Oral Med

Question 1

atypical odontalgia

Answer 1

dental pain without detected pathology

distinct pattern of pain
* pain free or mild between episodes which settles spontaneously
* typical acute pulpitis symptoms with irrational pt behaviour

tx - refer to primary care of OM
* chronic strategy - reduce chronic pain experience, reduce frequency of acute episodes
* acute strategy - opiod analgesics high intensitiy/short duration to control pain
extraction of tooth if needed

Question 2

persistent idiopathic facial pain

Answer 2

pain whic poorly fits into standard chronic pain syndromes which often has a high disability level (autonomic component)

management - refer to OM
* believe the pt and do not inc damage
* adopt hollistic strategy for pain control and quality of life issues

Question 3

alcohol and oral cancer

Answer 3

Oral Cancer Foundation - 2nd largest risk factor for development of oral cancer.

Alcohol has been found to dehydrate the cell walls enhancing the ability of other toxins such as tobacco carcinogens to penetrate mouth tissues and also nutritional deficiencies associated with heavy drinking can lower the bodies natural ability to use antioxidants to prevent formation of cancers

The Lancet in 2018 also published a paper describing how alcohol use linked with four types of oral cancer and that even one drink per day increases the relative risk of developing these. They described how alcohol damages cells which then try to repair themselves leading to DNA changes that could be the step towards oral cancer

Alcohol effect on general health
* risk of many cancers - liver, oral, stomach, colon and rectum
* decay and TW
* facial injuries

no more than 14units a week, spread over 3 or more days, 2 alcohol free days a week
=6pints of beer, 10small glasses of low strength wine, 14 singles

Question 4

alcohol brief intervention

Answer 4

raise issue
screen and give feedback
ask if interested in cutting down
suitable referral or information/advice

similar to 4As 1R

Question 5

SIRS actor
patient attends with swelling, ask for radiograph and go through history including temp, HR etc and then diagnose SIRS and how this is managed.

PA shows abscess relating to specific tooth

Answer 5

Abscess is pus enclosed in the tissues of the jaw bone at the apex of an infected tooth root/s. Usually the abscess originates from a bacterial infection that has accumulated in the soft, often dead, pulp of the tooth
* Causes of an abscess – caries, trauma, NCTSl, periodontal disease

ask pt symptoms
* swelling, trismus, dysphonia, dysphagia, drooling, poor neck flexion, inability to stick tongue out or swallow, pain, pyrexia, tachycardia, tachypnoea
* colour, size, duration of swelling
* ask about Temp, Pulse Rate, Resp Rate, Colour

SIRS - systemic inflammatory response syndrome
* Temp <36 or >38
* WCC <4 or >12x10^9/L
* Heart rate >90/min (tachycardia)
* Respiratory rate >20/min (tachypnoea)

2/4= postive SIRS, sepsis syndrome –> urgent referral to OMFS/A&E
inflammatory state affecting the whole body, frequently a response of
* the immune system to infection. It is related to sepsis a condition in which
individuals both meet criteria for sirs and have a known or highly suspected
infection.

Question 6

always refer if

Answer 6

• spread of infection to pharyngeal or submandibular space
• systemic manifestations and pt is immunocompromised
• trouble swallowing or breathing/drooling
• rapidly progressing infection

2/4 SIRS

Question 7

candidal leukplakia (chronic hyperplastic candidosis)

advice and management

Answer 7

fungal infectionof the cheek and side of mouth
potentially malignant
RF: OH, steroid inhaler, diet, diabetes, deficiency, dry mouth, antibiotics, immunosuppression

management
incisional biopsy - referral to OM
OHI, reduce carbohydrate intake, rinse mouth after inhaler
correct defeicncy, control diabetes, stop smoking, correct denture fault

systemic antifungal - review after 7 days
* fluconazole 50mg capsules, send 7 tablets, 1 tablet to be taken once per day for 7 days
* miconazole oromucosal gel 20mg/g, apply pea sized amount after food 4xday, cont for 7days after lesions healed
* nystatin oral suspension 1:100,000 units/ml, 1ml after food 4xdaily, for 7days

no azoles if on warfarin or statin

Question 8

facial pain hx
dentally sound

Answer 8

Site - may migrate from one site to another, can cross anatomical boundaries
Onsent - often chronic, pt may relate it to specific episode of tx
Character- varied, often contin sharp ache, can be throbbing
Radiation - often radiates across anatomical boundaries
Associations - no local sign of inflammation
Timing - generally continuous
E/R factors - associated with stimuli that usually do not elicit pain, analgesia gennerally ineffective
Severity - v

special investigations
* radiographs for caries
* sensibility tests
* mobility
* perio disease
* tooth slooth

