Clinical Atlas — from an OHT

About This Reference

This is a clinical study reference compiled by Elvira Wang from her own BOH (Bachelor of Oral Health) clinical placement notes, reorganised by knowledge structure rather than by placement date or appointment. All clinical reasoning, procedural knowledge and teaching content on this page originates from the author's personal coursework and clinical placement experience.

This reference contains no patient-identifying information. Clinical scenarios are presented only as generic teaching vignettes (e.g. "a 9-year-old high-caries-risk patient" rather than any real identity).

How to use this reference: use the search box above to jump to a keyword (e.g. "ICDAS", "SSC", "risks", "POIG"), or browse by module using the sidebar. This is a living document, updated periodically as the author's clinical training progresses.

© Elvira Wang. All content reflects the author's own study notes and clinical placement experience, compiled for personal and educational reference.

Foundations — Anatomy, Nerves & Development

Primary vs permanent teeth

Sequence of maxillary primary dentition — calcification, crown completion, eruption, root completion, exfoliation

Sequence of mandibular primary dentition — same milestones

Nerve supply (LA planning)

Diagnosis & Examination

ICDAS codes (caries)

Stain vs cavity at a glance — texture, appearance, radiograph, symptoms, cause and treatment differ on every row; a genuine cavitation (hole) is always a cavity, never a stain.

Quick visual differential for tooth discolouration. Ties together several points already covered elsewhere in this hub — e.g. the grey/non-vital appearance of pulp necrosis, and the "pink tooth" sign of internal resorption noted in the Pulp Therapy section.

BW diagnosis code table

Pulpal vs PDL pain

Once caries or a deep restoration has been identified above, the next diagnostic question is: is any pain coming from the pulp, or from the periodontal ligament (PDL)? And if it's pulpal, is the pulp reversibly inflamed, irreversibly inflamed, or necrotic?

Primary vs permanent tooth ID

See the Foundations table above for morphology cues. Common trap: critical error charting an erupting permanent tooth as its primary predecessor (or vice versa) — always cross-check size/colour/shape and ask about recent exfoliation.

Tooth mobility (Miller)

Occlusion classification

Permanent dentition — Angle's classification

Primary dentition — terminal plane relationships

Dental trauma assessment

4 factors to assess: colour, pain, mobility, pulp vitality.

Trauma diagnostic pathfinder — luxation/displacement/mobility branch to reach the correct trauma diagnosis

Management & follow-up: enamel fracture, enamel-dentine fracture, crown fracture with pulp exposure

Management & follow-up: crown-root fracture, root fracture, alveolar fracture

Tonsil grading

Part of a thorough EO/IO exam, especially relevant for airway/sedation risk assessment and snoring/mouth-breathing history: tonsils are graded 0–IV by how much of the oropharynx they occupy.

Grade 0 = not visible beyond the anterior pillar; Grade IV = tonsils meet at the midline

Caries risk & X-ray interval

Adults — periodontal risk

After subgingival/deep clean → review at 6 weeks, then 3 months.

OPG timing rules of thumb: 11-year-old — palpate for unerupted canine roots buccally first; if roots are palpable, an OPG may not be needed. 17-year-old — probe distal of 7s first; if pocket depth >4mm, refer for extraction of the 8 (before/without OPG).

Crown & bridge types (recognition only — not OHT scope)

Adult crown/bridge restorations use a different set of materials to paediatric SSC, each with different strength/aesthetic trade-offs. Placing these is outside OHT scope — this is here purely so an existing crown can be correctly identified and checked during an exam, not as a procedure to perform.

Left: a crown seated over a prepared tooth. Right: PFM cross-section — porcelain layered over a cast metal coping.

Detecting caries beneath an existing crown

A full-coverage crown can mask caries on both clinical exam and radiographs, so diagnosis relies on combining several lines of evidence rather than any single test:

• Clinical exam (most important): softness at the crown margin with a ball-ended probe/gentle explorer (avoid forceful probing), marginal gaps or open margins, staining at a defective margin (stain alone isn't diagnostic), localised plaque accumulation or gingival inflammation around one crown, food impaction, crown mobility/looseness.
• Bitewings: may reveal recurrent caries at the crown margins (especially proximal) or radiolucency extending beyond the margin — but caries beneath the metal coping itself usually can't be visualised.
• Periapicals: useful for periapical pathology, loss of supporting bone, and occasionally recurrent caries near accessible margins.
• Symptoms: cold sensitivity (if vital), pain on biting, food trapping, bad taste/recurrent swelling, a history of the crown debonding.
• When it stays uncertain: monitor if risk is low and findings are equivocal; if there's a defective margin, symptoms, or high clinical suspicion, the crown may need to be removed to directly inspect the tooth — often the only definitive way to diagnose caries hidden under a full-coverage crown.

My Case — Submerged Primary Molars

Pain History & Acute Care

SOCRATES pain history

Acute care differentials

Sinusitis — inflammation of sinus linings (viral/bacterial/allergic), facial pressure/pressure worse bending forward, nasal congestion, discoloured mucus, can present as maxillary posterior tooth pain/toothache. Acute lasts 7–10 days, chronic can exceed 12 weeks.

