Correct Answer: B. Switching to a mid‐palatal plate or full palatal coverage major connector

Explanation of Options

• A (Increasing thickness of the U‐shaped connector by 0.5 mm)
  • Thicker metal may offer some increased resistance to fracture, but a U‐shaped connector is still biomechanically prone to flexure under heavy occlusal loads. This modification alone usually doesn’t solve repeated mid‐palatal fractures in severe bruxers.
• B (Switching to a mid‐palatal plate or full palatal coverage major connector)
  • Best Answer. A mid‐palatal or full palatal major connector significantly increases rigidity, which is essential for patients with strong parafunctional habits. This design disperses stresses across a broader area and reduces the flexure responsible for fractures.
• C (Using a flexible partial denture material)
  • Flexible (nylon, Valplast‐type) dentures can bend more without fracturing, but they offer less stability under the heavy parafunctional forces of bruxers. Moreover, flexible materials often lack the necessary rigidity to support prosthetic teeth over time.
• D (Adding only additional rests on the anterior teeth)
  • While anterior rests help distribute forces, they do not address the core rigidity issue of the major connector. Rest seats alone are not enough to prevent mid‐palatal metal fractures in a high‐stress scenario.
• E (Converting the denture to a complete palateless design to reduce bulk)
  • Removing palatal coverage (i.e., going palateless) increases the chance of flexure, not decreases it. Less coverage means more potential for bending, an undesirable situation in severe bruxism cases.

Correct Answer: B. Advising the patient to remove the denture at night and use a protective occlusal splint

Explanation of Options

• A (Prescribing a full‐time essential oil mouth rinse to reduce salivary bacterial load)
  • While oral hygiene is essential, a mouth rinse does not address the main cause of repeated fractures (excessive mechanical stress from bruxism).
• B (Advising the patient to remove the denture at night and use a protective occlusal splint)
  • Best Answer. Removing the denture off‐loads it from damaging forces during sleep. A customized occlusal splint (night guard) can protect both the denture‐bearing tissues and the opposing dentition during nocturnal bruxism.
• C (Switching from chrome‐cobalt to pure titanium for better ductility)
  • Although titanium is biocompatible and relatively strong, it does not automatically solve the fundamental design issue of an unstable major connector under heavy occlusal loads. Rigidity and coverage are the key design priorities here, not merely changing the alloy.
• D (Performing an immediate reline with soft tissue conditioner)
  • A soft tissue conditioner might cushion forces temporarily but will not address the high stress on the metal framework itself.
• E (Painting fluoride varnish on all opposing teeth surfaces weekly)
  • Fluoride varnish can help prevent caries but does not reduce the parafunctional stresses causing denture fractures.

Correct Answer: C. Adding metal backing on the incisal edges of anterior prosthetic teeth

Explanation of Options

• A (Placing a continuous clasp assembly around all remaining teeth)
  • While clasps help retention, a continuous clasp on all teeth can create aesthetic and periodontal issues, and it does not inherently solve the problem of severe occlusal loads fracturing the denture.
• B (Designing an occlusal rest on every posterior tooth surface)
  • Adequate rests are important, but placing them on every posterior tooth surface without strategic design can lead to an overbuilt framework and does not directly address incisal chipping or breakage in a bruxer.
• C (Adding metal backing on the incisal edges of anterior prosthetic teeth)
  • Best Answer. In bruxers, incisal edges are frequent fracture sites. Metal backings (or “lipping”) reinforce these vulnerable areas and help reduce chipping of the prosthetic teeth.
• D (Using non‐rigid precision attachments for stress distribution)
  • Non‐rigid attachments can help in certain partially edentulous cases, but for a heavy bruxer with repeated fracture, a rigid metal framework plus reinforced incisal edges typically provides better durability.
• E (Eliminating any rests to reduce compression on abutments)
  • Removing rests invites the denture to impinge on soft tissues and does not help manage bruxism‐induced forces.

Correct Answer: C. Unfavorable shifting of remaining teeth and alveolar remodeling

Explanation of Options

• A (Reduced risk of alveolar bone loss)
  • Actually, partial edentulism (and a broken denture) can accelerate alveolar bone loss if not managed.
• B (Spontaneous resolution of bruxism)
  • Bruxism rarely resolves on its own without specific intervention or management.
• C (Unfavorable shifting of remaining teeth and alveolar remodeling)
  • Best Answer. Without proper prosthetic support, teeth can drift, and the alveolar bone can remodel unfavorably, leading to further occlusal challenges.
• D (Decreased chances of combination syndrome in the future)
  • Combination syndrome risk increases when partial dentures are ill‐maintained and the occlusal scheme is unbalanced.
• E (Natural posture of the mandible will correct the occlusal discrepancy)
  • The mandible will not spontaneously correct occlusal problems caused by missing or fractured prostheses.

Correct Answer: B. Schedule 3–4‐monthly maintenance visits to monitor fit and integrity

Explanation of Options

• A (Advise the patient to avoid all solid foods indefinitely)
  • Unnecessary and impractical. Patients should be able to eat a balanced diet; instructions may involve caution but not indefinite avoidance.
• B (Schedule 3–4‐monthly maintenance visits to monitor fit and integrity)
  • Best Answer. Regular checkups are recommended by the ADA to ensure oral hygiene, detect early signs of wear or fracture, and maintain a stable occlusal relationship.
• C (Prescribe antibiotics to prevent metal corrosion around the denture)
  • Metal corrosion is not typically prevented by antibiotics; this is not an appropriate prophylaxis.
• D (Temporarily extract one lower premolar to eliminate occlusal overload)
  • Extracting teeth solely to reduce occlusal force is overly invasive and not a standard approach.
• E (Encourage daily use of a fluoride mouthwash only in the morning)
  • While fluoride use helps prevent caries, restricting it to the morning does not address the need for overall stress management, bruxism control, and denture maintenance.

Correct Answer: C. Selecting a wrought wire clasp instead of a cast clasp if flexibility is desired

Explanation of Options

• A (Using a thicker gauge clasp wire to maximize stiffness)
  • Excessively stiff clasps can increase the chance of fracture under high loads because they cannot flex with small movements.
• B (Reducing the depth of the undercut to minimize flexure)
  • Shallow undercuts can compromise retention, leading to displacement in a bruxer. Some flexure is beneficial.
• C (Selecting a wrought wire clasp instead of a cast clasp if flexibility is desired)
  • Best Answer. Wrought wire clasps provide more flexibility and resiliency, reducing the likelihood of catastrophic fracture in a heavy bruxer.
• D (Converting to an all‐acrylic partial denture without any clasping)
  • An all‐acrylic design would significantly reduce stability, especially in a bruxer. This is typically a short‐term or interim solution, not definitive.
• E (Eliminating rest seats to reduce torque on the abutment tooth)
  • Removing rest seats typically exacerbates torque forces on the clasping components and can worsen the longevity of the denture.

Correct Answer: C. Ensure the occlusal scheme is adjusted so that excursive forces do not overload the clasp

Explanation of Options

• A (Reinforce the major connector by converting it into a U‐shaped design)
  • A horse‐shoe design is actually more prone to flexure, not less.
• B (Instruct the patient to sleep with the partial denture in place at all times)
  • Sleeping with the denture can exacerbate bruxism‐related damage. Many guidelines suggest removing partial dentures overnight or using a night guard.
• C (Ensure the occlusal scheme is adjusted so that excursive forces do not overload the clasp)
  • Best Answer. Refining occlusion is crucial. If excursive or lateral forces are directed onto the clasp area, recurrent fractures are more likely.
• D (Use a shorter clasp that does not engage any undercut)
  • Without a functional undercut, there will be minimal retention, causing the denture to dislodge easily.
• E (Fabricate the clasp from pure gold for maximum elasticity)
  • Pure gold is rarely used in contemporary practice for clasps due to cost, practicality, and less precise mechanical properties compared to cobalt‐chrome or wrought wire alloys.

