MJDF Oral Medicine and Surgery — Questions and Answers
Question 1: A 60-year-old male smoker presents with a non-healing white patch on the ventral surface of the tongue that cannot be rubbed off. Biopsy shows moderate epithelial dysplasia. What is the most appropriate management?
- Reassure and review in 12 months
- Complete surgical excision with clear margins, smoking cessation counselling, and regular long-term follow-up with clinical and histological surveillance (Correct answer)
- Prescribe topical antifungal treatment
- Apply topical corticosteroid and review in 6 weeks
Correct answer: Complete surgical excision with clear margins, smoking cessation counselling, and regular long-term follow-up with clinical and histological surveillance
A leukoplakia with moderate dysplasia on a high-risk site (ventral tongue) in a patient with a major risk factor (smoking) requires surgical excision to obtain clear margins. The malignant transformation rate for dysplastic leukoplakia is approximately 5-18% over 5 years, with higher rates for moderate/severe dysplasia, ventral tongue/floor of mouth location, and continued tobacco use. Post-excision management includes smoking cessation, regular clinical review (initially 3-monthly), and repeat biopsy of any recurrence. Leukoplakia can recur at the same or different site.
Question 2: What is the difference between an odontogenic keratocyst and an orthokeratinised odontogenic cyst, and why is the distinction clinically important?
- They are the same entity with different names
- The odontogenic keratocyst (OKC) has a parakeratinised lining with a high recurrence rate (25-60%) and association with Gorlin syndrome; the orthokeratinised variant has a lower recurrence rate (<5%) and no Gorlin association, making conservative treatment more predictable (Correct answer)
- The orthokeratinised variant is more aggressive and requires radical surgery
- Neither has any clinical significance
Correct answer: The odontogenic keratocyst (OKC) has a parakeratinised lining with a high recurrence rate (25-60%) and association with Gorlin syndrome; the orthokeratinised variant has a lower recurrence rate (<5%) and no Gorlin association, making conservative treatment more predictable
The distinction is crucial for prognosis and management. The OKC (parakeratinised type) has a thin, uniform parakeratinised epithelium with a corrugated surface, palisaded basal layer, tendency for satellite cysts and daughter cysts in the wall, high recurrence rate (25-60%), and association with Gorlin-Goltz syndrome (PTCH1 mutation). The orthokeratinised odontogenic cyst has an orthokeratinised lining with a prominent granular layer, recurrence rate below 5%, and no Gorlin association. Treatment of OKC may require peripheral ostectomy or Carnoy's solution application to reduce recurrence.
Question 3: A patient presents 48 hours after extraction of a lower premolar with increasing pain, swelling, trismus, and a temperature of 38.5°C. There is fluctuant swelling in the buccal sulcus. What is the diagnosis and management?
- Dry socket — irrigate and place Alvogyl
- Post-extraction abscess with subperiosteal collection — incision and drainage under local anaesthesia, copious irrigation, antibiotics (amoxicillin plus metronidazole), and review within 24-48 hours (Correct answer)
- Normal post-operative swelling — reassure and prescribe ibuprofen
- Osteomyelitis — refer for IV antibiotics and sequestrectomy
Correct answer: Post-extraction abscess with subperiosteal collection — incision and drainage under local anaesthesia, copious irrigation, antibiotics (amoxicillin plus metronidazole), and review within 24-48 hours
The triad of increasing pain, fluctuant swelling, and pyrexia at 48 hours post-extraction indicates a localised post-extraction abscess. The fluctuance suggests pus collection requiring surgical drainage. Management: local anaesthesia, incision through the most fluctuant point, blunt dissection to break down loculations, copious irrigation with saline, consider placing a drain, prescribe antibiotics (amoxicillin 500mg TDS plus metronidazole 400mg TDS for 5 days), analgesics, and review within 24-48 hours. If trismus is severe or there is any sign of spreading infection, hospital referral is warranted.
Question 4: What are the clinical features and management of oral candidiasis in a patient using a corticosteroid inhaler for asthma?