Pericoronitis — inflammation/infection of gum around a partially erupted tooth (classically a lower wisdom tooth), trapped food/bacteria under the operculum. Pain, swelling, halitosis, pus; severe signs include trismus, jaw/cheek swelling, fever, lymphadenopathy. Most common age 17–25 (wisdom teeth emerging) and with crowding/lack of space.

Radiographic caries pearl

My Case — Facial Swelling & Epilepsy

Medical History

Medical Emergencies

A medical emergency can present as, or alongside, a patient already in the chair, so it sits here alongside the rest of medical history. General framework: DRSABCD — Danger, Response, Send for help, Airway, Breathing, Circulation, Defibrillation. Always call for emergency assistance early if in doubt.

Allergies & Anaphylaxis Risk

Ask: what specifically happens on exposure (rash/hives vs swelling vs breathing difficulty vs collapse — mild intolerance is not the same as true allergy); the specific trigger(s) — latex, penicillin/other antibiotics, NSAIDs/aspirin, local anaesthetic (true LA allergy is rare; most "LA allergy" histories are actually a vasovagal episode, adrenaline palpitations, or a reaction to the sulfite preservative — worth clarifying which), iodine, chlorhexidine, metals (e.g. nickel), latex-associated foods (banana, kiwi, avocado); severity of the worst past reaction and whether it needed hospital treatment; whether they carry an adrenaline autoinjector (EpiPen, Anapen) and — critically — whether they have it with them today and it isn't expired; whether the patient (or a carer) is trained/confident to use it; whether they wear a MedicAlert bracelet/pendant.

Asthma

Ask: extrinsic (allergic) or intrinsic; known triggers (exercise, cold air, dust, smells, stress, NSAIDs/aspirin); how often the reliever is used (more than 2×/week suggests poor control); date of last attack; any ED visit, hospital admission or ICU/intubation; current medications and whether they've been taken today; whether they have their reliever with them.

Hypertension (High Blood Pressure)

Ask: how long diagnosed; current antihypertensive medication and compliance; date/result of last BP check; symptoms (headache, visual disturbance, chest pain); other cardiovascular history.

Hyperlipidaemia (High Serum Lipids / Cholesterol)

Ask: on a statin or other lipid-lowering therapy; any associated cardiovascular disease (angina, MI, stroke, peripheral vascular disease); family history.

Diabetes Mellitus

Ask: Type 1 or Type 2; how well controlled (home glucose monitoring, known HbA1c); time and content of last meal; insulin/medication dose and timing; history of hypoglycaemic episodes and their warning signs; any complications (renal, cardiovascular, delayed healing).

Cardiovascular Disease (IHD, Angina, MI, Arrhythmia, Pacemaker)

Ask: specific diagnosis; stents/bypass/pacemaker and when fitted; anticoagulant or antiplatelet medication; whether they carry a GTN spray and how often it's used; exercise tolerance/angina frequency; date of last cardiac event; any history of infective endocarditis or a high-risk valve/prosthetic condition.

Anticoagulant & Antiplatelet Therapy

Ask: which drug and dose (warfarin, DOAC — dabigatran/rivaroxaban/apixaban, aspirin, clopidogrel); indication (AF, DVT/PE, valve, stent); INR and when last checked if on warfarin; any personal bleeding history; other conditions affecting bleeding (e.g. liver disease).

Epilepsy

Ask: seizure type(s); date of the last seizure; known triggers (stress, flashing lights, sleep deprivation, missed medication); current medication and compliance; typical duration/severity and any aura/warning sign; what the patient wants done if a seizure occurs in the chair. (See the "My Case — Facial Swelling & Epilepsy" note in Pain History & Acute Care — a positive history needs full follow-through on all of these, not just a checkbox.)

Pregnancy

Ask: trimester/expected due date; any pregnancy complications; current obstetric care; medications.

Previous Surgery & Hospitalisation

Ask: type of surgery and date; reason; any complications (bleeding, anaesthetic reactions, infection); current recovery status; ongoing medications or devices related to it (joint prosthesis, cardiac device, VP shunt); any family history of malignant hyperthermia or personal GA reactions if sedation/GA is planned.

Oral Pathology & Soft Tissue

Describing a lesion — ISBAR

Lesion description checklist (say it in this order): Location · Number · Size · Shape · Colour · Texture · Consistency · Attachment · Other (wipeable? painful? bleeding? mobile? numb?)

Ulcer types

Variations of normal

• Palatal tori / palatal exostoses (hard bone — very rare in kids)
• Fissured tongue, geographic tongue
• Lingual tonsil (tonsil tissue anterior to the tongue base)
• Racial pigmentation
• Fordyce granules (buccal mucosa, more prominent with age)
• Lingual varicosities, sublingual caruncles
• Enlarged incisive papilla (soft — vs tori which is hard bone)
• Thickened/elongated frenum

Palatal tori (torus palatinus) — hard, bony midline swelling; rare in children

Fissured tongue

Geographic tongue — atrophy of filiform papillae with a raised white/red border

Fordyce granules — ectopic sebaceous glands, buccal mucosa, more prominent with age

Misc. soft tissue lesions

Ortho-appliance lesions

Buccal fibrosis / hyperkeratosis from wires: singular, irregular, elevated, well-defined white lesion caused by wire irritation. Management: orthodontic wax, warm salt water rinses, avoid irritating foods, monitor, refer back to orthodontist if ongoing.

