Oral Surgery Flashcards

Question 1

Q

Patient comes in with a right body mandibular fracture.
Other than pain, bruising and swelling. Please list 6 other signs and symptoms associated with mandibular
fracture. (3)

Answer

A

bleeding,
limitation of function,
Loose or mobile teeth,
lower lip numbness (think IADN)
occlusal derangement (not biting properly)
step deformity,
facial asymmetry
Deviation of the mandible to the opposite side.

Question 2

Q

Two radiographic views for mandibular fracture. (1)

Answer

A

OPT and PA (posterior anterior) mandible

Question 3

Q

What factors would cause a fracture to be displaced? (4)

Answer

A

direction of the fracture line (if unfavourable)

Opposing occlusion- can prevent the fracture being displaced.

Magnitude of force.

Other associated fractures (much higher chance of displacement if there are multiple fractures)

Question 4

Q

List 3 management options of a right body mandibular fracture (3)

Answer

A

If undisplaced- Do nothing,

If displaced or mobile-
open reduction and internal fixation- reflecting soft tissue to expose bone & reduce it properly.

Closed reduction and internal fixation- Reducing without exposing the fracture line. This uses intramaxillary fixation to assume if the teeth are in the right place, so is the mandible.

Question 5

Q

6 signs and symptoms of TMD

Answer

A

Intermittent pain of several months or years duration
Muscle / joint / ear pain (proximity to the auditory canal) particularly on wakening
Trismus / locking/limited mouth opening
‘Clicking/popping’ joint noises
Headaches (Pain in the temporalis)
intra-oral signs: linea alba and tongue scalloping

Question 6

Q

What two muscles would you palpate to check for TMD?

Answer

A

Masseter, Temporalis

Question 7

Q

What advice is given to manage TMD conservatively

Answer

A

Patient education

Counselling/reassurance: why its happening, how it happens, what the causes are, how we manage etc.

Advice: (standard approach)
* Reassurance
* Soft diet
* Masticate bilaterally
* No wide opening
* No chewing gum
* Don’t incise foods
* Cut food into small pieces
* Stop parafunctional habits e.g. nail biting, grinding
* Support mouth on opening e.g. yawning

Medication
- NSAIDs
- Muscle relaxants
- Tricyclic antidepressants (have muscle relaxant properties)
- Botox of masseter = prevents clenching (last resort tx)
- Steroids

Physical therapy
- Physiotherapy
- Massage/heat
- Acupuncture
- Relaxation
- Ultrasound therapy (not used as much)
- TENS (Transcutaneous Electronic Nerve Stimulation)
- Hypnotherapy and CBT

Splints
- Bite raising appliances
- Anterior repositioning splint e.g. wenvac or Michigan splint

Question 8

Q

How does bite splint work

Answer

A

They stabilize the occlusion and improve the function of the masticatory muscles, thereby decreasing abnormal activity.
They also protect the teeth in cases of tooth grinding

Eliminated occlusal interference
Habit breaker
Reduces loading on TMJ
Prevents the join head from rotating so far posteriorly in the glenoid fossa

Question 9

Q

What is arthrocentesis and mechanism of action?

Answer

A

Arthrocentesis = wash of the joint = increase lubrication
Under LA or GA
Inject lactate, hyaluronic acid and steroid into the capsule
Can lead to reduction of the disc and increase function

Action: Breaks fibrous adhesion and flushes away the inflammatory exudate to increase lubrication.

Question 10

Q

You extracted tooth 26, but the bleeding won’t stop.
List how would you manage? (4)

Answer

A

Take quick history

Apply pressure using damp gauze (so the blood clot doesn’t attach to the gauze)

If you still cannot get it to stop:
A-LA with adrenaline (to constrict the BV)
B- Place surgicel pack and sutures
C - cauterise/diatherymy (Burn the end of the vessel to create a protein plug in it)
D- Ligate vessel if it is larger

If it doesn’t stop- keep pressure on patient and get them to A&E

Question 11

Q

Local risk factors for delayed onset of bleeding. (1)

Answer

A

Mucoperiosteal tears or fractures.

(LA with vasoconstrictor wears off, Loosening the suture, Pt injury with tongue/finger/food)

Question 12

Q

List 2 congenital and 2 aquired reasons for delayed haemostasis?

Answer

A

Congenital: haemophilia A and haemophilia B

Acquired:
Medications - warfarin, aspirin, DOACS
Liver failure - ALD, hepatitis
Haematological malignancy - leukaemia, multiple myeloma

Question 13

Q

Patient in on new oral anticoagulant, when should you check the INR prior to extraction?

Answer

A

NOACS = No need to check INR

Warfarin only
SDCEP – recordings taken within 24 hours of extraction (poorly controlled)

can take recordings up until 72 hours before as long as patient INR is controlled however as close to the extraction date as possible is recommended

Question 14

Q

What is the SIRS 4 criteria with parameters

Answer

A

Temperature<36 degrees or >38 degrees
Heart Rate > 90bpm
Respiratory Rate >20bpm
WBC count =/> 12,000/mL or =/<4,000/mL, 10% immature neutrophils

Question 15

Q

How many of the Sirs criteria do you need to meet to diagnose as SIRS

Question 16

Q

Aside from site: 4 things to make note of in a facial swelling (9)

Answer

A

Duration- if it continues to swell after 48 hours could be infection.

Does swelling affect swallowing or breathing (straight to A&E)
Size of swelling.
Palpation (firm/mobile)
Sinus/Pus
Heat
Colour.
Systemic symptoms: Fever, malaise, lymphadenopathy

Any suspicion of sepsis = urgent referral to A &E.

Question 17

Q

Patient is having his lower left third molar removed under intravenous sedation.
Why is written consent gained prior to the sedation process? (1)

2020 paper 1 Q8

Answer

A

This allows the patient to decide without anxiety/pressure and also gives them time to change their mind.

Question 18

Q

As a UK practiced dentist, what drug is commonly used for intravenous sedation? What preparation would this drug be? (2)

2020 paper 1 Q8

Answer

A

Midazolam 5mg/ 5ml IV.
= water soluble imidazobenzodiazepine

Question 19

Q

Name 3 vital signs you would monitor before, during and after sedation. (3)

2020 paper 1 Q8

Answer

A

Oxygen saturation.
Blood pressure (every 5 to 10 minutes)
Heart rate (pulse)

Question 20

Q

Patient is having his lower left third molar removed under intravenous sedation. IV Midazolam is being used- What drug is used to reverse the effect of this drug? (1)

Answer

A

Flumazenil- 500micrograms in 5ml preparation
Provide 200micrograms then 100micogram increments every 60 seconds until a response is seen.

