Oral Surgery and Oral Med Flashcards
Perform an E/O exam to assess patient for facial fracture.
Diagnose the type of fracture
What futher investigations are required?
What further management if this patient presented to your clinic?
E/O exam - lacerations, nasal bleeding/deviation/patency, palpation of zygoma from behind, mandibular movement, exam of areas supplied by infraorbital nerve (upper lip, lateral nose, lower eyelid)
eye exam - periorbital ecchymosis/subconjuctival haemorrhage, eye mobility to 6 points, diplopia
I/O exam - tenderness, bruising/swelling/haematoma, occlusal derrangement, step deformities, lacerations, loose/broken teeth, anaesthesia/parasthesia
investigation: OM 15/30, CBCT or CT
Call OMFS and refer urgently. might need ORIF. conservative management if undisplaced
Pt has an unrestorable 26 which requires XLA. Pt is on warfarin
- introduce self
- ask about INR and when it was done - ask to see book
- explain why you cant extract tooth today - no jargon
- refer to guidelines - SDCEP: INR within 24hrs, up to 72 if stable <4 for months, do not interrupt meds
- deal with pain (acknowledge pain, analgesia +/- extirpiration
- ask the pt if they understand and if they have any questions
- engage with pt
- communication/sympathy/simple language
Discussion of MRONJ and XLA risks before pt starts therapy
- introduce self and designation
- alendronic acid is a BP
- action of BPs
- why this has a problem in dentistry
- disease called MRONJ and risk - low in osteoporosis (1:10 000)
- removal of tooth after Tx can lead to MRONJ
- does pt have any questions
- empathetic approach
Take a pain history and give provisional Dx
- introduce self and designation
- presenting complaint
- SOCRATES
- provisional diagnosis
- notes legible, well ordered, complete
- empathetic
Handpiece Safety
Back cap bur placement check coupling rotation of bur push bur to see if moves run for 5 seconds - listen and check movement
Suturing - Horizontal Mattress Suture (6 mins)
NB: Mark scheme for simple interrupted suture - pretty much do this twice.
● Correct choice of instruments - Kilner Needle Holders and Gillies Toothed Tissue Forceps (2 marks)
● Mount the needle 1/3 from end (2 marks)
● Correct grasp of needle holder (2 marks) - Hold the needle holders in your dominant hand by placing the thumb and ring finger into the rings and the index finger on the hinge of the blade
● Correct hold for tissue forceps (2 marks) - Hold in pen grip
● Atraumatic handling of flap of tissue with tissue forceps (2 marks)
● Insert the needle at right angles to the wound edge and perpendicular to the surface (2 marks)
● Insert the needle at appropriate distance from wound edge (~2-5mm) (2 marks)
● Pass the needle through flap and retrieve it with an instrument not fingers (2 marks)
● Remount needle correctly as above without use of fingers (2 marks)
● Take a full bite on 2nd side and retrieve it with an instrument – again, not fingers (2 marks)
○ Attempt to re-insert at the same depth in the opposite side of the wound and emerge out of the tissue the same distance from the wound edge as the insertion
● Demonstrate adequate pronation and supination of hand – you seriously get points for this… (2 marks)
● Needle secure during tying of knot (2 marks)
○ Needle placed to side and not flying around/ or thread gathered and needle held secured/ or needle clipped
● 1st throw – two turns, grasp suture at free end, approximate edges (2 marks)
● 2nd throw – one turn in opposite direction, grasp suture at free end and tighten (2 marks)
● 3rd throw – in opposite direction again (no extra marks)
● Cut suture to length suitable for wound site and material used (2 marks)
● Knot to side of the wound (2 marks)
● Final apposition of wound (2 marks)
○ Ensure wound ends close together but no tension on wound + secure knot
● Needle disposed of safely when finished – if not, clip it! (2 marks)
OAF - Take a history - Explain diagnosis from images, X-ray and history - Explain management & surgical closure (6 mins)
● Chronic OAF, patients may complain of:
○ Fluids from nose
○ Speech and singing of nasal quality
○ Problems playing wind instruments
○ Problems smoking or using the straw
○ Bad taste/odour, halitosis, pus discharge
○ Pain/sinusitis type symptom
● ‘An OAC is an acute communication of maxillary air sinus with the oral cavity’
● ‘In your case the communication hasn’t closed over and instead has healed by epithelialising forming a sinus and a permanent communication of the air sinus and the mouth’
● ‘This is something we want to manage as it makes you more prone to developing sinus infections’
● OAF Management
○ Excise sinus tract/fistula – removing epithelium
○ + buccal advancement flap
○ Antibiotics
■ Amoxicillin, 500mg, 7 days, send - 21 capsules, take 1 capsule 3 times daily
■ Doxycycline 100mg, 7 days, send - 8 capsules, take 1 capsule daily (take 2 on day 1)
○ Post-operative instructions:
■ Refrain from blowing nose or stifling a sneeze by pinching the nose
■ Steam or menthol inhalations
■ Avoid using a straw
■ Refrain from smoking
Consenting and Referral for GA
● Process
○ Discussion of GA risks/benefits and all other alternative options
○ Referral to hospital for specialist to assess - if any other teeth of poor prognosis they will be added to this plan to avoid future GA
○ GA will involve day in hospital - need to monitor for full recovery
○ Need of chaperone throughout.