White lesions

Red & pigmented lesions

Vesiculobullous disease

Erythema Multiforme (EM): triggered mainly by HSV or Mycoplasma pneumoniae (also NSAIDs, antiepileptics, antibiotics, vaccines). Skin: target lesions. Oral: haemorrhagic crusted lips + ulceration. Memory cue: "target skin lesions + bloody lips = EM." Ix: FBC/LFT/EUC/eGFR/HSV swab. Tx: oral steroids 1mg/kg, rapidly tapered, + treat trigger.

Hypersensitivity types (for context): Type I = immediate IgE (anaphylaxis, asthma). Type II = cytotoxic (PV, bullous pemphigoid). Type III = immune-complex (RA, SLE). Type IV = delayed T-cell mediated (EM, Type 1 diabetes, MS) — NOT antibody-mediated, NOT immediate (common exam trap).

Reactive gingival lesions

Oral oncology & OPMDs

Oral potentially malignant disorders (OPMDs) are a heterogeneous group of lesions with a risk of progressing to oral squamous cell carcinoma (OSCC). Main risk factors: tobacco, alcohol, areca nut, HPV-16.

High-risk sites (same as white-lesion risky sites): lateral border of tongue, floor of mouth, retromolar area. Any lesion here that is non-healing, ulcerated, indurated, or persists beyond 2–3 weeks needs urgent referral + biopsy.

Prevention — Fluoride, Sealants & Materials

Fluoride modalities

5000ppm toothpaste: use for at least 3–6 months initially, continue while high risk persists (can be long-term), review every 3–6 months, step down to 1450ppm once risk reduces.

Duraphat (fluoride varnish)

Applied 2–4×/year (every 3–6 months by caries risk).

Risks

• Local: temporary yellow staining, mucosal irritation, mild gingival soreness
• Allergic (rare): oral swelling, urticaria, anaphylaxis
• If swallowed: nausea, vomiting, abdominal discomfort

POIG

• Avoid hard foods for 4 hours
• Avoid brushing/flossing until next morning
• Soft foods only for the rest of the day
• Avoid hot drinks/alcohol for several hours
• Teeth may look rough/yellow temporarily — normal, disappears after brushing

Molar-Incisor Hypomineralisation (MIH)

MIH affects first permanent molars (± incisors): demarcated, qualitatively abnormal enamel that is porous and breaks down under masticatory load, often causing post-eruptive breakdown and marked sensitivity. Possible causes: childhood illness/fever, early antibiotic exposure, other medications, genetic component, maternal illness during pregnancy. Management ranges from monitoring (if stable) → sealants (protect grooves from breakdown) → SDF (slow decay/reduce sensitivity) → restore (fillings or full-coverage) → extract (severe cases, coordinated with orthodontic timing).

MIH — demarcated opacities and post-eruptive breakdown on molars/incisors, with causes and management options

FS vs FP (sealant vs protection)

Risks (both FS/FP)

• Sealant loss/partial retention (moisture contamination)
• Microleakage → caries under the sealant
• Occlusal interference if high
• Transient sensitivity
• Aspiration/ingestion risk (rare)
• False sense of protection — doesn't replace OH

POIG

• No eating for 30 minutes
• Avoid hard/sticky food for ~24 hours
• Good OH, fluoride toothpaste
• Return if bite feels high, or if it chips/falls off/persistent sensitivity
• Regular review (6–12 monthly)

Chlorhexidine (CHX)

Indications: gingivitis/plaque control, post-surgical care, acute care, high caries risk (adjunct), patients with reduced OH ability (e.g. disability).

Use: 0.12–0.2%, ~10–15mL, 2×/day, short-term (7–14 days typical); rinse 30–60s then spit (don't swallow, don't rinse with water after); wait ≥30 min after brushing (toothpaste reduces efficacy). Works via substantivity (binds tissue, releases slowly).

Side effects: brown staining, taste disturbance (esp. salt), increased calculus; less common — mucosal irritation, dry mouth/burning; rare — parotid swelling, hypersensitivity.

My Case — Prophylaxis Technique

My Case — Salicylate-Safe Toothpaste

Restorative Dentistry

Material longevity comparison

GIC material types

Simple rule: Fuji II LC = RMGIC, light-cure, stronger · Fuji IX = conventional GIC, ART · Equia = reinforced GIC for posterior.

CR material types

The composite protocols below default to the standard layering technique, but composite resin actually comes in a few working consistencies with different placement rules.

GIC Restoration — protocol

Instruments: restoration tray, slow+high speed handpiece, restoration/polishing bur kits, dry guard/gamer's clamp+cotton rolls, floss, dentine conditioner+microbrush, GIC gun/capsule, Tofflemire+matrix band+wedge (if proximal), articulating paper.

