Previous OSCE Stations Flashcards
Describe steps to place dam on a 16 for an endodontic procedure.
Choose correct clamp for correct tooth - in this case 16 so molars - A, AW, FW or K clamp
Hole punch into dam (largest single hole for endo)
Opal dam or oroseal for around clamp and dam - light cure
Placement of frame on outside of face
Relieve dam over nose by cutting it with scissors or folding it
Check seal using chlorhexidine
A paediatric patient attends for a hall crown, explain to the patient why this procedure is necessary and what is to be done.
Advantages of hall crowns:
- Preformed metal crown - fitted quickly and procedure is non-invasive as fitted over tooth with no preparation
- Can only be used when there is no radiographic or clinical signs of pulpal involvement
Procedure:
- Using two pieces of floss place separators between mesial and distal contacts if no space - see pt 3-5 days later for removal
- Sit child upright and place gauze swab to protect the airway
- Choose the crown - fit smallest size crown that will seat, crown should be subgingival or at least below the margins of the cavity
- Dry the crown and fill with GIC (aquacem) - dry the tooth and place crown over tooth
- Seat crown over tooth and partially seal until crown engages with the contact points and encourage the child to bite into place
- Extruded cement removed from margins with CWR
- Floss between contacts
- Reassure child and parent - explain crown is supposed to fit tight and gum will adjust
- Child will get used to feeling in 24h
- Occlusion tends to adjust to give contacts bilaterally within a few weeks
Faults with hall technique:
- Minor - secondary caries, filling/crown worn or lost, reversible pulpitis
- Major - irreversible pulpitis, abcess, inter-radicular radiolucency, filling lost and tooth unrestorable
You are a dentist in general practice.
Please give dietary advice to the mother and 6 y/o child.
Introduce yourself
Start with a diet analysis - 3 days and include at least one weekend
Explain to the mother she needs to record the time, content and amount of food and drink consumed as well as the tooth brushing times
Diet sheet should be checked with the patient and mother
Assess all nutritional value of meals
Highlight all sugar intake
Explain relation between sugary snacks and drinks between meals and decay - sugar acts as substrate which bacteria use to create acid which breaks down teeth/causes decay
Hints to give:
- save sweets to special time of week
- eat sweets all in one go
- chewing gum and cheese will stimulate saliva flow
- fizzy drinks contain sugar
- diet fizzy drinks can cause erosion even though they’re sugar free
A patient attends your practice a few days following XLA of 34. They are complaining of pain and a bad taste. Diagnose, explain and manage situation.
Introduce yourself to the patient
Take a pain history - SOCRATES
Take a MH - allergies, systems, medications
Take a SH - smoker, alcohol usage
Signs and Symptoms:
- Pain often begins 3-4 days after XLA and can take 7-14 days to resolve
- No blood clot present in socket
- Moderate to severe dull aching pain
- Pain keeps pt up at night
- Pain throbs and radiates to ear
- Exposed bone is sensitive and is source of pain
- Characteristic smell/halitosis w pt complaining of bad taste
Diagnosis:
- Alveolar osteitis is a very painful dental condition that is a common post operative complication of extractions. Localised osteitis is the inflammation affecting the lamina dura
- This causes dry socket which occurs when the blood clot at the site of an extraction fails to develop, dislodges or dissolves before wound heals.
Predisposing factors:
- Molars are more common - increased risk anterior to posterior
- Mandible more common than maxilla
- Smoking increases risk due to reduced blood supply
- More common in females than males
- Oral contraceptive pill
- Diabetes - poorer wound healing
- Traumatic XLA
- Excessive mouth rinsing post XLA
- FH or previous dry sockets
Management:
Initial management
- Reassurance
- Recommend optimal analgesia - ibuprofen (400mg 4x daily), paracetamol (1g 4x daily)
- Advise pt to avoid smoking and maintain good OH
- Advise pt to seek urgent dental care
- Give LA to relieve severe pain
Subsequent Care
- Irrigate socket with saline to flush out food and debris
- Curretage/debridement - encourage bleeding and new clot formation
- WHVP or Alvogyl - Ribbon gauze soaked in WHVP sutured into pocket which requires removal
- Alvogyl is a mix of LA and antiseptic (contains iodine)
- Both of which promote clotting and enhance clotting framework
- Use of analgesia and warm salty mw or CHX use
- Antibiotics are not required unless sign of spreading infection, systemic infection or immunocompromised pts
What is involved in an assessment for a suspected mandibular fracture?
Initial hx:
- Any associated headaches?
- Was there any loss of consciousness?
- Nausea or vomiting
- Numbness/alteration in sensation of the face?
- Any police involvement?
- Any other injuries?
E/O:
- Check for pain, swelling, bleeding
- Facial asymmetry
- Palpation of mandible bilaterally - condyle, ramus, body and symphysis
- Limited opening
- Mandibular deviation on opening
- Tenderness of TMJ
- Examination of sensation of lower lip/chin region supplied by the mental nerve - mandibular division of trigeminal nerve
I/O:
- haematomas, lacerations and blood-stained saliva. Gently clean/suction the mouth free of any clots and carefully examine the lingual (on the side of the tongue) and buccal (towards the cheeks) sulcus (the most inferior aspect of the gums on either side of the teeth). Palpation in both areas may reveal steps or deformities.
How do you classify maxillary/mandibular fractures? What further investigations may you carry out?
- Soft tissue involvement - simple, compound, comminuted
- Fractures involving the teeth expose the peridontium so are always compound fractures
- Number - single, double or multiple
- Side - unilateral or bilateral
- Site - condylar, subcondylar, body, coronoid, angle, ramus, parasymphyseal, symphyseal, alveolar, alveolar process
- Direction - favourable or unfavourable
- Displacement - displaced or undisplaced
- Further investigations - 2 radiographs at right angles - OPT and PA
How would you manage a fractured mandible/maxilla?
Stages of management:
- Clinical examination
- Radiographic assessment
- Tx
Tx:
- Urgent phone call to OMFS or A&E department and urgent referral if displaced
- Control of pain and infection
- Surgery
- Undisplaced/hairline fracture - no tx
- Displaced or mobile fracture - closed reduction and fixation (IMF) or open reduction and internal fixation (ORIF)
Patient attends with swelling, ask for radiograph and go through hx and diagnose SIRS and explain management.
Radiograph shows an abscess to a specific tooth.
- Abscess is pus enclosed in the tissues of the jaw bone
at the apex of an infected tooth/root.
Ask pt symptoms
- Swelling, trismus, dysphonia (abnormal voice), dysphagia (difficulty swallowing), drooling, poor neck flexion, inability to stick tongue out or swallow, pain, pyrexia, tachycardia, tachypnoea
- Colour, size and duration of swelling
- Ask about temperature, pulse rate, respiratory rate, colour
- Criteria for SIRS
Temp - <36 or >38
WCC <4 or >12x10^9/L
HR >90/min (tachycardia)
RR >20/min (tachypnoea)
2 out of 4 positive SIRS - Sepsis syndrome and requires urgent referral to OFMS or A&E
Always refer if
- Spread of infection to pharyngeal or submandibular space
- Systemic manifestations and patient is immunocompromised
- Trouble swallowing/breathing
- Rapidly progressing infection
Antibiotics for dental abscess if systemic manifestations or immunocompromised
- Local measures first - incise and drain, extract and drain, drainage through retraction of socket or instrumentation
- Pen V (250mg, 2 tablets 4x daily for 5 days)
- Metronidazole (400mg, 1 tablet 3x daily for 5 days)
Post-core crown actor – Radiograph shows that there is no endodontic treatment, caries lingually but no pain noted. Explain treatment options, disadvantages and advantages of all.
- Leave/monitor -
Advantages - it may stay asymptomatic but unable to tell for how long
Disadvantages - Risks of infection, abscess formation, pain, tooth breakdown, root fracture, eventual loss of tooth - Remove crown and caries, restore with new crown if restorable
Advantages - potentially lessens likelihood of pain and infection occurring
Disadvantages - crown may not be able to come off without the post being removed - Remove post-core crown - RCT and replace
Risks - root fracture, core/post fracture, ultimately may become unrestorable and require XLA
Explanation of root treatment - Extraction if unrestorable
Include options to replace teeth - leave space, bridge, denture, implant privately
Oral cancer diagnosis actor - risks of oral cancer and then explain findings of biopsy results
Risk factors for oral cancer;
Tobacco - smoke and smokeless
Alcohol
HPV16
Previous cancer
Family history of SCC
Sun exposure
Diet low in nutrients - fruit and veg
Malnourished
Immunocompromised - HIV/AIDS
Lichen planus
Poor oral health
Ask the pt what they are expecting from the appt
- Sit down next to pt and ask if they’ve brought someone with them
- How have you been since the last appt?