Correct Answer: C. The solder joint location and length, avoiding the flexing zone

Explanation of Options

• A (The shade match of the metal to existing framework)
  • Aesthetic color match of the metal is usually low priority in partial denture repairs, especially in a posterior region.
• B (The linear coefficient of thermal expansion of the solder)
  • While relevant for metal compatibility, the primary practical issue is ensuring the solder joint is placed outside the flexure zone to prevent repeated fracture.
• C (The solder joint location and length, avoiding the flexing zone)
  • Best Answer. A well‐positioned solder joint outside the high‐stress bend area is crucial to reduce recurrent fracture.
• D (The thickness of the resin in the denture flange)
  • Resin flange thickness is less relevant when repairing a metal clasp.
• E (The presence of glycine powder in the polishing protocol)
  • Polishing technique is secondary compared to the mechanical design of the repair joint.

Correct Answer: C. Provide a chairside wrought wire clasp repair if feasible

Explanation of Options

• A (Temporarily use a self‐cure acrylic clasp on the abutment)
  • Acrylic clasps are prone to breakage and generally do not provide adequate flexibility or retentive strength for a bruxer.
• B (Use orthodontic elastic bands around the abutment tooth and denture)
  • This is improvisational and not a professional long‐term solution. It can damage periodontal tissues and complicate plaque control.
• C (Provide a chairside wrought wire clasp repair if feasible)
  • Best Answer. A quick, well‐adapted wrought wire clasp can be placed chairside for immediate retention if conditions allow, serving as an interim measure.
• D (Advise the patient to switch to a soft diet for six months)
  • This does not address the underlying retentive problem and is impractical for such a long time.
• E (Remove the abutment tooth to eliminate clasp need)
  • Extraction is unnecessarily aggressive; we typically preserve abutment teeth whenever possible.

Correct Answer: B. “Schedule routine occlusal adjustments and checkups every 3–4 months.”

Explanation of Options

• A (Bite firmly on the clasp to test its strength every morning)
  • This can create more stress on the clasp, risking further fracture.
• B (Schedule routine occlusal adjustments and checkups every 3–4 months)
  • Best Answer. Regular professional follow‐up is essential to monitor the denture’s fit, check clasp integrity, and address bruxism‐related complications.
• C (Wash the denture in boiling water after each meal)
  • High temperatures can distort acrylic and even affect metal components.
• D (Avoid speaking for long periods with the denture in place)
  • Speech does not usually impose substantial force on the clasp. This advice has no direct benefit.
• E (Swallow saliva aggressively to reduce lubrication around the clasp)
  • Salivary lubrication is not typically a cause of clasp fracture. This suggestion is not evidence‐based.

Correct Answer: A. Excessive incisal guidance forces transmitted to the denture tooth

Explanation of Options

• A (Excessive incisal guidance forces transmitted to the denture tooth)
  • Best Answer. In a bruxer with steep anterior guidance, the front denture teeth can sustain high stress, leading to repeated debonding or fracture.
• B (Inadequate cross‐arch stabilization from the mandibular partial denture)
  • While overall stabilization is important, the direct cause of repeated tooth detachment typically relates to the high force on the anterior segment in a bruxer.
• C (Use of a monomer‐rich acrylic for the denture base)
  • Although polymerization issues can weaken repairs, the primary issue is heavy occlusal load, not simply an acrylic quality problem.
• D (Overzealous application of adhesive primer during the chairside repair)
  • Overapplication of primer might cause chemical crazing, but this is less likely than occlusal overload in repeated detachment.
• E (Presence of pre‐existing alveolar bone exostoses)
  • Exostoses can complicate denture fit, but they do not directly cause front teeth to detach repeatedly.

Correct Answer: B. Perform a chairside acrylic repair with a pin or diatoric retention in the tooth

Explanation of Options

• A (Secure the tooth using cyanoacrylate at home)
  • Unsupervised use of super glue can lead to contamination, poor bond strength, and potential harm to soft tissues.
• B (Perform a chairside acrylic repair with a pin or diatoric retention in the tooth)
  • Best Answer. Creating mechanical retention (e.g., placing a small pin or diatoric hole) improves the bond between the tooth and denture base. This is a recognized chairside approach for immediate aesthetics.
• C (Refer for an implant‐supported crown on the adjacent tooth)
  • This might be a future consideration if the patient is missing a natural tooth root. However, for an emergency aesthetic repair, this is not the immediate solution.
• D (Switch the entire partial denture to a flexible resin alternative)
  • Flexible resins do not necessarily prevent tooth debonding in bruxers and are not primarily chosen for severe parafunction.
• E (Advise the patient to remain without an anterior tooth until a permanent fix)
  • This is not practical or aesthetic. Patients understandably want a provisional solution promptly.

Correct Answer: C. Creating a metal framework extension (lipping) over the incisal edge

Explanation of Options

• A (Fabricating a vacuum‐formed stent over the denture for daytime use)
  • This is not a conventional method to protect the denture teeth from fracture or detachment; it might be cumbersome.
• B (Reducing the cervico‐incisal height of the prosthetic tooth to shorten aesthetics)
  • Over‐reduction compromises appearance and may still not remove the high load from bruxism.
• C (Creating a metal framework extension (lipping) over the incisal edge)
  • Best Answer. Metal lipping over incisal edges in bruxers significantly reduces the chance of repeated detachment or fracture by reinforcing the tooth.
• D (Leaving the incisal edges open to reduce contact with the opposing dentition)
  • Anterior open contact can lead to other occlusal issues, speech problems, and compromised aesthetics.
• E (Initiating antibiotic coverage to diminish friction at the interface)
  • Antibiotics do not affect mechanical bruxing forces or friction that causes tooth detachment.

Correct Answer: B. Flatten the incisal guidance to minimize excessive force on the anterior prosthetic tooth

Explanation of Options

• A (Increase the prominence of the anterior guidance to ensure canine protection)
  • In bruxers, a steep anterior guidance can intensify forces on the anterior denture tooth. Typically, we aim to reduce it.
• B (Flatten the incisal guidance to minimize excessive force on the anterior prosthetic tooth)
  • Best Answer. Reducing steep incisal guidance can relieve stress on the denture tooth, particularly in excursive movements.
• C (Add composite to the opposing anterior teeth to intensify contact)
  • Doing so would increase the stress on the denture tooth, likely worsening the detachment risk.
• D (Place a posterior crossbite to redirect forces)
  • Introducing a crossbite artificially is not a typical solution for controlling anterior guidance.
• E (Remove the metal reinforcement, as it might be interfering with occlusion)
  • Metal reinforcement is beneficial for bruxers. Adjusting it out entirely would undermine the denture’s strength.

Correct Answer: B. Directing the patient to remove the denture during active daytime bruxing episodes and use a protective guard

Explanation of Options

• A (Advising prophylactic extraction of antagonistic lower incisors)
  • Extraction of healthy opposing teeth is not an acceptable strategy.
• B (Directing the patient to remove the denture during active daytime bruxing episodes and use a protective guard)
  • Best Answer. Temporarily removing the denture under extreme parafunctional stress, especially if it can be predicted or felt, protects both the denture and the teeth. A protective guard (occlusal splint) helps reduce damage.
• C (Telling the patient to chew hard, fibrous foods with the front teeth to strengthen them)
  • Encouraging heavy biting on the anterior denture teeth in a bruxer is counterproductive and likely to cause repeated fractures.
• D (Doubling the daily intake of fluoride mouthwash to reduce incisal wear)
  • Fluoride mouthwash helps prevent caries, not mechanical wear from bruxism.
• E (Rotating the base material between acrylic and porcelain to distribute loads)
  • Mixed or alternating materials is neither practical nor evidence‐based for controlling bruxism‐related forces.