1. Assess & isolate (cotton rolls/dry guard/suction)
2. Cavity prep — remove infected dentine, preserve sound structure (minimal intervention)
3. Matrix system (Tofflemire) if proximal — select band, tighten retainer, insert wooden wedge
4. Condition (polyacrylic acid 10–20s), rinse, gently dry (don't desiccate dentine)
5. Mix GIC (capsule or hand mix, working time ~1–2min)
6. Place GIC from the base, adapt, slight overfill
7. Set: Fuji II LC → LC ~20s; Fuji IX → chemical set ~2–4min
8. Remove wedge first, then Tofflemire
9. Finish — remove excess, check proximal contact and occlusion
10. Coat if required (e.g. Equia Coat, LC ~20s) — protects during maturation, improves wear

Risks

• Lower strength/wear resistance vs composite
• Moisture contamination during early set weakens it
• Dehydration → cracking
• Surface roughness if unprotected
• Fracture in high-load areas, marginal breakdown over time

POIG

• Avoid eating ≥1 hour
• Avoid hard/sticky food 24h
• Good OH; reduce sugary snacks
• Return if high bite, fracture, or falls out
• Regular recall

CR Restoration — protocol

Material: Composite (e.g. Filtek, Tetric) — anterior & posterior, chosen when good isolation (rubber dam) is achievable, aesthetics/strength are needed, and caries risk is moderate–low.

Steps (with rubber dam)

1. Pre-op: consent, LA if needed, shade selection before isolation (tooth still hydrated)
2. RD placement — select clamp, punch tooth-specific hole, place clamp, stretch dam, secure frame, floss contacts, invert dam
3. Cavity prep — high speed for access, slow speed to remove caries selectively, smooth margins
4. Matrix (if proximal) — sectional matrix, wedge to seal gingival margin
5. Etch 37% phosphoric acid: enamel 30s / dentine 15s → rinse → dry (dentine kept moist) → bonding agent → LC 10s
6. Composite in ≤2mm increments, LC 20s each layer, build anatomy
7. Finish/polish, check occlusion, remove RD

Benefits

Aesthetic, adhesive/conservative prep, good strength/wear, immediate set, no mercury.

Risks

• Moisture-sensitive → failure if isolation poor
• Technique-sensitive (etch/bond errors)
• Polymerisation shrinkage → marginal gap
• Post-op sensitivity
• Not ideal for very high caries risk / poor cooperation

POIG

• Avoid eating until LA wears off
• Mild cold sensitivity possible (usually temporary)
• Avoid hard/sticky food 24h
• Good OH
• Return if pain persists, high restoration, or food trapping

Deep caries decision table

Class-by-class CR technique notes

Root caries (RC) restoration

Equigingival/supragingival RC (or RC with a shallow subgingival extension) can be restored; refer deep subgingival lesions. Code 1 → SDF; Code 2 → GIC (moisture tolerant, fluoride release, non-occlusal-bearing area, biocompatible for the sensitive root/gum region).

Restoration deficiencies

Monitor/repair only if: marginal staining without caries, slight gap without soft dentine, surface roughness, minor anatomical deficiency with no function issue, no packing/sensitivity/symptoms. Redo if: marginal breakdown, recurrent caries, open margin with soft dentine, loss of contact/food impaction, fracture, or symptoms.

Open sandwich technique

Scenario: a very deep caries lesion extends subgingivally. After rubber dam isolation and caries removal, this is the structured, step-by-step approach for its restoration.

1. Matrix & isolation control: modified Tofflemire (Garrison-type band) to achieve a tight seal at the deep subgingival margin (cut one bump off the band to get it equigingival). Place a wooden or anatomical wedge (may add PTFE tape) to prevent gingival leakage and control fluid — aim equigingival with no overhangs.
2. Gingival margin conditioning: apply 10% polyacrylic acid (dentine conditioner) for 20s, rinse, and gently blot dry — the surface should stay moist, not desiccated.
3. GIC placement (the "open sandwich" layer): place conventional GIC (Fuji IX, ~2min working time) or RMGIC (Fuji II LC) in the gingival box, about 1.5–2mm thick as a base. Ensure it covers the gingival cavosurface margin — this layer stays open to the oral cavity, but must stay below the contact point. Light-cure if using RMGIC. Protect with GIC varnish or a resin coat.
4. Shaping for the composite layer: once the GIC sets, trim and smooth it while keeping the cervical margin open.
5. Matrix for the composite: take off the Tofflemire, place a sectional (V3) matrix system with a wedge to build up the proximal contact.
6. Etching & bonding: selective-etch enamel only, 30s with 37% phosphoric acid; universal adhesive to enamel and dentine, LC 10s.
7. Composite build-up: incremental layering technique, ≤2mm layers, LC 20s each.
8. Finishing & polishing: check occlusion and contact with floss.
9. Final protection & advice: apply a GIC surface coat over any open GIC margin; POIG — advise the patient to avoid food/drink for 1 hour; reinforce good OH.

Open vs Closed Sandwich — the actual difference

My Case — Anterior Class IV Composite

Pulp Therapy

Pulp proximity rule

IPC vs DPC (pulp cap)

Goal: avoid pulp exposure, allow remineralisation, and preserve pulp vitality.

IPC step-by-step

1. Leave the affected (softened but not frankly infected) dentine on the pulpal floor — do not chase it deeper.
2. Dentine conditioner 20s (removes smear layer, improves chemical bonding of GIC to dentine) — spot apply only.
3. Dycal at the deepest point only (mix liquid:paste = 1:1) — pulp protection, stimulates reparative dentine formation.
4. Fuji II LC as a liner over the Dycal (mix liquid:powder = 1:1, LC 20s) — seals dentine, provides chemical adhesion.
5. Matrix system (if proximal) with wedge/rings, PTFE tape if needed — prevents overhangs, achieves a tight contact.
6. Selective etch enamel only, 30s, universal bond, LC 10s.
7. Bulk-fill or conventional layering technique — replace lost tooth structure with adequate curing depth per layer, minimise shrinkage.
8. Check occlusion and contact.
9. Finish and polish — reduces plaque retention, improves longevity.
10. POIG + OHI — set post-operative expectations.

