ANSWER
Excisional biopsy

OTHER OPTIONS
• Laser ablation – Destroys tissue
• Cryosurgery – Tissue lost, not ideal for premalignant lesions
• Incisional biopsy – used for large or suspicious lesions only

SYNOPSIS
• Small, clinically well-defined leukoplakic lesions should be completely removed and sent for histopathological examination
• Excisional biopsy is both diagnostic and therapeutic
• Allows evaluation of dysplasia or early carcinoma

REFERENCE
Shafer’s Textbook of Oral Pathology – 10th Edition

ANSWER
Burning mouth syndrome

OTHER OPTIONS
• Bismuth toxicity – causes black line (bismuth line)
• Candidiasis – erythema or white patches present
• Anemia – pallor, glossitis, angular cheilitis usually seen

SYNOPSIS
• Burning mouth syndrome (BMS) is characterized by
– Burning/scalding sensation
– Dysgeusia (metallic taste)
– Normal-appearing oral mucosa
• Common in middle-aged and post-menopausal women

REFERENCE
Shafer’s Textbook of Oral Pathology – 10th Edition

ANSWER
Semi Supine

OTHER OPTIONS
• Supine – Supine position may precipitate asthma symptoms.
• Prone – compromises respiration
• Decubitus – not practical for dental treatment

SYNOPSIS
• Semi-supine position
– Facilitates lung expansion
– Prevents respiratory distress

REFERENCE
Little and Falace – Dental Management of the Medically Compromised Patient

ANSWER
Trigeminal Neuralgia

OTHER OPTIONS
• TMJ Disorder – can cause pain in your jaw joint and in the muscles that control jaw movement
• Postherpetic neuralgia – Postherpetic neuralgia is the most common complication of shingles. The condition affects nerve fibers and skin, causing burning pain that lasts long after the rash and blisters of shingles disappear.
• Cluster headache – strikes quickly, usually without warning, although you might first have migraine-like nausea and aura. Common signs and symptoms during a headache include: Excruciating pain that is generally situated in, behind or around one eye, but may radiate to other areas of your face, head, and neck.

SYNOPSIS
• Trigeminal neuralgia, also called tic douloureux, is a chronic pain condition that affects the trigeminal or 5th cranial nerve.
• TN is a form of neuropathic pain (pain associated with nerve injury or nerve lesion.)
• The typical or classic form of the disorder (called Type 1 or TN1) causes extreme, sporadic, sudden burning or shock-like facial pain that lasts anywhere from a few seconds to as long as two minutes per episode. 
• The atypical form of the disorder (called Type 2 or TN2), is characterized by constant aching, burning, stabbing pain of somewhat lower intensity than Type 1.  Both forms of pain may occur in the same person, sometimes simultaneously. The intensity of pain can be physically and mentally incapacitating. 
• Pain varies, depending on the type of TN, and may range from sudden, severe, and stabbing to a more constant, aching, burning sensation. The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind. The pain may affect a small area of the face or may spread. Bouts of pain rarely occur at night, when the affected individual is sleeping.
• Treatment includes :
– Anticonvulsant medicines-used to block nerve firing are generally effective in treating TN1 but often less effective in TN2. These drugs include carbamazepine, oxcarbazepine, topiramate, gabapentin, pregabalin, clonazepam, phenytoin, lamotrigine, and valproic acid.
– Tricyclic antidepressants such as amitriptyline or nortriptyline can be used to treat pain. Common analgesics and opioids are not usually helpful in treating the sharp, recurring pain caused by TN1, although some individuals with TN2 do respond to opioids.  Eventually, if medication fails to relieve pain or produces intolerable side effects such as cognitive disturbances, memory loss, excess fatigue, bone marrow suppression, or allergy, then surgical treatment may be indicated. Since TN is a progressive disorder that often becomes resistant to medication over time, individuals often seek surgical treatment.

REFERENCE
Trigeminal Neuralgia Fact Sheet – National Institute of Neurological Disorders and Stroke

ANSWER
Observe over time

OTHER OPTIONS
• Extraction – Only done if there is no means of saving the tooth.
• Endodontic management – Done in closed apex cases with necrotic pulp changes.
• Pulpotomy – A pulpotomy is a dental procedure in which the pulp in the crown of a tooth is removed in order to save the tooth from infection or decay. 

SYNOPSIS
• Electric pulp testing is based on stimulation of sensory nerves and requires and relies on subjective assessments and comments from the patient. These can lead to false-positive and false-negative results.
• Younger or anxious patients can have false-positive results due to psychological factors.
• Likewise, false-negative results are possible in teeth with incomplete apical development, trauma, root canal calcification, periodontal disease, or in patients undergoing orthodontic treatment.
• So it’s always better to wait and observe for some time and evaluate the pulp status of the tooth.

REFERENCE
Grossman’s endodontic practice pg 378.

ANSWER
Cast post and core

OTHER OPTIONS
• Not applicable

SYNOPSIS
• The only tapered post design that is clinically recommended is the custom-cast post and core system.
• Custom-cast post and cores adapt well to extremely tapered canals or those with a non-circular cross-section or irregular shape and roots with minimal remaining coronal tooth structure.

REFERENCE
Custom-made post and core in Endodontics – Slideshare Article.

ANSWER
Pulp necrosis

OTHER OPTIONS
Not applicable

SYNOPSIS
• Necrosis is death of the pulp.
• It may be partial or total.
• Necrosis will result in dry gangrenous necrotic pulp.
• A necrotic pulp may not show painful symptoms and may not bleed while removing the pulp.
• Treatment is complete removal of pulp and obturation of root canals.

REFERENCE
Grossman’s Endodontic Practice – 13th Edition Page No 108.

ANSWER
Bite registration paste.

OTHER OPTIONS
• Modeling compound and wax hold many comparable characteristics. Once the record is made, it is subject to being blunted, distorted, scraped, and compressed.

SYNOPSIS
• Bite registration materials
– Waxes
– Quick setting plaster
– Impression compound
– Bite registration paste (ZnO-E)
– Bite registration silicone
• Zinc oxide and eugenol type of bite registration paste is one material of choice for the maxillomandibular record.
• Advantages
– Fluidity before setting – fluidity is a critical quality of a bite recording material because it provides nominal interference with mandibular closure during record-making procedures.
– Adherence to its carrier.
– After the final set, there is rigidity and inelasticity.
– Accuracy in recording occlusal and incisal surfaces of the teeth.
– High intensity of repeatability.
• Disadvantages
– Long setting time.
– Highly brittle.

REFERENCE
Interocclusal recording materials – A review.- Journal of Advanced Clinical and Research Insights (2019), 6, 20-23.

Answer
Reduce the chances of fracture of the metal seat

OTHER OPTIONS
Not applicable

SYNOPSIS
• The most common mistake in occlusal rest seat preparation is the insufficient reduction of the marginal ridge.
• This leads to the construction of a rest that is extremely thin and subject to fracture.
• An occlusal rest must be at least 0.5 mm thick at its thinnest point and should be between 1.0 and 1.5 mm thick where it crosses the marginal ridge.
• The marginal ridges are rounded off to reduce the chances of fracture of the metal seat

Reference Stewarts clinical RPD 3rd ed, pg 48

ANSWER
No mechanical preparation is necessary

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
• The special characteristics of these lesions are the presence of dentin or cementum in the gingival margins,
• Along with the lack of mechanical retention and difficulty in controlling moisture contamination in doing these restorations, longevity and marginal sealing are challenged.
• GICs are very durable in cervical restorations and compete with the composites, particularly where bonding to cervical dentin is required.
• Class V caries occur on the buccal and lingual aspects and may extend subgingivally, limiting the therapist’s ability to remove them completely and place a proper restoration.
• GICs have very low shrinkage and are thermally compatible with tooth structure.
• They can even bond to dentin surfaces without the removal of the smear layer and their biological compatibility is well proved.

REFERENCE
Sturdevant’s Art and Science of Operative Dentistry

ANSWER
Cold lateral condensation would be very difficult

OTHER OPTIONS
• Not applicable

SYNOPSIS
• Cold lateral condensation would be very difficult if a GP cone with a different taper than the taper of prepared canal is used.
• With the introduction of standardized endodontic instruments, standardized master cones were also made available, with various ISO sizes and a 2 percent taper.
• The standardized sizes are designed to match the size and taper of the corresponding stainless steel or nickel-titanium instruments employed for shaping the canals.
– ISO 2 percent from size Nos. 15 to 140
– Greater taper gutta-percha cones such as 4 or 6 percent taper
– Variable taper gutta-percha points suiting the taper of variable taper shaping instruments such as the ProTaper F1, F2, and F3.

REFERENCE
Grossman’s endodontics pg 317.

ANSWER
Mucocoele

OTHER OPTIONS
• Not applicable

SYNOPSIS
• A mucocele or mucous retention cyst is a benign pathologic lesion.
• The lesion is a result of the extravasation of saliva from an injured minor salivary gland.
• The collection of extravasated fluid develops a fibrous wall around itself forming a pseudocyst.
• The lesion can fluctuate in size depending on its fluid-filled state.
• The lesion is nonpainful, soft, doughy, and fluctuant to palpation.
• Clinically the overlying mucosa may have the same coloration as the lower lip or have a bluish hue.
• Lesions of longer duration may appear firmer and fibrotic and be difficult to distinguish from a fibroma.
• A mucocele most likely results secondary to a traumatic event that in most situations goes unrecognized.
• The lower lip is the most common location.

REFERENCE
The Mucous Retention Cyst – Surgery of Salivary Glands-2021

ANSWER
BT

OTHER OPTIONS
• Explained below

SYNOPSIS
• If the patient is otherwise normal, the patient usually prolongs the bleeding time by 1.5 – 2 minutes.
• Low-dose aspirin therapy (150 mg daily) does not affect either preoperative coagulation tests or postoperative blood loss.
• Only BT is affected in Patients under aspirin therapy no effect on other tests.

REFERENCE
Medical Emergencies – Stanley F Malamed

ANSWER
Osteonecrosis

OTHER OPTIONS
• Chronic osteomyelitis – Bone infection that is mainly caused by Staphylococcus bacteria
• Metastasis – The spread of cancer cells from the place where they first formed to another part of the bodyDry socket
• Alveolar osteitis – Dry socket is a painful dental condition that happens as a complication of extraction

SYNOPSIS
• Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a condition in which bones of the maxillofacial skeleton, in particular the tooth-bearing areas, become necrotic and exposed to the oral cavity.
• Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is thought to be caused by trauma to dentoalveolar structures that have a limited capacity for bone healing due to the effects of bisphosphonate therapy.
• Panoramic and plain radiography of the mandible reveal areas of sclerosis, destruction, sequestration, or pathologic fractures.
• Delayed or persistent tooth sockets after extraction may also be revealed in these patients.
• Management of bisphosphonate-related osteonecrosis of the jaw
– Nonsurgical management of bisphosphonate-related osteonecrosis of the jaw (BRONJ) may consist of the following:
1. Antimicrobial rinses
2. Systemic antibiotics
3. Systemic or topical antifungals
4. Discontinuation of bisphosphonate therapy
5. No dental therapy or minimally invasive dental therapy (ie, root canal therapy instead of extraction)
– Surgical intervention for bisphosphonate-related osteonecrosis of the jaw (BRONJ) remains limited because of the impaired ability of the bone to heal.