- Are you aware of what were here to discuss today? Do you know why we take a biopsy?
Ask permission to continue with discussion of the findings
- Inform the pt you have results from their biopsy and ask them if they would like you to go through them
Break the news slowly, empathetically
- “I wish I had better news”
- “The test we have done has shown some abnomalities in the cells… i’m afraid to say you have mouth cancer”
Allow pt time to digest information and ask questions
- “I am deeply sorry to break this news to you and know you will have lots of questions if anything comes to mind at the moment?”
Repeat the news and summarise
Give pt information about moving forward plan
- good news is that we have acted quickly and will be able to move forward with tx asap, Ill be speakingto OFMS consultants and surgeons and they will be seeing you in the coming weeks to discuss tx
Ask the patient if they understand and show empathy
- I understand this isnt the news that you wanted and there has been a lot of information put upon you today. I want you to take time and speak with friends and family and if you have further questions please dont hesitate to contact me. Offer the pt a follow up appt and phone no. for further questions.
Denture induced stomatitis – patient is diabetic and takes warfarin. Give findings and explain treatment to the patient
Patient has a sore denture and palate, tests done previously to confirm condition and you have the results. Denture induced stomatitis affecting the hard palate, provide with picture showing this as well as results of the swab. Medical history included type 2 diabetes and on warfarin for arterial fibrillation.
Explain findings to patient, recognise multifactorial condition and provide OH advice. You can ask relevant questions to the actors but you don’t need to take another MH.
Introduce yourself and who you are
Brief history
Acknowledge diabetic hx - ask about pt control and medications
Ask about AF and warfarin - INR below 4
Ask about denture - worn at night? how is it cleaned?
Signs and symptoms -
Sore palate, red palate
Erythematous and oedema of denture bearing area
Burning sensation
Inflamed mucosa under upper denture
Discomfort
Bad taste and halitosis
Newtons classification:
- Type I - localised inflammation with hyperaemic foci
Type II - diffuse inflammation and erythema confined to mucosa contacting denture without hyperplasia
Type III - granular inflammation with erythema and papillary hyperplasia
Explanation of clinical findings - Pt has denture induced stomatitis which is a fungal infection causing inflammation of the tissues that are in contact with denture and it can occur due to a variety of reasons and is more susceptible in pts that are immunocompromised
Management:
Local
Advise pt to brush palate 2x daily
Leave dentures out as often as possible especially at night
Mouth can be rinsed with chlorhexidine mouthwash 0.2% 10ml 2x daily rinsing for 1min
Cleaning dentures - brush with soft toothbrush and non-abrasive toothpaste after meals and in mrg and night
Soak in steradent morning and night
Ensure the denture fits appropriately - may require adjustments or relining
Limit smoking, sugar in diet and alcohol
Drug tx if required
- Nystatin oral suspension 100,000 units/ml
- Send 30ml; label 1ml after food 4x daily for 7 days
- Remove dentures before use, rinse suspension in mouth and hold near lesion for 5 minutes before swallowing
Continue use for 48h after lesions have healed
A fit and healthy 14 y/o attends your practice for a routine check up. Clinical photograph - anterior open bite.
Take a hx from pt to determine concerns and likely causes of the condition. Explain to them what you think are the likely causes and tx options.
- Introduce yourself to pt
- Ask if they have any problems with their bite
- Ask if they have any problems with eating
- Are they aware of the gap between top and bottom teeth, if yes, when did they first notice and has it changed with time?
- Ask if they ever sucked a thumb/finger, if they still do it, how often and duration
- Explain to pt this is possible aetiology of AOB and what the likely aetiology is in their case.
Aetiology of AOB:
- Habit - digit sucking (asymmetrical AOB + posterior crossbite)
- Soft tissue - endogenous tongue thrust
- Skeletal pattern
- Localised failure of alveolar development
In this case likely due to be digit sucking due to asymmetrical AOB with unilateral crossbite
- Explain cessation of habit can lead to spontaneous resolution of AOB during mixed dentition phase but as this pt is older only likely to improve but not entirely resolve
- Assess if the pt wishes help to stop habit
- Discuss ways to help cessation of habit - Thumb guard, appliance to break habit e.g. URA w midline screw to tx crossbite, nail polish
- Explain if AOB doesnt resolve they could be referred for orthodontic assessment
- Ask if pt has any questions
Note: If AOB is due to skeletal cause then the pt would need to be referred for a joint orthodontic and surgical opinion as correction of the AOB may require orthodontic treatment in conjunction with orthognathic surgery
You are a dentist in general practice. A mother has brought her 6 y/o daughter to your surgery for a routine check-up. The child has previous restorative work on her deciduous molar teeth.
Please give dietary advice to the mother and child.
- Introduce yourself to the patient and mother
- Establish rapport with patient and mother
- Start w diet analysis, should be 3-4 days including at least one weekend day
- Explain to the mother that she needs to record the time, the content, and the amount of food and drink consumed as well as the TB times
Examiner hands you a completed diet diary
- Diet sheet should be checked with mother and child
- Assess nutritional value of the meals
- Highlight all sugar intake
- Highlight any between-meal snacks and assess nutritional value
- Explain relationship between sugary snacks and drinks between meals and decay.
- Possible hints to give
a). Save sweets to a special time of the week e.g. Saturday morning
b). Eat sweets all in one go rather than spreading them out
c). Crisps, nuts etc, although more dentally friendly are very high in fat and salts and shouldn’t always be substituted for sweets
d). Chewing gum and cheese will stimulate salivary flow and may help after eating sugary snacks
e). Fizzy drinks contain a lot of sugar
f). Diet fizzy drinks can cause erosion even though they are sugar free
g). only drink plain milk or water between meals
h). Don’t eat or drink after brushing at night
i). Cheese can provide some protection but is high in fat
j). Fruit does contain natural sugars; however, consuming normal amounts does not contribute to caries - Overall aim is to decrease sugary snacks and fizzy drinks between meals
- Increase the amount of fresh fruit and vegetables eaten
You are a dentist in general practice, a mother has brought her 2 y/o son in to see you for his first dental appointment. The mother is unsure whether she should give her son fluoride supplements, as they live in a non-fluoridated area.
Please give fluoride advice to mother and son.
- Introduce yourself to patient and parent
- Establish rapport
- Explain to examiner you would carry out a caries risk assessment
a). Diet and sugar intake
b). Exposure to fluoride
c). Motivation of mother and family
d). Socio-economic group
e) Any MH
f) Lactobacillus and Strep Mutans counts - For a low risk child, the child would only need a smear of toothpaste containing no less than 1000ppm fluoride. As soon as teeth erupt in the mouth, brush twice daily.
- For high risk child, use a smear or pea-sized amount of toothpaste containing 1350-1500 ppm fluoride. Topical fluoride application in the form of Duraphat (2.26%) 3-4x annually would also be recommended.
- Explain that fluoride has been shown to reduce caries by 50%
- Fluoride can work on those teeth already erupted in the mouth, but will also have a beneficial effect on developing teeth
- There is an optimum level of fluoride ingestion. Exceeding this level can lead to problems of fluorosis, ranging from white opacities on the teeth to more severe discolouration and actual pitting of the teeth. Higher levels of fluoride ingestion can lead to toxicity and even death, so people must not exceed the advised dose. It is therefore important to know the level of fluoride in drinking water supply before any fluoride supplements are prescribed.
- The popular press has caused ppl to think fluoride will cause cancer - no evidence to support this.
- Child must spit out after brushing.
- Rinsing with water after brushing will remove some of the fluoride.
- Fluoride rinses not appropriate for this age group as patients this age will often swallow the liquid.
