#!/usr/bin/env python3
"""
MDS Basic Sciences - Pediatric & Preventive Dentistry
Complete Answer Book Generator
PT BD Sharma University of Health Sciences, Rohtak
Exam: July 21, 2026
"""

from docx import Document
from docx.shared import Pt, Inches, RGBColor, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.enum.table import WD_TABLE_ALIGNMENT, WD_ALIGN_VERTICAL
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import copy

doc = Document()

# ── Page Setup ──────────────────────────────────────────────────────────────
from docx.shared import Inches
section = doc.sections[0]
section.page_height = Inches(11.69)
section.page_width = Inches(8.27)
section.left_margin = Inches(1.0)
section.right_margin = Inches(1.0)
section.top_margin = Inches(1.0)
section.bottom_margin = Inches(1.0)

# ── Styles ───────────────────────────────────────────────────────────────────
normal_style = doc.styles['Normal']
normal_style.font.name = 'Times New Roman'
normal_style.font.size = Pt(12)

h1_style = doc.styles['Heading 1']
h1_style.font.name = 'Times New Roman'
h1_style.font.size = Pt(14)
h1_style.font.bold = True
h1_style.font.color.rgb = RGBColor(0x1F, 0x49, 0x7D)

h2_style = doc.styles['Heading 2']
h2_style.font.name = 'Times New Roman'
h2_style.font.size = Pt(13)
h2_style.font.bold = True
h2_style.font.color.rgb = RGBColor(0x2E, 0x74, 0xB5)

h3_style = doc.styles['Heading 3']
h3_style.font.name = 'Times New Roman'
h3_style.font.size = Pt(12)
h3_style.font.bold = True
h3_style.font.color.rgb = RGBColor(0x00, 0x00, 0x00)


def add_title_page(doc):
    p = doc.add_paragraph()
    p.alignment = WD_ALIGN_PARAGRAPH.CENTER
    run = p.add_run("PT BD SHARMA UNIVERSITY OF HEALTH SCIENCES, ROHTAK")
    run.bold = True
    run.font.size = Pt(14)
    run.font.color.rgb = RGBColor(0x1F, 0x49, 0x7D)

    p2 = doc.add_paragraph()
    p2.alignment = WD_ALIGN_PARAGRAPH.CENTER
    r2 = p2.add_run("MDS DEGREE EXAMINATION – FIRST YEAR")
    r2.bold = True
    r2.font.size = Pt(13)

    p3 = doc.add_paragraph()
    p3.alignment = WD_ALIGN_PARAGRAPH.CENTER
    r3 = p3.add_run("BASIC SCIENCES (Applied Basic Medical Sciences)")
    r3.bold = True
    r3.font.size = Pt(12)

    p4 = doc.add_paragraph()
    p4.alignment = WD_ALIGN_PARAGRAPH.CENTER
    r4 = p4.add_run("Branch: Pediatric and Preventive Dentistry")
    r4.font.size = Pt(12)

    p5 = doc.add_paragraph()
    p5.alignment = WD_ALIGN_PARAGRAPH.CENTER
    r5 = p5.add_run("Exam Date: July 21, 2026")
    r5.font.size = Pt(12)
    r5.italic = True

    doc.add_paragraph()

    p6 = doc.add_paragraph()
    p6.alignment = WD_ALIGN_PARAGRAPH.CENTER
    r6 = p6.add_run("COMPLETE ANSWER BOOKLET")
    r6.bold = True
    r6.font.size = Pt(16)
    r6.font.color.rgb = RGBColor(0xC0, 0x00, 0x00)

    doc.add_paragraph()
    doc.add_paragraph("─" * 80)
    doc.add_paragraph()


def add_section_header(doc, text):
    p = doc.add_paragraph()
    p.alignment = WD_ALIGN_PARAGRAPH.CENTER
    run = p.add_run(text)
    run.bold = True
    run.font.size = Pt(13)
    run.font.color.rgb = RGBColor(0xC0, 0x00, 0x00)
    # shade background
    from docx.oxml.ns import qn
    from docx.oxml import OxmlElement
    pPr = p._p.get_or_add_pPr()
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear')
    shd.set(qn('w:color'), 'auto')
    shd.set(qn('w:fill'), 'DEEAF1')
    pPr.append(shd)


def add_q_heading(doc, q_num, marks, title, subject):
    doc.add_paragraph()
    p = doc.add_paragraph()
    run = p.add_run(f"Q{q_num}.  {title}")
    run.bold = True
    run.font.size = Pt(13)
    run.font.color.rgb = RGBColor(0x1F, 0x49, 0x7D)

    p2 = doc.add_paragraph()
    r2 = p2.add_run(f"[{marks} Marks | Subject: {subject}]")
    r2.italic = True
    r2.font.size = Pt(10)
    r2.font.color.rgb = RGBColor(0x7F, 0x7F, 0x7F)
    doc.add_paragraph()


def add_body(doc, text):
    p = doc.add_paragraph(text)
    p.style = doc.styles['Normal']
    return p


def add_bullet(doc, text, level=0):
    p = doc.add_paragraph(style='List Bullet')
    p.add_run(text)
    p.paragraph_format.left_indent = Inches(0.3 * (level + 1))
    return p


def add_numbered(doc, text, level=0):
    p = doc.add_paragraph(style='List Number')
    p.add_run(text)
    p.paragraph_format.left_indent = Inches(0.3 * (level + 1))
    return p


def add_subheading(doc, text):
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.bold = True
    run.font.size = Pt(12)
    run.font.color.rgb = RGBColor(0x2E, 0x74, 0xB5)
    return p


def add_table(doc, headers, rows, col_widths=None):
    table = doc.add_table(rows=1 + len(rows), cols=len(headers))
    table.style = 'Table Grid'
    table.alignment = WD_TABLE_ALIGNMENT.CENTER

    # Header row
    hdr_cells = table.rows[0].cells
    for i, h in enumerate(headers):
        hdr_cells[i].text = h
        hdr_cells[i].paragraphs[0].runs[0].bold = True
        hdr_cells[i].paragraphs[0].alignment = WD_ALIGN_PARAGRAPH.CENTER
        tc = hdr_cells[i]._tc
        tcPr = tc.get_or_add_tcPr()
        shd = OxmlElement('w:shd')
        shd.set(qn('w:val'), 'clear')
        shd.set(qn('w:color'), 'auto')
        shd.set(qn('w:fill'), '2E74B5')
        tcPr.append(shd)
        hdr_cells[i].paragraphs[0].runs[0].font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)

    # Data rows
    for ri, row in enumerate(rows):
        row_cells = table.rows[ri + 1].cells
        for ci, val in enumerate(row):
            row_cells[ci].text = str(val)
            row_cells[ci].paragraphs[0].alignment = WD_ALIGN_PARAGRAPH.CENTER
            if ri % 2 == 0:
                tc = row_cells[ci]._tc
                tcPr = tc.get_or_add_tcPr()
                shd = OxmlElement('w:shd')
                shd.set(qn('w:val'), 'clear')
                shd.set(qn('w:color'), 'auto')
                shd.set(qn('w:fill'), 'DEEAF1')
                tcPr.append(shd)

    if col_widths:
        for ci, width in enumerate(col_widths):
            for row in table.rows:
                row.cells[ci].width = Inches(width)
    doc.add_paragraph()
    return table


def add_flowchart_text(doc, title, steps):
    """Creates a text-based flowchart using a table with arrow connectors."""
    doc.add_paragraph()
    p_title = doc.add_paragraph()
    run = p_title.add_run(f"FLOWCHART: {title}")
    run.bold = True
    run.font.color.rgb = RGBColor(0xC0, 0x00, 0x00)
    run.font.size = Pt(11)

    for i, step in enumerate(steps):
        # Step box
        table = doc.add_table(rows=1, cols=1)
        table.style = 'Table Grid'
        table.alignment = WD_TABLE_ALIGNMENT.CENTER
        cell = table.rows[0].cells[0]
        cell.text = step
        cell.paragraphs[0].alignment = WD_ALIGN_PARAGRAPH.CENTER
        cell.paragraphs[0].runs[0].bold = True if i == 0 or i == len(steps)-1 else False
        tc = cell._tc
        tcPr = tc.get_or_add_tcPr()
        shd = OxmlElement('w:shd')
        shd.set(qn('w:val'), 'clear')
        shd.set(qn('w:color'), 'auto')
        fill_color = 'BDD7EE' if i == 0 else ('D5E8D4' if i == len(steps)-1 else 'FFF2CC')
        shd.set(qn('w:fill'), fill_color)
        tcPr.append(shd)
        cell.width = Inches(5)

        if i < len(steps) - 1:
            arr = doc.add_paragraph()
            arr.alignment = WD_ALIGN_PARAGRAPH.CENTER
            arr.add_run("↓").font.size = Pt(14)

    doc.add_paragraph()


# ═══════════════════════════════════════════════════════════════════════════
# TITLE PAGE
# ═══════════════════════════════════════════════════════════════════════════
add_title_page(doc)
doc.add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
# SECTION A – LONG ESSAY QUESTIONS
# ═══════════════════════════════════════════════════════════════════════════
add_section_header(doc, "SECTION A – LONG ESSAY QUESTIONS (10 Marks Each)")
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════
# LEQ Q1: Saliva – Composition, Functions, Role in Caries Prevention
# ════════════════════════════════════════════════════════════════════
add_q_heading(doc, 1, 10,
              "Describe the composition and functions of saliva. Add a note on its role in prevention of dental caries.",
              "Physiology")

add_subheading(doc, "INTRODUCTION")
add_body(doc,
    "Saliva is a complex biological fluid produced by the major salivary glands (parotid, submandibular, sublingual) "
    "and numerous minor salivary glands. Approximately 1,000–1,500 mL is secreted daily. It is 99% water with 1% "
    "organic and inorganic solutes. Saliva is indispensable for oral homeostasis, digestion, lubrication, and – "
    "critically – protection against dental caries.")

