Therapeutics and Medical Emergencies

Firstly, do no harm. This is held as the first law of clinical practice when considering any intervention to improve the health of our patients. This may at times be a difficult proposition, especially when the approach to treating a condition is fraught with risks and can carry the danger of adverse and unwanted side effects. Prescribing therapeutics is the time perhaps when this maxim should be most at the forefront of a clinician’s mind, as therapeutic interven­tions may not cause any immediately discernible danger or harm in the same way as operative interventions. It is therefore important for the prescriber to understand the relevant pharmacodynamics (the effects of the agent on the body) and pharmacokinetics (the effects of the body on the agent). To add a further layer of complexity, the reader should understand that pharmacological sciences are possibly the fastest evolving part of medicine. It would be a fair bet to say that, within the course of the reader’s undergraduate education, entire new classes of therapeutics will have emerged and established perceptions of other agents would have significantly changed. Practically speaking, this does not mean that it is necessary to mem­orize the nuances of all therapeutic agents (although you should have a good grasp of those you prescribe regularly); rather it is more important that a clinician understands how to recognize potential dangers and then be resourceful enough to mitigate against them, given the best know­ledge available at the time. Access to an up- to-date formulary and the will to use it are the surest way to navigate any prescribing pitfalls. ‘We don’t rise to the occasion, we fall to the most basic level of our training’. Thankfully, medical emergencies occur infrequently in the general practice setting. It is the rarity of such events that often leads to anxieties when dealing with them. This reaction is amplified by the caregiver’s nat­ural instinct to do something immediately, but often not knowing exactly what to do because the diagnosis is not immediately clear. The ABCDE approach, as advocated by the Resuscitation Council, is a safe and methodical way to approach any emergency. ABCDE is not only a hierarchy of importance for systems critical to life, but it also acts as an aide- memoire to undertake examinations and interventions when necessary. Most importantly, it buys time whilst the diagnosis is found or declares itself, without adversely affecting the outcome by inaction. Key topics include: ● Common drugs for common medical conditions ● Drug interactions ● Oral side effects of medications ● Basic life support ● Medical emergencies in dentistry (including the Resuscitation Council UK guidelines) ● ABCDE approach.

Prosthodontics

Prosthodontics comprises most of the routine restorative treatments that practitioners perform on a daily basis. Much restorative work re¬sults from the impact of caries and periodontal disease. However, the prevalence of toothwear is dramatically increasing and can be expected to form a more prominent feature of the modern practitioner’s work¬load. There is a considerable theory base in prosthodontics, covering all aspects of fixed and removable treatments, both conventional and contemporary. Although the individual management of teeth can be tricky, a challenge many new practitioners struggle with is treatment planning on a patient level. Treatment planning is rarely black and white, with considerable variations in opinion among clinicians, even for more simple cases. The staging of treatment planning is fairly consistent across the profession (e.g. relief of pain first, then investigatory phase, etc.), but in complex cases, a second opinion may be warranted. Not only is treatment plan¬ning a difficult skill, but so is the execution. It takes practice to become adept at the variety of clinical skills in prosthodontics and the staging of treatment, but this makes for a rewarding and fascinating discipline. Modern dentistry has a much greater focus on minimal invasive treat-ment, relying on dentine bonding and adhesive dentistry to limit the need for aggressive preparations of teeth and protect the vitality of the pulp. Moreover, the progression in digital dentistry is exponential, with newer production methods and clinical techniques becoming increasingly accurate and ever more accessible. As such, the modern practitioner needs to have a good understanding of both conventional concepts and modern alternatives in order to be able to apply the material and tech¬nique of choice to achieve an optimal outcome. The questions in the chapter aim to cover a wide range of topics, testing conventional concepts in both fixed and removable prostho¬dontics, whilst touching on contemporary materials and production methods. It is hoped that the reader will be challenged and the more difficult questions will promote wider reading. Key topics include: ● Diagnosis and treatment planning ● Occlusion ● Toothwear ● Complete dentures ● Removable dentures (including denture design principles) ● Direct restorations ● Crown and bridge ● Implant restorations ● Laboratory processes ● Digital dentistry.

