Oral Surgery Past papers Flashcards by Helena Breslin

Q1 - a fit and healthy 32 year old patient requires surgical removal of his lower left wisdom tooth. He is very anxious about the surgery and has opted to have the treatment carried out under intravenous sedation.

why is written consent required in advance of the treatment day in sedation?

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What drug would a UK trained dentist select to sedate the patient via an intravenous route? and what preparation of this drug should be used?

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What vital signs should you monitor and record before, during and after sedation? (3 marks)

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In the event of over sedation, which drug should you use to reverse the patient?

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List three instructions that the patient should follow post sedation for a minimum of 12 hours after he is discharged from your care

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Q2 Your patient has sustained a displaced fracture of the right body of the mandible

Other than pain, bruising and swelling name six other clinical signs or symptoms commonly described in such an injury (3 marks)

numbness of lower lip
occlusal derangement (pt cannot bite together properly)
loose or mobile teeth/groups of teeth
anterior open bite (shortened ramus due to bilateral subcondylar fracture causes posterior teeth to meet prematurely)
facial asymmetry
deviation of mandible to opposite side

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Q2 Your patient has sustained a displaced fracture of the right body of the mandible

What are the two most appropriate standard radiographic views that may help in establishing the diagnosis of a mandibular fracture

Two radiographs at right angles to each other
- OPT and PA mandible (posterior anterior)

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Q2 Your patient has sustained a displaced fracture of the right body of the mandible

List three factors that may cause displacement of the fracture

direction of fracture line - if unfavourable direction then it is likely to be displaced
opposing occlusion
magnitude of force
mechanism of injury
whether soft tissues are intact or not (compound fracture more likely to be displaced than simple fracture)
number of other associated fractures

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Q2 Your patient has sustained a displaced fracture of the right body of the mandible

list three different treatment options for a fractured mandible

control the pain and infection, providing antibiotics if necessary
if undisplaced no treatment required and monitor and review
if displaced

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Q3 - A 35 year old male presents with pain, swelling, pus and discharge from around a partially erupted lower right wisdom tooth. He feels slightly unwell and has some mild facial swelling

Describe six features you would specifically consider relating to the patients history, extraoral examination or investigations (3 marks)

History of presenting complaint: frequency and severity of episodes, pain history, have they required antibiotics in the past for this
Extraoral examination: is there limited mouth opening

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Q3 - A 35 year old male presents with pain, swelling, pus and discharge from around a partially erupted lower right wisdom tooth. He feels slightly unwell and has some mild facial swelling

What is the appropriate immediate management of this patient? (5 marks)

incision of localised periocoronal abscess +/o local anesthesia (IDB) depending on patient pain
irrigation with warm saline (10-20ml syringe with blunt needle under the operculum)
consider XLA of upper third molar if traumatising the operculum
Advise pt to rinse frequently with warm saline or chlorhexidine mouthwashes
advise pt to use analgesia (paracetamol or ibuprofen)
instruct pt to keep fluid levels up and keep eating, sticking to a soft or liquid diet if necessary
Antibiotics indicated if pt is systemically unwell , prescribe metronidazole (200mg,1 tablet 3 times per day for 3 days)

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Q3 - A 35 year old male presents with pain, swelling, pus and discharge from around a partially erupted lower right wisdom tooth. He feels slightly unwell and has some mild facial swelling

What are the two main nerve branches at risk of damage during the removal of the lower wisdom teeth and which structures would be affected in the event of such damage? (2 marks)

inferior alveolar nerve > supplies mandibular teeth and mucosa/skin of lower lip and chin on that side
lingual nerve > supplies sensory innervation to anterior 2/3rd of the dorsal and ventral mucosa of tongue as well as lingual gingiva and floor of mouth

If these nerves were damaged sensation to the anterior 2/3rd tongue, lip and lower chin may be altered and taste of anterior 2/3rd tongue altered too

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Q4 - you have just completed surgical removal of tooth 37 which fractured during an attempted forceps extraction. Your pt is a 21 year old male with poorly controlled asthma. You intend to prescribe analgesia for the patient

Name a suitable analgesic for this patient that you are allowed to prescribe on an NHS prescription

paracetamol

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which group of analgesic drugs would you avoid in this patient?

NSAIDs

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List all of the essential information that you should include when you are writing an NHS prescription (16 marks)

-All prescriptions written legibly in ink
- Patients full name, address and CHI
- Age and DOB of patient (legal requirement if under 12)
- Name and address of prescriber
- Status of prescriber
- signature of prescriber in ink
- Write names of drugs and preparations clearly using approved titles and no abbreviations
- form (tablet/capsule/liquid) and strength of drug
- dose and dose frequency
- state quantity or volume to be supplied (send)
- duration of treatment
- instructions for how and when (label)

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Where would you refer to for the dose and possible interactions of a drug you are prescribing?