Question 21

Q

Give three pieces of advice you would give to the patients after sedation. (3)

Answer

A

Do not use public transport
Don’t go out alone.
no heavy machinery
no driving
Do not make any important decisions.
Dont drink or smoke.
Don’t return to work for 24 hours after IV sedation.

Question 22

Q

What are the indications (4) and contraindications for inhalation sedation? (6)

Answer

A

Medical conditions aggravated by stress of the treatment (epilepsy/ Hypertension/ asthma/ Ischaemic heart disease)
Medical conditions that affect co-operation (Mild to moderate movement or learning difficulties)
Psychosocial (phobias. Anxiety- milkd/mod. Gagging)
Dental- Difficult or unpleasant procedures

Contraindications:
* Common cold = blocked nose
* Tonsillar/adenoidal enlargement = natural mouth breathers – need to breathe through nose!
* Severe COPD
* First trimester of pregnancy
* Fear of “mask” / Claustrophobia
* Patients with limited ability to understand what is required of them during the procedure (i.e. small children under 7 or those with learning difficulties)

Question 23

Q

What are the advantages of Inhalation sedation over midazolam (IV)? (5)

Answer

A

Rapid recovery
Flexible duration.
No needles
No amnesia
No need for the adults to be chaperoned.

Question 24

Q

What are the contra-indications of using inhalation sedation?

Answer

A

Blocked nasal airways- Patient needs to be able to inhale the gas.
Patients with COPD.
Pregnant patients.
Need to be able to breathe through their nose (Problem with natural mouth breathers e.g. Patients with enlarged tonsils and adenoids)

Question 25

Q

List the safety feature of the quantiflex machine used in inhalation sedation.

Answer

A

Pin index system = prevents the wrong cylinder being attached
Diameter index system = prevents cross connection of piping
Minimum oxygen delivery = 30%
Oxygen fail safe = operates when oxygen pressure < 40 psi
Air entrainment valve
Oxygen flush button
Oxygen monitor
Reservoir bag
Colour coding = ensure the tanks aren’t attached to the wrong tubes.
Scavenging system = ensure nirous oxide not breathed into the atmosphere
Oxygen & nitrous oxide pressure dials
Pressure reducing valves
One way expiratory valve
Quick fit connection for positive pressure oxygen delivery

Question 26

Q

When might a referral for general anaesthetic be made?

Answer

A

Uncooperative/ pre-coperative patient
severely anxious or phobic
complex/long procedures (multiple extractions,)

MH contraindicating other sedation options
- Inhalation e.g. Tonsillar/adenoidal enlargement/mouth breathers, Severe COPD, Fear of mask/ Claustrophobia, Patients with limited ability to understand what is required of them during the procedure (i.e. small children under 7 or those with learning difficulties)
- IV-

Question 27

Q

What are the stages of anaesthesia?

Answer

A

Induction
Excitement
Surgical anaesthesia
Overdose

Question 28

Q

What needs to be included in a referral letter for GA? (7)

Answer

A

Patient details - name, DOB, address, contact details

guardian details - name, relation, address, contact

MH - allergies, meds, conditions

DH and justification for GA

TX plan

radiographs supporting the justification

GMP and GDP - name, contact details, address (referrer?)

Question 29

Q

What is the definition of conscious sedation?

Answer

A

A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation.
The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render unintended loss of consciousness unlikely.
The level of sedation must be such that the patient remains conscious, retains protective reflexes, and is able to understand and respond to verbal commands.

Lara definition- Where drug produces a state of depression in the central nervous system to enable treatment but the patient can remain conscious/ retain protective reflexes and understand & respond to verbal commands during treatment.

Question 30

Q

What is GABA?

Answer

A

Gamma Aminobutyric acid - inhibitory neurotransmitter

Question 31

Q

What is the function of GABA?

Answer

A

An inhibitory CNS neurotransmitter which prolongs time for receptor repolarisation of the cerebral cortex and motor circuits to slow the brain down.

Question 32

Q

What is the half life of midazolam?

Answer

A

90-150 mins

Question 33

Q

What are the contraindications for IV sedation?

Answer

A

Medical
- Severe or uncontrolled systemic disease = unfit for sedation
- Severe mental or physical disability = are unable to communicate and understand what is involved
- Severe psychiatric problems = are unable to communicate and understand what is involved
- Narcolepsy = if px fall asleep and cannot communicate with dentist that fails as part of the conscious sedation criteria
- Hypothyroidism
- myasthenia gravis (muscle wasting disorder) = don’t want to relax already weakened muscles as it can affect breathing further
-hepatic insufficiency (inability to metabolise the drug)
-Pregnancy & lactation- drug will pass to the baby

Social
- Unwilling: become more uncooperative
- Uncooperative: become more uncooperative
- Unaccompanied: have to be observed closely after treatment whilst drug is metabolised (different for inhalation)
- Children: IV cannot be used on those under 12
- Very old: IV cannot be used on these px

Dental
- Procedure too difficult and cannot be done with LA alone = long procedure, sedation wears off and px becomes uncooperative
- Procedure too long (same as above)
- Spreading infection = Airway threatening or Limits LA
- Procedure too traumatic (see first)

Question 34

Q

Give 6 things you assess a patient for before IV sedation (5)

Answer

A

MH: ASA class, medications, allergies

DH: Level of anxiety and cause/Cooperation level and willingness/ treatment needs

SH: Drug abuse, dependance, tolerance/alcohol/ employed (can’t return for 24h)/carer or dependants

Vital Signs:
HR
BP: taken at initial assessment and then every 5 mins during sedation (ensure BP cuff and oxygen saturation clip is on different arms)
Oxygen saturation: taken at initial assessment and then every 5 mins during sedation

BMI=weight (kg)/height (m2)

Question 35

Q

What is the ASA classification?

