OS/OM/OMFS

Question 1

You area GDP. A 72yo male presents C/O a 4/52 Hx of a sore tongue. There is no Hx of trauma and he is F+W

Your EO exam is clear

IO there is a 1cm ulcer on the right lateral tongue. There is a #d amalgam on tooth 47.

Take a SH and discuss your initial management of the ulcer.

List features that would make you suspicious that the ulcer is malignant

6 mins

Answer 1

Introduction - name and designation

SH - smoking (y/n/ex, frequency, amount, how long, product, prev quitting Hx, how soon after waking up), alcohol (frequency, quantity, product), occupation
FH - OSCC/prev cancer

Initial Mx - take photos, note lesion description, replace/repair/smooth amalgam fracture.
R/V - 7/7 for signs of healing

Malignant - non healing, raised rolled margins, firm necrotic centre, exophytic

Question 2

You are a DCT in OS. Obtain consent from the F+W 24yo female, for XLA of an unrestorable 46 under IV sedation

12 mins

Answer 2

Introduction - name and designation

How are you? Have you been well?

So you have a tooth down on the bottom right that needs to come out because we unfortunately aren’t able to save it. We’ve also agreed to take it out using sedation, so I’ll explain what the process will involve and then if you have any questions I’ll try to answer them for you.

If you are nervous about having treatment or the procedure is more complex, IV sedation is an ideal way of helping you relax. We give a sedative drug, called midazolam, into a vein. It usually takes a few minutes for us to get to the correct dose for you - this is when you will feel very relaxed and sleepy and less anxious. You will still be awake and able to understand and respond to requests from the dentist. It’s likely you’ll have amnesia once the effects wear off, so you won’t remember the operation.

So what happens? A very thin plastic tube will be put into a vein in one of your arms or in the back of one of your hands. The sedative will then be injected slowly and you’ll start to feel sleepy and relaxed. Throughout the procedure, you will have a monitor attached to your finger to measure your pulse and oxygen levels and a blood pressure cuff around you arm to measure your blood pressure.

Once you feel relaxed, you will be given local anaesthetic, which is an injection into the gum around the tooth that will be coming out. This will take a couple of mins to numb the area and makes sure that you won’t feel any pain during the procedure.

The sedation will last for around 40 minutes to an hour, which should be plenty of time to complete the extraction.

During the extraction, we will make a small cut in the gum beside the tooth, before using a drill to remove some of the bone that’s holding the tooth in. You’ll feel some vibrations and the water spray as well. Once we’ve down that, we’ll try to wiggle to the tooth out - you might feel some pushing or pressure and hear some funny noises. We might have to use the drill to help us remove the tooth and take it out in a few pieces. Once the tooth is out, we’ll put the gum back where it was and stitch it back together.

Before you come in, take any medications as normal unless advised otherwise. Have a light meal a n hour or two before. Don’t drink any alcohol or take any recreational drugs for 48 hours beforehand. You’ll need to bring an adult with you, to escort you home afterwards and care for you for the rest of the day. Don’t bring any children with you to your appointment.

After the sedation, you’ll need to stay in the recovery area until the effects have worn off. You’ll need to travel home with your escort. For the next 24 hours don’t drive, operate machinery, return to work or sign any important or legal documents. If you have children, you should arrange for someone else to look after them during this time.

After XLA - sore, numb, swollen, bleeding, bruising, temp/perm altered/painful/loss of sensation, dry socket, infection, damage to adjacent teeth, altered taste, jaw stiffness, stitches (will dissolve within 2-3/52). Will advise you on what to expect post-Rx and how to manage this at your treatment appointment.

The alternatives to having this would be local anaesthetic alone or general anaesthetic.

Does that all make sense? Do you have any questions?

Question 3

Give post-extraction instructions, explaining what to expect and how to manage the complications

6 mins

Answer 3

Introduction - name and designation

Going to run through a list of what to expect now that the tooth is out and how you can manage this

You’ll be numb for the next few hours. Take care not to bite your lip/cheek/tongue and avoid anything too hot. Once the anaesthetic wears off it might be sore, so take some painkillers before this happens. Take whatever painkillers you’re able to - you can take paracetamol or ibuprofen as explained on the box - usually it’s 2 tablets every 4-6 hours. You can alternate between them, taking one then the other 2 hours later, then the first 2 hours after that as long as you need them.

Bruising and swelling may develop over the next 2-3 days, it varies between people. If it does, you can use a cold compress (frozen peas covered with clean towel) for 20mins at a time to help reduce this.

A small amount of blood in your saliva/when you brush your teeth over the next few days is completely normal. If you think it’s more than expected, roll up a piece of gauze, wet it under the tap and bite firmly for 20 mins. If it’s still bleeding after 20 mins, repeat, if it’s still bleeding contact us/NHS24. There’s a clot forming in the socket, so try not to disturb this with your tongue or toothbrush. Avoid exercising or drinking alcohol today as this increases your blood pressure and increases the chance of it starting to bleed. If the clot is lost, there’s a chance that it might get sore and have a bad taste/smell - this is called a dry socket. If this happens, we’ll need to see you back and put something in it to calm it down. You’re more likely to get this if you smoke, so avoid smoking for the next 48 hours if you can, otherwise it would be a good time to quit

Your jaw might be a wee bit stiff over the next few days. Just take care not to open your mouth too far, so a soft diet for a few days would be advisable. You should cut your food up into small chunks and eat on the opposite side.

There’s a risk that it could get infected, so it’s important to keep it clean. Brush your teeth as normal with a soft toothbrush but take care around that area. From tomorrow, 1tsp of salt in hot water, gently swill around for 60s as a mouthwash will help keep it clean. Do this 3-4x per day.

You have a few stitches that are holding the gum together, to help it heal. These may be annoying but will dissolve over the next 2-3 weeks. If they fall out earlier, that’s alright.

If you have any questions or concerns, phone the practice during opening hours. Out with this, it would be NHS24 on 111.

I’ll give you some gauze and a copy of everything I’ve talked about on a piece of paper, so you don’t have to remember it all.

Does that all make sense? Do you have any questions?

Question 4

You are a DCT in OS. Obtain consent from the F+W 24yo female, for surgical XLA of her 48.

12 mins

Answer 4

Introduction - name and designation

The plan is to remove your bottom right wisdom tooth surgically using local anaesthetic. This means you will be awake but numb for the whole procedure

You will be numbed by a couple of injections at the back of your mouth that will numb up your lower lip, chin and tongue on the right side and the tooth itself and the gum around the tooth. This will mean that you won’t feel any pain during the treatment, but you might still feel pushing and pressure. We’ll check your nice and comfortable before starting.