doc.add_paragraph()
add_subheading(doc, "1. COMPOSITION OF SALIVA")

add_subheading(doc, "A. Inorganic Components")
add_table(doc,
    ["Electrolyte", "Concentration (approximate)", "Function"],
    [
        ["Sodium (Na+)", "15 mEq/L (low)", "Electrolyte balance"],
        ["Potassium (K+)", "20 mEq/L (higher than plasma)", "Electrolyte balance"],
        ["Chloride (Cl−)", "15–20 mEq/L", "Amylase activation"],
        ["Bicarbonate (HCO3−)", "20–60 mEq/L", "Buffering agent – most important"],
        ["Calcium (Ca2+)", "2–3 mM", "Remineralization, pellicle formation"],
        ["Phosphate (HPO42−)", "6–7 mM", "Remineralization, buffering"],
        ["Fluoride (F−)", "0.01–0.04 ppm (natural)", "Fluorapatite formation"],
        ["Thiocyanate (SCN−)", "Trace (higher in smokers)", "Antimicrobial (lactoperoxidase substrate)"],
    ],
    [2.0, 2.5, 2.5]
)

add_subheading(doc, "B. Organic Components")
add_table(doc,
    ["Component", "Source/Type", "Function"],
    [
        ["α-Amylase (ptyalin)", "Parotid (serous)", "Starch digestion; begins carbohydrate catabolism"],
        ["Mucins (MUC5B, MUC7)", "Submandibular, sublingual, minor glands", "Lubrication, viscoelasticity, pellicle"],
        ["Secretory IgA (sIgA)", "Plasma cells in gland stroma", "Antibody-mediated agglutination of bacteria"],
        ["Lactoferrin", "Acinar cells", "Iron chelation → bacteriostatic"],
        ["Lysozyme", "All glands", "Cleaves bacterial cell wall (peptidoglycan)"],
        ["Peroxidase system", "All glands", "Oxidizes SCN− → bactericidal hypothiocyanite"],
        ["Proline-rich proteins (PRPs)", "Parotid", "Tannin binding, pellicle formation, Ca2+ binding"],
        ["Cystatins", "All glands", "Cysteine protease inhibitors, anti-viral"],
        ["Histatins", "Parotid, submandibular", "Antifungal (anti-Candida), wound healing"],
        ["Statherin", "Parotid", "Inhibits Ca-P precipitation, lubricates"],
        ["Epidermal Growth Factor (EGF)", "Submandibular", "Mucosal repair, wound healing"],
        ["Urea", "Plasma filtrate", "Buffering (urease bacteria convert to NH3)"],
    ],
    [2.0, 2.2, 2.8]
)

add_subheading(doc, "2. FUNCTIONS OF SALIVA")
functions = [
    ("Digestive", "α-Amylase initiates starch hydrolysis to maltose/dextrin; lingual lipase begins fat digestion"),
    ("Lubrication & Mastication", "Mucins coat oral surfaces; facilitate bolus formation and swallowing"),
    ("Buffering", "HCO3−, phosphate, urea maintain resting pH 6.7–7.4; neutralize plaque acid after sugar intake"),
    ("Remineralization", "Supersaturated with Ca2+ and PO43− → deposits mineral into demineralized enamel"),
    ("Antimicrobial", "sIgA, lysozyme, lactoferrin, peroxidase, histatins reduce pathogen load"),
    ("Pellicle Formation", "PRPs, statherin, mucins form acquired pellicle on enamel within minutes of cleaning"),
    ("Dilution & Clearance", "Salivary flow dilutes and clears fermentable carbohydrates from oral cavity"),
    ("Taste", "Solubilizes tastants for delivery to taste buds; gustin (carbonic anhydrase) aids taste bud maturation"),
    ("Speech", "Keeps oral mucosa moist; essential for articulation"),
    ("Wound Healing", "EGF, histatin-3, fibronectin promote epithelial repair"),
    ("Thromboplastic activity", "Factors XII, XIII, fibrinogen – assist in clot formation at oral wounds"),
]
add_table(doc,
    ["Function", "Mechanism"],
    functions,
    [2.0, 5.0]
)

add_subheading(doc, "3. ROLE OF SALIVA IN PREVENTION OF DENTAL CARIES")

add_body(doc,
    "Dental caries is an infectious, multifactorial disease where cariogenic bacteria (chiefly Streptococcus mutans "
    "and Lactobacilli) ferment sugars to organic acids, causing demineralization of enamel and dentine. "
    "Saliva combats caries through five major mechanisms:")

add_flowchart_text(doc, "SALIVARY ANTI-CARIES MECHANISMS",
    [
        "DIETARY SUGAR ENTERS ORAL CAVITY",
        "Cariogenic bacteria (S. mutans) metabolize sugars → Lactic acid / Organic acids",
        "Plaque pH drops below critical pH 5.5 → Risk of enamel demineralization",
        "SALIVARY DEFENSE ACTIVATED",
        "① BUFFERING: HCO3− & Phosphate neutralize acid → pH restored to >5.5",
        "② DILUTION & CLEARANCE: Salivary flow washes out sugar & acid (SFT: Sugar clearance time)",
        "③ REMINERALIZATION: Ca2+, PO43−, F− diffuse into enamel → Re-deposits hydroxyapatite / fluorapatite",
        "④ ANTIMICROBIAL: sIgA agglutinates S. mutans; Lysozyme, lactoferrin, peroxidase kill bacteria",
        "⑤ PELLICLE: Acts as diffusion barrier; selective membrane controlling ion flux",
        "NET RESULT: Caries lesion ARRESTED or REMINERALIZED (subclinical white spot reversal)"
    ]
)

add_body(doc, "Key quantitative facts relevant to exams:")
add_table(doc,
    ["Parameter", "Value / Significance"],
    [
        ["Resting salivary flow rate", "0.1–0.3 mL/min (xerostomia risk < 0.1 mL/min)"],
        ["Stimulated flow rate", "1–3 mL/min"],
        ["Critical pH for enamel dissolution", "5.5 (drops with Stephan curve)"],
        ["Critical pH for dentine dissolution", "6.2 (demineralizes more readily)"],
        ["Salivary buffering capacity", "High = protective; low = high caries risk"],
        ["Ca:P ratio in saliva", "Supersaturated → favours remineralization"],
        ["Salivary IgA", "Most abundant antibody in saliva (~250 mg/day secreted)"],
        ["Caries risk in xerostomia", "Dramatically increased; rampant caries within 3–6 months"],
    ],
    [3.0, 4.0]
)

add_body(doc,
    "CLINICAL NOTE (Pediatric Dentistry): Infants and young children have relatively low salivary flow and "
    "immature antibody responses, predisposing them to Early Childhood Caries (ECC). Salivary diagnostics "
    "(Cariostat test, Dentocult SM, lactobacillus count) utilize salivary microbiology for caries risk assessment.")

doc.add_page_break()

# ════════════════════════════════════════════════════════════════════
# LEQ Q2: Fluoride – Mechanism, Dosage, Toxicity
# ════════════════════════════════════════════════════════════════════
add_q_heading(doc, 2, 10,
              "Describe the mechanism of action of fluoride in caries prevention. Discuss recommended dosage and toxicity.",
              "Biochemistry / Pharmacology")

add_subheading(doc, "INTRODUCTION")
add_body(doc,
    "Fluoride (F−) is the single most effective anticaries agent known. It acts through multiple synergistic "
    "mechanisms: enhancing remineralization, inhibiting demineralization, and suppressing the metabolic activity "
    "of cariogenic bacteria. It is available in systemic (water, supplements, salt) and topical (varnish, gel, "
    "toothpaste, silver diamine fluoride) forms.")

add_subheading(doc, "1. MECHANISM OF ACTION OF FLUORIDE")

add_subheading(doc, "A. Fluoride and Enamel Chemistry")
add_table(doc,
    ["Reaction", "Chemical Equation", "Significance"],
    [
        ["Incorporation into apatite", "Ca10(PO4)6(OH)2 + F− → Ca10(PO4)6(F)2\n(Hydroxyapatite → Fluorapatite)", "FAP less soluble than HAP; critical dissolution pH drops from 5.5 to 4.5"],
        ["Remineralization", "Ca2+ + PO43− + F− → Fluorapatite crystal nucleation at demineralized surface", "Partially dissolved enamel is repaired with FAP – stronger than original"],
        ["CaF2 reservoir", "Ca2+ + 2F− → CaF2 (on enamel surface after topical application)", "Acts as slow-release F− reservoir, releasing F− when pH drops"],
    ],
    [1.8, 2.5, 2.7]
)

add_subheading(doc, "B. Fluoride and Bacterial Metabolism")
add_flowchart_text(doc, "FLUORIDE's ANTI-BACTERIAL MECHANISM",
    [
        "Fluoride (HF) enters bacterial cell (lipid-soluble in acid environment)",
        "Intracellular dissociation: HF → H+ + F−",
        "Inhibition of ENOLASE (key glycolytic enzyme)\n→ Blocks conversion of 2-phosphoglycerate to phosphoenolpyruvate",
        "REDUCED ACID PRODUCTION from sugars",
        "Inhibition of H+-ATPase (proton pump)\n→ Acidification of cytoplasm → Bacteriostatic effect",
        "Inhibition of GLUCOSYLTRANSFERASE\n→ Reduces glucan synthesis → Impairs S. mutans biofilm adherence",
        "NET: Less acid, less plaque, reduced virulence of S. mutans"
    ]
)

