paradoxical respirations (chest
wall moves in on inspiration and out on • Place the patient standing or sitting • Place the patient in a
expiration), absent or altered voice, leaning forward. supine position.
cyanosis, lethargy, disorientation. • If object is visible and reachable→ Finger • Call 911.
Complete airway obstruction: sweep. • Initiate CPR.
• Phase 1 (1-2 mins) → Conscious, • If patient is coughing → Encourage • Administer Oxygen.
universal choking sign, struggling, Coughing. • During CPR, whenever
paradoxical respirations without air • If patient stopped coughing (silent the airway is opened
movement or voice, increased blood
breath)→ Abdominal thrust (chest thrust and two breaths are
pressure and heart rate.
• Phase 2 (2-5 mins) → Loss of for pregnant and obese patients). being delivered, look
consciousness, decreased respiration, • repeat abdominal thrust until object is inside the patient’s
blood pressure, and heart rate. cleared or until patient becomes mouth and perform a
• Phase 3 (>4-5 mins) → Cardiac arrest unconscious. finger sweep if the
(coma, absent vital signs, dilated object is visible.
pupils).
34
Mallya, S., Lam, E. (2018). White and Pharoah’s oral radiology:
principles and interpretation. (8th ed.) St. Louis: Mosby.
• In addition to clinical signs and symptoms such as increased
mobility, wear facets, unusual response to percussion, and a history
of contributing habits, there are associated findings in the images,
including widening of the PDL space, thickening of the lamina dura,
bone loss, and an increase in the number and size of trabeculae.
Other sequelae of traumatic occlusion include hypercementosis
and root fractures. Traumatic occlusion alone does not cause
gingivitis or periodontitis, affect the epithelial attachment, or lead to
pocket formation, but in the presence of preexisting periodontitis
bone loss may be accelerated.
35
Vital Pulp Therapy

3. Regenerative Endodontics
• Techniques used to control infection and regenerate vital tissues within the
pulp space of immature teeth for the purpose of promoting maturation of
the root.
• Also known as: Revascularization or revitalization.
• Indications:
1. Pulp necrosis or irreversible pulpitis.
AND
2. Immature tooth.
36
• If the diagnosis is irreversible pulpitis or pulpal necrosis, the
appropriate treatment is determined by the degree of root
development. If root development is complete and the apex is
closed, conventional root canal therapy can be performed. However,
when root development is incomplete, root-end closure must be
induced before obturation. Alternatively, a regenerative procedure
may be used, such as revascularization/revitalization of the pulp
tissue.
37
CAD/CAM Complete Dentures

• It is difficult to obtain impressions for complete dentures using
intraoral scanners:
• Intraoral scanners do not accurately capture soft tissues.
• Inability to perform border molding movements.
• An impression for a complete denture is made using a conventional
technique (custom tray and impression material), and the impression is
then scanned.
• The denture is then designed and fabricated using the CAD/CAM
software.
38
Step 1: Primary impressions for custom tray fabrication
39

Step 2: Secondary impression. The secondary impression is then
scanned and wax occlusal rims are fabricated.
40
Virtual Master Casts
41

Step 3: Recording midline, interocclusal relationships, selecting the
VDO, extraoral images taken for the patient (for digital smile design),
selecting size and shade of teeth.
42
Step 4: Interocclusal records are scanned and used to correlate the
maxillary and mandibular arches to one another.
43

Step 5: Digital teeth setting.
44
Step 6: Trial dentures are fabricated and
tried in the patient’s mouth to check
esthetics, vertical dimension, phonetics,
occlusion.
Any adjustments to the denture may be
made to the trial denture. If the trial
denture is adjusted, the trial denture is
scanned and sent for milling of the final
denture.
If no adjustments → send for milling.
45

Step 7: Denture Delivery.
46
How are the dentures fabricated?
• The dentures may be 3D-printed or milled.
47

Milling: The denture base and teeth are milled separately and then
bonded to each other.
48
3D Printing: The denture base and teeth are 3D-printed separately then
bonded to each other.
49

3D Printing: The entire denture is 3D-printed in 1 unit and then pink
composite is placed on the denture flange to mimic the shade of the
gingiva.
50
Little, J., Falace, D., Miller, C.S., Rhodus, N.L. (2018). Dental
management of the medically compromised patient. (9th ed.)
St. Louis: Elsevier Mosby.
• Oral complications of poorly controlled diabetes mellitus may
include xerostomia; bacterial, viral, and fungal infections (including
candidiasis); poor wound healing; increased incidence and severity
of caries; gingivitis and periodontal disease; periapical abscesses;
and burning mouth symptoms. Oral findings in patients with
uncontrolled diabetes most likely relate to excessive loss of fluids
through urination, altered response to infection; microvascular
changes; and, possibly, increased glucose concentrations in saliva.
51
CAD/CAM
• Note on onlays:
• It is preferrable not to create a margin (or ferrule) → a butt-joint margin with just reduction of
the cusp is preferred (see below)
Sharp line angles may lead to

overmilling.
52
Proffit, W.R. (2018). Contemporary orthodontics.
(6th ed.) St. Louis: Elsevier Mosby.
• The working bite, the jaw position to which the appliance is
assembled, is the same for fixed and removable functional
appliances. It is obtained by advancing the mandible to move the
condyles out of the fossa and establishing the desired vertical
opening.
• Unless an asymmetry is to be corrected, the mandible should be
advanced symmetrically so that the pretreatment midline
relationships do not change appreciably. We recommend a 4- to 6-
mm advancement and a 3- to 4-mm vertical opening, but always
one that is comfortable for the patient and does not move the
incisors past an edge-to-edge incisor relationship.
53
54
Preventative regimen for high risk (<6 years old)
toothpaste (1,200-1,500 ppm), consume water with optimal fluoride level (alternatively, take
fluoride supplement with fluoride- deficient water supplies), fluoride varnish every 3
months), sealant applied to primary molars, SDF.
- Therapeutic measures: active surveillance for non-cavitated, restore cavitated or enlarging
lesions, ITR can be used until permanent restorations can be placed.
- For patients <6 years: No prevident, No APF gel, No gum (<4 years), No CHx mouthrinse, No Fl rinses in
general
55
Preventative regimen for high risk (mixed dentition)

toothpaste (1,200-1,500 ppm), prevident 5000 ppm at bedtime, consume water with optimal
fluoride level (0.7ppm), fluoride varnish every 3 months), sealant applied to primary +
permanent molars, SDF, xylitol 6-10 gm/day, 0.12% CHx mouth rinse, Fl mouth rinse.
56
Preventative regimen for high risk (permanent
dentition before 3rd molar eruption)
fluoride level (0.7ppm), fluoride varnish every 3 months), sealant applied to permanent
molars, SDF, xylitol 6-10 gm/day, 0.12% CHx mouth rinse, Fl mouth rinse.
57
Preventative regimen for high risk (permanent

dentition after 3rd molar eruption)
fluoride level (0.7ppm), fluoride varnish every 3 months), sealant applied to permanent
molars, SDF, xylitol 6-10 gm/day, 0.12% CHx mouth rinse, Fl mouth rinse.
- Therapeutic measures: active surveillance for non-cavitated, restore cavitated.
58
Malamed, S.F. (2015). Medical emergencies in the dental
office. (7th ed.) St. Louis: Elsevier Mosby.
• In most instances of CVA and
TIA, the victim remains
conscious.
• A conscious patient reporting
the aforementioned signs and
symptoms should be placed in
a comfortable position; most
such patients prefer sitting
upright or semiupright.
59
Malamed, S.F. (2015). Medical emergencies in the dental

office. (7th ed.) St. Louis: Elsevier Mosby.
• The unconscious victim should be placed supine with the feet elevated
slightly. Minor alterations in this position may be indicated later.
• When the unconscious patient’s blood pressure is markedly elevated, the
position should be altered slightly from the normally recommended
supine position for unconscious patients. Because of the increase in
cerebral blood flow in the supine position and the markedly elevated
blood pressure observed in what is likely a hemorrhagic CVA, the patient
should be placed in a semi-Fowler position, an almost-supine position
with the head and chest elevated slightly. This new position must still
allow for the maintenance of a patent airway and ventilation, if
necessary. If cardiac arrest ensues and cardiopulmonary resuscitation
becomes necessary, the patient must be repositioned into the supine
position with their feet elevated
60
Neville, B.W. (2016). Oral & maxillofacial pathology.
(4th ed.) Philadelphia; Toronto: W.B. Saunders.
• The oral melanotic macule occurs over a
broad age range, with an average age at
diagnosis of 43 years and a 2 : 1 female-to-
male ratio. The lower lip vermilion is the
most commonly involved site (33% of
cases), followed by the buccal mucosa,
gingiva, and palate. Rare examples have
been reported on the tongue in newborns.
• The common blue nevus may affect any
cutaneous or mucosal site, but it has a
predilection for the dorsa of the hands and
feet, the scalp, and the face. Mucosal
lesions may involve the oral mucosa,
conjunctiva, and, rarely, sinonasal mucosa.
Oral lesions almost always are found on the
palate.
61
Hupp, J., Ellis, E., Tucker, M. (2018). Contemporary oral and

maxillofacial surgery. (7th ed.) St. Louis: Elsevier Mosby.
Edema
• Some oral surgical procedures result in a certain amount of edema or swelling after
surgery.
• Routine extraction of a single tooth will probably not result in swelling that the patient
can see, whereas the extraction of multiple impacted teeth with reflection of soft tissue
and removal of bone may result in moderately large amounts of swelling.
• Swelling usually reaches its maximum 36 to 48 hours after the surgical procedure.
• Swelling begins to subside on the third or fourth day and is usually resolved by the end
of the first week.
• Increased swelling after the third day may be an indication of infection rather than
renewed postsurgical edema.
62
Procedural Mishaps
During Cleaning and Shaping
5. Root Canal Perforation
Prognosis of treating perforations depends on location and size of the perforation.
Roots may be perforated at different levels:
• Coronal.
• Midroot (lateral).
• Apical.
The more coronal the perforation, the worse the prognosis.
63
Procedural Mishaps
During Access Preparation
Lateral Root Perforation
Above Level of Crestal Bone Below Level of Crestal Bone (Coronal 1/3 of
• Favorable prognosis. root)
• Can be repaired (amalgam, composite, GIC). • Very poor prognosis.
• Raising a flap and/or Periodontal curettage may • Often results in periodontal pocket formation.
be necessary to place, remove and smoothen • Managed by positioning defect above level of
repair material. crestal bone.
• Via orthodontic extrusion (aesthetic zones) or
crown lengthening (non-aesthetic zones).
• Internal repair by MTA.
64
Teeth with perforations below the crestal bone in the coronal third of
the root generally have the poorest prognosis. Attachment often
recedes, and a periodontal pocket forms, with attachment loss
extending apically to at least the depth of the defect.
65
management of the medically compromised patient. (9th ed.)
St. Louis: Elsevier Mosby.
66
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4921779/#:~:text=Thyroid%20cancer%20is%20the%2
0second%20most%20common%20malignancy%20during%20pregnancy,risk%20factors%20for%20thyr
oid%20cancer.
• Women are affected by thyroid cancer more than men as female to

male ratio may reach to 3–1. Thyroid cancer is the second most
common malignancy during pregnancy, preceded only by breast
cancer with an incidence of 14 per 100,000 live births.
• History of exposure to ionizing radiation, and iodine deficiency are
well established risk factors for thyroid cancer.
67
Resnik, R. (2019). Misch’s Contemporary

implant dentistry. (4th ed.) St. Louis: Mosby.
• There is no direct contraindication for dental implants in patients
who have RA. Because of the lack of mobility and dexterity, a fixed-
implant restoration is indicated. Special attention should be given
to the treatment medications because immunosuppressive,
glucocorticoid therapy and biologics may contraindicate implant
treatment.
• Dexamethasone has been reported to induce immunosuppression
when prescribed for long periods, which could be a concern with
implant therapy.
68
Newman, M.G., et al. (2018). Carranza's clinical periodontology.
(13th ed.) Philadelphia: Elsevier/Saunders.
• Interestingly, the early colonizers are either independent of defined
complexes (A. naeslundii, A. oris) or members of the yellow
(Streptococcus spp.) or purple complexes (A. odontolyticus). The
microorganisms primarily considered secondary colonizers fell into the
green, orange, and red complexes. The green complex includes Eikenella
corrodens, A. actinomycetemcomitans serotype a, and Capnocytophaga
spp. The orange complex includes Fusobacterium, Prevotella, and
Campylobacter spp. The green and orange complexes include species
recognized as pathogens in periodontal and nonperiodontal infections.
The red complex consists of P. gingivalis, T. forsythia, and T. denticola.
This complex is of particular interest because it is associated with
bleeding on probing.
69