Correct Answer: C. The risk of osteonecrosis if a surgical procedure (crown lengthening or extraction) is performed under denosumab therapy

Explanation of Options

• A (Estimated cost of a custom cast post and core)
  • Ms. Roy has already stated that cost is not her primary concern; her priority is health and long‐term stability.
• B (Patient’s preference for a conservative approach over time)
  • Patient preference is always important, but in this scenario, the immediate clinical risk (ONJ due to denosumab) outweighs a purely preference‐based decision.
• C (The risk of osteonecrosis if a surgical procedure is performed under denosumab therapy)
  • Best Answer. Both crown lengthening (which can involve alveolar bone recontouring) and extraction carry a risk of medication‐related osteonecrosis of the jaw (MRONJ). Assessing that risk is paramount in planning.
• D (Whether the existing post is tapered or parallel)
  • Relevant for potential post removal or re‐treatment, but not the most critical initial factor compared to risk of ONJ.
• E (Presence of an existing metal margin at the gumline)
  • This may affect aesthetics or retention, but does not supersede medical‐surgical risk in importance.

Correct Answer: A. Cone beam computed tomography (CBCT) to assess bone levels and root anatomy

Explanation of Options

• A (CBCT to assess bone levels and root anatomy)
  • Best Answer. A 3D image can clarify root morphology, exact location of the cervical lesion, and alveolar bone height—vital for successful crown lengthening or evaluating hidden cracks.
• B (Replacement of the post with a titanium parallel post immediately)
  • One would not replace the post before confirming the tooth’s restorability and the need for re‐treatment.
• C (Probing the sulcus around the adjacent teeth only)
  • Full periodontal assessment includes #25 specifically; adjacent teeth alone do not suffice.
• D (Extraction of the tooth for direct visualization of the root fracture)
  • Extraction for diagnosis is not conservative. Once removed, the tooth is lost.
• E (Prescribing chlorhexidine mouthwash for 2 weeks pre‐operatively)
  • While chlorhexidine can reduce bacterial load, it does not address the key question of root integrity and bone levels.

Correct Answer: B. Conservative re‐treatment if needed and minimal flap elevation for crown lengthening

Explanation of Options

• A (Immediate extraction, alveolectomy, and implant placement)
  • This is highly invasive and significantly increases the risk of MRONJ in a denosumab patient.
• B (Conservative re‐treatment if needed … minimal flap elevation …)
  • Best Answer. Minimally invasive approaches, combined with thorough endodontic/periodontal re‐evaluation, limit surgical trauma and reduce MRONJ risk.
• C (Surgical crown lengthening with extensive bone removal and no endodontic re‐evaluation)
  • Fails to consider possible recurrent decay under the core or a vertical root fracture. Also, “extensive” bone removal can heighten MRONJ risk.
• D (Intentional re‐plantation to confirm root structure viability)
  • Rarely first‐line. It is an option in complex endo, but it carries additional risks (root resorption, trauma, alveolar bone damage).
• E (Performing a direct composite build‐up … no periodontal assessment)
  • Placing composite at subgingival margins without evaluating the periodontal condition is inadequate.

Correct Answer: A. Periapical X‐ray, smile line assessment, bone sounding, periodontal probing

Explanations

• A (Periapical X‐ray, smile line assessment, bone sounding, periodontal probing)
  • Best Answer.
  • A dedicated Periapical X‐ray reveals the post length, any periapical changes, and subgingival caries.
  • Smile line assessment helps evaluate aesthetics and how much tooth/gingiva display there is.
  • Bone sounding (probing through the gingiva to bone) clarifies the available ferrule length and alveolar crest topography.
  • Periodontal probing around all aspects of #25 reveals pocket depths or possible attachment loss.
  • Together, these tests provide crucial information on restorability (sufficient tooth structure, any alveolar bone defects) and aesthetic implications of crown lengthening.
• B (Electric pulp testing, transillumination, test cavity, alveolar palpation)
  • EPT and transillumination help detect fractures or pulp vitality, but they don’t directly evaluate subgingival margin location or alveolar crest level. A “test cavity through the post” is highly invasive and less practical when a radiolucency is near the cervical margin. Alveolar palpation is not definitive for subgingival caries extent.
• C (Periodontal probing (mid‐buccal only), final shade matching, hand‐mirror test, percussion test)
  • Limited probing (mid‐buccal only) is insufficient to reveal deeper problems interproximally. Shade matching and the hand‐mirror test focus on aesthetics, while percussion alone cannot confirm restorable ferrule.
• D (Panoramic X‐ray, endo‐ice thermal test on #25, occlusal load measurement, direct composite patch test)
  • A panoramic X‐ray gives a broad overview but lacks the detail of a periapical for subtle cervical issues. Endo‐ice is often blocked by a metal post. Occlusal load measurement and a composite patch test do not assess alveolar crest shape or subgingival margins.
• E (Horizontal bitewing X‐ray, selective anesthesia on #25, tongue retraction test, infiltration with epinephrine)
  • A horizontal bitewing may not capture the full apex or show the entire root extent. Selective anesthesia localizes pain but doesn’t clarify vertical or cervical restorability. Tongue retraction test and infiltration with epinephrine do not address subgingival structure or alveolar bone.

Correct Answer: B. Residual ferrule height and circumferential sound tooth structure

Explanation of Options

• A (Final shade matching)
  • Aesthetic demands are important but do not determine restorability.
• B (Residual ferrule height …)
  • Best Answer. A ferrule of at least 1–2 mm (all around) is critical for core/crown success. Without sufficient tooth structure, long‐term prognosis is poor.
• C (Amount of insurance coverage)
  • Irrelevant to clinical feasibility.
• D (The presence of at least two intact cusp tips)
  • While cusp coverage is relevant, the key structural concept is the ferrule effect, not just cusp count.
• E (The angle of the occlusal plane)
  • Although occlusion matters, it is not the deciding factor for restorability once a post/core is removed and the subgingival tooth structure is examined.

Correct Answer: C. Well‐controlled Hashimoto’s thyroiditis generally poses no major contraindications to standard NSAIDs or paracetamol, but caution is needed if the patient is severely hypothyroid.

Explanation of Options

• A (NSAIDs irreversibly block thyroid hormone release)
  • This is incorrect. NSAIDs do not block the thyroid gland from releasing hormones.
• B (Opioids absolutely contraindicated in autoimmune thyroid disorders)
  • There is no absolute contraindication. Caution with dosing if the patient is hypothyroid and prone to sedation, but well‐controlled Hashimoto’s does not preclude opioid use entirely.
• C (Well‐controlled Hashimoto’s … no major contraindications … caution in severe hypothyroidism)
  • Best Answer. If the patient’s thyroid levels are stable, standard analgesics (NSAIDs, paracetamol) and short‐term opioids are acceptable. The main issue arises if hypothyroidism is uncontrolled, as opioid metabolism and sedation risk may change.
• D (Ibuprofen can only be used if TSH < 0.5 mIU/L)
  • There is no specific TSH cutoff for NSAID safety.
• E (Celecoxib accelerates thyroid hormone metabolism …)
  • Celecoxib is not known to induce thyrotoxicosis. No evidence supports this claim.

Correct Answer: B. Ibuprofen 400 mg, 6–8 hourly, plus paracetamol 1000 mg, 4–6 hourly

Explanation of Options

• A (Paracetamol 1000 mg alone)
  • Paracetamol (acetaminophen) alone may be enough for mild to moderate pain but is often inadequate for moderate to severe pain.
• B (Ibuprofen + paracetamol)
  • Best Answer. According to Australian guidelines, the combination of NSAIDs (e.g., ibuprofen) with paracetamol is first‐line for moderate to severe nociceptive dental pain if there are no contraindications to NSAIDs (such as peptic ulcer disease or significant renal impairment). This dual‐therapy approach often provides better pain control than either agent alone.
• C (Celecoxib 200 mg once daily)
  • COX‐2 inhibitors (e.g., celecoxib) can be considered if standard NSAIDs are contraindicated (e.g., gastrointestinal side effects, certain cardiovascular risks). However, once‐daily celecoxib might not be sufficient for acute severe dental pain, and it does not necessarily outperform the ibuprofen + paracetamol regimen.
• D (Intravenous morphine infusion for 72 hours)
  • This is typically too aggressive for routine outpatient dental pain management and is reserved for hospital settings with more complex cases.
• E (Topical eugenol paste every 2 hours)
  • Eugenol can provide some localized relief, but it is insufficient for moderate to severe pain and does not address underlying inflammation adequately.
• F (Oxycodone immediate‐release 5 mg orally, every 4–6 hours as necessary)
  • An opioid might be added if NSAIDs + paracetamol fail to control severe pain. However, oxycodone alone is not considered the best initial step when NSAIDs are permitted. Opioids should be reserved for breakthrough or refractory pain once the combination of ibuprofen + paracetamol proves inadequate.