add_subheading(doc, "C. Summary of Mechanisms")
add_table(doc,
    ["Mechanism", "Site of Action", "Effect"],
    [
        ["Fluorapatite formation", "Enamel crystal lattice", "Increases acid resistance"],
        ["Remineralization enhancement", "Demineralized enamel surface", "Repair of early caries lesions"],
        ["CaF2 reservoir", "Enamel pellicle / surface", "Sustained F− release at low pH"],
        ["Enolase inhibition", "Bacterial cytoplasm", "Decreased lactic acid production"],
        ["H+-ATPase inhibition", "Bacterial membrane", "Cytoplasmic acidification → bacteriostatic"],
        ["Glucosyltransferase inhibition", "Bacterial enzyme", "Reduced glucan/biofilm formation"],
    ],
    [2.5, 2.0, 2.5]
)

add_subheading(doc, "2. RECOMMENDED FLUORIDE DOSAGE")

add_subheading(doc, "A. Water Fluoridation")
add_body(doc, "The WHO-recommended optimal level of fluoride in drinking water is 0.5–1.0 ppm (mg/L), "
    "with the US CDC currently recommending 0.7 ppm (revised downward from 1.0 ppm in 2015). "
    "This level reduces caries by 25–40% while minimizing fluorosis risk.")

add_subheading(doc, "B. Systemic Fluoride Supplementation (Dietary Supplements)")
add_table(doc,
    ["Age Group", "Water F− < 0.3 ppm", "Water F− 0.3–0.6 ppm", "Water F− > 0.6 ppm"],
    [
        ["Birth – 6 months", "None", "None", "None"],
        ["6 months – 3 years", "0.25 mg F−/day", "None", "None"],
        ["3 – 6 years", "0.50 mg F−/day", "0.25 mg F−/day", "None"],
        ["6 – 16 years", "1.0 mg F−/day", "0.50 mg F−/day", "None"],
    ],
    [2.0, 1.7, 1.7, 1.6]
)
add_body(doc, "Source: American Dental Association (ADA) / American Academy of Pediatric Dentistry (AAPD) guidelines.")

add_subheading(doc, "C. Topical Fluoride Agents")
add_table(doc,
    ["Agent", "Concentration", "Frequency / Protocol", "Notes"],
    [
        ["NaF varnish (Duraphat)", "22,600 ppm (5%)", "2–4× per year in high-risk; 2× in moderate-risk", "Gold standard in pediatric practice; safe in <6 yrs"],
        ["APF gel (1.23% NaF)", "12,300 ppm", "4-min tray application, 2× per year", "Contraindicated in porcelain / composite restorations"],
        ["NaF gel (0.9%)", "4,060 ppm", "Tray application, 4 min", "Preferred for porcelain"],
        ["NaF toothpaste (low)", "500 ppm (children <6)", "Twice daily brushing, pea-size", "Safe for swallowing – low dose"],
        ["NaF toothpaste (standard)", "1,000–1,450 ppm", "Twice daily brushing", "Standard adult/adolescent"],
        ["Silver Diamine Fluoride (SDF)", "38% (~44,800 ppm F−)", "Annual or semi-annual application", "Arrests caries; stains black; ART alternative"],
        ["Fluoride mouthwash (0.05% NaF)", "225 ppm", "Daily rinsing (>6 yrs)", "Community water-deficient areas"],
    ],
    [1.8, 1.5, 2.0, 1.7]
)

add_subheading(doc, "3. FLUORIDE TOXICITY")

add_table(doc,
    ["Type", "Definition / Threshold", "Cause", "Features", "Management"],
    [
        ["Acute Fluoride Toxicity",
         "Certainly Lethal Dose (CLD): 32–64 mg F−/kg\nProbably Toxic Dose (PTD): 5 mg F−/kg",
         "Accidental ingestion of dental fluoride products (e.g., 1 tube of APF gel = 1,000 mg F−)",
         "Nausea, vomiting, abdominal pain, hypersalivation → Hypocalcemia → Tetany → Cardiac arrhythmia → Death (large doses)",
         "Induce vomiting; give milk/Ca gluconate (binds F−); gastric lavage; IV Ca gluconate for tetany; hospitalize"],
        ["Dental Fluorosis (Chronic)",
         "Exposure during tooth development (birth to 6–8 years)",
         "Excess systemic fluoride (>2 ppm in water)",
         "Enamel hypomineralization: white streaks/spots → pitting/brown staining → severe pitting (Dean's Index I–V)",
         "Prevention: do not exceed supplement schedule; use age-appropriate toothpaste amount; Cosmetic: microabrasion, bleaching, veneers"],
        ["Skeletal Fluorosis (Chronic)",
         "Long-term ingestion of >10 mg F−/day for years",
         "Endemic high-fluoride groundwater areas",
         "Joint pain/stiffness → Osteosclerosis → Calcification of ligaments → Crippling deformity",
         "Prevention: defluoridation of water supply; no curative treatment once advanced"],
    ],
    [1.3, 1.4, 1.2, 1.5, 1.6]
)

add_subheading(doc, "Dean's Index of Dental Fluorosis")
add_table(doc,
    ["Score", "Classification", "Description"],
    [
        ["0", "Normal", "Smooth, glossy, creamy white translucent enamel"],
        ["0.5", "Questionable", "Slight changes from normal – few white flecks or spots"],
        ["1", "Very Mild", "Small opaque white areas; < 25% of tooth surface"],
        ["2", "Mild", "White opaque areas < 50% of surface; no brown staining"],
        ["3", "Moderate", "All enamel surfaces affected; brown staining may appear"],
        ["4", "Severe", "All surfaces affected; pitting; brown/black staining; corroded appearance"],
    ],
    [0.8, 1.5, 4.7]
)

add_body(doc,
    "CLINICAL RELEVANCE: The 'safe swallowing amount' for fluoride toothpaste in children <3 years is a smear "
    "(< 0.1 g, < 0.1 mg F−). Children aged 3–6 years: pea-size (~0.3 g). This minimizes fluorosis risk "
    "while maintaining caries protection.")

doc.add_page_break()

# ════════════════════════════════════════════════════════════════════
# LEQ Q3: Local Anesthetics in Pediatric Dentistry
# ════════════════════════════════════════════════════════════════════
add_q_heading(doc, 3, 10,
              "Classify and describe local anesthetics used in pediatric dentistry. Discuss mechanism of action, dosage, and complications.",
              "Pharmacology")

add_subheading(doc, "INTRODUCTION")
add_body(doc,
    "Local anesthetics (LAs) are the cornerstone of pain control in pediatric dentistry. They reversibly block "
    "nerve conduction by inhibiting voltage-gated sodium channels. Their use in children requires special "
    "attention to weight-based dosing, rapid toxicity risk, and behavioral management.")

add_subheading(doc, "1. CLASSIFICATION OF LOCAL ANESTHETICS")

add_table(doc,
    ["Class", "Agent", "Linkage", "Duration", "Vasoconstrictors Used"],
    [
        ["AMIDE", "Lignocaine (Lidocaine)", "–NH–CO–", "Medium (60–90 min with epi)", "1:80,000 or 1:100,000 adrenaline"],
        ["AMIDE", "Mepivacaine", "–NH–CO–", "Short–Medium (45 min plain; 90 min with epi)", "1:20,000 levonordefrin or plain"],
        ["AMIDE", "Articaine", "–NH–CO–", "Medium–Long (90–120 min)", "1:100,000 or 1:200,000 adrenaline"],
        ["AMIDE", "Bupivacaine (Marcaine)", "–NH–CO–", "Long (4–9 hours)", "1:200,000 adrenaline"],
        ["AMIDE", "Prilocaine", "–NH–CO–", "Medium", "Felypressin or plain"],
        ["ESTER", "Benzocaine (topical only)", "–O–CO–", "Short (topical surface)", "None"],
        ["ESTER", "Procaine (historical)", "–O–CO–", "Short", "Epinephrine"],
        ["ESTER", "Tetracaine (topical)", "–O–CO–", "Medium (topical)", "None"],
    ],
    [1.0, 1.5, 1.0, 1.8, 2.7]
)

add_body(doc, "MEMORY AID: Amides have TWO 'i's in their name (lidocaINe, mepIvacaIne, artIcaIne, bupIvacaIne, prIlocaIne). Esters have ONE 'i' (procaIne). Amides are metabolized in the LIVER; Esters by plasma pseudocholinesterase.")