Write out a prescription for an immunocompromised teenager with primary herpetic gingivostomatitis
Aciclovir only prescribed to immunocompromised pts or when there is severe infection
Primary response to herpes simplex virus
- Sore mouth and throat
- Enlarged lymph nodes
- Period of malaise and fever (systemic symptoms)
- Self limiting - 7-10 days but can affect eating, sleeping etc which may have further detrimental health implications
Conservative management
- Plenty of bed rest
- Increase fluid intake
- Analgesic/antipyretics
- CHX 0.2% diluted swab to clean gums
Prescription form:
- Pts name, DOB, address, CHI, age in numbers if under 12
- Chlorhexidine mouthwash 0.2%
Send: 300ml
Label: Rinse mouth with 10ml for one minute twice daily
- Aciclovir 200mg tablets or oral suspension (200mg/5ml for 2-17y or 100mg/5ml for 6m-1y): one tablet five times daily for five days
Send: 25 tablets
Label: take 1 tablet 5x daily for 5 days
Bell’s palsy is sometimes associated with herpes simplex. Refer patients with Bell’s palsy to a
specialist or the patient’s general medical practitioner for treatment.
What are the different causes of facial nerve palsy and explain each?
Idiopathic – Bell’s palsy
Infectious – Ramsy Hunt syndrome
Iatrogenic – Local anaesthetic
Tumours – Acoustic neuroma, adenocarcinoma
Vascular – Stroke
Trauma
Congenital – Mobius syndrome
Idiopathic
Bell’s Palsy
What: Acute unilateral facial weakness or palsy with a rapid onset
Why: The cause of Bell’s palsy is currently unknown.
However, it has been speculated that inflammation and oedema could cause compression of the facial nerve
Who: It is the most common type of facial nerve palsy and accounts for approximately 80% of cases. Men and women are equally affected
Symptoms: Rapid onset, usually less than 72 hours. The affected side may include the ear and post-auricular regions. People may also experience dry mouth, taste disturbances and an inability to close the eye of the affected side
Treatment: Referral
Initiation of steroids within 72 hours of the onset of symptoms.
Infectious
Ramsay Hunt Syndrome
What: Acute unilateral facial weakness or palsy paired with blistering of the ear canal or mouth on the affected side
Why: Infection of the facial nerve by varicella-zoster virus (VZV). It is thought that following primary infection by VZV, the virus enters a latent period where it remains dormant in the geniculate ganglion of the facial nerve. When VZV in the geniculate ganglion is reactivated, it can lead to facial nerve palsy
Who: It is more common in females than males. Also, it is often seen in adults over 60 years of age
Symptoms: Ear pain, tinnitus or hearing loss may be experienced. As well as this, blistering of the ear canal or mouth on the affected side can occur
Treatment: Referral
Initiation of antivirals and steroids within 72 hours of onset of symptoms.
Iatrogenic
Local anaesthetic
What: Rapid unilateral facial palsy following administration of local anaesthetic, such as an inferior alveolar block
Why: Local anaesthetic is misplaced and injected into parotid gland and the area of the facial nerve, most commonly for a dental procedure
Symptoms: Immediate or delayed onset of facial palsy to the same side that the local anaesthetic was administered. This results in temporary unilateral paralysis of the facial nerve
Treatment: No treatment is required; the anaesthetic will gradually wear off over a few hours. Inform the patient of what has occurred, apologise and reassure. Also, surgical tape may be used to close the eye on the affected side if the patient is unable to close it.
Tumours
Acoustic Neuroma
What: Unilateral hearing loss and facial paralysis which shows no signs of improvement over a number of months
Why: Rare benign brain tumour of the eighth cranial nerve. Tumour growth leads to compression of the facial nerve, causing facial weakness as a result
Symptoms: Initially tinnitus, unilateral hearing loss and vertigo. Facial palsy then follows this
Treatment: Surgical removal of the tumour. However, this could result in permanent traumatic damage to the facial nerve.
Adenocarcinoma
What: Progressive unilateral facial nerve weakness and eventually palsy. This is most likely accompanied by a mass in parotid gland
Why: Adenocarcinomas are malignant tumours of the parotid gland. Infiltration of malignant cells into the facial nerve causes facial palsy as a result. Benign tumours are unlikely to cause facial nerve paralysis
Symptoms: Unilateral mass in the parotid gland which is increasing in size (either slowly or rapidly). As well as this, development on pain in the parotid lump and progressive unilateral weakness of the facial nerve
Treatment: Surgical removal of the tumour. However, this could result in permanent traumatic damage to the facial nerve.
Vascular
Stroke
What: Unilateral facial palsy with a rapid onset
Why: Either haemorrhagic or ischaemic in nature. In a haemorrhagic stroke bleeding results in excess pressure on the facial nerve and surrounding tissues. An ischaemic stroke causes restriction of oxygen to the facial nerve and surrounding tissues, resulting in ischaemia
Symptoms: Unilateral facial weakness. Unilateral weakness of an arm or leg (or both). Headache, confusion, dizziness or unsteadiness. Individuals may experience numbness in an area of the body. Loss of consciousness may occur in severe cases
Treatment: Strokes are a medical emergency and require urgent treatment. There are different methods of treating strokes based on the type. This may include medications or surgery.
Dental Implications
Xerostomia: Dry mouth possibly due to decreased salivary secretion from the submandibular or sublingual glands. The inability of an individual to close their mouth can also result in xerostomia. High fluoride toothpaste and salivary substitutes should be considered
Speech: Reduced innervation to the muscles of facial expression may result in speech difficulties. Speech may also be affected by xerostomia
Eating and drinking: Decreased innervation to the buccinator muscle may result in difficulty chewing. It can also lead to food collecting in the buccal sulcus. Reduced innervation to the orbicularis oris can cause a poor lip seal. Therefore, the patient may have difficulty drinking.
Key points:
There are multiple causes of facial nerve palsy
The most common type is Bell’s palsy, the cause of which is currently unknown
Facial palsy as a result of an inferior alveolar nerve block may initially seem concerning. However, it will resolve over a few hours
Aside from a facial palsy caused by local anaesthetic, all other types mentioned above will need referral for further assessment and treatment
A facial palsy may have implications on speech, eating and drinking
Xerostomia may also be a complication of facial palsy
Ortho discussion with examiner - using study models/photos to discuss classification (class II div 1) and tx options
- Skeletal classification - Class II - maxilla more than 2-3mm in front of the mandible; increased OJ, ANB>4 degrees
- Incisor classification - Class II Div 1 - lower incisor edge lies posterior to the cingulum plateau of the upper central incisors. The upper central incisors are proclined or of average inclination and there is an increased OJ
- Dental factors of class II div 1 malocclusion
Increased OJ - incisors proclined or of average inclination
Variable OB
Can have good alignment, crowding or spacing in dentition
Habitually parted lips may lead to drying of the gingivae and exacerbation of any pre-existing gingivitis
Reasons for tx:
- Concerns regarding aesthetics
- Concerns regarding dental health
- Prominent incisors are at risk of trauma especially w incompetent lips
- OJ > 9mm - 2x likely to suffer trauma - IOTN 5A
Management:
- Accept and monitor - when there is a mildly increased OJ and if pt isnt concerned, can give advice and use of mouth guard for trauma protection
- Attempt growth modification
Headgear - try and restrain growth of maxilla horizontally and/or vertically
Functional appliance - (twin bloc, medium opening activator) - utilise, eliminate or guide the forces of muscle function, tooth eruption and growth to correct malocclusion. These should be used during growth and coincide with pubertal growth spurt.
URA - Limited role unless there is very mild class II, when OJ is due to inclination of incisors and favourable OB
Only can be given after specialist assessment
Orthognathic surgery - Should be carried out when growth is complete and only when there is severe A/P skeletal discrepancy or vertical direction
Usually involved mandibular surgery but may include maxilla
Fixed appliances will be required before, during and after surgery
Paeds negligence actor - mum who doesnt bring her child along and now they’re in pain and mum sits on her phone during visit - explain to the parent to put the phone down during discussion and then talk about prevention
Explain nicely to the mother that during tx and discussion with her regarding her child we need her full attention and could she refrain from using her mobile in the surgery unless it is for emergencies.
Prevention
- Radiographs - under 3 only for trauma, high CRA or delayed development
- BW’s - high risk - 6m, low risk - 1y
- TBI - supervised gentle scrubbing motion of all surfaces until child is at least 7, 2x daily - mrg/night, spit dont rinse, modified bass technique, systematic approach
- Strength of fluoride toothpaste
- 1000ppm for up to 3 (smear 0.1ml)
- 1450ppm for 4-16y (pea 0.25ml)
- 2800 high risk 10+
- 5000 high risk 16+
- Fluoride supplementation use -
fluoride MW 225ppm children over 7
fluoride varnish 3-4x yearly - 22,600ppm - Diet advice
Reduce sugar content - have at meal times
Water/milk instead of juices/fizzy drinks
Cheese and bread sticks good alternative for snacks
Fissure sealants
Sugar free medicines
Consent for lower 3rd molar removal
Explanation of procedure
- Tx we have planned is to have your lower 3rd molar on L/RHS removed surgically under LA
- You will be awake during the procedure but you will be numbed up with an injection inside of your mouth which numbs up the area of the tooth and makes the experience more comfortable for you. You will not be able to feel anything sharp but you will still feel pressure which is normal.