Question 9

Cranial nerve test

Answer 9

CN1 (olfactory) - can pt smell as normal

CN 2, 3, 4, 6 (optical, ocluomotor, trochlear, abducens) - test visual acuity and eye movement

CN 5 (trigeminal) - any abnormal sensaiton to each branch? clench jaw> cornela reflex

CN 7 (facial) - facial muscles test - puff out cheeks, out, wrinkle forehead, raise eyebrows

CN 8 (vestibulocochlear) - hear normally, block one ear and check for differences

CN 9, 10 (glossophayrngeal and vagus) - deviation of uvula on saying ah, gag reflex

CN 11 (accessory) - shrug shoulders

CN 12 (hypoglossal) - protrude tongue, deviation on protrusion? asym?

Question 10

lichen planus

explain, causes, tx

Answer 10

lichen planus can present anywhere on skin and this includes in the mouth
one of the most common conditions they seen in OM dept

whiteness arises from extra kertin deposits, this is a protein that is present in all of your kim and can be stimulated to make more by several factors like friction (e.g. calluses)

LP is a kind of allegric reaction to something and in most cases we don’t know what - commonly medications, metal in silver filllings

LP has a small chance to develop into something sinister like mouth cancer (1% of cases in a 10 year av case)
However, it is a spectrum disease so can range from aymp white paches to painful erosive/ulcerative
depending on what area of spectrum you are on depends on risk of malignant transformation

we can manage the symptoms and try to remove the cause - not guaranteed will resolve fully

SLS free toothpaste/MW
avoid benzoates
soreness - difflam
corticosteroids
take pictures and review every 4-6months

any qs

Question 11

dry mouth and pt takes amitrityline

Answer 11

hx
* how dry mouth affecting pt? need water to swallow/affect speech, uncomfy?
* what meds? alcohol? smoking?
* any other medical conditions - diabetes/epilepsy/anxiety/stroke/sjogrens/CF/HIV

usual features
* swallowing diff
* clicking speech
* discomfort
* altered taste
* cevical caries
* hallitosis
* candidiasis

management
* tx cause - hydration, chew gum, modify drugs, control diabetes, reduce caffeiene, stop smoking/alcohol
* prevent diseases - high F toothpaste, CHX for candida
* saliva subs - spray, lozenges, gel, stimulants

GMP query med change

Question 12

given IDN and caused facial palsy

identify and manage

Answer 12

injection in parotid gland and in facial nerve

Dx - by testing facial nerve CNVII - move facial muscles

symp
* generalised weakness of ipsilateral side of face, inability to close the eyelids, obliteration of the nasolabial fold, drooping of the corner of the mouth, deviation of the mouth towards the unaffected side

confrim - temporal branch affected
if it was stroke would be able to wrinkle forehead

management
* reassurance
* cover eye with pad until blink reflex returns - eye patch, esp at night
* artifical tears and sunglasses to prevent exposure keratitis

Question 13

swollen lips all life
ask about it and give management advice

Answer 13

OFG - orofacial granuloamtous inflammation = blocked lymphatic channels causing swelling

autoimmune - type IV hypersensitivity to additives (benzoates, cinnamonaldehyde, sorbic acid, chocolate)

symptoms - lip swelling/cracks, angular cheiliits, buccala cobblestoning, ulceration, lympoedema, gingivitis

hx - full systems, should highlight bowel issues

dx - path test for 20mins?

management
* 3 month empirical dietary exclusion
* Topical treatment to angular chelitis/fissure - miconazole/hydrocortisone cream
* Topical treatment to lip swelling or facial erythema; Tacrolimus ointment 0.03%; Intralesional steroids to lip; Systemic immune modulation?

pt mentions bowel problems - potential for crohns
* inflammatory disease that cna affect any part of GI tract
* pathchy lesions in colon - causing perforation, stricture, obstruction, and in cancer risk
* refer to GP to investigate

Question 15

give biopsy results
epithelial dysplasia

give advice re alcohol

Answer 15

SPIKES
setting -invite to sit down and ask if anyone with them
perception - ask what they think today’s appt is about
invitation - say you have results
knowledge - give results
* ‘epithelial dysplasia which has a potential to be cancerous.’
* Stress to the patient: ‘This is not cancerous YET but there is evidence of a tissue change.’
* Ensure they understand: ‘This diagnosis implies there is a HIGHER risk for a transformation to malignancy.’
* ‘The good news is that the risk can be reduced by removing the factors that can cause cancer’
Empathy
Summary - advise
Alcohol advice - mentioning what unit of alcohol is and weekly intake guidelines and dental effects
here need to cut out completely due to being RF for dysplasia turning to cancer

Question 16

alcohol advice

4As 1R

Answer 16

Ask: How much do you drink/units? What kind? Eye-opener? Family
concerns?