Dental Materials

Dental material science can be a daunting subject for most dentists, given its origins in the pure sciences of physics and chemistry. Combining this with human biology, and trying to see through the fog of material manu­facturers’ commercial claims, can make it seem like a truly mystifying subject. It is important that any student of material sciences maintains a critical eye and an evidence- based approach when it comes to material selection and use. Today we are lucky enough to work with the most advanced dental materials we have ever had. But simply having such materials at your dis­posal does not ensure success. Clinical procedural techniques are often the prime focus in restorative dentistry; however, to achieve optimal aesthetics, function, and longevity from restorations, a clear under­standing of material sciences is required. Ancient Roman engineers clearly understood this concept when con­structing Rome. They had to work within the limitations imposed by the materials they had at their disposal. However, the longevity and solidity of the impressive infrastructure we see today can be attributed to their expertise in exploiting the unique properties of the material resources they had available. The Romans perfected concrete production (based on volcanic ash and lime reacting with seawater to form tobermorite crystals) to yield a water- hardening material, so durable and resistant to cracks that modern- day concrete (based on Portland cement) is still considered weaker. It can be argued whether operator skill or advancements in dental ma­terials have resulted in improvements in restorative dentistry. However, few would disagree that it is the combination of good operator skill and appropriate use of dental materials that is the key for successful long-term dentistry. Key topics include: ● Adhesive dentistry concepts ● Understanding material physical properties ● Elemental make- up of materials ● Manufacturing processing of materials ● Biocompatibility ● Appreciation of setting reactions and working time ● Appreciation of material aesthetic and optical properties.

Analgesia, Anaesthesia, and Sedation

The ability to practise dentistry and provide invasive treatments to pa­tients is based on the ability to make such procedures comfortable and acceptable for patients to tolerate, as well as manage post- operative pain. A good working knowledge of the different treatment modalities available, and analgesic agents that can be prescribed, is key to effective management of patients. This must include the indications and limita­tions of each modality. The pharmacology of most drugs used in modern- day dentistry has changed very little since their introduction, some as far back as 100 years ago. However, it is important to understand the processes regarding their method of action, their effect on the human body, and their indica­tions and contraindications. All of these factors must be considered to maximize the clinical benefit to the patient. Several guidelines regarding the use of conscious sedation in dentistry have recently been introduced, and it is important that those wishing to provide conscious sedation and refer patients appropriately familiarize themselves with these guidelines. Key topics include: ● Principles of analgesia, anaesthesia, and conscious sedation ● Pharmacology and pharmacodynamics of commonly used pharmaco­logical agents ● Indications and contraindications of commonly used pharmacological agents ● Conscious sedation with nitrous oxide ● Conscious sedation with midazolam ● General anaesthesia ● Treatment planning for conscious sedation and general anaesthesia ● Managing complications and adverse reactions

Periodontics

Periodontitis is estimated to be the sixth most prevalent disease in the world, and clinicians are likely to encounter this disease and other gin­gival conditions on a regular basis. It is therefore important to have a sound understanding of both the pathophysiology and management of periodontitis and related conditions. Periodontal disease may also be seen as a manifestation of systemic disease, so it may provide a window into the patient’s general health. Common conditions, such as diabetes mellitus, have a well- established relationship with the progression of periodontal disease, but rare gen­etic conditions, such as Ehlers– Danlos syndrome, may produce unusual findings. Therefore, the clinician should have a good breadth of know­ledge and be able to examine the patient as a whole, relating oral signs to systemic symptoms in order to diagnose and manage appropriately. The general dental practitioner’s role will focus mainly on diagnosis and non- surgical management of these patients, but awareness of the more advanced treatment will ensure appropriate referral and allow an informed discussion with the patient. A key challenge in the successful management of these patients is often getting them to obtain a suitable level of plaque control to stabilize the disease and maintain health. Ability to communicate this effectively and encourage excellent oral care is an invaluable asset. The questions in this chapter will test the readers’ knowledge of the fundamentals of periodontal diagnosis and practical skills. Moreover, questions are also presented examining the relationship with systemic disease and advanced treatment concepts. It is hoped that the questions in this chapter will test the readers’ baseline knowledge and promote further reading around complex or contentious subjects. Key topics include: ● Diagnosis/ disease classification ● Aetiology ● Systemic conditions ● Non- surgical management/ cause- related therapy ● Adjunctive therapies ● Surgical management/ corrective therapy ● Supportive therapy.

