dental ward history taking MBBS clinical posting guide oral examination

https://pocketdentistry.com/1-clinical-examination-and-histo…

dental ward common conditions MBBS student guide gingivitis periodontitis caries abscess

mkdir -p /home/daytona/workspace/dental-ward-guide && python3 << 'EOF' from repo…

mkdir -p /home/daytona/workspace/dental-ward-guide

~/dental-ward-guide/generate_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable, PageBreak
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.pdfgen import canvas

output_path = "/home/daytona/workspace/dental-ward-guide/Dental_Ward_Guide_MBBS.pdf"


class NumberedCanvas(canvas.Canvas):
    def __init__(self, *args, **kwargs):
        canvas.Canvas.__init__(self, *args, **kwargs)
        self._saved_page_states = []

    def showPage(self):
        self._saved_page_states.append(dict(self.__dict__))
        self._startPage()

    def save(self):
        num_pages = len(self._saved_page_states)
        for state in self._saved_page_states:
            self.__dict__.update(state)
            self.draw_page_number(num_pages)
            canvas.Canvas.showPage(self)
        canvas.Canvas.save(self)

    def draw_page_number(self, page_count):
        self.setFont("Helvetica", 8)
        self.setFillColor(colors.HexColor("#666666"))
        self.drawRightString(A4[0] - 2*cm, 1.2*cm, "Page %d of %d" % (self._pageNumber, page_count))
        self.drawString(2*cm, 1.2*cm, "Dental Ward Guide | MBBS 3rd Year")
        self.setStrokeColor(colors.HexColor("#CCCCCC"))
        self.line(2*cm, 1.5*cm, A4[0]-2*cm, 1.5*cm)


doc = SimpleDocTemplate(
    output_path,
    pagesize=A4,
    rightMargin=2*cm,
    leftMargin=2*cm,
    topMargin=2.5*cm,
    bottomMargin=2.5*cm,
    title="Dental Ward Guide for MBBS 3rd Year Students",
    author="Orris Medical AI"
)

styles = getSampleStyleSheet()

title_style = ParagraphStyle('CustomTitle', parent=styles['Title'],
    fontSize=26, textColor=colors.HexColor("#1a3a5c"),
    spaceAfter=6, fontName='Helvetica-Bold', alignment=TA_CENTER)

subtitle_style = ParagraphStyle('SubTitle', parent=styles['Normal'],
    fontSize=13, textColor=colors.HexColor("#2c6fad"),
    spaceAfter=4, fontName='Helvetica', alignment=TA_CENTER)

h1_style = ParagraphStyle('H1Custom', parent=styles['Heading1'],
    fontSize=15, textColor=colors.white, fontName='Helvetica-Bold',
    spaceBefore=14, spaceAfter=6,
    backColor=colors.HexColor("#1a3a5c"),
    leading=20, borderPad=6)

h2_style = ParagraphStyle('H2Custom', parent=styles['Heading2'],
    fontSize=13, textColor=colors.HexColor("#1a3a5c"),
    fontName='Helvetica-Bold', spaceBefore=10, spaceAfter=4, leading=16)

h3_style = ParagraphStyle('H3Custom', parent=styles['Heading3'],
    fontSize=11, textColor=colors.HexColor("#2c6fad"),
    fontName='Helvetica-Bold', spaceBefore=8, spaceAfter=3, leading=14)

body_style = ParagraphStyle('BodyCustom', parent=styles['Normal'],
    fontSize=10, fontName='Helvetica', leading=14, spaceAfter=4,
    alignment=TA_JUSTIFY, textColor=colors.HexColor("#222222"))

bullet_style = ParagraphStyle('BulletCustom', parent=styles['Normal'],
    fontSize=10, fontName='Helvetica', leading=14, spaceAfter=3,
    leftIndent=16, textColor=colors.HexColor("#222222"))

note_style = ParagraphStyle('NoteStyle', parent=styles['Normal'],
    fontSize=9.5, fontName='Helvetica-Oblique', leading=13, spaceAfter=4,
    textColor=colors.HexColor("#444444"), backColor=colors.HexColor("#fff8e1"),
    leftIndent=8, rightIndent=8, borderPad=5)

check_style = ParagraphStyle('CheckStyle', parent=styles['Normal'],
    fontSize=9.5, fontName='Courier', leading=14, spaceAfter=3,
    leftIndent=8, textColor=colors.HexColor("#222222"))

ref_style = ParagraphStyle('RefStyle', parent=styles['Normal'],
    fontSize=8, textColor=colors.HexColor("#777777"), alignment=TA_CENTER)


def sec(text):
    return Paragraph("  " + text, h1_style)

def sub(text):
    return Paragraph(text, h2_style)

def subsub(text):
    return Paragraph(text, h3_style)

def body(text):
    return Paragraph(text, body_style)

def bul(text):
    return Paragraph(u"\u2022  " + text, bullet_style)

def note(text):
    return Paragraph("<i>Note: " + text + "</i>", note_style)

def sp(h=0.3):
    return Spacer(1, h*cm)

def hr():
    return HRFlowable(width="100%", thickness=0.5,
                      color=colors.HexColor("#CCCCCC"), spaceAfter=4, spaceBefore=4)


def make_table(data, col_widths=None, hdr_bg=None):
    if hdr_bg is None:
        hdr_bg = colors.HexColor("#1a3a5c")
    if col_widths is None:
        col_widths = [4*cm] * len(data[0])
    t = Table(data, colWidths=col_widths, repeatRows=1)
    ts = TableStyle([
        ('BACKGROUND', (0, 0), (-1, 0), hdr_bg),
        ('TEXTCOLOR', (0, 0), (-1, 0), colors.white),
        ('FONTNAME', (0, 0), (-1, 0), 'Helvetica-Bold'),
        ('FONTSIZE', (0, 0), (-1, 0), 9),
        ('FONTSIZE', (0, 1), (-1, -1), 9),
        ('FONTNAME', (0, 1), (-1, -1), 'Helvetica'),
        ('ROWBACKGROUNDS', (0, 1), (-1, -1), [colors.white, colors.HexColor("#eef4fb")]),
        ('GRID', (0, 0), (-1, -1), 0.4, colors.HexColor("#AAAAAA")),
        ('ALIGN', (0, 0), (-1, -1), 'LEFT'),
        ('VALIGN', (0, 0), (-1, -1), 'TOP'),
        ('TOPPADDING', (0, 0), (-1, -1), 4),
        ('BOTTOMPADDING', (0, 0), (-1, -1), 4),
        ('LEFTPADDING', (0, 0), (-1, -1), 5),
        ('RIGHTPADDING', (0, 0), (-1, -1), 5),
    ])
    t.setStyle(ts)
    return t


story = []

# ── COVER ──────────────────────────────────────────────────────────────────
story.append(sp(3))
story.append(Paragraph("DENTAL WARD GUIDE", title_style))
story.append(Paragraph("For MBBS 3rd Year Students", subtitle_style))
story.append(sp(0.3))
story.append(Paragraph("Complete Reference for Your First Clinical Posting",
    ParagraphStyle('sub2', parent=subtitle_style, fontSize=11,
                   textColor=colors.HexColor("#555555"))))
story.append(sp(0.6))

cover_data = [
    ["Prepared for:", "MBBS 3rd Year - 1st Day Dental Ward Posting"],
    ["Date:", "July 2026"],
    ["Compiled by:", "Orris Medical AI  |  Based on Goldman-Cecil Medicine & Harrison's 22E (2025)"],
]
ct = Table(cover_data, colWidths=[4*cm, 13.5*cm])
ct.setStyle(TableStyle([
    ('BACKGROUND', (0, 0), (0, -1), colors.HexColor("#eef4fb")),
    ('FONTNAME', (0, 0), (0, -1), 'Helvetica-Bold'),
    ('FONTNAME', (1, 0), (1, -1), 'Helvetica'),
    ('FONTSIZE', (0, 0), (-1, -1), 10),
    ('GRID', (0, 0), (-1, -1), 0.5, colors.HexColor("#AAAAAA")),
    ('TOPPADDING', (0, 0), (-1, -1), 6),
    ('BOTTOMPADDING', (0, 0), (-1, -1), 6),
    ('LEFTPADDING', (0, 0), (-1, -1), 8),
]))
story.append(ct)
story.append(sp(0.6))

toc_data = [
    ["#", "Section"],
    ["1", "Introduction & Ward Etiquette"],
    ["2", "Dental History Taking"],
    ["3", "Systematic Oral Examination"],
    ["4", "Dental Charting & Notation"],
    ["5", "Common Dental Conditions"],
    ["6", "Investigations in Dentistry"],
    ["7", "Systemic Diseases & Oral Manifestations"],
    ["8", "Basic Dental Procedures - Observer's Guide"],
    ["9", "Dental Emergencies"],
    ["10", "Quick Reference Checklists"],
]
story.append(Paragraph("Table of Contents",
    ParagraphStyle('toc_h', parent=h2_style, alignment=TA_CENTER)))
story.append(make_table(toc_data, col_widths=[1.5*cm, 16*cm]))
story.append(PageBreak())

# ── SECTION 1 ──────────────────────────────────────────────────────────────
story.append(sec("1.  Introduction & Ward Etiquette"))
story.append(sp(0.2))
story.append(body(
    "Welcome to your first clinical posting in the Dental Ward. This guide will help you "
    "navigate the ward confidently, take a proper dental history, perform a systematic oral "
    "examination, and recognise common dental conditions. You are primarily an observer and "
    "learner - always seek permission before touching any patient and work under supervision."))
story.append(sp(0.2))
story.append(sub("1.1  Ward Etiquette"))
for t in [
    "Always introduce yourself as a medical student and obtain patient consent before any interaction.",
    "Maintain professional attire: white coat, clean hands, and a name badge at all times.",
    "Wash hands before and after every patient contact (WHO 5 Moments of Hand Hygiene).",
    "Do not use your mobile phone at the bedside or during consultations.",
    "Address patients respectfully by name and maintain strict patient confidentiality.",
    "When in doubt, always ask your supervisor before doing anything.",
    "Observe dental procedures from a safe distance unless invited closer by the dentist.",
    "Record all findings accurately and legibly in the case sheet.",
]:
    story.append(bul(t))

story.append(sp(0.2))
story.append(note(
    "Dental procedures carry infection risk. Always wear gloves, mask, and eye protection "
    "if you are assisting in any procedure."))