• Attachment and bone loss are associated with an increase in the
proportion of gram-negative organisms in the subgingival biofilm,
with specific increases in organisms known to be pathogenic and
virulent. Porphyromonas gingivalis, Tannerella forsythia, and
Treponema denticola, otherwise known as the red complex
bacteria, are frequently associated with ongoing attachment and
bone loss in chronic periodontitis. Development and progression of
chronic periodontitis may not depend on the presence of one
specific bacterium or bacterial complex alone.
70
• The complexes to the left
consist of species that are
thought to colonize the
tooth surface and to
proliferate at an early
stage.
• The orange complex
becomes numerically
dominant later; it is
thought to bridge the early
colonizers and the red
complex species, which
become numerically more
dominant during the later
stages of plaque
development.
71
Resnik, R. (2019). Misch’s Contemporary implant

dentistry. (4th ed.) St. Louis: Mosby.
• A smooth collar at the crest module may transmit shear forces to
the bone. Bone is strongest under compressive forces, 30% weaker
under tensile loads, and 65% weaker to shear forces. Bone may heal
to the smooth metal collar of the implant crest module from the
time of implant insertion to implant uncovery; but placed under
loading conditions, the weaker shear interface is more likely to
overload the bone. The first thread or a roughened surface
condition of the implant is where the type of force changes from
primarily shear to compressive or tensile loads. Therefore, in many
situations the 35% to 65% increase in bone strength, through
changes from shear to compressive and/or tensile loads, is sufficient
to halt the bone loss process.
72
Carr, A.B., Brown, D.T. (2016). McCracken's removable partial
prosthodontics. (13th ed.) St. Louis: Elsevier.
Abutment preparations on sound enamel or on existing restorations that
have been judged as acceptable should be done in the following order:
1. Proximal surfaces parallel to the path of placement should be prepared
to provide guiding planes.
2. Tooth contours should be modified, lowering the height of contour so
that (a) the origin of circumferential clasp arms may be placed well
below the occlusal surface, preferably at the junction of the middle and
gingival thirds; (b) retentive clasp terminals may be placed in the gingival
third of the crown for better esthetics and better mechanical advantage;
and (c) reciprocal clasp arms may be placed on and above a height of
contour that is no higher than the cervical portion of the middle third of
the crown of the abutment tooth.
73

prosthodontics. (13th ed.) St. Louis: Elsevier.
3. After alterations of axial contours are accomplished and before rest seat preparations
are instituted, an impression of the arch should be made in irreversible hydrocolloid
and a cast formed in a fast-setting stone. This cast can be returned to the surveyor to
determine the adequacy of axial alterations before proceeding with rest seat
preparations. If axial surfaces require additional axial recontouring, this can be
performed during the same appointment and without compromise.
4. Occlusal rest areas should be prepared that will direct occlusal forces along the long
axis of the abutment tooth. Mouth preparation should follow the removable partial
denture design that was outlined on the diagnostic cast at the time the cast was
surveyed and the treatment plan confirmed. Proposed changes to abutment teeth
should be made on the diagnostic cast and outlined in colored pencil to indicate the
area, amount, and angulation of the modification to be done. Although occlusal rest
seats may also be prepared on the diagnostic cast, indication of their location in
colored pencil is usually sufficient for the experienced dentist because rest
preparations follow a definite pattern.
74
RCDSO IPAC Standard
For offices using municipal or communal water supplies:
• Waterline heaters must not be used, as the heat encourages the growth of
microorganisms.
• All waterlines must be purged at the beginning of each workday by flushing them
thoroughly with water for a minimum of 2 minutes. Before purging is carried out,
handpieces, air / water syringe tips and ultrasonic tips must be removed from the
waterlines.
• Handpieces using water coolant must be run for a minimum of 20 seconds after
patient care in order to purge all potentially contaminated air and water. The
handpiece is then removed and, following cleaning and disinfection of clinical contact
surfaces, another sterilized handpiece may be attached for use with the next patient.
• Sterile water or sterile saline should be used when irrigating open surgical sites and
whenever bone is cut during invasive surgical procedures. Appropriate devices, such as
bulb syringes or single-use disposable products, should be used to deliver sterile
irrigation solutions.
75

Intrusion of Posterior Teeth to Close Anterior Open Bite.
• Most patients with anterior open bite have elongation of the maxillary and/or
mandibular posterior teeth, so the mandible is rotated downward and backward.
• The maxillary incisor segment often is reasonably well positioned relative to the upper
lip.
• Extrusion of the upper incisors to close the bite in a patient with this issue is neither
esthetically acceptable nor stable.
• Intrusion of the maxillary posterior segments so that the mandible can rotate
upward and forward is the ideal approach to treatment.
• This was essentially impossible until segmental maxillary surgery was developed in the
early 1970s so that the maxillary posterior segments could be moved upward. Skeletal
anchorage to intrude the posterior teeth has the potential to create the same
mandibular response. This now makes orthodontic intrusion a possible alternative to
surgery, at least for patients with the less severe long-face problems.
76
77
Management of the Medically Compromised

Table 9.3 Management of Hypoglycemia (Insulin Shock).
Signs and Symptoms Management
• BG < 3.0 mmol/L – Normal Range 5-7. • Conscious patient: • Unconscious patient or having
• Hunger, nausea. a seizure:
• Weakness, headache. • Place patient in an upright or • Place patient in a supine
• Rapid weak pulse (tachycardia). semi-upright position. position.
• Sweating, shaking, irritability. • Give a drink with high sugar. • Call 911.
• Slurred speech. • Monitor vital signs. • Head tilt/Chin lift.
• Pallor and piloerection. • Oxygen.
• Paresthesias. • 50% dextrose IV OR glucagon 1
• Tonic-clonic movement (seizures). mg SC or IM (or IV)
• Changes in mood or behavior. • Monitor vital signs.
• Hypotension. • If dextrose or glucagon are
• Hypothermia. unavailable → Administer 0.5
• Increased anxiety. mg of 1:1000 epinephrine SC
• Skin: cold and wet. or IM and repeat every 15
• Uncooperativeness. minutes.
• Loss of consciousness.
• increase in gastric motility.
• diminished cerebral function.
78
79
80
81

(13th ed.) Philadelphia:Elsevier/Saunders.
• Several local HMTs have been investigated for use as adjuncts to

surgical procedures to improve wound healing and stimulate
regeneration of lost bone, periodontal ligament, and cementum,
restoring the complete periodontal attachment apparatus. They
include enamel matrix proteins, bone morphogenetic proteins (e.g.,
BMP-2, BMP-7), growth factors (e.g., platelet-derived growth factor,
insulin-like growth factor), and tetracyclines.
82
MC2825346/
• Emdogain® (enamel matrix derivative, EMD) is well recognized in
periodontology, where it is used as a local adjunct to periodontal
surgery to stimulate regeneration of periodontal tissues lost to
periodontal disease. The biological effect of EMD is through
stimulation of local growth factor secretion and cytokine expression
in the treated tissues, inducing a regenerative process that mimics
odontogenesis. The major (>95%) component of EMD is
Amelogenins (Amel).
83
84
85
Procedural Mishaps
During Cleaning and Shaping Zipping
4. Zipping/Apical Transportation
• Zipping/Apical Transportation: A tear-drop shape that
may be formed in the apical foramen during
preparation of a curved canal when a file extends
through the apical foramen and subsequently
transports that outer wall; a procedural error that
complicates cleaning and obturation.
• Similar to ledge formation.
• Occurs at the apex.
• Tear-drop shaped defect.
• Caused by using large, stiff, files up to the working
length.
• If instrumentation is continued, it will lead to zipping
with apical perforation. Zipping with
apical
2023 Prep Doctors | All rights reserved perforation
86
• Apical transportation and zipping occur when relatively inflexible
files are used to prepare curved canals. The restoring force of the
file (the tendency to return to the original straight shape of the file)
exceeds the threshold for cutting dentin in a curved canal. When
this apical transportation continues with larger and larger files, a
teardrop shape develops, and apical perforation can occur on the
lateral root surface
87
88
AAPD Definition of Dental Home
• The dental home is the ongoing relationship between the dentist
and the patient, inclusive of all aspects of oral health care delivered
in a comprehensive, continuously accessible, coordinated, and
family-centered way. The dental home should be established no
later than 12 months of age to help children and their families
institute a lifetime of good oral health. A dental home addresses
anticipatory guidance and preventive, acute, and comprehensive
oral health care and includes referral to dental specialists when
appropriate.
89
Types of Tissue Necrosis

Liquefactive necrosis:
• Usually associated with bacterial, viral, parasitic or fungal infections.
• Liquefactive necrosis forms a viscous liquid mass as the dead cells are being digested. The micro-organisms
can release enzymes to degrade cells and initiate an immune and inflammatory response. Cellular
dissolution and digestion of dying cells may also release further enzymes, which speeds up the liquefying
process.
• The micro-organisms stimulate the leukocyte to home-in on the necrotic area and release powerful
hydrolytic enzymes (such as lysozymes) which causes local damage and cells to be lysed, causing a fluid
phase. The enzymes responsible for liquefaction are derived from either bacterial hydrolytic enzymes or
lysosomal hydrolytic enzymes. These are proteases (collagenases, elastases), DNases and lysosomal
enzymes.
• A creamy yellow liquid should be present as lots of leukocytes are found to be dead, this is generally called
pus.
• Gross appearance: liquid-like layer can be seen; pus should be present. Yellowing, softening or swelling of
the tissue should be seen. Malacia (softening, or loss of consistency) should be present.
90
Coagulative necrosis
• Generally occurs due to an infarct (lack of blood flow from an obstruction
causing ischemia) and can occur in all the cells of the body except the
brain.
• The heart, kidney, adrenal glands or spleen are good examples of organs
that may undergo coagulative necrosis.
• Cells that undergo coagulative necrosis can become dry, hard, and white.
• Coagulation occurs as the proteins are degraded and denatured, and an
opaque film starts to form.
• Gross appearance: a pale segment may be seen in contrast to
surrounding healthy tissues. The segment may be hard to the touch.
91

Caseous necrosis:
• Occurs when the immune system and body cannot successfully remove the
foreign noxious stimuli.
• For example, tuberculosis is a prime example where there is an aberrant
immune response (such as the alveolar macrophages are not responding
correctly) to the bacteria as the bacteria has infected the macrophages.
• The immune system seals off the foreign matter by using fibroblasts and white
blood cells such as lymphocytes, neutrophils, NK cells, dendritic cells and
macrophages. A granuloma may form with fibroblast cells (which creates an
encasing layer), leukocytes and the formation of Langerhans giant cells (fusion
of epithelioid cells).
• The organism is not killed but rather contained.
• Gross appearance: a yellow-white soft cheesy sphere that is enclosed by a
distinct border.
92
Gangrenous necrosis:
• Does not demonstrate a specific pattern of cell death but is preferably used in clinical
practice to describe the condition.
• Generally describes the damage that has occurred to the extremities (especially lower)
where there is severe ischemia.
• These extremities lack in blood supply and oxygen and typically cause coagulative
necrosis at different tissue planes (this is also called dry gangrene). Severe frostbite
injuries can lead to dry gangrene.
• If bacterial infection occurred, liquefactive necrosis could also be occurring due to the
degrading enzymes and the involvement of the leukocytes. When liquefactive necrosis
is present, the term ‘wet’ gangrene is used.
• Gross appearance: black skin is generally seen with a degree of putrefaction (the
process of decay or rotting in a body or other organic matter). The tissues may look
‘mummified’.
93
Neville, B.W. (2016). Oral & maxillofacial pathology. (4th

ed.) Philadelphia; Toronto: W.B. Saunders.
• Clinical Features:
• Inflammatory odontogenic cyst.
• Most common: mandibular first molar.
• Pathogenesis: unknown.
• Some of these lesions have been associated with teeth that demonstrate
buccal enamel extensions into the bifurcation area.
• Typically occurs in children from 5 to 13 years of age.
• Slight-to-moderate tenderness.
• Clinical swelling and a foul-tasting discharge.
• Pocket formation.
• May be associated with proliferative periostitis (onion-skin reaction).
• Unilateral or bilateral (bilateral in 1/3 of patients).
94
• Radiographic Appearance:
• Well-circumscribed unilocular radiolucency involving the buccal
bifurcation and root area of the involved tooth. 1.2-2.5 cm in size.
• An occlusal radiograph is most helpful in demonstrating the buccal
location of the lesion. The roots of the molar are displaced towards the
lingual surface.
95

