OMS Flashcards
A patient complains of an acute throbbing pain that is referred under the orbit of the eye and downward over the posterior maxillary teeth on the right side. The right posterior maxillary teeth are sensitive to percussion but test normally with pulp vitality testing. Which of the following is the MOST likely diagnosis?
A. Periodontal disease B. Periapical abscess on one of the teeth C. Hyperemic pulp on one of the teeth D. Occlusal trauma E. Acute sinusitis
E. ACUTE SINUSITIS:
Maxillary sinusitis occurs due to an acute bacterial infection. Symptoms may include pain that is either stabbing or throbbing. The pain will usually be referred under the orbit of the eye and downward over the posterior maxillary teeth. The pain is not localized to a single tooth, but the patient will complain that all the teeth in the arch are involved. A common symptom is percussion sensitivity on all of the molar teeth in the quadrant.
- Periapical abscess causes severe, persistent, throbbing toothache that can radiate to the jawbone, neck, or ear as well as sensitivity to hot and cold temperatures and to the pressure of chewing or biting and percussion. Also, fever; swelling of the face or cheek; and tender, swollen lymph nodes under the jaw or in the neck are signs and symptoms of periapical abscess.
- Pain with hot and cold intake persisting for sometimes after removal of stimuli, indicates a hyperemic pulp.
- Acute occlusal trauma presents signs and symptoms such as tooth pain, sensitivity to percussion, and increased tooth mobility. The affected tooth will be sensitive to pressure of chewing, biting, and percussion. Periapical abscess, hyperemic pulp, and occlusal trauma can be localized to a single tooth.
- Periodontal disease will not present with these symptoms and would be visible with periodontal probing and or erythematous gingival tissue.
All of the following are TRUE with respect to the process of wound healing EXCEPT:
A. only in tertiary wound healing, the wound is left open for granulation tissue to fill the defect. B. primary wound healing consists of closure of a wound within hours of its creation. C. wound healing is most rapid with a primary wound. D. secondary healing involves no formal wound closure. E. tertiary healing involves initial debridement of the wound for an extended period and then formal closure.
A. only in tertiary wound healing, the wound is left open for granulation tissue to fill the defect:
Wound healing is classified as primary, secondary, or tertiary.
- Primary healing: involves closure of a wound within hours of its creation. Wound healing is most rapid with a primary wound.
- Secondary healing: involves no formal wound closure; the wound closes spontaneously by contraction and re-epithelialization.
- Tertiary wound closure, also known as delayed primary closure, involves initial debridement of the wound for an extended period and then formal closure with suturing or by another mechanism.
When is an excisional biopsy NOT recommended?
A. The lesion is less than 1 cm in diameter. B. There is suspicion that the lesion may be a malignancy. C. The lesion can be removed completely without traumatizing the tissue. D. The lesion is small and pigmented.
B. There is suspicion that the lesion may be a malignancy:
Excisional biopsy should be limited to small lesions of less than 1 cm in diameter (choices A and D). When you are using an excisional biopsy, you need to be able to remove the lesion completely without traumatizing the tissue (choice C). If the patient has a lesion larger than 1 cm or has different characteristics at different locations, more than one area will need to be sampled. Avoid excisional biopsies in suspected malignancies so that you can be sure not to leave malignant tissue behind. Do an incisional biopsy or refer immediately for evaluation and possible surgical removal.
Which of the following conditions is a disruption of both the axon and axon sheath with a corresponding loss of function and is generally caused by transection of the nerve?
A. Axonopraxia B. Axonotmesis C. Neuroapraxia D. Neurotmesis
D. NEUROTMESIS:
Peripheral nerve injuries can be categorized functionally.
- Neurotmesis: disruption of BOTH the AXON and AXON SHEATH with a corresponding loss of function. Transection of a nerve is generally the cause of this abnormality.
- Neuroapraxia is a transient loss of function without axonal injury; structural damage does not occur. When one’s “foot goes to sleep” after crossing the legs, this is an example of functional loss without pathologic change.
- Axonotmesis: is a disruption of the AXON with a preservation of the axon sheath.