# ── SECTION 2 ──────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(sec("2.  Dental History Taking"))
story.append(sp(0.2))
story.append(body(
    "A thorough history is the cornerstone of dental diagnosis. The dental history follows "
    "the standard medical history framework but includes specific dental components. The goal "
    "is to understand the patient's complaint, place it in context, and identify systemic "
    "factors that could influence dental treatment."))

story.append(sp(0.2))
story.append(sub("2.1  Standard Format for Dental History"))

hist_data = [
    ["Component", "What to Ask / Record"],
    ["Patient Details",
     "Name, age, sex, occupation, address, date of consultation"],
    ["Chief Complaint (CC)",
     "In patient's own words. 'What brings you here today?' Record verbatim with site and duration."],
    ["History of Present Illness (HPI)",
     "Onset (sudden/gradual), duration, severity, character (throbbing/dull/sharp/constant/"
     "intermittent), aggravating factors (hot, cold, sweet foods), relieving factors, "
     "previous episodes, any treatment taken."],
    ["Past Dental History (PDH)",
     "Frequency of dental visits (regular/irregular/never), previous extractions, fillings, "
     "root canals, orthodontic treatment, dentures. Adverse reactions: haemorrhage "
     "post-extraction, problems with local anaesthesia, fainting."],
    ["Past Medical History (PMH)",
     "Diabetes, hypertension, cardiac disease, bleeding disorders, epilepsy, "
     "immunosuppression, liver/kidney disease. Hospitalisations, surgeries, blood transfusions."],
    ["Drug History",
     "Current medications - especially anticoagulants (warfarin, aspirin), bisphosphonates, "
     "steroids, antihypertensives, antiepileptics, calcium channel blockers. OTC drugs, "
     "herbal supplements. Any drug allergies."],
    ["Allergy History",
     "Drug allergies (especially local anaesthetics, penicillin, NSAIDs), latex allergy, "
     "food allergies. Always ask specifically even if patient volunteers 'no allergies'."],
    ["Family History (FH)",
     "Caries pattern in family, periodontal disease, malocclusion, genetic dental conditions "
     "(amelogenesis/dentinogenesis imperfecta), oral cancer."],
    ["Social History (SH)",
     "Tobacco smoking (cigarettes/bidis/hookah - type, quantity, duration). Tobacco chewing "
     "(gutkha/paan/areca nut). Alcohol (type, quantity, frequency). Occupation (acid/trauma "
     "exposure). Diet (frequency of sugar intake, fizzy drinks)."],
    ["Systemic Review",
     "Swelling, lumps, fever, weight loss, fatigue, altered taste, dry mouth (xerostomia), "
     "difficulty chewing (masticatory dysfunction) or swallowing (dysphagia), jaw clicking "
     "or locking."],
]
story.append(make_table(hist_data, col_widths=[4.5*cm, 13*cm]))

story.append(sp(0.3))
story.append(sub("2.2  Special Questions for Common Dental Complaints"))

story.append(subsub("For Pain (Toothache):"))
for t in [
    "SOCRATES: Site - which tooth/area? Onset? Character - throbbing, dull, sharp, electric?",
    "Radiation - does pain radiate to ear, jaw, temple, or neck?",
    "Associated features - swelling, fever, bad taste/smell, loose tooth?",
    "Timing - constant or intermittent? Worse at night (suggests irreversible pulpitis)?",
    "Aggravating factors: hot food/drink, cold water, sweet foods, biting down, lying flat?",
    "Relieving factors: cold water (may relieve reversible pulpitis temporarily), painkillers?",
    "Severity: 0-10 pain scale.",
]:
    story.append(bul(t))

story.append(subsub("For Swelling:"))
for t in [
    "Site and extent - intraoral or extraoral or both?",
    "Duration - how long present? Onset: sudden or gradual? Triggering event (trauma, toothache)?",
    "Character - hard or soft? Fluctuant (suggests abscess with pus)?",
    "Associated symptoms: pain, fever, trismus (difficulty opening mouth), difficulty swallowing?",
]:
    story.append(bul(t))

story.append(subsub("For Bleeding Gums:"))
for t in [
    "Spontaneous or provoked (brushing, eating)?",
    "Duration and frequency.",
    "Associated symptoms: pain, halitosis (bad breath), loose teeth?",
    "Oral hygiene: brushing frequency and technique, flossing?",
    "Any systemic bleeding elsewhere (nose bleeds, easy bruising)? - rule out haematological cause.",
    "Medications: anticoagulants, phenytoin (causes gingival overgrowth), CCBs (amlodipine)?",
]:
    story.append(bul(t))

story.append(subsub("For Mouth Ulcers:"))
for t in [
    "Single or multiple? Site (keratinized vs non-keratinized mucosa)?",
    "Duration - >3 weeks is a RED FLAG requiring biopsy or urgent referral.",
    "Pain: aphthous ulcers are painful; malignant ulcers may be painless.",
    "Recurrence pattern (suggests aphthous stomatitis).",
    "Systemic associations: bowel problems (Crohn's), genital ulcers (Behcet's), skin rash?",
    "Tobacco/alcohol use (risk factors for oral malignancy).",
]:
    story.append(bul(t))

story.append(sp(0.2))
story.append(note(
    "RED FLAGS in dental history: Ulcer >3 weeks | Unexplained loose teeth in young patient | "
    "Jaw/lip numbness or paraesthesia | Unexplained weight loss | Difficulty swallowing | "
    "Non-healing extraction socket | Trismus without clear cause"))

# ── SECTION 3 ──────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(sec("3.  Systematic Examination of the Oral Cavity"))
story.append(sp(0.2))
story.append(body(
    "The oral examination follows a systematic 'outside-in' approach. Examine from the "
    "outside (face and neck) progressively inward (lips, mucosa, gingiva, teeth, tongue, "
    "palate, oropharynx). Always use good lighting and dental mirror under supervision."))

story.append(sub("3.1  General Examination"))
for t in [
    "General appearance: Well/ill-looking, pallor, jaundice, nutritional status.",
    "Vital signs if relevant: Pulse, blood pressure (before procedures), temperature if infection suspected.",
    "Demeanour: Anxious (dental phobia is very common), distressed (acute pain).",
]:
    story.append(bul(t))

story.append(sub("3.2  Extraoral (EO) Examination"))
story.append(subsub("Face:"))
for t in [
    "Symmetry: facial asymmetry (swelling, muscle wasting, Bell's palsy)?",
    "Swelling: location - submandibular, parotid, submental, buccal space?",
    "Skin over swelling: erythema, fluctuance (abscess), sinus/fistula openings.",
    "Lips: colour, angular cheilitis (B-vitamin/iron deficiency or candida), herpes labialis.",
]:
    story.append(bul(t))

story.append(subsub("Temporomandibular Joint (TMJ):"))
for t in [
    "Palpate bilaterally as patient opens and closes mouth.",
    "Clicking or crepitus on movement.",
    "Maximum mouth opening: normal 35-45 mm (approximately 3 finger-breadths).",
    "Deviation of mandible on opening (deviates toward affected side in TMJ dysfunction).",
]:
    story.append(bul(t))

story.append(subsub("Lymph Nodes:"))
for t in [
    "Palpate: submental, submandibular, anterior/posterior cervical chain, preauricular, supraclavicular.",
    "Record: size, consistency (soft/firm/hard/rubbery), mobility, tenderness.",
    "Hard, fixed, non-tender lymph nodes = RED FLAG for malignancy.",
]:
    story.append(bul(t))

story.append(sub("3.3  Intraoral (IO) Examination"))
story.append(body(
    "Examine systematically in a fixed order. Do NOT go straight to the tooth the patient "
    "is pointing to - you may miss other important pathology."))

exam_data = [
    ["Step", "Structure", "What to Look For"],
    ["1", "Lips (inner surface)", "Ulcers, mucoceles, fibroma, pigmentation"],
    ["2", "Buccal mucosa (both cheeks)",
     "Linea alba (normal), ulcers, leukoplakia, erythroplakia, Fordyce spots, "
     "candidiasis. Use mirror/tongue depressor."],
    ["3", "Vestibule & Sulcus",
     "Swelling, sinus/fistula openings (parulis = gum boil), obliteration of sulcus"],
    ["4", "Gingiva",
     "Colour (normal: coral pink), contour (scalloped), consistency, bleeding on probing, "
     "recession, hyperplasia, ulceration"],
    ["5", "Teeth",
     "Count teeth present; note missing, decayed, filled teeth. Colour changes, fractures, "
     "mobility (grade 1/2/3), sensitivity, shape/size anomalies. Dental charting."],
    ["6", "Hard palate",
     "Torus palatinus (normal bony prominence - do not confuse with pathology), "
     "ulcers, candidiasis"],
    ["7", "Soft palate & uvula",
     "Movement on saying 'Aah', petechiae (thrombocytopenia), Kaposi's sarcoma, ulcers"],
    ["8", "Tongue",
     "Dorsum: fissured, geographic, hairy, coated. "
     "Lateral borders (most common site for oral carcinoma!) and ventral surface. Mobility."],
    ["9", "Floor of mouth",
     "Wharton's duct openings, ranula (mucous cyst), swelling, ulceration, calculi"],
    ["10", "Oropharynx",
     "Tonsils, posterior pharyngeal wall, any masses"],
]
story.append(make_table(exam_data, col_widths=[1.5*cm, 4.5*cm, 11.5*cm]))

story.append(sp(0.2))
story.append(note(
    "Any oral ulcer persisting >3 weeks must be considered potentially malignant and "
    "referred for biopsy. The lateral border of the tongue and the floor of the mouth are "
    "the most common sites for oral squamous cell carcinoma."))

# ── SECTION 4 ──────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(sec("4.  Dental Charting & Notation"))
story.append(sp(0.2))

story.append(sub("4.1  FDI (ISO) System - Most Widely Used"))
story.append(body(
    "Each tooth has a 2-digit number. First digit = quadrant (1-4 for permanent, 5-8 for "
    "primary). Second digit = tooth position within quadrant (1-8 from central incisor to "
    "3rd molar)."))

quad_data = [
    ["Quadrant", "Permanent Teeth (Adult)", "Primary Teeth (Child)"],
    ["Upper Right (Q1)", "11 - 18", "51 - 55"],
    ["Upper Left  (Q2)", "21 - 28", "61 - 65"],
    ["Lower Left  (Q3)", "31 - 38", "71 - 75"],
    ["Lower Right (Q4)", "41 - 48", "81 - 85"],
]
story.append(make_table(quad_data, col_widths=[5*cm, 6*cm, 6.5*cm]))
story.append(sp(0.15))
story.append(body(
    "<b>Examples:</b> Tooth 36 = lower left first molar. "
    "Tooth 11 = upper right central incisor. Tooth 21 = upper left central incisor."))

story.append(sp(0.2))
story.append(sub("4.2  Common Charting Symbols"))
sym_data = [
    ["Symbol / Abbreviation", "Meaning"],
    ["/ (diagonal line through box)", "Extracted tooth"],
    ["Shaded/coloured box or X", "Decayed (carious) tooth - shade the affected surfaces"],
    ["F or shaded tooth surface outline", "Filled/restored tooth"],
    ["UE", "Unerupted"],
    ["PE", "Partially erupted"],
    ["RCT or RC", "Root canal treated"],
    ["Cr", "Crown placed"],
    ["Mobility Grade 1", "Slight horizontal movement (just perceptible)"],
    ["Mobility Grade 2", "1-2 mm horizontal buccolingual movement"],
    ["Mobility Grade 3", ">2 mm movement in all directions including vertical (depressible)"],
    ["TTP", "Tender to percussion - tap tooth with mirror handle"],
]
story.append(make_table(sym_data, col_widths=[6.5*cm, 11*cm]))

story.append(sp(0.2))
story.append(sub("4.3  DMFT Index"))
story.append(body(
    "The DMFT Index measures caries experience. "
    "<b>D</b> = Decayed teeth, <b>M</b> = Missing due to caries, <b>F</b> = Filled teeth, "
    "<b>T</b> = Teeth examined. Maximum score = 28 (or 32 including wisdom teeth). "
    "Higher DMFT = greater caries burden."))