• Histology:
• Lined by nonkeratinizing stratified squamous epithelium with areas of
hyperplasia. A prominent chronic inflammatory cell infiltrate is present
in the surrounding connective tissue wall.
• Treatment:
• Enucleation (removal of involved tooth is not necessary).
• Within 1 year of surgery, there is usually complete healing with
normalization of periodontal probing depths and radiographic evidence
of bone fill.
96
Walton, R.E., Torabinejad, M., Fouad, A.J. (2015).
Endodontics: principles and practice. (5th ed.) New
York: Elsevier.
• With irreversible pulpitis, the teeth most difficult to anesthetize are
the mandibular molars, followed in order by the mandibular and
maxillary premolars, maxillary molars, mandibular anterior teeth,
and maxillary anterior teeth. The vital inflamed pulp must be
instrumented and removed. Also, pulpal tissue has a very
concentrated sensory nerve supply, particularly in the pulp chamber.
These factors, combined with others related to inflammatory effects
on sensory nerves and failures that occur with conventional
techniques, make anesthetizing patients with painful irreversible
pulpitis a challenge.
97
98
Fonseca, R., Marciani, R., Turvey, T. (2017). Oral and
maxillofacial surgery. (3rd ed.) Saunders.
Platform Switching
This concept refers to the inward horizontal
repositioning of the implant abutment junction so that
it is positioned away from the outer edge of the
implant and adjacent bone.
Lazzara and Porter introduced the concept by using
standard diameter components on wide platform
implants. They found a reduction of the expected
post-restoration crestal bone remodeling in
comparison to the “standard” implants.
There are multiple theories as to why the platform-
switching concept works.
99

Platform Switching
The Biomechanical Theory
• Connecting the implant to a smaller diameter abutment may limit bone
resorption by shifting the stress concentration zone away from the crestal
bone–implant interface and directing the forces of occlusal loading along
the axis of the implant.
The Biologic Width Theory
• Shifting the implant-abutment connection may medialize the location of the
biologic width and minimize the marginal bone resorption. Placing the IAJ at
or below the crestal bone level may cause vertical bone resorption to
reestablish the biologic width.
100
Platform Switching
The Inflammation at IAJ Theory
• This theory postulates that bone resorption is caused by an inflammatory
infiltrate at the IAJ.
• The presence of periimplant microbiota was suggested to influence the
crestal bone resorption by maintaining the inflammatory cell infiltrate at the
IAJ.
• The physical repositioning of the IAJ away from the outer external edge of
the implant and neighboring bone may limit bone resorption by containing
the inflammatory cell infiltrate within the angle formed at the interface
away from the adjacent crestal bone.
101
Hupp, J., Ellis, E., Tucker, M. (2018). Contemporary

oral and maxillofacial surgery. (7th ed.) St. Louis:
Elsevier Mosby.
• The two types of ranulas are the simple ranula and the plunging ranula.
• The simple ranula is confined to the area occupied by the sublingual
gland in the sublingual space, superior to the mylohyoid muscle.
• The progression of a simple ranula to a plunging ranula occurs when the
lesion extends through and below the level of the mylohyoid muscle
into the submandibular space.
• Ranulas may reach a larger size than mucoceles because their overlying
mucosa is thicker, and they occur less commonly because trauma that
would cause their formation is less likely in the anterior floor of the
mouth.
• As a result, a plunging ranula has the potential to extend through the
mylohyoid muscle into the neck and compromise the airway, resulting in
a medical emergency.
102
103
Ingle, J.I., Bakland, L., et al. (2015). Ingle’s

endodontics. (7th ed.) Hamilton: BC Decker Inc.
• Despite their relative effectiveness, studies have shown that the
accuracy of EALs may be affected by immature apices,
retreatment, calcified or blocked canals as well as severe
hemorrhage and inflammatory exudate into the canals. The
accuracy of EALs may also decrease as the size of the apical
diameter increases. For best results, a master cone radiographic
control should be taken to minimize possible errors. EAL reading can
also be affected by contact between the file and metallic
restorations and materials.
104
Hargreaves, K.M., Berman, L. (2016). Cohen’s pathways
of the pulp. (11th ed.) St. Louis: Elsevier.
• Some investigators have found no statistical difference between
roots with vital and necrotic tissue. Because apical root resorption is
prevalent in necrotic cases with longstanding apical lesions, it may
be concluded that apical resorption does not have a significant
effect on the accuracy of electronic apex locators.
105
Osteoplasty/Ostectomy
Osteoplasty refers to reshaping the bone without removing tooth-supporting bone.
Ostectomy, or osteoectomy, includes the removal of tooth-supporting bone.
→These procedures are best applied to patients with early to moderate bone loss
(2 to 3 mm) with moderate-length root trunks that have bony defects with one or
two walls.
→These shallow to moderate bony defects can be effectively managed by
osteoplasty and ostectomy.
→Patients with advanced attachment loss and deep intrabony defects are not
candidates for resection to produce a positive contour. To simulate a normal
architectural form, so much bone would have to be removed that the survival of
the teeth could be compromised.
106
Studies have consistently indicated that a deeper defect is correlated
with increased clinical attachment level and probing depth. One is
more likely to achieve improved regenerative results when the osseous
defects are narrow, circumferential, and with a three- or two-walled
configuration. Conversely, a wide osseous lesion with one wall or no
wall is less amenable to regenerative procedures. Even with the use
of iliac and autologous grafts, current regenerative approaches have
not been successful in regenerating one- or zero-walled osseous
defects.
107
108
York: Elsevier.
• The commonly accepted guideline is that the root filling should be
replaced if it is exposed to oral fluids for more than 2 to 3 months.
However, if the root filling has been performed to a high technical
standard and periapical pathology is absent, it may be sufficient to
replace the lost or leaking restoration rather than the entire root
filling.
109
Adhesive Dentistry
Dentin Bonding
Dentin bonding systems consist of: acid etchant, primer, and bonding
agent (adhesive).
Smear layer:
• Organic and inorganic debris that results from tooth
preparation.
• Occludes the orifices of dentin tubules forming “smear plugs”.
• Must be removed or chemically modified to permit resin
bonding to the underlying dentin.
• Removal of the smear layer by acid etching results in
“opening” of the dentinal tubules → fluid in the dentinal
tubules will exit the tubule onto the surface of dentin → this
fluid is hydrophilic, and the bonding agent and composite are
hydrophobic → primer resolves this issue.
110
Adhesive Dentistry
Dentin Bonding
Acid etchant: removes smear layer and demineralizes the calcified Composite
tissue.
Primer: Allows interface formation between hydrophilic dentin and Bonding Agent
hydrophobic bonding agent.
• Note: Etching dentin results in reduced surface energy of dentin
(opposite to what is seen with enamel). The primer will increase the Hybrid Layer
surface energy of dentin so that the bonding agent can be applied.
• In enamel, primer is not needed because the surface energy after
etching is increased, so bonding agent may be applied directly.
Bonding agent: Bonds the composite to the primed tooth surface.
When primer and bonding resin are applied to etched dentin, they
penetrate the: Resin Tag
• Intertubular dentin forming a resin–dentin hybrid layer.
• Open dentinal tubules forming resin tags.
111
Adhesive Dentistry
Dentin Bonding
Dentin should not be dried aggressively after
acid etching and rinsing:
• Aggressive drying may cause outward
movement of fluid in the tubules resulting
in displacement of odontoblasts into the
tubules.
• Aggressive drying will cause collapse of the
collagen framework, which will make it
difficult for bonding agent to impregnate
between the collagen fibers → weaker
hybrid layer.
112
Adhesive Dentistry
Dentin Bonding
Bonding to dentin is affected by remaining sound dentin thickness.
Bonding is less predictable in deeper cavities.
• Dentin close to the pulp has wider dentinal tubules (less intertubular dentin) → less hybrid
layer formation → less predictable bonding.
113

York: Elsevier.
Root canal Lubricants:
• Advantage to paste lubricants is that they can suspend dentinal debris and
prevent apical compaction.
• One proprietary product consists of glycol, urea peroxide, and EDTA in a special
water-soluble base. It has been demonstrated to exert antimicrobial action.
• Another type is composed of 19% EDTA in a water-soluble, viscous solution.
• A disadvantage of these EDTA compounds appears to be the deactivation of
NaOCl by reducing the available chlorine and potential toxicity.
• The addition of EDTA to the lubricants has not proved effective. In general, files
remove dentin faster than the chelators can soften the canal walls.
• When nickel-titanium rotary techniques are used, aqueous solutions (e.g.,
NaOCl), rather than paste lubricants, should always be present in the root
canal to reduce torque.
114
Speech Considerations with Complete
Dentures
• Speech sounds in the complete denture patient:
• LABIODENTAL SOUNDS:
• The labiodental sounds f and v are made between the upper
incisors and the labiolingual center to the posterior third of the
lower lip.
• If the upper anterior teeth are too short (set too high up), the v
sound will be more like an f. If they are too long (set too far
down), the f will sound more like a v
115
116
117