- The procedure involves making a wee cut along the gum and pulling the gum back so that some bone around the tooth can be removed in separate pieces. This part of the procedure involves some drilling similar to what happens when you get a filling. The area will then be cleaned out with some salty water and some stitches will usually be used to close the wound. These stitches usually resorb on their own. Once again you will be numb during the tx and will hear some noises and pressure but no sharpness or pain.
Potential complications
- Pain, bleeding, bruising, swelling, infection, dry socket (exposed bone, failure to heal and clot), jaw stiffness, damage to the adjacent teeth
- Temporary 10% or permanent <1% numbness of the lip chin and tongue on that side, prolonged nerve pain, tingling/alteration of sensation
- The nerves that run alongside the tooth are sensory and any nerve damage will have no effect on the appearance or the way your jaw moves but its something you need to be aware of
- IF there are signs on the x ray that the nerve is involved we may carry out a coronectomy instead which is the same procedure as above, however, we only remove the crown of the tooth and leave the roots within the bone which avoids risking nerve damage but this cannot be done if the tooth has decay or if the roots become mobile.
If you are happy with the above info and would like the procedure under LA we advise not to fast and eat as normal prior to the appt. It is not required you bring an escort with you as you will be fine to drive home but we do advise that you take the rest of the day of work to rest.
Any questions?
Give smoking cessation advice.
Ask
(Smoking history and habits)
○ Do you smoke?
○ What do you smoke?
○ How long have you smoked for?
○ How many cigarettes daily?
○ How quickly do you light up in the morning?
○ Why do you smoke?
○ Does anyone in the family smoke?
○ Do you have any kids in the house?
● Advise (of facts around smoking)
○ Smoking is harmful to general health - cardiovascular and respiratory problems
○ Smoking is detrimental to oral health - risk of tooth loss, reduced ability to heal, staining,
periodontal disease, oral cancer
○ Personal: money, bad breath
● Assess
(motivation to quit)
○ Are you interested in giving up now?
■ Ask about motivations to quit
○ Have you tried to quit in the past?
■ Why were you not successful? What worked in the past?
● Assist
○ Would you like help from the local stop smoking services
■ Increases quitting likelihood by 4 times
■ Best and evidenced based Tx = NRT - can help in the following ways:
● Champix
● Patches
● Gum
● E-cigs:
○ New to market: don’t fully know side effects
○ Respiratory side effects: fluid in lungs
○ Likely less harmful than tobacco
○ Don’t vape around children
○ No long term health data
○ Maintain habit and culture of smoking
● Refer
○ Those interested to local cessation services such as pharmacy, GP and stop smoking services
○ Self referral – Quit Your Way Scotland 0800 848484 or visit www.canstopsmoking.com
○ Run by NHS24 and staffed by trained advisors – talk, refer, offer quit packs
○ Offer written material
○ Arrange follow up
● Actor marks: non judgemental, clear and easy to understand advice, listening, good eye contact, open
body language
Facial Trauma: Right orbitozygomatic fracture (6 mins)
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.
Diagnosis: Fractured right cheek bone
● E/O exam:
○ Lacerations
○ Nasal bleeding/deviation/patency (by obstructing each nostril)
○ Palpation of zygoma bilaterally (supra/infra-orbital rims, zygomatic arch) from behind
○ Facial asymmetry
○ Limitation of mandibular movement?
○ Examination of sensation of infra-orbital region
■ 3 areas supplied by infraorbital nerve: upper lip, lateral nose, lower eyelid
○ Eye examination
■ Periorbital ecchymosis, subconjunctival haemorrhage
■ Vision assessment – pupillary reaction to light
■ Ask if presence of double vision (diplopia) – (haematoma, muscle/nerve injury)
■ Eyeball mobility assessment – steady pt’s head and ask to follow finger (to 6 points)
● Particularly upwards: either superior rectus nerve supply severed or more
commonly the inferior rectus is trapped due to an orbital floor fracture
● I/O features:
○ Tenderness of the zygomatic buttress
○ Bruising/swelling/haematoma
○ Occlusal derangement and step deformities
○ Lacerations (esp. gingivae)
○ Loose or broken teeth
○ Anaesthesia/paraesthesia of teeth in the upper right quadrant + gingivae above incisor/canine
● Further investigations:
○ Radiographs
- OM 15/30 or CBCT or CT
● Identification of relevant radiographic findings:
○ Correctly identifies fractures of the right cheek bone, radio-opacity of the sinus.
■ Always compare right side from left
● Further management of the patient:
○ Urgent phone to an OMFS unit or A&E dept for advice and URGENT referral
○ Surgical management: ORIF (if symptomatic e.g. diplopia/asymmetry/enopthalmos)
○ Conservative management if undisplaced, asymptomatic or >1-month-old
Toothache discussion - Unrestorable 26 requiring XLA - Warfarin
Introduce self & designation (1 mark)
● Gather info about patient’s coagulation status:
○ Ask about INR: when it was last done and what the value was (2 marks)
● Ask to see patient’s INR book (1 mark)
● Detailed and valid explanation as to why the tooth cannot be extracted today (4 marks)
○ No jargon!
○ ‘Due to high risk bleeding; which is a result of the warfarin; values above the recommended level
for safe extraction’
● Reference to relevant guidelines (1 mark)
○ SDCEP: INR ideally within 24hrs, 72hrs if stable (stable = INR <4 for last 3mths)
○ Proceed with procedure without interrupting medication IF INR <4
● Convincing patient and NOT proceeding with extraction (4 marks)
● Deal with patient’s pain (4 marks)
○ Acknowledge the pt is in pain and discuss dealing with the pain
■ analgesia +/- pulp extirpation/sedative dressing
● Ask if the pt understands the explanation and if they have any questions (2 marks)
● Engaging with patient/eye contact/good communication (2 marks)
● Actor marks: communication, empathy, simple language (2 marks)
Nurse sharps injury - BBV risk assessment - Discussion with pt and consenting blood tests (6 mins)
Nurse had a sharps injury after a safety plus syringe pierced her finger after finishing the treatment. Please
explain your concern to the patient and how you would manage this.
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 the available records and by asking the
appropriate risk-assessment questions and fully consent this patient for testing.
Explain nature of injury sustained by dental nurse to patient (2 marks)
○ Risks are to nurse and NOT the patient
● Explanation of risks from BBV to dental nurse (2 marks)
○ Risks of transmission of a BBV (giving examples e.g. HIV) to the dental nurse,
○ Estimate of risk (low - e.g. 1:300 if HIV) based on the type of injury, explained in detail
● Explanation of standard procedure for managing sharps injuries which is applied to all patients (2 marks)
○ Explanation of requirement for a source blood sample and clarity that this is a universal process
applied to ALL patients
○ Approach the request for a blood sample from the pt sensitively and professionally
○ Make it clear that there is no pressure on the pt to agree (2 marks)
● Undertake review of medical history (2 marks)
○ Have you ever been diagnosed with HIV? Hepatitis B? Hepatitis C?
○ Have you ever injected drugs? Have you ever 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 (please state the country)
○ Have you ever had a blood transfusion not in a country listed above?
○ Have you ever received dental treatment in a country not listed above? (please state the country)
○ Are you from a country that is not listed above? (please state the country)
○ Have you ever had a tattoo/body piercing done by an unlicensed artist in the UK or in a country
outside the UK?
○ Yes to any of the above indicate indicate high risk.