REFERENCE
Bisphosphonate-Related Osteonecrosis of the Jaw-Jan 08, 2021 – Medscape

ANSWER
Selected periapical and posterior bite wings

OTHER OPTIONS
• Not applicable

SYNOPSIS
• For first time visit a 7-year-old is recommended to take posterior bitewings and panoramic exam OR posterior bitewings and selected periapical
• For first visit , children of 1-5 year age group – posterior bitewings and periapical x-ray of anteriors. Bitewing x rays every 6-12 months for child with high caries risk and every 12-24 months for low caries risk children
• For 6-12 years old – posterior bitewings, selected periapical of anteriors or a Panoramic x ray and posterior bite wings .Bitewings are recommended every 6-18 months in high risk patients and every 12-36 months in low caries risk patients
• For those above 12 years of age with permanent teeth but no wisdom teeth,the Dentist might take bitewing x rays of posteriors, selected periapical x rays or a panoramic x ray, or a full mouth survey of x rays if there is evidence of widespread disease. Bitewings are recommended every 6- 18 months for high risk cases and every 12-36 months for low risk cases.

REFERENCE
AAPD Guidelines for use of Radiographs in Children

ANSWER
All the above

OTHER OPTIONS
• Not applicable

SYNOPSIS
• The marginal deterioration refers to poor marginal adaptation which may produce marginal discoloration, post-operative sensitivity, and secondary caries. These are the most frequent reasons to replace or repair an adhesive restoration.
• Amalgams that are corroded or have inadequate bulk to distribute stresses may fracture. At margins, where amalgams are thinner, extrusion may have occurred, and corrosion may have compromised the integrity of the amalgam, fracture is even more likely.
• Other factors include faulty manipulation and finishing of the filling.

REFERENCE
Deterioration of Restorative Materials and the Risk for Secondary Caries – A.J. Goldberg

ANSWER
Increase

OTHER OPTIONS
Not applicable

SYNOPSIS
• The periodontal disease progression has an inverse correlation with the dimension of the supracrestal connective tissue(SCTA).
• So after therapy attachment increases.
• The SCTA regains its original dimensions after periodontal therapy, in cases of shallow pockets (3-5 mm) treated with scaling and root planing, it takes 3 months.
• It may take 6 months in moderate pockets (5-7 mm) treated by periodontal flap surgery.
• Most changes in the SCTA occur within first 3 months and remain stable up to 6 months irrespective of the treatment protocol.

REFERENCE
Assessment of Supracrestal Tissue Attachment Variation in Patients with Chronic Periodontitis Before and After Treatment – A Clinical Radiographic Study.

ANSWER
Increasing tooth mobility due to trauma from occlusion

OTHER OPTIONS
• Bruxism without periodontal involvement – Bruxism alone requires occlusal splints but does not always mandate occlusal adjustment unless periodontal damage is evident.
• An extruded molar without functional interference – An extruded molar requires occlusal therapy only if it causes functional interference or traumatic occlusion.
• Stable occlusion with generalized gingivitis – Gingivitis with stable occlusion is managed primarily by plaque control, not occlusal therapy.

SYNOPSIS
• Occlusal therapy (occlusal adjustment, splinting, bite guards) is indicated when occlusal forces contribute to periodontal tissue injury, known as trauma from occlusion.
• Increasing mobility, fremitus, widened PDL space, and discomfort on chewing are classic signs where occlusal therapy is beneficial.
• Thus, occlusal therapy is most clearly indicated in increasing mobility caused by traumatic occlusal forces.

REFERENCE
Carranza’s Clinical Periodontology, 13th Edition

ANSWER
Decreased postoperative edema and discomfort

OTHER OPTIONS
• Less tissue reflection – Less tissue reflection is not the primary advantage; reflection depends on flap design and extent.
• Increased apical displacement of gingiva – Apical displacement is a feature of apically positioned flaps, not crestal incisions.

SYNOPSIS
• A crestal incision is placed within the keratinized gingiva and avoids crossing the mucogingival junction.
• Because the flap remains confined to attached gingiva
– Surgical trauma is minimized
– Blood supply is better preserved
– Postoperative edema, pain, and patient discomfort are reduced

REFERENCES
Carranza’s Clinical Periodontology, 13th Edition

ANSWER
Extraction with immediate implant placement

OTHER OPTIONS
• Socket preservation – It delays final rehabilitation and may compromise soft-tissue esthetics.
• Removable denture – Poor esthetics and unacceptable for a self-conscious patient.
• Early implant placement – It requires healing time (4–8 weeks), delaying esthetic rehabilitation.

SYNOPSIS
• In the esthetic zone, especially in patients with a high smile line, preservation of soft tissue contours and papillae is critical.
• Immediate implant placement
– Reduces overall treatment time
– Preserves alveolar bone height and gingival architecture
– Avoids the need for removable interim prosthesis
– Provides superior esthetic outcomes when case selection is ideal
• This option best fulfills the patient’s demands for
– Speed
– Esthetics
– Psychological comfort

REFERENCES
Carranza’s Clinical Periodontology, 13th Edition

ANSWER
Justice

OTHER OPTIONS
• Nonmaleficence – Considered to be the foundation of social morality. Actions of the healthcare provider should not harm the patients in anyway
• Autonomy – It is the principle that dictates that health care professionals respects patients right to make decisions concerning the treatment plan.
• Veracity- The patient – doctor relationship is based on trust.

SYNOPSIS
• Justice provide equal treatment to all without any prejudice
• Violation of justice – Discrimination between patients based on caste, creed, socioeconomic status, health condition .
• Principle of justice is to protect the weak and to ensure equality in rights and benefits, for both groups and individuals.

REFERENCE
Textbook of community dentistry Soben peter

ANSWER
Clipping the wire

OTHER OPTIONS
Not applicable

SYNOPSIS
• Thin wire called archwire runs through brackets that are attached to teeth.
• Sometimes, archwires can pop out of place.
• Archwires can be broken or protruded due to many reasons like hard or sticky foods, mechanical injuries etc.
• Protruded arch wires can cause discomfort, ulcer and even infection.
• Clinically, protruding archwires are clipped.

REFERENCE
Article on What to do If Braces Wires Broke.

ANSWER
Morphodifferentiation

OTHER OPTIONS
• Initiation – Supernumerary tooth and congenitally missing tooth develops due to defect in initiation.
• Apposition – Enamel hypoplasia develops due to disturbances during apposition.
• Histodifferentiation – Dentinogenesis imperfecta and amelogenesis imperfecta develops due to disturbances during histodifferentiation.

SYNOPSIS
• In morphodifferentiation stage, formative cells are arranged to outline the form and size of tooth.
• Morphologic pattern of tooth becomes established when inner epithelium epithelium is arranged so that boundary between it and odontoblasts outlines duture DEJ.
• Disturbances during this stage results in peg laterals, microdontia and macrodontia.

REFERENCE
Article on Development and Morphology of Teeth.

ANSWER
Autoclave for 40 min

OTHER OPTIONS
• 10 percent formalin for 2 weeks – Extracted tooth with amalgam restoration is sterilized by storing in formalin for 2 weeks.
• Sodium hypochlorite and Saline – Sodium hypochlorite, water or saline can be used but is not effective in reducing bacterial accumulation during storage.

SYNOPSIS
• Extracted teeth are collected to be used in dental education settings.
• Extracted teeth is placed in container with secure lid to prevent leakage during transport.
• Teeth without amalgam restoration should be heat sterilized for safe handling.
• Pantera and Shuster demonstrated elimination of microbial growth using autoclave for 40 minutes.

REFERENCE
Article on Safe Handling of Extracted teeth.

ANSWER
Plastic scaler

OTHER OPTIONS
Not applicable

SYNOPSIS
• All metal instruments and ultrasonic scalers increase the surface roughness of titanium.
• Use of plastic, teflon coated and carbon coated scalers and nonmetal ultrasonic tips are advocated for scaling titanium implant from contamination by other metals and reduce scratching the surface.

REFERENCE
Newman and Carranza’s Clinical Periodontology – 13th Edition Page No 864.

ANSWER
Inhibits synthesis of cell wall proteoglycan

OTHER OPTIONS
Not applicable

SYNOPSIS
• Penicillin is a narrow spectrum antibiotic.
• It is effective against some gram positive bacteria.
• It kills bacteria by blocking transpeptidase which in turn inhibits cell wall proteoglycan formation.
• Commonly used in pneumonia, ear infections, strep throat, otitis media etc.

REFERENCE
Essentials of Pharmacology for Dentistry, KD Tripathi – 3rd Edition.

ANSWER
Avulsion

OTHER OPTIONS
• Extrusion and Root fracture – Extrusion and root fracture rarely cause ankylosis.
• Intrusion – Intrusion, if left untreated can cause ankylosis.

SYNOPSIS
• Ankylosis or external replacement resorption is resposible for the metallic sound on percussion followed by trauma.
• Mainly caused by replantation of avulsed teeth.
• In ankylosis, the root structure is replaced by bone.
• Extraction of ankylosed tooth is considered to be very difficult an might need surgical approach.

REFERENCE
Grossman’s Endodontic Practise – 13th Edition Page No 139.

ANSWER
Cotton wool appearance

OTHER OPTIONS
• Orange peel appearance – Monostotic fibrous dyplasia is radiographically has a orange peel appearance.
• Soap bubble appearance – Ameloblastoma shows soap bubble or honey comb appearance.
• Sunburst appearance – Osteosarcoma shows sunburst appearance radiographically.

SYNOPSIS
• Paget’s disease is a chronic progressive disease of bone.
• Usually seen after 50 years of age.
• Affected bones show expansion and deformity.
• Mainly causes frontal bossing, headache, parasthesia, blindness, hearing loss and facial nerve palsy.
• Radiographically shows a cotton wool appearance.
• No specific treatment is done.

REFERENCE
Shafer’s Textbook of Oral pathology – 8th Edition Page No 470.

ANSWER
Adrenal crisis

OTHER OPTIONS
● Hyperglycemia – Symptoms are polyuria, polydipsia not sudden hypotension.
● Adrenal insufficiency – Chronic form, acute emergency is adrenal crisis.
● Hyperthyroidism – It causes tachycardia, anxiety, and hypertension not hypotension.

SYNOPSIS
● If the patient is on long-term steroid therapy for arthritis (e.g., prednisolone), their adrenal gland may be suppressed.
● Stress from dental treatment can lead to acute adrenal crisis.,
● Hypotension is the earliest and most important sign.
– BP 100-75 mmHg is low for a stressed state.
– Warm or weak feeling and discomfort further support a circulatory collapse picture.
● Patients on long-term steroids need stress dose steroid supplementation before major dental procedures to prevent adrenal crisis.