# ── SECTION 5 ──────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(sec("5.  Common Dental Conditions"))
story.append(sp(0.2))

story.append(sub("5.1  Dental Caries (Tooth Decay)"))
story.append(body(
    "<b>Definition:</b> Infectious, multifactorial disease causing demineralisation and "
    "destruction of tooth hard tissues by acids produced by bacteria "
    "(<i>Streptococcus mutans</i>, <i>Lactobacillus</i>)."))
caries_data = [
    ["Feature", "Details"],
    ["Aetiology (Keyes Triad)", "Bacteria + Fermentable carbohydrates + Susceptible tooth + Time"],
    ["Symptoms",
     "Initially asymptomatic. Later: sensitivity to sweet, cold, hot. "
     "Severe pain when cavity reaches pulp."],
    ["Signs", "White spot (early demineralisation), brown/black cavity, visible hole"],
    ["Black's Classification",
     "Class I: Pit & fissure | Class II: Proximal of posteriors | "
     "Class III: Proximal of anteriors | Class IV: Proximal + incisal edge | "
     "Class V: Gingival 1/3 of buccal/lingual | Class VI: Cusp tips"],
    ["Treatment",
     "Early (white spot): remineralisation with fluoride. "
     "Cavity: excavation + restoration (filling). "
     "Pulp involved: root canal treatment (RCT). Irreparable: extraction."],
    ["Prevention", "Fluoride toothpaste, fissure sealants, dietary advice, regular check-ups"],
]
story.append(make_table(caries_data, col_widths=[4.5*cm, 13*cm]))

story.append(sp(0.3))
story.append(sub("5.2  Pulpitis"))
story.append(body("<b>Definition:</b> Inflammation of the dental pulp, usually a sequel to untreated caries."))

pulp_data = [
    ["Feature", "Reversible Pulpitis", "Irreversible Pulpitis"],
    ["Pain character", "Sharp, brief on stimulus (cold, sweet)", "Severe, spontaneous, throbbing, prolonged"],
    ["Pain at night", "Usually absent", "Often worse at night"],
    ["Response to cold", "Brief pain resolving in seconds", "Pain lingers for minutes after stimulus removed"],
    ["Treatment", "Remove cause (fill cavity) - pulp recovers", "Root canal treatment (RCT) or extraction"],
]
pt = Table(pulp_data, colWidths=[4.5*cm, 6.5*cm, 6.5*cm])
pt.setStyle(TableStyle([
    ('BACKGROUND', (0, 0), (-1, 0), colors.HexColor("#1a3a5c")),
    ('TEXTCOLOR', (0, 0), (-1, 0), colors.white),
    ('FONTNAME', (0, 0), (-1, 0), 'Helvetica-Bold'),
    ('BACKGROUND', (0, 1), (0, -1), colors.HexColor("#eef4fb")),
    ('FONTNAME', (0, 1), (0, -1), 'Helvetica-Bold'),
    ('FONTNAME', (1, 0), (-1, -1), 'Helvetica'),
    ('FONTSIZE', (0, 0), (-1, -1), 9),
    ('ROWBACKGROUNDS', (1, 1), (-1, -1), [colors.white, colors.HexColor("#f5f5f5")]),
    ('GRID', (0, 0), (-1, -1), 0.4, colors.HexColor("#AAAAAA")),
    ('ALIGN', (0, 0), (-1, -1), 'LEFT'),
    ('VALIGN', (0, 0), (-1, -1), 'TOP'),
    ('TOPPADDING', (0, 0), (-1, -1), 5),
    ('BOTTOMPADDING', (0, 0), (-1, -1), 5),
    ('LEFTPADDING', (0, 0), (-1, -1), 5),
]))
story.append(pt)

story.append(sp(0.3))
story.append(sub("5.3  Periapical Abscess"))
story.append(body(
    "<b>Definition:</b> Localised collection of pus at the root apex, following pulp necrosis. "
    "One of the most common dental emergencies."))
for t in [
    "<b>Symptoms:</b> Severe, constant, throbbing pain. Tender on biting. Tooth feels 'raised' "
    "(extruded in socket due to pressure of pus).",
    "<b>Signs:</b> Tender to percussion (TTP). Facial swelling/cellulitis if spreading. "
    "Parulis (gum boil - sinus with pus discharge). Fever and cervical lymphadenopathy.",
    "<b>Investigations:</b> Periapical X-ray shows periapical radiolucency (dark halo at root tip). "
    "Vitality test: non-vital (no response).",
    "<b>Treatment:</b> Drainage via root canal access or incision & drainage (I&D) if fluctuant. "
    "Antibiotics if systemic features: amoxicillin 500 mg TDS or metronidazole 400 mg TDS. "
    "Definitive: RCT or extraction.",
    "<b>WARNING:</b> Untreated abscess can spread to cause Ludwig's angina (floor of mouth "
    "cellulitis - life-threatening airway emergency), cavernous sinus thrombosis, or septicaemia.",
]:
    story.append(bul(t))

story.append(sp(0.3))
story.append(sub("5.4  Periodontal Diseases"))
story.append(body(
    "<b>Gingivitis:</b> Inflammation confined to the gingiva without bone loss. Reversible. "
    "Caused by plaque. Signs: redness, swelling, bleeding on brushing/probing, halitosis. "
    "Treatment: professional scaling + oral hygiene instruction."))
story.append(sp(0.1))
story.append(body(
    "<b>Periodontitis:</b> Extension of inflammation to periodontal ligament and alveolar bone "
    "with irreversible bone loss. Signs: periodontal pocket formation (>3 mm), gingival "
    "recession, bone loss on X-ray, tooth mobility, furcation involvement. "
    "Treatment: scaling and root planing (SRP); surgical therapy for advanced cases."))
story.append(sp(0.1))
story.append(body(
    "<b>Pericoronitis:</b> Inflammation around a partially erupted tooth (most commonly lower "
    "wisdom tooth - 38 or 48). Food and bacteria trapped under the operculum (gum flap). "
    "Signs: pain, swelling, trismus, bad taste, halitosis. Treatment: irrigation under operculum, "
    "antibiotics, operculectomy or extraction when acute episode resolves."))

story.append(sp(0.3))
story.append(sub("5.5  Oral Mucosal Diseases"))

story.append(subsub("Aphthous Stomatitis (Canker Sores):"))
story.append(body(
    "Most common cause of oral ulcers - affects up to 20% of the population. "
    "Recurrent, painful ulcers on <b>non-keratinized</b> mucosa (buccal mucosa, "
    "ventral tongue, lips, alveolar mucosa). Three types:"))
aph_data = [
    ["Type", "Size", "Duration", "Number"],
    ["Minor (most common, 80%)", "<0.5 cm, flat", "5-10 days", "1-5"],
    ["Major", ">0.5 cm, raised borders, deep", "Weeks to months", "Usually solitary"],
    ["Herpetiform", "Tiny (<3 mm), clusters", "7-10 days", "10-100"],
]
story.append(make_table(aph_data, col_widths=[5*cm, 4.5*cm, 3.5*cm, 4.5*cm]))
story.append(body(
    "Treatment: topical steroids (triamcinolone acetonide gel), topical lignocaine, "
    "tetracycline mouthwash. No curative treatment for recurrence."))
story.append(note(
    "Key distinction: Aphthous ulcers occur on NON-keratinized (movable) mucosa. "
    "Herpes simplex ulcers occur on KERATINIZED (fixed, attached) mucosa - hard palate "
    "and attached gingiva."))

story.append(subsub("Oral Candidiasis (Thrush):"))
story.append(body(
    "Fungal infection by <i>Candida albicans</i>. Most common oral fungal infection. "
    "Predisposing factors: immunosuppression, diabetes, prolonged antibiotics, steroid "
    "inhalers, xerostomia, dentures."))
for t in [
    "Pseudomembranous (most common): White creamy plaques that CAN BE WIPED OFF, "
    "leaving a raw/bleeding surface. Common in neonates, elderly, HIV patients.",
    "Erythematous: Red patches on palate or dorsum of tongue.",
    "Angular cheilitis: Redness and cracking at corners of mouth.",
    "Treatment: nystatin suspension 100,000 units/mL, 4x/day (swish & swallow). "
    "Systemic: fluconazole 150 mg stat for severe/resistant cases. Always treat underlying cause.",
]:
    story.append(bul(t))

story.append(subsub("Leukoplakia & Erythroplakia:"))
story.append(body(
    "<b>Leukoplakia:</b> White patch that cannot be rubbed off and cannot be attributed to any "
    "other definable condition. Potentially malignant. Risk factors: tobacco (any form), alcohol, "
    "chronic irritation. ALL leukoplakias require biopsy to assess for dysplasia or malignancy."))
story.append(body(
    "<b>Erythroplakia:</b> Red velvety patch - carries a HIGHER malignant transformation risk "
    "than leukoplakia. Treat with high index of suspicion."))

story.append(subsub("Oral Submucous Fibrosis (OSMF):"))
story.append(body(
    "Chronic progressive scarring of oral mucosa. Strongly associated with areca nut (betel "
    "nut/gutkha/paan) chewing - very common in South Asia. Features: progressive trismus "
    "(restricted mouth opening), blanching and stiffening of mucosa, burning sensation on "
    "eating spicy food. Potentially malignant - 7-13% malignant transformation rate. "
    "Treatment: habit cessation, intralesional steroids, physiotherapy for trismus."))

# ── SECTION 6 ──────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(sec("6.  Investigations in Dentistry"))
story.append(sp(0.2))

story.append(sub("6.1  Dental Radiographs"))
xray_data = [
    ["Type", "What It Shows", "Common Uses"],
    ["Periapical (PA) X-ray",
     "Individual tooth + surrounding bone (root, PDL space, lamina dura, periapex)",
     "Caries, periapical abscess/cyst, root fracture, impacted teeth"],
    ["Bitewing X-ray",
     "Crowns of upper & lower posteriors on same film",
     "Proximal (interproximal) caries - best for early caries; bone level assessment"],
    ["OPG / Panoramic",
     "Entire dentition, both jaws, TMJ, sinuses in one film",
     "Overview of all teeth, impacted wisdom teeth, fractures, cysts, tumours"],
    ["Occlusal X-ray",
     "Cross-sectional view of entire arch",
     "Salivary duct stones, cysts, supernumerary teeth"],
    ["CBCT",
     "3D imaging of jaws/teeth",
     "Implant planning, complex impactions, jaw tumours - not routine"],
    ["Lateral Cephalogram",
     "Side profile of skull and jaws",
     "Orthodontic assessment, skeletal relationships"],
]
story.append(make_table(xray_data, col_widths=[3.5*cm, 6*cm, 8*cm]))
story.append(note(
    "On a PA X-ray: Dense (WHITE) = enamel, bone, metal restorations. "
    "Radiolucent (DARK) = caries, abscess, cyst, pulp chamber. "
    "A periapical radiolucency (dark halo at root tip) = periapical infection/granuloma/cyst."))

story.append(sub("6.2  Vitality (Sensibility) Tests"))
vital_data = [
    ["Test", "Method", "Normal / Abnormal Response"],
    ["Cold Test (most common)",
     "Ethyl chloride spray or ice on cotton pellet applied to tooth",
     "Normal: brief sharp sensation resolving in <10 sec. "
     "Non-vital: NO response. Irreversible pulpitis: prolonged lingering pain."],
    ["Heat Test",
     "Warm gutta-percha or warm water on tooth",
     "Normal: brief sensation. Positive if reproduces patient's pain."],
    ["Electric Pulp Test (EPT)",
     "Low electric current via probe on enamel surface",
     "Tingling sensation = vital pulp. No response = non-vital."],
]
story.append(make_table(vital_data, col_widths=[3.5*cm, 5.5*cm, 8.5*cm]))

story.append(sub("6.3  Periodontal Assessment"))
for t in [
    "Probing Pocket Depth (PPD): Measured with calibrated periodontal probe. Normal sulcus <3 mm. "
    "Pathological pocket in periodontitis: >3 mm.",
    "Bleeding on Probing (BOP): Indicates active gingival/periodontal inflammation.",
    "Furcation Involvement (multi-rooted teeth): Grade I/II/III depending on probe penetration.",
    "BPE (Basic Periodontal Examination): Screening using WHO probe. Scores 0-4 per sextant. "
    "Score 4 = complex periodontal treatment needed.",
    "Tooth Mobility: Grade 1 (<1 mm horizontal), Grade 2 (1-2 mm horizontal), "
    "Grade 3 (>2 mm or vertical).",
]:
    story.append(bul(t))

story.append(sub("6.4  Laboratory Investigations"))
for t in [
    "CBC (Complete Blood Count): Suspected anaemia, leukaemia, bleeding disorder, or infection.",
    "Blood glucose (fasting/random): Diabetes screening (associated with severe periodontitis).",
    "Coagulation profile (PT/INR, aPTT): Before surgical procedures; patients on anticoagulants.",
    "Biopsy (incisional): Any suspicious lesion - ulcer >3 weeks, leukoplakia, erythroplakia, "
    "suspected malignancy. Gold standard for diagnosis.",
    "FNAC (Fine Needle Aspiration Cytology): Neck lumps/lymphadenopathy workup.",
    "Culture & Sensitivity: Oral infections not responding to empirical antibiotics.",
]:
    story.append(bul(t))

