OSCE Book - Oral and Maxillofacial surgery Flashcards
You are a dentist in general practise. Mrs Begum, a fit and healthy 60-year old lady has attended as a new patient for a check up. Her social history reveals that she chews betel quid (paan) daily. Clinical examination reveals betel staining of her teeth and oral soft tissues. Please give the patient oral health advice regarding their betel quid usage.
- Introduce yourself to the patient
- Ask the patient what is contained in the quid that they chew?
- It is necessary to determine that amount and frequency of usage as well as the constituents of the betel. It usually consists of betel vine leaf, betel nut, spices and usually tobacco. which increases the harmful effects
- Explain to the patient that there is an association between chewing betel quid and changes in cytogenic structure of the oral mucosa, and this occurs with or without tobacco
- Changes that occur. i) sub mucosal fibrosis (limits mouth oppening and pre-malignant) ii) Potentially malignant lesions iii) OSCC
- Make sure patient understand that all of there conditions are serious
- Stopping or atleast reducing the frequency of usage would be very benefical as it would reduce the risk of these harmful effects
- Chewing betel quid also leads to unsightly staining of the teeth and mucosa
- Ask the patient if they have any questions
A 72-year old man attends your surgery complaining of soreness on his tongue. This has been present for 4 weeks. There is a no history of trauma on the tongue and he is F&W on examination.
There is no E/O abnormalities.
There is an ulcer, 1cm in diameter, on the RHS lateral border of the tongue.
There is a fractured amalgam restoration in the lower right second permanent molar.
1) What factors would you ask about while taking the permenant history?
- Details regarding smoking adn alcohol intake. Including the frequency and amount.
- As well as other high risk activities such as betel nut chewing and snus.
A 72-year old man attends your surgery complaining of soreness on his tongue. This has been present for 4 weeks. There is a no history of trauma on the tongue and he is F&W on examination.
There is no E/O abnormalities.
There is an ulcer, 1cm in diameter, on the RHS lateral border of the tongue.
There is a fractured amalgam restoration in the lower right second permanent molar.
2)What inital management would you carry out for this patient?
- Remove any local cause of irritation to the tongue, to exclude a traumatic cause for the ulcer.
- The 47 has a fractured amalgam, whihc could be the source of the problem. I would then either smooth the restoration or replace it. Leaving no sharp edges which could traumatise the tongue.
- If 47 is unrestorable xla
N.B take photographs of the lesion to compare at next appointment.
A 72-year old man attends your surgery complaining of soreness on his tongue. This has been present for 4 weeks. There is a no history of trauma on the tongue and he is F&W on examination.
There is no E/O abnormalities.
There is an ulcer, 1cm in diameter, on the RHS lateral border of the tongue.
There is a fractured amalgam restoration in the lower right second permanent molar.
3) What features of the ulcer would lead you to suspect that it was malignant?
- If once all traumatic causes are ruled out and treated, the ulcer still doesnt heal
- The ulcer is hard and fixed to touch
- The ulcer is raised with rolled edges
A 72-year old man attends your surgery complaining of soreness on his tongue. This has been present for 4 weeks. There is a no history of trauma on the tongue and he is F&W on examination.
There is no E/O abnormalities.
There is an ulcer, 1cm in diameter, on the RHS lateral border of the tongue.
There is a fractured amalgam restoration in the lower right second permanent molar.
4) If the lesion is thought to be malignant, which type of biopsy should be taken?
- Incisional biopsy. As this means when the maxfax surgeon eventually comes to treat it, he will be able to see where it is.
A 72-year old man attends your surgery complaining of soreness on his tongue. This has been present for 4 weeks. There is a no history of trauma on the tongue and he is F&W on examination.
There is no E/O abnormalities.
There is an ulcer, 1cm in diameter, on the RHS lateral border of the tongue.
There is a fractured amalgam restoration in the lower right second permanent molar.
5) The patient has returned 2 weeks later after your intial management. The ulcer has not healed and has raised rolled edges.
Please write a referral letter for the patient to see a specialist for management of the lesion.
Patient details
- Mr Thomas Smith
- DOB 13/8/1941
- Address 54 Burntash Av, Thamestown AB18 4CD
- 02071239876
Points to remember when writing the referral letter
- The letter must be addressed to a consultant in oral and maxillofacial surgery.