• Pleomorphic adenomas are best treated by surgical excision. For lesions
in the superficial lobe of the parotid gland, superficial parotidectomy
with identification and preservation of the facial nerve is recommended.
Local enucleation should be avoided because the entire tumor may not
be removed or the capsule may be violated, resulting in seeding of the
tumor bed. For tumors of the deep lobe of the parotid, total
parotidectomy is usually necessary, also with preservation of the facial
nerve, if possible. Submandibular tumors are best treated by total
removal of the gland with the tumor. Tumors of the hard palate usually
are excised down to periosteum, including the overlying mucosa.
• With adequate surgery the prognosis is excellent, with a cure rate of
more than 95%. The risk of recurrence appears to be lower for tumors of
the minor glands.
118
119
120
121
122
AFK Mock 3 References
Book 2
123
Ethics
Ethical Principles
• As health care professionals, dentists assume publicly-entrusted
responsibilities founded on the principle of:
• non-maleficence—first do no harm. Some of the many characteristics of being
an ethical dental professional are presented in the
• Autonomy: Patients have the right to determine what should be done with
their own bodies.
• Because patients are moral entities, they are capable of autonomous decision-
making. Respect for patient autonomy affirms this dynamic in the doctor-
patient relationship and forms the foundation for informed consent, for
protecting patient confidentiality, and for upholding veracity.
• The patient's right to self-determination is not, however, absolute. The dentist
must also weigh benefits and harms and inform the patient of contemporary
standards of oral health care.
124
Ethics
Ethical Principles
• Beneficence: often cited as a fundamental principle of ethics, is the obligation to
benefit others or to seek their good. While balancing harms and benefits, the dentist
seeks to minimize harms and maximize benefits for the patient. The dentist refrains
from harming the patient by referring to those with specialized expertise when the
dentist's own skills are insufficient.
• Justice: is often associated with fairness or giving to each his or her own due.
• Issues of fairness are pervasive in dental practice and range from elemental procedural
issues such as who shall receive treatment first, to complex questions of who shall
receive treatment at all.
• The just dentist must be aware of these complexities when balancing the distribution of
benefits and burdens in practice.
125
Ethics
Ethical Principles
• Veracity: often known as honesty or truth telling, is the bedrock of a trusting
doctor-patient relationship. The dentist relies on the honesty of the patient to
gather the facts necessary to form a proper diagnosis. The patient relies on the
dentist to be truthful so that truly informed decision-making can occur.
• Honesty in dealing with the public, colleagues and self are equally important.
126
Ethics
Legal aspects “Informed Consent“
• Any discussion about consent to treatment should take place before treatment. This
discussion needs to include information about the expected benefits of treatment; risks
and side effects; alternatives to the proposed treatment, including the likely result if no
treatment is done; materials to be used; any unique personal circumstances of the
patient; and fees to be charged. The dentist should ensure that he or she answers any
questions the patient may have.
• Professional, ethical and legal responsibilities dictate that a complete chart and record
documenting all aspects of each patient’s dental care be maintained. Patient records
must be well-organized, legible, readily accessible, and understandable. If the
practitioner of record were for any reason to become unable to practice, another
dentist should be able to easily review the chart and carry on with the care of the
patient.
127
Ethics
There is no age of consent relative to medical or dental treatment.
• It is the responsibility of the dentist to determine whether the patient is
capable of consenting to treatment and understanding the reasonably
foreseeable risks and consequences of the different treatment options and non-
treatment. Parents (legal guardians) may make consent decisions for minor
patients who are not capable of giving consent.
• Substitute decision-makers may make consent decisions for adults who are not
capable of giving consent because of their cognitive abilities.
128
Ethics
Who/what determines a patient’s capacity?
• No age of consent specified in the HCCA (an “age” may be prescribed in law for
other purposes)
• Capacity is assumed unless the practitioner has “grounds” to believe the patient
is incapable
• A “POA” (person who holds a Power of Attorney for Personal Care) or other SDM
(Substitute Decision Maker) cannot make decisions for a capable patient
• A capable patient is entitled to rely on others for “decision support”
• There is no legal provision for “shared decision making” and a capable person
cannot delegate treatment decisions to an SDM.
129
Ethics
Dentists should note that there is an age of majority (age 18) for entering into
contracts, including an agreement to pay for dental services.
• There is no minimum age for consent to treatment. A young teenager may be
perfectly capable of understanding and appreciating risks and can give consent.
If a teenager is capable of consenting to treatment in the dentist’s opinion, the
dentist should ask the patient for his/her consent to involve the parents in the
discussion regarding the cost of the different treatment options. This is
because the parents will be responsible for paying for the treatment. If the
teenager is not able to consent to treatment, the dentist must obtain the
parents’ consent to treatment, and their agreement to pay for treatment.
130
Ethics
Valid Informed Consent
Consent must relate to the treatment proposed, must be informed, voluntary, and cannot be
obtained by misrepresentation or fraud.
In order for consent to be informed and valid, patients, parents, legal guardians, or substitute
decision-makers must be provided with the following information during informed consent
discussions:
• The diagnosis or problem noted;
• The nature of the proposed treatment
• The expected benefits, material risks, side effects, and cost of the proposed treatment
• Alternative courses of action and risks, benefits, and costs associated with these
treatment options;
• The likely consequences of not proceeding the treatment, if any.
• The answers to any questions the patient asks, Whatever information the patient has
requested.
131
Ethics
• Dentists must take steps to ensure that the patient understands the information
being provided. This may mean, for example, using lay language.
• Where the dentist and the patient do not speak the same language, the dentist
must ensure that a translator is available to provide the patient with the
information in a language he/she can understand. The translator can be a dental
office staff member, or a friend, or family member of the patient.
• Visual aids or diagrams may also be helpful in such circumstances to ensure that
patients understand the dental treatment being proposed. If such aids are used,
document their use in the patient record.
132
Ethics
Consent to treatment is not required. If the health care practitioner presenting the
treatment believes:
• This is an emergency situation, where a delay in obtaining consent to treatment may
endanger a (minor or incompetent) patient’s life
• Patient can’t give or refuse consent to treatment due to lack of communication
(language barrier or disability)
• Reasonable steps in the present circumstances have been taken to facilitate ways of
communicating with the patient but were not possible.
• Waiting to find means of communication with the patient will result in prolonging the
patient suffering or will put him/her at risk of sustaining serious bodily harm
• No known reason to believe the patient is against the presented treatment
133
Ethics
• Who is responsible for obtaining the patient’s consent to treatment?
• Only the dentist may communicate a diagnosis as the cause of a patient’s
symptoms, as this is a controlled act under the Dentistry Act, 1991.
• In addition, it is only the dentist who has the knowledge to advise the
patient regarding the prognosis and risks of the different treatment
alternatives.
134
Ethics
Do I have to include fees in a discussion about informed consent for treatment?
• Yes, it is prudent to discuss a fee estimate or submit an insurance
predetermination. The cost of treatment (including whether the dental fees are
higher than the ODA suggested fee guide/not covered by the patient’s insurance
or dental benefits, how the deposit will be applied if the treatment is not
completed and whether additional payments will be required, and the terms of
payment/financial policies of the office) is a critical issue for many patients and
unfortunately may ultimately decide whether they proceed with treatment or
not. It should be clear to the patient whether or not the fees quoted include lab
fees, x-rays, etc.
135
Methotrexate is a folic acid antagonist that inhibits cytokine production

and purine nucleotide biosynthesis, leading to immunosuppressive and
anti-inflammatory effects. Response to methotrexate occurs within 3 to
6 weeks of starting treatment; it can also slow the appearance of new
erosions within involved joints.
The other DMARDs (Disease-Modifying Anti-Rheumatic Drugs) can be
added to methotrexate therapy if there is partial or no response to
maximum doses of methotrexate. Doses of methotrexate required for
RA treatment are much lower than those needed in cancer
chemotherapy and are given once a week, thereby minimizing adverse
effects. The most common side effects observed after methotrexate
treatment of RA are mucosal ulceration and nausea
136
Dowd, F., Johnson, B., Mariotti, A. (2016). Pharmacology
and therapeutics for dentistry. (7th ed.) Mosby Elsevier.
• Organic acids such as salicylate and probenecid inhibit the renal tubular
secretion of methotrexate, resulting in delayed drug clearance and toxicity.
• Penicillins can also compete with methotrexate for renal tubular secretion.
• In patients receiving high-dose methotrexate, the concurrent use of
nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided because this
drug class can also reduce renal blood flow and increase the risk of
nephrotoxicity.
• While the exact mechanism of the interaction is unknown, proton pump
inhibitors (PPIs) have also been shown to delay methotrexate clearance.
137
Indirect Retainers:
Definition: A part of a removable partial denture that
prevents rotational displacement of the denture about the
rests of the principal abutment teeth.
Indirect retainers usually take the form of rests, on the
opposite side of a fulcrum line. Vertical movements of distal
extension bases can occur in two directions. Movement of a
distal extension base toward the ridge tissues will be
proportionate to the displaceability of those tissues, the fit
of the denture base and the load applied. Movement of a
distal extension base away from the ridge tissues will occur
via either displacement of the entire denture (resisted by
the direct retainers), or a rotational movement about an
axis. This axis passes through rests of the most posterior
abutment teeth and is called the fulcrum line.
138
139
Fonseca, R., Marciani, R., Turvey, T. (2017). Oral and maxillofacial

surgery. (3rd ed.) Saunders.
An additional method of muscle relaxation is the use of botulinum
toxin A (Botox).103-105 Botulinum toxin A functions by inhibiting the
release of acetylcholine from cholinergic neurons, which decreases the
transmission of the neural stimulus to the muscle. Botulinum toxin A
has been used extensively to treat various dystonic syndromes. 106
Administration of botulinum toxin A requires direct injection into the
affected muscle. Most precise administration is accomplished with the
use of EMG-guided needles. Repeat dosing of botulinum toxin A is
delayed for approximately 6 months, giving time for the botulinum
toxin A to defuse from the acetylcholine receptors.
140
Okeson, J.P. (2019). Management of
temporomandibular disorders and occlusion. (8th
ed.) St. Louis: Elsevier Mosby.
Botox conclusion:
Patients with TMDs → botox is injected into the affected area (it can be
injected into any of the MoMs).
Patients with Bruxism→ botox is injected into the masseter
141
https://cpr.heart.org/
en/resuscitation-
science/cpr-and-ecc-
guidelines/algorithms
142
https://cpr.heart.org/
en/resuscitation-
science/cpr-and-ecc-
guidelines/algorithms
143
Malamed, S.F. (2019). Handbook of local

anesthesia. (7th ed.) St. Louis: Elsevier Mosby.
144
NADPH cytochrome P450 Oxidoreductase: Is an enzyme that plays a role in
the P450 system. Helps in the catalysis of the oxidation reduction reaction
Catechol-O-methyltransferase is an enzyme that degrades catecholamines

and various drugs and substances having a catechol structure.
Cytochrome b5 reductase is an enzyme in the blood. It controls the amount

of iron in red blood cells, and helps the cells carry the normal amount of
oxygen. Deficiency of this enzyme may lead to methemoglobinemia.
147
Dowd, F., Johnson, B., Mariotti, A. (2016).

Pharmacology and therapeutics for dentistry. (7th
ed.) Mosby Elsevier.
The metabolic inactivation of epinephrine and most injected
catecholamines (including norepinephrine) largely depends on COMT
because COMT is widely distributed throughout the body.
As with norepinephrine and epinephrine, dopamine is a substrate for
MAO and COMT.
148
149
Hyaline Cartilage: This is the most common type of cartilage and is found in various
locations, including the articular surfaces of joints, the rib cage, the nose, and the
trachea. Hyaline cartilage has a smooth and glassy appearance and provides
support, flexibility, and low-friction surfaces for joint movement.
Elastic Cartilage: Elastic cartilage contains elastic fibers in addition to collagen
fibers, making it more flexible and elastic than hyaline cartilage. It is found in
structures that require both support and elasticity, such as the external ear (pinna),
the epiglottis, and the Eustachian tube.
Fibrocartilage: Fibrocartilage is the toughest type of cartilage and contains a higher
concentration of collagen fibers than the other types. It is found in areas of the
body that require both support and resistance to compression and tension forces.
Examples of fibrocartilage locations include the intervertebral discs of the spine,
the pubic symphysis, and certain tendons (e.g., the knee menisci).
150
Pharmacology: Analgesics Doses for Orofacial Pain
Drug Adult Dose Daily Maximum
Nonopioids
Simple Analgesics
Acetaminophen 325-1000 mg Q4-6H po 4000 mg
NSAIDs
ASA 325-1000 mg Q4-6H po 4000 mg
Celecoxib 200 mg once daily to BID po 400 mg
Diflunisal 1000 mg x 1 dose po, then 500 mg Q12H 1500 mg
Etodolac 200-400 mg Q6-8H po 1200 mg
Floctafenine 200-400 mg Q6-8H po 1200 mg
Flurbiprofen 50-100 mg Q4-6H po 300 mg
Ibuprofen 400 mg Q4-6H po 2400 mg
Ketoprofen 25-50 mg Q6-8H po 300 mg
Ketorolac 10 mg Q4-6H po 40 mg
Naproxen 500 mg x 1 dose po, then 250 mg Q6-8H 1250 mg
Naproxen sodium 550 mg x 1 dose po, then 275 mg Q6-8H 1375 mg
Opioids
Codeine 30-60 mg Q4-6H po
Oxycodone 5-10 mg Q4-6H po
Pediatric Dose
Acetaminophen 10-15 mg/kg Q4-6H po 65 mg/kg or 2600 mg
Codeine 0.5-1 mg/kg Q4-6H po 3 mg/kg
Ibuprofen 10 mg/kg Q6-8H po 40 mg/kg or 2400 mg
151
• The main function of chemokines is the attraction of neutrophils. Chemokines play a

