OSCE Flashcards
Patient advices you that they are a smoker, give smoking cessation advice for this patient
Ask;
What do you smoke?
How long have you smoked for?
How many cigarettes daily?
Advise;
Smoking is harmful to your general health, it can cause cardiovascular and respiratory disease
Smoking is detrimental to oral health - there is a increased risk of staining, periodontal disease and oral cancer
Assess;
Are you interested in stopping smoking? If so, why?
Have you tried to quit in the past? Why do you think you were unsuccessful in stopping?
Assist;
Would you like some help from local stop smoking services?
If you use these services you are 4 times more likely to quit
The best and evidence based treatment for stopping smoking is nicotine replacement therapy e.g. patches, gum and E-cigs
Just be aware that e-cigs are relatively new to the market and we don’t fully know the side effects however it does contain less toxins than a normal cigarette)
Refer;
There are local cessation services which can be found at your pharmacy or GP
There is also a self referral service which can be found online at www.canstopsmoking.com - this is run by NHS24
Arrange a follow up
Actor marks; Non-judgemental Clear and easy to understand Listening Good eye contact Open body language
State the fracture type most likely from the photo available and clinical history
Perform an E/O exam (on mannequin) to assess patient for facial fracture
Describe I/O features that may be seen
Suggest further investigations for this fracture type, what you can see on the investigation and further management options for this patient
Right Orbitozygomatic fracture
E/O exam;
Look for any lacerations
Look for any nasal bleeding, deviation and patency (by obstructing each nostril)
Look for any facial asymmetry
Look for limitation of mandibular movement
Look for periorbital ecchymosis and subconjunctival haemorrhage
Palpate zygoma bilaterally from behind
Exam sensation of infra-orbital region - infra-orbital nerve supplies the upper lip, lateral nose and lower eyelid
Eyeball mobility assessment - steady pt’s head and ask to follow finger to 6 points
I/O features; Bruising and swelling Tenderness of zygomatic buttress Occlusal derangement Lacerations Broken teeth
Further investigations;
Radiographs - Occipitomental 15/30 view or CBCT
Radiographic findings;
Fracture of right cheek bone
Radio-opacity of sinus
Further management;
Urgently phone OMFS unit or A&E dept for advice and urgent referral
Surgical management ; ORIF - if symptomatic
Conservative management - if asymptomatic and undisplaced
Your patient has an unrestorable 26 requiring XLA but the patient is currently taking warfarin - the patient wants this tooth extracted now, what would be your actions for this patient?
Introduce self and designation
Ask about the patients INR - when was it last done and what value was it?
Ask to see the patients INR book
Give an explanation as to why the tooth cannot be extracted today;
There is a high risk of bleeding that can occur when we extract your tooth, which is a result of the warfarin you take
According to our guidelines (SDCEP) we need an INR value within 24hrs of carrying out the extraction
We can only proceed with the procedure without interrupting your medication when your INR is <4
Therefore it would not not be safe for us to extract your tooth today but I am happy to book a future appt for us to do this and we can arrange with your GP to have your INR checked the day before/morning of the appt - however INR must be less than 4
Deal with patient’s pain;
I appreciate that you are in pain therefore we have several options to help with this;
Analgesia for pain relief which is administered via an injection
Pulp extripation and sedative dressing which is removing the nerve of the tooth and placing a calming paste to help with infection and pain control
Do you understand why we can’t extract the tooth today and your options for pain removal?
Do you have any questions?