Answer

A

American Society of Anaesthologists- used to classify medical status.
1. A normal healthy patient (no medical conditions)
2. A patient with mild systemic disease (well controlled diabetes/ hypotension/smoker)
3. A patient with severe systemic disease (poorly controlled hypotension/ diabetes etc/ Alcohol dependence/ BMI >40)
4. A patient with severe systemic disease that is a constant threat to life (MI in last 3 months/ sepsis/ESRD)
5. A moribund patient who is not expected to survive without the operation (anerusym/intracranial bleed)
6. A declared brain-dead patient whose organs are being removed for donor purposes

IV sedation only compatible with ASA I or ASA II
IV sedation of the other ASA classified patients are treated with an anaesthetist led sedation in a hospital environment

Question 36

Q

What do you monitor in a sedated patient? (3)

Answer

A

Blood pressure, Oxygen saturation and heart rate

Question 37

Q

A patient attends your practice complaining of pain on biting. Intra-orally you see a 9mm suppurating pocket with vertical bony defect radiographically, associated with tooth 15.
List THREE differential diagnoses (3)

Answer

A

Perio-endo lesion
- with root damage
- without root damage

Periodontal abscess

Symptomatic periapical periodontitis

Question 38

Q

A patient attends your practice complaining of pain on biting. Intra-orally you see a 9mm suppurating pocket with vertical bony defect radiographically, associated with tooth 15.

What special investigation would you carry out to help with determining the definitive diagnosis? (1)

Answer

A

assume PA already taken

TTP (lateral= perio abscess or vertical)
Sensitivity testing: EPT/ECT
6ppc

Question 39

Q

A patient attends your practice complaining of pain on biting. Intra-orally you see a 9mm suppurating pocket with vertical bony defect radiographically, associated with tooth 15

Explain one suitable initial treatment that you would carry out for this tooth (2)

Answer

A

Non- vital = RCT (or extraction)

Vital = dilate/incise to drain, initially subgingival scale shy of base of pocket, advise analgesia and CHX, review and thorough PMPR once acute symptoms subside

Question 40

Q

A patient attends your practice complaining of pain on biting. Intra-orally you see a 9mm suppurating pocket with vertical bony defect radiographically, associated with tooth 15.
Your initial treatment fails and the tooth is extracted. Name two ways that the tooth can be replaced. (2)

Answer

A

Bridge
- resin retained or conventional
- fixed fixed or centilever

Implant

RPD

Question 41

Q

You have extracted the tooth & suspect a root has been left in the antrum. How do you investigate and treat a tooth or root in antrum as a GDP? (7)

Answer

A

Confirm radiographically = PA +/- OPT

if root is not quite in sinus you can try and retrieve it.
or
if small = consider leaving but advise risk of infection

If root is in the sinus:
Create BAF
Open access to sinus using electric handpeice (So you don’t force air into the tissues- which would cause infection)
A- suction the root out
B- Irrigate using saline.
C-Ribbon gauze- tuck it up into the antrum & try pull the root out when you remove the gauze.
Close like you would an OAC.

Prescribe antibiotics.Do we?

Question 42

Q

You have extracted a tooth in GDP but the crown of the tooth has fractured off.
How do you investigate and treat a fracture of crown/roots as a GDP (4)

Answer

A

Stop and evaluate
Explain what has happened to patient
Ensure pre-op radiograph is present
Discuss tx options w patient and get consent
1. leave and monitor = if tooth has no PA/hasnt been mobilised
2. try to remove with instruments e.g. coupland, cryers, root forceps
3. Progress to surgical
4. refer

Look in the socket to see what has been left behind.
If we can’t see anything radiograph

**Treatment options: **
Continue extraction- use Cryer’s elevator/ Upper root forceps / Lower root forceps.
Leave the roots- retained roots Factors allowing successful healing- If the tooth is still vital/Fractured root hasn’t been mobilised/Complete wound closing. But there are risks- future infection.

Question 43

Q

You have extracted an upper molar in GDP & have fractured the tuborosity.
How do you investigate and treat this?

Answer

A

Causes:
Single standing teeth (fragile surrounding bone)
Bone loss & unerupted teeth cause alveolar weakness.
Extracting in the wrong order (should extract back to front)
Inadequate alveolar support.
Pathological germination.

**How to diagnose:
**
Key indicator: Tear on the palate
Noise
Movement noted both visually or with supporting fingers
More than one tooth movement

Treatment is dependent on bone size & success of extraction:

If extraction is successful &
-Small bit of bone- disect out the bone and close the wound. (disect to prevent gum ripping)
-Large bit of bone- Put the bone back (reduce)and stabilise with
splints (rigid- achieved by splinting fractured area to stable bone/lots of stable teeth e..g 5/6/7/8)
orthodontic wire welded with composite/ arch wire

If extraction is unsuccessful:
1.Stabilise maxilla
2.If tooth is interfeering with occlusion (can be due to inflamed PDL & oedema) reduce the crown (it will be extracted anyway)
3.Antibiotics and keep mouth clean with an antiseptic mouthwash.
4.Leave extraction for 8 weeks and ensure patient is keeping splint clean-

if extraction was due to pain- we need to deal with the pain i.e. remove pulp and dress. Otherwise wait until the bone is fixed.

Give post op instructions.

Dissect out with the tooth (if its small enough) using a scalpel. Do not just try to pull the tooth out as the gum will rip.

Reduce using fingers or forceps (putting it back in the correct position)

Question 44

Q

What is pericoronitis?

Which teeth are most affected?

Answer

A

Inflammation around the crown of a partially erupted tooth

Food & debris gets trapped under the operculum resulting in inflammation or infection

3rd Molars

Question 45

Q

What are the signs and symptoms of pericoronitis? (12)

Answer

A

Pain – variable - starts mild and progresses, described as throbbing.
Swelling – Intra or extraoral at angle of the mandible
Bad taste
Pus discharge
Occlusal trauma to operculum from opposing cusps = Ulceration of operculum
Evidence of cheek biting
Foetor oris
Limited mouth opening – where extraoral swelling from angle moves to the submandibular area and can then move into submasseteric area
Dysphagia – when infection reaches parapharyngeal space/tonsils
Pyrexia (fever)
Malaise
Regional lymphadenopathy

Question 46

Q

What 7 radiographic signs show a close relationship of lower 8 with IAN?

what 3 signs increase the risk significantly?

Answer

A

Rood and Shehab paper 1990.

1. interruption of the white lines/lamina dura of the canal

2. darkening of the root where crossed by the canal

** 3. diversion/deflection of the inferior dental canal **

deflection of root;
narrowing of inferior dental canal;
Narrowing of the root;
Dark and bifid root; (split or divide over the canal)

Lara- same answer in order that makes more sense to me (everyone else ignore xx)
Roots:
* Darkening of the root where crossed by the canal (high risk)
* Deflection of the root.
* Narrowing of the root where they meet the canal.
* Dark and bifid root.

