Oral Health Group
Feature

Self Learning, Self Assessment

May 1, 2010
by Oral Health


The SLSA program is based on current, referenced literature and consists of 40 questions, answers, rationales are in the following issue at the end of each quiz.

Dentists who complete the 15 question quiz in the November, 2010 issue of Oral Health may be eligible for continuing education points. The names and license numbers of all who complete the quiz will be forwarded to their respective provincial licensing authorities.

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QUESTION 17

Pre-emptive pain control

1. reduces post operative pain.

2. uses analgesics.

3. uses anaesthetics.

4. is based on plasticity of the central nervous system (CNS).

A. 1, 2, 3

B. 1 and 3

C. 2 and 4

D. 4 only

E. All of the above.

Rationale

The concept of pre-emptive pain control for the management of post-operative pain incorporates use of analgesics and anaesthetics before, during and at the end of surgery. In the case of pre-emptive anaesthesia, a long lasting local anaesthetic can be used to prolong the period of post operative anaesthesia thus delaying onset of pain. Analgesic medications should be used immediately before treatment or 1-2 hours before and after treatment. The biological rationale in the use of pre-emptive pain control is based on the principle of central nervous system (CNS) plasticity or sensitization i.e. when the CNS is “primed” to recognize pain it will do so for a longer period if pre-emptive pain control is not used. Pre-emptive analgesia and anaesthesia blocks pain from reaching the brain and so the CNS is less likely to perceive and/or react to pain. Such a concept is exemplified in the use of regional local anaesthetic blocks in patients treated surgically under general anaesthesia. On recovery from the general anaesthetic the patient’s pain continues to be suppressed by the effects of the local anaesthetic injections.

REFERENCE

1. Kermalli, J., Tenenbaum, H.C. Prevention and management of acute orofacial pain; Treating the whole spectrum. Oral Health, February 29 – 37, 2008.

QUESTION 18

Which of the following is/are associated with estrogen and progesterone?

A. Changes in the gingival vasculature.

B. Altered local immune response.

C. Reduced capacity of gingival tissue for maintenance and repair.

D. All of the above.

E. None of the above.

Rationale

Many studies have identified changes in periodontal health associated with the shift in sex hormones that occur during puberty, menstruation and pregnancy. These are listed above. Contraceptive medications also create interest in their effect on oral tissues. Many of the deleterious periodontal effects of oral contraceptives have been associated with pills with high estrogen content. Although some investigators have concluded that the modern low-estrogen pill has no effect on periodontal health, others have demonstrated an increased extent of attachment loss related to long-term usage. A study was thus conducted to investigate the relationship between low-estrogen oral contraceptive use and the presence of progressive periodontitis in young females. It was found that twice as many patients with aggressive disease were pill users. There was a tendency toward higher levels of plaque, gingivitis and bleeding on probing in women taking the pill, but this difference was not statistically significant. Mean probing depth and attachment loss measurements were more severe in women taking the pill and pill users had deeper pockets and more attachment loss that was statistically significant. Dentists should be aware of the potential effects of oral contraceptives on aggressive forms of periodontitis.

REFERENCE

1. Mullaly, B.H., Coulter, W.A., Hutchinson, J.D. et al. Current oral contraceptive status and periodontitis in young adults. J. Periodontol 78 : 1031 – 1036, 2007.

QUESTION 19

To achieve the most effective anaesthesia for endodontic debridement of a maxillary first molar with irreversible pulpitis, you would use

A. infiltration anaesthesia.

B. posterior superior alveolar block anaesthesia.

C. infiltration anaesthesia along with an intraligamentary injection.

D. infiltration anaesthesia supplemented with an intraligamentary injection of fentanyl.

Rationale

Achieving satisfactory anaesthesia in instances of irreversible pulpitis is frustrating for both clinician and patient. Endodontic debridement relieves pain, but this treatment requires satisfactory anaesthesia which is not always achieved with block or infiltration techniques. Opioid drugs can achieve analgesia at the site of inflammation, but have rarely been used for dental disorders. The efficacy of an injection of fentanyl into the periodontal ligament to supplement standard local anaesthetic technique was investigated.

Patients with irreversible pulpitis of the maxillary first molar were randomly assigned to two groups. The primary anesthetic technique was infiltration with 1.8 ml of 2% mepivacaine with epinephrine 1:200,000. Half the patients received intraligamentary injections of 0.4 ml fentanyl (0.05 mg/ml) and half received 0.4 ml of 2% mepivacaine with 1:200,000 epinephrine. The injection was given as 0.2 ml on the mesial and 0.2 ml on the distal.

A highly significant decrease in pain intensity was noted by the fentanyl group. All the fentanyl patients rated the anaesthesia as excellent and reported no sensation of pain. Eighty percent of the local anaesthetic group rated the anaesthesia as adequate with 10 percent rating it as poor, 10 percent as excellent. The operator observed that those in the fentanyl group were more relaxed and cooperative than those in the mepivacaine group.

REFERENCE

1. Elsharrawy, E.A. and Elbaghaddly, Y.M. A double-blind comparison of a supplemental intraligamentary injection of fentanyl and mepivicaine with 1:200,000 epinephrine for irreversible pulpitis. J. Pain Symptom Manage. 33 ; 203 – 207, 2007.

QUESTION 20

Prevora is

1. a chlorhexidine varnish.

2. bacteriocidal.

3. an economic root caries treatment.

4. a proven preventive agent.

A. 1, 2, 3

B. 1 and 3

C. 2 and 4

D. 4 only

E. All of the above.

Rationale

Prevora is a two-stage high strength chlorhexidine coating applied topically to the whole dentition of the elderly patient at risk to root caries. It is invisible on the teeth and works first at a bacteriocidal level, then at inhibitory levels on the tooth surfaces for several weeks. The patient requires initially four treatments in the first eight weeks then a single application at normal recall appointments. This simple application by the hygiene team makes the care economic, low cost and simple. It falls into desirable low intervention care for the elderly in prevention and treatment of root caries. Studies in Canada, USA and Scotland have demonstrated the effectiveness of Prevora such that a 41% reduction in root caries over one year was recorded.

REFERENCE

1. Symington, J.M. and Perry, O.R. Breaking new ground in preventive dental care: the story of the Prevora antibacterial tooth coating for root caries reduction in older patients. Oral Health March 37 – 53, 2008.

Answers to the April 2010 SLSA questions:

13. E 14. E 15. E 16. E