King’s College London Dental Institute

This paper is part of an examination of the College counting towards

the award of a degree. Examinations are governed by the College
Regulations under the authority of the Academic Board.

Second Year Dentistry: Examination Paper One

Unit code: NBDPART2

TIME ALLOWED: TWO HOURS

Answer all questions. You are advised to spend approximately 30 minutes

answering each question.

All questions carry equal weighting and all parts within questions carry equal
weighting.

Answer each question in a separate answer booklet. Please write your

candidate number on each booklet.

Calculators are not permitted.

DO NOT REMOVE THIS PAPER FROM THE EXAMINATION ROOM

TURN OVER WHEN INSTRUCTED

Question one
Describe the protective mechanisms that prevent tooth demineralisation when an acidic
drink is taken into the mouth. Include the following concepts in your answer: salivary
reflex, taste buds, afferent and efferent nerves, neurotransmitters, Stefan’s curve, buffer
systems and calcium homeostasis.

Fail:
Only one main mechanism identified and with many errors or absence of detail.

Pass:
The main mechanisms identified, but lacking detail

Merit/Distinction:
Mentions the components of the salivary reflex, acid receptors in the taste buds, their
innervation, including sensory nerves to the nucleus tractus of solitarius, efferent nerves,
acetyl choline and noradrenaline, receptors on acinar and ductal cells, the Thaysen
osmotic mechanism of saliva production, role of aquaporins, secretion of bicarbonate and
protein. Protein as the main buffer system in resting saliva changing to bicarbonate
aided by carbonic anhydrase 6 in stimulated saliva. At the tooth, the components of the
acquired pellicle, the structure of teeth, mineral components. The main mechanisms are
the acquired pellicle, salivary buffering (including flow effects) and remineralisation
processes (by calcium).
Question two
a. A 16 year old patient attends your surgery and you note caries with cavitation on
the occlusal surface of both lower first permanent molars. What further
investigations would you carry out to determine what to do in the management of
this patient and why?

b. You decide that caries removal is required. What materials could you use to restore
the consequent cavities? Discuss in brief advantages and disadvantages of each one
and what precautions would be required for each of the materials.

Part a:
 Check Medical history for medical treatment/medications that might increase risk
of caries
 Diet analysis to assess risk of caries
 Check use of fluoride? Fluoride toothpaste or fluoride mouthwash
 Check toothbrushing technique for level of plaque control
 ICDAS score to obtain visual assessment of depth of caries
 Sensibility tests to check status of pulp
 Bitewing radiographs to assess radiographic extent of caries

Part b:
Conventional glass ionomer cement e.g. Fuji IX or resin modified glass ionomer cement
e.g. Fuji 2 LC

Advantages:
 Both GIC and RMGIC are adhesive, possible fluoride release, can be easily placed,
sets hard so short time durability and wear resistance quite good
 Management of caries if deep
 Minimally invasive, adhesive, good long term survival

Disadvantages:
 Will wear under occlusal loading after a period of time
 If caries deep and close to pulp then placement of biodentine followed by layering
with composite resin after a period of time.
 Biodentine has possible ability to reduce pulpal inflammation but long term data
is limited
 Needs moisture control – moisture control in the early stages of setting of
conventional GIC’s as it can dessicate or wash out of ions can occur therefore
matrix forming ions maybe lost yielding infereior mechanical properties
 In RMGIC, moisture control is not essential due to the presence of the resin phase
that undergoes polymerisation.

Fail:
Limited response with several key areas missed
Pass:
Discusses assessment of caries risk & special tests mentioned. Above materials
mentioned. Limited mention of advantages and disadvantages.

Merit/Distinction:
Most/all factors mentioned that could affect development of caries, ICDAS/sensibility
testing/bw radiographs explained. Mentions the reasons for protecting conventional
GIC’s & the reasons for placement of biodentine
Question three
Give an account of the anatomical structures (relating structure to function) involved in
biting and chewing but details of the tongue are not required. Which nerve supply the
muscles and where are their nuclei?

Masticatory muscle
Temporalis, masseter, medial & lateral pterygoid. Give attachments and actions
Explain how these muscles are used in biting e.g. for opening of the mouth by relaxing
the tone in temporalis (excellent if other muscles included), protruding the mandible;
lateral pterygoid, superior masseter, closing mouth; temporalis, masseter, medial
pterygoid, retrusion horizontal temporalis, masseter (deep fibres).

Chewing
Protrusion, lateral excursions (explain role of muscle) retrusion.
Could mention role of buccinator in preventing food entering the vestibule. Bonus if they
do.