REFERENCE
Medical Emergencies in the Dental Office – Stanley F Malamed 7th Edition

ANSWER
Double the dose of steroids on day of extraction

OTHER OPTIONS
Not applicable

SYNOPSIS
• Patients with Crohn’s disease are commonly on long-term corticosteroid therapy.
• Chronic steroid use can cause suppression of the hypothalamic–pituitary–adrenal (HPA) axis.
• Dental extraction of a grossly decayed molar is considered a minor–moderate surgical stress.
• In patients on long-term steroids, failure to provide stress-dose steroid supplementation may precipitate acute adrenal insufficiency (Addisonian crisis).
• Therefore, the recommended protocol is to Double the usual daily dose of steroids on the day of extraction, then return to the normal dose the following day.

REFERENCE
Article on Potentional Relationship between the Dosage of Prednisolone and Delayed Healing at Tooth Extraction.

ANSWER
Vasovagal Syncope

OTHER OPTIONS
• Hyperglycemia – It can occur as a complication after extraction if the extraction site is prone to infection.
• LA overdose – Confusion, dizziness, tinnitus, and perioral numbness which may progress to seizures, respiratory arrest, or coma.

SYNOPSIS
• Syncope is the most common emergency in dental practices.
• Psychogenic factors seem to play an important role in provoking syncope.
• Many individuals faint (vasovagal response) at the sight of a needle, the removal of a bandage, or even the discussion of a surgical procedure.
• Key signs are Pallor, sweating, nausea, bradycardia, hypotension, and loss of consciousness
• Placing the patient in a supine reclined position with raised legs in combination with the administration of oxygen seems effective for regaining consciousness.

REFERENCE
Medical emergencies in the Dental Office – Stanley F Malamed

ANSWER
21 days

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
• Gingivitis Development Timeline (Löe et al. study)
• Initial lesion – 2-4 days
Subclinical inflammation (not visible yet)
• Early lesion – 4-7 days
Clinical signs begin (redness, bleeding)
• Established lesion – 14-21 days
Clear gingival inflammation, edema, bleeding, possibly pseudopocket formation

REFERENCE
Carranza’s Clinical Periodontology (13th ed.)

ANSWER
When permanent centrals erupt.

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
• The American Association of Orthodontists (AAO) recommends an evaluation with an orthodontist no later than age 7.
• By that age, a child will have a mix of baby and permanent teeth, and the orthodontist will be able to recognize orthodontic problems (malocclusions) even in their earliest stages.
• The best age varies from patient to patient.

REFERENCE
Early Treatment for Malocclusion-Adam Husney MD – Family Medicine & Martin J. Gabica MD – Family Medicine & William F. Hohlt DDS – Orthodontics-October 27, 2020.

ANSWER
IgE antibodies

OTHER OPTIONS
• IgG or IgM antibodies – Type II is caused by cytotoxic reaction mediated by IgG or IgM antibodies.
• Immune complex mediated – Type III is reaction mediated by immune complexes.
• Cell mediated – Type IV is delayed reaction mediated by cellular response.

SYNOPSIS
• Hypersensitivity is immune and inflammatory responses that are harmful to the host.
• Type 1 hypersensitivity is IgE mediated.
• Antigen induces cross linking of IgE bound to mast cells and basophils with release of vasoactive mediators.
• It occurs immediately after contact with allergens or antigens.
• Response to the antigen occurs in two stages – the sensitization and the effect stage.
• In the sensitization stage, the host experiences an asymptomatic contact with the antigen.
• Subsequently, in the effect period, the pre-sensitized host is reintroduced to the antigen, which then leads to a type I anaphylactic or atopic immune response.
• Typical manifestations include systemic anaphylaxis, localized anaphylaxis such as hay fever, asthma, hives, food allergies and eczema.

REFERENCE
Type I Hypersensitivity Reaction by National Library of Medicine.

ANSWER
Replacement resorption

OTHER OPTIONS
• Internal resorption – Internal resorption is an uncommon resorption of the tooth, which starts from the root canal and destroys the surrounding tooth structure. 
• External resorption – External root resorption is when the body’s own immune system dissolves the tooth root structure. It can occur following tooth infection, orthodontic treatments or in the presence of unerupted teeth in the jaw.
• Inflammatory resorption – Inflammatory resorption is one of the potential consequences of trauma to the teeth. It occurs when there has been a loss of cementum due to damage to the external surface of the tooth root during trauma, plus the root canal system has become infected with bacteria.

SYNOPSIS
• Replacement Resorption is characterized by a pathologic loss of tooth substance (cementum, dentin, and PDL) with subsequent replacement of these tissues by bone, which results in the fusion of the root to the surrounding bone(ankylosis).
• It is usually a late complication of after trauma and is asymptomatic.
• A tooth undergoing external replacement resorption is ankylotic and gives metallic sound to percussion with a mirror handle

REFERENCE
External inflammatory and replacement resorption of luxated, and avulsed replanted permanent incisors – a review and case presentation – Dental Traumatology

ANSWER
Under extended post dam

OTHER OPTIONS
• Increased vertical dimension – Increased vertical dimension cause, TMJ pain, muscle pain, and clicking of posterior teeth.
• Over extended post dam – Overextended post dam causes gagging reflux and dislodging of denture.

SYNOPSIS
• Under post-damming is usually caused by the inaccurate depth of post-damming and improper application of the technique in obtaining PPS
• Recording PPS with a widely opened mouth causes tautness of the pterygomandibular fold, which leads to the spacing between the denture base and tissue when the fold is no longer activated.
• It can be diagnosed using two tests
1. When the denture is inserted in the patient’s mouth, examine the presence of space in the posterior border of the denture base when the patient is saying ‘ah’
2. Check for the presence of bubbles escaping when the wet denture base is placed and pressed in the midpalate region

REFERENCE
The Post Dam – A Review – Indian Journal of Dentistry

ANSWER
Passive clasp

OTHER OPTIONS
• Not applicable

SYNOPSIS
• A passive clasp does not engage the undercut properly, reducing retention and allowing for movement. This is a common reason for instability in RPDs.

REFERENCE
Stewart’s Clinical Removable Partial Prosthodontics, 5th ed.

ANSWER
Systemic steroids

OTHER OPTIONS
• Not applicable

SYNOPSIS
• IBD-associated oral lesions (like snail-track ulcers in ulcerative colitis) are immune-mediated and may require systemic immunosuppression.
• Systemic steroids are the treatment of choice in moderate to severe cases.

REFERENCE
Scully C. Oral and Maxillofacial Medicine, 3rd ed.

ANSWER
Lateral Pterygoid

OTHER OPTIONS
• Not applicable

SYNOPSIS
• The superior head of the lateral pterygoid inserts into the articular disc and capsule of the TMJ and plays a role in disc stabilization during movement.

REFERENCE
Okeson JP. Management of Temporomandibular Disorders and Occlusion, 8th ed.

ANSWER
Place her in supine position with elevated legs

OTHER OPTIONS
• Not applicable

SYNOPSIS
• This is likely a hypoglycemic episode or vasovagal syncope.
• The initial management is to increase cerebral perfusion by positioning her supine with legs elevated

REFERENCE
Malamed SF. Medical Emergencies in the Dental Office, 7th ed.

ANSWER
No fluoride supplementation is needed until 6 months

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
• Fluoride supplementation is not recommended for infants under 6 months of age, regardless of fluoride content in drinking water.
• For children 6 months to 3 years living in areas with less than 0.3 ppm fluoride, the AAP and ADA recommend 0.25 mg per day.
• Before 6 months, the risk of fluorosis outweighs the benefits, and systemic supplements are not beneficial.

REFERENCE
American Academy of Pediatrics (AAP) – Fluoride Use in Caries Prevention in the Primary Care Setting, Pediatrics 2014.

ANSWER
True periodontal pocket will not form

OTHER OPTIONS
• Faster than normal – Pocket formation is dependent on periodontal ligament detachment, which is absent in ankylosed teeth.
• Slower than normal – There is no true periodontal attachment to detach from, so a pocket cannot form at any rate.
• Both at the same rate – True periodontal pockets form in teeth with a periodontal ligament; since ankylosed teeth lack this, the rate is not comparable.

SYNOPSIS
• Ankylosed teeth are characterized by the fusion of the cementum or dentin directly to the alveolar bone, leading to the absence of a functional periodontal ligament (PDL)
• Lack of PDL – No normal periodontal attachment
• No normal bone resorption and remodeling – These teeth remain fixed in position while adjacent teeth continue to erupt, leading to infra occlusion
• Since the periodontal ligament is absent, true periodontal pockets do not form, as pockets require detachment of the gingival fibers from the root surface.

REFERENCE
Carranza FA, Newman MG. Carranza’s Clinical Periodontology, 13th ed. Elsevier, 2018.

ANSWER
Refer the patient to an oral medicine specialist for further evaluation

OTHER OPTIONS
• Reassure the patient that the lesion is benign and no treatment is required – Reassurance without further evaluation is not ideal due to the systemic implications.
• Prescribe antifungal medication and review in two weeks – HIV is viral infection.

SYNOPSIS
• The lesion described is characteristic of oral hairy leukoplakia (OHL), which commonly appears on the lateral tongue and is strongly associated with Epstein-Barr Virus (EBV) in immunocompromised patients, especially those with HIV/AIDS.
• OHL is not premalignant, but its presence may indicate HIV disease progression or poor immune function
• It does not typically require biopsy if the clinical diagnosis is clear, but a referral to a specialist is appropriate for confirmation, monitoring, and coordination of HIV care.

REFERENCE
Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition (2020). Chapter on oral manifestations of systemic disease.

ANSWER
Dentinogenesis imperfecta

OTHER OPTIONS
• Amelogenesis Imperfecta – It is usually characterized by smaller than normal teeth, the color of which may range from white to yellow-brown, and teeth that appear to be mottled or spotted. The enamel is thinner than normal with areas that are clearly less dense (hypomineralized) and pitted.
• Enamel hypoplasia – It can appear as a white spot, yellow to brown staining, pits, grooves, or even thin, chipped, or missing parts of enamel.
• Hypocalcification – Enamel hypocalcification is the presence of white, brown or yellow stains on teeth and opaqueness on the tooth enamel.

SYNOPSIS
• Dentinogenesis imperfecta is a condition characterized by teeth that are translucent and discolored (most often blue-grey or yellow-brown in color).
• Individuals with this disorder tend to have teeth that are weaker than normal, which leads to wear, breakage, and loss of teeth.
• This damage can include teeth fractures or small holes (pitting) in the enamel.
• Dentinogenesis imperfecta can affect both primary (baby) teeth and permanent teeth.