Your nurse has contracted a sharps injury following treatment of a patient. Discuss what has happened with the patient, assess their risk for BBV transmission both using available records and by asking appropriate risk-assessment questions and fully consent the patient for testing
Explain nature of injury;
Hi my name is Caitlin and one of my colleagues has sustained something we call a sharps injury which is where she has accidentally cut herself on an object that has been used on you and been in contact with your bodily fluids
I want to reassure you that this does not affect you and there is no risk to yourself however there is a standard procedure we need to follow to assess if the staff member is at risk of any infectious diseases such as hep b, c or HIV
The risk is extremely low but we can give the staff member treatment to prevent infection from occurring if there is a risk and this treatment needs to be given quickly
To assess the risk we need to ask 2 things if you;
1. We have a list of questions that we need to ask to see if the staff member requires treatment, and these questions are sensitive in nature but it is a standard procedure we must follow to assess risk
2. Your permission to take a blood sample from yourself to test for infections however this is a voluntary process and you do not have to consent to having blood taken - the decision lies directly with you and refusing to be tested will have no effect on your on going care
If you do refuse this discussion will be recorded in your personal notes
The actual risk figures of the transmission of a BBV to the staff member are low;
0.3% for HIV, 30% for hep B and 3% for hep C which we are all immunised against
If you don’t mind, I am going to take a more in-depth and sensitive medical history to protect both yourself and the nurse who has had the sharps injury - all answers are kept anonymous and the assessment is destroyed afterwards (answer yes or no)
Have you ever been diagnosed with HIV, Hep B or Hep C?
Have you ever injected drugs or had sex with someone who has?
Have you ever had sex with another man?
Have you ever had sex with someone from a country outside of the UK, Western Europe, Canada, USA, Australia, New Zealand?
Have you ever had a blood transfusion not previously mentioned?
Have you ever received dental treatment in a country not previously mentioned?
Are you from a country that is not listed above?
Have you ever had a tattoo/piercing done by an unlicensed artist in the UK or in a country outside of the UK?
yes to any of the above indicates high risk.
Gain consent;
Do you understand your different options available to you?
Do you have any questions?
Are you happy to give bloods - YES or NO?
Apologise for the inconvenience caused and thank them for the co-operation
Your patient is about to begin Bisphosphonate therapy for osteoporosis and has a sensitive tooth 36 which has lost a filling - have a discussion with the patient about MRONJ and XLA risks before pt starts therapy
Alendronic acid is a bisphosphonate drug
Essentially, bisphosphonates are drugs that reduce the turnover of bone, and bisphosphonates accumulate in sites of high bone turnover e.g. the jaw
Relevance to dentistry;
Therefore, this is relevant to dentistry but there is a risk of poor wound healing following a tooth extraction
We would need to remove any teeth of poor prognosis prior to beginning drug therapy and it is important to do everything possible to prevent further tooth loss
Reduced turnover of bone and reduced vascularity (which is what you will have during therapy) can lead to death of the bone - osteonecrosis
This is specifically called MRONJ - medication related osteonecrosis of the jaw
However, the risk of MRONJ in osteoporosis is low but it is just something we need to consider and make you aware of
Making clinical diagnosis and explaining to patient in simple terms;
Tooth 36 is grossly carious with chronic periapical periodontitis
There is an area of infection associated with the left back tooth (36), the tooth is too decayed to have a filling put back in
Discuss tx options;
Extraction is the only option for this tooth
Tooth is grossly carious beneath the gum line and therefore unrestorable
If tooth is kept you are at risk of MRONJ after beginning bisphosphonate therapy
Do you have any questions?
empathetic approach throughout
Take a pain history for a patient and give a provisional diagnosis.
Introduce self and designation
Presenting complaint?