add_subheading(doc, "2. MECHANISM OF ACTION")

add_flowchart_text(doc, "MECHANISM OF LOCAL ANESTHETICS",
    [
        "LOCAL ANESTHETIC (LA) INJECTED INTO TISSUE (pH ~7.4)",
        "LA exists as equilibrium: Ionized (BH+) ⇌ Unionized (B) form",
        "UNIONIZED form (lipid-soluble) crosses nerve membrane lipid bilayer",
        "Inside axoplasm (pH ~7.0): B + H+ → BH+ (re-ionizes)",
        "BH+ (ionized form) enters and BLOCKS voltage-gated Na+ channel from INSIDE",
        "Na+ cannot enter axon → ACTION POTENTIAL CANNOT BE GENERATED",
        "NERVE CONDUCTION BLOCKED → No pain signal reaches brain",
        "REVERSIBLE: LA diffuses away → channels recover → sensation returns"
    ]
)

add_body(doc, "Order of nerve fiber blockade (smallest to largest):")
add_table(doc,
    ["Order Blocked", "Fiber Type", "Diameter", "Function Lost"],
    [
        ["1st (most sensitive)", "C fibers (unmyelinated)", "0.3–1.3 µm", "Pain, temperature, autonomic"],
        ["2nd", "Aδ fibers (thinly myelinated)", "1–4 µm", "Sharp pain, temperature"],
        ["3rd", "B fibers (preganglionic autonomic)", "1–3 µm", "Autonomic"],
        ["4th", "Aβ fibers", "6–12 µm", "Touch, pressure"],
        ["Last (least sensitive)", "Aα fibers", "12–20 µm", "Motor, proprioception"],
    ],
    [1.5, 1.5, 1.3, 3.7]
)

add_subheading(doc, "3. MAXIMUM SAFE DOSES IN PEDIATRIC PATIENTS")
add_table(doc,
    ["Agent", "Max Dose (mg/kg body weight)", "Max Absolute Dose", "Concentration Available", "Comments"],
    [
        ["Lignocaine 2% + 1:100,000 epi", "4.4 mg/kg", "300 mg (adult)", "20 mg/mL → 36 mg/cartridge", "Most widely used; AAPD recommended"],
        ["Lignocaine 2% plain", "4.4 mg/kg", "300 mg", "20 mg/mL", "Use when epi contraindicated"],
        ["Mepivacaine 3% plain", "4.4 mg/kg", "300 mg", "30 mg/mL → 54 mg/cartridge", "Good for short procedures; no vasoconstrictor"],
        ["Articaine 4% + 1:100,000 epi", "5.0 mg/kg", "500 mg", "40 mg/mL → 72 mg/cartridge", "Better tissue penetration; use >4 years"],
        ["Bupivacaine 0.5% + 1:200,000 epi", "1.3 mg/kg", "90 mg", "5 mg/mL", "Post-op pain control; long procedures"],
        ["Prilocaine 4%", "6.0 mg/kg", "400 mg", "40 mg/mL", "Methemoglobinemia risk; avoid <6 months"],
        ["Benzocaine 20% topical", "Not applicable", "Max 200 mg surface", "Topical gel/spray", "Pre-injection topical only; methemoglobinemia risk in infants"],
    ],
    [1.8, 1.5, 1.3, 1.6, 2.0]
)

add_body(doc, "Dosage calculation example: 20 kg child using 2% lignocaine with 1:100,000 epinephrine:")
add_body(doc, "Max dose = 4.4 mg/kg × 20 kg = 88 mg. Each 1.8 mL cartridge contains 36 mg lidocaine. "
    "Therefore max = 88 ÷ 36 = 2.4 cartridges (round down to 2 cartridges for safety).")

add_subheading(doc, "4. COMPLICATIONS OF LOCAL ANESTHETICS")

add_table(doc,
    ["Complication", "Cause", "Features", "Management"],
    [
        ["LOCAL COMPLICATIONS", "", "", ""],
        ["Needle breakage", "Sudden patient movement during inferior alveolar block; bending needle before injection", "Fragment retention in tissue", "Prevention: never bend needle; use appropriate-length needles. Surgical removal if symptomatic"],
        ["Hematoma", "Accidental puncture of blood vessel (pterygoid plexus in PSA block)", "Swelling, bruising, trismus", "Pressure; ice pack; reassurance; resolves in 1–2 weeks"],
        ["Trismus", "Multiple injections, muscle damage, infection in pterygomandibular space", "Limited mouth opening", "Warm moist heat, physiotherapy, analgesics"],
        ["Paresthesia", "Nerve trauma; articaine-associated paresthesia (lingual/inferior alveolar)", "Persistent numbness/tingling post-procedure", "Usually resolves in weeks–months; refer if persistent > 8 weeks"],
        ["Self-inflicted soft tissue trauma", "Child bites numb lip/tongue post-procedure", "Ulceration, swelling", "Prevent with verbal/written instructions; lip guard; reverse articaine (phentolamine) to shorten numbness"],
        ["Facial nerve palsy", "Injection of LA into parotid gland (misplaced IANB)", "Temporary facial muscle paralysis", "Temporary (wears off with LA); cover eye if needed"],
        ["SYSTEMIC COMPLICATIONS", "", "", ""],
        ["Toxic/Overdose reaction (CNS)", "Exceeding maximum dose, rapid intravascular injection", "Mild: tinnitus, metallic taste, light-headedness → Severe: seizures, respiratory depression, cardiac arrest", "Lay flat; oxygen; IV diazepam/midazolam for seizures; CPR if needed; avoid respiratory depressants"],
        ["Anaphylaxis", "IgE-mediated allergy (more common with ester LAs); parabens preservative allergy", "Urticaria → bronchospasm → hypotension → anaphylactic shock", "Adrenaline 0.01 mg/kg IM (thigh); airway management; antihistamine; steroids; call emergency services"],
        ["Methemoglobinemia", "Prilocaine (o-toluidine metabolite) or benzocaine in infants", "Cyanosis unresponsive to O2; chocolate-brown blood", "IV methylene blue 1–2 mg/kg; oxygen; avoid in infants <6 months"],
        ["Syncope (vasovagal)", "Anxiety, pain, prolonged procedure in sitting/upright position", "Prodrome: pallor, nausea, diaphoresis → loss of consciousness", "Supine/Trendelenburg; cold compress; monitor BP/pulse; usually self-limiting"],
        ["Epinephrine-related", "Intravascular injection of vasoconstrictor", "Palpitations, tachycardia, anxiety, hypertension (transient)", "Supportive; usually resolves within 5 min; beta-blocker interaction can cause hypertensive crisis"],
    ],
    [2.0, 1.5, 2.0, 2.0]
)

add_body(doc, "PEDIATRIC SPECIAL CONSIDERATIONS:")
add_bullet(doc, "Use the lowest effective dose; calculate precisely per kg body weight")
add_bullet(doc, "Aspirate before injecting; inject slowly (1 mL/min)")
add_bullet(doc, "Topical benzocaine before needle insertion reduces pain behavior")
add_bullet(doc, "Avoid bupivacaine in young children – prolonged numbness increases self-injury risk")
add_bullet(doc, "Phentolamine mesylate (OraVerse) can reverse soft-tissue anesthesia in children ≥6 years, ≥15 kg")
add_bullet(doc, "Tell-Show-Do technique + adequate behavior management reduces need for excess LA")

doc.add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
# SECTION B – SHORT ESSAY QUESTIONS
# ═══════════════════════════════════════════════════════════════════════════
add_section_header(doc, "SECTION B – SHORT ESSAY QUESTIONS (5 Marks Each)")
doc.add_paragraph()

# ════════════════════════════════════════════
# SEQ Q1: Development of the Mandible
# ════════════════════════════════════════════
add_q_heading(doc, 1, 5, "Development of the Mandible", "Anatomy")

add_subheading(doc, "INTRODUCTION")
add_body(doc,
    "The mandible is the only movable bone of the skull. It develops primarily by intramembranous ossification "
    "around Meckel's cartilage, with secondary cartilages contributing to specific regions.")

add_subheading(doc, "STAGES OF MANDIBULAR DEVELOPMENT")

add_flowchart_text(doc, "MANDIBULAR DEVELOPMENT",
    [
        "WEEK 4–5: Mandibular arch forms from 1st pharyngeal arch (Meckel's cartilage)",
        "WEEK 6: Intramembranous ossification begins lateral to Meckel's cartilage (at mental foramen region)",
        "WEEK 6–7: Ossification spreads anteriorly and posteriorly forming body and rami",
        "WEEK 8–10: SECONDARY CARTILAGES appear: Condylar (largest) | Coronoid | Symphyseal",
        "BIRTH: Mandible is in two halves; symphysis menti is a fibrocartilagenous joint",
        "YEAR 1: Symphysis menti ossifies (fuses by end of 1st year)",
        "CHILDHOOD: Condylar cartilage – the PRIMARY GROWTH CENTRE – continues endochondral growth until 18–25 yrs"
    ]
)

add_table(doc,
    ["Component", "Embryological Origin", "Fate / Contribution"],
    [
        ["Meckel's Cartilage", "Cartilage of 1st pharyngeal arch (Mandibular arch)", "Does NOT form mandibular bone directly; acts as scaffold; posterior part → malleus & incus (middle ear ossicles); anterior part (symphyseal region) → symphysis fibrocartilage; disappears by ossification/resorption"],
        ["Intramembranous Ossification", "Mesenchymal cells condense lateral to Meckel's cartilage", "Forms bulk of mandible: body, alveolar process, ramus (without condyle/coronoid tips)"],
        ["Condylar Secondary Cartilage", "Independent mesenchymal condensation at condylar region (appears ~week 10)", "Grows by endochondral ossification; PRIMARY POST-NATAL GROWTH SITE; pressure-adaptive growth center"],
        ["Coronoid Secondary Cartilage", "Appears ~week 10 at coronoid process", "Transient; disappears early; contributes to coronoid process shape"],
        ["Symphyseal Secondary Cartilage", "At symphysis menti bilaterally", "Transient; allows symphyseal separation at birth; fuses by end of year 1"],
        ["Mental Ossicles", "Small accessory cartilages near mental region", "Contribute to mental tubercles; fuse with body"],
    ],
    [1.8, 2.0, 3.2]
)

add_subheading(doc, "ANOMALIES OF MANDIBULAR DEVELOPMENT")
add_table(doc,
    ["Anomaly", "Cause / Mechanism", "Features"],
    [
        ["Micrognathia", "Failure of adequate mandibular growth; condylar growth deficiency", "Small mandible; Pierre Robin sequence (micrognathia + glossoptosis + posterior cleft palate + airway obstruction)"],
        ["Macrognathia (Prognathism)", "Excessive condylar growth; acromegaly (excess GH)", "Protruding mandible; skeletal Class III; may need orthognathic surgery"],
        ["Hemifacial Microsomia", "Stapedial artery disruption; 1st arch mesenchyme deficiency", "Unilateral underdevelopment of mandible, ear, muscles; asymmetry"],
        ["Condylar Hyperplasia", "Unknown; continued condylar growth beyond adolescence", "Progressive facial asymmetry; mandibular deviation to opposite side"],
        ["Bifid Mandible", "Rare midline cleft; failure of fusion of two ossification centers", "Cleft in midline of mandible"],
        ["Treacher Collins Syndrome", "TCOF1 gene mutation (Neural crest cell migration)", "Bilateral mandibular hypoplasia, absent zygoma, ear anomalies, antimongoloid slant"],
    ],
    [1.8, 2.0, 3.2]
)

doc.add_paragraph()