- It must be marked urgent
- It must include your contact details i.e address, phone number
- It must include the patient’s details. DOB, name, address, phone number.
- It must include a brief summary of the problem, treatment which has been carried out and a provisional diagnosis
Please obtain consent from this patient for removal of the lower right first permenant molar under local anaesthetic and IV sedation.
Local anaesthesia and sedation
- Explain that the patient will be awake and able to maintain verbal contact at all times
- They will feel light-headed and perhaps a bit sleepy but not anxious or worried by what is going on
- The sedative agent is administered through a cannula in the back of the patients hand
- LA will also be given in the mouth to numb the area
- The must attend the appointment with a escort, who will drive them home and look after them for the rest of the day
- Patients should ot operate heavy machinary or sign any legal documents for next 24hrs. They should also not eat 2hrs prior to appointment, or fast like a GA appointment.
- They must take the rest of the day off work
The extraction
- They will not feel any pain during the procedure but may be aware of pushing and pressure
- If the tooth doesnt come out in one piece with the forceps. It may be required to pull back the gum, drill away some bone around the socket and cut the tooth into smaller pieces.
- You wont feel any of this and stitches will then be placed afterwards
- This tooth needs to be extracted as it has infection and a large cavity. it is unrestorable
Post-op
- It will be a bit sore and swollen
- May experience some bleeding from extraction site but instructions will be given to manage this.
- May have limited mouth opening, soft diet for a few days
- Keep area clean with warm salty water to prevent infection.
- Ask the patient if they have any questions and give them away a patient information leaflet.
You have just carried out forceps extraction of a lower right first permenant molar under LA. Please give post operative instructions to this patient.
- Intorduce yourself
- You should given written and verbal post-op instructions to the patient
- Pain is to be expected, so take pain killers before the local wears off to minimise this. A common dose would be 1g of paracetamol 4x daily. If pain is severe then can combine with ibuprofen 400mg 3x daily. Pain is to be expected post-op however worsening pain is abnormal so conact us if this is case
- Keep area clean with warm salty water rinses. Start this tomorrow or no soon than 6hrs post-op. A teaspoon of salt and warm water and rinse after each meal.
- If patient bleeds after they leave then bite down on some damp gauze for 30mins. If the bleeding does not stop then contact us or call 111/NHS 24
- Still brush your teeth and upkeep OH.
- Warn pt to be careful that they dont bite lip or burn themselves with hot foods/drinks as they are still numb
- Can eat and drink after procedure but avoid hot and chewy foods as may dislodge clot
- Advise the patient that some degree of swelling and limited mouth opening is normal and should resolve in a few days
- Rest the rest of the day and avoid smoking and alcohol for as long as possible
What is a contraindication to ibuprofen?
- Astmatic patients
- Patients with gastric/peptic ulceration
You have treatment planned this fit and healthy 26 year old patient for the surgical removal of all 4 wisdom teeth. Please warn the patient of the possible complications related to the surgery of removing these teeth (it is not necessary to talk about methods of anaesthesia used.)
Introduce yourself to the patient
Points to cover
1. The patient needs to be warned that the extraction is usually accompanied by some degree of pain, swelling, post-op bleeding and limited mouth opening after the procedure
2. They should be told the procedure will entail, as it is a surgucal procedure. A cut of the gum, some bone of the socket being removed, the tooth being but into pieces and the gum stitched back into place afterwards
3. Enucleation of any cystic tissue would be sent for pathological examination
4. They should be warned of specific complications assocaited with these extractions.
i) Temporary or permanent numbness of the lower lip and tongue
ii) Prognosis of lower second molars as there will be distal bone loss around these teeth
5. As extraction may be difficult patient could need to take time off work.
You are an SHO working in an oral and maxillofacial surgery department. You are seeing a fit and healthy 23-year old lady who requires surgical removal of all 4 wisdom teeth due to multiple episodes of pericornitis. The patient is unsure if she will be able to cope with the procedure under LA and wants to know if there are any other ways in which teeth could be removed, and what these would involve. Please explain to the patient what options are available to control pain and anxiety during surgical procedure (you do not need to discuss IHS).
Introduce yourself politely to the patient
GA
1. The patient will be asleep while the procedure is carried out so she will not be aware of what is going on
2. The anaesthetic is usually administered through a cannula in the arm, so she may feel a sharp scratchas the cannula is inserted.