The procedure will involve making a cut into the gum and raising it to push it away. Then some of the bone around the tooth will be removed and maybe some of the tooth will be cut to make it easier to take out. This will involve some drilling/vibrating, like the type used for fillings, with some salty water. You’ll then feel some pushing/pressure and strange noises as the tooth is removed.

Once the tooth is out, we’ll clean the area with some salty water, get rid of any infection that might be there and make sure the bone is nice and smooth before replacing the gum back to where it should be and stitching it to hold it in place while it heals together. The stitches will stay in place for around 2-3 weeks before dissolving.

Complications - pain, swelling, bleeding, bruising, infection, dry socket (failed clot/exposed bone), jaw stiffness, damage to adjacent tooth/restoration, tooth #, jaw #, altered taste, stitches, need for further treatment

There is a risk during the procedure of prolonged temp/perm altered/painful/loss of sensation. This might feel like numbness, tingling or a painful sensation and occurs due to damage to a nerve that runs close to the roots of the tooth. This is a sensory nerve and supplies sensation to the lower lip and chin on the right side of your mouth. It won’t affect how you look or how your jaw moves. There’s around a 10% risk of a temporary problem and a less than 1% risk of this happening permanently. If the roots of the teeth are on contact with the nerve, then the risks increase to 20% and 2% respectively. If this happens, it usually returns to normal within a few months. Rarely does it last for longer and very rarely does it persist permanently. There’s an even smaller risk of your taste being affected either temporarily or permanently

If this is the case, then we might offer to perform a treatment called a coronectomy of the tooth instead of taking it out. Practically this is very similar to the procedure, but we would cut the top off the tooth and remove it and leave the roots in place to avoid damaging the nerve. However if the tooth is decayed or the roots become mobile during the procedure, we will have to take them out.

Because you’re having this done under local anaesthetic only, make sure you have something to eat around 1-2 hours before hand - please don’t fast. You don’t have to bring anyone with you and you will be able to drive yourself home, however we would recommend at the very least taking the rest of the day off and probably the day after as well. Although minor, this is still a type of surgery, so make sure you give yourself the best chance to recover.

Does that all make sense? Do you have any questions?

Question 5

You are a DCT in OS. A F+W 27yo female attends for SR 38 due to recurrent pericoronitis and would like to know the options for XLA.

Discuss the options to control pain and anxiety during surgical procedures.

You do not need to take a history

6 mins

Answer 5

Introduction - name and designation

Pt concerns - anxiety?

Options:

1. LA only. This would involve a few injections at the back of the mouth and into the gum. It will numb you up, so you won’t feel any pain at all, but you’ll still feel some pressure and pushing. You will be awake and completely aware of what’s going on. You will be able to drive yourself home and won’t need anyone to look after you afterwards. It’s fairly simple, quick to do and is very effective
2. Sedation - IV. IV sedation involves putting a very thin plastic tube will be put into a vein in one of your arms or in the back of one of your hands through a cannula. A sedative will then be injected slowly and you’ll start to feel sleepy and relaxed. It helps to make you less anxious. You will still need to have local anaesthetic injections as it doesn’t numb you up. Throughout the procedure, you will have a monitor attached to your finger to measure your pulse and oxygen levels and a blood pressure cuff around you arm to measure your blood pressure. You will also need someone to drive you home and look after you for 24hrs afterwards and you shouldn’t drive, operate machinery origin legal documents during this time. You’ll also need to arrange for someone else to look after any children and it’s not suitable if you’re pregnant
3. GA. This would take place in a hospital. You would be put to sleep, through a cannula in your arm and an anaesthetic mask by an anaesthetist. Once you were asleep, you would have the tooth taken out. When you wake up you might have a headache, feel tired, nausea, be sick and have a sore throat/nose depending on where the breathing tube was. There are also some major risks. During GA, you need a machine to breathe for you. There is a very small risk - around 2-4 per million, that you might not wake up after anaesthesia or not be able to breathe independently again.
4. Pre-sedation medication. The final option would be to take a low dose sedative before having the procedure undertaken using LA only. This pill is take 1-2 hours before treatment and reduces anxiety and makes you more relaxed. You will still be aware of what’s going on and need an escort to and from the appointment. Because it’s such a small dose, the effect might be limited or unpredictable, but would mean you wouldn’t have to be assessed for sedation/put on a long waiting list

Does that all make sense? Do you have any questions?

During LA ± oral sedation, we can use relaxation and anxiety management techniques, such as stop signals, desensitisation and acclimatisation

Question 6

You are a GDP. A 40yo male emergency patient attends C/O RHS swelling. He has T1DM.

Your examination shows a carious 46, with a dentoalveolar abscess.

What clinical findings and features in the history would suggest a rapidly spreading infection and what criteria would you use to decide if to refer this patient

How would you treat this patient if they did not require referral

6 mins

Answer 6

Introduction - name and designation

Hx - how long for, progression (rapid onset), problems swallowing/talking/breathing, raised/firm FoM/tongue, very large swelling, tracking down neck/to submandibular area/parapharyngeal space, crossing midline, fever, sweating, uncontrolled diabetes, deviated uvula, increased HR, severe trismus, systemic Sx in immunocompromised pt

SIRS criteria - HR >90, RR >20, temp <36 or >38, WCC <4/>12x10^9/l. If 2/4 - refer

XLA/extirpate and I+D
ABx if systemic Sx/immunocomp - pen V 250mg 2x QDS 5/7 or amox 500mg TDS 5/7 or metro 400mg TDS 5/7

R/V within 7/7

Question 7

You are a GDP. A 43yo male attends C/O pain from 17. He is F+W.

Your examination shows the tooth is unrestorable. A PA XR shows that the roots are closely related to the sinus lining.

Discuss the procedure and possible complications

6 mins

Answer 7

Introduction - name and designation

Procedure - LA, test, loosen tooth, remove tooth, stop bleeding.

Risks - pain, bleeding, bruising, swelling, jaw stiffness, infection, dry socket, damage to adjacent teeth, prolonged temp/perm altered/painful/loss of sensation, tooth #, root in sinus, OAC/OAF, need for further Rx.

Specifically, OAC

OAC is a small communication between the air sinus and nose and mouth. This occurs due to the roots of the teeth being in the sinus and then removed, leaving a hole, or when they are very close to the thin sinus lining.

If this happens, you might feel a strange bubbling if you hold your nose and gently blow or fluid in your nose when you drink. If it persists, you might have a blocked/stuffy nose or sinusitis-type Sx.

If it happens and is a very small communication, these tend to resolve spontaneously. We might need to put in a stitches just to help it heal. If it’s a larger one, we might need to cut into the gum and stretch it over the top, to close it over. We would review you in a week or so and then depending on the stitches, we would review you back a week later to remove them or they would dissolve on their own after 2-3 weeks.