S = site of pain? O = when did pain start? C = how would you describe the pain? Throbbing/sharp? R = does the pain spread to anywhere else in the body? A = are there any associated symptoms? E.g. nausea? Does the pain keep you awake at night? T = how long does the pain last? Minutes, constant? E = does anything make the pain worse? E.g. hot/cold does anything help to relieve the pain? E.g. pain relief? S = what would you rate the pain in severity out of 10? With 1 being least and 10 being most sore
Provisional diagnosis - irreversible pulpitis
note taking legible, well ordered and complete
There is a 11 EDP fracture with an immature apex on an 8 year old - outline the procedure to the parent of this anxious child
Explain nature of injury in simple terms;
This is an enamel dentine pulp fracture which is simply a complicated pulp fracture
Explain treatment;
As this is a large exposure, the tx of choice is called a pulpotomy which is partial removal of the pulp (nerve of tooth)
The aim of this procedure is to keep undamaged pulp tissue alive so that the tooth stays alive and continues to grow
Baseline sensibility tests;
Some tests are required to see how the nerve responds in the injured tooth and the adjacent teeth also - the test results can be used for long term monitoring
LA required;
Local anaesthetic will be required for this procedure in order to keep the patient numb and comfortable - this involves an injection in the gum
Dental dam;
Dental dam is required for this procedure which is a rubber sheet that is placed over the tooth which acts like a mask to gain moisture control and protect the patients airway
Drilling/use of handpiece;
A drill will be used to remove some pulp tissue - this can produce some loud noise
Dressing;
Once the damaged pulp tissue is removed, we will place a dressing in the tooth such as setting CaOH - which has antibacterial properties which will help to calm the tooth
Composite restoration;
A white filling will be placed on the tooth to regain aesthetics for the patient
You have taken a pus aspirate from the 26 dentoalveolar abscess - complete a pathology form for this
Pt and clinician details;
Patient sticker - CHI, hosp no, name, sex, address and DOB
Hospital department, date, time, consultant, requested by and phone number
Clinical details;
Pain, swelling etc
Other relevant info - e.g. MH - nil of note
Provisional diagnosis - dentoalveolar abscess
Specimen details including site;
Type of sample - pus aspirate
Site - buccal mucosa of 26
Investigation;
Culture and sensitivity testing; bacterial/fungal
PRC and viral load; virus
Histopathology; tissue biopsies
Wearing appropriate PPE when handling specimen - gloves
Removal of needle safely, disposed in yellow sharps bin
LABEL syringe with pt details and place in plastic bag attached to request form
A parent brings her child to the clinic who is not feeling well and is distressed
You are provided with an image showing many small red vesicles on tongue, mucosa and commissures of mouth which look painful
Take a history and provide a diagnosis to the mother
Provide ways to treat the condition and answer any questions the mother may have
Take history; How would you describe the symptoms? No of days with symptoms? Does child have fever? Child less active than normal? Have you used any analgesia/pain relief? Did it work?
Diagnosis;
From the symptoms and presenting appearance (from photograph) this appears to be Primary Herpetic Gingivostomatitis
This is a contagious infection caused by the herpes simplex virus which is self limiting (will resolve on its own) and will disappear in 7-10 days
It is a common infection and most often occurs in young children
Explain symptoms;
Often will present with blisters on the tongue, cheeks, gums, lips and roof of mouth - after the blisters pop, ulcers will form
Other symptoms to watch out for are high fever, difficulty swallowing and swelling
Also, because the sores make it difficult to eat and drink, dehydration can occur
Child may or may not develop cold sores in the future
Management;
Increase fluid intake
Pain relief to control fever/pain
Bed rest, take it easy
Clean teeth with damp cotton roll or cotton cloth to rub around the gums
Can use dilute CHX to swab the gums
As the child has had problems for 3 days and is otherwise fit and healthy, antiviral medication (Aciclovir) is not recommended
Prescription - only is severe or immunocompromised
Aciclovir 200mg tablets for 5 days, 1 tablet 5 times daily
A patient has a sore mouth and palate and currently wears dentures.
You have received results from previous tests to confirm that denture induced stomatitis is affecting the hard palate provided with pic showing this and results of swab
Medical history includes type 2 diabetes and pt is on warfarin for atrial fibrillation
Explain findings to patient, recognise the multifactorial condition and provide OH advice
Examiner will ask at end “what antimicrobial agent would you prescribe to treat this condition?”
Brief history;
Is diabetes well controlled?
Is denture worn at night?
Denture hygiene procedure?
Explain clinical findings;
Denture induced stomatitis - this is a fungal infection that can be caused from denture wearing and poor denture hygiene
Management advice;
Conservative treatment initially
Brush palate daily with toothbrush and toothpaste
Brush denture after meals with a soft toothbrush and non-abrasive denture cream
Soak in CHX or sodium hypochlorite for 15 min twice daily only sodium hypochlorite for acrylic dentures
Leave denture out at night and as often as possible when in house etc.
Check denture fit - adjust if necessary
Limit smoking and sugar in diet
Confirm patient understands instructions
Answer examiners question;
Conservative management initially but if no improvement would prescribe Nystatin suspension
100,000 units/ml
Send; 30ml
Label; 1ml after food four times daily for 7 days
Take a history from this patient then explain her diagnosis from the images, x-ray and history (OAF)
Explain the management and surgical closure of this OAF
What drug would you prescribe and what post-op instructions would you give?