BNF - British National Formulary

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How long is an NHS prescription for a non-controlled drug valid for?

6 months

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Q5 - a 48 year old female presents complaining of fluid escaping from her nose when she drinks. She had tooth 27 extracted 6 months ago - this was a difficult extraction and she says she has been aware of a hole in her gum ever since. You examine her and find a communication between the oral cavity and maxillary sinus

What is the correct clinical term for this problem (1 mark)

Oral-antral fistula

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Other than fluid escape from the nose when drinking, list 5 patient symptoms that may be elicited on taking the history (5 marks)

problems with speech or singing
problems smoking or using a straw
bad taste/halitosis
pain and sinusitis type symptoms
problems playing brass or wind instruments

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Briefly describe the operative procedure to treat this condition, assuming appropriate anaesthesia has been achieved (4 marks)

Excise the epithelial sinus tract
Raise a flap, commonly a buccal advancement flap
excise the periosteum
Antral washout if there is chronic sinusitis
Close OAF using non-resorbing sutures
keep these sutures in for 2 weeks, reviewing the patient after 1 week to assess closure

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Q6 You have extracted tooth 26 but the bleeding won’t stop.

List how you would manage the situation and gain haemostasis

Apply pressure: get patient to bite on damp gauze or if edentulous use mechanical pressure with finger over gauze (gauze must be damp as dry gauze will pull out the clot)
sutures: can suture socket to encourage haemostasis
Haemostatic agents: surgical oxidised cellulose forms a scaffold for blood to clot to, LA with vasoconstrictor
Ligation of vessels with diathermy
Bone wax: bone wax on flat plastic gives waterproof layer over bone

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Q6 You have extracted tooth 26 but the bleeding won’t stop.

What is a local risk factor for delayed onset of bleeding? - revise this questions answer

mucoperiosteal tears
fractures of alveolar plate or socket wall

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Q6 You have extracted tooth 26 but the bleeding won’t stop.

List 2 conditions for each of the following - congenital and acquired bleeding disorders

congenital bleeding disorders: von willebrands’ disease, haemophilia A

Acquired bleeding disorders: end stage liver disease, vitamin K deficiency

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Q6 You have extracted tooth 26 but the bleeding won’t stop.

The patient is on a new oral anticoagulant, should you check the INR no more than 48 hours prior to extraction true or false?

False - INR is not required for NOAC’s
High risk bleeding procedures
- miss apixaban/dabigatran the morning of surgery
- delay rivaroxaban dose until later in day

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Q6 You have extracted tooth 26 but the bleeding won't stop. What should the INR be for a patient on warfarin for oral surgery to be carried out

Q7 A patient attends with suspected dry socket What is the scientific term for a dry socket

localised alveolar osteitis - condition occurring after tooth extraction which results in a dry appearance of the exposed bone in the socket due to the disintegration or loss of the blood clot

Q7 A patient attends with suspected dry socket What are the predisposing risk factors for a dry socket?

- molar teeth (risk increases from anterior to posterior) - mandibular teeth - smoking - female - oral contraceptive pill - local anaesthetic with a vasoconstrictor

Q7 A patient attends with suspected dry socket What are the treatment options

1. Reassure patient - check that it is a dry socket and that no tooth fragments or bony sequestra remain 2. LA block - provide pain relief to allow you to carry out irrigation 3. Irrigate socket with warm saline to wash out food and debris 4. Debridement with a small curette to remove any old clot, encourage bleeding and new clot formation 5. Pack socket with alvogyl (mixture of LA and antiseptic - will disintegrate on own) to sooth pain and prevent food packing 6. advise patient on analgesia and warm salty mouthwashes 7. review patient

Q8 A patient attends with pericoronitis of the lower 8 What is pericoronitis

Inflammation around the crown of a partially erupted tooth - food and debris get trapped under the operculum resulting in inflammation and infection

Q8 A patient attends with pericoronitis of the lower 8 What are the signs and symptoms of pericoronitis

- Pain - swelling intraoral or extraoral - bad taste - pus discharge - occlusal trauma to the operculum - ulceration of operculum - evidence of cheek biting - foetor oris bad breath - limited mouth opening - dysphagia difficulty swallowing food or liquid - pyrexia raised body temperature - malaise - regional lymphadenopathy

Q8 A patient attends with pericoronitis of the lower 8 How is pericoronitis treated

- incise localised periocoronal abscess if required +/- IDB depending on patient/ pain - irrigate with warm saline or chlorhexidine mouthwash (10-20ml in blunt needle under operculum) - XLA of upper third molars if traumatising the operculum - instruct pt to rinse with warm saline or chlorhexidine - give advise on analgesia - do not prescribe antibiotics unless severe

Q8 A patient attends with pericoronitis of the lower 8 What 6 radiographic signs show a close relationship of the lower 8 with IAN?