We would also advise you not to blow your nose, so air isn’t forced through the gap which might open it again. You should avoid using straws or playing any wind or brass instruments for a few weeks. Brush your teeth as normal, and you can rinse gently with a warm salt water mouth rinse from tomorrow. You can try steam inhalation as well and also stifle your sneezes if you can. Also avoid smoking

There’s a chance that it doesn’t heal and forms a chronic tract - this is called an OAF. If this happens, we would refer you to have this removed.

There’s also a small chance that if the tooth breaks when we’re removing it, that a small bit of the root breaks off into the sinus. If this happens, we’ll gently try to remove it, but failing that we would have to refer you to have it taken out.

Does that all make sense? Do you have any questions?

Question 8

You are a GDP. A 37yo male attends 3/12 after XLA of 25 C/O nasal speech.

Clinical photos and XR provided - photos 18

Take a Hx, provide a Dx and describe Mx options for this pt

6 mins

Answer 8

Introduction - name and designation

Hx - nasal speech/singing? Fluids from the nose? Problems playing wind/brass instruments? Problems using a straw/smoking? Bad taste/smell, breath? Pus discharge? Any pain or sinusitis Sx?

Dx - OAF

An OAC is a communication between the air sinus that sits beside the nose and the mouth. These can occur when a tooth is taken out and it’s roots were close to the lining of the sinus or they sat in the sinus. In some cases it heals normally, but in other cases the communication doesn’t close over and instead forms a permanent tract between the air sinus and the mouth. That’s what’s happened here. This is something we want to manage because it increases the likelihood of you getting sinus infections.

Mx - Removal of tract + primary closure/BAF.
To manage this, we would numb you up and cut out the tract. We might then need to cut into the gum to stretch it over the hole that’s left and then put in some stitches.

We would give you antibiotics (pen V 250mg 2 QDS 5/7 or doxy 100mg BD day 1, OD 7/7 (8 capsules)) and review you in a week or so to check the healing.

We would also advise you not to blow your nose, so air isn’t forced through the gap which might open it again. You should avoid using straws or playing any wind or brass instruments for a few weeks. Brush your teeth as normal, and you can rinse gently with a warm salt water mouth rinse from tomorrow. You can try steam/menthol inhalation as well. Don’t stifle your sneezes if you can. Also avoid smoking

Does that all make sense? Do you have any questions?

Question 9

You are a DCT in OMFS. A 27yo female presents C/O bilateral TMJ clicking and sore jaw muscles (worse in the morning). She is F+W and a school teacher

Clinical photos are provided for IO exam - photos 17

Provide a Dx to the patient and discuss conservative Mx

6 mins

Answer 9

Introduction - name and designation

Clinical photos - linea alba, tongue scalloping

Dx - TMD

You have something called temporomandibular disorder, or TMD. This is a very common condition, that around 75% of the population have it at some point.

The jaw joint sits in front of the ears. It is a ball and socket joint. The ball end on the lower jaw sits in a socket in the base of the skull. There is a thin disc running between them that acts as a cushion and allows the joint to move smoothly. Muscles around the joint control opening and closing. Like any muscle, it gets tired if it’s overworked - like how you legs get sore if you climbed a mountain. The way you would help your legs recover would be to rest them. However, because your jaw is used all the time for speaking and eating, it never gets a rest and the muscles become inflamed and sore.

It also causes other symptoms like tooth wear, especially your canine teeth, white lines along the inside of your cheeks and scalloping of your tongue.

The fact you’re also sore in the morning tells us that you clench and grind your teeth at night as well, which puts mores stress on the muscles and exacerbates the problem.

The clicking by your ear is caused when the disc the sits in the joint gets trapped in front of the bones and slips/clicks back into place

Before I tell you how we can manage it, do you have any questions?

The good news is the management is very simple - it involves helping the joint to rest.

Ways to do this include having a soft diet or cutting food into small pieces, chewing on both sides, avoiding chewing gum or sticky foods, avoiding opening wide, supporting your jaw when you yawn and avoid any habits in the day, such as biting nails or pen lids, clenching or grinding.

Other things you can do include using painkillers (ibuprofen/paracetamol). Take these regularly for a week or so (usually 2 tablets every 4-6 hours), before starting to reduce the dose. You can also use heat packs for 20 mins at at time and massage the muscles as well.

There’s evidence that it’s linked to stress, so general stress reduction, where possible, is useful, as are things like yoga, meditation or mindfulness.

We can also make you a mouthguard, called a splint, to wear at night and as often throughout the day as you’d like to break any clenching/grinding habits (upper hard acrylic appliance with canine rise).

If it doesn’t get any better, we can look at referring you to a physio or to a specialist who can prescribe other medications or we might refer you to someone who would flush out the joint

It’s a common condition that often improves with simple conservative Mx. It is important to try to reduce stress though, because this is likely making it worse. A lot of the time it’s easier said than done!

Does that all make sense? Do you have any questions?

Actor marks for communication, simplicity of language and empathy.

Question 10

You are a GDP. A 24yo female attends C/O a clicking jaw joint, with no pain. She has had this for a few years but has noticed recently that sometimes her jaw locks open

Explain what could be happening to cause her Sx and how she can manage them

6 mins

Answer 10

Introduction - name and designation

Dx - ADD ± R

You have something called anterior disc displacement.

The jaw joint sits in front of the ears. It is a ball and socket joint. The ball end on the lower jaw sits in a socket in the base of the skull. There is a thin disc running between them that acts as a cushion and allows the joint to move smoothly. Muscles around the joint control opening and closing.

Sometimes the disc can slip out of position in front of the joint. When this happens, it stretches during opening and then when the joint moves so you can open wider, it slips/clicks back over the joint into position, allowing you to open wider. Sometimes it gets stuck and you have to manually open/close your jaw to fix it.

The good news is the management is very simple - it involves helping the joint to rest.

Ways to do this include having a soft diet or cutting food into small pieces, chewing on both sides, avoiding chewing gum or sticky foods, avoiding opening wide, supporting your jaw when you yawn and avoid any habits in the day, such as biting nails or pen lids, clenching or grinding.

Other things you can do include using painkillers (ibuprofen/paracetamol). Take these regularly for a week or so (usually 2 tablets every 4-6 hours), before starting to reduce the dose. You can also use heat packs for 20 mins at at time and massage the muscles as well.

There’s evidence that it’s linked to stress, so general stress reduction, where possible, is useful, as are things like yoga, meditation or mindfulness.