3. She will need to allow some recovery time - several days off work/college
4. She will need to come with an escort
5. She should not drive, sign legally binding documents or operate heavy machinary for 24hrs
6. She will need to fast for 6 hours pre-op
7. she may feel nauseous and vomit after the procedure
8. Usually done as a day-case procedure, so does not stay overnight in hospital
9. Mordern anaesthetics are safe, but there is a risk of not waking up. However that is very small and estimated at 1 in 100,000.
LA and IVS
1. Explain that the patient will be awake and able to maintain verbal contact at all times
2. They will feel light-headed and perhaps a bit sleepy but not anxious or worried by what is going on
3. The sedative agent is administered through a cannula in the back of the patients hand
4. LA will also be given in the mouth to numb the area
5. The must attend the appointment with a escort, who will drive them home and look after them for the rest of the day
6. Patients should ot operate heavy machinary or sign any legal documents for next 24hrs. They should also not eat 2hrs prior to appointment, or fast like a GA appointment.
7. They must take the rest of the day off work but recovery time is shorter than GA
Oral sedation
1. Tablet form of sedation is administered at home or an hour before to procedure to help calm the patient
2. The effect is not as reliable/predictable as IVS
You are seeing an emergency patient, 40 year old with insulin dependent diabetes, who has presented with an E/O swelling caused by a dental abscess from a carious lower right first permenant molar
1. What clinical findings would lead you to believe that this patient has a rapidly spreading infection?
2. What criteria would you use for deciding whether or not to refer on for treatment
People with diabetes are at more risk of infections. Odontogenic infections can progress rapidly in diabetic patients, especially if the diabetes is poorly controlled. Infections can alter diabetic control, leading to changes in blood sugar levels.
Signs of spreading infection
- Increased pain
- radpidly increasing swelling
- Fever
- Increased pulse rate
- Uncontrolled diabetes
When to refer
- Raised temp >38
- Increased pulse rate
- Abnormal BGL
- Raised FOM
- Firm FOM
- Droolling
- Deviated uvula
- Severe trismus
- Difficultly swallowing
- Inability to speak complete sentences
You are seeing an emergency patient, 40 year old with insulin dependent diabetes, who has presented with an E/O swelling caused by a dental abscess from a carious lower right first permenant molar
- Who would you refer the patient onto
Refer to maxfax for emergency by contacting the department directly.
F&W patient has attended in pain in her 17. She wants it xla. Please explain to the patient what removing the tooth under LA involves, including possible complications
Introduce yourself politely to the patient. , points to cover:
1. The area will be numbed with local anaesthetic.
2. The procedure will be painless but the patient may experience sensations of pressure and pushing.
3. The tooth may come out with forceps in one piece. However, there is a large carious area so the tooth could fracture. The tooth may need to be removed surgically, which would involve a cut in the gum, bone removal, and possible cutting of the tooth into pieces to remove it. This would be followed by stitching of the gum.
4. The maxillary sinus is visible on the radiograph and close to the root so there is a possibility that removing the tooth may create a communication between the mouth and the sinus. If this is a very small hole it may close with no surgical intervention. However, larger communications will need surgical closure - otherwise food and drink will enter the sinus and come out of the patient’s nose while eating and drinking.
5. Closure can be carried out as soon as the tooth is removed if a communication is noted, by stitching the gum across the hole, or if necessary we will mobilise a bit of gum from inside of the cheek to cover the hole.
6. The patient will then have to avoid blowing their nose for 2 weeks.
7. They may need antibiotics, nasal inhalations and nose drops post-operatively.
8. There will be pain and swelling post-operatively.
9. There will be limited mouth-opening post-operatively.
10. The patient may need to take time off work
Ask if the patient has any questions
You see a 25 year old woman who you have diagnosed as suffering from myofacial pain in their masticatory system. Please give her advice on how she can manage the condition conservatively.