- diversion of the inferior alveolar nerve canal - darkening of the root where crossed by the canal - interruption of the white lines (tram lines) of the canal - deflection of the root - narrowing of the inferior alveolar canal - dark and bifid roots - juxta apical area

Q8 A patient attends with pericoronitis of the lower 8 What imaging is requested when an 8 is close to IAN?

- OPT

Q8 A patient attends with pericoronitis of the lower 8 What risks should be explained to the patient with regards to damage to IAN of extracting the tooth?

- change in sensation to the lower lip, chin and side of tongue. May also be a change in sensation of taste. This could be temporary or permanent; 10-20% temporary and <1% permanent

Q8 A patient attends with pericoronitis of the lower 8 What treatment option for this patient would reduce the risk of complications stated above?

coronectomy

Q8 A patient attends with pericoronitis of the lower 8 Name 2 scenarios where there would be an increased risk of bleeding for a patient and 2 post operative methods of achieving haemostasis

- patient on an anticoagulant or patient has bleeding disorder.

Q9 A patient attends you practice complaining of jaw stiffness and on examination you notice intra-oral signs of bruxism and diagnose TMD. What are 6 signs and symptoms of TMD

- intermittent pain of several months or years duration - pain on opening - limited mouth opening - muscle/joint/ear pain particularly on wakening - trismus and locking commonly associated - clicking and popping noises - headaches around temporalis region - signs of wear intraorally - linea alba, wear facets, tongue scalloping - facial aymmetry

Q9 A patient attends you practice complaining of jaw stiffness and on examination you notice intra-oral signs of bruxism and diagnose TMD. What 2 muscles should be palpated when querying TMD

- temporalis muscle and masseter muscle

Q9 A patient attends your practice complaining of jaw stiffness and on examination you notice intra-oral signs of bruxism and diagnose TMD You decide to give the patient conservative advice. List 5 points of conservative advice you would give

- reassurance about condition - soft diet - masticate bilaterally - stop parafunctional habits - support mouth opening on yawning - dont chew gum - jaw exercises - massages, relaxation techniques - splints (bite raising appliance like michigan) - medications - NSAIDs, muscle relaxants, tricyclic antidepressants

Q9 A patient attends your practice complaining of jaw stiffness and on examination you notice intra-oral signs of bruxism and diagnose TMD What nerve supplies the TMJ

auriculotemporal and masseteric branches of the mandibular branch of trigmenial nerve

Q9 A patient attends your practice complaining of jaw stiffness and on examination you notice intra-oral signs of bruxism and diagnose TMD What are the mechanisms of a bite splint

- aim to stabilize jaw and ease muscle tension

Q9 A patient attends your practice complaining of jaw stiffness and on examination you notice intra-oral signs of bruxism and diagnose TMD What is arthrocentesis

Q9 A patient attends your practice complaining of jaw stiffness and on examination you notice intra-oral signs of bruxism and diagnose TMD Give two possible surgical options

Q10 A patient attends your surgery for the provision of a complete upper denture. They are retaining one single tooth in the upper arch a 17, which must be extracted. Name 3 possible complications associated with the extraction of a lone-standing upper molar.

- oro-antral communication - fractured maxillary tuberosity - loss of tooth or root in the antrum

Q10 A patient attends your surgery for the provision of a complete upper denture. They are retaining one single tooth in the upper arch a 17, which must be extracted. describe how you would diagnose these 3 complications

Q10 A patient attends your surgery for the provision of a complete upper denture. They are retaining one single tooth in the upper arch a 17, which must be extracted. Outline your management of one of these complications (5 marks - outline all 3 for study purpose)

Q11 what are 6 signs and symptoms of ZOC fractures involving the orbit floor

Q11 what imaging would you take to confirm a ZOC fracture diagnosis

Q11 what are the management options for ZOC fractures

Q12 what are 2 local and 2 general factors to consider for implant placement

Q12 what factors does an implantologist consider before placing an implant

Q12 what bone dimensions are required and how are they best measured?

Q12 give three alternative treatment options instead of an implant

Q13 name the origin insertion and action of the masseter muscle

Q13 name the origin insertion and action of the temporalis muscle

Q13 - name the origin, insertion and action of the medial pterygoid and lateral pterygoid muscles

Q14 a 25 year old patient attends with impacted lower 8s - what are the SIGN guidelines for not advising removal of wisdom teeth?