Canal
* Interuption of white lines/lamina dura of canal (high risk)
* Diversion/ deflection of inferior dental canal (high risk)
* Narrowing of inferior alveolar canal

Question 47

Q

How is Acute periocoronitis treated?

How is it managed in the long term?

Answer

A

Usually transient and self limiting, however;

+/- local anaesthetic (IDB) – depends on pain/patient;

Incision of localised pericoronal abscess if required
Irrigation with warm saline (or chlorhexidine - controversial due to anaphylaxis)
(10-20ml syringe with blunt needle – under the operculum).

Post-op;
- Patient instructed on frequent warm saline or chlorhexidine mouthwashes at home
- Advice regarding analgesia
- Instruct patient to keep fluid levels up and keep eating (soft/liquid diet if necessary)

If px has a large extra-oral swelling, systemically unwell, trismus, dysphagia or breathing difficulties – refer to maxillofacial unit or A&E

AB Use:
Generally do not prescribe antibiotics unless more severe localised pericoronitis, px systemically unwell (fever etc), extra-oral swelling, severe trismus, px immunocompromised e.g. diabetic or if there is persistent infection after local measures.

Long term:
(if recurrent)
- 8’s extracted once the acute pericoronitis has been resolved

Extraction of upper third molar if traumatising the operculum

Question 48

Q

What risks should be explained to the patient with regards to damage to IAN during extraction of an M3M?

Answer

A

Nerve damage - Numbness (anaesthesia) or tingling (paraesthesia) of lower lip, chin, side of tongue (sensory damage NOT motor)
Demonstrate the areas that will be affected

Temporary numbness from IDB (lower lip and chin)
may take weeks/months to improve
10-20% will experience temporary effects
Permanent numbness from IDB;
Average <1% will experience this

Advise that risk can be greater than average if tooth/root is in close proximity to the IDC

Other nerve damages:
Lingual Nerve (one side of tongue, taste)
Temporary – Literature quotes 0.25 – 23%
Permanent – Literature quotes 0.14 – 2%

Altered taste (rare) (Chorda Tympani - arises from Facial nerve, taste buds from anterior two thirds of tongue, carries fibres via Lingual nerve)
Dysaesthesia (rare) – painful, uncomfortable, unpleasant sensation of lower lip, chin, tongue; sometimes neuralgia type pain.
Hypoaesthesia (reduced sensation) or heightened sensation (increased sensation).

Nerves mostly recover within 9 months however can recover up to 18-24 months but after this time there would not be much hope for any further recovery

Question 49

Q

What imaging is requested when an 8 is close to IAN?

Answer

A

CBCT (or CT if not available)

Question 50

Q

Treatment option to reduce the risks of complications during XLA M3M near IDN?

Answer

A

Coronectomy

Question 51

Q

Name 2 scenarios where there would be an increased risk of bleeding for a
patient and 2 post operative methods of achieving haemostasis.

Answer

A

Liver disease = reduced clotting factors

anticoagulant meds (warfarin or apixaban)

antiplatelets (clopidogrel)

inherited bleeding disorder - haemophilia A, B or von willebrand disease

(INR should be LESS THAN 4)

Post Op haemostasis:
- firm and even pressure with damp gauze for 20 mins ++
- La & vasoconstrictor
- oxidised regenerated cellulose (surgicel) pack and sutures
- fibrin foam
- gelatine sponge

Question 52

Q

How would you predict a OAC?
pre op(2) & diagnose it post extraction (7)

Answer

A

Pre-op Via:
- Size and location of tooth (last standing upper moalrs)
- large, bulbous, splayed roots.
- Radiographic position of roots in relation to antrum during pre-op assessment (roots wrapped around floor)

Post extraction:
- Bone at trifurcation of roots/type of roots
- Bubbling of blood at the socket post extraction
- Direct vision with Good light and suction
- change in suction sound (can sometimes create an echo)
- valsalva manoeuvre (careful and gently as can create an OAC if bone fractured but lining not torn)

RADIOGRAPHICALLY
-** A breach in the sinus lining- you can see the extraction socket overlapping the maxillary sinus.**
-Run a periodontal probe along the socket- you may feel the probe drop at one point- does it drop through? (take care not to create an OAC- some recommend not using this technique)
milk the socket to see where the blood is coming from??

Question 53

Q

What symptoms would a patient be complaining of with OAF (chronic)? (7)

Answer

A

Hx of upper extraction/non-healing socket
Problems with fluid consumption = fluids from nose
Problems with speech or singing (nasal quality)
Problems playing brass/wind instruments
Problems smoking cigarettes or using a straw
Bad taste/odour/halitosis/pus discharge/salty taste (post-nasal drip)
Pain/sinusitis type symptoms

Question 54

Q

What treatment is used for OAF? (4)

Answer

A

Remove the sinus tract (before the flap made)
Raise the flap;
- Buccal Advancement Flap (need to release the periosetum) -can fail in a larger communication
-f it fails:
- Buccal Fat Pad with Buccal Advancement Flap = reinforced/thicker flap using fatty globular tissue (More bruising/swelling )

3.Washout the antrum – not always done (OAF associated with sinusitis)

close the flap (tension free )

provide nasal drops: ephedrine 0.5% 10ml (1-2 drops 4x per days for a max of 7 days)
proovide pen V 250mg 2 tablets 4x per day for 5 days

Question 55

Q

What bone dimensions are required for implants (5) and how are they best measured? (1)

Answer

A

Bone dimensions:
Mesial/ distal :1.5mm away from adjacent teeth.
Bucco-palatally :2mm
Apico-coronally- 2mm from ACJ
2mm away from adajcent structures (IAN/ Maxillary sinus)
We want 7mm of space in the edentulous area .

CBCT
Allows more accurate assessment of;
- Root positions
- Bone width
- Bone volume

Question 56

Q

Give 3 alternative treatment options instead of an implant?

Answer

A

Bridge - adhesive or Conventional
fixed fixed (post) or cantilever (ant)
RPD
Accept the space
close with orthodontics

Question 57

Q

Name 3 possible complications associated with extraction of lone standing upper
molars.