# ── SECTION 7 ──────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(sec("7.  Systemic Diseases & Oral Manifestations"))
story.append(sp(0.2))
story.append(body(
    "The oral cavity is often a mirror of systemic health. Many systemic diseases have "
    "characteristic oral manifestations. This knowledge is essential both for diagnosis "
    "and for safe dental treatment planning."))

sys_data = [
    ["Systemic Disease", "Oral Manifestation / Clinical Relevance"],
    ["Diabetes Mellitus",
     "Severe periodontitis, increased caries, poor wound healing, recurrent candidiasis, "
     "xerostomia, burning mouth. Uncontrolled DM = relative contraindication for elective surgery."],
    ["Anaemia",
     "Pale oral mucosa, atrophic/smooth glossitis (iron, B12, folate deficiency), "
     "angular cheilitis. Koilonychia (spoon nails) in iron deficiency."],
    ["Leukaemia (especially AML)",
     "Gingival bleeding, gingival hyperplasia/enlargement, oral ulcers, petechiae. "
     "May be first presentation of leukaemia."],
    ["Thrombocytopenia",
     "Petechiae on soft palate (vibrating line), spontaneous gingival bleeding, "
     "prolonged bleeding after minor trauma."],
    ["HIV / AIDS",
     "Oral candidiasis (often first sign of HIV), hairy leukoplakia (lateral tongue - EBV), "
     "Kaposi's sarcoma (red/purple lesions on palate), major aphthous ulcers, "
     "linear gingival erythema, necrotising periodontitis."],
    ["Hypertension (on CCBs)",
     "Calcium channel blockers (amlodipine, nifedipine) cause gingival hyperplasia. "
     "Check BP before dental treatment; caution with adrenaline in LA."],
    ["Cardiac Disease\n(valvular)",
     "Antibiotic prophylaxis required before invasive dental procedures in HIGH-RISK patients: "
     "prosthetic cardiac valves, previous infective endocarditis, unrepaired cyanotic CHD."],
    ["Anticoagulant Therapy\n(warfarin/aspirin)",
     "Increased bleeding risk. Check INR <3.5 for minor procedures. Do NOT routinely stop "
     "warfarin - apply local haemostatic measures (sutures, haemostatic packing)."],
    ["Bisphosphonate Therapy",
     "MRONJ (Medication-Related Osteonecrosis of the Jaw): exposed bone failing to heal, "
     "especially post-extraction. More common with IV bisphosphonates. "
     "Avoid extractions if at all possible."],
    ["Sjogren's Syndrome",
     "Severe xerostomia (dry mouth), parotid enlargement, dramatically increased cervical "
     "caries, dysphagia. Dry eyes (keratoconjunctivitis sicca). Sicca symptoms."],
    ["Vitamin Deficiencies",
     "Vit C deficiency (scurvy): haemorrhagic gingivitis, loose teeth. "
     "B12/folate: atrophic glossitis, aphthous ulcers. "
     "Vit D: delayed tooth eruption, increased caries susceptibility."],
    ["Crohn's Disease / IBD",
     "Aphthous-like ulcers, cobblestone appearance of buccal mucosa, lip swelling "
     "(orofacial granulomatosis), mucogingivitis."],
    ["Pregnancy",
     "Pregnancy gingivitis (hormonal - very common). Pregnancy epulis (pyogenic granuloma "
     "on gums). Avoid X-rays in 1st trimester; avoid certain drugs (tetracyclines, metronidazole "
     "in 1st trimester)."],
    ["Renal Failure",
     "Uraemic stomatitis (whitish-grey pseudomembrane), metallic taste, xerostomia, "
     "hypoplastic enamel. Adjust drug doses for renal function."],
]
story.append(make_table(sys_data, col_widths=[4.5*cm, 13*cm]))

# ── SECTION 8 ──────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(sec("8.  Basic Dental Procedures - Observer's Guide"))
story.append(sp(0.2))
story.append(body(
    "As an MBBS student on posting, you will mainly observe. Understanding what is "
    "happening will help you learn and ask good questions."))

proc_data = [
    ["Procedure", "What Happens", "Key Points to Observe"],
    ["Local Anaesthesia (LA)",
     "Most common: Inferior alveolar nerve block (mandibular teeth) or "
     "infiltration anaesthesia (maxillary teeth). Lignocaine 2% with "
     "adrenaline 1:80,000 is standard.",
     "Always aspirate before injecting. Adrenaline contraindicated in uncontrolled "
     "cardiac disease. Complications: failed block, haematoma, transient facial nerve palsy."],
    ["Scaling & Root Planing",
     "Removal of calculus (tartar/plaque) from tooth surfaces and roots using "
     "ultrasonic scaler + hand instruments.",
     "Foundation of periodontal treatment. Bleeding expected. "
     "Post-op sensitivity for a few days is normal."],
    ["Dental Filling (Restoration)",
     "Caries removed, cavity prepared, filled with composite resin (tooth-coloured) "
     "or glass ionomer cement.",
     "Acid etching and bonding agents for composite. "
     "Occlusion checked with articulating paper after filling."],
    ["Root Canal Treatment (RCT)",
     "Pulp tissue removed, root canals shaped, cleaned, and filled with "
     "gutta-percha. Done to save a non-vital tooth.",
     "Multiple visits usually required. Rubber dam used for isolation. "
     "Pain for a few days after 1st visit is common. Final crown needed after RCT."],
    ["Dental Extraction",
     "Tooth removed under LA using forceps and elevators. Socket curretted, "
     "haemostasis achieved.",
     "Post-op instructions: bite on gauze 30 min, no hot food/drinks, "
     "no rinsing for 24h, no smoking. Watch for post-extraction haemorrhage."],
    ["Incision & Drainage (I&D)",
     "Surgical drainage of fluctuant dental abscess. Incision made, pus drained, "
     "corrugated drain placed.",
     "Antibiotics are adjunct, NOT a substitute for drainage. "
     "Drain reviewed and removed in 24-48h."],
    ["Dental X-ray",
     "Patient bites on periapical film/digital sensor. X-ray tube positioned "
     "outside mouth. Paralleling technique for accuracy.",
     "Lead apron for patient. "
     "Bitewing: both arches on same film for proximal caries."],
]
story.append(make_table(proc_data, col_widths=[4*cm, 6*cm, 7.5*cm]))

# ── SECTION 9 ──────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(sec("9.  Dental Emergencies"))
story.append(sp(0.2))
story.append(body(
    "Emergencies can occur during or after dental procedures. Know what to look for "
    "and call for help immediately."))

story.append(sub("9.1  Post-extraction Haemorrhage"))
for t in [
    "Primary: Bleeding during/immediately after extraction. Control with local pressure "
    "(bite on gauze for 30 minutes).",
    "Reactionary: Bleeding within first few hours - clot dislodged or vasoconstriction wearing off.",
    "Secondary: Bleeding 5-10 days post-extraction - usually due to infection.",
    "Management: Local pressure, irrigate socket, pack with haemostatic material (Surgicel/Gelfoam), "
    "suture if needed. Check coagulation profile if persistent. Rule out bleeding disorder.",
]:
    story.append(bul(t))

story.append(sub("9.2  Syncope (Vasovagal Attack)"))
story.append(body("Most common medical emergency in dental practice. Caused by anxiety, pain, or sight of needle/blood."))
for t in [
    "Features: Prodrome of pallor, sweating, nausea, dizziness, then brief loss of consciousness.",
    "Management: Lay patient flat (Trendelenburg position), loosen clothing, ensure airway. "
    "Usually self-limiting within 1-2 minutes. Monitor vital signs.",
]:
    story.append(bul(t))

story.append(sub("9.3  Anaphylaxis"))
for t in [
    "Causes: Local anaesthetic, latex, antibiotics (penicillin), NSAIDs.",
    "Features: Urticaria, angioedema, bronchospasm, hypotension, tachycardia.",
    "Management: STOP procedure immediately. "
    "Adrenaline (epinephrine) 0.5 mg IM (0.5 mL of 1:1000 solution) into anterolateral thigh. "
    "Call for emergency help. ABC management. IV fluids, antihistamine, hydrocortisone as adjuncts.",
]:
    story.append(bul(t))

story.append(sub("9.4  Ludwig's Angina"))
story.append(body(
    "Life-threatening bilateral cellulitis involving submandibular, sublingual, and "
    "submental spaces. Usually originates from mandibular 2nd or 3rd molar infection. "
    "<b>AIRWAY EMERGENCY.</b>"))
for t in [
    "Features: Brawny (firm, board-like, NON-fluctuant) swelling of floor of mouth and neck. "
    "'Hot potato' voice, dysphagia, drooling, elevated and displaced tongue, stridor.",
    "Management: AIRWAY FIRST - early intubation or surgical airway (tracheostomy/cricothyrotomy). "
    "High-dose IV antibiotics (penicillin + metronidazole). Surgical drainage of spaces.",
]:
    story.append(bul(t))

story.append(sub("9.5  Dry Socket (Alveolar Osteitis)"))
for t in [
    "Painful condition 2-4 days post-extraction due to loss or disintegration of blood clot.",
    "Features: Severe throbbing pain radiating to ear or temple. Empty socket with exposed bone. Halitosis.",
    "Risk factors: Smoking, poor oral hygiene, mandibular molar extractions, "
    "oral contraceptive use, traumatic extraction.",
    "Management: Gentle saline irrigation of socket. Placement of alvogyl dressing "
    "(eugenol-impregnated). Analgesics (NSAIDs). Dressing changed every 2-3 days until healed.",
]:
    story.append(bul(t))

story.append(sub("9.6  Dental Trauma"))
for t in [
    "Ellis Classification: Class I (enamel only), Class II (enamel + dentine), "
    "Class III (enamel + dentine + pulp exposed - dental emergency).",
    "Avulsed (knocked-out) tooth: Replant within 30 min if possible. "
    "Store in milk, saline, or patient's saliva if transport needed. "
    "Do NOT scrub root surface.",
    "Refer all dental trauma cases immediately.",
]:
    story.append(bul(t))