● Consent:
○ Establishes pt understands options (2 marks)
○ Give opportunities to ask questions (2 marks)
○ Confirm patient’s decision - Giving bloods: YES or NO
Bisphosphonates - Discussion of MRONJ and XLA risks before pt starts therapy
Introduce self & designation (2 marks)
● Explain that alendronic acid is a bisphosphonate drug (1 mark)
● Explain mode of action of bisphosphonate drugs
○ Bisphosphonates drugs reduce the turnover of bone (1 mark)
○ Bisphosphonates accumulate in sites of high bone turnover = jaw
(1 mark)
● Explanation of relevance of bisphosphonates to dentistry
○ There is a risk of poor wound healing following a tooth extraction (1 mark)
○ Need to remove any teeth of poor prognosis prior to beginning drug therapy (1 mark)
○ Important to do everything possible to prevent further tooth loss in the future (1 mark)
○ Reduced turnover of bone and reduced vascularity can lead to death of bone - osteonecrosis (1)
● Specifically name ‘MRONJ’ (1 mark)
● Risk of MRONJ in Osteoporosis - Low risk (1 mark)
● Making clinical diagnosis
○ Chronic periapical periodontitis (1 mark)
○ Gross caries in correct tooth (36) (1 mark)
● Explaining Clinical diagnosis in terms the patient can understand
○ Area of infection associated with left back tooth (36) (1 mark)
○ The tooth is too decayed to have a filling put in it (1 mark)
● Discuss tx options
○ Extraction is only option (1 mark)
○ Tooth is grossly carious beneath the gumline and therefore unrestorable (1 mark)
○ If tooth is kept risk of MRONJ after beginning therapy (1 mark)
● Ask if the pt has any questions (1 mark)
● Actor marks: empathetic/professional approach (2 marks)
Pain History - SOCRATES - Write up notes - Give provisional diagnosis - Irreversible pulpitis
Introduce self & designation (1 mark)
● Ask about presenting complaint/reason for attendance (1 mark)
● Ask when pain began/how long pt has had pain (2 marks)
● Ask about changes over time (2 marks)
● Ask about site of pain (2 marks)
● Ask about character of pain now - offer prompt: aching/throbbing etc. (2 marks)
● Ask about stimulants - offer prompt: hot, cold etc. (2 marks)
● Ask about relieving factors - offer prompt: cold, analgesics etc. (2 marks)
● Ask about duration of pain - offer prompt: minutes, longer, constant etc. (2 marks)
● Ask if kept awake (2 marks)
● Provisional diagnosis: Irreversible pulpitis (4 marks)
● Note taking: legible, well ordered, complete (4 marks)
● Actor marks: clear communication, showed empathy (4 marks)
Handpiece safety checks?
Back cap checked
: Gripped and turned anti-clockwise
● Bur security checked
: Suitable force applied to remove bur
● Tension applied to handpiece when fitted to coupling
: Assesses if handpiece is attached safely
● Bur rotated laterally with fingers
: Attempts to spin bur, rolls along finger
● Attempts to move bur laterally
: Pushes bur from side to side a few times
● Handpiece sound tested when running
: Runs for 5 secs or more, views bur movement
Paeds Trauma - 11 EDP# immature apex - 8 yr old - Outline procedure to parent of anxious child
Explain nature of injury in simple terms
○ Enamel dentine pulp fracture or complicated pulp fracture
● Explain treatment : PULPOTOMY (open apex)
○ As this is a large exposure the tx of choice is called a pulpotomy
○ Explain partial removal of pulp
○ Explain that aim is to keep undamaged pulp tissue alive
○ Explain that this is so the tooth stays alive and continues to grow
● Baseline sensibility tests
○ Tests required to see how the nerve in the injured and adjacent teeth respond
○ Tests required as baseline reading for long term monitoring
● LA required
○ Parent informed that LA is required
○ Required to keep patient numb and comfortable
○ Describe that LA involves injection in the gum
● Dental Dam
○ What this is - rubber sheet over tooth acts like mask
○ Why dam is placed - moisture control, protects airway
● Drilling/use of handpiece
○ Drill will be used to remove some pulp tissue
○ Aim is to leave only good tissue
● Dressing
○ Indicate that the tooth will be dressed; Setting CaOH, MTA
● Composite restoration
○ Indicate that a white filling will be placed to regain aesthetics
● Actor marks: Describing tx in an understandable manner, supportive and empathetic regarding injury
Pus Aspirate & Completion of Path Form - 26 dentoalveolar abscess
Pt details correctly entered on to form
○ Sticker (CHI number, Hosp. Number, Name, Sex, Address, D.O.B)
○ + Hospital department, Date, Time, Consultant, Requested by, Phone no.
● Clinical details entered on to form
○ Pain, swelling etc
○ Other relevant information - MH: nil of note
○ Provisional diagnosis - dentoalveolar abscess
● Specimen details including site
○ Type of sample - pus aspirate
○ Details of site - buccal mucosa of 26
● Investigation
○ Culture & sensitivity testing: bacterial/fungal
○ PRC and viral load: virus
○ Histopathology: tissue biopsies
● Wearing appropriate PPE when handling specimen
○ Examination gloves worn when handling specimen
● Removal of needle
○ Needle safely removed. (needle removed from syringe with sheath intact)
● Disposal of needle in yellow sharps bin
● Sealing syringe for transport
○ Red cap placed onto syringe hub
● LABEL SYRINGE with pt details & placed in plastic bag attached to request form
○ Fully labelled syringe in sealed bag with red hub cap in place & needle removed
Breaking Bad News - SCC - Give results of biopsy confirming oral cancer - SPIKES
Overview of marks:
1. Student listens and is empathetic
2. Asks patient what patient is expecting from appointment
3. Asks permission to continue findings
4. Break news slowly in chunks
5. Avoids jargon, or explains if used
6. Allows patient time to take in information and gives chance to ask questions
7. Repeats the news
8. Summarises what they’ve said
9. Gives patient information on plan moving forward
10. Actor asked if they understood, been shown empathy
● Setting:
○ Sitting down at same level as them
○ Did they bring someone with them?
○ How have they been since you last saw them?
● Perceptions:
○ What does the patient understand has happened up until now?
■ ‘Are you aware of what we’re here to discuss today?’
■ ‘Do you know what the purpose of your biopsy was?’
■ ‘Could you explain to me your understanding of things up till now?’
● Information:
○ Inform patient that you have the results of the biopsy
○ Ask them if they would like you to go through them…they’ll say yes
● Knowledge
○ Give a warning shot
■ ‘I wish I had better news’
■ ‘I’m afraid the news are not good’
…. pause for a bit
○ Give them the knowledge of what you know
■ ‘The test we have done has shown some abnormalities in the cells’
…pause…
■ ‘Mrs Smith I’m afraid to say that you have mouth cancer’
…then big pause…
○ Let it sink in and let them dictate the pace of the conversation from here
■ They might want to know loads of info really quickly or they might be in shock
■ Give them chance to ask questions
● Empathy:
○ Words to the effect of
■ ‘I am deeply sorry to break this to you’
■ ‘I understand you must have lots and lots of questions…do you have anything that comes
to mind?’
■ ‘Perhaps you would like to bring your husband in with you?’
● Summary and close:
○ Repeat news
○ Summarise what you’ve told them and the plan for going forward
■ ‘The good news in all of this is that we’ve acted quickly and will be able to move forward
with treatment as soon as possible’
■ ‘I’ll be speaking to the surgeons today and they’ll be seeing you in the coming week to
discuss treatment’
○ Offer them a follow-up appointment or phone number for any questions
○ Give written material if available
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 8mm pocket on the distal aspect as well as suppuration. The patient is
systemically 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.