# ════════════════════════════════════════════
# SEQ Q2: Streptococcus mutans and Dental Caries
# ════════════════════════════════════════════
add_q_heading(doc, 2, 5, "Streptococcus mutans and Dental Caries", "Microbiology")

add_subheading(doc, "PROPERTIES OF S. MUTANS")
add_table(doc,
    ["Property", "Details"],
    [
        ["Classification", "Gram-positive coccus; facultative anaerobe; Lancefield Group D"],
        ["Normal habitat", "Oral cavity; acquired from mother via vertical transmission (kissing, shared utensils)"],
        ["Window of infectivity", "Ages 19–31 months (initial acquisition period)"],
        ["Key species", "S. mutans (most virulent), S. sobrinus, S. cricetus, S. rattus – collectively 'mutans streptococci'"],
        ["Growth conditions", "Grows at pH as low as 4.0–4.5 (aciduric); produces lactic acid at low pH (acidogenic)"],
    ],
    [2.0, 5.0]
)

add_subheading(doc, "VIRULENCE FACTORS")
add_table(doc,
    ["Virulence Factor", "Gene/Enzyme", "Role in Caries"],
    [
        ["Glucosyltransferases (GTFs)", "gtfB, gtfC, gtfD", "Convert sucrose → water-insoluble glucans (mutans) & water-soluble dextrans; glucans mediate irreversible adherence to pellicle"],
        ["Fructosyltransferase (FTF)", "ftf", "Converts sucrose → fructans (levan) – intracellular energy reserve"],
        ["Glucan-binding proteins (GBPs)", "gbpA, gbpB, gbpC", "Bind to glucans; contribute to biofilm architecture and cell-cell coaggregation"],
        ["Acidogenicity", "Phosphoenolpyruvate phosphotransferase system (PTS)", "Efficient sugar transport; ferments glucose, fructose, sucrose → lactic acid via homofermentative glycolysis"],
        ["Aciduricity", "H+-ATPase, alkali production", "Survives and continues metabolizing at low pH (< 4.5); outcompetes other oral bacteria in acid"],
        ["Mutacins (bacteriocins)", "mub, mutA-E", "Kill competing oral streptococci (S. sanguis, S. gordonii) → dominance in biofilm"],
        ["Biofilm formation", "Combination of GTFs, GBPs, surface proteins", "Forms thick, diffusion-limiting plaque that concentrates acid at enamel surface"],
        ["IgA protease", "iga", "Cleaves salivary sIgA → evades immune clearance"],
    ],
    [2.0, 1.5, 3.5]
)

add_subheading(doc, "ROLE IN DENTAL CARIES – PATHOGENESIS")
add_flowchart_text(doc, "S. MUTANS CARIES PATHOGENESIS",
    [
        "SUCROSE INTAKE → GTFs convert sucrose to glucans on tooth surface",
        "S. mutans ADHERES irreversibly via glucan-GBP interactions (biofilm initiation)",
        "BIOFILM MATURES: complex community; S. mutans dominates in cariogenic niche",
        "S. mutans ferments sugars (sucrose >> glucose > fructose) → LACTIC ACID via glycolysis",
        "Plaque pH drops below critical pH 5.5 → ENAMEL DEMINERALIZATION begins",
        "S. mutans continues at low pH (aciduric) → sustained acid attack",
        "Mineral loss > mineral gain → INITIAL CARIES LESION (white spot)",
        "Progression → CAVITATION → dentinal caries → pulp involvement"
    ]
)

add_subheading(doc, "CLINICAL / DIAGNOSTIC SIGNIFICANCE")
add_table(doc,
    ["Test", "Principle", "Significance"],
    [
        ["Dentocult SM (Chair-side test)", "Selective agar with bacitracin; colony count of S. mutans in saliva", "< 100,000 CFU/mL = low risk; > 1,000,000 CFU/mL = high risk"],
        ["PCR/ELISA identification", "Genotyping of S. mutans strains", "Mother-child transmission studies"],
        ["Cariostat test", "pH change due to bacterial metabolism of cariogenic bacteria in sample", "Caries activity test in pediatric patients"],
    ],
    [2.0, 2.5, 2.5]
)

doc.add_paragraph()

# ════════════════════════════════════════════
# SEQ Q3: Conscious Sedation in Pediatric Dentistry
# ════════════════════════════════════════════
add_q_heading(doc, 3, 5, "Conscious Sedation in Pediatric Dentistry", "Pharmacology")

add_subheading(doc, "DEFINITION")
add_body(doc,
    "Conscious sedation (now termed 'Moderate Sedation' per AAPD/AAP 2019 guidelines) is a drug-induced "
    "depression of consciousness in which the child maintains a patent airway independently and continuously, "
    "retains protective reflexes, and responds purposefully to verbal commands or tactile stimulation. "
    "It is distinct from deep sedation (no purposeful response to verbal commands) and general anesthesia.")

add_subheading(doc, "CONTINUUM OF SEDATION")
add_flowchart_text(doc, "SEDATION CONTINUUM (AAPD/ASA)",
    [
        "MINIMAL SEDATION (Anxiolysis)\nNormal response to verbal stimuli; airway/ventilation/CV normal",
        "MODERATE SEDATION (Conscious Sedation)\nPurposeful response to verbal/tactile stimuli; no airway intervention needed",
        "DEEP SEDATION\nResponds to repeated/painful stimuli only; may need airway support",
        "GENERAL ANESTHESIA\nNot arousable; requires airway management; may need CV support"
    ]
)

add_subheading(doc, "AGENTS USED FOR CONSCIOUS SEDATION IN PEDIATRIC DENTISTRY")
add_table(doc,
    ["Agent", "Route", "Dose", "Onset", "Duration", "Notes"],
    [
        ["Nitrous Oxide (N2O)", "Inhalation", "30–50% N2O in O2", "2–3 min", "Wears off in 5 min", "Safest; anxiolytic + mild analgesic; requires cooperation; scavenging system mandatory"],
        ["Midazolam", "Oral", "0.3–0.5 mg/kg (max 10–15 mg)", "20–30 min", "45–60 min", "Most commonly used oral sedative; benzodiazepine; anterograde amnesia; use with monitoring"],
        ["Midazolam", "Intranasal (IN)", "0.2–0.3 mg/kg", "10–15 min", "30–45 min", "Rapid absorption; useful in non-cooperative children; nasal irritation common"],
        ["Midazolam", "IV", "0.05–0.1 mg/kg titrated", "1–2 min", "20–30 min", "Precise titration; hospital setting; reversal: flumazenil"],
        ["Dexmedetomidine", "IV / IN", "1–2 µg/kg IN", "15–20 min", "60–90 min", "α2-agonist; sedation + analgesia; minimal respiratory depression; increasing use"],
        ["Chloral Hydrate", "Oral", "25–75 mg/kg (max 1 g)", "30–45 min", "2–4 hours", "Being phased out due to unpredictability and carcinogen concern; still used in some settings"],
        ["Hydroxyzine", "Oral", "1 mg/kg", "30–60 min", "4–6 hours", "Antihistamine; anxiolysis; often combined with N2O; no respiratory depression"],
        ["Meperidine (Pethidine)", "IM/IV", "1–1.5 mg/kg", "15–30 min", "2–4 hours", "Opioid; used in combination regimens; requires careful monitoring; reversal: naloxone"],
    ],
    [1.6, 0.9, 1.3, 0.8, 0.8, 2.6]
)

add_subheading(doc, "INDICATIONS & CONTRAINDICATIONS")
add_table(doc,
    ["Indications", "Contraindications"],
    [
        ["Mild-moderate anxiety/dental phobia", "Upper respiratory infection (N2O contraindicated)"],
        ["Uncooperative child (Frankl 1–2) who cannot be managed with non-pharmacological behavior management", "Severe obstructive sleep apnea or airway compromise"],
        ["Mentally/physically challenged patients where behavior management has failed", "Cardiovascular compromise"],
        ["Short procedures requiring absolute stillness (e.g., bitewing X-rays in young children)", "Allergy to sedation agents"],
        ["Patients with gag reflex", "First trimester pregnancy (in adolescents – N2O contraindicated)"],
        ["Multiple quadrant treatments in single visit", "Patient/parent refusal"],
    ],
    [3.5, 3.5]
)

add_subheading(doc, "MONITORING REQUIREMENTS (AAPD)")
add_bullet(doc, "Continuous pulse oximetry (SpO2)")
add_bullet(doc, "Heart rate monitoring")
add_bullet(doc, "Blood pressure monitoring")
add_bullet(doc, "Respiratory rate assessment (capnography for deep sedation)")
add_bullet(doc, "Level of consciousness (response to stimuli)")
add_bullet(doc, "One dedicated individual (not the operating dentist) to continuously monitor the patient")
add_bullet(doc, "Written discharge criteria must be met before patient leaves clinic")

doc.add_paragraph()