Answer

A

Fracture of the maxillary tuberosity

OAC

Root in the antrum

Question 58

Q

What flap design is used for OAC? (2)

Answer

A

Buccal Advancement Flap (can fail in a larger communication)
Buccal Fat Pad with Buccal Advancement Flap = reinforced/thicker flap. Used if a buccal advanacement flap fails.

Question 59

Q

17 year old presets with congenitally missing 22 and 23
- The patient wants implants, what other treatment options could you advise?

Answer

A

Bridge - adhesive or Conventional
fixed fixed (post) or cantilever (ant)

RPD

orthodontics + restorative

Question 60

Q

17 year old presets with congenitally missing 22 and 23
- Give a problem relating to aesthetics

Answer

A

Midline shift and spacing
-Space is too wide for a 1 pontic bridge but too narrow for a 2 pontic bridge.
- psychological impact of no teeth

self conscious/lack of confidence
teasing/bullying by peers

Question 61

Q

17 year old presets with congenitally missing 22 and 23
Give a problem relating to function.

Answer

A

Problems with biting/incising food (mastication)

problems with speech (fricatives and whistling)

Missing canine (canine guidance)

Lower teeth- risk of overeruption.

Question 62

Q

Give 3 things a dentist would check before referral for implants (general)

Answer

A

History:
MH - medications, allergies, health issues e.g. Diabetes/ osteoporosis/ bisphosphonates, bleeding disorders etc (can affect Implant surgery)
DH - motivation, compliance (regular attender), caries risk, fear&anxiety.
SH - smoking/ ability to afford treatment.

Active disease:
- caries
- gingivitis/peridontal disease (BPE & 6PPC)

IOTN? (if ortho referral)

Question 63

Q

Give 3 things an implantologist checks (local) (6)

Answer

A

Root morphology

Alveolar bone width and height

Surrounding anatomy (maxillary sinus, IDN)

Alignment/spacing/crowding of the dentition

OH

disease status - caries & periodontal

Question 64

Q

Referring to the sign guidelines, when is it not advised to removal wisdom teeth? *****

Answer

A

Impacted wisdom teeth that are free from disease (healthy) should not be operated on.

(Emer -)
SIGN - unless justified, risk>benefit, no evidence of associated pathology, risk of surgical complications
NICE - Unless Pathology shouldn’t be removed

Answer 64

A

What are the therapeutic indications for extraction?
* infection: from caries, pericoronitis, periodontal disease or local bone infection (most common)
* Any history of pericoronitis, one or more cases of infection or untreatable pulpal/PA disease = extraction considered
* 8’s needing restored= poor access and poor moisture control
* Horizontal/Mesioangular impaction = more prone to bone loss distal to 7 (late removal > 30y/o = no improvement of perio disease on lower 7.

- Cysts = most commonly present between 20-50y/o
  Most common = dentigenous cyst - arises from reduced enamel epithelium separation from the crown.Most common = in mandible (10x)
- prior to cancer treatment: indicates remove of 8 if the px is receiving radiotherapy as it prevents removal at a later date and reduces risk of osteoradionecrosis
- **External resorption **of 7 or 8 – occurs commonly between 21-30y/o

Other indications:
- Surgical indications ie within the surgical field (orthognathic, fractured mandible, in resection of diseased tissue surgeries)
- If tooth has a high risk of disease e.g. in horizontal/mesioangular impaction
- Medical indications eg. awaiting cardiac surgery (must be dentally fit), immunosuppressed, starting bisphosphonates or to prevent osteonecrosis
- Accessibility to the dentist e.g. submariners, aid workers etc
- Patient age: complications and recovery time increase with age
- Autotransplantation: tooth relocated to another site i.e. 1st molar site (low success and not widely used)
- General Anesthetic: radical tx to prevent a further GA

Answer 65

A

Therapeutic Indications:
- Infection: from caries, pericoronitis, periodontal disease or local bone infection (most common)

Any history of pericoronitis, one or more cases of infection or untreatable pulpal/PA disease = extraction considered

Restoring 8’s = poor access and poor moisture control

Horizontal/Mesioangular impaction = more prone to bone loss distal to 7 (late removal > 30y/o = no improvement of perio disease on lower 7.

Cysts = most commonly present between 20-50y/o
Most common = dentigenous cyst - arises from reduced enamel epithelium separation from the crown
Most common = in mandible (10x)
Tumours: indicates remove of 8 if the px is receiving radiotherapy as it prevents removal at a later date and reduces risk of osteoradionecrosis
External resorption of 7 or 8 – occurs commonly between 21-30y/o

Other indications:
- Surgical indications ie within the surgical field (orthognathic, fractured mandible, in resection of diseased tissue surgeries)
- If tooth has a high risk of disease e.g. in horizontal/mesioangular impaction
- Medical indications eg. awaiting cardiac surgery (must be dentally fit), immunosuppressed, starting bisphosphonates or to prevent osteonecrosis
- Accessibility to the dentist e.g. submariners, aid workers etc
- Patient age: complications and recovery time increase with age
- Autotransplantation: tooth relocated to another site i.e. 1st molar site (low success and not widely used)
- General Anesthetic: radical tx to prevent a further GA

Answer 66

A

Presence or absence of disease (in 3M or elsewhere)
Anatomy of 3M (crown size, shape, condition, root formation – apical hooks or large curves)
Assess crown to root ratio
Depth of impaction
Orientation of impaction (vertical, horizontal, transverse, M or D)
Working distance (distal of lower 7 to ramus of mandible)
Follicular width (appears as radiolucency on an x-ray) : can become a cyst follicules > 2.5-3mm
Periodontal status
The relationship or proximity of upper third molars to the maxillary antrum and of lower third molars to the inferior dental canal
Any other pathology/abnoramlity

Answer 67

A

Temporary numbness may take weeks/months to improve;
10-20% will experience temporary effects

Permanent numbness;
Average <1% will experience this

Nerves mostly recover within 9 months however can recover up to 18-24 months but after this time there would not be much hope for any further recovery

Answer 68

A

Buccal mucoperiosteal flap:
2 sided or 3 sided

(various suturing pattern)

+/- raising a lingual flap

Answer 69

A

Post Op haemostasis:
- firm and even pressure with damp gauze for 20 mins ++
- La & vasoconstrictor
- oxidised regenerated cellulose (surgicel) pack and sutures
- fibrin foam
- gelatine sponge

Answer 70

A

Soft tissues – La & vasoconstrictor or oxidised regenerated cellulose (surgicel) pack and sutures

Bone – bone wax, pack (WHVP)