crucial role in recruiting and guiding neutrophils to sites of infection, inflammation, or
tissue damage. Neutrophils are a type of white blood cell that are important in the
initial response to infection and play a key role in the innate immune system's defense
against pathogens.
• While chemokines can also contribute to the activation of macrophages and T-cells,
their primary function is to attract and guide the migration of neutrophils. Chemokines
help create concentration gradients that direct neutrophils to the specific locations
where their actions are needed, allowing for an efficient immune response.
• Vasodilation is not considered the main function of chemokines. While chemokines can
indirectly influence vasodilation through the release of other molecules during
inflammation, their primary role lies in leukocyte recruitment rather than directly
causing vasodilation.
152
Open bite on the unaffected side
153
Motor Innervation
Vagus nerve (X):
The vagus nerve has several fibers that innervate the striated muscles of the
larynx and pharynx; there are two exceptions: the stylopharyngeus muscle (CNIX)
and the tensor veli palatini muscle (V3).
The vagus nerve innervates one muscle of the tongue: palatoglossus muscle–its
function is to elevate the posterior portion of the tongue.
The external branch of the superior laryngeal nerve supplies the cricothyroid
muscle.
The pharyngeal branches of the vagus supply: levator veli palatini,
salpingopharyngeus, palatopharyngeus, and the uvula.
Recurrent laryngeal nerves innervate the intrinsic muscles of the larynx, except the
cricothyroid muscle (the external branch of the superior laryngeal nerve)
154
Vagus nerve input to the laryngeal muscle is necessary for proper
swallowing and speech. Vagal nerve injuries can limit vocal nerve
function, affecting the voice including pitch quality and power.
Symptoms of vagopathy (vagus nerve dysfunction) affecting the larynx
can be chronic coughing, difficulty swallowing, hoarseness, and loss of
singing voice power.
155
Motor Innervation
Trigeminal n. (V)→ Muscles of mastication (masseter, temporalis, and
the lateral and medial pterygoids ), tensor veli palatini, mylohyoid,
tensor tympani, and the anterior portion of the digastric muscle.
Facial n. (VII)→ Muscles of facial expression, the stapedius muscle, the
stylohyoid muscle, and the posterior belly of the digastric muscle.
Glossopharyngeal n. (IX)→ The stylopharyngeus muscle, which is
responsible for elevating the pharynx and larynx.
Hypoglossal n. (XII)→ extrinsic muscles of the tongue (genioglossus,
hyoglossus, styloglossus) and intrinsic muscles of the tongue.
156
Tumors of the post-styloid compartment may show disability of cranial
nerves IX and X (decreased gag reflex, aspiration); cranial nerve X
alone, which would manifest as asymmetric palate elevation,
hoarseness, and dysphagia; and cranial nerve XI, which would manifest
as weakness of the trapezius muscle. An affected cranial nerve XII
would manifest as atrophy and paresis of the tongue.
157
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC613136
3/
The anti-anaphylactic effect of adrenaline/epinephrine is primarily due to the
stimulation of alpha and beta receptors. The alpha-adrenergic receptors are
responsible for vasoconstriction in the area of the precapillary arterioles of the
skin, mucosa, and kidneys and smooth muscle contraction in the venous vascular
bed, which results in increases in peripheral vascular resistance and blood
pressure. Subsequently, any tissue edema that has developed as a result of the
increased vascular permeability reduces (29). Concomitantly,
adrenaline/epinephrine dilates via beta-2 adrenergic receptors the bronchi and
vasculature especially in the skeletal muscles.
Stimulation of the beta-adrenergic receptors increases the heart rate and
contractility of the cardiac muscle while simultaneously expanding the coronary
arteries. The result is an increased output of the heart, accompanied by increased
oxygen consumption. Increased cardiac output in turn raises the systolic blood
pressure. At higher concentrations and with rapid administration (for example, if
given intravenously), adrenaline/epinephrine can have an arrhythmogenic effect.
158
Basic Concepts:
By definition, Surgical exodontia requires one or more of the following steps:
1. Elevation of a mucoperiosteal flap
2. Bone removal
3. Sectioning of the tooth
Flap Design
In surgical exodontia, a full-thickness mucoperiosteal flap is used to expose the underlying tooth or root fragment and its surrounding alveolar
bone. Careful consideration must be given to the position of the incisions and to the type and shape of the flap.
Bone Removal
In some cases, surgically exposing the crestal bone and the remaining tooth structure provides all the access needed to elevate the tooth
without further bone removal. More often, some amount of alveolar bone must be removed to expose the underlying tooth and provide
purchase for its removal. This is usually done with a dental burr in a surgical drill under constant irrigation (Figure 21-10, A). If the cortical bone
is thin, a rongeur may be used.
Sectioning and Removal of Multi-Rooted Teeth
When removing multi-rooted teeth, the surgeon may gain considerable advantage by dividing the tooth so that each root may be removed
separately. While unnecessary as a routine step, this is commonly necessary in cases with unusually dense alveolar bone, divergent or curved
dental roots, when care must be taken to preserve the maximum alveolar bone, or where excessive force applied to remove the tooth intact
would risk damage to adjacent teeth or structures.
159
management of the medically compromised patient. (9th
• A major manifestation of Parkinson disease is resting tremor (that is attenuated during
activity), muscle rigidity, slow movement (bradykinesia, shuffling gait), and facial
impassiveness (mask of Parkinson disease).
• The tremor, which is rhythmic and fine and is best seen in the extremity at rest, produces a
“pill-rolling rest tremor” and handwriting changes.
• Cogwheel-type rigidity (decreased arm swing with walking and foot dragging), stooped
posture, unsteadiness, imbalance (gait instability), and falls also are common features.
• In addition, pain, (musculoskeletal, sensory [burning, numbness, tingling] or akathisia—
subjective feeling of restlessness—restless leg syndrome), orthostatic hypotension, and
bowel and bladder dysfunction occur in approximately 50% of patients.
• Cognitive impairment of memory and concentration occurs to a variable degree, depending
on the extent of destruction of the cortical–basal ganglia–thalamic neural loops.
• Mood disturbances (depression, dysthymia, apathy, anxiety), insomnia, and fatigue occur in
approximately 40% of patients; dementia occurs in approximately 25%.
• Psychosis, related to dopaminergic medications, occurs in approximately 20% of patients.
160
Repair of Porcelain
Repair of Bonded Porcelain
Chipping:
• Chipping is defined as a cohesive fracture that occurs within the body of the
porcelain in areas of intense point loading'(usually an accidental traumatic
force).
• When Esthetic and function is not compromised → The chipped surface
can be selectively polished with fine-grain diamonds and silicon points and
left as is.
• When larger piece is chipped → The lost fragment should be replaced with
composite. Conditioning of the ceramic surface (sandblasting and
silanization) is required.
161
Anusavice, K.J. (2013). Phillips' science of dental

materials. (12th ed.) St. Louis: W.B. Saunders.
Zirconia is a nonmetal with an extremely low thermal conductivity—about 20% as
high as that of alumina (Al2O3). It is chemically inert and highly corrosion resistant.
Pure ZrO2 has a monoclinic crystal structure at room temperature and transforms
to tetragonal and cubic zirconia at elevated temperatures. The large volume
expansion that occurs during the transformation of nondoped zirconia from cubic
to tetragonal and tetragonal to monoclinic phases leads to structural expansion
and high tensile stresses that cause zirconia to crack during cooling from the
processing temperatures. To solve this problem, stabilizing oxides such as
magnesium oxide (MgO), yttrium oxide (Y2O3), calcium oxide (CaO), and cerium
oxide (Ce2O3) are added to zirconia. The stability of single-phase tetragonal
zirconia is enhanced by highly soluble trivalent stabilizers such as yttria.
The most common stabilizer for dental applications is yttria (Y2O3). The addition of
3 to 5 mol% of Y2O3 results in a stabilized core ceramic referred to as yttria-
stabilized zirconia or yttria-stabilized tetragonal zirconia polycrystals (Y-TZP).
162
Malamed, S.F. (2019). Handbook of local
anesthesia. (7th ed.) St. Louis: Elsevier Mosby.
Because intraosseous injections deposit local anesthetic into a vascular site, it is
suggested that the volume of local anesthetic delivered be kept to the
recommended minimum to avoid possible overdose.54
In addition, because of the high incidence of palpitation (conscious awareness of a
rapid heartbeat) noted when vasopressor-containing local anesthetics are used, a
“plain” local anesthetic is recommended, if possible, in the intraosseous injection.
Transient tachycardia has been reported following intraosseous injections with
epinephrine- or levonordefrin-containing local anesthetic solutions between 46%
and 93% of the time.55-57 The use of a plain solution such as 3% mepivacaine does
not lead to a significant increase in heart rate.58,59 However, discussion with
endodontists who use intraosseous injection frequently for management of
symptomatic irreversible pulpitis in mandibular molars indicates that the quality
and depth of anesthesia are not as great when plain local anesthetics are used. It is
suggested that when epinephrine is included in the local anesthetic solution that
the smallest volume of the least concentrated epinephrine solution be
administered (e.g., 1:200,000)
163
Ritter, A.V. (2018). Sturdevant's art and science of operative

dentistry. (7th ed.) St. Louis: Elsevier Mosby.
Current microhybrid and nanofilled composites contain filler particles
range from about 20 to 600 nm. This use of nanoparticle technology
allows the formulation of dental materials with high translucency,
excellent initial polish, and retention of gloss while maintaining
mechanical properties and wear resistance equivalent to those of
current clinically proven hybrid composites.
164
Ritter, A.V. (2018). Sturdevant's art and science of
operative dentistry. (7th ed.) St. Louis: Elsevier
Mosby.
• Translucency
• Translucency is the degree to which an object scatters light upon transmission, resulting in an
appearance between complete opacity and complete transparency. Complete opacity will obscure
the substrate beneath it by blocking the passage of light, while a completely transparent object will
transmit light without scattering and will clearly show the substrate beneath it.
• Iridescence
• Iridescence is a rainbowlike effect caused by the diffraction of light that changes according to the
angle from which it is viewed or the angle of incidence of the light source. Iridescence occurs when
light is diffracted from a thin layer that lies between two mediums of different refractive index (e.g.,
air and water), as in a soap bubble or a thin film of oil on water. Teeth do not display the property of
iridescence, which is often confused with opalescence.
• Opalescence
• Opalescence is a milky iridescence that resembles the internal play of colors of an opal. In a natural
tooth, opalescence is caused by light scattering between two phases of enamel that have different
indexes of refraction. Short wavelengths of light are reflected displaying a blue hue, whereas longer
light wavelengths, such as the orange and red, are transmitted through the tooth.
165
Inflammatory Bowel Disease

• Crohn's Disease:
• Further classified into:
• Defects in the mucosal immunity.
• Increased intestinal permeability.
• Characterized by segmental distribution of intestinal mucosal ulcer → Skip
lesions. These lesions are interrupted by normal mucosal tissue.
• The most frequent area’s affected are the ilium and the proximal colon
• The intestine displays thickening of the bowel wall
• Irregular glandular openings, mucosal fissuring, ulcerations, erosions, and
benign strictures.
• With chronic disease → the intestinal mucosa takes on a nodular or
“cobblestone” → as a result of dense inflammatory infiltrates and submucosal
thickening.
166
• Histopathologic picture is important in the diagnosis:
• Characterized by infiltration of activated immune cells (neutrophils, macrophages,
lymphocytes, and plasma cells).
• Non-caseating granulomas.
• Long-standing colonic Crohn’s disease increases the risk for the development of
colorectal cancer
•Signs and symptoms:
• Abdominal cramping and pain.
• Nausea and Diarrhea.
• Fever.
• Weight loss and malnutrition (which can lead to anemia)
• Patchy erythematous macules and plaques involving the attached and unattached
gingivae have been termed mucogingivitis.
• Soft tissue swellings that resemble denture-related fibrous hyperplasia may be seen.
• Aphthous-like oral ulcerations.
167
Little, J., Falace, D., Miller, C.S., Rhodus, N.L. (2018). Dental management
of the medically compromised patient. (9th ed.) St. Louis: Elsevier Mosby.
• At the microscopic level, ulcerative colitis and Crohn disease are

characterized by infiltrative lesions of the bowel wall that contain
activated inflammatory cells (neutrophils and macrophages),
immune-based cells (lymphocytes and plasma cells), and
noncaseating granulomas.
• Long-standing colonic Crohn disease increases the risk for the
development of colorectal cancer
168
• Two main types: Ulcerative Colitis – Crohn's Disease
• Both of them as a result of dysregulation in the
immune response against intestinal commensal flora
• Ulcerative Colitis:
• Targets the large intestine.
• Characterized by periods of remission and
exacerbation.
• It starts in the colon and rectum region and may
spread proximally to involve the entire large intestine.
• Increases carcinoma of the colon by 10 times.
169

• Histopathologic picture is important in the diagnosis:
• Epithelial necrosis.
• Edema.
• Vascular congestion.
• Cryptic architecture.
• Monocellular infiltration.
• Epithelial erosions and hemorrhage.
• Abscess formation.
• Submucosal fibrosis.
• Thickening and narrowing of the colon.
• Signs and Symptoms:
• Fever.
• Electrolyte imbalance.
• Abdominal cramps – pain.
170
Crohn's Disease Ulcerative Colitis
171
172
173
174
Kumar, V., Abbas, A., Aster, J. (2017). Robbins and
Cotran pathologic basis of disease. (10th ed.)
Philadelphia: Elsevier.
Granulomatous inflammation is a form of chronic inflammation
characterized by collections of activated macrophages, often with T
lymphocytes, and sometimes associated with central necrosis.
175
Granulomatous inflammation mainly includes macrophages.