# ════════════════════════════════════════════
# SEQ Q4: Down Syndrome – Oral and Dental Manifestations
# ════════════════════════════════════════════
add_q_heading(doc, 4, 5, "Down Syndrome – Oral and Dental Manifestations", "Genetics")

add_subheading(doc, "GENETIC BASIS")
add_body(doc,
    "Down syndrome (Trisomy 21) is the most common chromosomal disorder (1:700 live births). "
    "It results from an extra chromosome 21, usually due to maternal non-disjunction during meiosis I. "
    "Three types: (1) Free Trisomy 21 (95%); (2) Translocation – chromosome 21 fused to chromosome 14 (4%); "
    "(3) Mosaicism – only some cells have trisomy (1%). Risk increases with maternal age.")

add_subheading(doc, "ORAL AND DENTAL MANIFESTATIONS")
add_table(doc,
    ["System", "Manifestation", "Clinical Significance"],
    [
        ["LIPS & TONGUE", "Macroglossia (relative – tongue appears large due to small oral cavity + hypotonia)", "Open-mouth posture; mouth breathing; tongue protrusion; lip incompetence"],
        ["LIPS & TONGUE", "Fissured / geographic tongue (scrotal tongue)", "Benign; more pronounced with age; cosmetic concern"],
        ["LIPS & TONGUE", "Angular cheilitis (due to drooling + immune deficiency)", "Secondary Candida infection; treat with antifungal"],
        ["TEETH – DEVELOPMENT", "Delayed and irregular eruption sequence", "Primary teeth may erupt 1–2 years late; permanent tooth eruption also delayed"],
        ["TEETH – DEVELOPMENT", "Hypodontia (missing teeth)", "Congenitally absent teeth especially upper lateral incisors and lower 2nd premolars; 0–50% of cases"],
        ["TEETH – DEVELOPMENT", "Microdontia (small teeth)", "All teeth may be smaller than normal; especially laterals"],
        ["TEETH – DEVELOPMENT", "Taurodontism (enlarged pulp chambers)", "Particularly of molar teeth; important for endodontic planning"],
        ["TEETH – DEVELOPMENT", "Supernumerary teeth (mesiodens)", "Occasional; combined with hypodontia creates complex picture"],
        ["TEETH – STRUCTURE", "Enamel hypoplasia", "Related to early childhood illness and nutritional deficiencies; increased caries susceptibility"],
        ["OCCLUSION", "Anterior open bite", "Due to macroglossia + mouth breathing; tongue interposition"],
        ["OCCLUSION", "Class III malocclusion", "Maxillary deficiency + relative mandibular prognathism; crossbite common"],
        ["OCCLUSION", "Posterior crossbite", "Narrow maxillary arch; bilateral crossbite common"],
        ["OCCLUSION", "Crowding and spacing", "Variable; hypodontia may create spacing; narrow arch creates crowding"],
        ["PERIODONTAL", "Severe early-onset periodontitis", "Most significant dental problem in Down syndrome; affects >90% by age 30; begins in adolescence"],
        ["PERIODONTAL", "Neutrophil dysfunction", "Impaired chemotaxis, phagocytosis, killing ability of PMNs → rapid periodontal destruction despite good hygiene"],
        ["PERIODONTAL", "Accelerated bone loss", "Severity disproportionate to oral hygiene levels; Porphyromonas gingivalis and Treponema denticola predominate"],
        ["ORAL HYGIENE", "Increased dental plaque accumulation", "Due to intellectual disability limiting self-care; mouth breathing → dry mouth"],
        ["CARIES", "Variable caries rate (often lower than expected)", "High buffering capacity of saliva; lower sucrose metabolism efficiency; BUT enamel hypoplasia increases risk"],
        ["SALIVARY GLANDS", "High salivary alkalinity + high amylase activity", "May actually confer some caries protection despite poor hygiene"],
        ["MUSCULAR", "Hypotonia (generalized)", "Affects mastication efficiency; bruxism; abnormal swallow pattern"],
        ["HEART", "Congenital heart disease in 40–50%", "Antibiotic prophylaxis required before dental procedures in uncorrected CHD cases (AHA guidelines)"],
    ],
    [1.5, 2.5, 3.0]
)

add_subheading(doc, "DENTAL MANAGEMENT CONSIDERATIONS")
add_bullet(doc, "Cardiac evaluation and antibiotic prophylaxis if CHD present (amoxicillin 50 mg/kg, max 2g, 30–60 min before procedure)")
add_bullet(doc, "Atlantoaxial instability (AAI) present in 15–20%: avoid excessive neck flexion/extension; cervical spine X-rays recommended before GA")
add_bullet(doc, "Frequent recall (every 3 months) for preventive care and periodontal monitoring")
add_bullet(doc, "Caries prevention: fluoride varnish, pit and fissure sealants, dietary counseling")
add_bullet(doc, "Use of behavior guidance: adaptive approach, shorter appointments, possible sedation/GA")
add_bullet(doc, "Orthodontic treatment may be needed; implant rehabilitation for missing teeth in adults")

doc.add_paragraph()

# ════════════════════════════════════════════
# SEQ Q5: DMFT / dmft Index
# ════════════════════════════════════════════
add_q_heading(doc, 5, 5, "The DMFT / dmft Index", "Research Methodology & Biostatistics")

add_subheading(doc, "DEFINITION")
add_body(doc,
    "The DMFT index is the most widely used index for measuring dental caries experience in epidemiological "
    "surveys and clinical research. It was introduced by H. Trendley Dean (1938) for permanent dentition. "
    "The dmft (lowercase) is used for primary (deciduous) dentition. It represents a cumulative measure "
    "of past and present caries experience.")

add_subheading(doc, "COMPONENTS")
add_table(doc,
    ["Component", "Symbol (Perm/Primary)", "Definition", "Criteria (WHO)"],
    [
        ["Decayed", "D / d", "Tooth or surface with cavitated carious lesion or temporary restoration", "Cavity visible; probe catches; softened floor/wall. Does NOT include white spot/initial lesions in standard surveys"],
        ["Missing", "M / m", "Tooth extracted due to caries OR indicated for extraction due to caries", "Permanent: M = extracted due to caries only. Primary (m): missing primary tooth in child where age-appropriate exfoliation is excluded by judgment"],
        ["Filled", "F / f", "Tooth or surface with permanent restoration with no evidence of recurrent caries", "Intact restoration regardless of material; tooth crowned due to caries also counted as F"],
        ["Index", "DMFT / dmft", "Sum of D+M+F teeth per individual or mean per population", "Range: 0–28 (permanent, excluding 3rd molars) or 0–20 (primary)"],
    ],
    [1.2, 1.2, 2.0, 2.6]
)

add_subheading(doc, "WHO CATEGORIES FOR DMFT (12-YEAR-OLDS)")
add_table(doc,
    ["DMFT Value", "WHO Category", "Public Health Significance"],
    [
        ["0.0 – 1.1", "Very Low", "Excellent oral health; minimal public health concern"],
        ["1.2 – 2.6", "Low", "Good oral health"],
        ["2.7 – 4.4", "Moderate", "Requires preventive programs"],
        ["4.5 – 6.5", "High", "Significant problem; needs urgent preventive and treatment programs"],
        ["> 6.6", "Very High", "Major public health emergency"],
    ],
    [1.5, 1.5, 4.0]
)

add_subheading(doc, "VARIANTS")
add_table(doc,
    ["Variant", "Use"],
    [
        ["DMFS / dmfs", "Surface-level scoring (counts individual surfaces: 5 for posterior teeth, 4 for anterior teeth); more sensitive than tooth-level index"],
        ["Significant Caries Index (SiC)", "Mean DMFT of the one-third of the population with the highest scores; draws attention to high-caries subgroups"],
        ["ICDAS (International Caries Detection and Assessment System)", "Grades caries from 0–6 (includes non-cavitated initial lesions); more sensitive for research; replaces simple D in research settings"],
    ],
    [2.0, 5.0]
)

add_subheading(doc, "LIMITATIONS OF DMFT")
add_bullet(doc, "Does not detect non-cavitated (initial / white spot) lesions – underestimates caries burden")
add_bullet(doc, "Cumulative and irreversible – once D, M or F, always counted; does not reflect current disease activity")
add_bullet(doc, "Teeth extracted for reasons other than caries (periodontal, trauma) can falsely inflate M component")
add_bullet(doc, "Missing primary teeth difficult to classify in young children (exfoliation vs caries-related extraction)")
add_bullet(doc, "Equal weight given to each tooth regardless of functional importance")
add_bullet(doc, "Not sensitive enough for populations with low caries experience")

doc.add_paragraph()

# ════════════════════════════════════════════
# SEQ Q6: Acute Inflammation – Vascular Changes and Mediators
# ════════════════════════════════════════════
add_q_heading(doc, 6, 5, "Acute Inflammation – Vascular Changes and Mediators", "Pathology")

add_subheading(doc, "DEFINITION")
add_body(doc,
    "Acute inflammation is the immediate, short-term vascular and cellular response to injury or infection, "
    "characterized by the classic signs: rubor (redness), calor (heat), tumor (swelling), dolor (pain), "
    "and functio laesa (loss of function). It is protective but can cause tissue damage if uncontrolled.")

