oral surgery

Question 1

You assess that your patient requires removal of teeth 25 and 26 due to caries. The patient has never had teeth taken out before. When discussing their medical history, you elicit they take Warfarin for Atrial Fibrillation.

1. What type of drug is Warfarin AND what is its mechanism of action? (2 marks)

Answer 1

anticoagulant
vitamin K antagonist

involves inhibiting the synthesis of vitamin K-dependent clotting factors (Factors II, VII, IX, and X) in the liver = inhibition interferes with the normal clotting cascade = prolongs the time it takes for blood to clot.

Question 2

2. Which test must be carried out prior to the extractions (1 mark)

Answer 2

International normalised ratio (INR)
prothrombin time (PT)

Question 3

3. Which guidance document would you refer to for advice on dealing with patients on Warfarin AND within what timeframe should this test be carried out prior to the extractions
   (2 marks)

Answer 3

SDCEP - management of patients on anticoagulants

no more than 24 hours before
(up to 72 if stable)

Question 4

4. Below what level would it be safe to continue with extractions? (1 mark)

Answer 4

below 4

Question 5

You arrange an appointment for treatment and this is carried out uneventfully.
They return the next day complaining they have been bleeding all night.

5. Outline options that you could carry out clinically to deal with this post-operative bleeding.
   (3 marks)
6. If following your interventions, you still could not stop the bleeding – what would you do?
   (1 mark)

Answer 5

5. apply pressure
   la with vasoconstrictor
   diathermy
   surgicel
   sutures
   whitehead’s varnish pack - iodoform, gum benzoin, storax, balsam tofu, ethyl esther
   transexamic mouthwash
6. refer to a specialist - e.g transfusion, vitamin K injection, surgical intervention

Question 6

A fit and healthy patient presents to the surgery to have the surgical removal of a carious 48.

1. Anatomically, which nerves must be anaesthetised to remove this tooth safely?
   (3 marks)

Answer 6

inferior alveolar
lingual nerve
long buccal nerve

Question 7

2. List TWO different ways you could assess that anaesthesia has been achieved? (1 mark)

Answer 7

probe with a probe around the PDL
ask if the tongue and lip is numb on that side
start the procedure

Question 8

3. The patient presents one week later with neuro-sensory deficit affecting the right chin and lip region. Using the descriptions below provide the dental terminology.
   (3 marks)
   i) pins and needles feeling, or partial loss of sensation:

ii) painful, unpleasant or neuralgic sensation that lasts for a fraction of a second:

iii) total loss of sensation

Answer 8

i) paresthesia
ii) dysesthsia
iii) anaesthesia

Question 9

4. give 3 clinical reasons that can account for this neurodeficit?

Answer 9

damage to nerves
damage to gland
damage to muscles

Question 10

A dentist plans to extract an erupted but in-standing mandibular second premolar tooth in a healthy adult.

1. List FOUR common peri-operative complications associated with this procedure in a healthy dentate adult.
   (4 marks)

Answer 10

fracture of the root or tooth
fracture of alveolar bone
soft tissue damage
damage to adjacent teeth
damage to nerves/vessels
broken instruments
haemorrhage
difficult access

Question 11

2. When the tooth is extracted, it is noticed that a substantial part of the root of the tooth is missing. Which radiographic image would be the most appropriate for assessment of this situation?
   (1 mark)

Answer 11

periapical

Question 12

3. On the diagram below draw (or describe) the following:

i. the outline of the flap you would raise for surgical removal of the root fragment 45.