In a chronic OAF, patients may complain of;
Fluids from nose
Speech of nasal quality
Problems smoking or using a straw
Problems playing wind instruments
Bad taste/odour, halitosis and/or pus discharge
Pain/sinusitis type symptoms
An OAC is an acute communication of the maxillary sinus with the oral cavity
In your case the communication hasn’t closed over and instead has healed by forming an epithelial lining which has resulted in a permanent communication between the maxillary sinus and the mouth
This is something we want to manage as it makes you more prone to developing sinus infections
OAF management;
Excise the sinus tract which involves removing this epithelial lining that has formed the communication
We would then create a buccal advancement flap which help to cover this area and allow healing to take place
We would then prescribe either of these antibiotics;
Amoxicillin 500mg for 7 days, 1 tablet 3 times daily
Doxycycline 100mg for 7 days, 1 capsule daily (take 2 on day 1)
Post-op instructions; Refrain from blowing nose or stifling a sneeze Steam or methanol inhalation’s useful Avoid using a straw Refrain from smoking
Identify orthodontic problems from this image and discuss their dental health implications
Carry out tooth position determination from the radiographs provided
Problems; Increased OJ Increased OB Peg lateral Ectopic canine
Dental health implications;
Risk of trauma from OJ and OB
Risk of root resorption
Risk of cyst formation
Tooth position determination;
Parallax - from the OPT and oblique occlusal radiograph views I can see that the ectopic canine is positioning lingually using the SLOB rule
When we have moved from the OPT to the oblique occlusal, the tube has been moved upwards and on the oblique occlusal the ectopic canine is sitting higher and has moved upwards also = same lingual, opposite buccal
saved good photo of this to help understand
What is reciprocation and what areas of the denture provide this?
What is bracing and what areas of the denture provide this?
Reciprocation helps to resist lateral movement and is provided by any part of the denture that is directly opposite a clasp arm
Bracing helps to resist lateral movements and helps to transmit forces on a tooth which is provided by rest seats
A parent is concerned about why their 2 year old child needs fluoride varnish? They are concerned about fluoride toxicity
Reassure the patient;
F varnish promotes remineralisation (hardening of the tooth) and this helps to strengthen the tooth and protect it from acids and sugars found in our food and drink
It involves drying the teeth and painting a gel on to the tooth
Contraindicated in;
F varnish is only contraindicated in children with severe uncontrolled asthma and children with an allergy to colophony (which is found in plasters)
Aftercare instructions;
Don’t eat/drink for 1 hour
Fluoride toxicity;
Very small risk and mainly occurs if a small child consumes a large quantity of toothpaste
What is the difference between a type N and type B steriliser?
Discuss the cycle stages and parameters for a steriliser and the type of water used?
What tests are carried out for sterilisers?
There is a packet of instruments sitting on top of a steriliser - how do you know if they have been sterilised or not? What would you do if you were unsure?
Type N = non-vacuum, passive air removal with non-packaged instruments
Type B = better, vacuum, active air removal with packaged instruments
Cycle;
Stages = air removal, sterilising, drying and cooling
Parameters = 134-137 degrees, 2-2.3 bar for a min holding time of 3 mins
Type of water used = reverse osmosis, distilled, sterile or de-ionised
Steriliser tests;
Daily = wipe clean, change water, ACT, steam penetration test (Bowie dick/helix)
Weekly = ACT, steam penetration, vacuum leak test and automatic air detector function test
Quarterly = Validation report
Yearly = Annual report - done by company e.g. check pressure release valves
Instruments found on top of steriliser;
Check if colour change present = brown to pink
Check for recent print out from steriliser
Instruments should be set out, non-overlapping with hinged instruments open
If unsure, take tray of instruments back to the beginning of decon cycle
A 50 year old pt attended for HPT 3 months ago
Their 35 is tender, has a swelling around the tooth and a 8mm pocket on the distal aspect as well as suppurations
The patient is systemically well and has a normal body temperature
Discuss how you would like to investigate the matter further You may ask the examiner for the results of the special investigations
Provide your diagnosis to the patient and discuss how you would like to treat this
Inform pt that you wish to take a PA radiograph to identify if any pathology is present at the root of the tooth
Inform pt that you wish to carry out sensibility testing to see how the nerve of the affected tooth and adjacent teeth respond to stimuli
Ask examiner for results of these special investigations otherwise you won’t get them
EPT of 35 and 36 respond positively
PA radiograph shows periodontal/periapical pathology
Due to the following symptoms;
Swelling, presence of pocket with pus and bone loss from radiograph I believe this is a periodontal abscess
This is where a pocket(space) has developed between the tooth and the gum which has allowed bacteria into this pocket and has travelled up to the root of the tooth causing pain and infection
Treatment;
Irrigate through pocket
RSD
Hot salty mouthwash
No antibiotics since its a localised infection and no systemic involvement
A 28 year old female patient who works in television has had an accident in which she injured her face.