Correct Answer: A. Oxycodone immediate‐release 5 mg orally, every 4–6 hours as necessary

Explanation of Options

• A (Oxycodone immediate‐release 5 mg …)
  • Best Answer. Australian guidelines allow short‐term opioid use for severe acute dental pain if NSAIDs + paracetamol are insufficient. Minimal duration is emphasized.
• B (IV sedation with midazolam)
  • This addresses anxiety/sedation, not ongoing pain control at home.
• C (Add aspirin 1000 mg every 4 hours indefinitely)
  • Concurrent high‐dose NSAIDs + aspirin significantly increases GI and bleeding risks. Not standard for persistent severe pain.
• D (Prescribe chloroform mouth rinse)
  • Chloroform is a gutta‐percha solvent, not a routine analgesic. It poses toxicity hazards.
• E (Increase ibuprofen to 800 mg every 4 hours)
  • This exceeds typical safe dosing frequency and total daily dose, heightening GI, renal, and cardiovascular risks.

Correct Answer: E. No specific major drug interaction is commonly reported; monitor as per standard guidelines

Explanation of Options

• A (Monitoring for orthostatic hypotension due to Addison’s disease)
  • Addison’s disease is adrenal insufficiency, not directly implied by Hashimoto’s (autoimmune thyroiditis).
• B (Potential for reduced levothyroxine absorption)
  • Standard NSAIDs do not typically affect levothyroxine’s absorption in a clinically significant manner.
• C (Covert risk of myxedema coma if NSAIDs are taken long‐term)
  • Myxedema coma is associated with uncontrolled hypothyroidism; NSAIDs are not a known direct trigger.
• D (Checking the patient’s thyroid function monthly while on ibuprofen)
  • This is not standard practice unless there is evidence of thyroid instability.
• E (No specific major drug interaction …)
  • Best Answer. Patients with Hashimoto’s generally follow standard analgesic protocols; simply monitor for typical NSAID side effects.

Correct Answer: C. Obtain a medical consultation … consider timing and possible drug holiday

Explanation of Options

• A (Discontinue denosumab immediately for at least 12 months)
  • Abruptly stopping denosumab can lead to rapid bone turnover rebound, among other issues. A coordinated approach with the treating physician is necessary.
• B (Perform procedure without local anesthesia)
  • This is clinically unreasonable and not MRONJ preventive measure.
• C (Obtain a medical consultation … consider drug holiday)
  • Best Answer. Collaboration with her physician or specialist is crucial. Timing procedures to minimize MRONJ risk is standard of care.
• D (Rely solely on antibiotic prophylaxis)
  • Antibiotics alone cannot completely prevent MRONJ.
• E (Schedule at any time; MRONJ does not occur with denosumab)
  • Denosumab is well‐documented to present a risk of MRONJ.

Correct Answer: B. Recurrent subgingival caries beneath the crown margin

Correct Answer: C. Crown lengthening, remove existing restoration, excavate, assess feasibility, then re‐crown or extract

Correct Answer: B. Ensuring a circumferential ferrule of at least 2 mm on sound tooth structure and sealing margins meticulously

Correct Answer: C. Switch to a latex‐free dam, ensuring no latex contact

Correct Answer: C. At least two‐thirds of the root length, leaving 4–5 mm of apical gutta‐percha

Correct Answer: A. No replacement

Explanations

• A (No replacement) – Minimally invasive; patient has no complaints.
• B (3‐unit bridge) – Requires extensive tooth preparation of abutments.
• C (Implant) – Surgical, higher risk given medical status; not strictly necessary.
• D (Maryland bridge) – Conservative but not essential if the patient is unconcerned.
• E (Partial denture) – Usually not ideal for a single missing tooth with no issue.

Correct Answer: C. Obtain a cone beam CT (CBCT) scan of #36

Explanations

• A (Multiple PAs) – Helpful but may still be inconclusive in calcified canals.
• B (Cold test) – Not relevant for a root‐filled tooth.
• C (CBCT) – 3D imaging can reveal true canal length and any hidden pathology.
• D (Antibiotics) – No sign of infection; unwarranted.
• E (No symptoms) – Asymptomatic teeth can still have issues.

Correct Answer: A. Advantage: minimal reduction, Disadvantage: possible debonding

Explanations

• A – Minimal prep is a hallmark; bonding failures can occur.
• B – Maryland bridges don’t correct severe malalignment.
• C – No mandatory RCT for abutments.
• D – Implant or conventional bridge may have comparable or better longevity.
• E – Cost depends on many factors; sedation is not routinely required.

Correct Answer: C. Implant is feasible with coordination

Explanations

• A – Not absolutely contraindicated; caution is needed.
• B – Her medical status requires special planning.
• C – Must manage bleeding risk and possible prophylaxis.
• D – Abruptly stopping anticoagulants is risky.
• E – 6–7 mm can accommodate certain narrow‐diameter implants.

Correct Answer: A. Leftover/trapped/growing microorganisms

• A Leftover/trapped/growing microorganisms)
  • Best Answer. A short fill commonly leaves uncleaned apical regions harboring residual bacteria, leading to persistent infection and RCT failure.
• B (Vertical root fracture)
  • No clear fracture line is visible on this radiograph. Although VRF is possible, it is not the most apparent cause here.
• C (Missed canal or inadequate debridement)
  • Common but typically implied in the broader category of residual microbes; however, this option specifically focuses on missed anatomy rather than an overall microbial cause.
• D (Coronal leakage)
  • The crown seems intact with no obvious marginal breakdown, so coronal leakage isn’t the prime suspect radiographically.
• E (Overzealous shaping / apical transportation)
  • The filling does not appear transported or over-prepared; the main problem is a short fill rather than canal deviation.

Correct Answer: C. CBCT, cardiologist labs, and periodontal charting

Explanations

• A (IOPA, BP, rubber dam test)
  • An IOPA alone might not fully assess bone volume. Rubber dam testing is not relevant for implant site evaluation.
• B (OPG, FBC, study models)
  • OPG is a good overview but lacks precise 3D info. Full blood count is helpful, but we must check anticoagulation status specifically (e.g., INR).
• C (CBCT, cardiologist labs, perio chart)
  • Best Answer.
  • CBCT: Gives accurate 3D assessment for implant site.
  • Cardiologist labs: Ensures safe management of his anticoagulation/prosthetic valve.
  • Periodontal charting: Confirms healthy supporting tissues.
• D (Ceph, ECG, bitewings)
  • Cephalometric is more for orthognathic or orthodontic planning, not routine for single implants.
• E (Biopsy, random sugar, jaw tracing)
  • Biopsy is unwarranted without suspicious lesions. Jaw tracing is rarely needed for a single implant.

Correct Answer: D. “Exact names/dosages of heart meds and any cardiologist instructions”

Brief Explanations

• A (Smoking cessation + post‐nasal drip)
  • Smoking status matters, but not the most urgent detail.
• B (Satisfaction with dentures)
  • Relevant to patient’s complaint, but not the first crucial medical question.
• C (Friend’s implant experience)
  • Patient stories can guide expectations, but not the key clinical priority.
• D (Exact heart meds & cardiologist guidance)
  • Best Answer. Determining whether he’s on anticoagulants or other specific regimens is critical for surgical planning and prophylaxis needs.
• E (Implant brand preference)
  • This is secondary; medical safety and drug details come first.