Granulomatous inflammation is a distinctive type of chronic inflammation characterized by the
formation of granulomas. Granulomas are organized aggregates of immune cells that form in
response to certain infections, autoimmune disorders, foreign substances, or other persistent
stimuli.
Macrophages play a central role in granulomatous inflammation. They are the primary immune
cells involved in the formation of granulomas. When a stimulus triggers the immune system,
macrophages are activated and recruited to the affected site. Once at the site, they can fuse
together to form giant cells or epithelioid cells, which are a hallmark of granulomatous
inflammation.
Macrophages in granulomas display specific characteristics, including an enlarged and activated
state. They release various cytokines and chemokines, which attract other immune cells such as
lymphocytes, to the site of inflammation. Macrophages also phagocytose and attempt to eliminate
the offending agent but may not always succeed, leading to the persistence of the granuloma.
While other immune cells, such as lymphocytes, may also be present within granulomas,
macrophages are the key immune cells involved in the initiation, maintenance, and organization of
granulomatous inflammation.
176
Terminology and Equations
The Odds Ratio:
• Odds:
• Odds of an event happening is defined as the likelihood that an event
will occur, expressed as a proportion of the likelihood that the event
will not occur. Therefore, if A is the probability of subjects affected
and B is the probability of subjects not affected, then odds = A /B.
• Therefore, the odds of rolling four on a dice are 1/5 or 20%.
• Odds Ratio (OR) is a measure of association between exposure and
an outcome. The OR represents the odds that an outcome will occur
given a particular exposure, compared to the odds of the outcome
occurring in the absence of that exposure.
177

Odds ratio:
• The odds that a given action leads to a particular outcome.
Interpretation:
• Odd ratio of 1= no difference between the groups.
• Odds ratio >1= Risk will lead the event.
• Odds ration <1=Risk will less likely lead to the event.
178
Odds of the disease in the exposed group= a/b
Odds of the disease in the unexposed group =c/d
Odds of exposure in the diseased group = a/c
Odds of exposure in the nondiseased group = b/d
Odds Ratio:
• Is a measure of association between exposure
and an outcome
The odds ratio can be calculated by dividing the odds of
exposure in the diseased group by the odds of exposure
in the nondiseased group
= (a/c)/(b/d)
=ad/bc
179

Confidence Interval:
A confidence interval, in statistics, refers to the probability that a
population parameter will fall between a set of values for a
certain proportion of times.
180
Interpretation of 95% confidence interval for a specific parameter:
For example:
• An odds ratio of 5.2 with a 95% confidence interval of 3.2 to 7.2 suggests
that there is a 95% probability that the true odds ratio would be likely to lie
in the range 3.2-7.2 95% of the times.
• If the odds ratio of 5.2 with 95% CI (3.2-7.2) this means that the odds ratio is
statistically significant and can be relied on.
• If the odds ratio 5.2 with 95% CI (0.3-) this means that there is a 95% chance
that the confidence interval you calculated contains the true odds ratio
making the odds ratio in the example statistically insignificant.
• If the odds ratio 1.6 with 95% CI (0/8-1.9) → although the odds ratio is
included in the CI, but the results are insignificant as the CI spans over (1).
181
Malamed, S.F. (2015). Medical emergencies in the

dental office. (7th ed.) St. Louis: Elsevier Mosby.
• Clinical signs and symptoms of hypoglycemia are similar to those
exhibited by individuals during acute anxiety states or after the
administration of excessive doses of epinephrine (“epinephrine
reaction”), except for the mental disorientation seen in
hypoglycemia.
• The lack of adequate blood glucose levels alters the normal
functioning of the cerebral cortex and manifests clinically as mental
confusion and lethargy.
182
management of the medically compromised patient. (9th
• Most common NSAIDS can exacerbate HF with a relative risk of 1.4
times normal. Celecoxib and particularly rofecoxib are significantly
more likely to exacerbate HF with more than twice the risk.32
Consequently, dentists should be aware and cautious regarding the
use of NSAIDS for managing pain in patients with HF.
• In a large trial of subjects who were high polyp formers, with an
average age of 60 years and almost half with cardiovascular disease
or related risk factors (angina, previous MI, hypertension, and/or
poor lipid profile), celecoxib at 200 mg and 400 mg taken twice per
day increased the risk of a serious cardiovascular event (MI,
stroke, or heart failure) by 2.5- to 3.4-fold, respectively, compared
to placebo after 36 months of treatment.
183

Elsevier Mosby.
When tori with a small pedunculated base are present, an osteotome and
mallet may be used to remove the bony mass. For larger tori, it is usually
best to section the tori into multiple fragments with a burr in a rotary
handpiece. Careful attention must be paid to the depth of the cuts to avoid
perforation of the floor of the nose.
The major complications of maxillary tori removal include postoperative

hematoma formation, fracture or perforation of the floor of the nose, and
necrosis of the flap. Local care, including vigorous irrigation, good hygiene,
and support with soft tissue conditioners in the splint or denture, usually
provides adequate treatment.
184
The mechanism of edema involves one or more of the following:
• Increased capillary hydrostatic pressure
• Decreased plasma oncotic pressure
• Increased capillary permeability
• Obstruction of the lymphatic system
185
Hall, J. (2016). Guyton and Hall: textbook of

medical physiology. (13th ed.) Philadelphia: Elsevier
Edema refers to the presence of excess fluid in the body tissues. In
most instances, edema occurs mainly in the extracellular fluid
compartment, but it can involve intracellular fluid as well.
186
INTRACELLULAR EDEMA
Three conditions are especially prone to cause intracellular swelling: (1) hyponatremia, as
discussed earlier; (2) depression of the metabolic systems of the tissues; and (3) lack of
adequate nutrition to the cells. For example, when blood flow to a tissue is decreased, the
delivery of oxygen and nutrients is reduced. If the blood flow becomes too low to maintain
normal tissue metabolism, the cell membrane ionic pumps become depressed. When the
pumps become depressed, sodium ions that normally leak into the interior of the cell can
no longer be pumped out of the cells and the excess intracellular sodium ions cause
osmosis of water into the cells. Sometimes this process can increase intracellular volume of
a tissue area—even of an entire ischemic leg, for example—to two to three times normal.
When such an increase in intracellular volume occurs, it is usually a prelude to death of the
tissue.
Intracellular edema can also occur in inflamed tissues. Inflammation usually increases cell
membrane permeability, allowing sodium and other ions to diffuse into the interior of the
cell, with subsequent osmosis of water into the cells.
187

EXTRACELLULAR EDEMA
Extracellular fluid edema occurs when excess fluid accumulates in the
extracellular spaces. There are two general causes of extracellular
edema: (1) abnormal leakage of fluid from the plasma to the interstitial
spaces across the capillaries, and (2) failure of the lymphatics to return
fluid from the interstitium back into the blood, often called
lymphedema. The most common clinical cause of interstitial fluid
accumulation is excessive capillary fluid filtration.
188
Factors That Can Increase Capillary Filtration
Any one of the following changes can increase the capillary filtration
rate:
• Increased capillary filtration coefficient
• Increased capillary hydrostatic pressure
• Decreased plasma colloid osmotic pressure
189
Nowak, A., et al. (2019). Pediatric dentistry: infancy

through adolescence. (6th ed.) Elsevier.
• For the primary dentition, no radiographs are indicated when all
proximal surfaces can be visualized and examined clinically. This
includes both anterior and posterior teeth.
• When the proximal surfaces cannot be visualized and clinically
examined, bitewing radiographs are indicated to determine the
presence of interproximal caries.
190
191
Shillingburg, H.T., et al. (2012). Fundamentals of fixed prosthodontics.

(4th ed.) Chicago: Quintessence Publishing Co.
Modified ridge lap

The modified ridge lap design gives the illusion of a tooth, but it
possesses all or nearly all convex surfaces for ease of cleaning. The
lingual surface should have a slight deflective contour to prevent food
impaction and minimize plaque accumulation.14 There may be a slight
faciolingual concavity on the facial side of the ridge, which can be
cleaned and tolerated by the tissue as long as the tissue contact is
narrow mesiodistally and faciolingually.
192
Fixed Prosthodontics
Pontics
- Modified ridge-lap pontic
- Gives the illusion of being a tooth, but possesses all convex surfaces for
ease of cleaning.
- This design is the one of choice for pontics in the appearance zone (where
esthetics are important) for both maxillary and mandibular bridges .
193
Question Explanation
A modified ridge lap pontic in a fixed partial denture should be?
The pontic should be convex in all directions
Rosenstiel, S.F., Land, M.F., Fujimoto, J. (2016). Contemporary fixed prosthodontics.

(5th ed.)
St. Louis: Elsevier.
The modified ridge-lap pontic combines the best features of the hygienic and saddle
pontic designs, combining esthetics with easy cleaning. Figures 20-16 and 20-17
demonstrate how the modified ridge-lap pontic overlaps the residual ridge on the
facial side (to achieve the appearance of a tooth emerging from the gingiva) but
remains clear of the ridge on the lingual side. To enable optimal plaque control, the
gingival surface must have no depression or hollow; rather, it should be as convex as
possible from mesial to distal aspects (the greater the convexity, the easier the oral
hygiene).
194
For the administration of oral moderate sedation to patients under 12 years of age, the
use of oral midazolam, diazepam or hydroxyzine may be considered by those
dentists who have successfully completed additional training in their use. The dose of
the oral sedative drug must be calculated, based on the weight of the patient:
● For oral midazolam, the dose must not exceed 0.5 mg/ kg, with a maximum dose
of 15 mg for 1 appointment.
● For oral diazepam, the dose must not exceed 0.5 mg/ kg, with a maximum dose
● For oral hydroxyzine, the dose must not exceed 1.0 mg/kg, with a maximum dose
195
196
Circulatory Shock
• Shock usually results from inadequate cardiac output. Therefore,
any condition that reduces the cardiac output far below normal may
lead to circulatory shock.
• Circulatory shock comprises a collection of different entities
that share certain common features.
• The feature that is common to all the entities is inadequate tissue
perfusion with a relatively or absolutely inadequate cardiac
output.
197
Neonatal pemphigus is a rarely reported transitory autoimmune

blistering disease caused by transfer of maternal IgG autoantibodies to
desmoglein 3 to the neonate through the placenta when the mother is
affected with pemphigus.
It is clinically characterized by transient flaccid blisters and erosions on
the skin and, rarely, the mucous membranes.
Neonatal pemphigus vulgaris has never been reported to persist
beyond the neonatal period and progress to adult disease
198
Little, J., Falace, D., Miller,
C.S., Rhodus, N.L. (2018).
Dental management of the
medically compromised
patient. (9th ed.) St. Louis:
Elsevier Mosby.
199
Little and falace page 554

In interactions with the patient, the dentist should convey an appropriate level of
personal interest. Verbal and nonverbal components of communication must be
consistent (Box 28.3). An often helpful approach is to begin by mentioning that the
patient appears anxious and then to inviting the patient to talk about relevant
feelings, which may include attitudes toward the dentist. During these discussions,
tension-free pauses between expressions of ideas should be permitted, allowing a
temporary state of regression to occur that will help the patient to restore a more
anxiety-free state. Some patients may respond well to this approach without ever
indicating why they were anxious.
If a patient remains anxious, the dentist may elect to use hypnosis, oral or
parenteral sedation agents, or nitrous oxide plus oxygen to better manage the
dental treatment (see Box 28.3). A recent study demonstrated a beneficial effect of
acupuncture on the level of anxiety in patients with dental anxiety.5
200
Elsevier Mosby.
Non-Odontogenic Infection of maxillary sinus:
• Aerobic, anaerobic, or mixed bacteria may cause infections of the maxillary
sinuses.
• The organisms usually associated with maxillary sinusitis of nonodontogenic
origin include those usually found within the nasal cavity.
• Mucositis that occurs within the sinus allows for colonization of these
organisms.
• The causative bacteria are primarily aerobic, and a few are anaerobes.
• The important aerobes are Streptococcus pneumoniae, Haemophilus
influenzae, and Branhamella catarrhalis.
• Anaerobes include Streptococcus viridans, Staphylococcus aureus,
Enterobacteriaceae, Porphyromonas, Prevotella, Peptostreptococcus,
Veillonella, Propionibacterium, Eubacterium, and Fusobacterium.
201