Introduce yourself to the patient
Information
1. Reassurance and explaination play a big role in the treatment of myofacial pain
2. Explain that the condition is very common, especially in young women
3. The exact cause is unknown although there are predisposing factors
i) it is often stress related, so worrying about it will make it worse
ii) Can be due to a discrepancy in the bite or previous trauma
iii) Sometimes it can be related to parafunctional habit like nail biting, chewing pen, clenching and grinding
4. The condition is usually self-limiting, although it may take months to years to resolve
5. Explain that her pain is coming from the muscles that move her jaw, which will get worse during use.
Treatment
1. Explain that the treatment will take many forms and will take a while to work
2. The important point is to rest the jaw as much as possible
3. Soft food diet. examples mashed potatoes and scambled egg.
4. Limit mouth opening, supported yawning
5. Limit parafuctional habits, biting nails, pens, clenching and grinding. No chewing gum
6. She should apply heat to muscles and NSAIDs
7. Arrange follow up to check her progress and if conservative approach isnt working can make patient a soft bite raising appliance.
Answer any questions
Name these instruments and what they would be used for?
Top - Mitchell trimmer. Used for curettage of soft tissues
Bottom - Howarths periosteal elevator. Used for retracting periosteal flaps and raising mucoperiosteal flaps
Name these instruments and what they would be used for?
Wards buccal retractor
- Retracting periosteal flaps
Name these instruments and what they would be used for?
Warwick james
- Used for extraction of upper 8’s and elevation of teeth and roots
Name these instruments and what they would be used for?
Lower root forceps
- Used for extracting lower anterior teeth and roots
Name these instruments and what they would be used for?
Top - Bowdler Henry rake retractor
Used for retracting mucoperiosteal flaps
Bottom - American style sucker. Used for aspirating blood and liquid from the operating site
Name these instruments and what they would be used for?
Bone nibbler
Used for removing bone
Name these instruments and what they would be used for?
Laster’s retractor. Used for retracting mucoperiosteal flaps when remving upper wisdom teeth.
Name these instruments and what they would be used for?
Couplands elevator
Used for elevating teeth and roots
You have been called to see a patient who has a bilateral dislocation of the TMJ. You have examined the patient and have a OPT to confirm the diagnosis. Describe how you would proceed to reposition the mandible.
Reduction of dislocated TMJs can be carried out manually. IT may be necessary to augment the treatment with LA, sedation, or GA
1. Introduce yourself to the pateint and explain what has happened. Use the OPT to aid explaining that they have dislocated their TMJ (can see on opt that the condyles are not sitting in the glenoid fossa)
2. Explain to the patient what you are about to do.
3. Warn their patient not to open their mouth immediately after as it is likely to redislocate
4. Perform the reduction with the patient sitting in a chair or in the supine position.
Patient sitting down
1. It is important that the head is supported while you relocate the jaw
2. Stand infront of the patient
3. Place you thumbs on the extrernal oblique ridge and push down. While also pushing up with your fingers on the patients chin. (DO not push back at any point)
4. May be easily to relocate one side at a time
5. Once relocated continue upward pressure on the chin for one minute to prevent redislocation
6. Advise the patient to avoid wide mouth opening for 24hrs
If reduction alone is unsuccessful then may require sedation, LA into lateral pterygoid and around the joint or GA
These three lines describe paths of opening of the mandible as measured from the tip of the central incisors when looking AT the patient from the front.
- What is happening in the TMJ’s to account for the different lines of opening?
A - There are adhesions within the left TMJ, so when the patient opens their mouth the mandible deviates to the left as the left condyle is not able to translate.
B - There is a non-reducible obstruction within the RHS of joint. Intially opening is straight as this is the hinge or axis rotation part of opening. Then the anteriorly displaced disc in the right TMJ prevents translation causing the mandible to deviate to the RHS.
C - There is a reducible obstruction within the TMJ. Opening starts straight and there is a deviation when the obstruction is encountered. However, the obstruction or the disc moves out of the way and so further opening is straight.
These three lines describe paths of opening of the mandible as measured from the tip of the central incisors when looking AT the patient from the front.
- You want to ask a patient to carry out returded jaw opening excercises. Please explain to them how to do these excercises?
Retruded jaw opneing excercises
1. Introduce yourself to the patient
2. Explain that the excercises are like physiotherapy for the jaw and need to be done regularly. Intially ten times each 4x daily.
3. Advise them to do the excercises in front of a mirror
4. Ask them to curl the tip of their tongue to the back of their hard palate. This will retrude the mandible
5. With the tongue in that position ask the patient to open and close their mouth slowly
6. Ensure that they do not deviate to one side on opening hence the need to sit infront of a mirror
7. Ask them to repeat back to you so you are sure they can do it.
8. GIve information leaflet away with the patient if you have them