REFERENCE
Shafer’s Textbook of Oral Pathology

ANSWER
Ameloblastoma

OTHER OPTIONS
• Not applicable

SYNOPSIS
• Ameloblastoma is a benign but locally aggressive odontogenic tumor that commonly occurs in the mandible.
• The classic radiographic appearance is a multilocular radiolucent lesion with a soap bubble or honeycomb appearance.
• Histopathologically, ameloblastomas show epithelial cells with reverse polarity and stellate reticulum-like areas, which are characteristic findings.
• Treatment typically involves surgical resection due to the tumor’s potential for local recurrence.

REFERENCE
Shafer’s Textbook of Oral Pathology

ANSWER
Kingsley scraper

OTHER OPTIONS
• Lecron carver – LeCron carver is popular for the carving of inlay wax in the production of crowns. This carver is used cold to shape modeling wax in the production of dentures.
• Small wax knife – A small wax knife is most commonly used in the fabrication of crowns for placing and carving inlay wax.
• Large wax knife Used for melting, placing, and carving modeling wax in the production of dentures.

SYNOPSIS
• Techniques for recording PPS
1. Conventional technique.
2. Fluid wax technique.
3. Arbitrary scrapping of the mastercast.
• Using a Kingsley scraper, the area between the anterior and posterior vibrating line is scraped in the master cast to a depth of 1 to 1.5 mm on either side of the mid-palatine raphe. In the region of the mid-palatine raphe, it should be only 0.5 to 1mm in depth.

REFERENCE
Boucher, Prosthodontic Treatment for Edentulous Patients, pg 118-120

ANSWER
Attachment level or Attachment loss

OTHER OPTIONS
• NIL

SYNOPSIS
• The severity of the disease is based on the amount of clinical attachment loss (CAL).
• It is described as
– Mild when the CAL is 1 to 2 mm,
– Moderate the CAL is 3 to 4 mm, or
– Severe when the CAL is more than 5 mm

REFERENCE
Carranza’s Clinical Periodontology

ANSWER
Pain will resolve on its own

OTHER OPTIONS
• NIL

SYNOPSIS
• After completion of root canal treatment, patients usually complain of pain, especially on biting and chewing.
• More postoperative discomfort is encountered in endodontic treatment of posterior teeth.
• Etiology
– Overinstrumentation
– Persistent periapical inflammation
– Overfilling
– Missed canal
– Hyperocclusion
– Poor coronal seal
– Fracture of crown or root
• Management
– Generally, there is some discomfort following obturation that subsides in 2-5 days.
– Pain that persists beyond this period should make the operator reassess the treatment performed

REFERENCE
Grossman’s Endodontic Practice-14th.ed.

ANSWER
Hodgkin’s lymphoma

OTHER OPTIONS
• Non-Hodgkin’s lymphoma – NHL does not characteristically show Reed-Sternberg cells.
• Burkitt’s lymphoma – It is associated with Epstein-Barr virus (EBV) and presents with aggressive jaw involvement in endemic cases.
• Multiple myeloma involves plasma cells and does not exhibit Reed-Sternberg cells.

SYNOPSIS
• Reed-Sternberg (RS) cells are large binucleated or multinucleated cells with prominent nucleoli, classically seen in Hodgkin’s lymphoma (HL).
• HL typically presents with painless lymphadenopathy, fever, weight loss, and night sweats.

REFERENCE
Kumar V, Abbas AK, Aster JC. Robbins and Cotran Pathologic Basis of Disease. 10th ed. Elsevier; 2020.

ANSWER
2

OTHER OPTIONS
• Not applicable

SYNOPSIS
• MRD of Lidocaine for children = 4.4 mg/kg
• For a 20 kg child – 20×4.4=88 mg 
• 2% Lidocaine = 20 mg/mL
• Each cartridge (1.8 mL) contains, 20×1.8=36 mg of Lidocaine
• No of catridge = 88/36 = 2.4 catridges

REFERENCE
Malamed SF. Handbook of Local Anesthesia. 7th ed. Elsevier; 2020.

ANSWER
When there is excessive force on a tooth exceeding its adaptive capacity

OTHER OPTIONS
• Not applicable

SYNOPSIS
• Traumatic occlusion occurs when excessive occlusal forces exceed the tooth’s adaptive capacity, leading to damage to the periodontium.
• Primary occlusal trauma occurs when excessive force is applied to a tooth with a normal periodontium.
• Secondary occlusal trauma occurs when normal occlusal forces cause damage due to a weakened periodontium (e.g., due to periodontitis).
• Clinical Signs of Traumatic Occlusion:
Increased tooth mobility
Widening of the PDL space
Fremitus (vibration of teeth during occlusion)
Tooth migration and abfraction lesions

REFERENCE
Carranza FA, Newman MG. Carranza’s Clinical Periodontology. 13th ed.

ANSWER
High pull headgear

OTHER OPTIONS
• Twin Block appliance – Twin Block Appliance is used for Class II malocclusion correction but does not effectively control vertical growth.
• Herbst appliance – Herbst Appliance is primarily used to advance the mandible in Class II cases but does not control vertical facial height.
• Frankel II Appliance – It is a functional regulator for Class II malocclusion, but it does not specifically address vertical growth control.

SYNOPSIS
• Hyperdivergent mandible (skeletal open bite) is characterized by excessive vertical growth of the face, often due to overeruption of molars and clockwise rotation of the mandible.
• The goal of treatment is to control vertical maxillary growth, restrict molar eruption, and reduce mandibular clockwise rotation.
• High-Pull Headgear applies an upward and backward force on the maxilla, limiting downward growth and controlling the occlusal plane.

REFERENCE
Proffit WR, Fields HW, Larson BE, Sarver DM. Contemporary Orthodontics. 6th ed. Elsevier; 2018.

ANSWER
6 hours

OTHER OPTIONS
• Nil

SYNOPSIS
• Preoperatively, the heparin should be stopped 6 hours before the procedure.
• Postoperatively, the heparin can be restarted when the surgeon agrees it is safe, usually 6-12 hours postoperatively.

REFERENCE
Preoperative Anticoagulation Management – Medscape

ANSWER
Vit B12 deficiency

OTHER OPTIONS
• Geographic tongue – Geographic Tongue is characterized by map-like, red patches on the tongue with white borders, but it typically does not cause significant swelling or difficulty in swallowing.
• Candidiasis – Oral Thrush (candidiasis) presents as white, creamy plaques that can be scraped off, often accompanied by soreness, but not typically a swollen, red tongue with dysphagia.
• Herpetic gingivostomatitis – Herpetic Stomatitis is caused by herpes simplex virus and presents with multiple painful vesicles and ulcers in the oral cavity, not specifically with glossitis and dysphagia.

SYNOPSIS
• Glossitis (inflammation of the tongue) accompanied by dysphagia can be indicative of a nutritional deficiency, particularly Vitamin B12 deficiency.
• This condition is common in individuals following a strict vegan diet, as Vitamin B12 is primarily found in animal products.

REFERENCE
Shafer’s Textbook of Oral Pathology

ANSWER
Turner’s hypoplasia

OTHER OPTIONS
• Dens in dente – A condition resulting from invagination of the inner enamel epithelium producing the appearance of a tooth within a tooth.
• Dens evagenatus – Describes an outfolding of the enamel organ that results in an extra cusp, usually in the central groove or ridge of posterior teeth and in the cingulum area of the anterior teeth, sometimes called a talon cusp.
• Ankylosis – Fusion of tooth to bone

SYNOPSIS
• Trauma to the primary teeth may progress to cellulitis, and may result in aborted development or enamel hypoplasia of the succedaneous tooth.
• Enamel hypoplasia or hypomineralization can be generalized throughout the dentition or it can be localized.
• Enamel development, or amelogenesis, is an exquisitely regulated process at the molecular level but can be disrupted by many environmental factors, such as fever, infection, trauma, changes in oxygen saturation, antibiotics, and many other factors.
• Trauma leads to hypomineralization to marked enamel hypoplasia, which manifests as blue-gray to yellow-brown color.
• The altered tooth is called Turner’s tooth.

REFERENCE
Pediatric dentistry Arthur.J.Nowak Page

ANSWER
Put in 2 percent sodium nitrate in an open or perforated container

OTHER OPTIONS
• Not applicable

SYNOPSIS
• Autoclaving burs can cause rusting.
• Spraying or dipping instruments with solutions containing sodium nitrite decreases rust.
• Burs can be protected during autoclave by keeping them submerged in a small amount of 2 percent sodium nitrite solution, 1cm above the burs.

REFERENCE
Decontamination Methods Used for Dental Burs – A Comparative Study

ANSWER
Administer intramuscular epinephrine

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
• Although the patient’s reaction appears to be mild, it is prudent to treat any potential allergic reaction to antibiotics, especially in a patient with a prosthetic heart valve, as anaphylaxis can develop rapidly.
• Epinephrine is the first-line treatment for anaphylaxis and can prevent progression to a more severe reaction.
• After the administration of epinephrine additional management may be considered.
• H1 antihistamines (e.g., diphenhydramine) can help alleviate itching and rash. H2 antihistamines (e.g., ranitidine) can provide additional symptomatic relief. Corticosteroids (e.g., prednisone) can help prevent a biphasic allergic reaction.
• Continuous monitoring and supportive care are essential to ensure the patient’s condition does not worsen.

REFERENCE
Medical Emergencies in Dental Practice – Stanley F Malamed

ANSWER
Movement greater than 1 mm horizontally

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
• Grade 0 – No physiological mobility.
• Grade 1 – Slight mobility of less than 1mm horizontally.
• Grade 2 – Movement of more than 1mm in the horizontal direction.
• Grade 3 – More than 1mm mobility in the horizontal and vertical direction.

REFERENCE
Carranza’s Clinical Periodontology

ANSWER
Give milk

OTHER OPTIONS
Not applicable

SYNOPSIS
• Accidental ingestion of excessive amounts of fluoride containing products can lead to acute or chronic toxicity.
• Acute toxicity can cause a sudden onset of nausea, abdominal pain, vomiting, diarrhea, cytotoxic effects, hyperkalemia, seizures and multiple organ failure.
• Treatment includes inducing vomiting, give 1 percent calcium chloride or tolerated levels of milk orally and inform emergency department.

REFERENCE
Pediatric Dentistry Infancy through Adolescence – 6th Edition Page No 292.

ANSWER
Pleomorphic adenoma

OTHER OPTIONS
• Warthin’s tumour – Warthin’s tumour is the second most frequent benign neoplasm of the salivary glands after pleomorphic adenoma.
• Adenoid cystic carcinoma – Adenoid cystic carcinoma is a malignant neoplasm affecting salivary gland manifested as early local pain, facial nerve paralysis, swelling with marked tendency to spread through perineural spaces.
• Mucoepidermoid carcinoma – Mucoepidermoid carcinoma is the most common malignant salivary gland tumor, accounting for 10-15 percent of all salivary gland tumors and one-third of all salivary gland malignancies.