We can also make you a mouthguard, called a splint, to wear at night and as often throughout the day as you’d like to break any clenching/grinding habits (upper hard acrylic appliance with canine rise).

If it doesn’t get any better, we can look at referring you to a physio or to a specialist who can prescribe other medications or we might refer you to someone who would flush out the joint.

We will take a scan to look at the joints and can refer you for an ultrasound scan of them. This will help us to see if there are any problems with the bones of the joint themselves, or the disc, and see if they need any direct treatment.

It’s a common condition that often improves with simple conservative Mx. It is important to try to reduce stress though, because this is likely making it worse. A lot of the time it’s easier said than done!

Does that all make sense? Do you have any questions?

Question 11

List post-extraction complications that may occur

6 mins

Answer 11

Pain, bleeding, swelling, bruising, jaw stiffness, infection, dry socket, prolonged temp/perm altered/painful/loss of sensation, damage to adjacent teeth/restorations, tooth #, need for further Rx/referral ± stitches ± Bx

Upper - root in sinus, OAC/OAF, maxillary tuberosity #
Lowe - altered taste, jaw #

Question 12

Describe how to place a:

1. Simple interrupted suture
2. Horizontal mattress suture
3. Vertical mattress suture

Select a suitable suture material for an IO wound

Describe operator positions for XLAs

6 mins

Answer 12

Use Kilner needle holders and Gillies toothed tissue forceps
Mount needle 1/3 from end of stitch. Kilner in thumb/ring finger, Gillies pen grip.

1. Atraumatic handling of tissues. Needle 90 degrees to wound edge, perpendicular to surface. 2-5mm from wound edge. Pass through, retrieve with instrument, remount, full bite on second side, retrieve with instrument (same depth and distance from wound as first side). Drop needle, hold suture in L hand, Kilners in R. 2 throws away, tighten flat. 1 throw back, tighten flat. 1 throw away, tighten flat. Ensure knot on wound edge, not on top. Cut to 3-5mm, final wound apposition (edges close, no wound tension, secure knot). Dispose of needle
2. First pass as per 1. Then remount suture facing opposite way, insert distal and parallel to first suture and repeat process (going in opposite direction), finishing up on original side, same distance from wound edge. Tie suture as per 1
3. First pass as per 1, but 5mm from wound edge and deep. Second pass as per 2, but superficial to first pass, in line and 3mm from wound edge. End up on same edge as where started, suture ends in line, 2-3mm apart. Tie suture as per 1

Resorbable - most IO wounds. Polyfilament (Vicryl, Velosorb, Polysorb). Monofilament (Monocryl).

Non-resorbable - OAC, skin closure, hold dressings when exposing canines. Polyfilament (silk), monofilament (Prolene, nylon)
Polyfilament not for contaminated wounds - absorbs fluids and bacteria causing colonisation of suture strands (wicking)

Upper - pt supine. Lowers - pt upright
UR, UL, LL - stand in front and to right
LR - stand behind and to the right

Question 13

Discuss O2 saturation curve, alarms, max NO2 in RA and contraindications for sedation

6 mins

Answer 13

Normal O2 - 97-100%. O2 saturation curve measures affinity for O2 (Hb/blood). Alarm at 90%< hypoxic at 85%. If dropping, stimulate the pt, supplemental O2 (nasal cannula - 2l/min), reverse with flumazenil (500mcg/5mg)

Max NO2 - 70% (min 30% O2)

Sedation C/I - severe COPD, hepatic insufficiency, pregnancy/lactation, myasthenia graves, hypothyroidism, <12yo. ASA III/IV

RA C/I - common cold, tonsillitis, nasal blockage, severe COPD, pregnancy (first trimester), clautrophobia, unable to coordinate nasal breathing with mouth open (too young/learning difficulties). ASA III/IV

Question 14

What information should be included in a referral letter for SR lower 8

6 mins

Answer 14

Pt details - name, CHI/DoB, address, contact number
GDP details

Reason and urgency (C/O, HPC)
MH, PDH, SH
Exam - EO (lymphadenopathy), IO (STs, tooth in question if erupted). UE/PE/erupted, close to IDC (attach XRs ± photos)
Any other relevant info - LA/sedation/GA
Discussed Rx with pt inc risks/benefits, alternatives
Aware first appt is assessment, not Rx

Question 15

You are a GDP. You have just administered an IDB on a pt, when their face and mouth start to droop.

Describe what you think may have happened and how you would manage this

6 mins

Answer 15

Stop what you are doing

Introduction - name and designation

Ask if pt can close eye, raise arms straight and hold them, wrinkle forehead.

Dx - facial palsy.
Explain -some of the anaesthetic from the injection has made it’s way into the salivary gland at the side of your face, in your cheek. There is a nerve in here that supplies feeling and action to some of your face, including your forehead, eyelid and mouth. Some of the anaesthetic has numbed this nerve up, causing it to stop working temporarily.

Other Sx - slurred speech, generalised weakness ipsilateral face, obliterated nasolabial fold

Mx - reassure (confirm not a stroke), will wear off when the LA wears off, cover eye with damp pad until blink returns. Rebook Rx

Phone pt later to see if ok (same day, next day)

Question 16

You are a GDP. A 36yo male emergency patient attends with pain, inflammation and pus suppuration around 48, with generalised lymphadenopathy and is feeling unwell.

You have diagnosed pericoronitis.

You have irrigated but feel antibiotics are required to treat the patient. The patient is an alcoholic.

Write a prescription for this patient

6 mins

Answer 16

Introduction - name and designation

Explain - because feeling unwell/neck swelling, shows that infection has spread beyond tooth into lymph nodes. Will give antibiotics to help fight this infection

Normally prescribe metro, but as interacts with alcohol (disulfiram-like reaction), will make pt v unwell if drinks alcohol.

Amoxicillin capsules, 500mg. Send 9 capsules. Label 1 capsule three times daily for 3 days

Pt name, address, postcode, CHI. Number of days of treatment - 43 days
Score out rest of prescription
GDP stamp/details and sign and date

Question 17

You are a DCT in OS. A 63yo male attends for I+D of an abscess around 44, which has persisted after a course of antibiotics.

Describe how to sample this and complete the path form

6 mins

Answer 17

HH, PPE (gloves)

Aspirate - needle and syringe into abscess, draw up pus. Safely remove needle (sheath intact, safely remove, into sharps). Red cap on syringe hub. Label with pt details and place in plastic bag

Path form - pt details on top (sticker if possible, if not CHI, DoB, sex, surname, first name, address, postcode)
Requested by - full name
Consultant - full name
Contact number
Hospital - GDH, 378 Sauchiehall Street, Glasgow, G2 3JZ
Dept - Oral Surgery

Ix required - culture and sensitivity (bacterial/fungal), PCR and viral load (viral), hystopath (tissue Bx)

Collection date and time - date and time of aspire

Nature of specimen/site - pus aspirate of buccal mucosa of tooth 44 (lower right first premolar)

Clinical details/provisional Dx - Xmm swelling buccal mucosa of tooth 44. Tooth was unrestorable with acute apical periodontitis. Tooth was extracted. Sample of pus from associated swelling/area of infection. MH - X.