- Axonopraxia: is an abnormal derangement of the axon of the neuron; axonal injury is present.
The MOST commonly encountered postoperative conditions that require attention after the removal of impacted teeth are
A. diarrhea and vomiting. B. infection and pain. C. pain and edema of the local area. D. paresthesia and pain of the local area. E. paresthesia and nausea.
C. pain and edema of the local area:
By definition, impacted teeth are those whose normal eruption is prevented by adjacent teeth or bone or those teeth that have been driven into the alveolar process or surrounding tissue as a result of trauma. The most commonly encountered postoperative conditions that require attention after the removal of these teeth are pain and edema/inflammation of the local area. As a general rule, pain and edema/inflammation are the most common complications of any surgical procedure.
Diarrhea and vomiting may occur following a procedure.
Infection is a common complication of any surgical procedure, especially those where proper prophylactic measures have not been taken.
A paresthesia is an abnormal sensation of burning, pricking, tickling, tingling or numbness that is a possible complication of a surgical procedure to remove an impacted tooth. This is most commonly found following mandibular molar extraction. However, none of these conditions is as common as pain and swelling.
In individuals taking abnormally high doses of Percocet (oxycodone and acetaminophen), one would expect to see all of the following adverse effects EXCEPT:
A. constipation. B. lethargy. C. mydriasis. D. nausea. E. respiratory depression.
C. Mydriasis:
In individuals taking abnormally high doses of Percocet (oxycodone and acetaminophen), one would not expect to see mydriasis, or dilation of the pupils. Those using oxycodone or other related opioid analgesics typically experience miosis or constriction of the pupils. Patients taking large doses of opioids are typically described as having ‘‘pinpoint” pupils. The most common side effects of opioid usage are constipation (choice A), lethargy (choice B), and nausea (choice D). There is some degree of central nervous system (CNS) depression that can occur with normal usage of these narcotic analgesics; profound CNS depression tends to occur in individuals taking large quantities of the medication. Respiratory depression (choice E) can occur with the administration of any amount of oxycodone, however, as well as large amounts of opioids.
The ideal time to remove an impacted third molar is when the roots are approximately:
A. 10% formed. B. 25% formed. C. 50% formed. D. 66% formed. E. 100% formed.
D. 66% formed:
The ideal time to remove an impacted third molar is when the roots are approximately two thirds or 66% formed. At this time, the patient would be between 17 and 20 years of age. During this time, the bone is more flexible, and the roots are not formed well enough to have developed curves. Root morphology and the number of roots affect the surgical difficulty. Limited root formation permits rotation of the tooth around its axis.
The MOST common cause of osteomyelitis is which of the following?
A. Streptococcus pyogenes B. Mycobacterium tuberculosis C. Lactobacillus D. Staphylococcus aureus E. Streptococcus mutans
D. Staphylococcus aureus:
Osteomyelitis is an infection of the bone, and it is commonly caused by Staphylococcus aureus. This infection usually starts somewhere in the body and spreads to the bone via blood. Pus is produced in the bone, causing a bone abscess. This abscess will deprive the bone of blood supply, leading to tissue death. Research has shown that patients who have reduced blood supply will often be predisposed to osteomyelitis.
- Cellulitis: S. aureus, Streptococcus pyogenes
- Streptococcus pyogenes: also linked to acute rheumatic fever (ARF) and acute glomerulonephritis, toxic shock syndrome (TSS), and life-threatening skin and soft-tissue infections, especially necrotizing fasciitis.
- Mycobacterium tuberculosis: is a causative agent of tuberculosis.
- Lactobacilli: have been implicated in the progression of dental caries.
- S. mutans is considered to be the primary pathogen causing dental caries.
A patient with poorly controlled type 2 diabetes is in need of an emergency tooth extraction. You need to be concerned about all of the following, EXCEPT:
A. the possibility of diabetic shock and coma. B. when the patient last ate. C. the possibility of poor healing. D. the likelihood of antibiotic follow-up. E. prolonged bleeding.
E. Prolonged bleeding:
Prolonged bleeding is not a complication of poorly controlled diabetes. It may be caused due to platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced).