(2 marks)

Answer 12

outline of the gingival margin around the affected tooth

horizontal incision along gingival margin
vertical at both ends of the horizontal incision

Question 13

4. Give TWO anatomical structures which are supplied by the mental nerve?
   (2 marks)

Answer 13

lower lip - skin and mucous membrane
chin and lower gingiva
lower teeth anterior to mental nerve

Question 14

A patient returns to the clinic with symptoms and signs of a dry socket.
1. What is the correct terminology for this? (1 mark)

Answer 14

alveolar osteitis

Question 15

2. List THREE predisposing factors that could contribute to this?
   (3 marks)

Answer 15

poor OH
trauma during XLA
smoking
gender - being female
molars or mandible
oral contraceptive pill
excessive mouth rinsing after extraction

Question 16

3. List THREE symptoms or signs that the patient may present with.
   (3 marks)

Answer 16

severe pain
halitosis
dislodged blood clot
radiating pain
awake at night
bad odour

Question 17

4. How would you manage this situation? (3 marks)

Answer 17

pain management
irrigation with saline and alveogyl dressing
post op instructions - oh, avoid smoking, rinsing with warm salt water, no straws
curettage and cleaning

Question 18

1.) a.) Two aims for raising a flap (2)
b.) 4 things that influence flap design (4)

Answer 18

a) provide better access to underlying tissues
good visibility and visualisation
protect soft tissues

b) type of procedure
anatomical considerations
blood supply
aesthetics and function
surrounding nerves
effect on gum recession

Question 19

c.) Type of handpiece used for bone removal (1)

Answer 19

surgical straight handpiece
saline cooled
with a round tungsten carbide bur

Question 20

d.) 3 methods of debridement (3)

Answer 20

physical - bone file or handpick
mitchells trimmer or victorias curette for soft tissues debris

irrigation - sterile saline/water into socket and under flap

suction - aspirate under flap, check for retainer apices

Question 21

3.) a.) Drug family of apixaban (1)
b.) What does apixaban inhibit? (1)
c.) What else is apixaban used for (2)
d.) What blood tests before treatment (1)
e.) What to do with dosage for surgical treatment vs simple extraction (2)
f.) 3 methods of haemostatic control (3)

Answer 21

a) direct oral anticoagulants
non-vitamins K antagonists

b) Factor Xa

c) stroke and blood clot prevention
prevention of deep vain thrombosis
pulmonary embolism

d) renal function tests (e.g. serum creatinine and glomerular filtration rate)
liver function = enzymes

e) low bleeding = do not interrupt
high bleeding = miss or delay morning dose

f) local pressure
homeostatic agents - oxides cellulose, fibrin sealants
sutures
surgicel
bone wax

Question 22

a) XLA of premolar. List 4 preoperative complications (4 marks)

Answer 22

Tooth position inadequate for access for elevators or forceps.
Patient’s medical history states bleeding tendency.
Radiograph states or shows tooth appeared to be ankylosed or infraoccluded or signs of hypercementosis.
Close to relevant anatomical structure e.g. mental foramen.

Question 23

a) XLA of premolar. List 4 perioperative complications (4 marks)

Answer 23

• Difficulty of Access
  
  • Fracture of tooth/root
  • Fracture of alveolar plate
  • Fracture of tuberosity
  • Jaw fracture
  • Involvement of maxillary Antrum (OAC/OAF)
  • Loss of tooth
  • Soft tissue damage
  • Damage to nerves/vessels
  • Haemorrhage
  • Dislocation of TMJ
  • Damage to adjacent teeth/restorations
  • Extraction of permanent tooth germ
  • Wrong tooth

Question 24

c) Draw the flap design for a surgical extraction of 44. (2 marks)

Answer 24

crevicular incision with a distal relieving incision

Question 25

18. Oral Surgery & Anticoagulants (pp)
    a) Table given, with columns of date, INR, comments and signature.
    Which 2 columns would give you the most useful information on XLA a tooth of a patient on warfarin (2 marks)

Answer 25

INR and date

Question 26

b) On which 2 dates would you not carry out the XLA? (2 marks)

Answer 26

INR has to be below 4 and reading should have been done no more than 24 hours

Question 27

c) Circle the most appropriate analgesic for this patient, post-extraction.
Options included paracetamol, ibuprofen, aspirin and … (1 mark)

Answer 27

paracetamol

Question 28

d) The patient’s INR is unstable. How would the GP assess this? (2 marks)

Answer 28

By taking a blood sample of the patient to assess the prothrombin time

Question 29

e) The patient has switched their medication to apixaban. What is the mechanism of apixaban as a drug? (1 mark)

Answer 29

Factor Xa inhibitor