Nerve supply, mandibular division of trigeminal nucleus in the floor of the fourth
ventricle under the superior cerebellar peduncle.
(Buccinator facial nerve nucleus in the pons (fibres encircle the abducent nucleus before
leaving the pons)

Fail:
A list of muscles or even less

Pass:
Mention the major feature but lacks the structure/function relationship

Merit:
Not all of the information given as fully e.g. individual muscle actions rather than a
coordinated approach

Distinction:
All attachments of muscles given and their action both individually and in context of
their role in both biting and chewing. For the nuclei these need to be fully described.
Structure must always be related to function.
Question four
A 45-year-old woman has recently been diagnosed with generalised moderate chronic
periodontitis. This patient has never had any periodontal treatment. Describe FOUR
clinical signs you would expect to find in this patient. Discuss how host cells, tissues and
innate and adaptive immune mechanisms may protect the host.

Any four signs

 Plaque
 Poor OH and calculus deposits
 Moderate Loss of attachment affecting more than 1/3, or more than 1/2, of the
attachment
 Increased/Moderate probing depths 4-7mm
 Bleeding on probing
 Inflammatory changes in soft tissue- erythema and oedema
 Mobility
 Recession
 Drifting of the teeth- change in tooth position
 Discharge of pus
 Halitosis

Host cells and tissues in chronic periodontitis

Physical barrier to bacteria with saliva/gingival crevicular fluid:
Epithelial cells:
 chemokine/cytokine production
 changes in structure of sulcular and junctional epithelium- ulceration and/or
keratinisation and rete peg formation, migration of junction epithelium

Gingival crevicular fluid:

 GCF containing neutrophils, complement, IgG, IgM, and IgA as well as cytokines.
sIgA in saliva.

Changes in the connective tissue:

 loss of collagen to make room for the inflammatory infiltrate
 vascular proliferation-angiogenesis
 destruction with fibrotic response varying from spongy oedematous to fibrotic
tissue changes.

Innate and adaptive Immune mechanisms function together

Innate
 Complement in formation of MAC, opsonisation and formation of chemotaxins C5a
and C3a recruitment of neutrophils to the periodontal tissues (sulcular/junctional
and connective tissue)
 Neutrophils- phagocytosis, relative abundance and rapid response compared to
macrophages
  Macrophages- phagocytosis and as APC and pro-inflammatory responses, TNF-
alpha, IL-6, IL-1alpha, and other sources of these cytokines.

Adaptive
 T Lymphocytes- specific immunity and memory; CD4 cells and CD8; cytotoxic cells
are unlikely to play any significant role; APC required to present antigen with
HLA-class II for CD4 T cells ( HLA-I for CD8 cytotoxic cells) or there is no T cell
recognition of antigen.
 B Lymphocytes- Antibody specific immunity and memory if CD4 Th2 cells involved;
no APC required for B cell recognition of antigen. B cell effector cells- plasma
cells.
 Pro-inflammatory Th1 (IFN-gamma) and anti-inflammatory Th2 (IL-4, IL-5
promoting B cell differentiation into plasma cells and antibody production); Th17-
role in promoting either Th1 or Th2 cells dependent on cytokine milieu.
 Cytokines elicited in innate and adaptive immune mechanisms can have pro-
inflammatory effects, enhance bone resorption directly or indirectly by promoting
differentiation of osteoclasts. Some have systemic effects too (TNF-alpha, IL-6, IL-
1alpha).

Fail:
Cannot describe any clinical sign of chronic periodontitis. Cannot discuss the protective
role of neutrophils or lymphocytes.

Pass:
Can describe three clinical signs of chronic periodontitis. Can discuss the protective role
of neutrophils and lymphocytes.

Merit:
Can describe plaque/true pocketing and bone loss as key signs of chronic periodontitis.
Can discuss the protective role of neutrophils and lymphocytes and their effector
cells/molecules; the location of these cells and details of the protective mechanisms as a
part of the chronic inflammatory response/process.

Distinction:
Can describe anaerobic plaque/moderate attachment loss and/or moderate bone loss/
proportion of teeth affected as key features of generalised moderate chronic
periodontitis. Can discuss the protective role of neutrophils and lymphocytes and their
effector cells/molecules; the location of these cells and details of the protective
mechanisms as a part of the chronic inflammatory response/process; can discuss the
interplay between innate and adaptive immunity or relate the chronic inflammation to
changes in periodontal architecture