add_subheading(doc, "VASCULAR CHANGES IN ACUTE INFLAMMATION")

add_flowchart_text(doc, "VASCULAR EVENTS IN ACUTE INFLAMMATION",
    [
        "INJURY / INFECTION (Tissue damage, bacteria, trauma)",
        "↓ TRANSIENT VASOCONSTRICTION (seconds; neurogenic; axon reflex)",
        "↓ VASODILATION – Arterioles dilate first (histamine, NO, prostaglandins)\n→ INCREASED BLOOD FLOW → Redness (rubor) + Heat (calor)",
        "↓ INCREASED VASCULAR PERMEABILITY\nEndothelial cell contraction (postcapillary venules)\nInterendothelial gaps form → Protein-rich exudate leaks out → EDEMA (tumor)",
        "↓ SLOWING OF BLOOD FLOW (Stasis)\nRBCs remain in center; WBCs (PMNs) marginate to vessel wall (Pavementing)",
        "↓ LEUKOCYTE MARGINATION → ROLLING → ADHESION (via selectins, integrins) → TRANSMIGRATION (Diapedesis)",
        "↓ CHEMOTAXIS: PMNs migrate toward injury site (C5a, LTB4, IL-8, bacterial products)",
        "↓ PHAGOCYTOSIS by PMNs (opsonization by IgG, C3b → phagolysosome → killing)"
    ]
)

add_subheading(doc, "MEDIATORS OF ACUTE INFLAMMATION")
add_table(doc,
    ["Mediator", "Source", "Action", "Significance"],
    [
        ["VASOACTIVE AMINES", "", "", ""],
        ["Histamine", "Mast cells, basophils, platelets", "Vasodilation; increased vascular permeability (early – first 15–30 min)", "First mediator released; triggers triple response of Lewis"],
        ["Serotonin (5-HT)", "Platelets (released during aggregation)", "Vasoconstriction (at high conc); vascular permeability", "Less important than histamine in humans"],
        ["PLASMA PROTEIN SYSTEMS", "", "", ""],
        ["Bradykinin", "Kinin system (from kininogen by kallikrein)", "Vasodilation; increased permeability; PAIN (stimulates C-fibers); contraction of smooth muscle", "Major pain mediator; prolonged permeability"],
        ["C3a, C5a (Anaphylatoxins)", "Complement system activation", "Mast cell degranulation → histamine; C5a = powerful chemotaxin for PMNs; vasodilation", "C5a most potent complement fragment"],
        ["Fibrin degradation products", "Coagulation/fibrinolytic system", "Increase vascular permeability", "Link between inflammation and coagulation"],
        ["ARACHIDONIC ACID METABOLITES", "", "", ""],
        ["Prostaglandins (PGE2, PGI2)", "Cyclooxygenase (COX-1, COX-2) pathway; macrophages, mast cells", "Vasodilation; pain sensitization (hyperalgesia); FEVER (hypothalamus); edema", "Blocked by NSAIDs, aspirin (COX inhibitors)"],
        ["Thromboxane A2 (TXA2)", "COX pathway; platelets", "Vasoconstriction; platelet aggregation", "Opposes PGI2"],
        ["Leukotrienes (LTB4)", "Lipoxygenase pathway; neutrophils, macrophages", "LTB4: potent PMN chemotaxis; adhesion\nLTC4/D4/E4 (SRS-A): bronchoconstriction, permeability", "Blocked by zileuton (lipoxygenase inhibitor) and montelukast (LT receptor antagonist)"],
        ["PAF (Platelet-Activating Factor)", "Mast cells, PMNs, endothelium, platelets", "Platelet aggregation; increased permeability (10,000× more potent than histamine at low conc); PMN activation", "Important in severe allergic reactions"],
        ["CYTOKINES", "", "", ""],
        ["IL-1 and TNF-α", "Activated macrophages", "Fever (via PGE2 at hypothalamus); upregulate endothelial adhesion molecules; acute phase proteins; systemic effects", "Master cytokines of inflammation; targeted in RA (biologics)"],
        ["IL-8 (CXCL8)", "Endothelial cells, macrophages", "Powerful PMN chemotaxis; PMN activation", "Classic CXC chemokine"],
        ["IL-6", "Macrophages, T cells", "Fever; stimulates liver acute phase protein production (CRP, fibrinogen, complement)", "Elevated in all inflammatory conditions"],
        ["FREE RADICALS & OTHERS", "", "", ""],
        ["Nitric Oxide (NO)", "Endothelial cells, macrophages", "Vasodilation (major role); kills bacteria (in macrophages); inhibits platelet aggregation", "Produced by iNOS (inflammation) and eNOS (physiologic)"],
        ["Reactive Oxygen Species (ROS)", "PMN NADPH oxidase (respiratory burst)", "Kill microorganisms; but also cause collateral tissue damage", "Deficiency → Chronic Granulomatous Disease"],
    ],
    [2.0, 1.8, 2.5, 1.7]
)

doc.add_paragraph()

# ════════════════════════════════════════════
# SEQ Q7: Stephan Curve
# ════════════════════════════════════════════
add_q_heading(doc, 7, 5, "Stephan Curve – Draw and Explain", "Physiology")

add_subheading(doc, "DEFINITION AND HISTORY")
add_body(doc,
    "The Stephan curve is a graphical representation of the change in dental plaque pH over time following "
    "a sugar rinse or meal. It was first described by Robert M. Stephan (1944). The curve demonstrates the "
    "dynamic balance between acid production (demineralization) and acid clearance/buffering (remineralization) "
    "in dental plaque.")

add_subheading(doc, "THE STEPHAN CURVE (TEXT REPRESENTATION)")

# Text-based curve representation
add_body(doc, "")
table = doc.add_table(rows=1, cols=1)
table.style = 'Table Grid'
table.alignment = WD_TABLE_ALIGNMENT.CENTER
cell = table.rows[0].cells[0]
cell.text = (
    "STEPHAN CURVE\n\n"
    "pH\n"
    "7.0 |------- RESTING pH (6.7–7.0) --------\n"
    "    |                                       \\___\n"
    "6.5 |                                            \\    ← pH drops rapidly (2–5 min)\n"
    "    |                                             \\\n"
    "5.5 |...........CRITICAL pH LINE (5.5)..........._X_  ← ENAMEL DEMINERALIZATION BEGINS\n"
    "    |                                          /\n"
    "5.0 |                                         / ← pH NADIR (lowest point, ~3–5 min)\n"
    "    |                                        /\n"
    "4.5 |                                   ____/\n"
    "    |                                          ↑ Recovery phase (buffering + dilution)\n"
    "    |___________________________________\n"
    "        0    5    10   15   20   25   30  35  40  min\n"
    "               ↑ SUGAR RINSE"
)
cell.paragraphs[0].runs[0].font.name = 'Courier New'
cell.paragraphs[0].runs[0].font.size = Pt(9)
tc = cell._tc
tcPr = tc.get_or_add_tcPr()
shd = OxmlElement('w:shd')
shd.set(qn('w:val'), 'clear')
shd.set(qn('w:color'), 'auto')
shd.set(qn('w:fill'), 'FFFDE7')
tcPr.append(shd)

doc.add_paragraph()

add_subheading(doc, "PHASES OF THE STEPHAN CURVE")
add_table(doc,
    ["Phase", "Time", "Description", "pH Range"],
    [
        ["Resting", "Before sugar exposure", "Normal plaque pH; buffered by saliva and plaque fluid", "6.7 – 7.0"],
        ["Rapid drop", "0–5 min after sugar", "Cariogenic bacteria (S. mutans, Lactobacilli) ferment sugars; rapid lactic acid production; salivary buffering overwhelmed", "7.0 → 4.5–5.0"],
        ["Nadir (pH minimum)", "3–5 min", "Lowest pH; below critical pH 5.5 → enamel HAP dissolves", "4.5–5.0"],
        ["Recovery", "5–30 min", "Saliva dilutes and buffers acid; HCO3−/phosphate system neutralizes; Ca2+, PO43− redeposited", "4.5 → 5.5 → 7.0"],
        ["Return to resting", "30–40+ min", "Plaque pH restored to baseline; remineralization possible if F− present", ">6.5 – 7.0"],
    ],
    [1.5, 1.5, 3.0, 1.0]
)

add_subheading(doc, "CLINICAL SIGNIFICANCE")
add_table(doc,
    ["Factor", "Effect on Stephan Curve", "Clinical Implication"],
    [
        ["Sucrose (most cariogenic sugar)", "Deepest, most prolonged pH drop", "Limit sucrose intake; most dangerous for caries"],
        ["Sugar-free sweeteners (xylitol, sorbitol)", "Minimal or no pH drop", "Recommended as sucrose substitutes"],
        ["Frequency of sugar intake", "Each intake = one Stephan curve event; multiple curves = prolonged demineralization", "Sipping / snacking frequency more harmful than total sugar amount"],
        ["Fluoride", "Reduces pH drop depth; accelerates recovery; promotes remineralization", "Fluoride toothpaste use after meals; F− in plaque fluid"],
        ["Saliva (high flow)", "Faster buffering; faster recovery", "Stimulating salivary flow (chewing sugar-free gum) helps"],
        ["Reduced salivary flow (xerostomia)", "Slower recovery; more prolonged pH depression", "Rampant caries in xerostomia patients"],
        ["Critical pH (enamel) = 5.5", "Time below this line = demineralization period", "Goal: minimize time below 5.5"],
        ["Critical pH (dentine) = 6.2", "Dentine dissolves more readily", "Exposed root surfaces at higher risk"],
    ],
    [2.0, 2.5, 2.5]
)

add_body(doc, "KEY EXAM FACT: The Stephan curve demonstrates that it is the FREQUENCY of sugar consumption "
    "(number of acid attacks) rather than the total amount of sugar that determines caries risk. "
    "This is the scientific basis for advising patients to limit snacking between meals.")