● Risks
○ Very common minor risks:
■ Headache, nausea, vomiting, drowsiness
■ Sore throat or sore nose/nose bleed from intubation
○ Risks from treatment:
■ Pain, bleeding, swelling, bruising, infection, loss of space, stitches
○ Rare major risks:
■ Brain damage
■ Death (say as follows):
● 3 in a million. Need a machine to breathe during op and there is a very small risk that you will not be able to breathe independently again on waking - ie never waking again.
○ Upset when coming round - can make underlying anxiety worse
○ Malignant hyperpyrexia (v. rare - important to ask for FH)
● Conditions requiring special care (can be contraindications)
○ Sickle cell disease (or any hypoxia)
○ Diabetes - can’t fast in same way
○ Down’s syndrome
○ Malignant hyperpyrexia
○ CF or Severe asthma
○ Bleeding disorders
○ Cardiac or Renal conditions
○ Epilepsy
○ Long QT syndrome
● Referral
○ 1. Patient name
○ 2. Patient address
○ 3. Patient/Parent contact numbers (landline and mobile)
○ 4. Patient medical history
○ 5. Patient GP details
○ 6. Parental responsibility
○ 7. Justification for GA
○ 8. Proposed treatment plan
○ 9. Previous treatment details
■ Letter must include:
■ Recent radiographs or if not available an explanation of why (e.g. pt uncooperative)
● Assessment appointment:
○ For treatment planning ONLY and plan may change with specialist opinion
○ **Informed consent - MUST be written
○ GA process, side effects and complications
○ Adult escort with no other children
○ Pre-operative fasting
○ Post-operative arrangements
○ Post-operative care and pain control
50-year old patient about to begin chemotherapy for breast cancer. No idea of need to go to a dentist for assessment but oncologist sent her to you as her GDP. Explain the relevance of dental health for cancer treatment, diagnose a condition of a tooth (gross caries/apical periodontitis from radiographs) and your proposed management. Talk through side effects of treatment and how you can help to manage these.)
● Talk about getting them dentally fit, improving their oral hygiene & looking after their oral health.