# ── SECTION 10 ──────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(sec("10.  Quick Reference Checklists"))
story.append(sp(0.2))

story.append(sub("Checklist 1: Complete Dental History"))
checklist1 = [
    "[ ]  Patient ID: Name, age, sex, occupation, address, date",
    "[ ]  Chief Complaint: patient's own words, site, duration",
    "[ ]  HPI: SOCRATES (Site, Onset, Character, Radiation, Associated features, Timing, "
    "Exacerbating/Relieving factors, Severity)",
    "[ ]  Past Dental History: visit regularity, previous treatments, adverse reactions to LA",
    "[ ]  Past Medical History: DM, HTN, cardiac disease, bleeding disorder, epilepsy, "
    "renal/liver disease",
    "[ ]  Drug History: anticoagulants, bisphosphonates, CCBs, steroids, antiepileptics",
    "[ ]  Allergy History: LA, penicillin, NSAIDs, latex - ask even if patient says 'none'",
    "[ ]  Social History: tobacco (type, amount, duration), alcohol, diet",
    "[ ]  Family History: relevant genetic or dental conditions",
    "[ ]  Systemic Review: swelling, fever, dysphagia, weight loss, altered sensation",
]
for item in checklist1:
    story.append(Paragraph(item, check_style))

story.append(sp(0.3))
story.append(sub("Checklist 2: Systematic Oral Examination"))
checklist2 = [
    "[ ]  General: appearance, pallor, jaundice, nutrition",
    "[ ]  EO - Face: symmetry, swelling, skin changes, draining sinuses",
    "[ ]  EO - Lips: colour, angular cheilitis, herpes labialis",
    "[ ]  EO - TMJ: click, crepitus, tenderness, maximum mouth opening",
    "[ ]  EO - Lymph nodes: submental, submandibular, cervical chains",
    "[ ]  IO - Lips (inner surface) and labial mucosa",
    "[ ]  IO - Buccal mucosa bilaterally and sulcus",
    "[ ]  IO - Gingiva: colour, contour, BOP, recession, hyperplasia",
    "[ ]  IO - Teeth: chart, mobility, TTP, caries, restorations",
    "[ ]  IO - Hard palate and soft palate/uvula",
    "[ ]  IO - Tongue: dorsum, lateral borders (critical!), ventral surface",
    "[ ]  IO - Floor of mouth",
    "[ ]  IO - Oropharynx and tonsils",
    "[ ]  Record all findings systematically in case sheet",
]
for item in checklist2:
    story.append(Paragraph(item, check_style))

story.append(sp(0.3))
story.append(sub("Checklist 3: Red Flags - Always Report to Supervisor Immediately"))
rf_data = [
    ["Red Flag", "Possible Significance"],
    ["Oral ulcer persisting >3 weeks", "Oral squamous cell carcinoma or other malignancy"],
    ["White or red patch that cannot be rubbed off",
     "Leukoplakia / erythroplakia - potentially malignant, biopsy needed"],
    ["Unexplained loose teeth in young patient",
     "Aggressive periodontitis, leukaemia, Langerhans cell histiocytosis, tumour"],
    ["Jaw or lip numbness / paraesthesia",
     "IAN involvement by tumour (Vincent's sign) - urgent investigation"],
    ["Swelling not responding to antibiotics",
     "Deep neck space infection, malignancy, TB lymphadenopathy"],
    ["Trismus without clear cause",
     "OSMF, masticator space infection, malignancy, fibrosis"],
    ["Rapidly expanding jaw swelling in child",
     "Ameloblastoma, dentigerous cyst, Burkitt's lymphoma"],
    ["Weight loss + oral lesion",
     "Underlying malignancy, HIV, systemic disease"],
    ["Gingival bleeding not responding to scaling",
     "Leukaemia, thrombocytopenia, haemophilia - requires haematological workup"],
]
story.append(make_table(rf_data, col_widths=[6*cm, 11.5*cm],
                        hdr_bg=colors.HexColor("#8B0000")))

story.append(sp(0.5))
story.append(Paragraph("Good Luck on Your First Day!",
    ParagraphStyle('gl', parent=title_style, fontSize=20,
                   textColor=colors.HexColor("#1a3a5c"))))
story.append(sp(0.2))
story.append(body(
    "Remember: observe carefully, ask questions respectfully, and never perform any procedure "
    "without direct supervision. The dental team is there to teach you. "
    "Be enthusiastic, be punctual, and maintain professionalism at all times. "
    "Every patient encounter is a learning opportunity."))

story.append(sp(0.3))
story.append(hr())
story.append(Paragraph(
    "Sources: Goldman-Cecil Medicine 2024 | Harrison's Principles of Internal Medicine 22E (2025) "
    "| Pocket Dentistry - Greenwood | Oxford Handbook of Clinical Dentistry - Mitchell | "
    "ADA Medical/Dental Health History Guidelines",
    ref_style))

doc.build(story, canvasmaker=NumberedCanvas)
print("SUCCESS:", output_path)

cd /home/daytona/workspace/dental-ward-guide && python3 generate_pdf.py

ls -lh /home/daytona/workspace/dental-ward-guide/Dental_Ward_Guide_MBBS.pdf

ls -lh /home/daytona/workspace/dental-ward-guide/ && python3 -c " from pypdf imp…

base64 /home/daytona/workspace/dental-ward-guide/Dental_Ward_Guide_MBBS.pdf | wc…

base64 /home/daytona/workspace/dental-ward-guide/Dental_Ward_Guide_MBBS.pdf

python3 -c " import base64, os with open('/home/daytona/workspace/dental-ward-gu…

~/dental-ward-guide/generate_docx.js

const {
  Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
  HeadingLevel, AlignmentType, WidthType, BorderStyle, ShadingType,
  PageBreak, Header, Footer, PageNumber, NumberFormat, VerticalAlign
} = require('docx');
const fs = require('fs');

// ── COLOUR PALETTE ──────────────────────────────────────────────────────────
const NAVY   = "1a3a5c";
const BLUE   = "2c6fad";
const WHITE  = "FFFFFF";
const YELLOW = "FFF8E1";
const RED    = "8B0000";
const LGRAY  = "EEF4FB";
const GRAY   = "555555";

// ── HELPER: thin border set ──────────────────────────────────────────────────
function thinBorder() {
  const b = { style: BorderStyle.SINGLE, size: 4, color: "AAAAAA" };
  return { top: b, bottom: b, left: b, right: b, insideHorizontal: b, insideVertical: b };
}

// ── HELPER: heading paragraph ────────────────────────────────────────────────
function h1(text) {
  return new Paragraph({
    heading: HeadingLevel.HEADING_1,
    children: [new TextRun({ text, bold: true, color: WHITE, size: 32 })],
    shading: { type: ShadingType.SOLID, color: NAVY, fill: NAVY },
    spacing: { before: 280, after: 120 },
  });
}

function h2(text) {
  return new Paragraph({
    heading: HeadingLevel.HEADING_2,
    children: [new TextRun({ text, bold: true, color: NAVY, size: 28 })],
    spacing: { before: 200, after: 80 },
    border: { bottom: { style: BorderStyle.SINGLE, size: 4, color: BLUE } },
  });
}

function h3(text) {
  return new Paragraph({
    heading: HeadingLevel.HEADING_3,
    children: [new TextRun({ text, bold: true, color: BLUE, size: 24 })],
    spacing: { before: 160, after: 60 },
  });
}

function body(text) {
  return new Paragraph({
    children: [new TextRun({ text, size: 20 })],
    spacing: { after: 80 },
  });
}

function bodyRich(runs) {
  return new Paragraph({ children: runs, spacing: { after: 80 } });
}

function bullet(text) {
  return new Paragraph({
    children: [new TextRun({ text: "\u2022  " + text, size: 20 })],
    indent: { left: 360 },
    spacing: { after: 60 },
  });
}

function bulletBold(label, rest) {
  return new Paragraph({
    children: [
      new TextRun({ text: "\u2022  " + label, bold: true, size: 20 }),
      new TextRun({ text: rest, size: 20 }),
    ],
    indent: { left: 360 },
    spacing: { after: 60 },
  });
}

function noteBox(text) {
  return new Paragraph({
    children: [new TextRun({ text: "Note: " + text, italics: true, size: 18, color: "444444" })],
    shading: { type: ShadingType.SOLID, color: "FFF8E1", fill: "FFF8E1" },
    border: { left: { style: BorderStyle.SINGLE, size: 8, color: BLUE } },
    indent: { left: 180 },
    spacing: { after: 100 },
  });
}

function pageBreak() {
  return new Paragraph({ children: [new PageBreak()] });
}

function sp() {
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// ════════════════════════════════════════════════════════════════════════════
// BUILD DOCUMENT
// ════════════════════════════════════════════════════════════════════════════
const children = [];

// ── COVER ───────────────────────────────────────────────────────────────────
children.push(new Paragraph({
  children: [new TextRun({ text: "DENTAL WARD GUIDE", bold: true, size: 56, color: NAVY })],
  alignment: AlignmentType.CENTER, spacing: { before: 800, after: 200 },
}));
children.push(new Paragraph({
  children: [new TextRun({ text: "For MBBS 3rd Year Students", size: 32, color: BLUE })],
  alignment: AlignmentType.CENTER, spacing: { after: 100 },
}));
children.push(new Paragraph({
  children: [new TextRun({ text: "Complete Reference for Your First Clinical Posting", size: 24, color: GRAY, italics: true })],
  alignment: AlignmentType.CENTER, spacing: { after: 400 },
}));

children.push(makeTable([
  ["Prepared for:", "MBBS 3rd Year - 1st Day Dental Ward Posting"],
  ["Date:", "July 2026"],
  ["Compiled by:", "Orris Medical AI  |  Goldman-Cecil Medicine & Harrison's 22E (2025)"],
], [25, 75]));

children.push(sp()); children.push(sp());
children.push(new Paragraph({
  children: [new TextRun({ text: "Table of Contents", bold: true, size: 28, color: NAVY })],
  spacing: { before: 200, after: 120 },
}));
children.push(makeTable([
  ["#", "Section"],
  ["1", "Introduction & Ward Etiquette"],
  ["2", "Dental History Taking"],
  ["3", "Systematic Oral Examination"],
  ["4", "Dental Charting & Notation"],
  ["5", "Common Dental Conditions"],
  ["6", "Investigations in Dentistry"],
  ["7", "Systemic Diseases & Oral Manifestations"],
  ["8", "Basic Dental Procedures - Observer's Guide"],
  ["9", "Dental Emergencies"],
  ["10", "Quick Reference Checklists"],
], [10, 90]));
children.push(pageBreak());

// ── SECTION 1 ────────────────────────────────────────────────────────────────
children.push(h1("1.  Introduction & Ward Etiquette"));
children.push(body("Welcome to your first clinical posting in the Dental Ward. This guide will help you navigate the ward confidently, take a proper dental history, perform a systematic oral examination, and recognise common dental conditions. You are primarily an observer and learner - always seek permission before touching any patient and work under supervision."));
children.push(h2("1.1  Ward Etiquette"));
for (const t of [
  "Always introduce yourself as a medical student and obtain patient consent before any interaction.",
  "Maintain professional attire: white coat, clean hands, and a name badge at all times.",
  "Wash hands before and after every patient contact (WHO 5 Moments of Hand Hygiene).",
  "Do not use your mobile phone at the bedside or during consultations.",
  "Address patients respectfully by name and maintain strict patient confidentiality.",
  "When in doubt, always ask your supervisor before doing anything.",
  "Observe dental procedures from a safe distance unless invited closer by the dentist.",
  "Record all findings accurately and legibly in the case sheet.",
]) children.push(bullet(t));
children.push(noteBox("Dental procedures carry infection risk. Always wear gloves, mask, and eye protection if you are assisting in any procedure."));