There are no other injuries and you have completed the examination as well as taken a radiograph
You have diagnosed the tooth as having a vertical root fracture and is unrestorable
Explain your findings to the patient and how you would treat them
SPIKES
Setting;
Sitting down at same level as them, try to make them comfortable
Perceptions;
“Are you aware of what might be wrong?”
Information;
“I would like to go ahead and discuss the outcome of this tooth, are you happy to discuss this?”
Knowledge;
Give a warning shot = “I wish i had better news i’m afraid…” pause for a bit
“Your tooth is unrestorable and requires to be extracted” big pause
Let it sink in and let them dictate the pace of the conversation from there
Empathy;
“I am deeply sorry to have to break this news to you and I understand this must be hard for you”
Summary and close;
Summarise what you’ve told them and the plan for going forward
“We will aim to restore this tooth as soon as possible for you”
Immediate options;
Immediate denture
Bridge
Permanent options
Bridge
Denture
Implant (need to wait 3 months after XLA to allow bone to stabilise)
“Do you have any questions?”
You are presented with a cast and surveying tripod - survey this cast
What are the different undercut gauges and what material of clasp should be used for this undercut size?
- Mount each cast on tripod and draw 3 lines with the analysis road and pencil on the casts
- Use the analysing rod for abutment teeth and soft tissue undercuts
- Use pencil rod to make survey lines of all abutment teeth and soft tissue undercuts
- Change path of insertion to highlight undercuts
- Make new survey lines with red rod to show difference in paths of insertion
- Decide on location of clasps with undercut gauges (buccal of upper molars and lingual of lower molars)
- 25mm CoCr
- 5mm Gold
- 75 SS
Patient has presented with severe pericoronitis and is feeling unwell and pus is suppurating from the site. You have irrigated but feel antibiotics are required to treat the patient but he 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 for anaerobic infections common in pericoronitis BUT
Metronidazole should not be prescribed as it is contraindicated in alcoholics
Prescription;
Patients name, address, CHI and age if under 12
Amoxicillin capsules 500mg
Send 9 tablets
Label 1 capsule three times daily for three days
Prescription signed and dated
Written in ink and remaining pad scored out
You are required to fit an upper removable appliance to a 9 year old. Examine the prescription and appliance, look for defects and answer examiners questions.
- You are asked about the FABP, asked to demonstrate making adjustments to adams clasps and activate palatal finger spring*
- You are also asked what checks you would do before appliance and delivery and what aftercare instructions you would give*
Typical component faults; Z spring encased in acrylic Arrowhead fault (might not fit in undercut) Flyover fault (might not fit in contact point)
Prescription faults;
Southend clasp included meaning appliance is not suitable
Adams clasp on C instead of D
FABP instead of PBP
Rectifying errors;
Re-make appliance by taking new impressions
Activating palatal spring;
Use spring former pliers = 1-2mm activation
Fitting a URA;
Check its correct appliance for right patient
Check its the correct design and matches the prescription
Check for any sharp areas on fitting surfaces
Check integrity of wire work
Try in the patient’s mouth
Check for any signs of blanching or trauma to soft tissues
Check occlusion =
1. Check flyover posterior retention
2. Check arrowheads
3. Check anterior retention
Activate appliance for 1mm movement per month
Demonstrate to patient correct insertion and removal of appliance - ensure they demonstrate this back to you
Book review appt every 4-6 weeks
Instructions to patient;
Will feel big and bulky but you will get used to this
Likely to impinge on speech - trying reading aloud at home to improve this
Mild discomfort - sign that appliance is actually working
Initial increase on salivation but will pass within 24 hrs
Wear 24/7 including meal times
Only remove appliance to clean with soft brush after each meal or when taking part in contact sports
Store in safe container when taking part in sports
Avoid hard sticky foods
Be cautious with hot food and drinks
Non compliance will lengthen treatment
Give emergency contact number if there are any problems
Place a hall crown on this child
Child chokes on hall crown - deal with the emergency appropriately
1.
