’You are shown a clinical image of the tongue rolled with lingual varices present and the pt is worried that this is cancerous. They have not been to the GDP since precovid - the pt mentions they have a family history of oral cancer.
Explain the most likely diagnosis.
sublingual varices -
- nothing to worry about as this is normal anatomy.
- commonly happens when we get older (veins weaken)
- small swollen veins under the tongue.
(sublingual varices case)
The pt asks how to notice if the lesion or any lesion is suspicious.
something that has been there for over 3 weeks.
- ulcers or a swelling that has been there for 3 weeks.
- persistent unexplained lump in the neck.
- dysphagia (difficulty SWALLOWING) for 3 weeks.
- hoarseness of voice for 6 weeks.
- any red and white patch that can’t be explained (erythroplakia / erythroleukoplakia).
- unexplained tooth mobility.
(sublingual varices case)
How would you manage this patient? - advice + action.
reassure but consider their strong FH of cancers.
- advise they continue to attend for regular checkups (this lets us check inside and outside, especially in areas common for cancer).
- eat healthily.
- space out alcohol consumption (not exceeding 14 units)
- no smoking
The mother is worried about the ‘missing’ front tooth of her child. You are given an upper standard occlusal and it shows that the ULA is retained and there is a supernumerary above which blocks the eruption of the UL1. The contralateral UR1 has erupted and the patient is 10 years old. The mother mentions that her child is being teased at school but is not having any pain.
Explain the issue to the mother.
- the x ray shows an extra tooth (we call it supernumerary) which is blocking the adult tooth from coming down.
- the normal age for eruption of these teeth is 7-8 years old.
- because of this, there is a retained front baby tooth (ULA).
(supernumerary central case)
Mum asks what would happen if you do nothing about it.
to do nothing -
- has the potential to cause harm to teeth either side.
- may be forced into the roots of teeth either side, causing resorption of those roots (root shrinks back).
- tissue around the unerupted permanent teeth may form a cyst which may destroy the bone around it and displace the tooth more.
(supernumerary case)
How would you manage this patient?
- refer to a specialist - would remove the tooth, cut a small flap window and take out the extra tooth impacting eruption and attach a gold chain to help guide the tooth down.
They will have a chat and take a look to come up with a plan, - keep attending regular checkups here - so we can ensure brushing is up to scratch for when and monitor the eruption of other teeth.
You are shown 2 images (anterior teeth and occlusal photograph) and an OPG with discolouration of their incisors and molars. The child is 7, having pain from the molars but none from the anteriors. They were born prematurely and their mum is worried (also class II div).
Explain the likely diagnosis.
Molar Incisor Hypomineralisation -
- common condition affecting front incisor teeth and first adult molars.
- means that the enamel didn’t form properly during development
- usually due to a disturbance in the process - the cause isn’t fully understood but can be linked to traumatic / premature birth or any childhood illness, particularly where they were prescribed antibiotics.
- means the enamel is more porous, sensitive and vulnerable to damage, hence they are experiencing pain.
IT IS NOT YOUR FAULT - something you cannot control.
(MIH case)
Explain how you manage this as a GDP.
main focus is on prevention -
- fluoride varnish (high conc fluoride paste, like toothpaste but stronger) to help strengthen the remaining enamel.
- fissure seal the back teeth in the grooves where bacteria collects to prevent further breakdown and decay.
I WOULD LIKE TO REFER to a specialist for the molars -
- because of the extent of the hypomineralisation on these back teeth, it is likely they won’t be able to last their entire lifespan.
- options: extract, stainless steel crown, white filling but depends.
- it is likely that due to the poor prognosis they will need to be extracted but the opinion of an orthodontist as well as the paeds specialist will be needed.
- this is to try and optimise closure of the space to get the second adult molars to close the gap.
- they will then be able to discuss options for the appearance of the front teeth.
(the specialist will go through this will you following the initial chat)
(MIH case)
How would you manage the aesthetics of the front teeth?
Refer for a specialists opinion -
- microabrasion (removes a thin outer layer of enamel)
- white composite filling
- resin infiltration (fill the enamel pores to change the way light hits it).
- veneers (when older)
- whitening (when older)
Images given with erosion and attrition, BPEs of 1s and 2s. RMH has heart burn but on no medications. No active caries and no treatment to be done today. They drink lots of sugar free fizzy drinks and eat citrus fruits. Mentioned her husband says she ‘grinds’ at night but isn’t aware of it.
Explain the potential diagnoses and cause for this.
- attrition - from grinding at night.