Patients with diabetes pose special problems in dental treatment. This is especially true when surgical procedures are planned and when the patient’s blood glucose is poorly controlled. Especially problematic is the possibility of excessively low blood glucose, which may cause syncope, diabetic shock, and coma. This is a medical emergency, and the immediate treatment is to get sugar to the patient’s blood, orally if possible, or IV if needed. Ideally, the patient should have eaten normally that day and recently before the visit. The patient should be taking his or her medication as indicated. This combination should help avoid excessively high or low glucose levels during the procedure. Uncontrolled diabetics heal slowly and are highly prone to post-operative infections. Antibiotic coverage should be considered on a case-by-case basis.
A patient with a positive history of heavy alcohol intake has an INCREASED risk of prolonged bleeding and/or poor wound healing after a surgical procedure BECAUSE of all of the following, EXCEPT:
A. sickle-cell traits are often found in patients with a history of alcoholism. B. alcohol can lower the platelet count. C. excessive use of alcohol affects the liver. D. excessive alcohol causes depletion of vitamin C.
A. sickle-cell traits are often found in patients with a history of alcoholism:
People who have inherited one sickle cell gene and one normal gene have sickle cell trait; it is a hereditary condition and not associated with alcoholism. It does not cause prolonged bleeding or affect wound healing.
Chronic alcoholism can cause thrombocytopenia, which can cause prolonged bleeding. Excessive alcohol use can cause severe liver damage, resulting in coagulation issues. The production of vitamin K-dependent coagulation factors (factors II, VII, IX, and X) can be affected. Patients who require oral surgery and who show signs of or have given a history of severe alcoholic liver disease should be treated in a hospital setting. It is important to obtain liver function tests, coagulation profile, and a medical consultation before surgery. It is also recommended that drugs that are metabolized in the liver be closely monitored or changed. Chronic alcoholism also causes depletion of vitamin C from the body, thereby affecting wound healing.
Surgical intervention (excision or incision) is indicated in the treatment of all of the following, EXCEPT:
A. chloasma of the gingiva. B. melanoma of the palate. C. squamous cell carcinoma of the buccal mucosa. D. nevi (lentigo maligna) of the palate. E. periapical abscess.
A. chloasma of the gingiva:
Physiological changes occur in a woman late in pregnancy to produce a “characteristic” pigmentation of the facial skin and gingiva, termed chloasma gravidarum or the “mask of pregnancy.” This condition is attributed to melanocyte stimulation by maternal ACTH and various other hormones. Chloasma is commonly seen on the gingiva and skin as a macular darkening of this skin and mucosa. Since this condition is asymptomatic and is not pathological, no treatment measures are indicated.
Surgical interventions, either excision or incision, are indicated in the treatment of all of the other answer choices, when no contraindications exist. Both melanoma of the palate and squamous cell carcinoma of the buccal mucosa will require complete excision and possible concomitant chemotherapy. Nevi of the palate will often require excision when diagnosed as the lentigo maligna type. A periapical abscess can be effectively treated with incisional surgery and antibiotics.
If a patient presents with a painful fluctuant abscess that is located at the base of the third molar and the periodontal ligament is involved, which of the following would most likely NOT be part of the recommended treatment?
A. Incision and drainage of the abscess B. Tooth removal C. Administration of prednisone D. Administration of clindamycin E. Administration of naproxen
C. Administration of prednisone:
A periapical abscess is an infectious process that can occur from the introduction of bacteria to the local tissue resulting in the development of severe pain and inflammation. This type of abscess may burrow through bone and affect the periodontal ligament. The involved tooth becomes painful to percussion and may become slightly mobile. The two key points to consider in the diagnosis of a periapical abscess is that there is an “acute onset” of pain and the involvement of the periodontal ligament. Treatment of this condition involves the removal of the abscess through incision and drainage and/or tooth extraction, usually after acute infection is resolved.
Antibiotics, such as Clindamycin, are indicated to help eradicate the infection, often in conjunction with incision and drainage. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as Naproxen, are also indicated to help decrease both the pain and inflammation associated with this condition.