// ── SECTION 2 ────────────────────────────────────────────────────────────────
children.push(pageBreak());
children.push(h1("2.  Dental History Taking"));
children.push(body("A thorough history is the cornerstone of dental diagnosis. The dental history follows the standard medical history framework but includes specific dental components. The goal is to understand the patient's complaint, place it in context, and identify systemic factors that could influence dental treatment."));
children.push(h2("2.1  Standard Format for Dental History"));
children.push(makeTable([
  ["Component", "What to Ask / Record"],
  ["Patient Details", "Name, age, sex, occupation, address, date of consultation"],
  ["Chief Complaint (CC)", "In patient's own words. 'What brings you here today?' Record verbatim with site and duration."],
  ["History of Present Illness (HPI)", "Onset (sudden/gradual), duration, severity, character (throbbing/dull/sharp/constant/intermittent), aggravating factors (hot, cold, sweet foods), relieving factors, previous episodes, any treatment taken."],
  ["Past Dental History (PDH)", "Frequency of dental visits (regular/irregular/never), previous extractions, fillings, root canals, orthodontic treatment, dentures. Adverse reactions: haemorrhage post-extraction, problems with local anaesthesia, fainting."],
  ["Past Medical History (PMH)", "Diabetes, hypertension, cardiac disease, bleeding disorders, epilepsy, immunosuppression, liver/kidney disease. Hospitalisations, surgeries, blood transfusions."],
  ["Drug History", "Current medications - especially anticoagulants (warfarin, aspirin), bisphosphonates, steroids, antihypertensives, antiepileptics, calcium channel blockers. OTC drugs, herbal supplements. Any drug allergies."],
  ["Allergy History", "Drug allergies (especially local anaesthetics, penicillin, NSAIDs), latex allergy, food allergies. Always ask specifically even if patient says 'no allergies'."],
  ["Family History", "Caries pattern in family, periodontal disease, malocclusion, genetic dental conditions, oral cancer."],
  ["Social History", "Tobacco smoking (cigarettes/bidis/hookah - type, quantity, duration). Tobacco chewing (gutkha/paan/areca nut). Alcohol (type, quantity). Diet (frequency of sugar intake, fizzy drinks)."],
  ["Systemic Review", "Swelling, lumps, fever, weight loss, dry mouth (xerostomia), difficulty chewing or swallowing, jaw clicking or locking."],
], [25, 75]));

children.push(h2("2.2  Special Questions for Common Dental Complaints"));

children.push(h3("For Pain (Toothache):"));
for (const t of [
  "SOCRATES: Site - which tooth/area? Onset? Character - throbbing, dull, sharp, electric?",
  "Radiation - does pain radiate to ear, jaw, temple, or neck?",
  "Associated features - swelling, fever, bad taste/smell, loose tooth?",
  "Timing - constant or intermittent? Worse at night (suggests irreversible pulpitis)?",
  "Aggravating factors: hot food/drink, cold water, sweet foods, biting down, lying flat?",
  "Relieving factors: cold water, painkillers? Severity 0-10.",
]) children.push(bullet(t));

children.push(h3("For Swelling:"));
for (const t of [
  "Site and extent - intraoral, extraoral, or both?",
  "Duration, onset - sudden or gradual? Triggering event (trauma, toothache)?",
  "Character - hard or soft? Fluctuant (suggests pus/abscess)?",
  "Associated symptoms: pain, fever, trismus (restricted mouth opening), difficulty swallowing?",
]) children.push(bullet(t));

children.push(h3("For Bleeding Gums:"));
for (const t of [
  "Spontaneous or provoked (brushing, eating)?",
  "Duration and frequency.",
  "Associated symptoms: pain, halitosis (bad breath), loose teeth?",
  "Oral hygiene: brushing frequency and technique, flossing?",
  "Any systemic bleeding elsewhere (nose bleeds, easy bruising)? - rule out haematological cause.",
  "Medications: anticoagulants, phenytoin (gingival overgrowth), calcium channel blockers?",
]) children.push(bullet(t));

children.push(h3("For Mouth Ulcers:"));
for (const t of [
  "Single or multiple? Site (keratinized vs non-keratinized mucosa)?",
  "Duration - >3 weeks is a RED FLAG requiring biopsy or urgent referral.",
  "Pain: aphthous ulcers are painful; malignant ulcers may be painless.",
  "Recurrence pattern (suggests aphthous stomatitis).",
  "Systemic associations: bowel problems (Crohn's), genital ulcers (Behcet's), skin rash?",
  "Tobacco/alcohol use (risk factors for oral malignancy).",
]) children.push(bullet(t));

children.push(noteBox("RED FLAGS in dental history: Ulcer >3 weeks | Unexplained loose teeth in young patient | Jaw/lip numbness or paraesthesia | Unexplained weight loss | Difficulty swallowing | Non-healing extraction socket | Trismus without clear cause"));

// ── SECTION 3 ────────────────────────────────────────────────────────────────
children.push(pageBreak());
children.push(h1("3.  Systematic Examination of the Oral Cavity"));
children.push(body("The oral examination follows a systematic 'outside-in' approach. Examine from the outside (face and neck) progressively inward (lips, mucosa, gingiva, teeth, tongue, palate, oropharynx). Always use good lighting and dental mirror under supervision."));

children.push(h2("3.1  General Examination"));
for (const t of [
  "General appearance: well/ill-looking, pallor, jaundice, nutritional status.",
  "Vital signs if relevant: pulse, blood pressure (before procedures), temperature if infection suspected.",
  "Demeanour: anxious (dental phobia is very common), distressed (acute pain).",
]) children.push(bullet(t));

children.push(h2("3.2  Extraoral (EO) Examination"));
children.push(h3("Face:"));
for (const t of [
  "Symmetry: facial asymmetry (swelling, muscle wasting, Bell's palsy)?",
  "Swelling: location - submandibular, parotid, submental, buccal space?",
  "Skin over swelling: erythema, fluctuance (abscess), sinus/fistula openings.",
  "Lips: colour, angular cheilitis (B-vitamin/iron deficiency or candida), herpes labialis.",
]) children.push(bullet(t));

children.push(h3("TMJ (Temporomandibular Joint):"));
for (const t of [
  "Palpate bilaterally as patient opens and closes mouth.",
  "Clicking or crepitus on movement.",
  "Maximum mouth opening: normal 35-45 mm (approximately 3 finger-breadths).",
  "Deviation of mandible on opening (deviates toward affected side in TMJ dysfunction).",
]) children.push(bullet(t));

children.push(h3("Lymph Nodes:"));
for (const t of [
  "Palpate: submental, submandibular, anterior/posterior cervical chain, preauricular, supraclavicular.",
  "Record: size, consistency (soft/firm/hard/rubbery), mobility, tenderness.",
  "Hard, fixed, non-tender lymph nodes = RED FLAG for malignancy.",
]) children.push(bullet(t));

children.push(h2("3.3  Intraoral (IO) Examination - Systematic Order"));
children.push(body("Examine in a fixed order. Do NOT go straight to the tooth the patient is pointing to - you may miss other important pathology."));
children.push(makeTable([
  ["Step", "Structure", "What to Look For"],
  ["1", "Lips (inner surface)", "Ulcers, mucoceles, fibroma, pigmentation"],
  ["2", "Buccal mucosa (both cheeks)", "Linea alba (normal), ulcers, leukoplakia, erythroplakia, Fordyce spots, candidiasis. Use mirror/tongue depressor."],
  ["3", "Vestibule & Sulcus", "Swelling, sinus/fistula openings (parulis = gum boil), obliteration of sulcus"],
  ["4", "Gingiva", "Colour (normal: coral pink), contour (scalloped), consistency, bleeding on probing, recession, hyperplasia, ulceration"],
  ["5", "Teeth", "Count teeth present; note missing, decayed, filled. Colour changes, fractures, mobility (grade 1/2/3), sensitivity. Dental charting."],
  ["6", "Hard palate", "Torus palatinus (normal bony prominence - do not confuse with pathology), ulcers, candidiasis"],
  ["7", "Soft palate & uvula", "Movement on 'Aah', petechiae (thrombocytopenia), Kaposi's sarcoma, ulcers"],
  ["8", "Tongue", "Dorsum: fissured, geographic, hairy, coated. Lateral borders (most common site for oral carcinoma!) and ventral surface. Mobility."],
  ["9", "Floor of mouth", "Wharton's duct openings, ranula (mucous cyst), swelling, ulceration, calculi"],
  ["10", "Oropharynx", "Tonsils, posterior pharyngeal wall, any masses"],
], [8, 25, 67]));
children.push(noteBox("Any oral ulcer persisting >3 weeks must be considered potentially malignant. The lateral border of the tongue and the floor of the mouth are the most common sites for oral squamous cell carcinoma."));

// ── SECTION 4 ────────────────────────────────────────────────────────────────
children.push(pageBreak());
children.push(h1("4.  Dental Charting & Notation"));
children.push(h2("4.1  FDI (ISO) System - Most Widely Used"));
children.push(body("Each tooth has a 2-digit number. First digit = quadrant (1-4 for permanent, 5-8 for primary). Second digit = tooth position within quadrant (1-8 from central incisor to 3rd molar)."));
children.push(makeTable([
  ["Quadrant", "Permanent Teeth", "Primary Teeth"],
  ["Upper Right (Q1)", "11 - 18", "51 - 55"],
  ["Upper Left  (Q2)", "21 - 28", "61 - 65"],
  ["Lower Left  (Q3)", "31 - 38", "71 - 75"],
  ["Lower Right (Q4)", "41 - 48", "81 - 85"],
], [34, 33, 33]));
children.push(body("Examples: Tooth 36 = lower left first molar. Tooth 11 = upper right central incisor. Tooth 21 = upper left central incisor."));

children.push(h2("4.2  Common Charting Symbols"));
children.push(makeTable([
  ["Symbol / Abbreviation", "Meaning"],
  ["/ (diagonal line through box)", "Extracted tooth"],
  ["Shaded box or X", "Decayed (carious) tooth - shade affected surfaces"],
  ["F or shaded outline", "Filled/restored tooth"],
  ["UE / PE", "Unerupted / Partially erupted"],
  ["RCT or RC", "Root canal treated"],
  ["Cr", "Crown placed"],
  ["Mobility Grade 1", "Slight horizontal movement (just perceptible)"],
  ["Mobility Grade 2", "1-2 mm horizontal buccolingual movement"],
  ["Mobility Grade 3", ">2 mm movement in all directions including vertical (depressible)"],
  ["TTP", "Tender to percussion - tap tooth gently with mirror handle"],
], [35, 65]));

children.push(h2("4.3  DMFT Index"));
children.push(body("D = Decayed teeth, M = Missing due to caries, F = Filled teeth, T = Teeth examined. Maximum score = 28 (or 32). Higher DMFT = greater caries burden. Widely used in epidemiological surveys and clinical assessments."));