- Oral candidiasis does not occur with inhaled corticosteroids
- Pseudomembranous candidiasis (white patches that can be wiped off leaving erythematous mucosa) or erythematous candidiasis on the palate/dorsal tongue; managed by advising spacer use, rinsing mouth after inhaler use, and prescribing topical miconazole oral gel or nystatin suspension (Correct answer)
- It presents as black hairy tongue and requires no treatment
- It always requires systemic fluconazole and discontinuation of the inhaler
Correct answer: Pseudomembranous candidiasis (white patches that can be wiped off leaving erythematous mucosa) or erythematous candidiasis on the palate/dorsal tongue; managed by advising spacer use, rinsing mouth after inhaler use, and prescribing topical miconazole oral gel or nystatin suspension
Inhaled corticosteroids deposit on the oropharyngeal mucosa, causing local immunosuppression that predisposes to oral candidiasis. It typically presents as pseudomembranous candidiasis (removable white plaques) or erythematous candidiasis (red patches on the palate or tongue). Prevention: use a large-volume spacer device (reduces oropharyngeal deposition by 80%), rinse the mouth with water after each inhaler use, and practice good denture hygiene. Treatment: miconazole oral gel 20mg/mL (2.5 mL QDS for 7-14 days) applied after rinsing, or nystatin suspension 100,000 units/mL. Systemic fluconazole is reserved for refractory cases.
Question 5: What is the recommended protocol for managing an avulsed permanent incisor in a 10-year-old child who presents within 30 minutes of the injury with the tooth stored in milk?
- Discard the tooth and plan for future prosthetic replacement
- Replant the tooth immediately: rinse gently with saline (do not scrub the root surface), replant into the socket, apply a flexible splint for 2 weeks, prescribe antibiotics and tetanus check, begin root canal treatment 7-10 days post-replantation (Correct answer)
- Store the tooth indefinitely and replant when the child is older
- Place the tooth in the socket but do not splint it
Correct answer: Replant the tooth immediately: rinse gently with saline (do not scrub the root surface), replant into the socket, apply a flexible splint for 2 weeks, prescribe antibiotics and tetanus check, begin root canal treatment 7-10 days post-replantation
According to the International Association of Dental Traumatology (IADT) guidelines, for an avulsed permanent tooth with a closed apex, replanted within 60 minutes with the tooth stored in appropriate medium (milk, saline, Hank's balanced salt solution): gently rinse the root surface with saline (do not scrub or remove attached PDL cells), replant into the socket, apply a flexible (passive) splint for 2 weeks (using orthodontic wire and composite), prescribe systemic antibiotics (doxycycline 100mg or amoxicillin if under 12), verify tetanus immunisation, and initiate root canal treatment 7-10 days post-replantation (before splint removal) to prevent inflammatory resorption.
Question 6: A patient with Sjögren's syndrome presents with xerostomia and multiple cervical caries. What is the underlying pathology and how should the dental management be tailored?
- The condition only affects the eyes and has no oral implications
- Sjögren's syndrome involves autoimmune destruction of salivary (and lacrimal) glands, reducing salivary flow; dental management includes frequent fluoride application (5000 ppm toothpaste, fluoride varnish), saliva substitutes/stimulants, sugar-free diet counselling, and regular short-interval recall appointments (Correct answer)
- Treatment is limited to prescribing pilocarpine only
- No dental modifications are needed — treat caries as normal
Correct answer: Sjögren's syndrome involves autoimmune destruction of salivary (and lacrimal) glands, reducing salivary flow; dental management includes frequent fluoride application (5000 ppm toothpaste, fluoride varnish), saliva substitutes/stimulants, sugar-free diet counselling, and regular short-interval recall appointments
Sjögren's syndrome is an autoimmune condition where lymphocytic infiltration destroys salivary and lacrimal glands, causing xerostomia and keratoconjunctivitis sicca. Reduced saliva eliminates its protective buffering, antimicrobial, and remineralising functions, leading to rampant cervical and incisal caries. Dental management: prescribe 5000 ppm fluoride toothpaste, apply fluoride varnish quarterly, recommend saliva substitutes (containing fluoride and calcium) and stimulants (sugar-free gum, pilocarpine if severe), counsel on sugar avoidance, use GIC restorations for fluoride release, and schedule 3-monthly recalls. Monitor for oral candidiasis and parotid gland swelling.
MJDF Oral Medicine and Surgery
A 60-year-old male smoker presents with a non-healing white patch on the ventral surface of the tongue that cannot be rubbed off.
Biopsy shows moderate epithelial dysplasia.
What is the most appropriate management?