Prednisone is a steroidal anti-inflammatory agent used in the treatment of severe inflammatory conditions. The use of this agent would dramatically decrease the inflammation; however, this agent should not be used in the treatment of this patient since it possesses immunosuppressive effects and could impair the healing process, increasing the chances of postoperative infection.
If a patient presents with a fracture line that extends through the zygomatic arch, down the lateral orbital wall to the inferior orbital fissure, along the medial wall of the orbit, over the bridge of the nose, and through the pterygomaxillary fissure, the patient MOST likely has which of the following?
A. Bilateral condylar fracture B. Le Fort I fracture C. Le Fort II fracture D. Le Fort III fracture E. Pyramidal fracture
D. Le Fort III fracture:
There are five basic types of maxillary fractures:
- Le Fort I fracture: maxillary alveolus. It is often a horizontal fracture of the maxillary alveolus. This type of fracture effectively separates the maxillary alveolus containing the dentition from the upper part of the face.
- Le Fort II fracture: aka pyramidal fracture, is an alveolar process fracture as well as a fracture across the bridge of the nose. The fracture goes near the lacrimal sac, down along the infraorbital rim, and exits around the foramen to the anterior wall of the sinus and underneath the zygomatic buttress.
- Le Fort III fracture: extends through the zygomatic arch down the lateral orbital wall to the inferior orbital fissure, along the medial wall of the orbit, over the bridge of the nose, and then through the pterygomaxillary fissure. Patients often experience a bloody nose with this type of fracture.
- Zygomatic-maxillary complex
- Orbital floor blowout.
A patient presents to your office with mucosal bleeding that began bleeding a few hours ago for no apparent reason. If her past medical history is significant for easy bruisability and prolonged bleeding after any traumatic event, the patient is MOSTlikely suffering from:
A. antithrombin III deficiency. B. hemophilia A. C. hemophilia B. D. platelet-release defects. E. von Willebrand disease.
E. Von Willebrand disease:
is the most common inherited bleeding disorder. It is an autosomal-dominant coagulopathy that is characterized by a deficiency of factor VIlI and abnormal platelet function. Patients with this disorder typically have a lifelong history of easy bruisability and prolonged bleeding after surgery or trauma. As the disease progresses, individuals may experience spontaneous epistaxis or oral mucosal, gastrointestinal, or genitourinary bleeding.
- Antithrombin III deficiency: is an uncommon disorder characterized by repeated episodes of thrombosis, not bleeding.
- Hemophilia A and hemophilia B: generally do not result in spontaneous tissue bleeding; however, a history of easy bruisability and prolonged bleeding after trauma is common.
- Platelet-release defects: include aspirin and NSAID-related bleeding disorders; this type of defect is often associated with easy bruising, and there may be prolonged bleeding after surgery or trauma; however, spontaneous bleeding from the gingiva is rare.
A normal prothrombin time would be:
A. 5 to 7 seconds. B. 8 to 10 seconds. C. 11 to 14 seconds. D. over 18 seconds.
C. 11-14 seconds:
Prothrombin time (PT) is a blood test that measures the extrinsic and common pathways of the coagulation cascade. A time of 11 to 14 seconds is considered within normal limits. This test is often used to determine whether oral surgery can be performed safely on a patient taking any oral anticoagulant. This value is always given with a control. Prothrombin time is prolonged in factor I, II, V, VII, and X deficiency and in anticoagulant therapy, cirrhosis of liver, hepatitis, obstructive jaundice, colitis, coeliac disease, sprue, and salicylate therapy.
Other coagulation tests such as partial thromboplastin time (PTT) normally range from 25 to 35 seconds. This measures the intrinsic and common pathways of the coagulation cascade. It may be administered periodically to see how patients respond while on blood thinners such as heparin. It is used to detect bleeding disorders due to deficiencies of factors VIII, IX, and XI and inhibitors of the intrinsic and common pathway factors (including lupus anticoagulant and therapeutic anticoagulants). It also detects deficiency of factor XII.