// ── SECTION 5 ────────────────────────────────────────────────────────────────
children.push(pageBreak());
children.push(h1("5.  Common Dental Conditions"));

children.push(h2("5.1  Dental Caries (Tooth Decay)"));
children.push(body("Infectious, multifactorial disease causing demineralisation and destruction of tooth hard tissues by acids produced by bacteria (Streptococcus mutans, Lactobacillus)."));
children.push(makeTable([
  ["Feature", "Details"],
  ["Aetiology (Keyes Triad)", "Bacteria + Fermentable carbohydrates + Susceptible tooth + Time"],
  ["Symptoms", "Initially asymptomatic. Later: sensitivity to sweet, cold, hot. Severe pain when cavity reaches pulp."],
  ["Signs", "White spot (early demineralisation), brown/black cavity, visible hole"],
  ["Black's Classification", "Class I: Pit & fissure | Class II: Proximal of posteriors | Class III: Proximal of anteriors | Class IV: Proximal + incisal edge | Class V: Gingival 1/3 of buccal/lingual"],
  ["Treatment", "Early: remineralisation with fluoride. Cavity: excavation + restoration (filling). Pulp involved: RCT. Irreparable: extraction."],
  ["Prevention", "Fluoride toothpaste, fissure sealants, dietary advice, regular check-ups"],
], [25, 75]));

children.push(h2("5.2  Pulpitis"));
children.push(makeTable([
  ["Feature", "Reversible Pulpitis", "Irreversible Pulpitis"],
  ["Pain character", "Sharp, brief on stimulus (cold, sweet)", "Severe, spontaneous, throbbing, prolonged"],
  ["Pain at night", "Usually absent", "Often worse at night"],
  ["Response to cold", "Brief pain resolving in seconds", "Pain lingers for minutes after stimulus removed"],
  ["Treatment", "Remove cause (fill cavity) - pulp recovers", "Root canal treatment (RCT) or extraction"],
], [30, 35, 35]));

children.push(h2("5.3  Periapical Abscess"));
children.push(body("Localised collection of pus at the root apex, following pulp necrosis. One of the most common dental emergencies."));
for (const [label, rest] of [
  ["Symptoms: ", "Severe, constant, throbbing pain. Tender on biting. Tooth feels 'raised' (extruded in socket due to pus pressure)."],
  ["Signs: ", "Tender to percussion (TTP). Facial swelling/cellulitis. Parulis (gum boil - sinus with pus). Fever and cervical lymphadenopathy."],
  ["Investigations: ", "Periapical X-ray: periapical radiolucency (dark halo at root tip). Vitality test: non-vital (no response to cold)."],
  ["Treatment: ", "Drainage via root canal access or I&D if fluctuant. Antibiotics if systemic features. Definitive: RCT or extraction."],
  ["WARNING: ", "Untreated abscess can spread to cause Ludwig's angina (floor of mouth cellulitis - life-threatening airway emergency) or cavernous sinus thrombosis."],
]) children.push(bulletBold(label, rest));

children.push(h2("5.4  Periodontal Diseases"));
children.push(bodyRich([
  new TextRun({ text: "Gingivitis: ", bold: true, size: 20 }),
  new TextRun({ text: "Inflammation confined to the gingiva without bone loss. Reversible. Caused by plaque. Signs: redness, swelling, bleeding on brushing/probing, halitosis. Treatment: professional scaling + oral hygiene instruction.", size: 20 }),
]));
children.push(bodyRich([
  new TextRun({ text: "Periodontitis: ", bold: true, size: 20 }),
  new TextRun({ text: "Extension of inflammation to periodontal ligament and alveolar bone with irreversible bone loss. Signs: periodontal pocket formation (>3 mm), gingival recession, bone loss on X-ray, tooth mobility, furcation involvement. Treatment: scaling and root planing (SRP); surgical therapy for advanced cases.", size: 20 }),
]));
children.push(bodyRich([
  new TextRun({ text: "Pericoronitis: ", bold: true, size: 20 }),
  new TextRun({ text: "Inflammation around a partially erupted wisdom tooth. Food and bacteria trapped under the operculum (gum flap). Signs: pain, swelling, trismus, bad taste. Treatment: irrigation under operculum, antibiotics, operculectomy or extraction when acute episode resolves.", size: 20 }),
]));

children.push(h2("5.5  Oral Mucosal Diseases"));
children.push(h3("Aphthous Stomatitis (Canker Sores):"));
children.push(body("Most common cause of oral ulcers - affects up to 20% of the population. Recurrent, painful ulcers on non-keratinized mucosa (buccal mucosa, ventral tongue, lips, alveolar mucosa)."));
children.push(makeTable([
  ["Type", "Size", "Duration", "Number"],
  ["Minor (most common, 80%)", "<0.5 cm, flat", "5-10 days", "1-5"],
  ["Major", ">0.5 cm, raised borders, deep", "Weeks to months", "Usually solitary"],
  ["Herpetiform", "Tiny (<3 mm), clusters", "7-10 days", "10-100"],
], [30, 25, 25, 20]));
children.push(body("Treatment: topical steroids (triamcinolone gel), topical lignocaine, tetracycline mouthwash. No curative treatment for recurrence."));
children.push(noteBox("Key distinction: Aphthous ulcers occur on NON-keratinized (movable) mucosa. Herpes simplex ulcers occur on KERATINIZED (fixed, attached) mucosa - hard palate and attached gingiva."));

children.push(h3("Oral Candidiasis (Thrush):"));
for (const t of [
  "Pseudomembranous (most common): White creamy plaques that CAN BE WIPED OFF, leaving raw/bleeding surface. Common in neonates, elderly, HIV patients, steroid inhaler users, diabetics.",
  "Erythematous: Red patches on palate or dorsum of tongue.",
  "Angular cheilitis: Redness and cracking at corners of mouth.",
  "Treatment: nystatin suspension 4x/day (swish & swallow). Systemic: fluconazole 150 mg stat for severe cases. Treat underlying cause.",
]) children.push(bullet(t));

children.push(h3("Leukoplakia & Erythroplakia:"));
children.push(bodyRich([
  new TextRun({ text: "Leukoplakia: ", bold: true, size: 20 }),
  new TextRun({ text: "White patch that cannot be rubbed off and cannot be attributed to any other definable condition. Potentially malignant. Risk factors: tobacco (any form), alcohol, chronic irritation. ALL leukoplakias require biopsy to assess for dysplasia or malignancy.", size: 20 }),
]));
children.push(bodyRich([
  new TextRun({ text: "Erythroplakia: ", bold: true, size: 20 }),
  new TextRun({ text: "Red velvety patch - carries HIGHER malignant transformation risk than leukoplakia. Treat with high index of suspicion.", size: 20 }),
]));

children.push(h3("Oral Submucous Fibrosis (OSMF):"));
children.push(body("Chronic progressive scarring of oral mucosa. Strongly associated with areca nut/gutkha/paan chewing - very common in South Asia. Features: progressive trismus (restricted mouth opening), blanching and stiffening of mucosa, burning sensation. Potentially malignant - 7-13% malignant transformation rate. Treatment: habit cessation, intralesional steroids, physiotherapy for trismus."));

// ── SECTION 6 ────────────────────────────────────────────────────────────────
children.push(pageBreak());
children.push(h1("6.  Investigations in Dentistry"));

children.push(h2("6.1  Dental Radiographs"));
children.push(makeTable([
  ["Type", "What It Shows", "Common Uses"],
  ["Periapical (PA) X-ray", "Individual tooth + surrounding bone (root, PDL space, lamina dura, periapex)", "Caries, periapical abscess/cyst, root fracture, impacted teeth"],
  ["Bitewing X-ray", "Crowns of upper & lower posteriors on same film", "Proximal (interproximal) caries - best for early caries; bone level assessment"],
  ["OPG / Panoramic", "Entire dentition, both jaws, TMJ, sinuses in one film", "Overview of all teeth, impacted wisdom teeth, fractures, cysts, tumours"],
  ["Occlusal X-ray", "Cross-sectional view of entire arch", "Salivary duct stones, cysts, supernumerary teeth"],
  ["CBCT", "3D imaging of jaws/teeth", "Implant planning, complex impactions, jaw tumours - not routine"],
  ["Lateral Cephalogram", "Side profile of skull and jaws", "Orthodontic assessment, skeletal relationships"],
], [22, 38, 40]));
children.push(noteBox("On a PA X-ray: Dense (WHITE) = enamel, bone, metal restorations. Radiolucent (DARK) = caries, abscess, cyst, pulp chamber. A periapical radiolucency (dark halo at root tip) = periapical infection/granuloma/cyst."));

children.push(h2("6.2  Vitality (Sensibility) Tests"));
children.push(makeTable([
  ["Test", "Method", "Normal / Abnormal Response"],
  ["Cold Test (most common)", "Ethyl chloride spray or ice on cotton pellet applied to tooth", "Normal: brief sharp sensation resolving in <10 sec. Non-vital: NO response. Irreversible pulpitis: prolonged lingering pain."],
  ["Heat Test", "Warm gutta-percha or warm water on tooth", "Normal: brief sensation. Positive if reproduces patient's pain."],
  ["Electric Pulp Test (EPT)", "Low electric current via probe on enamel surface", "Tingling sensation = vital pulp. No response = non-vital."],
], [22, 38, 40]));

children.push(h2("6.3  Periodontal Assessment"));
for (const t of [
  "Probing Pocket Depth (PPD): Calibrated periodontal probe. Normal sulcus <3 mm. Pathological pocket in periodontitis: >3 mm.",
  "Bleeding on Probing (BOP): Indicates active gingival/periodontal inflammation.",
  "Furcation Involvement: Grade I/II/III depending on probe penetration between roots.",
  "BPE (Basic Periodontal Examination): Screening using WHO probe. Scores 0-4 per sextant. Score 4 = complex periodontal treatment needed.",
  "Tooth Mobility: Grade 1 (<1 mm horizontal), Grade 2 (1-2 mm horizontal), Grade 3 (>2 mm or vertical).",
]) children.push(bullet(t));

children.push(h2("6.4  Laboratory Investigations"));
for (const t of [
  "CBC: Suspected anaemia, leukaemia, bleeding disorder, or infection.",
  "Blood glucose (fasting/random): Diabetes screening (associated with severe periodontitis).",
  "Coagulation profile (PT/INR, aPTT): Before surgical procedures; patients on anticoagulants.",
  "Biopsy (incisional): Any suspicious lesion - ulcer >3 weeks, leukoplakia, erythroplakia, suspected malignancy. Gold standard.",
  "FNAC (Fine Needle Aspiration Cytology): Neck lumps/lymphadenopathy workup.",
]) children.push(bullet(t));

// ── SECTION 7 ────────────────────────────────────────────────────────────────
children.push(pageBreak());
children.push(h1("7.  Systemic Diseases & Oral Manifestations"));
children.push(body("The oral cavity is often a mirror of systemic health. Many systemic diseases have characteristic oral manifestations. This knowledge is essential for diagnosis and safe dental treatment planning."));
children.push(makeTable([
  ["Systemic Disease", "Oral Manifestation / Clinical Relevance"],
  ["Diabetes Mellitus", "Severe periodontitis, increased caries, poor wound healing, recurrent candidiasis, xerostomia, burning mouth. Uncontrolled DM = relative contraindication for elective surgery."],
  ["Anaemia", "Pale oral mucosa, atrophic/smooth glossitis (iron, B12, folate deficiency), angular cheilitis."],
  ["Leukaemia (especially AML)", "Gingival bleeding, gingival hyperplasia/enlargement, oral ulcers, petechiae. May be first presentation of leukaemia."],
  ["Thrombocytopenia", "Petechiae on soft palate, spontaneous gingival bleeding, prolonged bleeding after minor trauma."],
  ["HIV / AIDS", "Oral candidiasis (often first sign of HIV), hairy leukoplakia (lateral tongue - EBV), Kaposi's sarcoma (red/purple lesions on palate), major aphthous ulcers, linear gingival erythema."],
  ["Hypertension (on CCBs)", "Calcium channel blockers (amlodipine, nifedipine) cause gingival hyperplasia. Check BP before dental treatment; caution with adrenaline in LA."],
  ["Cardiac Disease (valvular)", "Antibiotic prophylaxis required before invasive dental procedures in HIGH-RISK patients: prosthetic cardiac valves, previous infective endocarditis, unrepaired cyanotic CHD."],
  ["Anticoagulant Therapy", "Increased bleeding risk. Check INR <3.5 for minor procedures. Do NOT routinely stop warfarin - apply local haemostatic measures."],
  ["Bisphosphonate Therapy", "MRONJ (Medication-Related Osteonecrosis of the Jaw): exposed bone failing to heal, especially post-extraction. More common with IV bisphosphonates."],
  ["Sjogren's Syndrome", "Severe xerostomia (dry mouth), parotid enlargement, dramatically increased cervical caries, dysphagia. Dry eyes (sicca symptoms)."],
  ["Vitamin Deficiencies", "Vit C (scurvy): haemorrhagic gingivitis, loose teeth. B12/folate: atrophic glossitis, aphthous ulcers. Vit D: delayed tooth eruption, increased caries."],
  ["Crohn's Disease / IBD", "Aphthous-like ulcers, cobblestone appearance of buccal mucosa, lip swelling (orofacial granulomatosis)."],
  ["Pregnancy", "Pregnancy gingivitis (hormonal - very common). Pregnancy epulis (pyogenic granuloma on gums). Avoid X-rays in 1st trimester."],
  ["Renal Failure", "Uraemic stomatitis, metallic taste, xerostomia, hypoplastic enamel. Adjust drug doses for renal function."],
], [28, 72]));

