MFDS Part 1 - Membership of Faculty of Dental Surgery Oral Surgery and Exodontia Questions and Answers — Questions and Answers
Question 1: A 68-year-old patient taking apixaban for atrial fibrillation requires a routine extraction of a single molar tooth. According to the Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance, what is the most appropriate management plan?
- Advise the patient to stop taking apixaban for 48 hours prior to the extraction.
- Refer the patient to a hospital setting for the extraction under specialist care.
- Proceed with the extraction without altering the medication regimen, using local haemostatic measures. (Correct answer)
- Proceed with the extraction but advise the patient to miss their morning dose of apixaban on the day of the procedure.
Correct answer: Proceed with the extraction without altering the medication regimen, using local haemostatic measures.
SDCEP guidance on managing patients on anticoagulant drugs states that for procedures with a low risk of bleeding, such as a simple extraction, patients taking Direct Oral Anticoagulants (DOACs) like apixaban should not have their medication interrupted. The risk of a thromboembolic event from stopping the medication outweighs the risk of post-operative bleeding, which can be effectively managed with local measures like suturing and packing the socket.
Question 2: According to the National Institute for Health and Care Excellence (NICE) Technology Appraisal Guidance [TA1], which of the following is an accepted indication for the surgical removal of an impacted third molar?
- To prevent potential future crowding of the anterior teeth.
- A single, mild episode of pericoronitis that resolved with local measures.
- The presence of non-treatable pulpal pathology in the third molar. (Correct answer)
- The patient is asymptomatic but the tooth is horizontally impacted.
Correct answer: The presence of non-treatable pulpal pathology in the third molar.
NICE guidance TA1 explicitly states that the prophylactic removal of pathology-free impacted third molars should be discontinued. It lists specific pathological conditions as indications for removal, which include non-treatable pulpal and/or periapical pathology, unrestorable caries, cellulitis, abscesses, and cysts. A single mild episode of pericoronitis is not a firm indication, though recurrent or severe episodes are. Preventing future crowding is not an evidence-based indication for removal.
Question 3: During the extraction of a maxillary first molar, a 3mm oro-antral communication (OAC) is created. The sinus lining appears intact and the patient is healthy with no history of sinusitis. What is the most appropriate immediate management?
- Refer the patient immediately to an oral and maxillofacial surgery department for primary closure.
- Provide post-operative instructions to avoid nose-blowing and allow healing by secondary intention. (Correct answer)
- Surgically close the defect with a buccal advancement flap and prescribe antibiotics.
- Pack the socket with antiseptic gauze and review the patient in one week.
Correct answer: Provide post-operative instructions to avoid nose-blowing and allow healing by secondary intention.
For a small oro-antral communication (generally considered <5mm) with an intact sinus membrane in a healthy patient, the blood clot is often sufficient to seal the defect and allow for spontaneous healing. The most critical immediate step is to provide clear post-operative instructions to protect the clot, such as avoiding nose-blowing, sneezing with the mouth open, and using straws. Surgical closure with a flap is typically reserved for larger defects (>5mm) or if conservative management fails.
Question 4: A 72-year-old patient has been taking oral alendronic acid for osteoporosis for seven years. They require extraction of a mandibular molar. According to SDCEP guidance on Medication-related Osteonecrosis of the Jaw (MRONJ), which factor places this patient in the 'higher risk' category?
- The extraction is in the mandible.
- The patient's age is over 70.
- The duration of bisphosphonate use is greater than 5 years. (Correct answer)
- The patient has a diagnosis of osteoporosis.
Correct answer: The duration of bisphosphonate use is greater than 5 years.
The SDCEP guidance categorises patients based on their risk of developing MRONJ. For patients taking oral bisphosphonates for osteoporosis, the duration of therapy is a key risk factor. Use for over 5 years elevates the patient to the 'higher risk' category. Other factors for higher risk include concurrent systemic steroid use or a history of cancer. While mandibular extractions and age are general risk factors, the duration of therapy is the specific criterion listed that defines the higher risk category in the guidance.
Question 5: When raising a full-thickness mucoperiosteal flap for the surgical removal of an impacted mandibular third molar, which technical principle is most crucial for preventing iatrogenic injury to the lingual nerve?
- Placing the initial incision deep in the lingual sulcus to be away from the surgical field.
- Using a broad, flat retractor to actively pull the lingual tissues away from the mandible.
- Making a large distal relieving incision that extends towards the buccal aspect.
- Keeping the periosteal elevator in constant, firm contact with the lingual plate of bone during elevation. (Correct answer)
Correct answer: Keeping the periosteal elevator in constant, firm contact with the lingual plate of bone during elevation.
The lingual nerve has a variable course but often lies in very close proximity to the lingual cortical plate, sometimes within the periosteum. The safest technique is to keep the elevator firmly on the bone surface, elevating the entire mucoperiosteum (including the nerve) as a single, intact unit. This protects the nerve from being torn or crushed. Placing retractors blindly or making incisions directly into the lingual soft tissues significantly increases the risk of direct nerve trauma.
Question 6: A patient presents three days after an extraction complaining of severe, radiating pain and a foul taste. The socket appears empty with exposed bone. Which of the following represents the most appropriate initial management for alveolar osteitis (dry socket)?
- Vigorously curette the socket to stimulate bleeding and prescribe a course of amoxicillin.
- Gently irrigate the socket with warm saline and place an obtundent dressing. (Correct answer)
- Take a radiograph to rule out a retained root and then suture the socket closed.
- Prescribe a strong opioid analgesic and advise hourly hot salt water mouthwashes.
Correct answer: Gently irrigate the socket with warm saline and place an obtundent dressing.
The management of alveolar osteitis is primarily palliative, aimed at relieving pain and promoting a clean environment for healing. The standard of care is to gently irrigate the socket with an agent like warm saline or chlorhexidine to remove debris, followed by the placement of an obtundent dressing (e.g., Alvogyl) to soothe the exposed bone. Aggressive curettage is contraindicated as it can cause further trauma and delay healing. Systemic antibiotics are not indicated unless there are signs of systemic infection.
MFDS Part 1 - Membership of Faculty of Dental Surgery Oral Surgery and Exodontia Questions and Answers
A 68-year-old patient taking apixaban for atrial fibrillation requires a routine extraction of a single molar tooth.
According to the Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance, what is the most appropriate management plan?