DPC step-by-step (dentist scope — know the sequence for understanding/assisting)

1. RD isolation, high-speed access, slow-speed to finish caries removal.
2. Achieve haemostasis with gauze (5% sodium hypochlorite pellet is one option) at the exposure site.
3. MTA or Biodentine placed directly at the exposed pulp.
4. Vitrebond (RMGIC) to cover the pulpal floor and axial walls, LC 20s.
5. Matrix system if proximal.
6. Etch + bond.
7. Bulk-fill or layering composite build-up.
8. Check occlusion/contact, finish and polish, POIG.

Pulpotomy

Definition: removal of the inflamed/infected coronal pulp (deep caries) while preserving the vital radicular pulp, followed by a medicament to fix/mummify or stimulate healing of the remaining pulp.

Why it matters in paeds: maintains vitality until exfoliation, prevents premature loss (→ malocclusion), avoids extraction in children where surgery is higher risk (bleeding disorders, congenital heart disease), preserves arch length/function.

Risks

POIG

LA regions for pulpotomy

SSC cementation material choice (post-pulpotomy)

Stainless Steel Crowns (SSC) / Hall Technique

Advantages / disadvantages

Advantages: very high success rate, no LA/drilling (Hall technique), seals and arrests caries progression, durable until exfoliation. Disadvantages: metal appearance, temporary bite raising, mild initial discomfort.

Risks

• Nickel allergy
• Gum inflammation from plaque accumulation
• High bite for 1–2 weeks
• Crown wear/displacement causing soft tissue damage
• Crown loss (rare) — wrong size or weak bond
• Might not fit / seated too high → may change TP
• Undiagnosed pulp pathology may still deteriorate under the crown

POIG

• Avoid sticky food 24h (same for separator placement)
• Avoid normal/soft food for 1h
• Bite may feel different — normal
• Return if pain/swelling
• Brush carefully while separators are in

Size selection & seating

• Try from the middle size (size 4) and go up/down.
• Seat from lingual to buccal. If it feels like it wants to tip in / bounce, try a different size.
• If one size is too small but the next is a bit wobbly, you can crimp the margin inward on a flat surface to make it more snug, then re-try.
• Most important safety step — always cover the throat with gauze throughout crown try-in/cementation to prevent swallowing/aspiration; never leave a loose (uncemented) crown unsupported in the mouth — keep pressing it while waiting for the CE, or remove it.

Cement material choice

Seating & cementation steps

1. Remove separators
2. Gauze throat protection
3. Try sizes, choose best fit
4. Cement (Fuji Plus / GCem)
5. Seat lingual→buccal, press all the way down; check occlusion
6. Patient bites cotton roll tightly for 2 minutes (support their chin closed)
7. Remove all excess cement with gauze/floss/explorer — check every surface; ultrasonic scaler is useful interproximally; never use polishing strips around a crown margin
8. Recheck occlusion

Wait 4–6 weeks before seating/adjusting an opposing crown (allows initial settling).

SSC competency checklist

• ✓ Explain risks and POIG to parent/carer
• ✓ Know occlusal adjustment timing for an opposing SSC (4–6 weeks)
• ✓ Gauze throat protection in place throughout
• ✓ Correct crown size selection
• ✓ Correct cement material selection + cementation
• ✓ Correct seating direction (lingual→buccal), fully pushed down
• ✓ Patient bites cotton rolls tightly for 2 minutes
• ✓ All excess cement fully removed
• ✓ Occlusion checked

Paeds communication scripts

Extraction / Oral Surgery

Advantages: removes infection source, definitive treatment, no restoration-failure risk. Disadvantages: space-loss risk, may need space maintainer, more traumatic.

Risks

• Prolonged pain/bleeding
• Infection → abscess or delayed healing
• Space loss without a maintainer
• Dry socket (exposed bone/nerve)
• Nerve injury → lip/cheek numbness
• Damage to adjacent teeth/soft tissue, alveolar bone or socket fracture

POIG

• Bite on gauze 30 minutes for clotting
• Ice pack outside the cheek, 10–20 min intervals, first 24h (swelling)
• Rest: head elevated, avoid strenuous activity 24–48h
• Soft diet, avoid hot food 24h, chew opposite side
• No rinsing/spitting/straw for 24h (risk of dislodging the clot)

LA for extraction

Positioning & technique

• Patient nearly upright. Clinician position: Q1/Q2/Q3 → 7 o'clock; Q4 → 11 o'clock (standing). For a right-handed clinician doing an upper-right anterior extraction, ~8–9 o'clock.
• Grasp: maxillary → palm up; mandibular → palm down.
• Forceps beaks seated just apical to the CEJ, not on the crown.
• Supporting (non-dominant) hand: supports alveolar bone, retracts soft tissue, gives tactile feedback.