Provisional Dx - dentoalveolar abscess.

Risk of infection - no

Name and signature and date

Question 18

Name and describe the purpose of the oral surgery instruments provided in the clinical photos

Photos provided - photos 19

6 mins

Answer 18

1. Bowdler Henry Tissue (Rake) Retractor - flap reflection, protect soft tissues
2. Bone Ronguers/nibblers - trim bone, remove spicules
3. Curved Mosquito forceps - pick up sequestra. # instruments/posts, artery clips
4. Gillies toothed tissue forceps (toothed tweezers) - manipulate suture, soft tissue handling
5. Mitchell’s Trimmer - debridement of soft tissue and bone
6. Bone Rasp (File) - smooth down rough bone
7. Victoria curette - soft tissue debridement
8. Fickling forceps - hold soft tissues, pick up teeth
9. Spencer Wells foceps - picking up teeth, removing sharp bony spicules
10. Curved Iris scissors - cutting suture
11. Allis Tissue forceps - hold soft tissues, pick up teeth
12. Kilner Needle Holder - hold suture needle
13. Lacks Tongue Depressor - depress/retract tongue soft tissue retraction/protection
14. Kilner (S-Shaped) check Retractor - retract cheek/soft tissues
15. Light handle (green) cover - cover light, allow it to be moved to improve vision whilst maintaining clean surgical field
16. 20mls plastic syringe - for aspirating/flushing out with saline
17. Galli pot - storing liquids (saline), storing teeth/fragments of bone
18. Swabs (x5) - achieve haemostasis, keep site clean/free of debris/blood
19. Blade remover - removing blade from scalpel handle safely
20. Sharps pad (behind) - sticky pad to stick sharps on to reduce chance of needle stick injury. Folded and disposed of in sharps box when all sharps on pad
21. LA Syringe (long) - delivering LA
22. Marking pen - marking site/drawing flap
23. Cryers elevators (R&L) - elevate teeth and roots, create space for forceps placement (dilate sockets, create application point), removal of interradicular bone
24. Warrick James elevator (R, L, straight) - elevate teeth and roots (particularly upper 8s), create space for forceps placement (dilate sockets, create application point)
25. Couplands elevators (1,2,3) - elevate teeth and roots, create space for forceps placement (dilate sockets, create application point)
26. Ash Periosteal elevator - raise soft tissue flap, flap retraction
27. Howarth Periosteal elevator (x2) - raise mucoperiosteal flaps, flap retraction
28. Swann Morton Scalpel handle (with No 15 blade) - incision for flaps/Bx/access
29. Dental probe - test LA, test surface, caries detection
30. Collage tweezers - handle pledgets, decried soft tissues/sequestra
31. Dental mirror - indirect vision, soft tissue retraction

Others
Luxators (3, 5, S, C) - sever/break PDL, improve access and mobility of teeth
Surgical aspiration tip - aspirate blood, saline, saliva, keep site free from contaminants and improve visibility
Forceps (upper straight/universal/L+R molars/roots/Bayonets/Bayonet roots; lower universal/molars/cowhorns/roots) - extraction of teeth/roots

Question 19

State the fracture type most likely from the photo available and clinical history.

Perform an E/O exam (on a mannequin) to assess this patient for the facial fracture.

Suggest further investigation for this fracture type, what you can see on the investigation, and further management if you had this patient present to you in a standard dental surgery.

Clinical photos provided - photos 20

6 mins

Answer 19

Dx - mandibular #

Hx - full out head injury (LoC, headache, amnesia, dizzy, vomiting, nausea, confusion), how it happened, what hit with, how many times, direction, police/alcohol, witnesses

ATLS principles - ensure airway and C-spine clear, breathing, circulation, disability, exposure. Once happy, secondary survey (EO exam)
Look from above and in front - asymmetry, bruising (SL haematoma), AOB/occlusal derangement (deviation), step deformity, paraesthesia (lower lip/chin), lacerations, pain, limited opening, loose/displaced/# teeth, bleeding, mucosal tears/IO bruising, step deformity, root exposure, gaps between teeth, battle signs (bruising behind ears/bleeding from ears)

Ix - OPT and PA mandible (likely 2#s) ± CBCT

Mx as a GDP - phone OMFS/ED - urgent referral for assessment ± surgery (closed reduction + IMF or ORIF). Conservative advice - limit opening, analgesia, v soft diet for 4/52 ± splint any teeth, maintain good OH

Classification - simple/compound/communited, single/double/multiple, site, uni/bilateral, displaced/not, favourable/not, greenstick/pathological/hairline

Question 20

State the fracture type most likely from the photo available and clinical history.

Perform an E/O exam (on a mannequin) to assess this patient for the facial fracture.

Suggest further investigation for this fracture type, what you can see on the investigation, and further management if you had this patient present to you in a standard dental surgery.

Clinical photos provided - photos 21

6 mins

Answer 20

Dx - ZOC #

Hx - full out head injury (LoC, headache, amnesia, dizzy, vomiting, nausea, confusion), how it happened, what hit with, how many times, direction, police/alcohol, witnesses

ATLS principles - ensure airway and C-spine clear, breathing, circulation, disability, exposure. Once happy, secondary survey (EO exam)
Look from above and in front - forehead, orbits (supra/infra-orbital rim), zygoma, maxilla/mandible, asymmetry, nasal bleeding/dpatency/deviation/CSF leak, bruising, AOB/occlusal derangement (deviation), step deformity, paraesthesia (upper lip, lateral nose, lower eyelid, IO region/cheek), lacerations, pain, limited opening, loose/displaced/# teeth, bleeding, mucosal tears/IO bruising, step deformity, altered sensation of teeth/gingivae in upper quadrant
Eyes - periorbital ecchymosis, subconjunctival haemorrhage, diploma, visual acuity, reactive to light, pain on movement, tethered, exophthalmos/enophthalmos, vertical/horizontal dystopia

Ix - OM 15 and OM 30 views ± CBCT. Look for #s (sharp corners/broken bones, radiopacity in sinus)

Mx as a GDP - phone OMFS/ED - urgent referral for assessment ± surgery (Gillies lift ± IF). Conservative advice - limit opening, analgesia, v soft diet for 4/52 ± splint any teeth, maintain good OH

Classification - Hendersons. I - undisplaced, II - z arch, II tripod intact FZ suture, IV - tripod FZ suture displaced, V - orbital blowout, VI - orbital rim, VII - communited/complex

Question 21

A clinical photo of a lesion is provided (photos 22).