Vessels (veins, arteries, arterioles) – diathermy and ligatures (bigger vessels)

Answer 71

A

Liver disease = reduced clotting factors

anticoagulant meds (e.g. warfarin apixaban)

antiplatelets (e.g. clopidogrel aspirin)

inherited bleeding disorder - haemophilia A, B or von willebrand disease

(INR should be LESS THAN 4)

Answer 72

A

Thumb in the coronoid notch of the ramus of the mandible

fingers on the posterior border of the mandible

barrel of LA over the opposite premolars and visualise the

pterygomandibular raphe
- union of the superior pharyngeal constrictor muscle and the buccinator muscle

hold thumb horizontal in the notch and have the needle at the superior border of you finger nail, in the middle of the triangle 1cm above the last standing molar
advance needle until you contact bone (1cm of needle still visible), retract slightly, aspirate and deposit
if too much needle showing retract slightly and move back
if needle doesn’t contact bone retract slightly and move further forward

Answer 73

A

Akinosi Block technique:
Used for patients with severe trismus (they are unable to open their mouth)

Pull cheek away
Needle moves in parallel to the floor just above the gingival margin of the upper molars.
Keep inserting the needle until the barrel end is in line with the 7 and 8s.
Inject

Gow Gate technique:
(requires px to open wide)
Injection site - anterior to the neck of the condyle in proximity to the mandibular branch of the trigeminal nerve after its exit from the foramen ovale.

Answer 74

A

Apologise and explain what has happened to the patient and why it had happened.

Give them reassurance that it is a temporary

Provide eye protection (eye patch) until blink reflex returns to normal

Advise length of paralysis can vary but will improve over a period of days/week

Review the patient

Answer 75

A

Ensure flap has adequate circulation/perfusion and is of adequate size - so that the flap doesn’t become necrotic

Use scalpel in one continuous stroke

No sharp angles created in the soft tissue

Minimise trauma to the papillae

Do not crush the raised flap/soft tissues

Keep the tissues moist

Ensure the margins of the flap where the sutures will be placed are on sound bone

Wounds must not be closed under tension - high risk that the wound will breakdown
Aim for healing by primary intention as it minimises scarring.
Occurs when edges of the wound are close together/held together by sutures/glue
Secondary is when the dermal edges are not in close proximity and the wound heals from the bottom upwards = scarring.

Answer 76

A

Achieve anaesthesia – ensures pain relief and haemostasis
* Local Anaesthesia
* IV Sedation & LA
* General Anaesthetic
Access - 2/3 sided buccal mucoperiosteal flap
+/- raising a lingual flap
Bone removal as necessary
Electrical straight handpiece with saline cooled bur and a Round or fissure stainless steel & tungsten carbide burs
buccal aspect of the tooth around the margin and onto the distal aspect of the impaction
Tooth/root division as necessary and remove
Ensure apices intact
Inspect and debridement the socket
- Bone file or handpiece to remove sharp bony edges
- Mitchell’s trimmer or Victoria curette to remove soft tissue debris
- Flush Sterile saline into socket and under flap = irrigation
- Aspirate under flap to remove debris = suction
Suture
Achieve haemostasis
biting down on a damp guaze (10/15 mins
Post-operative instructions (verbal and written)

Answer 77

A

To irrigate sockets after extraction

Answer 78

A

Jaw fracture (rare)
Loss of tooth
Soft tissue damage
Damage to nerves
Damage to vessels
Haemorrhage
Dislocation of TMJ
Damage to adjacent teeth/restorations
Broken instruments
fracture of tooth/roots

Answer 79

A

Neurapraxia:
Contunity of epieneural sheath and axons maintained (bruised)

Axonotmesis:
Continuity of axons disrupted but no damage to the epineural sheath

Neurotmesis:
Complete loss of nerve continuity/(nerve transected)

Answer 80

A

Reposition tissues
Cover bone
Compress blood vessels
Prevent wound breakdown
Achieve haemostasis

Answer 81

A

Non Absorbable
i.e. Mersilk, Prolene, Ethylon

When used?
supported and retained for long periods of time i.e. closure of OAF and exposed canines.

Absorbable
i.e. Velosorb fast

Last for 1/2 weeks
Broken down via hydrolysis

When used?
When it is not possible to remove sutures
When edges only have to be held together temporarily

Monofilaments: (1 strand of material)
i.e. Proline and ethylon
These are also Non-Absorbable
Used in areas more prone to scarring

polyfilaments: (several strands of material)
i.e. Velosorb fast (A) and Mersilk (NA)

Answer 82

A

Fracture of the tooth/root

Fracture of the alveolar plate

Fracture of the maxillary tuberosity

Jaw fracture

Oro-antral communication

Loss of tooth

Soft tissue damage

Damage to nerves/vessels

Haemorrhage

Dislocation of TMJ

Damage to adjacent teeth

Broken instruments

Wrong tooth

Answer 83

A

Assess INR 24 hours before (if poorly controlled)
or 48 (72?) hours before if better controlled.
= Should be less than 4.

Stage treatment
Limit treatment area
Treat early in the day and early in the week

Avoid lingual infiltration and IDB
- if have to do IDB use vasoconstrictors and aspiration technique

Ensure an atraumatic technique

Use additional haemostatic aids such as extra la+vasoconstrictor, surgical pack (oxidised regenerated cellulose) and sutures.

ensure haemostatsis before px leaves surgery and provide thorough post op instructions including what to do if the bleeding starts and cannot be controlled + emergency contact details

book for a review appt.

Answer 84

A

Bisphosphonates are widely used to treat and prevent bone-related conditions.

They act by inhibiting osteoclast activity and bone resorption= poor healing of the bone socket

used for:
osteoporosis (in postmenopausal women)

Paget’s disease of bone

anticancer treatment regimens, particularly for metastatic bone cancer and multiple myeloma

Answer 85

A

HX: Those on bisphosphonates, anti-angiogenic or RANKL inhibitors.

Exam: Exposed bone/lack of healing of bone that can be probed via an intra-oral or extra-oral fistula and has been present for 8 weeks.