Ask for: otherwise you won’t get it
○ PA radiograph (2 marks)
○ Sensibility testing (2 marks)
EPT 35 & 36 respond positively
PA radiograph shows periodontal/periapical pathology
Swelling (2 marks)
● Pocket with pus (2 marks)
● Bone loss from radiograph (2 marks)
● Diagnosis - Periodontal abscess (2 marks)
● Treatment
○ Irrigate through pocket (2 marks)
○ Debridement (2 marks)
○ Hot salty mouthwash (2 marks)
● No antibiotics, since it’s a localised infection (2 marks)
● Actor marks: Empathy (1 mark), Communication (1 mark), Understanding (1 mark)
Fluoride Varnish - 2 year old child - Talk through parent’s concerns (6 mins)
Why needs fluoride varnish, fluoride toxicity, and asks for OHI after application
Reassure the patient
○ Fluoride varnish is placed on the tooth and is minimally invasive
○ Promotes remineralisation (hardening of tooth) and prevents demineralisation (softening of tooth)
○ It involves dry the teeth and painting a gel on to the tooth
● Contraindicated in:
○ Severe uncontrolled asthma (hospitalised in the last 12 months)
○ Allergy to colophony (sticking plasters)
■ We can use a colophony free version if needed
● Instructions afterwards
○ Don’t eat/drink for 1 hour
○ Soft diet for the rest of the day
■ No dark coloured foods
○ Avoid fluoride supplements today
● Fluoride toxicity:
○ Very small risk and technically relevant if small child consumes a quantity of toothpaste
○ 5mg/kg: milk
○ 5-15mg/kg: oral calcium gluconate, milk and possible referral
○ >15mg/kg: hospital referral for IV calcium gluconate
Class 3 Malocclusion - 20 year old - Treatment options
Accept and Monitor
● Intercept with a URA – procline uppers
○ notice pt’s age in scenario – this might not be possible
● Growth Modification: with functional appliance (reverse twin block) or (RME + protraction headgear)
○ notice pt’s age in scenario – this might not be possible
● Camouflage with fixed appliances
○ Accept underlying skeletal classification problem, move teeth with fixed ortho to hide it
■ procline uppers and retrocline lowers
■ Risks of ortho: decal, root resorption, relapse, gingival recession
○ Usually together with XLA U5s & L4s (most likely lowers to reduce necessary tipping)
● Orthognathic surgery with combined orthodontics
○ Surgical manipulation of the mandible and/or maxilla to produce optimal aesthetics/function
○ Multidisciplinary team – careful planning
■ Orthodontist, maxillofacial surgeon, clinical psychologist etc
○ Pre-surgical orthodontics – 12-18 months
■ arch alignment, arch coordination, de-compensation
○ Post-surgical orthodontics – 12 months
○ TOTAL TIME = 36 months
Suturing station - process for simple interrupted suture
Correct choice of instruments - Kilner Needle Holders and Gillies Toothed Tissue Forceps (2 marks)
● Mount the needle 1/3 from end (2 marks)
● Correct grasp of needle holder (2 marks) - Hold the needle holders in your dominant hand by placing the
thumb and ring finger into the rings and the index finger on the hinge of the blade
● Correct hold for tissue forceps (2 marks) - Hold in pen grip
● Atraumatic handling of flap of tissue with tissue forceps (2 marks)
● Insert the needle at right angles to the wound edge and perpendicular to the surface (2 marks)
● Insert the needle at appropriate distance from wound edge (~2-5mm) (2 marks)
● Pass the needle through flap and retrieve it with an instrument not fingers (2 marks)
● Remount needle correctly as above without use of fingers (2 marks)
● Take a full bite on 2nd side and retrieve it with an instrument – again, not fingers (2 marks)
○ Attempt to re-insert at the same depth in the opposite side of the wound and emerge out of the
tissue the same distance from the wound edge as the insertion
● Demonstrate adequate pronation and supination of hand – you seriously get points for this… (2 marks)
● Needle secure during tying of knot (2 marks)
○ Needle placed to side and not flying around/ or thread gathered and needle held secured/ or
needle clipped
● 1st throw – two turns, grasp suture at free end, approximate edges (2 marks)
● 2nd throw – one turn in opposite direction, grasp suture at free end and tighten (2 marks)
● 3rd throw – in opposite direction again (no extra marks)
● Cut suture to length suitable for wound site and material used (2 marks)
● Knot to side of the wound (2 marks)
● Final apposition of wound (2 marks)
○ Ensure wound ends close together but no tension on wound + secure knot
● Needle disposed of safely when finished – if not, clip it! (2 marks)
OAF - Take a history - Explain diagnosis from images, X-ray and history - Explain management &
surgical closure (6 mins)
Chronic OAF, patients may complain of:
○ Fluids from nose
○ Speech and singing of nasal quality
○ Problems playing wind instruments
○ Problems smoking or using the straw
○ Bad taste/odour, halitosis, pus discharge
○ Pain/sinusitis type symptom
● ‘An OAC is an acute communication of maxillary air sinus with the oral cavity’
● ‘In your case the communication hasn’t closed over and instead has healed by epithelialising forming a
sinus and a permanent communication of the air sinus and the mouth’
● ‘This is something we want to manage as it makes you more prone to developing sinus infections’
● OAF Management
○ Excise sinus tract/fistula – removing epithelium
○ + buccal advancement flap
○ Antibiotics
■ Amoxicillin, 500mg, 7 days, send - 21 capsules, take 1 capsule 3 times daily
■ Doxycycline 100mg, 7 days, send - 8 capsules, take 1 capsule daily (take 2 on day 1)
○ Post-operative instructions:
■ Refrain from blowing nose or stifling a sneeze by pinching the nose
■ Steam or menthol inhalations
■ Avoid using a straw
■ Refrain from smoking
Reline Complete Denture - Procedure - Selecting correct material - Prescription
Reasoning:
○ Relines: when fitting surface inadequate but denture otherwise okay
■ Ie occlusal planes, OVD, profile are acceptable but fitting surface underextended, not
supportive/stable or retentive
○ Rebase: when you want to keep occlusal surface, but change fitting and polished surface
● Method:
○ Check all the occlusal relationships are acceptable and appropriate
○ Remove undercuts from dentures fitting surface using acrylic bur
○ Adjust border for under/over extension with green stick
○ Apply adhesive to fitting surface of the denture to be refined
○ Insert impression material (light body PVS) into the fitting surface and seat the denture
○ Functional impression: ask the patient to bite together so the impression is taken in OVD
○ Take a lower impression with denture in situ (gold standard but may not be required)
○ Take a bite registration if OVD is not obvious
○ When set remove the impression and send the denture for reline
■ Please pour impression in 100% dental stone using denture impression provided. Please
mount upper to cast and create a self cure PMMA reline to change the impression surface.
Primary herpetic gingivostomatitis (6 mins)
A patient brings her child to the clinic, not feeling well and is distressed - Provided with an image
Take a history, provide a diagnosis to the mother, provide ways to treat the condition and answer any
questions the mother may have.
ntroduce self & designation (2 marks)
● Take history:
○ No. of days symptoms? (1 mark)
○ Does the child have a fever? (1 mark)
○ Child less active than normal? (1 mark)
○ Analgesia used? (1 mark)
○ Did it work? (1 mark)
■ PHG Signs: lymphadenopathy, malaise, pyrexia, erythematous gingivae, ulceration
■ PHG Symptoms: sore mouth and throat, fever, enlarged lymph nodes
● Diagnosis from photograph:
○ Primary herpetic gingivostomatitis - explanation in lay persons terms (2 marks)
○ Contagious primary infection caused by herpes simplex virus (1 mark)
○ Self limiting and will disappear in 7-10 days (1 mark)
○ High carriage rate in population, common (1 mark)
■ Most often occurs in young children and is usually the first exposure a child has to herpes
virus (which is also responsible for cold sores & fever blisters)
○ Most initial infections are subclinical but can present as this florid infection (3 marks)
■ Explain in lay persons terms - usually no symptoms
■ Often will present with blisters on the tongue, cheeks, gums, lips & roof of the mouth. After
the blisters pop, ulcers will form.
■ Other symptoms to watch out for are high fever, difficulty swallowing, drooling and
swelling.
■ Also, because the sores make it difficult to eat & drink, dehydration can occur.
○ Child may or may not develop cold sores in future (1 mark)
● Management:
○ Push fluid intake (1 mark)
○ Analgesia to control fever/pain (2 marks)
○ Bed rest, take it easy (1 mark)
○ Clean teeth with damp cotton roll or cotton cloth to rub around gums (1 mark)
○ Can use dilute CHX to swab gums (1 mark)
○ As child has had problems for 3 days and is otherwise fit and healthy antiviral medication
(Aciclovir) is not recommended is not recommended (2 marks)
● Actor marks: empathetic, supportive and understanding (2 marks)
● Prescription: (if necessary - ie severe or immunocompromised) - NB if under 2ys half dose (100mg):
○ Aciclovir 200mg tablets - 5 day regime, Send: 25 tablets, Label: take 1 tablet 5 times daily
● Refer immunocompromised patients to hospital
Crown Critique - Gold crown fitted onto mounted casts (6 mins)
Use articulating paper, shimstock and calipers to assess crown
Make decision to redo prep and send back to lab
Pre-cementation checks
○ Is it the restoration as asked for?