Steps

1. Gauze protection
2. Flat plastic to luxate first (firm pressure to expand the socket)
3. Seat forceps just apical to CEJ; gentle apical pressure before luxation
4. Buccal–lingual / figure-of-8, slow controlled rotation (rotate, hold, rotate further each time), avoiding jerky movement
5. Buccal delivery
6. Gauze bite → check haemostasis at 5 + 5 minutes → bite for 30 minutes total

Forceps choice

• Upper anterior — straight beaks aligned with handles
• Upper 1st molar (universal) — symmetrical beaks, not side-specific
• Upper 2nd molars — asymmetrical beaks, "pointed beak to cheek" (buccal), rounded beak palatal
• Lower anterior — conform to facial/lingual contour
• Lower molars — both beaks pointed, fit root bifurcation
• Paedodontic forceps are smaller/easier to conceal — reduces anxiety
• Grade-3-mobile primary tooth: use the correct small forceps (e.g. premolar forceps for a mobile primary molar) — an IAN block is not appropriate here; buccal + palatal/lingual alveolar infiltration alone is enough.

My Case — Primary Tooth Extraction

Local Anaesthesia

Equipment per treatment type

Assembly / disassembly / disposal

• Infiltration needle = 30G short; Block needle = 27G long. Check expiry of both needle and cartridge.
• Assembly: twist the needle on by hand (only step where fingers touch the needle) → twist ring out → pull plunger out → open body → insert cartridge → close body → twist ring in → push plunger in gently, engage harpoon into the bung.
• Disassembly: pull plunger out slowly → open body → drop cartridge out → close body → use forceps to twist the needle shield off → into the sharps box.
• Sharps disposal: keep fingers entirely outside/under the edge of the sharps box, drop needle+cartridge in.
• Engaging the bung: needle pointing down, two quick smacks with the heel of the palm, then gently pull back slightly to confirm it's fully engaged — you cannot aspirate if the bung isn't engaged.

Buccal / Palatal infiltration

Buccal infiltration — midline of the tooth, at the junction of attached gingiva and mucosa

Palatal infiltration — junction of attached gingiva and palate, needle ~45° off the palatal surface

Local anaesthetic maximum recommended doses (MRD) by drug, with/without vasoconstrictor

IAN Block

1. 27G long needle; check expiry.
2. Palpate first: coronoid notch + posterior border of ramus, then identify pterygomandibular raphe & pterygotemporal depression. The raphe sits posterior to the disto-lingual cusp of the last molar.
3. Topical anaesthetic 2 minutes; retract cheek tightly with a mirror.
4. Bevel faces bone. Horizontal angulation: above, between the contralateral premolars (slightly closer to the 1st premolar). Vertical angulation: parallel to occlusal plane, ~1.5cm above it.
5. Must stay lateral to the raphe — check twice before inserting, especially on the left side.
6. Advance ~2/3–3/4 of the needle until bone contact, aspirate (no blood), inject ~1.5mL slowly.
7. Withdraw ~10mm, contact the lingual nerve, aspirate again, inject the remainder, withdraw, sheathe.

Anatomical landmarks — pterygomandibular fold, anterior border of ramus, external/internal oblique ridge, retromolar triangle, coronoid notch

Pterygomandibular raphe — the injection point sits lateral to this fold

Horizontal insertion point (quarter-marks along the raphe) and the "~1cm above occlusal plane" vertical landmark

Overall needle trajectory for an IAN block, schematic view

Long Buccal Block

Palpate the internal oblique ridge; inject distal & buccal to the most posterior mandibular molar, at occlusal plane height, parallel to the dentition. Insert only 2–4mm, 0.2–0.3mL. Seat at 7 o'clock for Q4.

Long buccal block — provides soft tissue anaesthesia to buccal gingiva/mucosa of the mandibular molars and 2nd premolar; usually given after the IAN block

Risks & facial nerve paralysis

• Pain/discomfort at injection site
• Bruising/haematoma
• Trismus
• Prolonged numbness/paraesthesia of lip or tongue
• Temporary facial nerve paralysis if anaesthetic reaches the parotid gland during IAN block (rare)
• Allergic reaction (rare)

POIG (LA)

• Do not bite lip/cheek/tongue while numb
• Avoid hot food/drinks until sensation returns (numbness usually 2–4h, children ~1–2h)
• If facial weakness occurs, it resolves as anaesthetic wears off; protect the eye if needed
• Contact the clinic if numbness persists longer than expected, or swelling/pain/trismus develops

Scenario → nerve selection

Paeds communication (LA)

My Case — IAN Block Troubleshooting

Periodontal & Radiography

Perio charting

• A complete perio chart needs pocket depths + mobility + furcation + suppuration + bleeding. You legally can't charge a full periodontal exam item, or accurately stage/grade, without all of these.
• Suppuration vs plaque: pus is a yellowish/whitish, watery, continually-flowing discharge around the gum margin with a transparent, swollen gingival margin. Plaque is more solid and comes away more easily with the probe. Don't confuse topical anaesthetic gel residue with pus either.
• Severe generalised perio tends to show many Grade 1 mobilities with several Grade 2/3s, rather than a single mobile tooth.
• Watch posture — keep elbows down, don't sit/stand too high relative to the patient (long-term ergonomic risk).

