Fall Midterm Exam Review

2) Discuss the types of injections of local anesthesia that are required to achieve anesthesia in the maxillary and mandibular arches of the primary and mixed dentition

PSA à not commonly used in pediatric patients (unless older with severe carious lesions)

Infiltrations à Each tooth to be treated should receive 1/3 carpule

Infiltrations in between teeth are not recommended

Penetration is approximately 2/3 mm

Maxillary à recommended for all teeth

Mandibular à recommended for incisors and sometimes premolars/molars

Often and Inferior Alveolar Block is better

Interdental à in order to achieve anesthesia of the lingual aspects of the papillae in addition to the Infiltration

Inject directly into the papilla (after buccal infiltration)

Look for blanching and test with explorer

When injecting on the opposite side, turn the patients head towards you à Use the palm grasp

Palatal Infiltration à used in addition to Infiltration and Interdental

Less anesthetic affect than a traditional palatal, but adequate for most procedures (pulpotomy, SSC, extraction)

Introduce needle into lingual sulcus (mid-lingual) à bevel is toward the tooth

Palatal blanching should be observed

Inferior Alveolar à for all mandibular teeth

Approach from contralateral canine; sound on osseous; aspirate

Inject 2/3 carpule à deliver a small amount as the needle is removed to anesthetize the lingual nerve

Level of mandibular foramen is at or just below the occlusal plane (lower than in adults)

Long Buccal à indicated for mandibular molars and clamp placement

May be painful

Inject after the IA without removing needle from mouth

Only a few drops are needed

Periodontal Ligament Injection à more of a last resort when achieving anesthesia is difficult

Concerned with introducing anesthetic into follicular sac of developing tooth

Insert needle at a 30° angle to long axis of tooth with bevel toward bone

Maximum Dose à 2.0 mg/lb or 4.4 mg/kg

Age	Average Weight (lbs.)	Carpules 2% Lidocaine
2	32	1.7
3	37	2.0
4	45	2.5
5	49	2.7
6	54	3.0
7	60	3.3
8	70	3.8
9	82	4.5
10	94	5.2
11	105	5.8
12	122	6.7
13	136	7.5

3) Discuss the anatomical differences in the child versus the adult, which would influence the effectiveness of a local anesthetic

See question 1

4) Describe the methods of delivering a local anesthetic in the maxillary and mandibular arch for a child patient

Topical anesthetic is always used à have patient guess the flavor

Dry injection site and apply topical with cotton tip for 2 minutes

«Hidden Syringe Technique à standard protocol for Pacific Pediatric Clinic

5) Describe a method of ascertaining the effectiveness of a local anesthetic administration in a child patient

IA à ask child if lip feels fat/sleepy/funny

Use explorer tip (use “push” rather than “pinch”) à may actually push tip to bone

Observe child’s eye and body reflexes

Infiltrations à (as above)

Unusual to have an infiltration that does not give soft tissue anesthesia

May need to eliminate sound and vibration as the source of “pain”

«Instructor approval is necessary before a second carpule is used

6) Discuss the precautions taken to prevent post-operative trauma
Caution the child and parent about chewing the lip/cheek

«Always give the child a sticker on the side that was anesthetized as a reminder

Instruct the patient and parent to avoid eating until anesthetic wears off

Bites may take 3-4 days to heal, but do not scar (rinse with warm saline)

7) List and discuss the indications for nitrous oxide inhalation at different levels
A severely anxious child (may have had bad prior experience)

Long appointments (increased potential for nausea and vomiting)

Young emergency patient

Patients who are prone to gagging

8) Describe the symptoms of nitrous oxide inhalation at different levels

Nitrous Oxide % Concentration	Effect
10-20	Tingling feeling, sensation of warmth
20-40	Numbness/tingling of extremities (fingers/toes) Sensation of floating Auditory changes (distant humming noise)
30-50	« General effective range used Similar effect as 20-40% range Increase in patient pain threshold General relaxation Altered perception of passage of time
40-70	Dreaming Laughing Sweating Uncoordinated movement Loss of eyelid reflex (nystagmus) Nausea and vomitting

9) List the precautions/contraindications for clinical nitrous oxide use

Defiant/combative child à usually won’t accept nitrous oxide; will struggle against apparatus

