OSCE - Perio

Question 1

Periodontal Abscess (6 mins)
A 50-year-old male patient attended for HPT with the hygienist 3 months ago. Their 35 is tender, has a swelling around the tooth and has an 8mm pocket on the distal aspect as well as suppuration.
The patient is systematically well and has a normal body temperature.
Provide your diagnosis to the patient and discuss how you would like to investigate the matter further.
Indicate to the examiner when you wish to receive the results of the special investigations.

Answer 1

1. Ask for (otherwise you won’t get it)
   * PA radiograph (2 marks)
   * Sensibility testing (2 marks)
2. EPT 35 and 36 respond positively
   PA radiograph shows periodontal pathology
   Swelling (2 marks) (Rule out PA abscess)
3. Pocket with pus (2 marks)
4. Bone loss from radiograph, explain to the patient using the radiograph that they have bone loss on this tooth. (2 marks)
   (can be associated with food packing and tightening of the gingival margin post HPT)
5. Signs / symptoms- swelling, pus, TTP (lateral direction), deep pocket, bleeding, suppuration, usually vital, commonly pre-existing perio disease
6. Diagnosis- periodontal abscess (2 marks)
7. Treatment
   - Irrigate through pocket (2 marks)
   - Debridement (2 marks)
   - Hot salty mouthwash (2 marks)
   - Tx- subgingival instrumentation just short of base of pocket, if pus present- drain by incision or through the pocket, recommend 0.2% CHX, recommend analgesia, and only prescribe antibiotics if clear signs of systemic involvement or spreading infection; extract tooth if hopeless prognosis, arrange for review and definitive periodontal treatment and appropriate recall interval.
   No antibiotics- since it’s a localised infection (2 marks)
   Actor marks- empathy (1 mark), communication (1 mark), understanding (1 mark)

Question 2

Explain and give a diagnosis from an OPT

Patient has generalised periodontitis, stage 4 grade C, currently unstable, risk factors include smoking.

Explain diagnosis to the patient and how you will manage them.

Answer 2

Discussion of disease
* You have periodontal disease which is a disease as a result of plaque(furry white stuff on your teeth) in the mouth causing an inflammatory response which results in bone loss.
* You have bone loss on more than 30% of your mouth, stage 4 means the boss loss is into the apical third, grade C means the percentage of bone loss is higher than your age, meaning it is fast spreading, stable means the disease is active with pockets of over 4mm and a risk factor is smoking.
* Discuss other risk factors that increase risk of perio such as smoking, diabetes and poor OH. Discuss prognosis of the teeth with regards to loss of attachment, mobility and furcation involvement.
* Explain that it is Important to screen and monitor siblings and children of patients as they are at greater risk if there is a familial link.
* Emphasise it is treatable, and they can help the situation with good OH and reducing modified risk factors,
Treatment
* Provide oral hygiene instruction through TIPPS – brushing, fluoride toothpaste, ID cleaning, MW use
HPT – MP&BS, 6PPC, sub and supra and sub gingival PMPR >4mm, diet diary
* 2-week course of daily CHX MW and spray

No need for antibiotics as first line treatment as if doesn’t treat the cause and the disease is manageable with localised treatment

If no change after 3 months the patient should be referred to specialist periodontal services if they adhere to optimum oral hygiene and deal with risk factors.

This is old diagnosis type. Now just follow BSP S3 guidlines

Question 3

30-year-old patient not registered with GDP. C/O signs of ANUG. Smokes 20 cigarettes daily.
Otherwise fit and well. Has cervical lymphadenopathy.
Discuss diagnosis with patient and proposed management.
No need to obtain more information from the patient.

Answer 3

Introduce self and designation

Description for patient:
* Rare condition presenting as an acute form of gum disease which develops much faster and more severely than normal- resulting in pain, destructive ulceration and dead tissue.
* RISK FACTORS = Stress, immunocompromised, smoking, severely malnourished, poor OH, sleep deprivation, HIV

Treatment:
* Give LA
* Ultrasonic debridement + removal of necrotic tissue- encourages healing
* CHX 0.2% x 2 daily
* If systemic symptoms present = 400mg metronidazole x 3 daily for 3 days (9 tablets)
* Ibuprofen if fever
* Provide smoking cessation, diet advice and vitamin supplements
* PMPR- after acute symptoms subside
500mg Amoxycillin 3x daily for 3 days (9 tablets) 250mg Penicillin V 3x daily for 3 days
use doxycycline if patient on warfarin = 1x 200mg tablet on first day then 1x 100mg tablet for 21 days

Show actor photos as part of discussion if they are available

Question 4

Comparing Pre- and Post-Treatment Pocket Charts (12 mins)
Indicate reasons for failure.

Answer 4

Reasons for failure
Smoking
Patient not compliant- OH is poor
Inability for patient to practice OH effectively
- Hard to reach areas- furcations, lone standing teeth, wisdom teeth
- Poor manual dexterity- dementia / Parkinson’s / age
Systemic factors- stress, diabetes, pregnancy, malnutrition / poor diet
Difficulty accessing for debridement / inadequate debridement (time constraint, patient cannot tolerate)
Iatrogenic factors- overhangs, poor margins