○ Chemotherapy puts a toll on the entire body, including the mouth
○ GDP attempt to reduce complications in chemotherapy regime
■ avoid unscheduled interruption of chemotherapy regimen
■ remove potential sources of infection
■ avoid exacerbation of mucositis
○ Finally, plan prevention and rehabilitation
● Tx to be carried out:
○ Full mouth scaling
○ Remove any dubious prognosis teeth or areas of possible infection
■ Normally XLA need ~10 days to heal
■ Should not be done during chemo due to high risk of infection
■ If done after chemo - again higher risk of infection, slower healing, risk of MRONJ
○ Impression for soft splint
○ Smooth down sharp teeth
● Pre-Treatment Prevention:
○ Oral Hygiene
■ x2 brushing daily at least 2 mins time at a time
■ prescribe 2800ppm duraphat (0.619%)
■ interdental cleaning - specifically instruct how to use
○ Fluoride therapy:
■ fluoride varnish, Duraphat toothpaste, trays to fill at night
○ Diet advice
■ avoid spicy and hot foods, avoid fizzy drink, fruit juices, acidic fruit
○ Smoking and alcohol advise if relevant to SH
● Mid-Treatment Management:
○ Minimal role unless emergency +/- manage pathology
○ Mucositis
■ Inflammation and ulceration, severe pain requiring analgesia, impacts on eating and oral hygiene
■ Management:
● General: Avoid smoking, spirits, spicy foods, tea, coffee, non-prescription medicine
● Topical: oral cooling prior therapy – ice, topical lignocaine, saline, sodium bicarbonate, benzydamine hydrochloride, gelclair, caphasol, tea tree oil m/w
○ Candidosis: Pseudomembranous candidosis (Thrush) - Antifungals
● Post-treatment Palliative Care:
○ Maintenance of oral and dental health
○ Prevention: diet, OH, fluoride
○ Monitoring: increased frequency check-ups, pros maintenance
○ MRONJ risk
○ Altered taste
○ Dry mouth
■ Decreased salivary flow: 50-60% in first week, further 20% in next 5-6 weeks
■ Change in saliva consistency and character: increased viscosity, decreased pH
■ Change in taste perception
■ Recovery over period of years, will not return to normal
■ Associated problems: dysphagia, dysarthria, dyspepsia, quality of life
■ Increased risk of: caries, perio, candidiasis, sialadenitis, prosthodontics difficulties
Oral Med - White Patch on FOM (6 mins)
Discuss need for biopsy + possibility of oral cancer. Discuss pt risk factors (smoking + alcohol)
● 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’
● Information on 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
■ Don’t mention 14 units - Consider the patch as a wake-up call to quit
● Urgent cancer referral guidelines:
○ 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
Surgical removal of 8 - Discuss surgical procedure, go through complications for consent (12 mins)
● ‘The treatment is to have the lower L/R third molar removed surgically under local anaesthetic’
● ‘You will be awake throughout the procedure’
● ‘You will be numbed up firstly by an injection in the back of your jaw which will numb that side of your jaw all the way down to your chin. You will not be able to feel anything sharp while we take the tooth out but you will still be able to perceive pressure.’
● ‘The procedure will involve making a cut and raising a bit of your gum, removing bone around the tooth, and possibly sectioning the tooth and removing it piece by piece. This will involve drilling, similar to the one used for fillings. Then we will clean the area with salty water and place some sutures to close up the wound. Once again, you will be numb in the area of treatment during this procedure and will hear sounds of the tooth coming up as well as pressure but no sharpness or pain’
● Complications: pain, swelling, bleeding, bruising, infection, dry socket (failed clot/exposed bone), jaw stiffness, damage to adjacent tooth
● Also: temporary/permanent numbness, prolonged nerve pain, tingling due to damage to the nerve.
○ ‘This is a sensory nerve and any nerve damage will have no effect on your appearance or the way your mouth or jaw moves. This is something only you will be aware of.’
○ Risks: 10% temporary, <1% permanent
○ If roots involved with IDN then nerve damage risks increase to 20% temporary and 2% permanent.
○ If IDN involvement: Coronectomy ‘involving the same procedure as above up to the sectioning of the tooth however only the the crown of the tooth is removed leaving the roots in place to avoid risking nerve damage - this cannot be done if the tooth is carious. If the roots become mobile they will have to be removed as well’
● ‘If you have this procedure performed under local anaesthetic we advise that you refrain from fasting. It is not required to bring someone with you and you will be more than capable of driving yourself home if required however it is advised that you take the rest of the day off from work.’
● Ask if they have any questions.
. Lymph node exam - Cancer Suspicion - Urgent referral (6 mins)
Extraoral exam checking for swollen lymph nodes and you should be able to name the different ones. You get given a picture of a lesion (probably FOM) and you need to take brief history from actor and tell them it could be sinister. Need to console patient and tell them they’ll be referred urgently and what happens next.
● LN Palpation:
○ preauricular, parotid, submandibular, submental
○ occipital, posterior auricular, jugulo-digastric, jugulo-omohyoid, deep cervical, supraclavicular
● Take a brief history
○ Noticed lesion? How long for? Painful? Pain/Problems eating or swallowing? Hoarseness of voice?
