MJDF Part 1 - Membership of Joint Dental Faculties Oral Surgery and Exodontia Questions and Answers — Questions and Answers
Question 1: A 68-year-old patient taking apixaban 5mg twice daily for atrial fibrillation requires a routine extraction of a single mobile maxillary premolar. The procedure is expected to be straightforward. According to the Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance, what is the most appropriate management of their anticoagulant therapy?
- Advise the patient to stop taking apixaban for 3 days prior to the extraction.
- Liaise with the patient's GMP to arrange bridging therapy with low molecular weight heparin.
- Check the patient's INR on the day of the procedure and proceed if it is below 4.0.
- Proceed with the extraction without altering the apixaban regimen, using local haemostatic measures. (Correct answer)
Correct answer: Proceed with the extraction without altering the apixaban regimen, using local haemostatic measures.
The SDCEP guidance 'Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs' states that for patients on a Direct Oral Anticoagulant (DOAC) like apixaban undergoing a procedure with a low risk of bleeding complications (such as a routine single extraction), treatment should proceed without interrupting their anticoagulant medication. Enhanced local haemostatic measures, such as packing and suturing, should be employed. Stopping the medication or using bridging therapy is not recommended for low-risk procedures and increases thromboembolic risk. INR monitoring is only relevant for patients taking Vitamin K antagonists like warfarin.
Question 2: A 24-year-old patient presents with severe, localised pain and a foul taste two days after the surgical extraction of their lower right third molar (LR8). On examination, the socket appears empty with exposed bone, and a blood clot is absent. Which of the following is considered the most significant patient-related risk factor for developing this condition?
- Male gender
- Age over 50 years
- Use of an oral contraceptive pill (Correct answer)
- History of pre-operative anxiety
Correct answer: Use of an oral contraceptive pill
The clinical presentation is classic for alveolar osteitis (dry socket). While multiple factors contribute, hormonal changes associated with the oral contraceptive pill are a significant risk factor. Oestrogens are thought to increase fibrinolysis, leading to premature breakdown of the blood clot. Third molar extractions, particularly in the mandible, have a higher incidence of dry socket compared to routine extractions.
Question 3: During the surgical extraction of a multi-rooted lower first molar, the mesial root is removed, but the distal root fractures and remains in the socket. Which instrument is specifically designed to be applied into the empty socket, using the inter-radicular bone as a fulcrum, to elevate the remaining fractured root?
- Coupland's elevator
- Warwick James elevator
- Cryer's elevator (Correct answer)
- Hospital pattern forceps
Correct answer: Cryer's elevator
A Cryer's elevator has a triangular, sharp working end which is ideal for this specific clinical situation. It is inserted into the empty socket (where the mesial root was) and rotated, engaging the mesial aspect of the remaining distal root and using the inter-radicular bone as a fulcrum to elevate the fragment. Coupland's and Warwick James elevators are straight elevators used for luxation, while forceps are used for grasping the tooth or root once mobilised.
Question 4: During the extraction of an upper left second premolar (UL5), a 2mm apical root fragment fractures and remains in the socket. A periapical radiograph confirms the fragment is small, not in close proximity to the maxillary sinus, and there is no evidence of pre-existing infection. What is the most appropriate definitive management?
- Immediately refer the patient to an oral surgeon for removal under sedation.
- Inform the patient, document the event, and leave the fragment in situ for monitoring. (Correct answer)
- Attempt surgical removal by raising a flap and removing bone for at least 30 minutes.
- Prescribe a 5-day course of amoxicillin and review the patient in one week.
Correct answer: Inform the patient, document the event, and leave the fragment in situ for monitoring.
For a small (typically <3mm), non-infected root fragment that is not close to vital structures like the maxillary sinus or inferior dental nerve, the risks of surgical removal often outweigh the benefits. The accepted management is to inform the patient fully, document the discussion and decision in the clinical notes, and leave the fragment to be monitored. Surgical intervention carries risks of bone removal and potential damage to adjacent structures. Antibiotics are not indicated as there is no sign of infection.
Question 5: A 22-year-old patient presents with acute, localised pain and swelling associated with a partially erupted lower left third molar (LL8). There is pus exuding from beneath the operculum on gentle pressure. The patient is systemically well, with no fever, facial cellulitis, or significant trismus (<2 finger breadths opening). According to the Faculty of General Dental Practice (UK) 'Antimicrobial Prescribing in Dentistry' guidelines, what is the most appropriate initial management?
- Prescribe a 5-day course of metronidazole 400mg.
- Perform local debridement and irrigation of the pericoronal space. (Correct answer)
- Advise hot salt water mouthbaths and arrange for extraction in one week.
- Prescribe a 5-day course of amoxicillin 500mg.
Correct answer: Perform local debridement and irrigation of the pericoronal space.
The guidelines for managing pericoronitis state that antibiotics should only be prescribed as an adjunct to local measures if there is evidence of systemic spread or severe infection (e.g., fever, cellulitis, significant trismus, lymphadenopathy). In cases of localised infection without systemic signs, the first-line and definitive treatment is to establish drainage and debride the area, typically by irrigating under the operculum with an antiseptic solution like chlorhexidine or saline.
Question 6: Following the extraction of a maxillary first molar, the 'nose-blowing' test is positive, and a visible defect of approximately 4mm is noted in the socket floor. Which of the following represents the most appropriate immediate management for this oroantral communication (OAC)?
- Pack the socket with haemostatic gauze and provide standard post-operative instructions.
- Advise nasal decongestants and antibiotics and review the patient in 24 hours.
- Attempt primary surgical closure of the defect, typically with a buccal advancement flap. (Correct answer)
- Take an occlusal radiograph to determine the exact size of the communication.
Correct answer: Attempt primary surgical closure of the defect, typically with a buccal advancement flap.
An oroantral communication (OAC) of 2-5mm or greater, especially if diagnosed at the time of extraction, requires immediate surgical closure to prevent the formation of a persistent oroantral fistula and subsequent sinusitis. The most common technique is to raise a buccal advancement flap and suture it over the socket to achieve a tension-free, watertight primary closure. Simply packing the socket or relying on medication alone is insufficient for a defect of this size and risks failure. A radiograph is not the priority over immediate treatment.
MJDF Part 1 - Membership of Joint Dental Faculties Oral Surgery and Exodontia Questions and Answers
A 68-year-old patient taking apixaban 5mg twice daily for atrial fibrillation requires a routine extraction of a single mobile maxillary premolar.
The procedure is expected to be straightforward.
According to the Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance, what is the most appropriate management of their anticoagulant therapy?