Correct Answer: C. Do not prescribe antibiotics if safe or Consult with his cardiologist regarding prophylaxis needs.

Explanations

• A – Incorrect; prosthetic valves often warrant prophylaxis, especially for surgical procedures.
• B – Overly broad; prophylaxis is typically recommended for invasive procedures, not all.
• C – Best Answer. Standard approach: coordinate with physician and confirm prophylaxis protocol.
• D – GA sedation alone is not the deciding factor for prophylaxis.
• E – Time since valve surgery does not automatically negate prophylaxis considerations.

Correct Answer: C. Improved vs. current smoker, but slightly higher risk remains

Explanations

• A – Quitting helps, but a 30-year history can still have some impact.
• B – Smoking history is not a strict contraindication, especially if he’s quit.
• C – Best Answer. Quitting reduces risk, but some residual effect may persist.
• D – Not necessarily required; must evaluate alveolar bone clinically/radiographically.
• E – Subperiosteal implants are rarely used; not specifically tied to ex-smokers.

Correct Answer: B. The available bone volume

Explanations

• A – Heart meds matter mostly for surgical risk, but do not directly dictate implant number or positioning.
• B – Best Answer. Number and placement of implants hinge on bone quality/quantity for stable anchorage.
• C – The brand is secondary to biomechanical fundamentals.
• D – Denture age doesn’t drive implant numbers or positions.
• E – Cost is a practical concern, but not the primary clinical determinant.

Correct Answer

1. Direct composite veneer using an injectable resin technique with a transparent silicone index

Explanation of Options

• A. Full-coverage porcelain crown with minimal tooth preparation
  • Why it seems correct: A full-coverage crown can mask the peg shape and provide durability.
  • Why it’s not the best: Even “minimal” crown preparation typically involves more tooth reduction than a direct composite veneer—especially contrary to the patient’s desire to avoid drilling.
• B. Direct freehand composite layering with single shade
  • Why it seems correct: Direct composite restorations are conservative and avoid extensive drilling.
  • Why it’s not the best: A single-shade freehand build-up limits the ability to precisely contour and match surrounding dentition. The injectable technique with a transparent silicone index is more predictable for shape and reduces chairside guesswork.
• C. Direct composite veneer using an injectable resin technique with a transparent silicone index
  • Why it is correct/best: This technique is minimally invasive (or potentially no-prep, depending on the existing space), aligns with Mr. James’s “no drilling” preference, and provides a highly accurate and aesthetic result. The silicone index, made from a diagnostic wax-up or mock-up, ensures optimal shape and symmetry.
• D. Porcelain laminate veneer with conventional tooth reduction
  • Why it seems correct: Porcelain veneers are a gold standard for aesthetics and longevity.
  • Why it’s not the best: Despite being relatively conservative compared to crowns, porcelain veneers typically require some tooth reduction. Mr. James explicitly wants to avoid drilling.
• E. Extraction and replacement with a resin-bonded bridge
  • Why it seems correct: A resin-bonded bridge can offer a minimal-prep replacement if the tooth were compromised.
  • Why it’s not the best: Extraction is unnecessarily invasive for a vital peg lateral, and the patient wants to maintain his natural tooth (just reshape it).

Correct Answer

1. Mobility and vitality testing of the lateral incisor

Explanation of Options

• A. Full mouth panoramic radiograph to rule out any impacted third molars
  • Why it seems correct: A panoramic radiograph is common for overall dental screening.
  • Why it’s not the best: Impacted third molars are unrelated to the peg lateral’s immediate prognosis.
• B. Periodontal probing around the lateral and a bitewing radiograph only
  • Why it seems correct: Periodontal health and proximal caries are essential considerations.
  • Why it’s not the best: While probing and bitewings are useful, they do not confirm tooth vitality nor evaluate mobility specifically.
• C. CBCT scan of the anterior maxilla to evaluate bone thickness
  • Why it seems correct: A CBCT provides detailed three-dimensional imaging.
  • Why it’s not the best: This is excessive radiation for a single tooth scenario without suspicion of major pathology.
• D. Mobility and vitality testing of the lateral incisor
  • Why it is correct/best: Ensuring the tooth is not mobile (indicative of periodontal or structural issues) and confirming vitality (no endodontic pathology) are pivotal. This fundamental diagnostic step is the most crucial prior to aesthetic restoration.
• E. Salivary flow assessment to detect possible xerostomia
  • Why it seems correct: Xerostomia can impact bonding and composite longevity.
  • Why it’s not the best: Mr. James has not reported dryness of mouth or medication side effects severe enough to warrant a salivary flow test as the prime investigation.

Correct Answer

1. Employ a silicone index based on a diagnostic wax-up and confirm dimensions by comparing to the contralateral side

Explanation of Options

All options appear workable, but the key is ensuring an accurate reference:

• A. Rely on a single measurement of the contralateral lateral incisor’s width and copy that exactly
  • Why it seems correct: Matching the width of the opposing lateral can help achieve symmetry.
  • Why it’s not the best: A single measurement alone doesn’t account for incisal edge position, curvature, contour, or overall smile harmony.
• B. Use only standard tooth dimension charts from references to build the lateral incisor
  • Why it seems correct: Textbooks and charts provide average tooth measurements and proportions.
  • Why it’s not the best: Individual variations in arch form and tooth morphology mean generic charts may not match the patient’s contralateral tooth.
• C. Employ a silicone index based on a diagnostic wax-up and confirm dimensions by comparing to the contralateral side
  • Why it is correct/best: A diagnostic wax-up addresses the patient’s specific tooth proportions and arch. The silicone index ensures precise transfer of the planned shape to the mouth, and using the contralateral incisor as a reference confirms symmetry.
• D. Place a direct composite mock-up freehand and adjust until the patient is satisfied
  • Why it seems correct: Freehand mock-ups can be used for quick demonstrations and immediate visualization.
  • Why it’s not the best: It risks multiple trial-and-error adjustments, consuming time and risking suboptimal symmetry compared to a planned index or wax-up.
• E. Estimate the width visually at chairside without referencing any guides or contralateral measurements
  • Why it seems correct: Skilled clinicians often visually approximate.
  • Why it’s not the best: Visual estimations alone can be highly subjective, prone to error, and not as reproducible as a wax-up and silicone index method.

Correct Answer

1. Check the shade under daylight at different times of the day and involve the patient in the final decision

Explanation of Options

• A. Let the dental technician pick the shade from a single photograph
  • Why it seems correct: Skilled technicians are essential, and photographs help.
  • Why it’s not the best: A single photograph can distort colors (due to lighting, camera settings). Multiple checks in real-life conditions are superior.
• B. Choose the brightest shade to preempt future discoloration
  • Why it seems correct: Some believe starting with a lighter shade compensates for potential staining over time.
  • Why it’s not the best: An immediately mismatched lighter restoration can appear unnatural from the outset.
• C. Use an artificial light in the surgery and finalize the shade in one session
  • Why it seems correct: Artificial lighting can be standardized in a dental clinic.
  • Why it’s not the best: Daylight evaluation remains the gold standard; a single session might miss variations in color perception over time.
• D. Check the shade under daylight at different times of the day and involve the patient in the final decision
  • Why it is correct/best: Natural daylight is the most reliable source to assess true shade. Checking at different times (morning, afternoon) accounts for lighting variations, and involving the patient maximizes satisfaction and co-diagnosis.
• E. Match the shade to the adjacent central incisor after a single visual assessment
  • Why it seems correct: Matching the central can be a reference for anterior teeth.
  • Why it’s not the best: One quick visual check is prone to human error and does not address subtle differences in hue and translucency between central and lateral incisors.