Q14 a 25 year old patient attends with impacted lower 8s - what are the SIGN guidelines for advising removal of wisdom teeth

Q14 a 25 year old patient attends with impacted lower 8s what are the strong indications for removal of wisdom teeth

Q14 a 25 year old patient attends with impacted lower 8s what is assessed during radiological assessment when removing 3rd molars

Q14 a 25 year old patient attends with impacted lower 8s what is the incidence of a) temporary and b) permanent loss of sensation when extracting mandibular wisdom teeth

Q14 a 25 year old patient attends with impacted lower 8s what type of flap is used for removal of an impacted lower 8

Q14 a 25 year old patient attends with impacted lower 8s name 4 other post operative complications

Q15 Extraction of lower molar How would you achieve haemostasis after an extraction

Q15 what tissues could be responsible for the prolonged bleeding and how would you manage each?

Q15 name 4 risk factors for bleeding

Q16 a 65 year old obese reformed smoker with a history of IHD who successfully completed course of cause related therapy. Despite excellent oral hygiene, his teeth have pockets of 6-7mm that bleed on probing. He is keen to pursue treatment, you elect open flap curettage What information would you give the patient so he can give informed consent?

Q16 a 65 year old obese reformed smoker with a history of IHD who successfully completed course of cause related therapy. Despite excellent oral hygiene, his teeth have pockets of 6-7mm that bleed on probing. He is keen to pursue treatment, you elect open flap curettage After surgery the patient complains of central crushing pain across his chest and down the left of his arm. What is the likely diagnosis and what would be your immediate management if the patient remains conscious

Q16 a 65 year old obese reformed smoker with a history of IHD who successfully completed course of cause related therapy. Despite excellent oral hygiene, his teeth have pockets of 6-7mm that bleed on probing. He is keen to pursue treatment, you elect open flap curettage what do you want the patient to know to minimise the incidence of any post operative complications?

Q16 a 65 year old obese reformed smoker with a history of IHD who successfully completed course of cause related therapy. Despite excellent oral hygiene, his teeth have pockets of 6-7mm that bleed on probing. He is keen to pursue treatment, you elect open flap curettage when should the next review be after 1 week for suture removal and what is the rationale behind this time interval

Q16 a 65 year old obese reformed smoker with a history of IHD who successfully completed course of cause related therapy. Despite excellent oral hygiene, his teeth have pockets of 6-7mm that bleed on probing. He is keen to pursue treatment, you elect open flap curettage what clinical findings would indicate that the treatment has been successful

Q17 Mandibular fracture what are the signs and symptoms of a mandibular fracture?

Q17 how can a mandibular fracture be classified?

Q17 what radiographs would you take?

Q17 what factors would cause a fracture to be displaced?

Q17 how is a mandibular fracture managed?

Q18 maxillary fractures what are the signs and symptoms of a maxillary fracture?

Q18 maxillary fracture - what is the Le Fort classification

Q18 maxillary fracture - what special radiographs would you use?

Q18 maxillary fracture - how is it managed?

Q19 Orthognathic surgery What are the indications for orthognathic surgery

Q19 - what are the risks of orthognathic surgery

Q19 - what investigations are carried out before surgery?

Q19 - give two types of mandibular surgery

Q19 - give two types of maxillary surgery

Q20 - Flap design Design a flap for removal of an impacted lower 8

Q20 flap design Design a flap for a surgical removal of lower 5

Q20 flap design What are the principles of flap design

Q20 flap design what do you assess on a radiograph before removing an 8

Q20 flap design Briefly describe the surgical removal of an impacted lower 8

Q20 flap design what is the use of iodoine for extraction of lower 8

Q20 flap design What are the peri-operative complications

Q20 flap design what are the post operative complications

Q20 flap design Name 3 types of nerve damage

Q20 flap design what are the risks of temporary and permanent nerve damage of removing lower 8s

Q20 flap design what are the aims of suturing

Q20 flap design name 4 types of sutures and give examples

Q21 Sialolith - what might a patient complain of if they have a sialolith?

Q21 what gland/duct is most commonly affected and why

Q21 what investigations can be done

Q21 how can you manage it

Q22 what are the risks related to extractions and how are they managed

Q22 how do you manage an extraction differently for a patient who is on warfarin

Q22 when should warfarin be checked before extractions

Q23 MRONJ - what are bisphosphonates and what conditions are they used for

Q23 how is MRONJ diagnosed

Q23 how do you manage a patient receiving extractions in general practice