SYNOPSIS
• Pleomorphic adenoma is the most common salivary gland tumor, is also known as benign mixed tumors.
• It is the commonest of all salivary gland tumors constituting up to two-thirds of all salivary gland tumors.
• Pleomorphic adenoma mostly presents as a solitary mobile slow growing, painless mass, which may be present for many years.
• In the parotid gland, signs of facial nerve weakness occur when the tumor is large.
• Histology will reveal proliferation of myoepithelial and epithelial cells of the ducts.
• Presently pleomorphic adenoma of the parotid gland is treated either with superficial or total parotidectomy or excision.

REFERENCE
Shafer’s Textbook of Oral Pathology – 8th Edition Page No 266.

ANSWER
9 mm

OTHER OPTIONS
Not applicable

SYNOPSIS
• A reduced interarch space can be treated by osteoplasty, selective grinding, root canal and crown of opposing tooth or by surgical reduction of tuberosities.
• Interarch space required for fixed implant in anterior region is around 8-10 mm and posterior region 7mm.
• Interarch space required for removable implant prosthesis in anterior region is around 12 mm and posterior region 12 mm.

REFERENCE
Textbook of Prosthodontics, V Rangarajan – Page No 769.

ANSWER
Extraction

OTHER OPTIONS
Not applicable

SYNOPSIS
• Vertical root fracture is longitudinal fractures that originate in roots of teeth and with few exceptions, these fractures occurs mostly in endodontically treated teeth.
• Characterized by dull, spontaneous pain, tooth mobility, bony radiolucencies.
• Tooth becomes hopeless after vertical root fracture and hence extraction is treatment of choice.
• In multirooted teeth, hemisection can be done.

REFERENCE
Grossman’s Endodontic Practise – 13th Edition Page No 152.

ANSWER
Cortical decalcified freeze dried bone graft

OTHER OPTIONS
• Explained below

SYNOPSIS
• If the defect is lined by only two walls of bone, the defect is a two-wall defect.
• Cortical decalcified freeze-dried bone allograft is used for 2 walled osseous defects
• Cortical bone contains pure cortex-dense bone, hence it is used for weight or force-bearing areas
• Freeze drying decreases antigenicity and facilitates long-term storage
• Decalcifying improves osteostimulatory properties
• Cancellous bone provides more open spaces for faster revascularisation, but it lacks mechanical strength, particularly when used for non-weight or non-force-bearing areas

REFERENCE
Carranza’s Clinical Periodontology

ANSWER
OKC

OTHER OPTIONS
• Not applicable

SYNOPSIS
• Odontogenic keratocyst (OKC) is the cyst arising from the cell rests of the dental lamina.
• It can occur anywhere in the jaw but is commonly seen in the posterior part of the mandible.
• Radiographically, most OKCs are unilocular when presented at the periapex and can be mistaken for a radicular or lateral periodontal cyst.
• The exact reason for the high recurrence rate of OKC has not been established, it is thought to be due to incomplete removal of the primary lesion with thin epithelial lining, the presence of satellite cysts, and epithelial remnants.

REFERENCE
Shafer’s Textbook of Oral Pathology

ANSWER
Acute exacerbation of chronic apical periodontitis 

OTHER OPTIONS
• Nil

SYNOPSIS
• An acute exacerbation of a chronic periapical lesion is called phoenix abscess.
• It is a dental abscess that can occur immediately following root canal treatment.
• Another cause is due to untreated necrotic pulp (chronic apical periodontitis).
• It is also the result of inadequate debridement during the endodontic procedure.
• Risk of occurrence of a phoenix abscess is minimized by correct identification and instrumentation of the entire root canal ensuring no missed anatomy.
• Clinical Features
– Pain Loss of Vitality
– Tender to Touch
– Mobility.
• Radiographically there will be a periapical lesion associated with the tooth.
• This lesion is normally existent prior to this episode.
• Widened periodontal ligament (PDL) space is visible.
• For most situations urgent treatment is required to eliminate the pain and swelling.

REFERENCE
Grossman’s Endodontic practice

ANSWER
Lidocaine

OTHER OPTIONS
• Nil

SYNOPSIS
• The second trimester is weeks 14 through 27 in terms of gestational age. The risk of the teratogenic effects of drugs is lower during this period than during the first trimester.
• Elective dental treatment has been reported to be relatively safe during this period.
• Anesthesia is safer to perform in pregnant women for non-obstetric surgery in the second trimester than in the first or third trimester. 
• Lidocaine with adrenaline is considered safe in pregnancy.
• Vasoconstrictors, mostly epinephrine, are added to lidocaine to reduce the absorption of the local anesthetic, reduce toxicity, and increase the analgesic effects.
• Vasoconstriction induced by epinephrine delays the absorption of local anesthetics by the mother, allowing the absorption of lidocaine to gradually occur in the maternal systemic circulation, while also allowing blood levels of lidocaine to gradually increase. The local anesthetic is transferred to the fetus slowly, and its margin of safety is also increased.

REFERENCE
Use of local anesthetics for dental treatment during pregnancy, safety for parturient -Journal of Dental Anesthesia and Pain Medicine

ANSWER
Vertical root fracture

OTHER OPTIONS
• Not applicable

SYNOPSIS
• The radiographic halo appearance is a classic sign of a vertical root fracture (VRF).
• This fracture typically occurs in endodontically treated teeth due to excessive force during obturation or post-placement.
• Other signs include isolated deep periodontal pockets and persistent sinus tracts.

REFERENCE
Cohen S, Hargreaves KM. Pathways of the Pulp – 11th edition, Elsevier, 2015.

ANSWER
Subgingival fracture extension

OTHER OPTIONS
• Not applicable

SYNOPSIS
• Subgingival fracture extension compromises the biological width and makes restorability difficult.
• It can lead to periodontal complications and poor aesthetics.
• Endodontic and restorative procedures may be challenging or impossible without crown lengthening or orthodontic extrusion

REFERENCE
Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th Edition, Wiley-Blackwell, 2007.

ANSWER
Initiate systemic antifungal treatment

OTHER OPTIONS
• Not applicable

SYNOPSIS
• Patients with HIV are prone to fungal infections like oral candidiasis, which may not respond to topical steroids.
• Systemic antifungal treatment (e.g., fluconazole) is recommended in such cases.

REFERENCE
Neville BW, Damm DD, Allen CM, Chi AC.Oral and Maxillofacial Pathology. 4th Edition, Elsevier, 2015.

ANSWER
Difficulty in achieving parallelism

OTHER OPTIONS
• Not applicable

SYNOPSIS
• The mesial tilt of 37 can make it challenging to create parallel abutments for fixed prostheses, leading to improper load distribution and eventual failure.
• Orthodontic uprighting may be required before prosthetic placement.

REFERENCE
Shillingburg HT. Fundamentals of Fixed Prosthodontics. 4th Edition, Quintessence Publishing, 2012.

ANSWER
Kaposi Sarcoma

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
• Kaposi sarcoma is always caused by an infection with a virus called human herpesvirus 8, which is also known as Kaposi sarcoma-associated herpesvirus (KSHV). The virus, which is in the same family as Epstein-Barr virus.
• Hodgkins lymphoma, Burkits lymphoma and Infectious mononucleosis are caused by EBV virus.

REFERENCE
Shafer’s Textbook of Oral Pathology

ANSWER
Primary herpetic gingivostomatitis

OTHER OPTIONS
• Not applicable

SYNOPSIS
• The symptoms of fever, irritability, painful oral sores, and swollen lymph nodes are characteristic of primary herpetic gingivostomatitis, which is caused by the herpes simplex virus (HSV).
• HSV-1 is most commonly responsible for primary herpetic gingivostomatitis in children. HSV-2 is typically associated with genital infections.
• Management includes antiviral medication (such as acyclovir) to reduce the duration and severity of the infection, pain relief (analgesics or topical anesthetics), and ensuring the child stays hydrated, as oral intake can be challenging due to pain.

REFERENCE
Shafer’s textbook of Oral Pathology

ANSWER
Rheumatic fever

OTHER OPTIONS
• SLE – Systemic lupus erythematosus can present with fever and arthritis but usually involves multiple organ systems and specific autoantibodies, which are not mentioned here.
• Infective endocarditis – Infective endocarditis can cause heart valve abnormalities and fever but is typically associated with a more severe systemic illness and not migratory arthritis.

SYNOPSIS
• Rheumatic fever is an inflammatory disease that can develop after an infection with Streptococcus bacteria.
• It commonly presents with fever, malaise, joint pain (migratory arthritis), and carditis, which can lead to valvular heart disease, such as a thickened mitral valve.
• The Jones criteria for the diagnosis of rheumatic fever include major criteria such as carditis (evidenced by the thickened mitral valve) and polyarthritis (migratory joint pain), along with a positive streptococcal infection test.

REFERENCE
Shafer’s Textbook of Oral Pathology

ANSWER
Anterior Bite plane

OTHER OPTIONS
• Z-spring – A Z-spring is typically used for minor tooth movements, such as tipping or aligning individual teeth or single tooth crossbite. It is not designed to address deep overbites or prevent palatal trauma.
• Labial bow – A labial bow is a component of some removable appliances, used primarily for retention or minor tooth movement in the anterior segment. It is not sufficient alone to manage a deep overbite or prevent palatal ulceration.
• Hawley retainer – While it can include a bite plane feature, a standard Hawley retainer is primarily used for retention after orthodontic treatment and does not specifically address deep overbites or palatal trauma without modifications.

SYNOPSIS
• A removable bite plane is designed to provide immediate relief from the deep overbite by preventing the lower incisors from contacting the palate.
• This helps to open the bite and reduce the risk of further palatal ulceration.
• It can be either anterior (fitted to the upper arch) or posterior (fitted to the lower arch), depending on the specific case requirements.

REFERENCE
Removable Appliance – Orthodontics Art and Science SI Bhalaji

ANSWER
Plaque control

OTHER OPTIONS
• Sensibility test – This test assesses the vitality of the tooth’s pulp and is typically used when symptoms suggest endodontic issues, not for initial management of periodontal conditions.
• Radiographs – Radiographs can be helpful to assess the extent of bone loss and other periodontal conditions. However, plaque control is a more immediate and fundamental step in managing the condition.
• Referral to periodontist – Referral to a periodontist may be necessary if the condition does not improve with initial management or if the case is complex. However, starting with plaque control is critical before considering a referral.

SYNOPSIS
• Effective plaque control is essential in managing gingival overgrowth and attachment loss.
• It is the first step in periodontal treatment and helps in controlling the underlying cause of gingival overgrowth and attachment loss.
• Improving the patient’s oral hygiene can reduce inflammation and improve periodontal health.

REFERENCE
Carranza’s Clinical Periodontology

ANSWER
Behcet’s syndrome

OTHER OPTIONS
• Reiter’s syndrome – Reiter’s syndrome is characterized by urethritis, arthritis and conjuctivitis.
• Lichen planus – Lichen planus is a mucocutaneous lesion mainly seen as greyish white striae on skin and oral cavity.