Take a brief Hx, perform lymph node exam and give possible Dx and Mx

6 mins

Answer 21

Introduction - name and designation

Hx - noticed lesion? How long? Any pain/Sx (bleeding, problems eating/drinking/swallowing/talking)? Any changes in voice? Any systemic Sx (weight loss, dyspnoea, haemoptysis)? Do you smoke? Drink alcohol? Last attended GDP? Prev/FH of OSCC?

LN exam - bimanual palpation. Submental, SL, SM, DCLN, supraclavicular, JD, JO, occipital, post-auricular, pre-auricular, facial/buccal

Discuss - the cause of this could be a number of things, from something that’s completely benign and harmless or something more serious and potentially cancerous. As this is a high-risk site for mouth cancer and you have other RFs, I’m suggesting we refer you to a specialist for an opinion ± Bx and Rx.

A biopsy involves LA, cutting away a bit of the lesion, which is then sent to the lab so they can analyse it under a microscope and some stitches. It will feel like having an ulcer - it’ll be raw and sore for a few days. Pain, bleeding, bruising, infection, altered/loss of/painful sensation, stitches (dissolve 2-3/52). Advise - pain killers, keep clean (soft TB, WSMW from tomorrow). Will have a R/V appt to discuss results and further Rx if required.
FNA - if neck lump, might sample this
In meantime - quit smoking/alcohol. Consider this a wakeup call if nothing more. Take photos today for monitoring.

Does that all make sense? Do you have any questions? Give contact number

HNC referral - >3/52 Hx of unexplained persistent lump/ulcer/red/red and white/hoarseness/dysphagia/throat pain

Question 22

You are a GDP. A 68yo male attend for a check up. MH - HTN, 25mg atenolol.

Exam shows homogenous white patch on L BM. You are uncertain of the cause and wish to refer.

Explain why you are concerned and why you have referred the pt

6 mins

Answer 22

Introduction - name and designation

Hx - noticed lesion? How long? Any pain/Sx (bleeding, problems eating/drinking/swallowing/talking)? Any changes in voice? Any systemic Sx (weight loss, dyspnoea, haemoptysis)? Do you smoke? Drink alcohol? Last attended GDP? Prev/FH of OSCC?

Discuss - the cause of this could be a number of things, from something that’s completely benign and harmless or something more serious and potentially cancerous. Because I’m uncertain of what it is, I’m suggesting we refer you to a specialist for an opinion ± Bx and Rx. There are many causes, and a whole spectrum of severity

Causes of white patches - hereditary, keratosis (trauma, smoking), lichenoid/LP, lupus, pseudomembranous/chronic hyperplastic candidosis, carcinoma/SCC, medications, burns, viral, leukoplakia

A biopsy involves LA, cutting away a bit of the lesion, which is then sent to the lab so they can analyse it under a microscope and some stitches. It will feel like having an ulcer - it’ll be raw and sore for a few days. Pain, bleeding, bruising, infection, altered/loss of/painful sensation, stitches (dissolve 2-3/52). Advise - pain killers, keep clean (soft TB, WSMW from tomorrow). Will have a R/V appt to discuss results and further Rx if required.
FNA - if neck lump, might sample this
In meantime - quit smoking/alcohol. Consider this a wakeup call if nothing more. Take photos today for monitoring.

Does that all make sense? Do you have any questions? Give contact number

Question 23

You are a GDP. A 67yo male attends for a new patient assessment.

Your examination reveals smokers keratosis on his palate.

Give smoking cessation advice to the patient

6 mins

Answer 23

Introduction - name and designation

5As

Ask - do you smoke? How many/day? What do you smoke? How long have you smoked for? How quickly after waking? Does anyone else in the house smoke?

Advise - smoking puts you more at risk of a number of conditions that affect your mouth, including gum disease and tooth loss, staining, bad breath and mouth cancer. It also impairs how your mouth heals after injury or extraction. In terms of your general health, smoking increases your risk of many other cancers including as lung cancer, throat cancer and stomach cancer, as well as putting you at higher risk of heart disease and conditions that affect your breathing. It also has a financial cost that I’m sure you’re aware of.
Quitting reduces your risk of developing all of these smoking-related health conditions

Assess - would you be interested in quitting? Why now? Tried quitting before? Did it work? How long for? Why didn’t it last? Do you want help?

Assist - there are smoking cessation support services available that increase the success of quitting significantly. There are some run by the NHS, called Quit Your Way, which can involve 1-to-1 support from a pharmacy as well as free NRT. They will help to advise you on the best form of NRT for you as well - this might include patches and gum. E-cigarettes are a relatively new development. They are thought to be 90-95% less harmful than regular cigarettes and still maintain the hand-to-mouth and social aspects of the habit. However there are limited LT studies so the evidence is still uncertain and there are some emerging studies linking it with other inflammatory lungs diseases

Arrange F/U - book next appt and advise to self-refer. Can visit canstopsmoking.com for further advice, as well as the NHS Inform Quit Your Way website

Does that all make sense? Do you have any questions?

Question 24

You area GDP. A 45yo female attends for a check-up, C/O a sore mouth.

Clinical photos and recent blood tests are provided (photos 23)

Take a Hx, provide a Dx and describe Mx options to the patient

6 mins

Answer 24

Introduction - name and designation

Hx - how long for, recurrence, how long last, any Sx

Dx - iron-deficient microcytic anaemia

SPIKES

Setting
Perception - are you aware of what we’re here to discuss today? You were here a few weeks ago complaining of painful ulcers 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?

Information - let me start by saying there is nothing sinister going on here. your bloods showed that you have developed a type of anaemia called microcytic anaemia caused by an iron deficiency in your blood.

Knowledge - this is a condition where a lack of iron in the body leads to a reduction in the size of red blood cells. Iron is used to produce red blood cells, which help store and carry oxygen in the blood. If you have smaller red blood cells than is normal, your organs and tissues won’t get as much oxygen as they normally would.

Many people with iron deficiency anaemia only have a few symptoms, most commonly tiredness and lack of energy, shortness of breath, noticeable heartbeats and a paler complexion. In addition, In some cases, including yours, people develop small ulcers in the mouth. These ulcers are very common and around 25% of the population have them. It’s often linked to vitamin deficiency and they may be exacerbated by stress, illness, smoking or immunocompromise

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. You may also have difficulty absorbing iron from foods.