doc.add_paragraph()

# ════════════════════════════════════════════
# SEQ Q8: Amelogenesis Imperfecta
# ════════════════════════════════════════════
add_q_heading(doc, 8, 5, "Amelogenesis Imperfecta – Genetic Basis and Clinical Features", "Genetics")

add_subheading(doc, "DEFINITION")
add_body(doc,
    "Amelogenesis Imperfecta (AI) is a clinically and genetically heterogeneous group of inherited disorders "
    "affecting enamel formation, in the absence of a generalized systemic disease. It affects both primary "
    "and permanent dentitions and is caused by mutations in genes encoding enamel matrix proteins or enzymes "
    "involved in enamel biomineralization. Prevalence: 1:718 to 1:14,000 (varies by population).")

add_subheading(doc, "ENAMEL FORMATION – BRIEF OVERVIEW")
add_flowchart_text(doc, "NORMAL AMELOGENESIS",
    [
        "Ameloblasts differentiate from inner enamel epithelium (IEE) of enamel organ",
        "SECRETORY PHASE: Ameloblasts (Tomes' processes) secrete enamel matrix proteins:\n→ Amelogenin (90%), Enamelin, Ameloblastin (AMBN), Amelotin",
        "Enamel matrix proteins guide HYDROXYAPATITE crystal nucleation and growth",
        "MATURATION PHASE: Amelogenins cleaved by MMP-20 (enamelysin) and KLK4 (kallikrein-4)",
        "Degraded proteins removed by endocytosis; mineral density increases to 96% by weight",
        "FINAL ENAMEL: Hardest biological tissue; highly mineralized; acellular – no capacity for repair"
    ]
)

add_subheading(doc, "GENETIC BASIS OF AI")
add_table(doc,
    ["Gene", "Protein Encoded", "Chromosome", "Function", "AI Type Caused if Mutated"],
    [
        ["AMELX", "Amelogenin", "X-linked (Xp22.3) + small copy on Y", "Major structural protein; controls crystal growth in width; hydrophobic assembly", "Hypoplastic AI (X-linked); most common X-linked form"],
        ["ENAM", "Enamelin", "4q21", "Largest enamel matrix protein; nucleation of enamel ribbons; crystal elongation", "Hypoplastic AI (AD) – most common autosomal dominant form; 'snow-capped' teeth"],
        ["AMELOBLASTIN (AMBN)", "Ameloblastin", "4q21", "Cell adhesion; ameloblast differentiation; sheath proteins", "Hypoplastic AI (AD)"],
        ["MMP20", "Enamelysin (MMP-20)", "11q22", "Protease that cleaves amelogenin during secretory phase", "Hypomaturation AI (AR) – snow-white opaque enamel"],
        ["KLK4 (Kallikrein-4)", "Kallikrein-4 serine protease", "19q13", "Protease active in maturation phase; removes residual matrix proteins", "Hypomaturation AI (AR) – chalky/opaque enamel"],
        ["FAM20A", "FAM20A (kinase)", "17q24", "Phosphorylates enamel matrix proteins; required for maturation", "Hypocalcification AI + Gingival fibromatosis (Enamel-Renal syndrome)"],
        ["FAM83H", "FAM83H", "8q24", "Unknown; possibly involved in maturation-stage signaling", "Hypocalcification AI (AD) – most common AD hypocalcification form"],
        ["WDR72", "WDR72", "15q21", "Involved in vesicular trafficking in maturation-stage ameloblasts", "Hypomaturation AI (AR)"],
        ["SLC24A4", "NCKX4 (Ca transporter)", "14q32", "Ca2+ transport into enamel during maturation", "Hypomaturation AI (AR) – brown, soft enamel"],
        ["ITGB6", "Integrin β6", "2q24", "Cell adhesion; ameloblast-matrix interaction during maturation", "Hypomaturation AI (AR)"],
    ],
    [1.0, 1.5, 1.1, 2.2, 2.2]
)

add_subheading(doc, "WITKOP CLASSIFICATION (Modified) OF AI")
add_table(doc,
    ["Type", "Subtype", "Defect Phase", "Inheritance", "Clinical Features"],
    [
        ["TYPE I: HYPOPLASTIC", "Ia: Pitted (generalized)", "Secretory phase", "AD (ENAM)", "Random pits on enamel surface; full enamel thickness but defective; normal color initially"],
        ["TYPE I: HYPOPLASTIC", "Ib: Locally hypoplastic", "Secretory phase", "AD", "Horizontal rows of pits in bands"],
        ["TYPE I: HYPOPLASTIC", "Ic: Smooth hypoplastic", "Secretory phase", "AD/AR/XL (AMELX)", "Thin, smooth, shiny enamel; yellowish/brown; widely spaced teeth; open bite common"],
        ["TYPE I: HYPOPLASTIC", "If: Snow-capped (ENAM)", "Secretory phase", "AD (ENAM)", "White chalky enamel on incisal/occlusal portions; most common AD hypoplastic form"],
        ["TYPE II: HYPOMATURATION", "IIa: Pigmented (AR)", "Maturation phase", "AR (MMP20, KLK4)", "Mottled white/brown/yellow enamel; full thickness but soft; easy attrition; 'cheese-like' texture"],
        ["TYPE II: HYPOMATURATION", "IIb: Snow-capped (AR)", "Maturation phase", "AR (MMP20)", "White opaque incisal tips; rest of enamel normal color"],
        ["TYPE II: HYPOMATURATION", "IId: X-linked (AMELX female)", "Maturation phase", "X-linked (AMELX in females)", "Alternating vertical bands of normal and hypomatured enamel (lyonization pattern)"],
        ["TYPE III: HYPOCALCIFICATION", "IIIa: Autosomal dominant", "Maturation phase", "AD (FAM83H)", "Normal enamel thickness but very soft and poorly mineralized; orange/yellow/brown; chips easily on eruption"],
        ["TYPE III: HYPOCALCIFICATION", "IIIb: Autosomal recessive", "Maturation phase", "AR (FAM20A)", "Similar to IIIa; associated with gingival fibromatosis and renal calcifications"],
        ["TYPE IV: HYPOMATURE + HYPOPLASTIC (Taurodontism)", "IVa/b", "Both phases", "AD", "Combined features + taurodontism of posterior teeth"],
    ],
    [1.5, 1.5, 1.2, 1.3, 2.5]
)

add_subheading(doc, "CLINICAL FEATURES SUMMARY")
add_table(doc,
    ["Feature", "Hypoplastic", "Hypomaturation", "Hypocalcification"],
    [
        ["Enamel thickness", "Reduced (thin)", "Normal", "Normal"],
        ["Enamel hardness", "Normal to slightly reduced", "Reduced (soft)", "Very soft – chips easily"],
        ["Color", "Yellow-brown (dentine shows through)", "White-yellow-brown mottled", "Yellow-orange-brown"],
        ["Radiographic appearance", "Thin enamel layer; normal radiodensity", "Normal thickness; reduced radiodensity", "Enamel same density as dentine (poor contrast)"],
        ["Sensitivity", "Mild to moderate", "Moderate", "Severe"],
        ["Attrition/abrasion", "Moderate", "Rapid (soft enamel)", "Most rapid (crumbles on eruption)"],
        ["Open bite", "Common", "Less common", "Less common"],
        ["Gingival health", "Usually normal", "May be inflamed", "Gingival inflammation common (enamel fragments subgingival)"],
    ],
    [2.0, 1.8, 1.8, 1.8]
)

add_subheading(doc, "TREATMENT PRINCIPLES IN PEDIATRIC DENTISTRY")
add_table(doc,
    ["Age/Stage", "Treatment Options"],
    [
        ["Primary dentition", "Composite restorations; stainless steel crowns (SSCs) for severely affected molars; fluoride varnish; pain management"],
        ["Mixed dentition", "SSCs; composite resin coverage; oral hygiene instruction; fluoride protocols; casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)"],
        ["Permanent dentition (young adult)", "Full coverage crowns; porcelain laminate veneers; composite build-up; implants for extracted teeth"],
        ["Orthodontics", "May be needed for open bite, spacing correction after prosthodontic phase"],
        ["Genetic counseling", "Identify gene mutation; advise on recurrence risk for future children; prenatal testing if appropriate"],
    ],
    [2.0, 5.0]
)

# ─── Final Page ────────────────────────────────────────────────────────────
doc.add_page_break()

p_end = doc.add_paragraph()
p_end.alignment = WD_ALIGN_PARAGRAPH.CENTER
run_end = p_end.add_run("*** END OF ANSWER BOOKLET ***")
run_end.bold = True
run_end.font.size = Pt(14)
run_end.font.color.rgb = RGBColor(0x1F, 0x49, 0x7D)

p_wish = doc.add_paragraph()
p_wish.alignment = WD_ALIGN_PARAGRAPH.CENTER
r_wish = p_wish.add_run("All the best for your MDS examination on July 21, 2026!")
r_wish.italic = True
r_wish.font.size = Pt(12)

# Save
import os
os.makedirs('/tmp/workspace/mds-answers/', exist_ok=True)
out_path = '/tmp/workspace/mds-answers/MDS_Basic_Sciences_Complete_Answers.docx'
doc.save(out_path)
print(f"SUCCESS: Document saved to {out_path}")
print(f"File size: {os.path.getsize(out_path):,} bytes")