oral & maxfax scenarios Flashcards
A 72 year old man attends c/o soreness on his tongue. This has been present for 4 weeks with no history of trauma to the tongue.
OE: ulcer, 1cm in diameter on the right lateral border of the tongue.
Fractured amalgam in the LR7.
What 2 factors would you ask about regarding the pt’s social history?
Smoking and alcohol intake (incl. betel nut chewing and snuff usage).
A 72 year old man attends c/o soreness on his tongue. This has been present for 4 weeks with no history of trauma to the tongue.
OE: ulcer, 1cm in diameter on the right lateral border of the tongue.
Fractured amalgam in the LR7.
What would the initial management be for this patient?
Remove any local cause of irritation to exclude a traumatic cause of the ulcer.
- Smooth and temporise the LR7.
- Review in 2 weeks.
A 72 year old man attends c/o soreness on his tongue. This has been present for 4 weeks with no history of trauma to the tongue.
OE: ulcer, 1cm in diameter on the right lateral border of the tongue.
Fractured amalgam in the LR7.
What features of an ulcer would lead you to believe it is malignant?
Rolled edges and firm to touch.
A 72 year old man attends c/o soreness on his tongue. This has been present for 4 weeks with no history of trauma to the tongue.
OE: ulcer, 1cm in diameter on the right lateral border of the tongue.
Fractured amalgam in the LR7.
If the lesion is thought to be malignant, which type of biopsy should be taken?
Incisional Biopsy
This is because the surgeon who comes to treat the lesion will still be able to see where it is whereas this would not be the case if an excisional is taken.
You have just carried out an extraction of a lower right molar under LA.
Please give post-operative instructions.
- No rinsing of the mouth for 6 hours as this may disturb the clot.
- if bleeding occurs, bite on a clean pack for 15 mins to stop the bleeding.
- OHI - hot salty mouthwashes to keep the socket clean, start after 6 hours.
- mouthwashes should be used until they can clean around the socket. - Analgesics may be used when the LA n begins to wear off (paracetamol +/- ibuprofen).
- try to take prior to it wearing off. - Post-op pain and swelling is to be expected but if it worsens over time, this should be checked.
Outline the process of GA and things the patient needs to be aware of post-op.
- The pt will be asleep for the full procedure - usually done as a day case procedure.
- Anaesthetic is usually administered through a cannula in the arm.
- Will require recovery time (several days off work).
- Will need to attend with an escort and not drive, sign documents or operate machinery for 24 hours after.
- Fasting is required 6 hours prior to the procedure.
- No anaesthetic is without risk but it is safe.
Outline the advice you would give to a patient prior to LA with IV sedation.
- Fast for 2 hours prior to the procedure.
- An injection will still be required to numb the area in the mouth.
- The sedation is administered via a cannula in the arm.
- Pt will need to bring an escort to look after them for the recovery period.
- No signing legal documents, operating machinery or driving for 24 hours after.
- Recovery time is shorter in comparison to GA and a safer procedure.
An emergency pt presents with an extra-oral swelling caused by a dental abscess from a carious lower right first molar.
This pt is a 40 year old with insulin-dependent diabetes.
Discuss how the severity of infection can differ in pts with diabetes compared to those without.
- Pts with diabetes are more at risk of infections.
- Odontogenic infections can progress rapidly in diabetics, especially poorly controlled.
- Infections can alter diabetic control, causing changes in blood sugar levels.
An emergency pt presents with an extra-oral swelling caused by a dental abscess from a carious lower right first molar.
This pt is a 40 year old with insulin-dependent diabetes.
What are the signs of a rapidly spreading infection in a pt with diabetes?
- Increasing pain.
- Increasing swelling.
- Fever.
- Increased pulse rate.
- Uncontrolled diabetes.
An emergency pt presents with an extra-oral swelling caused by a dental abscess from a carious lower right first molar.
This pt is a 40 year old with insulin-dependent diabetes.
When would you refer this patient’s infection?
- Raise temperature (over 38º).
- Increased pulse rate.
- abnormal blood glucose levels.
- Firm and raised floor of mouth.
- Drooling.
- Deviated uvula.
- Severe trismus.
- Difficulty swallowing.
- inability to speak in complete sentences.
A fit and healthy 24 year old attends your surgery c/o a clicking jaw joint although this is not associated with any pain. This has been occurring over the past few years but recently she has noticed that sometimes her jaw locks and she can’t open it.
Explain to her what might be happening to cause these symptoms.
- Explain that within the joint, there is the head of the jawbone (condyle) and the socket (temporal bone) and between them is a cartilaginous disc.
- This disc is supposed to be closely associated with the condyle but sometimes it becomes a bit loose and lies in front of it.
- In this situation, the condyle moves but the disc doesn’t and pressure builds up as it tries to move under the disc.
- suddenly the pressure gets too much and both return to their original position. - Explain this movement creates a popping/clicking sensation that you can hear and feel.
- In some instances, the condyle is unable to get past the disc and this results in a lock.
A 65 year old man has been referred to the clinic for the extraction of his LR6. He has a prosthetic heart valve and takes Warfarin 5mg daily.
Explain what pre-operative tests or measures are needed to manage this pt with regards to his warfarin usage.
- Taking warfarin will make this pt more likely to experience a haemorrhage during or after the XLA.
- temporary withdrawal outweighs the risk of bleeding so dose should not be stopped prior. - The XLA can only be taken if the pt knows his INR less than 72 hours before.
- acceptable if less than 4. - NSAIDs should not be used as post-op analgesics due to the risk of bleeding.
- any prescribed antibiotics should not interfere with warfarin (e.g: avoid metronidazole).
When should an extraction appointment ideally be scheduled for if a patient is taking warfarin?
Early in the day and early in the week so any post-op complications/bleeding can be managed with during the working week.
(sutures may need to be used and socket packed with haemostatic agent in this pts case).
A 65 year old man has been referred to the clinic for the extraction of his LR6. He has a prosthetic heart valve and takes Warfarin 5mg daily.
What are the potential complications with regards to this pts prosthetic heart valve?
- Puts him at a greater risk of infective endocarditis (inflammation of the endocardium).
- NICE no longer requires antibiotic prophylaxis, just have to take into consideration