Official periodontitis staging reference (2017 World Workshop classification) — interdental CAL, RBL, tooth loss and complexity factors by stage

Official periodontitis grading reference — Grade A/B/C, rate of progression and risk factors (used alongside staging above)

Scaling / Prophylaxis

• Stubborn stains: prophy paste mixed with pumice works better; an Airflow machine is more effective still. If stains persist, switch to ultrasonic + hand scaling and be patient.
• After disclosing gel + scaling, use ultrasonic only to clear gel near the gumline/interproximally, then switch to the prophy cup for the bulk surface area (faster than trying to chase every trace with the ultrasonic tip).
• Prophy cup technique: light, controlled pressure, reposition regularly, adapt around contours/gingival margins — excess pressure wears through cups and risks soft tissue trauma.
• Orthodontic patients: use the ultrasonic tip's side (not the point) around brackets/wires, small overlapping strokes, dry and reassess frequently; use hand instruments where access is limited.

Radiography

Dental radiography doses are very low compared to medical imaging (e.g. a chest CT is roughly 1000× a single PA) — useful framing for anxious patients/parents, without ever suggesting radiographs are "harmless" or routine.

OPG

1. Explain to patient/parent, gain consent
2. Remove metal items
3. Set correct exposure dose; bite block with plastic cover; insert chin + bite block; adjust machine height before the patient steps in
4. Patient grips the hand holder, stands still, bites the block, wraps lips around it firmly
5. Adjust head holder; align the vertical red line with the posterior of the upper canines (patient smiling); align the horizontal red line at the bottom of the eye sockets
6. Hold the exposure button until the beep

Communication: to a child — "We're going to take a special picture of your teeth, it doesn't hurt, you'll stand very still while the machine slowly goes around your head like a big smile photo." To a parent — "A panoramic X-ray showing how the adult teeth are developing, whether they're coming in correctly, and whether any are missing, extra or impacted. The dose is very low and only taken when clinically necessary, following ALARA."

Bitewing (BW)

Holder priority: accuracy/reproducibility (older child) → BW holder; comfort/speed (younger child) → bite tab; digital sensor/infection control → paper tab; gag reflex → bite/paper tab.

Ortho patients — use ALAHRA reasoning to decide if a BW update is due: caries risk/history, demineralisation, OH/plaque around brackets, diagnostic value with appliances present, time since previous films. Low-risk permanent dentition → update every 18–24 months even in a child.

Periapical (PA)

Always take a PA before an extraction. Choose the correct holder (posterior vs anterior colour-coded); set exposure dose and arm position before starting; the cone's midline must be parallel to the floor or you'll get elongation. Upper anteriors: size 2 film, patient closes lips, cone faces the film.

My Case — Worked Perio Staging

Communication & Behaviour Management

Full child/parent communication scripts, organised by treatment stage:

Behaviour mgmt & communication

Exam & diagnosis scripts

Preventive treatment scripts

Restorative & surgical scripts

Developmental / trauma scripts

Professionalism pearls

My Case — Behaviour Management Tip

Cross-Procedure Comparison Module

The same four questions come up for every treatment-planning decision and every informed-consent conversation: 1) Indications/contraindications 2) Advantages/disadvantages 3) Risks 4) Post-op instructions (POIG). Below, related decisions are laid out side-by-side for revision as a set, rather than split across separate procedure sections.

SSC vs GIC restoration

GIC vs CR restoration

SSC vs extraction

Pulpotomy vs extraction

SDF vs Hall-technique SSC

Space maintainer vs monitor

Monitor vs immediate restoration

Master risk & POIG matrix

Longevity table (all materials)

Competency & Common Errors Bank

Every "critical error / breach / competency feedback" pattern from clinical placement experience, de-identified and grouped by theme — presented as recurring failure modes to learn from, rather than as isolated incidents tied to one appointment.

Rubber dam & moisture control

• Critical error Etching enamel for only 15s instead of the required 30s → restoration/sealant debonds with the clamp.
• Critical error Removing the rubber dam before the CE has checked the restoration/sealant and occlusion — treated as a professionalism breach, not just a technical miss.
• Critical error Polishing lower teeth without a gamer's clamp "because moisture control isn't needed" — it also protects the tongue; omission has caused tongue lacerations.
• Punch the RD hole close to the midline, slightly toward the working side; bring a punch chart for reference if unsure of tooth-specific hole sizing.
• Clamp must sit on the tooth, not the gingiva — clamping onto gum causes bleeding/soft tissue trauma and is a common reason competencies aren't signed off.
• For a strong tongue thrust: still use a gamer's clamp + cotton rolls, stabilise with the non-dominant hand rather than removing it. Apply cocoa butter only once material has begun to set (too early wipes the material off).
• If RD isolation genuinely can't be achieved (tooth anatomy, partial eruption), it's acceptable to change the treatment plan (e.g. FS → FP, or switch to cheek-guard/cotton-roll isolation) — document the reasoning.

Cavity prep & caries removal

• Critical error Removing a marginal ridge / converting an O lesion into an unnecessary Class II — always confirm with the CE, BW, and clinical appearance whether the contact point is actually involved before deciding Class I vs II.
• Always drill based on radiographic findings — a mesial prep that looks "caries-free" superficially may not have reached the actual lesion seen on the BW; some deep caries hides behind apparently sound enamel.
• Interproximal caries usually sits at/below the contact point — extend further apically/below the contact rather than pushing deeper toward the pulp if you haven't found it yet.
• Distinguish caries (inconsistent darker brown, sticky) from normal dentine (consistent dark yellow, smooth) after caries removal — don't over-prep chasing "dentine" that's actually sound.
• Equigingival caries needs very good bur control angled toward the tooth to avoid cutting the interproximal gum; if bleeding starts, firm cotton-pellet pressure for 5 minutes usually achieves haemostasis (and it's more likely soft-tissue trauma than pulp exposure — check where the pulp actually is first).