Advise: Effects on general and dental health
Stress that alcohol increases the risk of oral cancer!
Oral effects: fungal, caries, dry mouth, perio, poor wound healing,
dental erosion, bruxism
*increased bleeding – reduced clotting
General effects: increased risk of stroke, cardiac disease, liver
disease

Assess: whether the pt is willing to reduce drinking, inform them that this if fundamental to prevent oral cancer

Refer: Alcoholics Anonymous

Guidelines - Maximum 14 units per week with at least 2-3 drink free days

Question 17

FRAMES conselling approach

Answer 17

short, non judgemental, motivational

F – feedback - given to patient about behaviour
R – responsibility - for change is placed on patient
A – advice - how to do that change, given by practitioner
M – menu of options - self-directed change options and treatments offered
E – empathetic - warmth, respect and understandingS – self-efficacy - is
engendered to encourage change
S - summary

Question 18

lymph node exam for cancer suspicion

Answer 18

LN Palpation:
* preauricular, parotid, submandibular, submental
* occipital, posterior auricular, jugulo-digastric, jugulo-omohyoid, deep cervical, supraclavicular

Hx
* Noticed lesion? How long for? Painful? Pain/Problems eating or swallowing?
* Hoarseness of voice?
* Relevant MH? Smoker? Alcohol? Regular attender? Daily mouthwash use (alcohol)?

DWP
* ‘The lesion on the FOM has a number of possible causes. Some of these are
* harmless and benign. However, some causes could be more serious and possibly cancerous.’
* As the site is a high risk for oral cancer, and you have other risk factors, it would be appropriate to refer you on to have this looked at.’
* ‘In order to be sure I will make an urgent referral to OM/Macfac dept where they will take a biopsy of the white patch so that a laboratory can tell us what it is’

what to expect at OM
Biopsy
* LA injection around the site of the sample
* Taking a small amount of tissue to send to the lab for analysis
* Sutures will be placed to close up the wound
* Lymph node biopsy - Fine needle aspirate?
Post-op advice
* it will be sore for a week after the procedure, similar to having an ulcer
* Risks: pain, swelling, bleeding, bruising, infection, numbness/altered sensation
* Sutures will dissolve and come out on their own in around 2-4 week
* Advice will be provided - salt water mouthwashes, softer diet, limit
* smoking etc
Review appointment to be booked to discuss findings

management of RF
* Smoking cessation advice
* Reduce alcohol consumption

Question 19

urgent cancer referral guidelines

Answer 19

Persistent unexplained head and neck lumps for >3 weeks

Ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks

All red or speckled patches of the oral mucosa persisting for >3 weeks

Persistent hoarseness lasting for >3 weeks (request chest x-ray at the same
time)

Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks

Persistent pain in the throat lasting for >3 weeks

Question 20

White Patch on FOM (6 mins). Discuss need for biopsy + possibility of oral cancer.

Discuss pt risk factors (smoking + alcohol)

Answer 20

Possible causes of white patch:
* Hereditary, Keratosis (Smoking, Traumatic), Lichenoid, Lupus,
Pseudomembranous or Chronic Hyperplastic Candidiasis (not in this site), Carcinoma/SCC

Discussing the lesion
* ‘The lesion on the FOM has a number of possible causes. Some of these are
* harmless and benign. However, some causes could be more serious and possibly cancerous.’
* ‘As the site is a high risk for oral cancer, and you have other risk factors, it would be appropriate to refer you on to have this looked at.’
* ‘In order to be sure I will make an urgent referral to OM/Macfac dept where they will take a biopsy of the white patch so that a laboratory can tell us what it is’

what to expect at OM:
Biopsy
* LA injection around the site of the sample
* Taking a small amount of tissue to send to the lab for analysis
* Sutures will be placed to close up the wound

Post-op advice
* It will be sore for a week after the procedure, similar to having an ulcer
* Risks: pain, swelling, bleeding, bruising, infection, numbness/altered sensation
* Sutures will dissolve and come out on their own in around 2-4 weeks
* Advice will be provided - salt water mouthwashes, softer diet, limit
* smoking etc
Review appointment to be booked to discuss findings

Management of Risk factors
* Smoking cessation advice
* Reduce alcohol consumption

Question 21

27-year old patient presents with ulcers. The patient’s ulcers are no more than 10mm in size (history
provided etc). Using this information and the available lab results (Patient has low iron and folate). Discuss the lab findings, the diagnosis and management options for this
condition with the patient. You do not need to gain any more information from the patient.