Answer 86

A

Low risk:
Px NOT currently being treated with systemic glucocorticosteroids and
- oral BP’s < 5 years
- IV BP’s < 5 years
- denosumab

High risk:
- Use in cancer treatment
- Used alongside corticosteroids
- Used for > 5 years
- Had MRONJ before

oral or IV BP’s > 5 years
BP’s or denosumab WITH systemic glucocorticosteroids
anti-resorptive or anti-angiogenic drugs
previous MRONJ

Answer 87

A

Assess risk and discuss risks with the patient and obtain valid consent

Low risk:
Perform straightforward extractions and procedures that may impact on bone in primary care. (no AB’s necessary)

higher risk:
Explore all possible alternatives to extraction where teeth could potentially be retained e.g. retaining roots in absence of infection.
If extraction remains the most
appropriate treatment, proceed as
for low risk patients

For both:
provide POI and advise the patient to contact the practice if they have any concerns, such as unexpected pain, tingling, numbness, altered sensation or swelling in the extraction
area.
Review healing. If the extraction socket is not healed at 8 weeks and you suspect that
the patient has MRONJ, refer to an oral surgery/special care dentistry specialist as per local protocols.

Answer 88

A

A localised osteitis - inflammation of the lamina dura
Its delayed healing NOT associated with infection

What causes this?
The normal clot partially/fully disappears or doesn’t form at all

Symptoms:
Intense, dull aching, throbbing pain that keeps the patient up at night.
Pain can radiate to the ear
Bad smell
Bad taste

Answer 89

A

initial healing = 1-2 weeks

soft tissue healing = 3-4 weeks

Answer 90

A

Predisposing factors:
Molars - posterior teeth are more prone
Mandibular teeth: blood supply is worse, only from 1 main artery.
Smoking/ex-smokers as it reduces the blood supply: warn them
Females
OCPs
LA with vasoconstrictor: lots of
Excessive trauma during extraction
Excessive mouth rinsing post extraction
Previous dry socket: variable

Answer 91

A

Check that there’s no tooth fragments/bony sequestra remaining in the socket
- Take a radiograph to confirm

Reassurance that this is common

Advise analgesics and hot salty mouthwashes

LA block
Irrigate socket with warm saline (with regular appointments)

Debride the socket to encourage new clots (controversial)

Antiseptic pack e.g. alvogyl: packed into the socket and it disintegrates itself. No sutures.
or
BIP paste/gauze packed into the socket, needs to be replaced as they don’t dissolve. Suture over the top.

Don’t prescribe antibiotics as its not an infection

Answer 92

A

Patients who have received radiotherapy of the head and neck, the mandible is the most commonly affected (because it has one main artery)

What occurs In these patients?
At a site of radiation injury the bone becomes non-vital, the blood supply reduces (from endarteritis obliterans), bone turn over slows down and Self repair is ineffective.

Answer 93

A

Patients who have received radiotherapy of the head and neck

the mandible as it is the most commonly affected because it has one main artery

if radiation dose to the primary tumour = exceeded 60Gy

The dose fraction was large with a high number of fractions
Those with local trauma as the result of a tooth extraction (especially mandibular extractions as it is perfused less), uncontrolled periodontal disease or an ill-fitting prosthesis.
The person is immunodeficient
The person is malnourished

Answer 94

A

ensure px dentally fit before tx.
- ensure XLA done 10 days before starting

Scaling and reinforcing good OHI

Careful and atraumatic technique

achieve primary closure after invasive treatment

Hyperbaric oxygen before and after the extraction: increases tissue oxygen and increases vascular ingrowth to hypoxic areas.

Refer and take advice

SDCEP- NO LONGER ANTIBIOTIC or CHX

Answer 95

A

Refer the patient:
Small exposure- Patient will be monitored/ OHI/ antibiotics/ antibacterial mouthwash.

Irrigate and remove necrotic debris

Remove loose sequestra/necrotic sequestra (bone)

Large wounds: resect the exposed bone and close the soft tissues

Hyperbaric oxygen therapy:
increases tissue oxygen and increases vascular ingrowth to hypoxic areas.

use vitamin E and pentoxyfylline

Answer 96

A

Upper Forceps
Straight- 13 to 23

Universal (curved handle)- canine and premolars

Molars x2- there is a left and right instrument, the rule is beak to cheek

Upper root - look identical to upper universal with thinner beaks used on roots

3rd molar bayonets - straighter handle, bend in the tip, thicken beak than the root forceps (8’s)

straight vs universal - both identical however the universal instrument has a curved handle
universal vs root - both identical however the root instrument has a much smaller tip

Lower Forceps
All have a 90 degree bend on the tip
Universal- 35 to 45

Molar- two beaks to engage the space between the mesial and distal roots and can be used for both left and right side

Cowhorn (sharper and narrower pincers) used on either side
can be used in: molars with lack of crown, with divergent roots, in young patients

Root - identical to universal with a smaller tip

Answer 97

A

Use: to loosen and widen the PDL (space)

Types:
Coupland’s - square/sharp edge
The higher the number the bigger

Cryer’s (sets of 2 = left and right)
remove retained roots or fragments AND engage furcation region of molars

Warwick James (sets of 3 = left, right and straight)
used for wisdom teeth

Answer 98

A

Elevator&luxator techniques:
Lever technique:
Use your non-dominant hand to support the alveolar bone and retract soft tissues
Always use it buccally
Start from the mesial and move distally
Ensure concave (sharp edge) surface is engaging the tooth
Use it buccally and as far down the crown/slightly on to the root - ensure it’s not interdental
Turn the instrument upwards engaging the tooth surface to raise the tooth

Wedge:
Use your non-dominant hand to support the alveolar bone and retract soft tissues
Always use it buccally
Start from the mesial and move distally
Wedge down the PDL and wiggle the instrument

Wheel and axle:
Approach from buccal aspect (you can change application point- mesial, distal etc)
Come almost horizontal
Wedge tip so that is engaging acj (as deep as possible)
Twist wrist to rotate instrument and lift the tooth
This can be used with cryers when extracting retained roots
If retained root is mesial- you may start with a distal application point (as this part of socket is empty), this gives you space to get the instrument in to engage the root. You may fracture some bone between the roots but then the tooth will start to elevate.

Answer 99

A

Function: to loosen and widen the PDL (space)

???
- remove retained roots
- provide a point of application for forceps

Answer 100

A

function: to tear and sever the PDL

Answer 101

A

Bacterial infection of the cancellous bone, which then spreads to cortical bone and then the periosteum.
(inflammation of bone marrow)

This can result in a compromised blood supply (from increased tissue hydrostatic pressure) which causes ischaemic and necrotic tissue.

Occurs in patients whos host defences are compromised by diabetes, alcoholism, iV drug use, malnutrition and myeloproliferative disease e.g. leukaemia, sickle cell.