○ Relevant MH? Smoker? Alcohol? Regular attender? Daily mouthwash use (alcohol)?
● 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’
● Information on 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 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
■ Don’t mention 14 units - Consider the patch as a wake-up call to quit
● Urgent cancer referral guidelines:
○ 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
. Radiographic Reporting - OPT - Discuss with clinician what you can see (6 mins)
● Go through OPT in systematic manner:
● Demographics
○ type of X-ray, age, date etc
● Quality
○ Grade 1: diagnostically excellent, no positioning errors
○ Grade 2: diagnostically acceptable with error in positioning/elsewhere
○ Grade 3: diagnostically unacceptable
● Dentition
○ Teeth: erupted/unerupted, permanent/primary/mixed, missing/supernumerary, impacted, ectopic
○ Restorations: heavily/moderate/mild restored, overhangs, fractures, poor margins
○ Trauma
● Disease:
○ Caries: primary/secondary, supra/sub-gingival, periapical pathology
○ Perio: periodontal bone levels, localised/generalised, supra/sub-gingival calculus
○ Endo: well/poorly compacted, material, ?mm from apex/to apex, separated instruments etc
○ TMJ
○ Other pathology: cysts
● Diagnosis
Pericoronitis Prescription - Alcoholic (6 mins)
Patient has severe pericoronitis, is feeling unwell and has pus suppurating from the site.
You have irrigated but feel antibiotics are required to treat the patient. Note the patient is an alcoholic.
You are provided with all the details and a prescription pad to write a prescription.
● Amoxicillin prescription
○ Metronidazole is the most common antibiotic, but it’s contraindicated due to an alcohol problem.
○ Still get a mark for prescribing metronidazole but have to mention alcoholism on prescription for pharmacist.
● Prescription:
■ Amoxicillin Capsules, 500mg
■ SEND: 9 capsules
■ LABEL: 1 capsule 3 times daily for 3 days
○ Patient’s name - correct place (2 marks)
○ Patient’s address, postcode - in full (2 marks)
○ Patient’s CHI - correct area (2 marks)
○ Number of days treatment - correct number of days - 3 (2 marks)
○ Acceptable drug and formulation - amoxicillin, 500mg capsules (1 mark)
○ Correct drug dose - 500mg (2 marks)
○ Correct frequency - 3x a day (2 marks)
○ Correct duration of treatment - three days (2 marks)
○ Total number of capsules - 9 (2 marks)
○ Prescription signed and dated - correct area (2 marks)
○ Written in indelible ink - pen used (2 marks)
Extraction Post-op Advice (6 mins)
● Bleeding:
○ If bleeding does occur, arrest with wet gauze using firm pressure for 20 minutes, if unable to arrest, contact the emergency number provided
○ If it doesn’t stop bleeding, phone emergency contact first
○ If continues to bleed/out of hours go to A&E
● Rinsing:
○ Do not rinse the area, for the first 24 hrs
○ After 24hrs you should rinse mouth with warm saline/salt water gently 3-4 times day
● Care:
○ Do not bite lip, cheek or tongue while numb
○ Do not disturb socket with finger, tongue or toothbrush, avoid probing the site
○ Brushing other teeth as normal, avoid that area
○ Inform the patient that they may experience swelling and bruising - should peak at 48hrs, if increasing after this, contact the GDP
○ Avoid hot and hard foods
○ Avoid excessive exercise
○ Eat soft foods on opposite side to extraction for a few days
○ Avoid/Cut down smoking over the next few days/week
○ Avoid alcohol for as long as possible (24 hours)
○ Gentle rinsing after the first day with warm salty water
○ Swelling: peaks at 48 hours, resolves in around 7 days.
■ Can use ice pack today when you go home (5 mins on, 5 minutes off for an hour)
○ If sutures: dissolve on their own in about 2-4 weeks
● Pain :
○ Expect some pain at first
○ Painkillers before analgesia wears off fully
○ Take normal painkillers: Ibuprofen and Paracetamol
○ If pain worsens after 2-3 days return to the practice: possible infection or dry socket
○ Take analgesia as for a headache for 1-3 days after the op and begin before LA wears off
● Provide emergency contact number