Iron deficiency can easily be managed with iron supplements that can be prescribed by your GP, and an increase of iron in the diet (eating more leafy green veg, red meat, fish and eggs). Foods high in vitamin C also help absorb iron. This tends to resolve the small ulcers in your mouth, which tend to go away in 1-2 weeks without scarring. Your GP might take more bloods to monitor your iron levels and determine if they need to investigate anything else

Empathy

Summary - in the meantime, as well as increasing the iron in your diet, you should avoid spicy/acidic foods or anything that has a very strong flavour. We can give you a numbing or steroid mouthwash to make your mouth more comfortable if you’re struggling to eat

The good news is this is a common condition and the ulcers tend to go away in 1-2 weeks without scarring. We now know what the cause is and we can manage it.

Does that all make sense? Do you have any questions?

Benzydamine m/w, 0.15% - Send: 300ml, Label: Rinse or gargle using 15ml every 1.5 hours as required

Betamethasonetablets 0.5mg. Dissolve in 10ml water and use as MW

Actor marks communication and simple language

Question 25

Name the antimicrobials that you would prescribe for the following conditions

1. Acute apical/perio abscess
2. NG/pericoronitis
3. Angular cheilitis
4. Denture stomatitis
5. Recurrent herpes labialis
6. PHG

6 mins

Answer 25

1. Pen V tablets 250mg. 2 QDS 5/7
   Metro 400mg tablets. 1 TDS 5/7
2. Metro 400mg tablets. 1 TDS 3/7
   Amox 500mg capsules. 1 TDS 3/7
3. 2% miconazole cream 20g. Apply to angles of mouth BD
   Sodium fusidate ointment 2%. 15g. Apply to angles of mouth QDS
4. Fluconazole 50mg capsules. 1 OD 7/7
   Miconazol oromucosal gel 20mg/g. 80g. Pea-sized amount to upper denture fitting surface after food QDS
   Nystatin oral suspension 100,000unit/ml. 30ml. 1ml after foods QDS 7/7 (rinse for 5 mins)
5. Aciclovir cream 5%. 2g. Apply to lesion every 4hrs (5x/day) 5/7
6. Aciclovir tablets 200mg. 1 5x/day 5/7

Question 26

You are a GDP. An 83yo male presents C/O dry mouth.

Take a Hx, list the causes and possible dental complications associated with a dry mouth and provide the pt with some Mx options

6 mins

Answer 26

Introduction - name and designation

Hx - how long for? Progressive? How does it affect pt? Need water to swallow? Speech affected/clicking? Sore? Dentures? Altered taste?

MH - conditions and meds, prev RTx/CTx

SH - smoking, alcohol, anxiety

Causes - drugs (TCAs, antihistamines, diuretics, antipsychotics), CT disease (Sjogren’s, autoimmune), RTx, undiagnosed diabetes, SG aplasia/agenesis, dehydration

Complications - cervical caries, halitosis, sore mouth, unretentive dentures, altered taste, swallowing/speech problems, angular cheilitis/candidosis

Mx - hydration, modify drugs (GP), control diabetes, reduce caffeine, stop smoking
saliva - frequent sips of water, SF gum/pastilles, ice cubes, artificial saliva - gel, spray, pastilles (Saliva Orthana)
Prevention - Duraphat TP, F/CHx MW, ID cleaning, new dentures

Does that all make sense? Do you have any questions?

Question 27

You are a GDP. A 42yo female presents C/O sore mouth.

She is F+W, not taking any medications and doesn’t smoke.

Clinical photos are provided - photos 24

Use the clinical photos to give the likely Dx and explain the Dx and Mx to the pt.

You do not need to take a history

6 mins

Answer 27

Dx - lichen planus (reticular). Others - erosive, papular, plaque-like, bulbous, atrophic

Other sites - scalp, genitalia, wrists (raised itchy purple patches)

You have these white patches around your mouth. This is due to a common condition called lichen planus. Lichen planus can present anywhere on the skin, including the scalp and wrist, as well as around genitalia and in your mouth. The whiteness arises from extra keratin extra keratin deposits. Keratin is a protein that is present all around your skin and the body can be stimulated to make more by several factors like friction (causing calluses on fingertips).

Lichen planus is kind of an allergic reaction to something and in most cases we don’t really know what causes it. Most common culprits are reactions to medications or metal in silver fillings or sometimes dental plaque or a substance called SLS which is in toothpastes. In these cases, it is called a lichenoid reaction and often resolves by removing the cause.

Lichen planus has a small chance to develop into something sinister like a mouth cancer. The risk is less than 1% over 10 years. It’s important to note though that it’s a spectrum disease which ranges from simple asymptomatic white patches to more sinister erosive sore ulcerated areas. Depending on what area of the spectrum you’re on the risk of malignancy can be higher or lower.

Unless there is a cause, such as silver fillings or medication, it’s unfortunately something we can’t treat, only manage. It can last for a number of years, but is not infectious.

To confirm the Dx, we would look at performing a biopsy, so taking a small sample of the lesion to view under a microscope and take some bloods to exclude possible underlying conditions. We would keep an eye on it and look to take photos every 3-6/12, checking for any changes in it. If there are any changes, we might consider performing another biopsy.

Management involves avoiding know triggers, such as SLS in TP and MW and avoiding spicy/acidic foods. We can

We can give you a numbing or steroid mouthwash to make your mouth more comfortable if you’re struggling to eat and you can use CHx to help keep things clean. Making sure you keep your teeth clean by brushing properly and using brushes to clean in between the teeth as well will help reduce plaque build up.

In the mouth it can take around 3-5 years to resolve and if it doesn’t respond to initial treatment, we can refer you to a specialist who will be able to prescribe some different medications and potentially perform some other tests.

Does that all make sense? Do you have any questions?

Benzydamine m/w, 0.15% - Send: 300ml, Label: Rinse or gargle using 15ml every 1.5 hours as required

Betamethasonetablets 0.5mg. Dissolve in 10ml water and use as MW

Question 28

You are a GDP. A dentally fit 40yo female presents C/O facial pain

Take a history and suggest some Ix options

6 mins

Answer 28

Introduction - name and designation

S - where, fixed, moves, crosses midline/anatomical boundaries, diffuse, can/can’t localise
O - acute/chronic, how long, when started
C - sharp/dull, shooting/throbbing, changes
R - pain elsewhere, anatomical boundaries
A - infection/inflammation, fever, malaise
T - regular/not, how long lasts, affecting sleep
E/R - better/worse, analgesia effective/not, triggering stimuli (prev dental Rx), press trigger point. Stimuli that don’t usually elicit pain
S - scale 1-10. Constant/changes

Ix - XRs, sensibility tests, perio probing, TTP, mobility, tooth sleuth, CN test
If no dental pathology, refer to specialist

Question 29

You are a GDP. A dentally fit 50yo female presents C/O a burning mouth.