SYNOPSIS
• Behcet’s syndrome is a multisystemic chronic disorder.
• Mainly seen between 25-40 years and predominantly in males.
• Characterized by oral and genital aphthous ulcers, ocular lesions and skin lesions.
• Initially begins with oral or genital ulcers.
• A positive skin pathergy test is characterised by erythematous induration at the site of the needle stick with a small pustule containing sterile pus at its centre, is among the criteria required for a diagnosis of Behcet’s disease.
• No specific treatment other than supportive measures.

REFERENCE
Shafer’s Textbook of Oral Pathology – 8th Edition Page No 595.

ANSWER
Airway management and stabilization, followed by surgical intervention

OTHER OPTIONS
• Immediate open reduction and internal fixation – Immediate open reduction and internal fixation (ORIF) without first ensuring airway management can be dangerous if the patient’s airway is compromised.
• Placement of intermaxillary fixation (IMF) and observation – Placement of intermaxillary fixation (IMF) and observation may not address the complexity and instability of a Le Fort III fracture and is not sufficient for definitive management.
• Antibiotic therapy and analgesics only – Antibiotic therapy and analgesics only do not address the critical need for surgical repair and stabilization of the facial fractures.

SYNOPSIS
• In the management of Le Fort III fractures, which involve a complete craniofacial disjunction, the most critical initial step is to ensure the patient’s airway is secure and that the patient is hemodynamically stable.
• This is crucial because these fractures can significantly impact the airway and breathing due to the displacement of facial structures.
• Airway management and stabilization – Ensuring a clear airway and addressing any immediate life-threatening conditions take precedence. This might involve intubation or tracheostomy if necessary.
• Once the airway is secured and the patient is stabilized, surgical intervention (such as open reduction and internal fixation) is necessary to repair the fractures and restore the structural integrity and function of the facial skeleton.

REFERENCE
Le Fort III fractures – An approach to resuscitation and management – Annals of Medicine and Surgery

ANSWER
Reversible pulpitis

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
• There are three primary outcomes of a pulp sensitivity test, as described.
a)Normal Response – Healthy pulps are expected to respond to sensitivity testing by eliciting a short, sharp pain that subsides when the stimulus is removed, indicating that the nerve fibers are present and responsive. Teeth with clinically normal pulps do not respond to heat they only respond to heat when they are inflamed. Hence, the heat test cannot be used to differentiate a normal pulp from a necrotic pulp or a tooth with a pulpless and infected root canal system.
b) A Heightened or Prolonged Response – An exaggerated or lingering response to sensitivity testing indicates some degree of pulpal inflammation. If the pain is pronounced yet subsides once the stimulus has been removed, a diagnosis of reversible pulpitis may be probable. However, a lingering pain that continues despite the removal of the stimulus is indicative of irreversible pulpitis.
c) No Response – A lack of response to sensitivity testing suggests that the nerve supply to the tooth has been diminished, as in the case of pulpal necrosis or in previously root-treated canals.
• The AAE diagnostic standards for Reversible Pulpitis is as follows
– No spontaneous pain, sensitive responses to cold and heat tests compared with those of control teeth ,which lasts for only 1 to 2 seconds or no more than 10 seconds after the removal of the stimulus, and no significant radiographic changes in the periapical region.
– Because the pulp is sensitive to temperature changes, particularly cold, the application of cold is an excellent method of locating and diagnosing the involved tooth.
– A tooth with reversible pulpitis reacts normally to percussion, palpation, and mobility, and the periapical tissue is normal on radiographic examination.

REFERENCE
Dental Pulp Testing, A Review – International Journal of Dentistry. 2009

ANSWER
Periapical tissues of tooth 26

OTHER OPTIONS
• Not applicable

SYNOPSIS
• As the tooth 26 is tender to percussion, the source of pain should be due to periapical changes in relation to 26
• Pain on percussion is the diagnostic feature of primary symptomatic apical periodontitis.
• It is distinguishable from asymptomatic apical periodontitis in which the tooth has no pain on percussion and has distinct radiographic periradicular bone changes.

REFERENCE
Grossmans Endodontic Practice Page No 74

ANSWER
True combined lesion

OTHER OPTIONS
• Not applicable

SYNOPSIS
• In certain cases, the signs and symptoms of pulpal and periodontal involvement are such that it is clinically not possible to differentiate which started first. Such a chronic lesion with gross pulpal and periodontal destruction is referred to as a true combined lesion.
• It is recommended that endodontic treatment should precede periodontal therapy, regardless of the cause of disease.

REFERENCE
Grossmans endodontic practice pg 410

ANSWER
Circumferential clasp

OTHER OPTIONS
• I bar clasp – This clasp is commonly used for anterior teeth restoration in several countries as it requires minimal tooth contact compared to circumferential clasps and provides adequate retention with minimal undercut.
• Ring clasp – These retentive clasp arms are used in situations where the most distally located tooth in the arch is a tipped molar.
• Combination clasp – Used when additional flexibility is needed.

SYNOPSIS
• A circumferential clasp is the most appropriate design for a fully tooth-supported removable partial denture.
• This type of clasp encircles the tooth and provides excellent retention and stability, leveraging the support from the remaining teeth.
• For a fully tooth-supported situation, a circumferential clasp is preferred for its reliability and effectiveness.

REFERENCE
Stewart clinical Removable Partial Denture

ANSWER
Modified stillman technique

OTHER OPTIONS
• Fones technique – Fones technique is indicated in children, physically and emotionally handicapped children.
• Charter’s technique – Charter’s technique is used in open interdental spaces with missing papilla, temporary cleaning in areas of healing wounds after periodontal surgery and in patients with orthodontic appliances or fixed partial dentures.
• Modified bass technique – Modified bass technique is commonly used for general brushing.

SYNOPSIS
• Modified stillman’s technique is indicated in patients with gingival recession, as it provides good gingival massage.
• It is also used in root exposure cases to minimize abrasive tissue destruction.
• Bristles are placed partly over the cervical portion of the teeth and partly over attached gingiva with sweeping movement of bristles in a coronal direction.
• But this technique is difficult to learn and implement.

REFERENCE
Toothbrushing Techniques by PerioBasics.

ANSWER
Traumatic Ulcer

OTHER OPTIONS
• Herpetic Gingivostomatitis – Caused by primary herpes simplex virus (HSV-1) infection. Painful vesicles that rupture to form ulcers, diffuse involvement of the oral cavity and gingiva is typical. Fever, irritability, and lymphadenopathy are commonly seen.
• Herpangina – Caused by Coxsackievirus, typically seen in young children. Vesicular lesions are primarily located on the soft palate, tonsils, and pharynx, not the labial frenum. High fever and malaise are common.
• Allergy – Allergic reactions to substances such as foods or oral hygiene products. Usually diffuse erythema or vesicular eruptions, often involving multiple areas of the oral mucosa.

SYNOPSIS
• Traumatic ulcer typically caused by repetitive trauma, such as gnawing on toys, as described in this case.
• Presents as a localized white lesion or ulcer, often on the labial frenum or other areas prone to contact injury.
• Usually absent unless secondary infection occurs.
• Resolves with removal of the traumatic stimulus, no specific treatment is needed unless secondary infection occurs.

REFERENCE
Pinkham JR, Casamassimo PS, McTigue DJ, et al. Pediatric Dentistry: Infancy through Adolescence. 5th ed. Elsevier; 2018.
Neville BW, Damm DD, Allen CM, Chi AC. Oral and Maxillofacial Pathology. 4th ed. Elsevier; 2016.

ANSWER
0.018

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
• To calculate the amount of adrenaline in 1.8cc of 1:80,000, 2% lidocaine
• 1:80,000 means 1 gram of adrenaline in 80,000 mL of solution
• Concentration of adrenaline = 1 gram / 80,000 mL = 0.0125 mg/mL
• Amount of adrenaline in 1.8 mL = 0.0125 mg/mL × 1.8 mL = 0.0225 mg
• So, the amount of adrenaline in 1.8cc of 1:80,000, 2% lidocaine is 0.0225 mg.
• The nearest value here is 0.018

REFERENCE
Clinical Anesthesia by Barash et al.

ANSWER
No need to stop the anticoagulant.

OTHER OPTIONS
• Not applicable

SYNOPSIS
• For most routine dental extractions, there is no need to stop anticoagulant medication in patients with atrial fibrillation.
• Studies have shown that the risk of significant bleeding is minimal when the extraction is performed under local measures, such as using hemostatic agents (e.g., collagen sponges, sutures) and applying pressure post-operatively.
• Stopping anticoagulants increases the risk of thromboembolic events, which can be life-threatening.
• The dentist should consult the patient’s physician if there is any uncertainty, but routine anticoagulant therapy should generally be continued.

REFERENCE
Guidelines on the Management of Anticoagulant Therapy in Dental Procedures by the American College of Cardiology.

ANSWER
Connective tissue and epithelium

OTHER OPTIONS
• Bone and connective tissue – Bone and connective tissue are critical for periodontal regeneration and are not excluded.
• Epithelium and bone – Bone is essential for periodontal healing, so excluding it would impair regeneration.
• Cementum and periodontal ligament – These tissues are the primary targets for regeneration and must not be excluded.

SYNOPSIS
• Guided tissue regeneration (GTR) aims to regenerate the periodontal apparatus, including the cementum, periodontal ligament, and alveolar bone.
• To achieve this, the procedure involves the placement of a barrier membrane to selectively exclude epithelium and connective tissue from rapidly proliferating into the defect site, as these tissues can interfere with the slower regeneration of periodontal tissues.
• By blocking epithelial and connective tissue invasion, the membrane allows the periodontal ligament and bone cells to repopulate the area, facilitating true regeneration rather than repair.

REFERENCE
Carranza’s Clinical Periodontology G. Newman et al., 13th Edition.

ANSWER
Decreased alkaline phosphatase and increased phosphoethanolamine

OTHER OPTIONS
• Not applicable

SYNOPSIS
• Hypophosphatasia is a rare metabolic disorder characterized by defective bone and tooth mineralization due to mutations in the ALPL gene, which encodes tissue-nonspecific alkaline phosphatase (TNSALP). This condition is marked by
• Decreased levels of alkaline phosphatase (ALP) – The enzyme responsible for breaking down substances like pyrophosphate, which inhibits bone mineralization, is deficient.
• Increased levels of phosphoethanolamine (PEA) in blood and urine – Due to the reduced activity of ALP, PEA, one of its substrates, accumulates.
• These biochemical markers are critical for the diagnosis of hypophosphatasia.

REFERENCE
Pathophysiology of Hypophosphatasia – The New England Journal of Medicine by Whyte, M. P. (2017).