Emphysema à high oxygen may suppress drive to breath

Otitis Media à increased middle ear pressure

Emotional disturbances à claustrophobia related anxiety

Nasal obstruction à decreases the amount inhaled

Upper respiratory tract infections à decreases the amount inhaled

Pregnant women à (esp. first trimester) applies to patients, staff, dentist

Chronic exposure has shown birth defects, spontaneous abortion, reduced fertility

Asthma à these patients have reactive airways; nitrous may stimulate an attack

10) Be familiar with Pacific Pediatric Clinic policies and procedures relating to local anesthesia and nitrous oxide administration

« Hidden syringe technique

« Instructor approval for second carpule

« Child always gets reminder sticker

« General effective range used is 30-50% nitrous oxide

« Rapid Induction à initially administer 30-50% nitrous oxide

Administer 100% oxygen for 5 minutes following procedure, prior to dismissing the patient

« Parents are asked not to feed their children for 3 hours prior to an appointment which will include nitrous oxide

11) Be familiar with the use of conscious sedation and general anesthesia for pediatric dental patients

Protective reflexes are intact with conscious sedation (but not in general anesthesia)

Patients are still able to respond to stimuli and communicate

Must have special certification to administer oral conscious sedation to a pediatric patient

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Sealants and Preventative Resin Restorations

1) Understand the rationale of sealant application

A physical barrier for caries-susceptible pits and fissures

Retained by micro-mechanical locking of resin tags in the porosities produced by etching

Evidence suggests they are effective in preventing caries and arresting minimal lesions

Considered an essential preventative method

2) Be familiar with the types of sealants and their properties

Most are light cured

Some are clear, others are opaque à similar retention

Some incorporate fluoride (most don’t)

3-step sealants à require primer and etchant; 2-step sealants à require only etchant

Unfilled	Partially Filled
NO glass filler particles	Glass filler particles
Low abrasion resistance	Moderate abrasion resistance
Lower viscosity	Higher viscosity
Minimal occlusal adjustment	More frequent occlusal adjustment

« UltraSeal XT plus à used in Pacific Pediatric Clinic

Partially filled

Visible Light Cure

Opaque

NO incorporated fluoride

3-step system

Syringe dispensed

3) Be familiar with sealant delivery and application systems

Most systems utilize syringe delivery à not unit dosed

Minimal waste, prevents light exposure

Variety of application tips

4) Discuss the indications and contraindications for placement of sealants

Indications

Primary or Permanent teeth with caries susceptible pits and fissures

Teeth which can be adequately isolated

Areas of teeth without frank clinical caries

Other factors to consider

Overall caries susceptibility

History of compliance with home oral care

History of tooth (a tooth present in the mouth for a long time without caries may not need a sealant)

Position of tooth in mouth

5) Discuss the most common reasons for sealant failure in pediatric patients

Faulty isolation and salivary contamination is the most common reason for sealant failure

6) Discuss the options for isolation of a tooth to be sealed

The method used is less important than maintaining a dry, uncontaminated operating field

Rubber Dam Isolation à most ideal method

Clamp placement often requires anesthesia (esp. in partially erupted permanent molars)

Cotton Roll/Dri-Angle Isolation à incorporates cotton rolls or Dri-Angles

Metal or plastic cotton roll holders in mandible

Dri-Angles are place over the parotid duct in the maxilla

Local anesthesia is not required

7) Understand the options for surface preparation for teeth to receive sealants

Debriding / Cleansing à tooth surface must be clean

Run explorer through grooves followed by vigorous rinsing and drying

Pumice slurry (non-fluoridated) can be used with a prophy cup

Fluoride may negatively affect etching

Enameloplasty à widening of grooves to be sealed (1/4 round or fissurotomy bur)

Local anesthesia is usually not necessary

Also performed using air abrasion

Less conservative than routine sealant placement

« NOT routinely done in the Pacific Pediatric Clinic

Used in areas where some carious activity is suspected

If caries is uncovered, consider a preventive restorative resin

8) Understand the technique for sealant placement

This technique is specific for UltraSeal XT plus

Isolate the tooth to be sealed

Carefully examine grooves and pits

Debride/clean all surfaces

Re-examine tooth

Etch areas to be sealed for 15 seconds à then thoroughly rinse

Apply PrimaDry to etched surface and gently air dry for 5 seconds

Carefully apply sealant to grooves and pits à avoid excess; avoid air bubbles

Light cure for 20 seconds

Check retention and marginal integrity

Check occlusion

Post-operative

Slight occlusal irregularities may later be adjusted

Sealant will be checked at recall appt.