Floss 2 pieces of floss through the ortho separator
Pull tight and move down between the contacts but not sub ginigval
Leave in place for 2-7 days and then remove with blunt probe
2.
Sit child upright for hall crown placement
Place gauze to protect airway
Choose appropriate crown that will seat using sticky stick
Dry the crown and fill with GIC (aquacem)
Dry the tooth and place crown over tooth
Seat crown with finger pressure
Get child to bite down on gauze for 2-3 mins
Remove excess cement
Floss between contacts
3. *Choking emergency* DRSABCDE - are you choking? 5 back slaps between shoulder blades 5 abdominal thrusts between belly button and sternum Continually check for object dislodging Re-evaluate ABCDE BLS if not resolved Call 999 and refer to hospital to check for rib fractures
There is a 30 yr old patient Mr Smith who is not registered with a GDP - he is complaining of signs of ANUG
He smokes 20 per day but is otherwise fit and well
You notice on E/O that the patient has cervical lymphadenopathy
Discuss the diagnosis with the patient and proposed management - there is not need to obtain any more info from the patient
Diagnosis;
Mr Smith after our examination I’m afraid you are suffering from a condition called acute necrotising ulcerative gingivitis or ANUG for short
This is a rare condition presenting as an acute form of gum disease which means that the gum disease develops much faster and more severely than normal
Aetiology;
It can be caused by a variety of reasons but it tends to occur in people who are stressed, have poor oral hygiene, smokers, poorly nourished or have an underlying medical condition causing them to become immunocompromised
High plaque levels can make the condition worsen
Symptoms;
Common symptoms include bleeding/painful gums, painful ulcers, receding gums, bad breath, metallic taste, excess saliva and difficulty speaking or swallowing
The disease can also extend away from the mouth and cause systemic symptoms such as swollen lymph nodes or high temp resulting in a fever
Management;
I just want to reassure you that this disease can often be managed by local measures such as;
OHI
HPT including RSD under LA (deep clean)
CHX 0.2% or hydrogen peroxide 6% mouth rinse
Smoking cessation
Stress reduction
Systemic involvement;
Metronidazole 400mg 1 capsule 3 times daily for 3 days (no alcohol)
Amoxicillin 500mg 1 capsule 3 times daily for 3 days
Recommend use of ibuprofen for pain relief
Register with GDP
Review within 10 days - referral if no changes
List and discuss the different waste streams used in clinic
Black - Domestic household waste e.g. paper towels
Orange - Low risk clinical waste e.g. PPE
Yellow - high risk clinical waste e.g. teeth/body parts
Red - Hazardous waste e.g. amalgam
Yellow box with blue lid - LA that hasn’t been fully used
Yellow box with orange lid - sharps box e.g. needles
Brown waste - Confidential
How would you deal with a blood spillage?
Stop what you are doing
Apply appropriate PPE - apron, mask, visor and gloves
Cover spill with disposable paper towels
Apply sodium hypochlorite powder 10,000ppm
Leave for 3-5 minutes then use scoop to take up gross contamination and put into orange waste
Clean area with general purpose neutral detergent disinfectant wipes
How would you carry out a radiographic report of an OPT?