Radiology and Radiography

When you consider that, with direct vision alone, you can only see the coronal few millimetres of teeth and none of the surrounding alveolus, it becomes clear that, without additional visual aids, we can only assess and treat a relatively small proportion of our patient’s oral health needs. In 1895, only months after the very first medical radiograph, Dr Otto Walkhoff recorded the very first dental radiograph. This exposure was of his own dentition and lasted a lengthy 25 minutes. Since then, radiography has become a staple tool of the profession and refinement of the technology has allowed us to reduce exposure times down to milliseconds, with radiation doses smaller than those ex­perienced by people taking short- haul flights. Further advances in dose reduction and reformatting protocols have allowed for computed tom­ography to become increasingly popular for diagnostics and treatment planning in endodontic, oral surgery, and orthodontic cases. The benefits of dental radiography make them an indispensable resource, but since all types of radiation pose some degree of risk to human health, the clinician must consider how useful the information from the proposed exposure will be. There are no shortages of tragic stories of employees working with radiation who suffered ill health years after stopping work. Today dental radiography can be performed routinely and safely as a result of the valuable lesson learnt from the debilitating consequences suffered by past medical professionals, nuclear workers, and even the ‘radium girls’ who painted luminous material onto watch faces. Key topics include: ● Limitations of radiographs ● Image selection criteria ● Radiation physics, protection, and legislation ● Radiographic interpretation ● Types of dental radiographic imagery.

Orthodontics

Orthodontics is ‘the specialty of dentistry concerned with growth of the face, the development of dentition, and the prevention and correction of occlusal anomalies. A malocclusion can be defined as ‘a deviation from the ideal that may be aesthetically or functionally unsatisfactory, with a wide range of occlusal traits’. Orthodontics is a constantly evolving specialty, with ever changing principles and techniques continuing to be developed. There has been huge progress in orthodontics in recent times, with changes in the types of brackets, archwire materials, and appliance systems (such as tem­porary anchorage devices and aligner technology). The key principles of orthodontics date back to 1899 when Edward Angle described ‘the key to a normal occlusion as the anteropos­terior relationship between the upper and lower first molars’. In 1972, Lawrence Andrews described ‘six keys to an ideal static occlusion’. This was the basis of early orthodontic treatment planning. Knowledge of craniofacial development and growth is required as a foundation for understanding the aetiology of a patient’s malocclusion, to reach a diagnosis, and to plan orthodontic treatment. A basic under­standing of the types of orthodontic appliances is beneficial (mainly fixed appliances, functional appliances, some use of removable appliances, and retainers). In addition to the management of a malocclusion, orthodontic treat­ment is often required in conjunction with other specialties, including oral and maxillofacial surgery, paediatric and restorative dentistry Key topics discussed in this chapter include: ● Fixed appliances ● Functional appliances ● Removable appliances ● Retention ● Index of treatment need ● Orthodontic assessment and diagnosis ● Cephalometric analysis ● Malocclusion ● Ectopic canines ● Dental anomalies.