Answer 21

Build-up and Diagnosis:
* ‘Are you aware of what we’re here to discuss today?’
* ‘You were here a few weeks ago complaining of painful ulceration…etc and we took some bloods to see if we could identify what is causing your symptoms.’
* ‘Would you like for me to talk through our findings?’
* ‘Let me start by saying there is nothing sinister going on here…’
* ‘But your bloods showed that you have developed a type of anaemia called
* microcytic anaemia caused by an iron deficiency in your blood’

Description of disease:
* ‘Iron deficiency anaemia is a condition where a lack of iron in the body leads to a reduction in the number of red blood cells.’
* ‘Iron is used to produce red blood cells, which help store and carry oxygen in the blood.’
* ‘If you have fewer red blood cells than is normal, your organs and tissues won’t get as much oxygen as they usually would.’
* Many people with iron deficiency anaemia only have a few symptoms.’
* ‘Most common symptoms are tiredness and lack of energy (lethargy), shortness of breath, noticeable heartbeats (heart palpitations) and a paler complexion’
* ‘In addition, In some cases, including yours, people develop minor ulceration in the mouth’

Aetiology:
* ‘There are many things that can lead to a lack of iron in the body.’
* ‘Sometimes it can simply be explained by a lack of iron in the diet.’
* ‘However there are other common causes like heavy menstruation (if woman) or bleeding in the stomach and intestines which can be caused by a stomach ulcer or taking NSAIDs.’

Management
* ‘Iron deficiency can easily be managed with iron supplements and an increase of iron in the diet.’
* ‘This would also resolve the minor ulceration in your mouth which tend to go away in 1-2 weeks without scarring.’
* Your GP should be able to prescribe you iron supplements in tablets to be taken twice daily and might chose to investigate you further to determine if there is an underlying condition.’
* ‘My advice in the meantime is to try to increase the iron in your diet, avoid spicy foods like curries and if you’re mouth is very sore (can’t eat etc) i can prescribe a numbing m/w to allow you to be more comfortable’
Benzydamine m/w, 0.15% - Send: 300ml, Label: Rinse or gargle using
15ml every 1.5 hours as required
Can be diluted 1:1 with water if stinging Spit out after rinsing - not more >7 days

Diet advice:
* Dark-green leafy vegetables, such as watercress and curly kale, iron-fortified
* cereals or bread, brown rice, pulses and beans, nuts and seeds, meat, fish, tofu, eggs, dried fruit (prunes/raisins)
* Vit C rich foods/drinks help body absorb Fe
* Tea, coffee and calcium (found in dairy products like milk) make it harder to
* absorb iron in large quatities

Summary
* Reassure patient - common condition
* Ulcers go away in up to 2 weeks without scarring
* We know what the cause is and we can manage it
* Any questions?

Actor marks communication and simple language

Question 22

Pt diabetic and taking Warfarin - Give findings and explain Tx (6 mins).

patient has a sore denture and sore palate, test done previously to
confirm condition and you have received the results.
Denture-induced stomatitis affecting the hard palate, provided with picture showing this as well as results of swab.

Medical history includes diabetes type 2 and on warfarin for atrial fibrillation.

Explain findings to the patient, recognise the multifactorial condition and provide oral hygiene advice. You can ask relevant questions to the actor, but you don’t need to take another
medical history

Answer 22

Introduce self & designation

Brief history
* Acknowledge diabetic history and ask about control (2 marks)
* Ask if denture worn at night (1 mark)
* Ask about denture hygiene (1 mark)

Explanation of clinical findings
* Denture induced stomatitis - explain clearly with no jargon (2 marks)
* a fungal infection causing inflammation of the tissues that are in contact with the denture and it can occur due to a variety of reason and is more susceptible in patients who are immunocompromised.

Newton’s classification
Type I – localised inflammation with hyperaemic foci
Type II – diffuse inflammation and erythema confined to mucosa contacting denture without hyperplasia Type III – granular inflammation with erythema and papillary hyperplasia

Management advice:
* Palate brushing daily to treat condition (1 mark)
* Advice on cleaning denture (2 marks - 1 for each)
* Brushing after meals with a soft toothbrush and non-abrasive denture
cream (or detergent)
Soaking in CHX m/w or sodium hypochlorite for 15 minutes x2 daily
NaOCl only for acrylic dentures
* Leaving denture out at night and as often as possible during treatment period (1 mark)
* Check denture fit - if themselves contributing to problem: adjust or remake (1 mark)
* Limit smoking if possible
* Limit sugar in diet

Confirm patient understands instructions (1 mark)

Examiner asks “What antimicrobial agent would you prescribe to treat this condition?”
* None or Chlorhexidine ( 2 of 2 marks)
* Nystatin suspension (1 of 2 marks)
* Azole antifungal (deducted 2 marks due to warfarin interaction!!)

Actor marks on communication and simplicity of language (2 marks)