Emphasize continued role of home oral hygiene

9) Understand the rationale of preventative resin restorations (PRRs)

Address small, isolated carious lesions in the grooves or pits of teeth

More conservative than amalgam or composite restorations

Prep extension is to remove caries only

10) Discuss the components of a typical PRR, and variations that are used

Isolated composite restoration in a carious area

Sealant placed over the composite restoration and susceptible grooves and pits

Sometimes a glass ionomer is placed instead of composite

« Composite is preferentially used in the Pacific Pediatric Clinic

11) Discuss the indications and the contraindications for preventative resin restorations

Isolated carious areas

No pulp exposure

Teeth must be adequately isolated (isolation is critical)

Primary or permanent teeth

12) Discuss the options for surface preparation for teeth to receive PRRs

Remove all caries

Small lesions à ¼ to 2 round bur

Large lesions à 330

13) Discuss the role of local anesthesia in the PRR procedure

Not always needed for a PRR (school age and adolescent kids are usually comfortable) à use slow-speed

Apply local anesthesia if:

Patient discomfort becomes evident

Inability to adequately isolate (need a rubber dam)

Other procedures in the same quadrant that may require anesthesia

14) Understand the technique for the PRR procedure

Evaluate (clinically and radiographically)

Isolate

Remove caries

Evaluate prep (place a glass ionomer base if near the pulp)

Etch, prime and dry

Place bonding resin then composite and light cure

Etch area for sealant

Place sealant and light cure for 20 seconds

Check retention and marginal integrity

Check occlusion with post-operative instructions as previously noted

15) Be familiar with Pacific Pediatric Clinic policies and procedures (*) relating to sealants and preventive resin restorations

UltraSeal XT plus is the sealant used

Enameloplasty is not routinely done
Composite is preferred in a PRR

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Restorative Dentistry in the Primary Posterior Dentition

1) Know the morphology of primary vs. permanent teeth and the influence of anatomic features on the primary tooth cavity preparations

Enamel is thinner in primary teeth, and ends in a ridge at the cervical area

Enamel rods in the cervical portion point occlusally (permanent point gingivally)

Roots of primary molars flare more

Pulp horns are higher in primary molars (MB is usually the highest)

Greater thickness of dentin over occluso-pulpal wall in primary molars

CEJ is more constricted

Buccal and lingual surfaces converge more towards the occlusal (constricted occlusal table)

Prominent cervical bulge is present (esp. MB)

Proximal contacts tend to be broad and flat

Lighter in color and less translucent

MD width of primary molars is greater than MD width of succedaneous premolars

Spacing is common and desirable

MI slope of max. primary canine should occlude along the DI slope of the mand. canine

2) Understand the rationale for use of the various restorative materials in intracoronal preparations, with the indications for each

Amalgam à still widely used and has many advantages

Resin à increased usage

Glass Ionomer and Resin-Ionomer hybrids à gaining acceptance

3) Know the desirable characteristics for intracoronal restorations in primary posterior teeth

Conservative in extent

Sufficiently extended to remove all carious tooth structure

Designed to provide adequate retention for restorative material to be used

Extend into dentin for amalgam for retention and adequate bulk of material

Cavosurface bevels may be advantageous for composite restorations

Pulpal floor should be of uniform depth with internal line angles slightly rounded

4) Know the indications for each preparation type

Small carious lesions where ideal amalgam preps are possible

Non-esthetic areas of mouth

Teeth which are free of cervical decalcification or caries not included in the prep

5) Know the class I preparation and restoration technique

Carious pit and fissure areas of molars

Anesthetize and isolate

Do not cross oblique ridge, or the transverse ridge

Buccal and lingual walls should slightly converge toward the cavosurface

Check area for small pulp exposures (most likely over the MB pulp horn)

Depth à 1.00 – 1.25 mm

BL width à 1/3 intercuspal distance

6) Know the class II preparation and restoration technique

Composite is generally note indicated due to difficulty of isolation and placement

Design includes an interproximal area

Barely break buccal and lingual contact (spit contact)