Local anaesthesia

• Critical error Choosing an IAN block for a Grade >3 mobile primary tooth — minimal buccal+lingual/palatal infiltration is all that's needed; requesting to sign off a competency for a technique that isn't indicated shows a knowledge gap, not just a skill gap.
• Always confirm the bung is engaged before injecting (needle down, two quick smacks with the palm heel, then check).
• Inject slowly — this is explicitly assessed, not just a comfort nicety.
• Review exact anatomical insertion points before every block (palatal infiltration and IAN landmarks are commonly slightly mis-located).
• LA should be purposeful, not routine — e.g. an occlusal Class I on a primary tooth may not need LA at all; don't anaesthetise "just in case."

Radiography

• Critical error / breach Saving an X-ray into the wrong patient's file.
• Retake rather than accept an elongated/overlapping film — check angulation, cone coverage, and holder choice before exposing.
• OPG documentation order: purpose → normal findings → bone level → abnormal findings → recommendation.
• Don't take multiple PAs "to be safe" when an OPG (not yet taken) would answer the question with less radiation — sequence your imaging requests logically.

Radiograph & ICDAS coding accuracy

• Review ICDAS codes carefully — this was one of the most frequently repeated feedback themes (miscoding, missing interproximal shadows, confusing NCL/erosion cupping with caries).
• Cross-reference the odontogram with previous charts and X-rays — this reliably catches missed crowns/fillings and previous restorations.
• Don't miss soft-tissue pathology while focused on hard-tissue charting (e.g. an inflamed/bulbous gum margin suggesting abscess, orthodontic-appliance trauma lesions).

Documentation & professionalism

• Treatment notes are a medico-legal document — they must reflect what was actually discussed/examined/planned, not just the procedure code.
• Double-check tooth number and surface before confirming notes — wrong-tooth/wrong-surface entries risk wrong-tooth treatment later.
• Write consent explanations in plain language the parent can understand.
• Complete all item numbers and the problem list before sign-off, not just the clinical note text.
• Match communication style to the patient's age — some medical-history questions that are routine for adults are not appropriate to ask a young child directly.
• Follow up positive medical history findings with specific questions (triggers, frequency, severity, medication) rather than just recording the label (e.g. "epilepsy", "autism", "asthma").

Official BOH Competency Checklist

Distilled from the BOH Competency Based Clinical Assessment book (v7, 2026) — this is exactly what a Clinical Educator ticks Yes/No against when you request a sign-off. Repeated boilerplate criteria are factored out once below; each competency then lists only what's distinctive to that task. Grading is binary: Learner (needs assistance in ≥1 of infection control / technical ability / patient management / knowledge / professional attitude) vs Competent (independent in all five). You must pass every criterion — there's no partial credit — and a competency can never be attempted the very first time you're asked to perform that task.

1–3. Infection Control · Ergonomics · Communication

4. Prevention

5. Examination & Treatment Planning

6. Local Anaesthetic

Shared across all 4 LA competencies (buccal infiltration, IAN+lingual block, palatal infiltration, long buccal block): correct anaesthetic selection + max dose knowledge; correct anatomical landmarks for this specific patient; correct armamentarium assembly; anatomical puncture point identified; correct needle orientation to landmarks; correct depth/syringe orientation; correct dose administered; profound anaesthesia achieved; no soft tissue trauma; correct recapping/dismantling/sharps disposal. IAN block additionally requires appropriate aspiration to be demonstrated.

7. Restorations

8. Periodontal Treatment

9. Extraction

9.1 Extraction of primary tooth: no greater than Grade 1 mobility; anterior or posterior; correct forceps grip and extraction technique; appropriate apical drive established; complete tooth removal; airway protection is a distinct explicit criterion; hae­morrhage management assessed.

10. Radiographs

All three radiograph competencies also require complete diagnosis and interpretation of the radiographic findings as a pass/fail criterion — taking a technically perfect film isn't enough without the write-up.

Cheat Sheet / Quick Numbers

Item-number logic (from notes)

• 221 (full periodontal exam) only chargeable after a complete perio chart (pockets + mobility + furcation + suppuration + bleeding).
• 222 (subgingival instrumentation) only for pockets ≥4mm, per tooth.
• Don't charge an OPG-reporting item (e.g. 037) if you didn't take the OPG yourself.

Diagrams

Key reference diagrams (eruption charts, perio stage/grade, tonsil grading, LA landmarks, trauma classification, MIH, common soft-tissue variants) are embedded directly in the relevant sections above (see assets/). A few remaining image-heavy topics (ICDAS clinical photos, occlusion photos, step-by-step clinical photos for pulpotomy/SSC/CR) are captured here as reasoning, numbers and tables rather than as photos.

Case Simulator

De-identified clinical scenarios drawn from real placement experience. Each one poses a genuine diagnostic or management decision — read the scenario and prompt, work through your own differentials/reasoning first, then reveal the reasoning actually used to compare.