Bacteria proliferate because natural blood borne defences cannot reach the tissue.
affects the mandible as it has a poorer blood supply (only one main artery)
The infection will spread until arrested by antibiotics or surgery.

Answer 102

A

Compromised host defence (diabetes/ Alcoholism/Leukaemia / chemotherapy treated cancer)
Fracture of the mandible
Odontogenic infection
Infected teeth (smaller odontogenic)
Bad periodontal disease

Answer 103

A

Referal:
* Blood investigations to assess host defences
* antibiotics - clindamycin/penicillins (good bone penetration) these courses are usually 6 weeks to 6 months.
* Surgical treatment- clearing the infected area of non-vital teeth/ loose pieces of bones etc unitl you reach healthier bone )

Severe, acute and systemically unwell = hospital admission and IV AB

Answer 104

A

Max Doses- 70kg
Lidocaine 2% is 4.4mg/kg – 7 cartridges

Articaine 4% is 7mg/kg- 5 cartridges

Prilocaine 3% is 6mg/kg- 8 cartridges

Mepivacaine 3% is 4.4mg/kg- 6 cartridges

Answer 105

A

An inherited bleeding disorder where there is an inability of a patient to clot due to a deficiency in factor 8 (blood clotting protein).

Answer 106

A

An inherited bleeding disorder where there is an inability of a patient to clot due to a deficiency in factor 9. (blood clotting protein).

Answer 107

A

A combination of reduced platelet aggregation (from a defect in the VW protein attached to platelets) and Reduced factor 8 levels.

Answer 108

A

Haemophilia A
Mild/moderate = DDAVP to release factor 8 & tranexamic acid (inhibit fibrinolysis)
Severe = factor 8

Haemophilia B- Recombinant factor 9 (+/- transexamic acid occassionally)

Von willebrand’s = DDAVP (for the factor 8 deficency) & transexamic acid (to stop fibrinolysis)

Answer 109

A

Examination
Treatments that do not manipulate the mucosa
Supragingival restorations/ crowns/bridges
Infiltration anaesthesia.

Answer 110

A

Pain/ Swelling/ Infection/ Bleeding/ Bruising.
Medication related osteonecrosis of the jaw (Patient is on bisphosphonates)
Dry socket
increased infection risk due to the immunosuppresion.

Answer 111

A

Headaches (Due to Temporalis pain)
Limited jaw movement (lateral or protrusive)
Trismus
Clicking or popping noises.
Crepitus (grating noise)
Deviation of the mandible to affected side.
Ear pain (proximity to the auditory canal)

I/O Signs:
Cheek biting. Linea alba. Tongue scalloping. Occlusal non carious tooth surface loss.

Answer 112

A

Soft diet,
Stop parafunctional habits e.g. nail biting,
Support mouth upon opening e.g. yawning,
Wear bite raising appliance
Don’t incise foods,
Chew bilaterally,
Cut food into small pieces,
No wide opening,
No chewing gum
Relaxation e.g.physiotherapy,

Answer 113

A

PH- Time of Pain- In the morning (bruxism) During the day habits)

SH- stresses

E/O- MoM hypertrophy.
TMJ clicking/ crepitus.
Tenderness on palpatation.
Range of movement.

I/O
intercisial opening distance (measure with willis bite gauge)
Signs of bruxism- (Wear facets, Scalloped tongue,
Linea alba, occlusal NCTSL)

Answer 114

A

Female>Males,
18-30yrs,
Stress,
Habits - chewing gum/ chewing pens/ grinding/ clenching.

Answer 115

A

Patient education

Counselling/reassurance: why its happening, how it happens, what the causes are, how we manage etc.

Advice: (standard approach)
* Reassurance
* Soft diet
* Masticate bilaterally
* No wide opening
* No chewing gum
* Don’t incise foods
* Cut food into small pieces
* Stop parafunctional habits e.g. nail biting, grinding
* Support mouth on opening e.g. yawning

Medication
- NSAIDs
- Muscle relaxants
- Tricyclic antidepressants (have muscle relaxant properties)
- Botox of masseter = prevents clenching (last resort tx)
- Steroids

Physical therapy
- Physiotherapy
- Massage/heat
- Acupuncture
- Relaxation
- Ultrasound therapy (not used as much)
- TENS (Transcutaneous Electronic Nerve Stimulation)
- Hypnotherapy and CBT

Splints
- Bite raising appliances
- Anterior repositioning splint e.g. wenvac or Michigan splint

Answer 116

A

Myofascial pain syndrome: no clicky,
Pericoronitis of L8- Clinical signs of pericoronitis.
Dental pain- radiographs
Sinusitis- get patient to bend their head forward (sinusitis has pain on movement)
Atypical odontoalgia- Dental pain without dental pathology. (This is only a diagnosis if we try to treat TMD and our treatment isn’t successful- ONLY DIAGNOSED when everything else is excluded.

Answer 117

A

We can ask for:
Soft acrylic splint
“A full coverage soft acrylic splint”
Using the lower impression.

Hard splint: (Michigan)
“A full coverage hard acrylic splint”
Cover all teeth,

Using the Upper and lower alginate impressions with facebow registration and wax bite.
Adam’s clasps on the 6s
(It blocks lateral movement of the teeth)

Answer 118

A

Full medical history- Medical conditions/ Medications/ Immunocompromised? / Any allergies- might need to prescribe antibiotics.

HPC- When did the pain start? Have they had it before? -
When did the swelling start? Has the swelling increased?
When did the patient begin to feel unwell? - can they eat/ drink
Severity of pain.
Have they been taking any medications for pain relief?

E/O exam:
Is the swelling affecting their airway? (any changes in voice)
Any swelling on the floor of the mouth?
Assess mouth opening
Any difficulties swallowing
Any swelling around the eyes.
Lymph nodes- palpable.

Investigations- OPT

Answer 119

A

Reassure patient and gain consent.
LA infiltration around area of abscess
Drainage of the pus and swelling around the 47.
Remove source of infection (Ideally on the day but may have to be at another appointment to allow swelling to die down)
Antibiotic due to spreading infection – Pen V 2x250mg 4x daily for 5 days. Or Metronidazole 400mg 3xdaily for 5 days.
Review patient after antibiotic treatment.

Answer 120

A

Lingual nerve- Tongue
Inferior alveolar nerve- Lower lip and chin

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