Elsevier Mosby.
Odontogenic infection of maxillary sinus:
• Sources of odontogenic infections that involve the maxillary sinus include acute and
chronic periapical diseases and periodontal
• diseases. Infection and sinusitis may also result from trauma to the dentition or from
surgery in the posterior maxilla, including removal of teeth, alveolectomy, tuberosity
reduction, sinus lift grafting and implant placement, or other procedures that create
an area of communication between the oral cavity and the maxillary sinus.
• Maxillary sinus infections of odontogenic origin are more likely to be caused by
anaerobic bacteria, as is the usual odontogenic infection.
• Rarely does H. influenzae or S. aureus cause odontogenic sinusitis.
• The predominant organisms are aerobic and anaerobic streptococci and anaerobic
Bacteroides, Enterobacteriaceae, Peptococcus, Peptostreptococcus, Porphyromonas,
Prevotella, and Eubacterium.
202
MC5620463/
In conclusion, a majority of the maxillary
incisors were positioned close to the buccal
cortical plate and had a thin buccal bone
wall.
203
Newman, M.G., et al. (2018). Carranza's clinical

periodontology. (13th ed.) Philadelphia:
Elsevier/Saunders.
The association between periodontitis and metabolic syndrome is
thought to be the result of systemic oxidative stress and an increased
inflammatory response. It may be explained by common risk factors
such as obesity and obesity-related habits including diet, exercise, and
poor oral hygiene. Obesity is associated with increased cytokine
production as well as T-cell and monocyte/macrophage dysfunction,
factors known to contribute to periodontitis. The proinflammatory
cytokines interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α),
which are elevated in obese individuals, are thought to be produced by
activated macrophages that have infiltrated adipose tissue.
204
Neville, B.W. (2016). Oral & maxillofacial
pathology. (4th ed.) Philadelphia; Toronto: W.B.
Saunders.
Treatment of Actinomycosis:
The treatment of choice for actinomycosis in chronic fibrosing cases is
prolonged high doses of antibiotics in association with abscess drainage
and excision of the sinus tracts. A high antibiotic concentration is
required to penetrate larger areas of suppuration and fibrosis.
Although penicillin remains the standard of care with no documented
in vivo resistance, some clinicians believe amoxicillin represents a
better first-choice antibiotic.
205
Implications of Dabigatran, a Direct Thrombin Inhibitor,

for Oral Surgery Practice
J Can Dent Assoc 2013;79:d74
Table Management for Patients taking Dabigtran Recommendations:

• Minor Oral Surgical Procedures (simple extraction): • Major Oral Surgical Procedures (multiple
→ No discontinuation of the medication → extractions, significant oral maxillofacial surgical
bleeding is expected to be increased but clinically procedures) → consideration to discontinue the
manageable by local hemostatic agents. medication with timing determined by renal
function.
If discontinuation is recommended – timing is determined by creatinine clearance (CLCr) → normal range 88-
137 mL/min.
Minor risk of bleeding: Major risk of bleeding:
• CLCr above 50 mL/min→ 24 hours before the • CLCr above 50 mL/min → 2-4 days before the
procedure. procedure.
• CLCr between 30 and 50 mL/min → 2 days before • CLCr between 30 and 50 mL/min→ 4 days before
the procedure the procedure
• CLCr less than 30 mL/min → 2-5 days before the • CLCr less than 30 mL/min→ more than 5 days
procedure. before the procedure.
• If discontinuation of anticoagulation is not advisable and extensive major oral surgery procedures are
required, bridging to an appropriate dose of subcutaneous LMWH is recommended
206
The direct thrombin inhibitors— lepirudin, desirudin, argatroban, and
bivalirudin—are injectable drugs used primarily in patients with a
history of HIT. They all have very short half-lives of only several hours.
The dentist is unlikely to have patients on any of these medications
because they are used most often in a hospital setting. However, if the
dentist has a patient taking one of these drugs, many invasive dental
procedures can be done without stopping the drug. Most invasive
dental procedures can be performed for patients taking the oral
direct thrombin inhibitor dabigatran. Consultation with the patient’s
physician is recommended. Because of the short half-lives of these
drugs, only 1 day would be needed without the drug for more
invasive procedures.
207
Neuropraxia
• The integrity of the axon is maintained, and the injury indicates a local
conduction block from a transient anoxic event due to acute vascular
interruption of the epineurial or endoneurial vasculature. Neuropraxia is
usually the result of a mild nerve manipulation, traction, or compression
injury and is characterized by a reversible conduction block, with a
favorable outcome and complete recovery within days to weeks of the
event.
208
Axonotmesis
• Axonotmesis involves axonal damage, demonstrates variable degrees of
demyelination and axonal injury, and therefore, spontaneous recovery
varies significantly in this category of injuries.
Neurotmesis
• Neurotmesis implies complete or near-complete nerve transection that
includes epineurial discontinuity. Spontaneous recovery is unlikely, whereas
neuroma formation is common.
209
210
Rosenstiel, S.F., Land, M.F., Fujimoto, J. (2016). Contemporary fixed prosthodontics. (5th ed.) St.
Louis: Elsevier.
Page 81
Because of the conical shape of most roots (Fig. 3-23), when one third of the root length has been
exposed, half the supporting area is lost.
211

prosthodontics. (13thed.) St. Louis: Elsevier.
Occlusal rest seat preparations in existing restorations are treated the
same way as those in sound enamel.
The possibility that an existing restoration may be perforated in the
process of preparation of an ideal occlusal rest seat is always present.
Although some compromise is permissible, the effectiveness of the
occlusal rest seat should not be jeopardized for fear of perforating an
existing restoration.
212
Rosenstiel, S.F., Land, M.F., Fujimoto, J. (2016). Contemporary
fixed prosthodontics. (5th ed.) St. Louis: Elsevier.
213
Pulp Therapy for Primary and Immature Permanent Teeth

https://www.aapd.org/media/Policies_Guidelines/BP_PulpThera
py.pdf
Radiographic evaluation of primary tooth pulpotomies should occur at
least annually because the success rate of pulpotomies diminishes
over time.15 Bitewing radiographs obtained as part of the patient’s
periodic comprehensive examinations may suffice. If a bitewing
radiograph does not display the interradicular area, a periapical image
is indicated.
Clinicians should evaluate non-vital pulp treatments for success and

adverse events clinically and radiographically at least every 12
months.
214
Walton, R.E., Torabinejad, M., Fouad, A.J. (2015). Endodontics: principles
and practice. (5th ed.) New York: Elsevier.
Recommended follow-up periods have ranged from 6 months

to 5 years.8-13 Six months is a widely accepted and reasonable
interval for a recall evaluation for most patients.
215
Local Anesthesia: Calculations

L.A Maximum Recommended Doses
Maximum Dose Maximum no.
Drug MRD
(mg/kg) of Cartridges
Articaine 4% with epinephrine 1:100 000 7 none listed 11
Articaine 4% with epinephrine 1:200 000 7 none listed 22

Bupivacaine- 0.5% with epinephrine 1:200 000 2 90 10
Bupivacaine Plain none listed 90 10
Lidocaine 2% with epinephrine 1:50 000 7 500 5
Lidocaine 2% with epinephrine 1:100 000 7 500 11
Mepivacaine 2% with levonordefrin 1:20 000 6.6 400 11
Mepivacaine 3% plain 6.6 400 7
Prilocaine 4% plain 8 600 8
Prilocaine 4% with epinephrine 1:200 000 8 600 8
216
LA Calculation:
0.5% → 5 mg/ml – in 1.8 ml → 9mg
1 carpule of 0.5% Bupivacaine contains 9mg
Maximum dose for a 20 kg patient = 2 X 20 = 40 mg
# of carpules 40/9 = 4.4 carpules
Always round down to avoid overdose.
217
Epinephrine Calculation:
Maximum dose = 0.2 mg or 0.003 mg/kg
1:200,000 = 0.02mg/ml
In 1.8 ml = 0.02 X 1.8 = 0.036 mg
Maximum dose in a 20 kg patient = 0.003 X 20 = 0.06 mg
# of carpules = 0.06/0.009= 6.6 carpules
218
Mallya, S., Lam, E. (2018). White and Pharoah’s oral radiology: principles
and interpretation. (8th ed.)
St. Louis: Mosby.
Bitewing (interproximal) views are used to record the coronal portions of the
maxillary and mandibular teeth in one image. They are useful for detecting
interproximal caries and evaluating the height of alveolar bone.
• Size 2 film is normally used in adults;
• Size 1 is preferred in children.
• Small children → Size 0 may be used.
Periapical views are used to record the crowns, roots, and surrounding bone.
Film packs come in three sizes:
• Size 0 for small children (22 mm × 35 mm);
• Size 1, which is relatively narrow and used for views of the anterior teeth (24 mm ×
40 mm).
• Size 2, the standard film size used for adults (30.5 mm × 40.5 mm).
• Occlusal film, size 4, is more than three times larger than size 2 film. It is used to
show larger areas of the maxilla or mandible than may be seen on a periapical film.
219
Mallya, S., Lam, E. (2018). White and Pharoah’s oral radiology:

principles and interpretation. (8th ed.) St. Louis: Mosby
Vertical bitewing projections.
Vertical bitewing projections are used
when the patient has moderate to severe
alveolar bone loss. Orienting the length of
the receptor vertically increases the
likelihood that the residual alveolar crests in
the maxilla and the mandible will be
recorded on the radiograph (Fig. 7.20). The
principles for positioning the receptor and
orienting the x-ray beam are otherwise the
same as for horizontal bitewing projections.
Bite blocks specifically designed for vertical
orientation of the sensor are available.
220
Fascial Spaces and Infections
Cavernous Sinus Thrombosis:
• Uncommon but potentially lethal extension of odontogenic infection.
• Contents of the cavernous sinus:
• Causes:
• Infection ascending from the maxillary teeth, upper lip, nose, or orbit
(Danger triangle)
• Valve-less veins →allow retrograde flow of infection from face to sinus
221

• Contents of the cavernous sinus
222
• Clinical manifestation:
• Headache, spiking fever, obtruded state of consciousness
• Periorbital edema, visual impairment, CN dysfunction (III, IV, first and
second division of V &, VI) Chemosis, proptosis, papilledema
• Microbiology:
• Generally S.Aureus
• Streptococci, pneumococci and fungal
223
224
Ludwig’s Angina:
• Life-Threatening cellulitis of the floor of
the mouth
• When the perimandibular spaces
(submandibular, sublingual and
submental) are bilaterally involved in an
infection
• This infection is a rapidly spreading
cellulitis that can obstruct the airway and
commonly spreads posteriorly to the
spaces of the neck
• Diagnosis is based on history and nature
with CT
225

Ludwig’s Angina:
• Signs & Symptoms:
• Neck rigidity
• Dysphagia
• Open mouth syndrome → drooling
• Supero-posteriorly positioned tongue (elevation of the tongue)
• Airway Obstruction → labored breathing
• Treat:
• Airway Management
• Massive antibiotic coverage (IV)
• Surgical incision and drainage
226
Heart Sounds:
• First sound S1 → closure of the A-V valves.
• Second sound S2 → closure of the aortic and pulmonary valves.
• Third sound S3 → the beginning of the middle third diastole.
• May be normally present in children, adolescents, and young adults but
generally indicates systolic heart failure in older adults.
• Follows closely after S2, during the rapid filling wave in diastole.
• Fourth sound S4 →Occurs just before S1, coincident with atrial
contraction, and is never heard in the absence of atrial contraction. atrial
contraction.
• Often heard in older patients with left ventricular hypertrophy.
• Most commonly is a pathologic finding.
227
228
Malamed, S.F. (2017). Sedation: a guide to patient
management. (6th ed.) St. Louis; Toronto: Mosby.
• “Lack of response to verbal command or, more significantly, a lack
of response to a painful stimulus (i.e., local anesthetic injection)
may indicate that the patient is overly sedated. Lack of response to
sensory stimulation is always an indication for the dentist to stop
treatment and evaluate the patient’s level of CNS depression and
airway and ventilatory status.”
• “The IV administration of the benzodiazepine antagonist
flumazenil, in an initial dose of 0.2 mg (2 mL) with subsequent
doses administered every minute as needed (to a maximum dose
of 1.0 mg), will reverse the respiratory depression (and other
clinical actions of benzodiazepines) more rapidly.”
229
Allodynia : Pain caused by a stimulus that does not normally provoke

pain
Analgesia: Absence of pain in response to stimulation that would
normally be painful
Anesthesia: Absence of all sensation
Hyperalgesia: Increased sensitivity to noxious stimulation
Hypoalgesia: Diminished sensitivity to noxious stimulation
Neuralgia: Pain in the distribution of a nerve or nerves
Paresthesia: Abnormal sensation, whether spontaneous or evoked
230
Forms of Periodontitis
1. Necrotizing Periodontal Diseases
• Necrotizing Gingivitis.
• Associated with malnutrition, tobacco use, and stress
• punched-out, craterlike depressions at the crest of the
interdental papillae (necrosis of papillae is the most common
finding. Herrera et al. 2018)
• gingival crater is covered by a gray, pseudomembranous slough
surrounded by an erythematous margin
• No CAL
• Lesions bleed easily, painful, and have metallic foul taste.
• May be associated with lymphadenopathy, leukocytosis, fever,
or malaise
• Spirochete (treponema pallidum), Prevotella intermedia,
fusiform bacilli
• Necrotizing Periodontitis
• Similar to NG + CAL and bone loss
• Deep interdental osseous craters
• Immunocompromised patient (HIV/AIDS)
231
Forms of Periodontitis
1. Necrotizing Periodontal Diseases.
• Necrotizing stomatitis
• Severe inflammatory condition of the periodontium
and the oral cavity in which soft tissue necrosis extends
beyond the gingiva and bone denudation may occur A
through the alveolar mucosa, with larger areas of
osteitis and formation of bone sequestrum
(Papapanou, Sanz et al. 2018)
• May occur separately or as an extension of NUP
• Occurs in severely immunocompromised patients B
• Associated with the severe suppression of CD4 immune (A) Necrotizing ulcerative stomatitis in
the left mandibular molar area. (B)
cells and an elevated viral load in AIDS patients Radiographic view. Note the large
osseous sequestrum
232
Mucositis:
• Oral mucositis has been shown to be the single most debilitating complication
of high-dose chemotherapy and radiation therapy to the head and neck.
• Associated with local discomfort, an increased need for total parenteral
nutrition, prolonged hospital stays, and most importantly, systemic bacteremia
and sepsis.
• Approximately 80% of patients treated with head and neck radiation develop
oral mucositis, and this prevalence approaches 100% for those being treated for
mouth and oropharyngeal cancers.
• Risk factors include young age: female sex, poor oral hygiene, oral foci of
infection, poor nutrition, impaired salivary function, tobacco use, and alcohol
consumption.
233