○ Check on the cast
■ Rocking, M/D contact points, marginal integrity, aesthetics
■ Check contact points on adjacent teeth on cast to ensure not damaged
● Can be damaged when prepped tooth is sawn off the cast to invest
■ Occlusal interference on excursions
■ No natural teeth contacting
(checked with shimstock 8μm)
■ Inadequate reduction DL cusp
○ Remove crown from cast
■ Check if the natural teeth occlude properly now
■ Check if tooth is under-prepped
■ Measure crown thickness using calipers
● Minimum 0.5mm circumferential
● Minimum 1.5mm for functional cusps (1.0mm for non-functional)
● Management
○ Check amount of interference by dropping incisal pin and calculate the difference
■ If do-able to reduce crown without making it too thin then adjust and cement, otherwise…
○ Re-do prep and send back to lab
■ Follow crown prep principles: Ideal taper 6o, retentive grooves/slots, bevel functional
cusps, two plane buccal reduction, smooth prep margin at gingival margin
● Avoiding fault in future
○ Measure temp crown thickness before cementing
○ Use sectioned putty index when prepping
Complaints Procedure - Pt annoyed they had to wait an hour + receptionist was rude
Take concerns seriously, answer questions as able:
○ ‘Hello there, what seems to be the problem?’
○ ‘Can i offer some assistance?’
● Acknowledge anger ‘I can see that you’re upset and I am sorry that you feel this way.’
○ This does not accept blame. DO NOT ACCEPT BLAME
● Try to offer practical help:
○ Offer investigation with receptionist and provide feedback to the patient
○ If you can offer another appointment - ‘Do you still have time for us to see you?’
○ ‘What would like to do, we can work around you?’
● Making an apology:
○ Be honest
○ Acknowledge the offence
○ Explain how it happened
○ Express remorse: deep guilt, express it! (I am so sorry!)
○ Ensure amends: ‘Is there anything we can do?’
● If formal complaint requested, advise on NHS complaints procedure
○ Then, if required: a local resolution (payout)
○ If satisfactory: complaint closed
○ If unsatisfactory: healthcare commission or health service ombudsman
● The NHS complaints procedure
1. Acknowledge the complaint and provide the patient with the practice complaint procedure.
2. Inform the dental defence organization if you require advice.
3. Inform the patient of timescales and stages involved.
4. Acknowledge the complaint in writing, by email or by telephone as soon as you receive it – 3
working days maximum but ideally within 24 hours.
5. Early Resolution 5 working days: For issues that are straightforward and easily resolved, requiring
little or no investigation.
6. Investigation 20 working days: For issues that have not been resolved at the early resolution stage
or that are complex, serious or ‘high risk’.
7. Independent External Review Ombudsman: For issues that have not been resolved.
Medical Emergency - Explain hypoglycaemia & seizure/epilepsy drugs to nurse
Correct drug - Detailed action (detailed) - Description of emergency (signs/symptoms)
● Hypoglycaemia
○ Medication: Glucagon → increases the concentration of glucose in the blood by promoting
gluconeogenesis and glycogenolysis to convert glycogen to glucose.
○ Type 1 Diabetic Hypoglycaemic coma – normal = 5-7mmol, unconscious <3mmol
○ Assess ABCDE
○ Signs: pale, shaky, sweaty, clammy, dizzy, hungry, confusion, blurred vision, loss of consciousness
■ they must mention loss of consciousness as it defines Tx:
○ If conscious and cooperative → administer oral glucose 10-20g or sugary drink
○ If unconscious/uncooperative → 1mg IM glucagon injection and oral glucose when regain
consciousness.
○ After they regain consciousness (15 mins – 2nd dose if not) supply oral glucose/sugary drink as
they would have depleted their glycogen stores - they will be unwilling to drink this…
○ IM injection and technique
■ Inject diluting solution in vial with glucagon powder
■ Swirl to mix - don’t shake (will foam up)
■ Syringe solution back into syringe
■ Use Z-track technique to inject into thigh or bicep
● Spread skin, advance needle in skin 90o, aspirate, inject 30s, pull out, release
tension - thigh, hip, deltoid, buttock.
● Say ‘I would normally prepare needle/change needle, remove clothing, alcohol
wipe skin, but not going to as life threatening and saves time’
○ Reassess ABCDE – assess effect of medication, more oral glucose required?
● Epilepsy
○ Medication: Midazolam → a short-acting benzodiazepine → enhances the effect of the
neurotransmitter GABA on the GABA receptors resulting in neural inhibition
○ Signs: loss of consciousness, uncontrollable muscle spasms, drooling, tonic (falls rigid), clonic
(sharp jerky movements), hypotension, hypoxia, loss of airway tone
○ Assess ABCDE
○ Do not try to restrain convulsive movements - ensure the patient is not at risk from injury.
○ Secure airway
○ Administration:
■ Administer 100% oxygen, 15L/min flow rate
■ If the fit is repeated or prolonged (>5min): give Midazolam 2ml oromucosal solution,
5mg/ml topically into buccal cavity (10mg) - repeat after 5 minutes if not worked
● Check expiry date and the form of midazolam is compatible with buccal
administration, choose appropriate dosage of midazolam by age (different tubes of
midazolam with different dosage available)
○ If subsided: recovery position and check airway
○ Refer to hospital if: first seizure, seizure is atypical, injury was caused or difficult to monitor patient
Set teeth (4 upper anterior teeth) for tooth trial
Tooth trial: Check denture extension, support, retention (trial denture will be looser than the actual one),
stability, occlusion (balanced occlusion and articulation), speech, aesthetics (tooth mould, shade, gingivae
position). Mark post dam on cast.
Treatment Planning - Examination of information, Diagnosis and Tx planning (12 mins)
35-year old male - C/O BOP on brushing and shortened clinical crowns. Smokes 20 cigarettes daily, drinks
25 units alcohol weekly and 1-litre full fat fizzy juice daily.
Casts provided: show lower crowding.
Photos provided: show erosive wear, gingival erythema.
Full mouth PA views on viewer: impacted lower 8, mild bone loss upper anterior teeth.
Spend 3-4 minutes looking at these, then diagnose the conditions present and outline your treatment plan.
● Smoker + Alcohol + Acid Erosion/NCTSL + Perio disease + Impacted 8’s.
Problem list - Smoker + Alcohol + Acid Erosion/NCTSL + Perio disease + Impacted 8’s.
● Immediate
○ Pain (Pericoronitis? Toothache? Perio abscess? PAP?)
● Initial
○ HPT:
■ Diet advice: including erosion
■ Consider medical referral if GI intrinsic acid
■ Smoking cessation, alcohol advice
■ Supragingival scaling, RSD
○ Removal of non-symptomatic teeth of poor prognosis: Impacted 8’s
■ Inform of risks: pain, swelling, bleeding, bruising, infection, dry socket, IDN damage
leading to numbness/altered sensation that can be temporary/permanent
○ NCTSL management
■ Find cause: Diet? Alcohol? Medications? MH? Habit? Parafunction?
● Tx: diet diary, study casts, photos, DBA, GI, composite
■ Fluoride – toothpaste, mouthwash
■ Dietary advice: change habits - don’t swill drink around mouth, use straws, watch ‘healthy
eating’ acids (5-a-day), avoid sports gels/drinks - milk/water instead, chew gum, cheese
■ Desensitising agents – stannous fluoride, potassium nitrate - for symptomatic relief
○ Caries management
○ Endodontic treatment: temporary restorations
● Re-evaluation
○ Perio: 6-8 weeks post completion
○ NCTSL (pics, casts)
● Re-constructive
○ Filling spaces: Dentures, Bridgework, Implant?
● Maintenance
○ Perio, NCTSL
You overhear a nurse bad-mouthing a patient to a colleague in a public place in the surgery. They refer to
them in a derogatory manner and joke about potentially posting this on social media. The patient and
family are easily identifiable from the information discussed as well. Discuss this issue with your nurse.
● Introduce yourself and ask the nurse if it is ok to sit down with you - ‘Do you have a minute to talk’
● Facts:
○ Facts of the situation, what, when, where, how?
○ Ask the individual for their account of the situation
○ ‘Unfortunately, there were remarks said publicly and a talk about posting on social media. I was
wondering if you knew anything about this?’
- allow the nurse to reply
○ ‘Is it ok if I hear your side of the story?’
● Issues:
○ What is the issue here?
○ Explain the issue to the individual and why it is bad.
○ Quote GDC standards - i.e breach of confidentiality, brings profession into disrepute
○ ‘I know it may have been misjudged. But unfortunately, it is not acceptable to say things publicly
about patients or post things on social media.’
○ ‘As the GDC standards state, it is our obligation to have pt best interests and to protect their
information. Speaking in the public can breach confidentiality. The patients are recognisable from
the posts and this is not protecting them. For example, if it was someone speaking/posting about
your family member, how would you feel?’
○ ‘It is also not providing the public with confidence in you, us and the profession as a whole. The
practice could be in question and the GDC could be informed of this in the future.’
● Options:
○ If involves patient, what options are there to manage this event (short/medium/long term).