7) Know the restoration techniques unique to adjacent proximal amalgam restorations

Usually placed at the same time

When placing amalgam, fill the proximal boxes simultaneously to ensure equal contour

Carve the marginal ridges prior to removing the matrix to prevent fracture

Remove one matrix at a time

8) Understand the appropriate use and precautions for matrices for class II preparations

« Denovo matrix bands (pre-formed) are used in the Pacific Pediatric Clinic

Wedge should be seated correctly on unprepared tooth structure just below the cervical margin of the proximal box

9) Know the class V preparation and restoration technique

Restoration of caries on the buccal or lingual surfaces at the level of the gingiva

For amalgam à extend 0.5 mm into dentin

For resin or resin/glass hybrids à no need to extend into dentin

Walls should converge towards cavosurface

10) Be able to self-evaluate, and correct where necessary, intracoronal preparations and restorations

11) Know the morphological features of primary posterior teeth that are relevant to restoration of those teeth with stainless steel crowns
see question 1

12) Be familiar with the two most prevalent types of stainless steel crowns available in the marketplace
Unitek crowns

Straighter sides

Longer occluso-cervically

Require more trimming and more contouring/crimping

Advantageous in restoring teeth with caries that extend cervically

Ion crowns

Come partially trimmed and contoured

Can often be adapted without trimming and with crimping alone

« Common in the Pacific Pediatric Clinic

13) Know the desirable characteristics for stainless steel crown preparations as well as for stainless steel crown restorations

Preparation	Restoration, SSC
Include removal of all carious tooth structure	Reproduce natural tooth contours and proximal contacts to maintain arch length integrity
Reduce the coronal dimensions sufficiently for a SSC to be fitted without significant occlusal interference, but maintain original proportions of unprepared tooth	Cover all prepared areas of the underlying tooth
Leave the natural cervical constriction of the tooth intact (utilized for retention)	Retained by proper contour to engage the cervical constriction of the tooth
	All margins should be closed

14) Know the indications for stainless steel crown restorations in posterior primary teeth

Significant loss of tooth structure

Clinical decay that has broken through a marginal ridge

Overextended class II preparations

Encroaches on proximal line angles

Floor of proximal box dropped below cervical constriction

Excessive bucco-lingual isthmus width

Pulpotomy or pulpectomy

Significant cervical decalcification or caries

Severely broken-down or endodontically treated young permanent teeth which are not candidates for FVC/PFM

15) Know the steps, in order, for preparation of a primary molar for restoration with a stainless steel crown

Evaluate occlusion and identify landmarks for retaining proper proportions

Select the crown

Confirm pulpal status and restorability

Anesthetize and isolate

Reduce occlusal surface first (1.5 – 2.0 mm) à no need for occlusal anatomy

Make proximal converging slices leaving a knife-edge margin; be sure to conserve cervical constriction

Sometimes papillary gingiva is damaged

Contact must be completely broken

Place buccal and lingual bevels (brings cusp tips back in line) à B and L surfaces are otherwise untouched

Seating of the crown

Crimping margins to adapt to tooth

Engage the lingual surface first and snap the crown in place over the buccal surface

Once the fit is established, remove and polish margins

Final cementation options

« Glass ionomer cement à most frequent in Pacific Pediatric Clinic

Polycarboxylate cement (Durelon)

Zinc-oxide and eugenol (IRM)

16) Know the common pitfalls with stainless steel crown preparations and restorations

Ledges in the prep design

17) Be able to self-evaluate stainless steel crown preparations and restorations

18) Be able to discuss and give appropriate post-op instructions to patients and parents

Avoid lip/cheek biting

Crown may feel tight due to interproximal pressure à resolves in 1-2 days

Avoid sticky, chewy candy or other such foods to prevent crown loss

19) Be familiar with the techniques and materials most often used in the Pacific Pediatric Dentistry Clinic

Denovo matrix bands

Ion crowns

Glass ionomer cement

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Restorative Dentistry in the Primary Anterior Dentition

1) Know the diagnostic considerations in choosing to use Atraumatic Restorative Technique (A.R.T.)

Most often used in very young, pre-cooperative children with asymptomatic caries of anterior primary teeth

A form of caries control à quick and thorough

Resulting defects are covered with fluoride releasing glass ionomer

Less esthetic, but easily placed with less associated trauma

May require more traditional restorations at a later time

2) Know the technique for A.R.T.