An oral surgeon has decided to perform a radical antral procedure in a patient using the Caldwell-Luc approach. This procedure is performed by making a transverse incision in the maxillary area over the:
A. canine, first premolars, and second premolars. B. first molars only. C. first, second, and third molars. D. incisors, cuspids, and first bicuspids. E. third molars only.
D. incisors, cuspids, and first bicuspids:
The Caldwell-Luc approach is the standard approach to the maxillary sinus and is made intraorally. This procedure is performed by making a transverse incision in the maxillary area over the incisors, cuspids, and first bicuspids. The flap is developed superiorly by exposing the anterior wall of the sinus in the canine fossa. This procedure is commonly used as an entrance to perform a radical antral procedure (curetting out chronically infected antral lining) as well as for the retrieving of teeth and roots and for the reduction of complex zygomatic fractures.
Keeping in mind the concepts of injectable anesthetics, the number of pain receptors is GREATESTin which of the following?
A. Fascia B. Mucous membranes C. Periodontium D. Periosteum E. Skin
E. Skin:
The action potential begins in pain receptors. These are free nerve endings that are not encapsulated with myelin but are covered with a sheath of Schwann. They are located in the deep epithelium and subepithelial layers of the skin and mucosa. Receptors occur in the greatest abundance in the following tissues (in order of decreasing number of receptors):
skin > mucous membranes > periodontium > periosteum > arteries > ligaments > tendons > fascia > veins > interconnective tissue.
An elderly woman recently had an operation to remove a large squamous cell carcinoma from the tonsillar bed; 3 days after the surgery, she was spiking fevers to 103º F and had a persistent “pus-like” drainage from one of the sites of incision. She was then administered cephalothin and tobramycin for 7 days. If, over the past 5 days, her serum creatinine level has INCREASED, her urine output is maintained at 1.4 U/day, and there is no evidence of renal obstruction and no history of hypotension, the MOST likely etiology of the patient’ s renal condition is:
A. acute glomerulonephritis. B. acute renal failure secondary to cephalothin. C. gentamicin nephrotoxicity. D. renal artery occlusion. E. systemic sepsis.
C. gentamicin nephrotoxicity:
Squamous cell carcinoma of the tonsil may arise in the tonsil, tonsillar bed, or the tonsillar pillars. Since carcinoma of the tonsil appears to be more radiosensitive than other primary-site squamous cell carcinomas, the usual approach is to treat it with curative radiation, then surgical resection followed by reconstruction of the area. When large tumors are present and/or the primary tumor has invaded the adjacent bone or pterygoid muscles, surgical resection is indicated before radiation. Due to the patient’s initial presentation, she had an infection of the surgical site that needed to be treated with intravenous antibiotics and then had a “reaction” to the antibiotic therapy. A small percentage of patients (5% to 10%) develop a nonoliguric form of acute renal failure when treated with aminoglycosides, such as tobramycin and gentamicin. Tobramycin can accumulate in the kidney to produce a delayed form of acute renal failure, resulting in an excessive rise in the serum creatinine level. Subsequently, the rise in the serum creatinine exacerbates the renal dysfunction and prolongs the course of acute renal failure. The nonoliguric form of renal failure, seen in this patient, is the typical presentation for aminoglycoside nephrotoxicity.
- Acute glomerulonephritis: typically associated with hypertension and the appearance of urinary sediment-containing casts, red blood cells, and protein.
- Cephalothin: first-generation cephalosporin commonly used in the treatment of severe infection of the genitourinary, gastrointestinal, and respiratory tracts as well as skin and skin structure infections. This antibiotic can produce an acute interstitial nephritis; however, the patient’s presentation is consistent with gentamicin nephrotoxicity.
- Interstitial nephritis is commonly associated with the development of acute renal failure, fever, rash, and eosinophilia.
- Renal artery occlusion: is commonly caused by thrombosis or embolism. The clinical features of acute renal artery occlusion are hematuria, flank pain, fever, nausea, elevated LDH, elevated SGOT, and acute renal failure.
- Since the patient has normal vital signs and no prior history of hypotension, a diagnosis of sepsis is unlikely.