○ What is in the patient’s best interest?
○ ‘There are a few options to rectify this:’
■ ‘If there is a social media post – delete it and any photographs immediately’
■ ‘Apologise to the patient’ if still around…
● If not, the practice can contact patient to ideally attend for a formal apology
● Now:
○ What issues do you need to deal with right now?
○ ‘Inform the nurse that this shouldn’t happen again.’
● Ask/Advise:
○ Ask the individual if they would be willing to undertake training or education on this matter
■ ‘It would be acceptable if we had training on this in the future and have meetings about
social media to increase awareness’
■ ‘Would you be willing to have training on this?’
○ If problem repeats:
■ Get advice from someone more senior (defence union, VT trainer) how to manage this.
● Record: document conversation
155. Recurrent Aphthous Stomatitis - Recurrent Minor Ulcers (6 mins)
Recurrent Aphthous Stomatitis - Recurrent Minor Ulcers (6 mins)
27-year old patient presents with ulcers. The patient’s ulcers are no more than 10mm in size (history
provided etc). Using this information and the available lab results (Patient has low iron and folate). Discuss
the lab findings, the diagnosis and management options for this condition with the patient. You do not
need to gain any more information from the patient.
Build-up and Diagnosis:
○ ‘Are you aware of what we’re here to discuss today?’
○ ‘You were here a few weeks ago complaining of painful ulceration…etc 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?’
○ ‘Let me start by saying there is nothing sinister going on here…’
○ ‘But your bloods showed that you have developed a type of anaemia called microcytic anaemia
caused by an iron deficiency in your blood’
● Description of disease:
○ ‘Iron deficiency anaemia is a condition where a lack of iron in the body leads to a reduction in the
number of red blood cells.’
○ ‘Iron is used to produce red blood cells, which help store and carry oxygen in the blood.’
○ ‘If you have fewer red blood cells than is normal, your organs and tissues won’t get as much
oxygen as they usually would.’
○ ‘Many people with iron deficiency anaemia only have a few symptoms.’
○ ‘Most common symptoms are tiredness and lack of energy (lethargy), shortness of breath,
noticeable heartbeats (heart palpitations) and a paler complexion’
○ ‘In addition, In some cases, including yours, people develop minor ulceration in the mouth’
● Aetiology:
○ ‘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.’ (or
stomach/bowel cancer but don’t say this)
● Management:
○ ‘Iron deficiency can easily be managed with iron supplements and an increase of iron in the diet.’
○ ‘This would also resolve the minor ulceration in your mouth which tend to go away in 1-2 weeks
without scarring.’
○ ‘Your GP should be able to prescribe you iron supplements in tablets to be taken twice daily and
might chose to investigate you further to determine if there is an underlying condition.’
○ ‘My advice in the meantime is to try to increase the iron in your diet, avoid spicy foods like curries
and if your mouth is very sore (can’t eat etc) I can prescribe a numbing m/w to allow you to be
more comfortable’
■ Benzydamine m/w, 0.15% - Send: 300ml, Label: Rinse or gargle using 15ml every 1.5
hours as required
● Can be diluted 1:1 with water if stinging - Spit out after rinsing - not more >7 days
● Diet advice:
○ Dark-green leafy vegetables, such as watercress and curly kale, iron-fortified cereals or bread,
brown rice, pulses and beans, nuts and seeds, meat, fish, tofu, eggs, dried fruit (prunes/raisins)
○ Vit C rich foods/drinks help body absorb Fe
○ Tea, coffee and calcium (found in dairy products like milk) make it harder to absorb iron
■ Only in large quantities
● Summary
○ Reassure patient - common condition
○ Ulcers go away in up to 2 weeks without scarring
○ We know what the cause is and we can manage it
○ Any questions?
● Actor marks communication and simple language
Ortho - Retained ULA + Unerupted UL1 (6 mins)
Photos of discoloured 61 and labial/buccal segments of an 8 year old. PA of a dilacerated floating 21 that
could be anything. Please identify the problem present for this patient and discuss its further
investigation/management with your examiner.
Causes of retained ULA/Unerupted 21
○ Trauma to A - causing damage to the 1
■ Complications: Ankylosis, arrested tooth (21) formation, dilaceration, displacement
○ Lack of permanent successor/Hypodontia
○ Ectopic tooth germ
○ Crowding
○ Supernumerary: tuberculate most common
● Signs:
○ Discolouration of A, retained A
○ Radiographic
○ Lateral erupted before central
● Investigations:
○ Radiographic localisation for ortho treatment
■ Another PA or anterior occlusal, or alternatively OPT and occlusal, CBCT for 3D view
● Management:
○ Always palpate: usually U1 is buccal and central (high)
○ Options:
■ Leave and monitor - inform of possible cyst or resorption
■ Extract retained A (leave U1) and space maintenance (warn of cyst formation risk)
■ Surgical removal of both teeth and space maintenance
■ Refer for orthodontic opinion/Tx - Inform of possible ortho tx benefits/risks
■ Auto-transplantation
○ Other options:
■ Extract retained A and hope spontaneous eruption (very unlikely since dilacerated)
■ Expose (closed or open) +/- bonding/traction (won’t work if dilacerated)
Nursing Bottle Caries (6 mins)
Concerned mother with 2 year old in pain. Take a brief pain history then photo of decayed 52-62 (upper
incisors) provided. Explain diagnosis to parent, prevention and management options (GA)
Brief history:
○ Take pain history
■ How long for? Any analgesia (calpol)? How much analgesia? - within limits
○ Feeding bottle to bed?
○ What is in the feeding bottle?
● Look at pics carefully to identify pattern of decay
○ Pattern is usually upper incisors, D’s and lower canines (lower incisors protected by tongue)
● Advice:
○ Feeder cup replacing bottle from 6 months
○ No feeding at night (lactose in milk - decreased salivary flow and held in mouth)
○ No on-demand breastfeeding
○ No sweetened milk, soy milk (unless medically advised)
○ Milk and water only between mealtimes
○ Sugarfree variations of drinks/foods/medicine (e.g. sugar-free calpol)
○ Safe snacks include, cheese, breadsticks, fruit, plain crisps
○ Toothbrushing:
■ Assist the child until 7yo
■ Brush in the morning and last thing at night
■ No food/ drink except water after brushing
■ Spit don’t rinse
● Management:
○ Extraction of carious teeth under GA: as in pain (discuss GA risk and benefit)
○ GIC remaining teeth and review: if no pain (acclimatisation)
○ Fluoride (supplements + varnish)
● Extra points for empathy
Consenting and Referral for GA:
Process
○ Discussion of GA risks/benefits and all other alternative options
○ Referral to hospital for specialist to assess - if any other teeth of poor prognosis they will be added
to this plan to avoid future GA
○ GA will involve day in hospital - need to monitor for full recovery
○ Need of chaperone throughout.
● Risks
○ Very common minor risks:
■ Headache, nausea, vomiting, drowsiness
■ Sore throat or sore nose/nose bleed from intubation
○ Risks from treatment:
■ Pain, bleeding, swelling, bruising, infection, loss of space, stitches
○ Rare major risks:
■ Brain damage
■ Death (say as follows):
● 3 in a million. Need a machine to breathe during op and there is a very small risk
that you will not be able to breathe independently again on waking - ie never
waking again.
○ Upset when coming round - can make underlying anxiety worse
○ Malignant hyperpyrexia (v. rare - important to ask for FH)
● Conditions requiring special care (can be contraindications)
○ Sickle cell disease (or any hypoxia)
○ Diabetes - can’t fast in same way
○ Down’s syndrome
○ Malignant hyperpyrexia
○ CF or Severe asthma
○ Bleeding disorders
○ Cardiac or Renal conditions
○ Epilepsy
○ Long QT syndrome
● Referral
○ 1. Patient name
○ 2. Patient address
○ 3. Patient/Parent contact numbers (landline and mobile)
○ 4. Patient medical history
○ 5. Patient GP details
○ 6. Parental responsibility
○ 7. Justification for GA
○ 8. Proposed treatment plan
○ 9. Previous treatment details
■ Letter must include:
■ Recent radiographs or if not available an explanation of why (e.g. pt uncooperative)
● Assessment appointment:
○ For treatment planning ONLY and plan may change with specialist opinion
○ **Informed consent - MUST be written
○ GA process, side effects and complications
○ Adult escort with no other children
○ Pre-operative fasting
○ Post-operative arrangements
○ Post-operative care and pain control