Preventative and Paediatric Dentistry

The child patient can be a challenging and daunting proposition for the junior dentist and dental student. Whilst children can be anxious, unco­operative, and unpredictable, they also present an extremely rewarding opportunity, which, if managed correctly, may go on to influence their healthcare experiences for the rest of their lives. Excellent behavioural management of the child patient (and their parents!) is fundamental to a successful clinical and patient- reported outcome. Aside from possible behavioural issues, paediatric patients may pre­sent with a series of unique clinical presentations that require additional skills and knowledge above and beyond those required for adult pa­tients. Differences in the micro- and macro- structures of primary and permanent teeth, coupled with variations in eruption dates, lead to an evolving mixed dentition that can lead to some difficult diagnostic and treatment planning scenarios. Furthermore, dental anxiety and the pre­ponderance for dento- alveolar trauma in children and young adults may exacerbate the patient management of an already complex situation. Prevention is central to paediatric dentistry. However, whilst signifi­cant progression has occurred in some areas, poor dietary habits and suboptimal oral hygiene regimes remain significant concerns for the pro­fession, with large numbers of dental extractions still performed under general anaesthesia each year. Key topics include: ● Tooth anatomy and eruption patterns ● Abnormalities of structure and form ● Prevention and management of dental caries, including pulp therapy ● Dental trauma ● Dental extractions and space management ● Behavioural management ● Safeguarding ● Pharmacological management.

Anatomy of the Head and Neck

Both are routine questions encountered by students during their time in dental school, and both require sound knowledge of the anatomy of the head and neck. From wrestling with basic anatomical concepts and planes to tracing the branches of the external carotid artery, anatomy will underpin the rest of your practising career and is a fundamental building block on which all other knowledge can be laid down. Basic ana­tomical knowledge begins with the osseous structures of the head and neck, blood vessels, lymphatics, and nerves. Interpretation of this know­ledge is required for functional and clinical applications, which is a daily occurrence for practising dentists and dental care professionals. Such a large subject is difficult to assess in a small number of questions, but this chapter touches on aspects of developmental embryology and tooth formation, along with functional anatomical questions designed to test the theory behind some common dental procedures and clinical presen­tations. Undoubtedly, excellent knowledge of the innervation and blood supply to the teeth and surrounding structures will be most beneficial for dentists and dental care professionals during their practising careers. Key topics include: ● Anatomical planes and terminology ● Craniofacial development ● The musculoskeletal system, including ossification and bony remodelling ● Innervation and vascular supply to the head and oral cavity, including the cranial nerves ● Structure of the eye, ear, nasal cavity, and oral cavity ● Odontogenesis ● Histology of the oral cavity.

Statistics, Epidemiology, and Dental Public Health

The content of this subject is frequently overlooked, as it is often ‘not seen as pertinent’ to practitioners’ day- to- day work. However, the impact of dental public health (DPH) as a discipline can be far reaching. DPH is concerned with improving the oral health of the population, rather than the individual. It has been described as the science and art of preventing oral disease, promoting oral health, and improving quality of life through the organized efforts of society. DPH teams have numerous responsibilities, including oral health sur­veillance, developing and monitoring quality dental services, oral health improvement, policy and strategy development and implementation, and strategic leadership and collaborative working for health. As such, the impact of DPH can frequently been seen at a local level, e.g. through health promotion campaigns or provision of new/ redistribution of ser­vices (in conjunction with commissioners) to meet local needs. DPH is predominantly a postgraduate subject, and although the undergraduate curriculum does not cover the whole topic, some core knowledge is valuable. In particular, understanding research method­ology and basic statistics is a useful skill to help interpret the dental lit­erature appropriately. This is ever more necessary in the modern era of evidence- based dentistry. The questions in this chapter will predominantly cover the fundamen­tals of statistics relevant to medical research, along with the basics of study design. Additional questions will touch on the concepts of health promotion and epidemiology, with further reading suggested to supple­ment the content. Key topics include: ● Study design ● Data analysis ● Critical appraisal ● Epidemiology ● Health promotion ● Strategic working and collaboration ● Assessing evidence on oral health and dental interventions, pro­grammes, and services ● Developing and monitoring quality dental services.