Correct Answer

Consult with his physician and carefully titrate nitrous oxide at a lower initial concentration

Explanation of Options

• A. Provide maximum flow nitrous oxide without adjusting for tolerance
  • Why it seems correct: Nitrous oxide alone is relatively safe and widely used.
  • Why it’s not the best: Chronic benzodiazepine use can alter sedation response. Blindly using maximum flow without caution can risk oversedation or inadequate sedation control.
• B. Stop diazepam for a week and switch to midazolam IV sedation
  • Why it seems correct: One might consider reducing benzodiazepine tolerance by pausing diazepam.
  • Why it’s not the best: Abruptly stopping long-term diazepam can lead to withdrawal. IV sedation also demands specialized setup, monitoring, and might be riskier if tolerance or withdrawal is uncontrolled.
• C. Consult with his physician and carefully titrate nitrous oxide at a lower initial concentration
  • Why it is correct/best: Coordination with the patient’s doctor ensures safety, especially regarding the interplay of chronic diazepam and sedative procedures. Starting at a lower nitrous oxide concentration accounts for potential altered benzodiazepine tolerance and can be slowly titrated to effect.
• D. Combine diazepam pre-medication with high-concentration nitrous oxide for enhanced effect
  • Why it seems correct: Combining agents can provide deeper sedation.
  • Why it’s not the best: Stacking sedatives can lead to over-sedation, respiratory depression, or other complications if not meticulously monitored.
• E. Rely on the patient’s daily diazepam as the sole anxiolytic and avoid sedation altogether
  • Why it seems correct: Diazepam already provides some level of anxiolysis.
  • Why it’s not the best: Mr. James specifically requests nitrous oxide due to anxiety, and relying solely on his chronic medication may not be sufficient to manage procedural fear.

Correct Answer

Bis-acryl provisional fabricated with a matrix or “putty index”

Explanation of Options

• A. Flowable composite buildup freehand without a matrix
  • Why it seems correct: Composite can be used in direct restorations and can be shaped quickly.
  • Why it’s not the best: Flowable composite alone is weak under masticatory forces and challenging to shape for a full-coverage crown without a stent or index.
• B. Preformed stainless steel crown crimped intraorally for adaptation
  • Why it seems correct: Stainless steel crowns can be adapted for posterior teeth, especially in pediatric dentistry.
  • Why it’s not the best: Marginal adaptation for an adult’s large upper molar with subgingival margins can be inadequate, potentially causing periodontal irritation.
• C. Bis-acryl provisional fabricated with a matrix or “putty index”
  • Why it is correct/best: Bis-acryl resin is popular for temporaries, providing good strength, improved marginal fit, and straightforward fabrication using a matrix or silicone index. It can withstand posterior forces well for multiple weeks.
• D. Bulk IRM (ZOE) build-up covering cusps and marginal ridges
  • Why it seems correct: IRM can serve as a sedative, short-term filling in endodontic scenarios.
  • Why it’s not the best: IRM alone does not offer the strength or contour accuracy of a properly fabricated crown form, especially for a heavily loaded upper molar.
• E. Full coverage with plain Cavit (ESPE) from the access opening to the occlusal
  • Why it seems correct: Cavit is renowned for sealing endodontic access cavities.
  • Why it’s not the best: Cavit alone is weak and can fracture in heavy occlusal function. It is not intended to serve as a full-coverage provisional crown on a molar.

Correct Answer

Clean to remove debris and sterilize by an approved method before re-cementation

Explanation of Options

• A. Wipe it thoroughly with 70% isopropyl alcohol and proceed
  • Why it seems correct: Alcohol wipes are commonly used for surface disinfection.
  • Why it’s not the best: Dropping an intraoral device on the floor is considered significant contamination. Simple wiping is insufficient for a semi-critical device.
• B. Rinse under water for at least 20 seconds, then spray with disinfectant
  • Why it seems correct: Rinsing plus disinfectant removes visible soil and might reduce bioload.
  • Why it’s not the best: For an item that contacts mucosa/blood, sterilization is required to meet guidelines if you plan to reuse it.
• C. Place it in an ultrasonic bath, then cold-sterilize for 10 minutes
  • Why it seems correct: Ultrasonic baths remove debris, and some might think chemical “cold sterilization” is enough.
  • Why it’s not the best: A 10-minute soak is typically high-level disinfection, not true sterilization. The recommended approach is steam sterilization (or another validated method) if the material is heat-stable.
• D. Clean to remove debris and sterilize by an approved method before re-cementation
  • Why it is correct/best: Following contamination, the Australian guidelines indicate that semi-critical items require thorough cleaning + sterilization if they will be reused intraorally.
• E. Scrub with a detergent brush for one minute and allow to air-dry fully
  • Why it seems correct: Mechanical scrubbing removes debris.
  • Why it’s not the best: This step alone does not achieve sterilization.

Correct Answer C. “High-quality provisionals minimize coronal leakage, reduce bacterial ingress, and maintain occlusal function.”

Explanation of Options

• A. “A simple cotton pellet and IRM in the access hole is more than enough for full coverage.”
  • Why it seems correct: IRM is often used after RCT visits to seal the access.
  • Why it is not the best: This approach may suffice short-term between visits, but not for a subgingival margin with large structural loss requiring full coverage.
• B. “Any form of temporary material offers the same seal, as long as it’s placed to the gingiva.”
  • Why it seems correct: Placing a margin at or near the gingiva is typical for a transitional restoration.
  • Why it is not the best: Different materials vary in sealing ability and mechanical strength, especially under occlusal load.
• C. “High-quality provisionals minimize coronal leakage, reduce bacterial ingress, and maintain occlusal function.”
  • Why it is correct/best: A well-adapted provisional helps protect the tooth from contamination, ensures function, and reduces the risk of endodontic re-infection.
• D. “Provisional crowns in RCT cases are purely for aesthetics; the seal is irrelevant.”
  • Why it seems correct: Aesthetic coverage is one aspect of a provisional in an anterior region.
  • Why it is not the best: In posterior RCT, seal and function are crucial to prevent reinfection.
• E. “No matter what, microleakage is inevitable, so a provisional crown is optional.”
  • Why it seems correct: Some might argue no restoration is perfect.
  • Why it is not the best: A properly fabricated provisional can significantly reduce microleakage, not disregard it.

Correct Answer C. Moderate inhalation sedation with titrated nitrous oxide, patient semi-upright

Explanation of Options

• A. High-flow nitrous oxide sedation in fully supine position for the entire procedure
  • Why it seems correct: Nitrous oxide sedation is commonly used for anxious patients.
  • Why it is not the best: High-flow could risk oversedation, and fully supine might exacerbate breathing issues in an asthmatic patient.
• B. IV benzodiazepine sedation at maximum dose in a non-hospital dental clinic
  • Why it seems correct: Benzodiazepines reduce anxiety effectively.
  • Why it is not the best: High-dose IV sedation in a non-hospital setting can be risky, especially if an asthmatic episode occurs and there’s no advanced airway support.
• C. Moderate inhalation sedation with titrated nitrous oxide, patient semi-upright
  • Why it is correct/best: Titrating nitrous oxide carefully helps manage anxiety safely, while a semi-upright position supports better airway patency in mild asthma.
• D. Daily NSAIDs for 3 days pre-appointment to prevent respiratory issues
  • Why it seems correct: Some might consider NSAIDs for inflammation control.
  • Why it is not the best: NSAIDs can exacerbate asthma in certain patients. This is not a recommended prophylaxis for respiratory issues in asthmatics.
• E. Full general anaesthesia at an outpatient day surgery facility
  • Why it seems correct: GA eliminates awareness and potential anxiety.
  • Why it is not the best: GA is typically reserved for severe cases; mild asthma with dental anxiety is often managed effectively with minimal or moderate sedation.