Demographics;
Type of x-ray
Pt age
Date it was taken
Quality;
Grade 1, 2 or 3
Dentition;
Teeth = erupted/unerupted, permanent/primary/mixed, missing/supernumerary, impacted/ectopic
Restorations = heavy/moderate/mild restored dentition, overhangs and fractures
Trauma
Diseases;
Caries = primary/secondary, supra/sub gingival
Perio = bone levels, localised/generalised, supra/sub gingival calculus
Endo = well/poorly compacted, material used
TMJ
Other pathologies e.g. cyst
Diagnosis from OPT; Perio diagnosis Poor prognosis teeth Treatment planning Any supplementary radiographs required
A patient complains of a dry mouth - take a history and identify the underlying cause
History;
HPC =
How do you feel the dry mouth is affecting you?
Do you struggle to swallow without water
Do you require more than your normal fluid intake?
Are you uncomfortable when eating, speaking and swallowing?
MH =
Are you on any medications? patient is on Amitriptyline
Do you have any medical conditions such as diabetes, epilepsy, anxiety, stroke, Sjorgen’s, cystic fibrosis or HIV?
Do you smoke?
Do you drink?
Management; Treat underlying cause; 1. Rehydrate 2. Chew sugar free gum/lozenges 3. Modify medications - discuss with GP about alternative for amitriptyline 4. Control systemic diseases 5. Reduce caffeine 6. Alcohol and smoking cessation
Prevent oral diseases;
1. Caries - high fluoride toothpaste
Saliva substitutes;
- Spray/lozenges
- Saliva orthana
- Stimulants - pilocarpine
Your patient has been diagnosed with lichen planus
Explain this disease to the patient and the management options
Explanation;
- Explain to patient that they have white patches around their mouth which may be a lichenoid tissue reaction or lichen planus
- These conditions can present anywhere on the skin but in some cases it presents in the mouth and it is one of the most common conditions we see in the oral medicine department
- The white of the tissue arises from a extra keratin layer of protein being deposited from factors such as friction
- Lichen planus can be thought of as a type of autoimmune or allergic reaction to something and in most cases we don’t really know what causes it, most common causes are reactions to medications, SLS (a component found in some toothpastes) or metals in silver fillings
- Lichen planus has a small chance of developing into something more sinister such as mouth cancer (about 1% of cases in 10 years average) the area and extent of lichen planus can increase or decrease the risk of malignancy
Management;
Asymptomatic;
1. Observe and give CHX mouthwash
Symptomatic;
- Attempt to identify and remove the causative agent e.g. SLS free toothpaste, removing amalgams
- Topical or systemic steroid use
- Difflam mouthwash can help to numb any sore areas
In the mouth lichen planus can take between 3-5 years to resolve and in the meantime we would like to keep an eye on you by taking some pictures and reviewing you every 4-6 months by ourselves if in high risk area or by GDP if low risk area to monitor any changes
Do you have any questions?
What are the normal inhalation sedation levels for a patient?
What are the contraindications for inhalation sedation?
What are the contraindications for IV sedation?
Normal sedation levels;
- Minimum oxygen delivery 30%
- Maximum nitrogen dioxide delivery 70%
- Oxygen stats should be 97-100
- Alarm bells at 90 - stimulate patient and ask them to take a deep breath
- Hypoxic at 85 - supplemental oxygen via nasal cannulation 2L/min, reversal with flumazenil 500mg/5ml
Contraindications for inhalation sedation;
- Common cold
- Tonsillitis
- Nasal blockages
- Severe COPD
- MS
- Pregnancy - 1st trimester
- Unable to nasal breathe
Contraindications for IV sedation;
- Severe systemic disease or special needs
- COPD
- Hepatic insufficiency
- Pregnancy and lactation
- Social - uncooperative, extremes of age
- Dental - too long a procedure
How would you carry for cranial nerve testing for the trigeminal and facial nerve?
demonstrate on patient
Cranial Nerve V - Trigeminal
- involved in sensory supply to the face and motor supply to the muscles of mastication
- Sensory supply - Check sensation from each branch by lightly touching the face with a piece of cotton wool around jawline, cheek and forehead
- Motor supply - Can patient clench their jaw? (Palpate the masseter and temporal is muscle) Can they open their mouth against resistance?
- Corneal reflex - lightly touch cornea with wisp of cotton from the side
Cranial Nerve VII - Facial
- involved in motor supply to the muscles of facial expression
- Facial muscle test - Crease forehead (raise eyebrows), close eyes and keep them closed against resistance, puff out cheeks, reveal their teeth and pout