ANSWER
ASA III

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
• The ASA classification system is used to determine the physical status of a patient and assess their anesthetic risk. It ranges from ASA I (healthy patient) to ASA VI (brain-dead patient).
– ASA I – A healthy patient with no systemic disease.
– ASA II – A patient with mild systemic disease that does not limit daily activities (e.g., controlled hypertension, mild asthma).
– ASA III – A patient with severe systemic disease that limits daily activity but is not incapacitating (e.g., poorly controlled diabetes, sickle cell anemia with frequent crises).
– ASA IV – A patient with severe systemic disease that is a constant threat to life (e.g., unstable angina, recent myocardial infarction).
• The patient has sickle cell anemia, a severe systemic condition.
• Frequent vaso-occlusive crises indicate the condition significantly impacts daily life.
• However, the patient is stable at the time of the consultation and not in acute crisis, so they do not fall into the ASA IV category.
• Thus, the patient is classified as ASA III.

REFERENCE
Chapter 1 – Patient Assessment and Risk Management – Malamed SF. Handbook of Local Anesthesia, 7th Edition,

ANSWER
Depth at which elevator should be applied

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
• Winter’s WAR lines (1926)
• White Line – Provide information regarding the depth & inclination
• Amber Line – Indicate the margin of the alveolar bone enclosing the teeth.
– One must differentiate betweenthe external oblique ridge and bone lying distal tothe impacted tooth.
• Red Line – Provides information about depth at which elevator should be applied
• Longer the line difficult to remove or access the tooth
• Length: difficulty: 1:3

REFERENCE
Winter GD. Surgical Removal of Impacted Third Molars. Oral Surgery, Oral Medicine, Oral Pathology, 1926.

ANSWER
Have passive contact with the ridge tissue with no blanching

OTHER OPTIONS
• Nil

SYNOPSIS
• Pontic is the artificial tooth in the fixed or removable partial dentures, that is, the suspended portion of the fixed partial denture (bridge) replacing the missing natural tooth or teeth.
• Designing a pontic is not simple, an exact anatomic replica of the tooth in the space would be difficult to manage.
• The ridge lap is the gingival part of the pontic which contacts and has a direct relation to soft tissue and the edentulous ridge
• The pontic should touch the ridge passively rather than making pressure
• Pontic selection depends primarily on aesthetics and oral hygiene
• In the anterior region where aesthetics is a concern, the pontic should be well adapted to the tissue to make it appear that it emerges from the gingiva, conversely, in the posterior regions oral hygiene is the prime goal.
• The recommended designs for the anterior maxillary region are ovate and modified ridge lap pontics.
• The ovate pontic has high aesthetic value, therefore, is considered most suitable in the anterior maxillary region.
• This gives the illusion that the replaced tooth emerges from the gingiva like a natural tooth.

REFERENCE
Different pontic design for porcelain fused to metal fixed dental prosthesis – Contemporary guidelines and practice by general dental practitioners.

ANSWER
1.5 mm

OTHER OPTIONS
• Not applicable

SYNOPSIS
• The recommended minimum mesiodistal distance between tooth and implant is 1.5mm
• Maintaining at least 1.5 mm of distance from a natural tooth helps prevent damage to the periodontal ligament and supports the long-term stability of the gingiva and bone.
• Ensuring this space reduces the risk of bone loss and promotes healthy remodeling around the implant and adjacent structures.

REFERENCE
Biomechanics of Implant Design and Placement – Contemporary Implant Dentistry – Carp E Misch

ANSWER
Antimalarial

OTHER OPTIONS
Not applicable

SYNOPSIS
• Lichenoid reaction is similar to lichen planus but associated with an underlying cause.
• Drugs like antimalarials, NSAIDS, antihypertensives, antiretrovirals, dental restorative materials like amalgam, gold, chromium, cobalt, epoxy resins etc can trigger lichenoid reactions.
• Seen as greyish white streak or even ulcerations.
• Lesions are usually unilateral.
• Treatment is to identify and eliminate trigger factors.

REFERENCE
Shafer’s Textbook of Oral Pathology – 8th Edition Page No 548.

ANSWER
Wavy

OTHER OPTIONS
• NIL

SYNOPSIS
• Periodontal ligament fibers have a wavy structure, which allows them to stretch slightly and accommodate the forces exerted during chewing and biting.
• This wavy morphology helps in shock absorption and maintains the attachment of the tooth to the alveolar bone, preventing damage during normal function.

REFERENCE
Carranza’s Clinical Periodontology

ANSWER
Increase PH of fluoride

OTHER OPTIONS
• Increase Fluoride ions in solution – Increasing the concentration of fluoride ions in the solution enhances its effectiveness in strengthening enamel and reducing caries.
• Increase exposure time to topical fluoride – Increasing exposure time allows for better fluoride uptake by the enamel, improving the remineralization process
• Pre-treat enamel with 0.5 percent phosphoric acid – Pre-treating enamel with phosphoric acid helps demineralize the enamel slightly, allowing better penetration of fluoride into the tooth surface.

SYNOPSIS
• Increasing the pH of fluoride is not a suggested method to increase the effectiveness of topical fluoride application.
• Fluoride is more effective at a lower pH.
• Fluoride solutions are typically more effective in acidic conditions because lower pH facilitates the release of fluoride ions that integrate with enamel.
• Increasing pH would reduce the efficacy of fluoride.

REFERENCE
Essentials of Public Health Dentistry – Soben Peter

ANSWER
Require minimum interocclusal distance.

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
• When constructing a complete denture prosthesis for an orthognathic ridge relationship, the following considerations are typically included
Support and Retention – Ensuring that the denture provides adequate support and retention based on the anatomy of the ridge and surrounding soft tissues.
Esthetics – Designing the denture to achieve natural appearance, considering factors such as lip support, tooth shape, and shade.
Occlusion – Achieving a functional occlusion that allows for proper chewing and minimizes movement or instability of the denture during function. This includes careful planning of tooth arrangement and occlusal relationships.
Jaw Relationships – Accurately determining the maxillomandibular relationship to ensure that the dentures align properly with the patient’s occlusal plane and facial aesthetics.
Comfort – Ensuring the denture is comfortable for the patient to wear, with consideration for any anatomical changes due to orthognathic surgery.
Functional Movement – Ensuring the denture accommodates functional movements such as chewing, speaking, and swallowing without discomfort or dislodgement.
Material Selection – Choosing appropriate materials for the denture base and teeth that provide durability and biocompatibility.
Mucosal Health – Considering the health of the oral mucosa and ensuring that the denture design does not irritate or cause pressure points.
• These considerations help in creating a complete denture prosthesis that is functional, comfortable, and aesthetically pleasing for patients with orthognathic ridge relationships.
• While maintaining appropriate space is important, a strict minimum interocclusal distance is not a primary focus. The emphasis is on overall fit and function rather than a specific distance.

REFERENCE
Occlusal Considerations in Complete Dentures-Sandro Palla-Restorative and Prosthodontic Therapy.

ANSWER
Infrabony pockets

OTHER OPTIONS
• Explained in synopsis

SYNOPSIS
• Gingivectomy is the excision of gingival tissue, usually to remove the diseased wall of a periodontal pocket (true pocket or pseudopocket). The term gingivectomy was coined by Pickerill in 1912.
• The basic prerequisites for gingivectomy are as follows
– There should be an adequate zone of attached gingiva so that the excision of part of it will still leave a functionally adequate zone.
– The underlying alveolar bone must be in normal or nearly normal form.
– There should be no infrabony defects or pockets.
• Indications
– Elimination of supra bony fibrous and firm pockets.
– Elimination of gingival enlargement.
– Increase clinical crown height.
– Need for bone surgery.
– When the bottom of the pocket is apical to the Mucogingival junction.
– Aesthetic considerations, particularly in the anterior region of the Maxilla.
– Surgical gingivectomy.
• Contraindications
– In the presence of thick alveolar edges, interdental craters.
– Presence of infrabony pockets.
– Situations in which the bottom of the pocket is apical to the mucogingival junction.
– Inadequate oral hygiene maintenance by the patients.
– Medically compromised patients.
– Dentinal sensitivity before the surgical procedure.

REFERENCE
Carranza’s Clinical Periodontology

ANSWER
Inferior alveolar nerve

OTHER OPTIONS
• Lingual nerve – Supplies tongue and lingual gingiva.
• Buccal nerve – Supplies buccal gingiva of molars and cheek mucosa.
• Mylohyoid nerve – Motor to mylohyoid & anterior digastric, minimal sensory fibers.

SYNOPSIS
• Sensory supply to the chin and lower lip is provided by the mental nerve, which is a terminal branch of the inferior alveolar nerve (IAN).
• If paresthesia occurs but the mental nerve is not directly listed, the injury must be on the main trunk proximal to the mental nerve’s exit.
• Therefore, damage to the Inferior Alveolar Nerve before it enters or emerges from the mental foramen will result in:
– Loss of sensation in the lower lip
– Loss of sensation in the chin
– Sometimes also the labial gingiva of anterior teeth

REFERENCE
Malamed – Handbook of Local Anesthesia – 7th Edition

ANSWER
Macroglossia with fissured tongue

OTHER OPTIONS
• Not applicable

SYNOPSIS
• Patients with Down syndrome (Trisomy 21) commonly exhibit
– Relative macroglossia / protruding tongue (due to small oral cavity and hypotonia)
– Fissured tongue
– Delayed eruption of teeth
– Microdontia
– Anterior open bite
– Periodontal disease is more common, but dental caries incidence is typically LOWER than the general population
– Taurodontism may also be present
• Lower caries due to altered saliva, microdontia, and better caregiver-controlled diet.

REFERENCE
Burket’s Oral Medicine, 12th edition

ANSWER
Mandibular tori

OTHER OPTIONS
• Fibroma – Fibromas are firm smooth papule in the mouth most often appear on the inside of the cheek where the upper and lower teeth meet.
• Gingival hyperplasia – Gingival (Gum) enlargement, also known as gingival hyperplasia or hypertrophy, is an abnormal overgrowth of gingival tissues.
• Ameloblastoma – Ameloblastoma is a rare, noncancerous (benign) tumor that often develops in the jaw near the molars.

SYNOPSIS
• Torus mandibularis is a nontender, bony outgrowth located on the lingual side of the mandible, in the canine or premolar region, above the attachment of the mylohyoid muscle.
• In most cases, bilateral tori are present.
• Usually asymptomatic with very slow growth and may stop spontaneously. 
• Surgical resection is seldom necessary but is indicated when ulceration, articulation disorder, or problems inserting dentures are present.