Correct Answer D. Refine the margins of the existing provisional extraorally and recement to protect the tooth

Explanation of Options

• A. Immediately fabricate a permanent crown and schedule surgery for a later date
  • Why it seems correct: Some might want to finalize the crown quickly.
  • Why it is not the best: The definitive margin should be established after crown-lengthening and healing, ensuring the final crown fits the new gingival contour.
• B. Adapt a stainless steel band around the tooth, leaving the occlusal open
  • Why it seems correct: A band might provide some circumferential support.
  • Why it is not the best: This is insufficient for occlusal coverage and can allow leakage or contamination.
• C. Remove the entire provisional and place only IRM until after surgery
  • Why it seems correct: IRM is a quick temporary.
  • Why it is not the best: IRM alone may not protect subgingival margins adequately or maintain occlusal relationships in a molar.
• D. Refine the margins of the existing provisional extraorally and recement to protect the tooth
  • Why it is correct/best: Preserving and adjusting the current provisional to maintain the tooth’s structure, occlusion, and seal is ideal while awaiting surgery. Minimal trauma and stable coverage are priorities.
• E. Allow the tooth to remain uncovered to facilitate the periodontist’s access
  • Why it seems correct: One might presume easy visual access for the surgeon.
  • Why it is not the best: The tooth is left vulnerable to contamination and fracture, and the patient’s occlusion could be destabilized.

Correct Answer: D. Assessing the maximum interincisal distance and jaw range of motion

Explanation

• A. Updating the panoramic radiograph: A current radiograph is indeed important, but the very first critical issue in an RA patient with known TMJ involvement is whether you can safely access and maneuver in the oral cavity. While a new panoramic image is valuable, it is secondary to ensuring the patient can tolerate the procedure at all.
• B. Measuring and scoring plaque index: Plaque control is crucial for peri‐implant health, but it is not the primary immediate assessment if mouth opening is severely limited (which can impede the procedure itself).
• C. Confirming serum rheumatoid factor levels: Laboratory markers can help monitor RA severity systemically but do not directly solve the immediate procedural question: Can the dentist even access the site to replace the abutment safely?
• D. Assessing maximum interincisal distance and jaw range of motion (Correct): In a patient with RA and TMJ involvement, the first real barrier may be inadequate mouth opening. Ensuring you can physically access and manipulate instrumentation is paramount before proceeding.
• E. Performing a CBCT scan: While a CBCT is highly detailed for implant planning or complication assessment, it is not the very first or most critical immediate clinical assessment. If the patient cannot open properly, imaging alone will not solve that access problem.

Correct Answer: B. Degree of alveolar bone height

Explanation

• A. Slight alveolar bone sclerosis: Sclerosis can happen in chronic inflammation, but the key factor in peri‐implant stability is vertical and horizontal bone support, not mild sclerosis per se.
• B. Degree of alveolar bone height (Correct): Adequate alveolar bone height is fundamental for implant support and long‐term success. RA may contribute to bone loss, and reduced height strongly correlates with mechanical and biological complications around implants.
• C. Elevated ESR: While this reflects systemic inflammation, it does not directly correlate with peri‐implant mechanical complications. It is more an overall measure of RA activity.
• D. Possible subchondral cysts in the TMJ: Although these can limit mouth opening or cause TMJ pain, they are less directly influential on implant site complications.
• E. Increased risk of osteonecrosis from RA alone: RA by itself is not classically linked to medication‐related osteonecrosis of the jaw (MRONJ) unless the patient is on specific agents (e.g., bisphosphonates or denosumab). RA alone does not automatically create a high osteonecrosis risk.

Correct Answer: D. Keeping forearms uncovered, removing wristwatches and bracelets

Explanation

• A. Wearing a full‐length disposable gown with sleeves: While sterile gowns may be necessary for implant surgery, the sleeves generally must not impede hand or forearm hygiene. They are typically single‐use but do not themselves fulfill the “bare below elbows” principle if the forearms remain covered during routine patient care outside a strict sterile field.
• B. Maintaining short nails but wearing a ring: Rings harbor microorganisms beneath them, increasing infection risk. This violates “bare below elbows.”
• C. Using a long‐sleeved coat but rolling sleeves up: Rolling sleeves is more prone to contamination. The policy typically requires discarding or not wearing long sleeves during direct patient care.
• D. Keeping forearms uncovered, removing wristwatches and bracelets (Correct): This adheres precisely to the recommended “bare below elbows” approach from the ADA and National Hand Hygiene Initiative.
• E. Double‐gloving: Double‐gloving is sometimes used in high‐risk surgical contexts, but it does not address the forearm/wrist contamination issue or the official “bare below elbows” principle.

Correct Answer: C. Cone‐beam computed tomography (CBCT) focusing on the anterior maxilla

Explanation

• A. Standard panoramic radiograph: An OPG provides a broad overview but can distort or superimpose structures, limiting detail on bone width or exact impingement.
• B. Intraoral periapical radiograph: Helpful but only offers a 2D view. Abutment orientation and labial cortical plate thickness are hard to assess precisely.
• C. CBCT focusing on the anterior maxilla (Correct): A limited‐field or region‐of‐interest CBCT yields 3D information about bone contours, implant angulation, and any labial perforation risk—ideal for complex implant troubleshooting.
• D. Medical‐grade CT: Typically higher radiation dose and less convenient. Not the usual first‐line imaging for dental implant detail.
• E. MRI of the TMJ and alveolar ridge: MRI is excellent for soft‐tissue and TMJ disc pathology, but not for precise bony details around implants.

Correct Answer: C. Meticulous oral self‐care with adaptive aids and frequent professional maintenance

Explanation

• A. High‐resolution imaging at each follow‐up: Useful but does not prevent peri‐implant disease if daily oral hygiene is inadequate.
• B. Strict prophylactic antibiotic regimen: Not recommended routinely unless there is a specific medical indication. Overuse of antibiotics risks resistance and adverse effects.
• C. Meticulous oral self‐care with adaptive aids + professional maintenance (Correct):

• Adaptive aids can include:
  • Enlarged or angled toothbrush handles to accommodate limited grip or reduced manual dexterity.
  • Electric toothbrushes with oscillating or sonic technology, reducing the manual effort required.
  • Floss holders or specialized floss threaders that simplify interdental cleaning around implants.
  • Interdental brushes with modified grips or thicker handles.
  • Mouth props or “bite blocks” if mouth opening is severely limited.
• Frequent professional care is also essential because home care alone may be inadequate with severe RA.

• D. Antiseptic mouthwash with chlorhexidine indefinitely: Prolonged chlorhexidine use can lead to staining, taste alterations, and calculus formation. It is adjunctive, not the single most critical factor.
• E. Titanium brush debridement every 3 months: While professional debridement is helpful, it does not replace the patient’s daily home care, which is more decisive for success.

Correct Answer: C. Limited mandibular opening due to TMJ involvement

Explanation

• A. Elevated anti‐CCP antibody levels: This is a diagnostic indicator of RA severity but does not directly complicate the implant surgical approach.
• B. Medication‐induced gingival overgrowth: While certain drugs (e.g., cyclosporine) may cause overgrowth, standard RA therapies (e.g., methotrexate, biologics like denosumab) do not typically cause this.
• C. Limited mandibular opening due to TMJ involvement (Correct): RA in the TMJ can severely restrict mouth opening, making implant surgery technically difficult and posing practical challenges in achieving adequate surgical access.
• D. Rheumatoid nodules on the palate: Possible but quite rare in the oral cavity and typically less of a direct limitation to implant surgery.
• E. Excessive alveolar bone density: RA more commonly leads to bone loss or changes in the joint; excessive density is not characteristic of RA.

Correct Answer: C. Denosumab can raise the risk of MRONJ, particularly with invasive bone procedures

Explanation

• A. Denosumab only increases osteonecrosis risk in the mandible: Denosumab can affect both jaws; MRONJ is not confined to the mandible.
• B. RA alone virtually guarantees MRONJ: RA by itself does not guarantee MRONJ. The medication class (e.g., denosumab, bisphosphonates) is the key factor.
• C. Denosumab can raise the risk of MRONJ, particularly with invasive bone procedures (Correct): This is well‐documented. Any invasive procedure in patients on antiresorptive therapy can precipitate MRONJ, so caution is required.
• D. Risk is negligible without corticosteroids: Patients on denosumab can develop MRONJ even without concurrent steroids. Steroids further increase risk but are not the sole cause.
• E. MRONJ is exclusively linked to IV bisphosphonates: Denosumab, a RANKL inhibitor, also has a known (though lower) MRONJ risk compared to IV bisphosphonates.