// ── SECTION 8 ────────────────────────────────────────────────────────────────
children.push(pageBreak());
children.push(h1("8.  Basic Dental Procedures - Observer's Guide"));
children.push(makeTable([
  ["Procedure", "What Happens", "Key Points to Observe"],
  ["Local Anaesthesia (LA)", "Inferior alveolar nerve block (mandibular teeth) or infiltration anaesthesia (maxillary teeth). Lignocaine 2% with adrenaline 1:80,000 is standard.", "Always aspirate before injecting. Adrenaline contraindicated in uncontrolled cardiac disease. Complications: failed block, haematoma, transient facial nerve palsy."],
  ["Scaling & Root Planing", "Removal of calculus (tartar) from tooth surfaces and roots using ultrasonic scaler + hand instruments.", "Foundation of periodontal treatment. Bleeding expected. Post-op sensitivity for a few days is normal."],
  ["Dental Filling (Restoration)", "Caries removed, cavity prepared, filled with composite resin (tooth-coloured) or glass ionomer cement.", "Acid etching and bonding agents for composite. Occlusion checked with articulating paper after filling."],
  ["Root Canal Treatment (RCT)", "Pulp tissue removed, root canals shaped, cleaned, and filled with gutta-percha. Done to save a non-vital tooth.", "Multiple visits usually required. Rubber dam used for isolation. Pain for a few days after 1st visit is common. Crown needed after RCT."],
  ["Dental Extraction", "Tooth removed under LA using forceps and elevators. Socket curetted, haemostasis achieved.", "Post-op: bite on gauze 30 min, no hot food, no rinsing for 24h, no smoking. Watch for post-extraction haemorrhage."],
  ["Incision & Drainage (I&D)", "Surgical drainage of fluctuant dental abscess. Incision made, pus drained, corrugated drain placed.", "Antibiotics are adjunct, NOT substitute for drainage. Drain reviewed and removed in 24-48h."],
  ["Dental X-ray", "Patient bites on periapical film/digital sensor. X-ray tube positioned outside mouth.", "Lead apron for patient. Bitewing: both arches on same film for proximal caries detection."],
], [22, 38, 40]));

// ── SECTION 9 ────────────────────────────────────────────────────────────────
children.push(pageBreak());
children.push(h1("9.  Dental Emergencies"));

children.push(h2("9.1  Post-extraction Haemorrhage"));
for (const t of [
  "Primary: Bleeding during/immediately after extraction. Control with local pressure (bite on gauze for 30 minutes).",
  "Reactionary: Bleeding within first few hours - clot dislodged or vasoconstriction wearing off.",
  "Secondary: Bleeding 5-10 days post-extraction - usually due to infection.",
  "Management: Local pressure, irrigate socket, pack with haemostatic material (Surgicel/Gelfoam), suture if needed. Check coagulation if persistent.",
]) children.push(bullet(t));

children.push(h2("9.2  Syncope (Vasovagal Attack)"));
children.push(body("Most common medical emergency in dental practice. Caused by anxiety, pain, or sight of needle/blood."));
for (const t of [
  "Features: Prodrome of pallor, sweating, nausea, dizziness, then brief loss of consciousness.",
  "Management: Lay patient flat (Trendelenburg position), loosen clothing, ensure airway. Usually self-limiting within 1-2 minutes. Monitor vital signs.",
]) children.push(bullet(t));

children.push(h2("9.3  Anaphylaxis"));
for (const t of [
  "Causes: Local anaesthetic, latex, antibiotics (penicillin), NSAIDs.",
  "Features: Urticaria, angioedema, bronchospasm, hypotension, tachycardia.",
  "Management: STOP procedure immediately. Adrenaline (epinephrine) 0.5 mg IM (0.5 mL of 1:1000) into anterolateral thigh. Call for emergency help. ABC management. IV fluids, antihistamine, hydrocortisone as adjuncts.",
]) children.push(bullet(t));

children.push(h2("9.4  Ludwig's Angina - AIRWAY EMERGENCY"));
children.push(body("Life-threatening bilateral cellulitis involving submandibular, sublingual, and submental spaces. Usually from mandibular 2nd/3rd molar infection."));
for (const t of [
  "Features: Brawny (firm, board-like, NON-fluctuant) swelling of floor of mouth and neck. 'Hot potato' voice, dysphagia, drooling, elevated/displaced tongue, stridor.",
  "Management: AIRWAY FIRST - early intubation or surgical airway (tracheostomy/cricothyrotomy). High-dose IV antibiotics (penicillin + metronidazole). Surgical drainage of spaces.",
]) children.push(bullet(t));

children.push(h2("9.5  Dry Socket (Alveolar Osteitis)"));
for (const t of [
  "Painful condition 2-4 days post-extraction due to loss or disintegration of blood clot.",
  "Features: Severe throbbing pain radiating to ear or temple. Empty socket with exposed bone. Halitosis.",
  "Risk factors: Smoking, poor oral hygiene, mandibular molar extractions, oral contraceptive use, traumatic extraction.",
  "Management: Gentle saline irrigation of socket. Placement of alvogyl dressing (eugenol-impregnated). Analgesics (NSAIDs). Dressing changed every 2-3 days until healed.",
]) children.push(bullet(t));

// ── SECTION 10 ───────────────────────────────────────────────────────────────
children.push(pageBreak());
children.push(h1("10.  Quick Reference Checklists"));

children.push(h2("Checklist 1: Complete Dental History"));
for (const t of [
  "[ ]  Patient ID: Name, age, sex, occupation, address, date",
  "[ ]  Chief Complaint: patient's own words, site, duration",
  "[ ]  HPI: SOCRATES (Site, Onset, Character, Radiation, Associated features, Timing, Exacerbating/Relieving factors, Severity)",
  "[ ]  Past Dental History: visit regularity, previous treatments, adverse reactions to LA",
  "[ ]  Past Medical History: DM, HTN, cardiac disease, bleeding disorder, epilepsy, renal/liver disease",
  "[ ]  Drug History: anticoagulants, bisphosphonates, CCBs, steroids, antiepileptics",
  "[ ]  Allergy History: LA, penicillin, NSAIDs, latex - ask even if patient says 'none'",
  "[ ]  Social History: tobacco (type, amount, duration), alcohol, diet",
  "[ ]  Family History: relevant genetic or dental conditions",
  "[ ]  Systemic Review: swelling, fever, dysphagia, weight loss, altered sensation",
]) children.push(new Paragraph({ children: [new TextRun({ text: t, size: 19, font: "Courier New" })], spacing: { after: 60 }, indent: { left: 180 } }));

children.push(h2("Checklist 2: Systematic Oral Examination"));
for (const t of [
  "[ ]  General: appearance, pallor, jaundice, nutrition",
  "[ ]  EO - Face: symmetry, swelling, skin changes, draining sinuses",
  "[ ]  EO - Lips: colour, angular cheilitis, herpes labialis",
  "[ ]  EO - TMJ: click, crepitus, tenderness, maximum mouth opening",
  "[ ]  EO - Lymph nodes: submental, submandibular, cervical chains",
  "[ ]  IO - Lips (inner surface) and labial mucosa",
  "[ ]  IO - Buccal mucosa bilaterally and sulcus",
  "[ ]  IO - Gingiva: colour, contour, BOP, recession, hyperplasia",
  "[ ]  IO - Teeth: chart, mobility, TTP, caries, restorations",
  "[ ]  IO - Hard palate and soft palate/uvula",
  "[ ]  IO - Tongue: dorsum, lateral borders (critical!), ventral surface",
  "[ ]  IO - Floor of mouth",
  "[ ]  IO - Oropharynx and tonsils",
  "[ ]  Record all findings systematically in case sheet",
]) children.push(new Paragraph({ children: [new TextRun({ text: t, size: 19, font: "Courier New" })], spacing: { after: 60 }, indent: { left: 180 } }));

children.push(h2("Checklist 3: Red Flags - Always Report to Supervisor Immediately"));
children.push(makeTable([
  ["Red Flag", "Possible Significance"],
  ["Oral ulcer persisting >3 weeks", "Oral squamous cell carcinoma or other malignancy"],
  ["White or red patch that cannot be rubbed off", "Leukoplakia / erythroplakia - potentially malignant, biopsy needed"],
  ["Unexplained loose teeth in young patient", "Aggressive periodontitis, leukaemia, Langerhans cell histiocytosis, tumour"],
  ["Jaw or lip numbness / paraesthesia", "IAN involvement by tumour (Vincent's sign) - urgent investigation"],
  ["Swelling not responding to antibiotics", "Deep neck space infection, malignancy, TB lymphadenopathy"],
  ["Trismus without clear cause", "OSMF, masticator space infection, malignancy, fibrosis"],
  ["Rapidly expanding jaw swelling in child", "Ameloblastoma, dentigerous cyst, Burkitt's lymphoma"],
  ["Weight loss + oral lesion", "Underlying malignancy, HIV, systemic disease"],
  ["Gingival bleeding not responding to scaling", "Leukaemia, thrombocytopenia, haemophilia - haematological workup needed"],
], [40, 60], RED));

children.push(sp()); children.push(sp());
children.push(new Paragraph({
  children: [new TextRun({ text: "Good Luck on Your First Day!", bold: true, size: 36, color: NAVY })],
  alignment: AlignmentType.CENTER, spacing: { before: 200, after: 200 },
}));
children.push(body("Remember: observe carefully, ask questions respectfully, and never perform any procedure without direct supervision. The dental team is there to teach you. Be enthusiastic, be punctual, and maintain professionalism at all times."));
children.push(new Paragraph({
  children: [new TextRun({ text: "Sources: Goldman-Cecil Medicine 2024 | Harrison's Principles of Internal Medicine 22E (2025) | Pocket Dentistry (Greenwood) | Oxford Handbook of Clinical Dentistry (Mitchell) | ADA Health History Guidelines", size: 16, color: GRAY, italics: true })],
  alignment: AlignmentType.CENTER, spacing: { before: 160 },
}));

// ── BUILD ─────────────────────────────────────────────────────────────────────
const doc = new Document({
  creator: "Orris Medical AI",
  title: "Dental Ward Guide for MBBS 3rd Year Students",
  description: "Complete reference for dental ward clinical posting",
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Packer.toBuffer(doc).then(buffer => {
  fs.writeFileSync('/home/daytona/workspace/dental-ward-guide/Dental_Ward_Guide_MBBS.docx', buffer);
  console.log('SUCCESS: DOCX created');
}).catch(err => { console.error('ERROR:', err.message); process.exit(1); });

cd /home/daytona/workspace/dental-ward-guide && node generate_docx.js 2>&1

~/dental-ward-guide/generate_docx.js

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/dental-ward-guide/generate_docx.js'

cd /home/daytona/workspace/dental-ward-guide && node generate_docx.js 2>&1 && ls…