Evaluate à if pulpal exposure then chose an alternative restoration method

Isolate with cotton rolls

Excavate grossly carious tooth structure with spoon excavator

Clean and dry excavated areas

Place glass ionomer restorative material over the excavated sites

3) Know the diagnostic considerations in choosing between class III and class IV restorations

Caries that extends to both the buccal and lingual embrasures often necessitates a class IV restoration

4) Know the indications for class III restoration of anterior primary tooth caries

Used to address proximal caries in anterior teeth where the incisal angle is NOT compromised

Access is gained from the buccal or lingual embrasure

Composite is often the choice for esthetic areas à amalgam for distal of canines

5) Know the indications for class IV restoration of anterior primary tooth caries

Used to address proximal caries in anterior teeth where the incisal angle is cariously involved or otherwise compromised

Proximal decay typically involves both the buccal and lingual embrasures

Retention in preparation design is of greater consideration (include dovetails on buccal and lingual surfaces)

6) Know the restorative materials that are appropriate for restoration of class III and class IV caries, and the indications and special preparation adaptations for each

Pulpal protection should be considered (« glass ionomer) if preparation encroaches the pulp

Amalgam à adequate for non-esthetic areas; requires dovetails for retention

Composite à better for esthetic areas

Dovetails are oriented cervically to conserve incisal tooth structure

7) Know the matrices available for restoration of anterior primary tooth caries and the indications for each

Matrices are NOT wrapped around anterior teeth; a thin strip is wedged adjacent to the interproximal preparation

Amalgam à « Denovo metal matrix

Composite à « clear mylar matrix

8) Be able to self-evaluate anterior intracoronal preparations and restorations

9) Know the appropriate management of a pulp exposure, should it occur while completing intracoronal preparation
Carefully examine the preparation for pulpal exposure (may need a base if close to pulp)

Pulpotomy or pulpectomy with extracoronal restoration, or extraction

Direct pulp caps are not indicated in primary teeth as the stimulate resorption

10) Know the appropriate management of a pulp exposure, should it occur while completing extracoronal preparation
see question 9

11) Know the diagnostic considerations in electing to restore anterior primary caries with an extracoronal restoration
Situations where there is inadequate tooth structure for retention

Anterior teeth that have been endodontically treated

12) Know the indications for restoration with anterior stainless steel crowns and strip crowns

Strip Crowns

Excessive loss of tooth structure secondary to caries or trauma

Initial advantage of good esthetics

Ultimate strength depends on amount of remaining enamel in the preparation and patient’s occlusion

NOT typically used for canines (SSC or composite window SSC)
SSC

Similar to strip crowns but with inadequate tooth structure or occlusal problems

Most durable

Least esthetic

13) Know the esthetic and practical implications each of the extracoronal primary anterior tooth restorations
see question 12

14) Understand the variations of the anterior stainless steel crown and the advantages, disadvantages and limitations of each
Laboratory processed acrylic faced stainless steel crowns

Generally used for maxillary incisors

Available in many sizes, but just one color and relatively expensive

Micromesh spot welded to the facial surface and acrylic built on top

Bulky with “Chicklet” appearance

Esthetics will match similar crowns, but nothing else

Can have significant failure rates à usually lose acrylic facing

Composite window stainless steel crowns

A cemented crown can be further prepared to accept a composite facing to improve esthetics

Preparation extends into the proximal embrasures, and just short of the cervical margins

It can be extended to or just over the incisal edge of the crown (negative impact on durability)

Create an undercut with a 35 inverted cone bur

Remove only facial surface of SSC à finish with composite

Tend to be durable and usually have acceptable esthetics

Disadvantage à time intensive procedure

15) Be familiar with the techniques and materials most often used in the Pacific Pediatric Dentistry Clinic

Glass ionomer for pulpal protection (base)

Glass ionomer cement for SSC

Denovo matrix for amalgam

Mylar matrix for composite

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Rubber Dam and Sequencing Restorations

1) Understand the rationale and indications for rubber dam use in pediatric patients