A young child presents morbilliform cutaneus eruptions, urticaria, a fever of 102º F, mild lymphadenopathy and a complaint of “bone pain.” If the child recently had an oral abscess “removed” and is currently taking cefaclor suspension as a prophylactic measure, the child should be treated with:
A. aspirin and diphenhydramine. B. erythromycin and diphenhydramine. C. intravenous penicillin and diphenhydramine. D. oral prednisone and diphenhydramine. E. topical betamethasone.
D. Oral Prednisone and Diphenhydramine:
Serum sickness is a condition commonly caused by drug hypersensitivities; it is suggested that the medication acts as a hapten, which binds to plasma proteins. This drug-protein complex is recognized as being “foreign” by the patient’s body and induces a serum sickness-like illness. Common signs and symptoms of serum sickness include fever, cutaneous eruptions (morbilliform and/or urticarial), lymphadenopathy, and arthralgias. Erythema multiforme may also appear in severe cases. With respect to cefaclor, the incidence of serum sickness is much higher in infants and children than in adults. Due to the severity of the signs and symptoms in this patient, oral prednisone and diphenhydramine should be administered. The prednisone will treat the arthralgias and the skin rash, and the diphenhydramine will alleviate the urticaria.
- The use of aspirin in young children with a fever is not indicated due to the risk of Reye syndrome. If the patient had not completed his antibiotic therapy and/or signs and symptoms of the infection were still present, switching the antibiotic to a non-beta lactam would be indicated.
- However, prescribing erythromycin for a patient with no signs and symptoms of infection would not be indicated.
- IV Penicillin: would not be indicated for the following reasons: There is no infection in this patient; the use of IV penicillin is reserved for serious infections. Furthermore, penicillin is the most common cause of serum sickness.
- Topical betamethasone: may help to treat the rash and urticaria; however, due to the appearance of other signs and symptoms, oral prednisone and diphenhydramine would be a better choice.
A patient who has a history of heart disease and has limitations placed on his daily activities is BEST managed for a surgical procedure by:
A. treatment in a hospital setting with general anesthetic. B. elective surgery only after medical consultation. C. referral to an oral surgeon. D. only using local anesthetic without a vasoconstrictor. E. using nitrous oxide and local anesthetic without a vasoconstrictor.
B. It is very important to take a good medical history before treating a patient. If a patient gives a history of heart disease, it is essential to know the type of disease and how it affects his daily routine. Patients who have no or mild limitations can usually be treated successfully in an office setting. Patients who report shortness of breath upon mild to moderate exercise and who have severe limitations placed on normal daily activities will require medical consultation and possibly extra caution before beginning treatment. All elective surgeries in such patients should be carried out after proper medical consultation.
- Treatment in a hospital setting with general anesthetic is rarely necessary for routine dental surgical procedures. The complexity of the procedure will determine whether it should be referred to the oral surgeon or be performed by the treating dentist. A small amount of adrenaline in the anesthetic solution usually does not result in complication development in patients with controlled cardiovascular diseases.
All of the following are indications of dental elevators EXCEPT:
A. luxate teeth. B. expand and dilate the alveolar bone. C. remove broken root tips. D. peel off thinned out bone.
D. peel off thinned out bone:
One of the most important instruments used in the extraction procedure is the dental elevator. This instrument is used to luxate or loosen teeth by expanding/dilating the surrounding alveolar bone. Loosening of teeth with an elevator before the application of the forceps helps reduce the incidence of broken roots and teeth and makes the delivery of the tooth easier. Luxation is also important in the removal of a broken root. Some elevators are designed with specific shapes to facilitate the removal of roots from sockets.
Rongeur forceps are used to peel off thinned out bone over cystic or tumorous lesions. They are also used to nibble sharp bony margins and trim sharp bony ridges. Note: Elevator blades can vary in size and shape. Based on the blades, they can be classified as straight or gouge, triangular type, or pick type. Never use the adjacent tooth (unless needs to be extracted) or buccal or lingual plate as the fulcrum while using the elevator. Always elevate from the mesial side of the tooth. The flat surface of the elevator should face the tooth/root that needs to be elevated. Use finger guards to protect the soft tissues.