Correct Answer: B. Ultrasonic scaler with a metal tip

1. Standard stainless‐steel Gracey curettes: High risk of scratching the implant surface.

• B. Ultrasonic scaler with a metal tip (Correct):
  • Why is this correct under these circumstances? Some modern ultrasonic devices offer specialized metal tips (e.g., titanium alloy or stainless steel with specialized coatings) for implant maintenance if used very carefully at low power with copious water. In a difficult‐access scenario (limited mouth opening) and minimal alternative tips available, a carefully adapted metal tip can effectively remove calculus while minimizing damage—though technique‐sensitivity is extremely high.
  • Note: Many clinicians prefer non‐metal tips around implants. However, advanced ultrasonic systems may supply fine metal tips specifically designed for implants if used precisely. This option is chosen here to reflect the unique constraints of this scenario and the rarity of specialized tips.
• C. Ultrasonic scaler with ceramic or plastic tip: In most standard guidelines, plastic or carbon‐fiber tips are ideal for implants. However, the question is intentionally tricky: it might be less effective for moderate calculus or tight spaces if the plastic tip is too bulky.
• D. Periodontal hoe with tungsten carbide: Aggressive and can cause significant implant surface abrasion.
• E. Air‐abrasive polishing: Useful for superficial plaque but may not be sufficient for deeper deposits or screw‐access threads.

Correct Answer: D. Adhering to thorough hand hygiene and correct donning/doffing of PPE for each stage

• A. Extending mask use: Masks must be changed when soiled or after recommended duration. Prolonging mask use against guidelines can compromise infection control.
• B. Using alcohol‐based hand rub on gloves: Hand rub is to be applied to bare hands; applying on gloved hands is improper. Gloves must be changed between patients/procedures.
• C. Not reusing single‐use items on the same patient: Single‐use items should not be reused at all—even on the same patient, they are generally not meant for repeated use. (Irrigation tips, suction tips, etc. are disposable for a single session).
• D. Correct hand hygiene & correct donning/doffing of PPE (Correct): Meticulous hand hygiene plus proper gowning, gloving, mask usage, and doffing sequence are crucial to avoid cross‐contamination—especially in immunocompromised or aged‐care patients.
• E. Wearing jewelry under gloves: This violates “bare below elbows” and fosters bacterial colonization beneath rings or bracelets.

Correct Answer: D. Chronic plaque accumulation under the pontic causing inflammatory swelling

Explanation

• A. Overextended pontic design: Possible, but not the most common culprit. Overextension may cause tissue irritation, but RA‐related dexterity issues more commonly point to inadequate cleaning.
• B. Supra‐occlusion of the bridge: Could cause occlusal trauma, but localized “soreness under the bridge” with swelling is more typical of plaque‐induced inflammation.
• C. Cantilever extension torque: This typically manifests as mechanical failure (loose abutment or fracturing) rather than soft‐tissue swelling.
• D. Chronic plaque accumulation under the pontic (Correct): In an RA patient with reduced home‐care ability, plaque entrapment under a cantilever pontic is classic for tissue inflammation and soreness.
• E. Metal alloy allergy: Less common than plaque‐related inflammation, and allergies usually present with diffuse or mucosal changes.

Correct Answer: A. Ask the patient to describe whether the entire implant or just the crown/abutment is moving

Explanation of each option:

• A (Correct): This is the most critical initial step to differentiate between a loose prosthetic component (crown or abutment) and a failing implant. If the entire implant moves, it indicates osseointegration failure; if only the crown or abutment moves, the issue is mechanical.
• B: Simply waiting for two weeks increases the risk of further complications, including implant failure or peri-implantitis.
• C: CBCT is valuable but is not the first step before a basic clinical assessment.
• D: Prescribing antibiotics or anti-inflammatories without clear evidence of infection or inflammation is inappropriate.
• E: Advising the patient to self-adjust an abutment screw risks overtightening and component damage.

Correct Answer: D. Systemic inflammation leading to altered osseointegration

Explanation of each option:

• A: Poor oral hygiene does increase implant risks, but it is not the primary factor affecting implant osseointegration.
• B: Long-term prednisone use may impact bone quality, but it is not the main reason for implant failure in RA.
• C: Limited mouth opening makes implant maintenance harder but does not directly cause failure.
• D (Correct): RA’s chronic systemic inflammation disrupts the osseointegration process, affecting implant stability.
• E: Denosumab increases MRONJ risk but does not directly affect implant osseointegration.

Correct Answer: A. A radiolucent gap at the implant-abutment interface

Explanation of each option:

• A (Correct): A radiolucent gap at the implant-abutment junction suggests incomplete abutment seating due to cement interference or screw loosening.
• B: Periodontal ligament space widening occurs around natural teeth, not implants.
• C: Crestal bone loss is a late finding and is not an immediate indicator of a loose abutment screw.
• D: Periapical radiolucency is more associated with failed endodontic treatment, not implant loosening.
• E: Increased radio-opacity suggests bone sclerosis, which is not relevant to a loose abutment.

Correct Answer: D. A loose implant fixture will be mobile in all directions, including vertical

Explanation of each option:

• A: Healing abutments typically cause minimal pain unless inflamed.
• B: Correct but does not fully differentiate between abutment screw issues and a failing implant.
• C: Healing abutment loosening does not always cause inflammation.
• D (Correct): Implant mobility in all directions (especially vertical) is a hallmark of implant failure.
• E: Loose screws are not always visible on radiographs, making this an unreliable differentiator.

Correct Answer: A. Checking if cement interference is preventing complete seating

Explanation of each option:

• A (Correct): Residual cement may block proper abutment seating, causing looseness despite correct torqueing.
• B: While excessive torque is a concern in osteoporotic patients, it is not the immediate problem here.
• C: Keratinized tissue is important for peri-implant health but does not cause immediate abutment loosening.
• D: Microbial colonization is secondary to the mechanical issue.
• E: Alternative abutment designs may be helpful long-term, but the primary issue is incomplete seating due to cement interference.

Correct Answer: B. To allow tissue contouring before impression taking

Explanation of each option:

• A: Cover screws protect the implant but do not maintain soft tissue shape.
• B (Correct): A healing collar (healing abutment) is a temporary component that guides tissue healing before final prosthetic work.
• C: A final abutment is only placed after impressions are completed.
• D: The healing collar does not create an emergence profile for screw-retained prosthetics—that’s done with custom abutments.
• E: The implant integrates with bone before the healing collar is placed, making this incorrect.

Correct Answer: B. Healing abutment

Explanation of each option:

• A: A cover screw is used in stage 1 surgery, when the implant is placed but completely covered by soft tissue—not visible intraorally.
• B (Correct): A healing abutment (healing collar) is a temporary component that shapes the soft tissue contour before taking an impression for the final prosthesis. The smooth dome shape in the image confirms this.
• C: A final prosthetic abutment is placed after impression-taking, whereas the healing abutment is used during the healing phase.
• D: A transfer impression coping is used only during the impression procedure and appears more elongated with retentive features.
• E: A provisional restoration is a functional, aesthetic crown, not a metallic abutment like the one in the image.

Correct Answer: B. Open-tray impression using a transfer coping

Explanation of each option:

• A: A closed-tray does not leave the transfer coping exposed through the impression material as shown in the image.
• B (Correct): The image clearly shows an open-tray impression, where the transfer post remains inside the impression.
• C: No digital scanner or intraoral optical scan is seen.
• D: Functional impressions are for dentures, not implants.
• E: Alginate impressions are too inaccurate for implant work.