There are no clinical signs of pathology evident on examination

Take a history, provide a Dx and Mx options to the pt

6 mins

Answer 29

Introduction - name and designation

Pain Hx - SOCRATES
MH - including meds and allergies
SH - smoking, alcohol, occupation, stress

Sx - pain crossing midline, bad/altered taste

Dx - oral dysaesthesia/burning mouth syndrome

Explain - reassure not sinister. BMS is a condition which typically affects the tongue, mouth and lips. The burning sensation is usually present constantly. It tends to affect women more than men. The cause of BMS is uncertain, but factors that may play a role include hormonal changes (menopause) or vitamin deficiencies. Psychological factors may also play a part as Sx can often appear at times of increased stress. It is not linked to cancer.

Mx - to start, we would take some blood and test it for any underlying vitamin deficiencies - checking your iron, B12 and folate levels, as well as look at your glucose levels. We’d look to see if there were any possible causes in your mouth, such as dentures that didn’t fit well, or any teeth or fillings that were sharp or causing a minor allergic reaction and seek to treat these.

We can give you a prescription for a mouthwash that can help numb the burning and you can use up to every 90 mins if needed.

We could also refer you to a specialist if the Sx didn’t resolve and they could offer you other types of medications if they thought they might work.

It’s important to realise that this is a long-term condition and may take years to disappear. You should also be aware how stress affects your Sx and to learn to manage it. Relaxation, yoga, meditation and mindfulness can all help reduce stress.

Burning is often worse when your mouth is dry, so taking frequent sips of water, chewing SF gum or sucking on ice cubes can help prevent your mouth getting dry. Sprays, gels and pastilles for dry mouth can also be prescribed.

Making sure you keep your teeth clean is important as well, because decay or gum disease can make your Sx worse.

Does that all make sense? Do you have any questions?

Question 30

You are a GDP. A F+W 24yo female presents C/O recurrent cold sores.

Explain what the sores are to the pt and provide Mx options

6 mins

Answer 30

Introduction - name and designation

Dx - herpes labialis

Explain - reassure, very common. Cold sores are caused by a virus called herpes simplex. When you were younger, you were infected by this, maybe without even realising. Around 70% of the world population have this virus. What happens in some people is the virus goes into a nerve and then essentially goes to sleep. One nerve that it can sleep in is called the trigeminal nerve, which is the nerve that supplies the skin of the face and mouth.
Cold sores are the reactivation, or the reawakening, of this virus. It can be caused by stress, trauma, UV exposure, fever/illness or menstruation and causes a crop of blisters around the mouth that crust over. Sometimes you can get a sort of prodromal tingling 24hrs before the blisters appear. They tend to last 7-10 days. It is contagious, so try to avoid touching your face or hugging/kissing any small children or adults with serious health conditions particularly.

We can give you a cream that can help with the cold sores. It’s most effective when used when the first Sx appear - this includes the tingling that may occur up to 24 hours before.

Does that all make sense? Do you have any questions?

Aciclovir cream 5%. 2g. Apply to lesion every 4hrs (5x/day) 5/7

Question 31

You are a DCT in OS. A 38yo male is referred from GDP for surgical excision of FEP on the tongue under LA.

The pt is a F+W non-smoker.

Obtain consent for the procedure, describe how you would carry out the procedure, including providing post-op instructions and completing the pathology form

12 mins

Answer 31

Introduction - name and designation

Plan is to remove the small lump of fibrous tissue on the tongue under LA. The small lump is called a fibre-epithelial polyp - essentially a fibrous overgrowth in response to chronic low-grade trauma/irritation. It’s not contagious or sinister.

We’ll numb up your tongue around the FEP, cut it out and then stitch the tongue together and stop any bleeding. We’ll send the growth to the lab who will look at it under the microscope to confirm the Dx and we’ll review you with the results when they’re back.

Risks - pain, bleeding, swelling, bruising, altered taste, temp/perm altered/painful/loss of sensation, infection, stitches, recurrence, need for further Rx. We’ll provide advice on wound care at the appt to remove it, but essentially it’s like an ulcer - will be raw and sore and you’ll need to keep it clean. The stitches will be annoying, but they tend to dissolve themselves within 2-3 wks.

Does that all make sense? Do you have any questions?

LA around FEP, test LA. Elliptical incision, ensuring whole lesion removed. Pull/hold with forceps, cut lesion off from attachment mucosa underneath. Place into path pot without touching formalin.
Apply pressure, approximate edges and suture (undermine edges if required to ensure tension-free primary closure). Ensure haemostasis achieved

POI - stitches dissolve in 2-3/52, rest today, don’t increase BP. If bleeding - roll up damp gauze and apply firm pressure for 20-30mins. Numb for a few hours, take pain killers before LA wears off and as required over next few days. Will be bit bruised and swollen, might alter speech until swelling goes down. Soft diet, nothing to hard/crunchy/sticky for 7/7. WSMW (60s) from tomorrow. TB as normal today. R/V with results approx 6/52

Does that all make sense? Do you have any questions

Path form - Ix - histopathology
Date and time of Bx
Nature of specimen/site - exicisional (Xmm punch) biopsy of homogenous white overgrowth, anterior dorsal tip of tongue, midline
Clinical details - Xmm homogenous white overgrowth, anterior tip of dorsal tongue, midline. Present for X. No other similar lesions. Pt F+W, no meds, non-smoker
Prov Dx - FEP. Please exclude dysplasia
Date and sign

Question 32

You are a DCT in OM. A 47yo female is referred by her GDP. She is F+W and smokes 40cpd.

Clinical photos are provided - photos 25

Provide the likely Dx, as well as your Mx for the pt

6 mins

Answer 32

Introduction - name and designation

Dx - candidal leukoplakia/chronic hyperplastic candidosis

Explain - the white patch on the inside of your mouth is caused by a fungal infection. This is something that, in it’s early stages can be managed relatively easily. It does however increase your risk of getting mouth cancer by approx 5%. With that in mind, it would be a smart idea to take a sample of the lesion to check it and make sure it’s behaving itself at the moment.

The major risk factor for this is smoking. With treatment and quitting smoking, it’s likely to go back to normal and not give you any problems. However smoking does also increase your risk of mouth cancer.

Mx - incisional Bx and photos (every 6/12 to check for any changes), improve OH, smoking cessation, CHx MW. Fluconazole 50mg OD 7/7 ± miconazole oromucosal gel

R/V 2/52

Does that all make sense? Do you have any questions?