Improves quality of restorations and efficiency of service

Provides improved visibility

Allowing the treatment team to maintain a relatively dry operating field

Limited tongue mobility

Provides many safety advantages

Prevents aspiration or swallowing foreign bodies

Protected against accidental injury, mechanical or chemical

Should be used whenever possible for restorative care

Teeth are adequately erupted for clamp placement

Adequate anesthesia can be obtained

Always used for pulp therapy in primary teeth

2) Be familiar with the basic rubber dam armamentaria and its use

Armamentaria	Euphemism	Use
Rubber Dam	Raincoat	« Latex, 5x5, medium weight « Slot dam technique Holes punched in upper middle 3^rd for maxilla Holes punched in lower middle 3^rd for mandible
Clamp	Tooth Ring	Winged and Wingless clamps are used « W14 à primary molars « W14A à permanent molars « 8A à primary or permanent molars
Rubber Dam Forceps	Tooth Ring Holder	Locked open to place clamp Sometimes a noise (tell patient)

3) Understand the design of the rubber dam based on dentition and procedures to be accomplished

4) Be familiar with rubber dam placement and removal procedures

Safety	Clamps are always pre-ligatured before placement Ligature is tied around bow of the clamp
Patient Presentation	Tell-Show-Do Use euphemisms à “hugging”, “stretching” Reassure the patient they can swallow Reassure the patient the dam will be removed
Clamp Placement	Pre-ligate the clamp Operator places clamp à watches his side Assistant watches other side of tooth Check stability with finger pressure
Dam Placement	Dam is attached to frame Pass ligature through prepared hole in rubber dam Stretch hole in dam over clamp and teeth Floss dam material below height of contour Ligature passed between the dam and frame
Dam Removal	Rubber dam forceps placed on clamp Immediate team rinse

5) Understand the sequencing of restorations in a quadrant
General advantageous to work from distal to mesial if all other factors are equal

If terminal tooth cannot be isolated with rubber dam of a sequence

Anesthetize, restore terminal tooth, then place rubber dam and continue

Presence of the rubber dam stimulates salivation à get to restorations requiring isolation first

SSC should be placed and cemented prior to adjacent alloy à avoids fracture of alloy

6) Be familiar with techniques to compensate for space loss affecting teeth to be restored

Flatten contact areas of SSC to accommodate space loss

Lessen the crimp

7) Be familiar with techniques to adjust stainless steel crown

Contour pliers à for decreasing an excessive crimp

Howe pliers à for flattening contact areas

8) Be familiar with techniques and procedures as used in the Pacific Pediatric Clinic («)

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Sample Questions

1) Carlos, your 4 year old patient, requires a disto-occlusal amalgam restoration in tooth #L. Which of the followoing local anesthetic techniques would be the most appropriate in the Pacific Pediatric Clinic for Carlos? [e]

a. Buccal infiltration

b. Palatal infiltration

c. Inferior Alveolar block

d. Interdental

e. c & d

2) Which of the following describe the sealant material currently used in the Pacific Pediatric Clinic? [b]

a. unfilled

b. visible light cured

c. clear

d. a and b

e. b and c

3) Justin (6 years old) is in your chair for adjacent class II restorations on teeth S and T. You have completed the preparations and have seated matrix bands, and placed a wedge. The next step is to: [d]

a. fill the prep in S because it is the most anterior tooth

b. fill the prep in T because it is the most posterior tooth

c. check the occlusion on the matrix bands

d. fill both preps incrementally

e. c and d

4) You have just completed a stainless steel crown preparation for your patient Sarah (7 years old). You are attempting to seat the crown, but it will not seat completely. What is the most likely problem? [c]

a. the stainless steel crown is too small

b. the preparation does not duplicate the tooth morphology (i.e. cusp inclines, etc)

c. there is a ledge in the preparation

d. the crown is too long

e. the crown is too short

Your patient Jackson is 6 years old, and he needs an occlusal alloy in tooth #S and an occlusal alloy in tooth #T. You are also planning to place a sealant on tooth #30.

5) Where would you expect to be able to place a rubber dam clamp for Jackson's rubber dam? [c]

a. #30

b. #29

c. #T

d. #S

e. a or b

6) In what order will you sequence Jackson's needs in this quadrant of his mouth? [b]

a. #T then #S then #30

b. #30 then #T then #S

c. #S then #T then #30

d. #30 then #S and T at the same time

e. #S and T at the same time, then #30

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