Mucositis:
• Cases of oral mucositis related to radiation or chemotherapy are similar in their
clinical presentations.
• The manifestations of chemotherapy develop after a few days of treatment;
radiation mucositis may begin to appear during the second week of therapy.
• Both chemotherapy radiation-induced mucositis resolve slowly 2 to 3 weeks
after cessation of treatment.
• Oral mucositis associated with chemotherapy typically involves the
nonkeratinized surfaces (i.e., buccal mucosa, ventrolateral tongue, soft palate,
and floor of the mouth)
• Radiation therapy primarily affects the mucosal surfaces within the direct
portals of radiation.
234
Mucositis:
• The earliest manifestation is development of a whitish discoloration
from a lack of sufficient desquamation of keratin.
• This is soon followed by loss of this layer with replacement by
atrophic mucosa, which is edematous, erythematous, and friable.
Subsequently, areas of ulceration develop with formation of a
removable yellowish, fibrinopurulent surface membrane.
• Pain, burning, and discomfort are significant and can be worsened
by eating and oral hygiene procedures.
235
The trochlear nucleus is unique in

that its axons run dorsally and
cross the midline before emerging
from the brainstem posteriorly.
236
The muscles that supply the eye:
SO 4 → Superior oblique by trochlear nerve
LR 6 → Lateral rectus by abducens.
R 3 → Remaining muscles by oculomotor.
237
Red Lesions
Burning Mouth Syndrome (STOMATOPYROSIS,GLOSSOPYROSIS):
Is a common condition in which the patient feels as if the lining of their
mouth is being scalded (burned).
It mainly affects post-menopausal women.
Any mucosal regions may be affected, although the tongue is by far the
most commonly involved site.
The exact etiology is unknown, and it’s a “diagnosis of exclusion”
Diagnosis is based on a detailed history, a clinical examination,
laboratory studies, and exclusion of all other possible oral problems
Clinically the lining of the mouth appears completely normal.
238
Red Lesions
Burning Mouth Syndrome cont.:
When burning sensation occurs in the absence of both clinical and
laboratory findings, the condition is classified as primary or idiopathic
BMS.
Secondary BMS is reserved for those clinical presentations which are
associated with underling local (xerostomia, chronic mouth breathing,
chronic tongue thrust habit, chronic mechanical trauma, oral
candidiasis) or systemic factors (vitamin B deficiency, diabetes mellitus,
chronic gastritis, estrogen deficiency, anxiety, stress, and depression).
Treatment: correcting underlying local or systemic cause if present,
pharmacologic therapies includes: anxiolytics, antioxidants (alpha lipoic
acid), antidepressants and/or anticonvulsants alone or in combination.
Cognitive behavioral therapy is useful in patients with underlying
psychological factors.
239
Symptoms of burning mouth syndrome may include:

• A burning or scalding sensation that most commonly affects your tongue,
but may also affect your lips, gums, palate, throat or whole mouth
• A sensation of dry mouth with increased thirst
• Taste changes in your mouth, such as a bitter or metallic taste
• Loss of taste
• Tingling, stinging or numbness in your mouth
240
Hupp, J., Ellis, E., Tucker, M. (2018). Contemporary oral and maxillofacial
surgery. (7th ed.) St. Louis: Elsevier Mosby. Page 248
• Allogeneic bone grafts procured from cadavers are processed to achieve sterility and
decrease the potential for immune response.
• The sterilization process destroys the osteoinductive nature of the graft; however, the
graft provides a scaffold, allowing bone ingrowth (osteoconduction).
• Bony incorporation, followed by remodeling and resorption, occurs during the healing
phase.
• Granular forms of allogeneic graft material provide increased surface area and
improved adaptation within the graft and are the most commonly used for augmenting
alveolar ridge contour defects.
• The advantages of allogeneic bone grafting include the avoidance of an additional
donor site, unlimited availability, and the fact that patients can undergo this type of
procedure in an outpatient setting.
• The disadvantage is that a significant amount of grafted bone is resorbed, which
results in a much smaller volume of bone for implant placement.
241
Hupp, J., Ellis, E., Tucker, M. (2018). Contemporary oral and maxillofacial
surgery. (7th ed.) St. Louis: Elsevier Mosby. Page 202
• If a soft tissue flap is replaced and sutured without an

adequate bony foundation, the unsupported soft
tissue flap often sags and separates along the line of
incision.
• A second cause of dehiscence is suturing the wound
under tension. If the soft tissue flap is sutured under
tension, the sutures cause ischemia of the flap margin
with subsequent tissue necrosis, which allows the
suture to pull through the flap margin and results in
wound dehiscence. Therefore sutures should always
be placed in tissue without tension and tied loosely
enough to prevent blanching of the tissue.
• A common area of exposed bone after tooth
extraction is the internal oblique ridge. After
extraction of the first and second molars, during
initial healing, the lingual flap becomes stretched
over the internal oblique (mylohyoid) ridge.
242
maxillofacial surgery. (3rd ed.) Saunders. Volume 2 page
507
• At the tissue level, bisphosphonates will inhibit bone resorption and decrease bone
turnover as assessed by biochemical markers. The degree to which these
compounds will also alter bone formation is related to their effects on bone
turnover, which is closely coupled to bone formation.
• On a cellular level, the bisphosphonates target the osteoclasts and may inhibit their
function in several ways: (1) inhibition of osteoclast recruitment, (2) reduction of
osteoclast life span, and (3) inhibition of osteoclastic activity at the bone surface.
• At a molecular level it has been postulated that bisphosphonates modulate
osteoclast function by interacting with a cell surface receptor or an intracellular
enzyme.
243
Non-Steroidal Anti-Inflammatory Drugs

COX-2 inhibition and CVS risk
• Normal state: TxA2 and PGI2 are in balance
• In atherosclerosis: ↑ TxA2 and PGI2, in balance
• If COX-2 inhibition: ↓ PGI2 and therefore a relative ↑ TxA2 and therefore
thrombosis is more likely
244
Non-Steroidal Anti-Inflammatory Drugs
245
Embryology
Formation of the Face:
246
Failure if fusion between:
• Maxillary process and lateral nasal process → Oblique facial cleft
• Two medial nasal processes → Median clef lip (harelip)
• Maxillary process and median nasal process → Cleft lip
• Maxillary process and mandibular process → Lateral cleft lip
• Excessive merging of the mandibular and maxillary processes → Microstomia
• Insufficient merging of the maxillary and mandibular processes→ Macrostomia
247
Fonseca, R., Marciani, R., Turvey, T. (2017). Oral and maxillofacial surgery. (3rd ed.)
Saunders.
Management of Zygomatic Fractures

These deformities can occur without severe impairment of function.
However, fractures of the zygomatic arch can cause functional
impairment by impinging on the temporalis muscle or obstructing the
path of the coronoid and causing trismus. Zygomatic fractures
impinging on the infraorbital nerve cause paresthesia or dysesthesia of
the second division of the trigeminal nerve (V2). Disruption of the
position of the globe can cause diplopia. Therefore, an examination of
the orbit and the globe, including extraocular movements, an
evaluation of the maxillary sinus, a determination of V2 sensation, and
an examination of the range of motion of the mandible are essential in
diagnosing zygomatic injuries
248
Fracture and Fracture Management
Facial Le Fort I (Guerin Fracture) Le Fort II (Pyramidal Le Fort III (Craniofacial Zygomaticomaxillary
Fractures fracture) Dysjunction) complex
Pure maxillary fracture. Separation between the Separation between the Fracture of the zygomatic
Separates the maxilla from maxilla and nasal complex facial bones and the bone at any of the
the middle face → thus is from the orbital and cranial fossa. following areas:
called trans-maxillary zygomatic bones. Separation takes place at 1) Frontal Process
fracture. The attachment of the the naso-orbital- 2) Zygomaticomaxillary
zygomatic bone to the ethmoidal complex, and buttress
skull is intact. the zygoma and maxilla 3) Infraorbital rim
from the cranial base. 4) Zygomatic arch
Described as Panda face 5) Lateral orbital wall
and Racoon face due to
the edema and
ecchymosis in the mid-
face and the around the
eyes.
249
Gagging
Gagging is a potential problem during many dental procedures, especially in the
maxillary palatal and the posterior mandibular lingual regions. Although there is no
absolute solution to this problem (other than general anesthesia), inhalation
sedation with N2O-O2 has proven to be highly effective in eliminating or at least
minimizing severe gagging. Patients are titrated with N2O-O2 to their sedation
level, at which point impressions, radiographs, or other procedures may be
completed. The use of N2O-O2 to diminish the gag reflex may require placing the
patient in an upright position for some or all of the procedure. Although this
position is not usually recommended during sedation (supine is preferred), some
procedures, such as impressions in the maxilla, may require modification of
position for increased patient safety. Where other sedation techniques (especially
IV sedation) are also effective in decreasing gagging, only N2O is practical to use for
extremely short procedures, such as radiographs or impressions.
250
Anusavice, K.J. (2013). Phillips' science of dental
materials. (12th ed.) St. Louis: W.B. Saunders.
251
Mallya, S., Lam, E. (2018). White and Pharoah’s oral

radiology: principles and interpretation. (8th ed.)
St. Louis: Mosby.
“Because film-processing conditions are standardized and the mA and
kVp settings are fixed, the only decision the dentist or the assistant
needs to make is to select the proper exposure time for the age of the
patient (less for young patients) and the region of the mouth being
imaged (less in the anterior region).”
252
Little, J., Falace, D., Miller, C.S., Rhodus, N.L. (2018).
Dental management of the medically compromised
patient. (9th ed.) St. Louis: Elsevier Mosby.
Hypertension is the most important risk factor for ischemic and
hemorrhagic stroke. The incidence of stroke increases directly in
relation to the degree of elevation of systolic and diastolic arterial
blood pressure above threshold values.
253
Anosmia →the loss of the sense of smell, either total or partial. It may
be caused by head injury, infection, or blockage of the nose.
Allodynia →pain caused by a stimulus that does not normally provoke
pain.
Dysphagia →difficulty or discomfort in swallowing.
Dystonia →a disorder characterized by involuntary muscle contractions
that cause slow repetitive movements or abnormal postures. The
movements may be painful, and some individuals with dystonia may
have a tremor or other neurological symptoms.
254

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AFK Mock 3 References

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CBCT Volume Indications

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Preventative regimen for moderate risk (permanent

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Walton, R.E., Torabinejad, M., Fouad, A.J. (2015). Endodontics:

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Walton, R.E., Torabinejad, M., Fouad, A.J. (2015). Endodontics:

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Walton, R.E., Torabinejad, M., Fouad, A.J. (2015). Endodontics:

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Soft Tissue Calcifications

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Soft Tissue Calcifications

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