REFERENCE
Mandibular tori – Canadian Medical Association Journal

ANSWER
Internal oblique ridge

OTHER OPTIONS
• Not applicable

SYNOPSIS
• Also called the internal oblique line.
• A bony ridge on the medial surface of the mandible.
• Formed by the mylohyoid muscle attachment but anatomically located superior and posterior to the mylohyoid line.
• On radiographs
– Appears as a radiopaque line
– Runs downward and forward from the ramus toward the mandibular molars
– Often superimposed on the roots of the mandibular molars

REFERENCE
Oral Radiology – Principles and Interpretation – Stuart C. White & Michael J. Pharoah – 8th Edition

ANSWER
Poor

OTHER OPTIONS
• Refer Synopsis

SYNOPSIS
a) Instrument fractured in the apical part of the canal – Removal of the fractured file fragment should not be attempted. One should change the working length prepare canal up to the fragment use some type of NaOCl agitation and obturate the canal in the same visit. Prognosis is generally poorer for a fractured instrument located in the apical third because it is more difficult to access,remove or bypass. Additionally, it may impede proper cleaning and sealing of the canal.
b) Instrument fractured in the middle part of the canal – One should try to bypass the broken instrument. If bypass is impossible the recommendation is to obturate the canal up to the instrument. The prognosis for a fractured instrument in the middle third is generally better compared to the apical third due to easier access and a high likelihood of successful removal or bypass. However, follow-up is obligatory and in case of post-treatment endodontic disease apical surgery should be considered.
c) Instrument fractured in coronal part of canal – Removal of a fractured instrument should be attempted with minimal dentin removal, different types of grasping equipment can be used.
• If instrument fracture occurs in the cervical third during RCT it shows a better prognosis because of better visualisation, and accessibility making the removal easier.

REFERENCE
Broken Instruments – Clinical Decision Making Algorithm- American Association of Endodontists.

ANSWER
Lichen planus

OTHER OPTIONS
• Candidiasis – Oral thrush, also known as oral candidiasis, is a fungal infection that can affect the mouth. Symptoms include a white or yellow buildup on the tongue, or mucosa and an unpleasant taste, and discomfort.
• Geographic tongue – Geographic tongue (also known as benign migratory glossitis) is an inflammatory disorder that usually appears on the top and sides of the tongue. Usually asymptomatic.
• Oral lichenoid reaction – Lichenoid reaction (LR) is an adverse effect that may be caused by the systemic administration of drugs including antihistamines, corticosteroids, and some other triggers. 

SYNOPSIS
• Lichen planus is a chronic inflammatory disease that affects the mucus membrane of the oral cavity.
• It is a T-cell mediated autoimmune disease in which the cytotoxic CD8 T cells trigger apoptosis of the basal cells of the oral epithelium.
• Symptoms include white patches or lacy threads on the inside of the cheeks.
• Burning sensation is common.
• For mild cases no treatment is needed. In severe cases, corticosteroids can aid in relieving the pain.

REFERENCE
Shafer’s Textbook of Oral Pathology 8th Edition

ANSWER
From 12-16 years

OTHER OPTIONS
• 5-9 years – Mixed dentition period, not advisable for treatment.
• After 18 years – can be done. Always a second option if the growth period is missed.

SYNOPSIS
• Comprehensive orthodontic care in the adolescent permanent dentition again includes both orthopedic and orthodontic components.
• There are three basic alternatives for treating skeletal discrepancies- growth modification, camouflage, and orthognathic surgery.
• Growth modification is a means to change skeletal relationships by using the patient’s remaining growth to alter the size or position of the jaws.
• Growth modification during the early mixed-dentition years is effective in treating skeletal malocclusions.
• It is easiest to correct skeletal problems if a child is undergoing maximal facial growth during treatment.
• Girls tend to enter the adolescent growth spurt as defined by obvious somatic growth at approximately 10 years and boys at approximately 12 years.
• Growth modification appliances change the absolute size of one or both jaws. For example, a class II skeletal profile may be treated by making a deficient mandible larger to fit a normal-sized maxilla or by limiting the size of an oversized maxilla.
• The right time to treat skeletal class II falls from 12 to 16 years during growth spurts

REFERENCE
Pediatric dentistry Arthur.J.Nowak page 512,513

ANSWER
Refer for biopsy to rule out dysplasia

OTHER OPTIONS
• Not applicable

SYNOPSIS
• An erythematous lesion persisting for >2 weeks, unresponsive to local measures, must be evaluated for erythroplakia or epithelial dysplasia or early SCC.
• Immediate referral for biopsy is indicated in this case.

REFERENCE
Neville BW. Oral & Maxillofacial Pathology

ANSWER
Replace restoration and monitor

OTHER OPTIONS
• Extraction – Indicated only if prognosis hopeless. Not supported here.
• RCT – Indicated in irreversible pulpitis (lingering pain).
• Analgesics only – Symptomatic relief without removing the cause.

SYNOPSIS
• Pain that goes away immediately – reversible pulpitis.
• Cracked restoration can cause microleakage leading to sensitivity.
• First step is remove defective restoration, evaluate crack, and place a bonded restoration.

REFERENCE
Hargreaves & Cohen. Pathways of the Pulp, 12th edition.

ANSWER
Primary hyperparathyroidism

OTHER OPTIONS
• Osteoporosis – Does not cause loss of lamina dura or elevated PTH.
• Fibrous dysplasia – Ground-glass bone but normal PTH and usually unilateral craniofacial involvement.
• Paget’s disease – Cotton wool appearance, not ground-glass, elevated ALP, not PTH.

SYNOPSIS
• The specific combination of clinical and radiological findings – loss of the lamina dura and a ground-glass appearance in bones, along with elevated parathyroid hormone (PTH) and hypercalcemia is indeed a classic presentation for primary hyperparathyroidism.
• These signs are indicative of significant bone resorption due to excess PTH, a condition often caused by a benign tumor (adenoma) on one of the parathyroid glands.
• The radiological features are sometimes referred to as osteitis fibrosa cystica, a severe manifestation of the disease.

REFERENCE
Neville BW et al. Oral & Maxillofacial Pathology, 4th edition

ANSWER
Physiological barriers

OTHER OPTIONS
• Psychological barriers – Psychological barriers are due to the emotional character and mental limitations of human beings. These barriers result in absent-mindedness, the fear of expressing one’s ideas to others, excitement, and emotional instability-all accounting for an overwhelming number of communication problems.
• Environmental Barriers – They often limit or prevent a person with a disability from fully participating in social, occupational, and recreational activities. For a wheelchair user, environmental barriers may include stairs, narrow doorways, heavy doors, or high countertops.
• Cultural barrier – A cultural barrier is an issue arising from a misunderstanding of meaning, caused by cultural differences between sender and receiver.

SYNOPSIS
• Physiological barriers to communication are related to the limitations of the human body and the human mind (memory, attention, and perception).
• Physiological barriers may result from individuals’ personal discomfort, caused by ill-health, poor eyesight, or hearing difficulties.

REFERENCE
Oxford clinical dentistry 7th edition pg 678

ANSWER
Bilateral balanced occlusion

OTHER OPTIONS
• Lingualized occlusion – Maxillary lingual cusps contact mandibular central fossae useful for resorbed ridges.
• Monoplane – Flat teeth no cuspal interdigitation.
• Group function – Natural dentition concept, not for complete dentures.

SYNOPSIS
• In complete dentures, bilateral balanced occlusion ensures simultaneous contact of teeth on both working and non-working sides during all excursive movements, enhancing denture stability and retention.

REFERENCE
Prosthodontic Treatment for Edentulous Patients (Zarb & Bolender), 13th ed

ANSWER
Obturate till the file separation and follow up

OTHER OPTIONS
Not applicable

SYNOPSIS
• The common approach for dealing with a broken instrument is its removal.
• If instrument fractured after major cleaning and shaping in apical third of the canal, removal of the fractured file fragment should not be routinely attempted.
• Obturation up to the fragment is recommended.
• A broken file by itself does not induce inflammation.
• Periapical healing takes place if during Endodontic treatment disinfection decreases microbial load beneath the specific threshold.

REFERENCE
Broken Instruments – Clinical Decision Making Algorithm by American Association of Endodontists.

ANSWER
Ibuprofen at standard doses

OTHER OPTIONS
• Regular-dose acetaminophen – Acetaminophen is primarily metabolized by the liver. In patients with liver impairment and acetaminophen allergy, it must be avoided.
• Aspirin 325 mg every 6 hours – Aspirin is avoided because it can increase bleeding risk (especially dangerous in cirrhosis patients who often have coagulation problems).
• Codeine with acetaminophen combination – Codeine with acetaminophen is contraindicated because of the acetaminophen allergy and the liver metabolism concerns.

SYNOPSIS
• Ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), can be used with caution
• It does not rely on liver metabolism as heavily as acetaminophen.
• However, NSAIDs should still be used carefully in liver patients because they can cause renal issues and gastrointestinal bleeding – but if short-term pain control is needed and bleeding risk is managed, standard-dose ibuprofen is the better choice among the options provided.

REFERENCE
Little JW, Falace DA, Miller CS, Rhodus NL

ANSWER
Intralesional corticosteroid injection

OTHER OPTIONS
Not applicable

SYNOPSIS
• Oral submucous fibrosis is a chronic, progressive, scarring disease.
• Habitual chewing of areca nut is an important factor in etiology of OSF.
• Burning sensation in mouth, excessive salivation or dryness of mouth, trismus and defective gustatory sensations are features.
• In advanced cases, fibrous bands are seen in buccal mucosa, causing fixation and shortening of uvula and soft palate.
• Management includes reduction or elimination of habit with nutritional support with proteins, vitamin B and other vitamins, physiotherapy, immunomodulatory drugs, local drug delivery with local injections of corticosteroids hyaluronidase or collagenase etc.
• Surgical management by resection of fibrotic bands and replacement with partial thickness skin or mucosal graft but it seems to be a poor option in overall management as it may result in more fibrosis and disability.

REFERENCE
Shafer’s Textbook of Oral Pathology – 8th Edition Page No 151.

ANSWER
2 mm

OTHER OPTIONS
Not applicable

SYNOPSIS
• A safety distance of 2 mm has been widely accepted as the standard measurement to prevent implant related nerve injuries.
• Implant placement is the second most common cause for IAN damage, following the removal of impacted wisdom teeth.
• New studies says that if one can avoid thermal, pressure, and traumatic damage to the IAN, then implants can be placed closer than 2 mm to the Inferior Alveolar Canal.

REFERENCE
A New Concept of Safety Distance to Place Implants in the Area of the Inferior Alveolar Canal to Avoid Neurosensory Disturbance.

ANSWER
Bilateral band and loop

OTHER OPTIONS
• Lingual arch – When the permanent molars and incisors erupt, a lower lingual holding arch can replace the band and loop appliances.
• Distal shoe – If the loss occurs just before the eruption of the first permanent molar, that is, when the first molar crown is still covered with oral mucosa and a thin partial covering of bone, a space maintainer to guide the positioning of the first permanent molar into normal occlusion is desirable.

SYNOPSIS
• Indications of Band and Loop space maintainer
– In case of premature loss of any primary molar in primary dentition or primary molar in transitional dentition with permanent successor not erupting clinically for the next two years and its root length is less than one-third mature.
– Premature loss of a primary second molar as the permanent first molar is erupted clinically.
– Bilateral loss of single primary molar before the eruption of the permanent incisors.

• Contraindications
– A dentition that is extremely crowded or already exhibits marked space loss
– High caries risk
– Replacement of primary anteriors
– Replacement of primary second molars in transitional dentition with permanent molar tooth not erupted.

REFERENCE
Pediatric dentistry – Arthur.J.Nowak