- erosion - from heartburn (potential acid reflux) and a highly acidic diet.
(toothwear case)
Explain how you would monitor this.
- clinical photographs
- study models
- putty index (if teeth no longer fit then toothwear has progressed)
- Basic Erosive Wear Index - scores the sextent of toothwear.
(toothwear case)
How would you manage this case?
(alongside the monitoring - focus on preventing it from getting worse)
- fluoride varnish to strengthen remaining enamel
- diet diary + advice - helps analyse and change current diet.
- keep acid attacks to meal times, only water or milk in between and only 4 a day.
- drink through a straw
- better to have fruits whole instead of blended as this releases all the sugars so more acidic.
- make sure not to swirl / hold in mouth.
- dairy products after acid attacks help neutralise and increase salivary flow. - soft splint to wear at night for grinding.
- refer to GP for heartburn.
- toothbrushing advice - brush 2 mins twice a day, wait 30 mins before brushing after eating or eating after brushing.
- high fluoride toothpaste
- PMPR + OHI to remove calculus and prevent plaque build up.
Radiograph of URHS where the upper 7 has caries into the pulp and is causing pain. Bone levels good, UR8 is impacted into the 7.
Explain the radiograph to the pt and how to manage.
radiograph -
- this is the tooth causing pain, this is the wisdom tooth.
- 7 has decay which is into the nerve of the tooth so unrestorable
- 8 coming in at an angle so is impacted against the 7.
- bone levels are good, no other areas of concern.
mx -
- will need to refer for the extraction of the 8 as is likely to be a difficult xla.
- in the meantime can extirpate to get out of pain (clean out the nerve and place medicine into the tooth).
- pt would be left with a gap after xla.
(impacted 8 case)
Pt asks if this was a straightforward extraction and if there are other options to manage in the meantime.
- looks like it would be a difficult extraction due to the decay in the 7, root morphology and sometimes if doing routinely, can cause fracture of a bit of bone at the top of the jaw. (consider sinus proximity too)
- would involve a cut in the gum to make a window, take away a little bit of bone to then remove both teeth more safely.
- stitches then placed which should then fall out by themselves.
(impacted 8 case)
Pt then asks how long the referral will be.
- would have to look at when the next available appt would be / how long the waiting list would be before giving a definitive answer.
- EXTIRPATE IN THE MEANTIME TO GET YOU OUT OF PAIN.
(impacted 8 case)
Pt asks what type of painkiller they should be taking.
what you would normally take for a headache -
ibuprofen (if no RMH) or paracetamol.
Pt presents with their upper broken complete acrylic denture. Dropped it on kitchen tile whilst cleaning it (missing piece of the central and lateral incisor). This denture has been repaired multiple times. The patient is exempt from paying for NHS treatment.
Can this denture be repaired? Explain the mx to pt who really wants it to be repaired.
- denture is missing pieces which means we would not be able to repair.
- could try to get the lab to repair in the meantime whilst new dentures being made (BUT MIGHT NOT BE EFFECTIVE).
- has reduced weakness when it has been repaired each time.
(meanwhile should clean over sink of water to prevent dropping again)
(broken denture case)
Pt would like to know the stages involved in the process and how long it would roughly take.
5 steps, usually 1-2 week turnaround depending on practice.
(may take longer if steps need to be repeated)
- first imps (use a standard tray to make one that is more adapted to the mouth)
- second imps (special tray used to take a more accurate imp so the base will be better fitted to the mouth)
- jaw reg (wax blocks used for the correct height and record the way you bite together)
- wax try in (teeth are set in wax and tried in to check happy with the appearance and fit)
- finish (dentures finished in acrylic)
(broken denture case)
Pt says they are exempt but wants to know how much treatment would cost.
Explain that despite being exempt, they will still have to pay £98 for the replacement of the denture.
- usually would have to pay £326 for denture to be remade as well.
- these are the current regulations for when an appliance is lost or broken.
- can be claimed back if proved that the cost has caused you financial hardship or shown that you previously looked after the denture with care.
UR1 has been avulsed at 16 years old. Place a trauma splint using instruments on bracket table (gauze, different lengths of splint, probe and wards carver).
(use ribbon wax as compsite)
- select wire that extends 1 tooth either side (UL1, UR1, UR2)
- 6 balls of ribbon wax
- place first 3 balls
- add splint
- cover with next 3 balls
- check sharp edges are covered
(splint case)
When would you review the patient next?
In 2 weeks to REMOVE SPLINT and INITIATE RCT
(RCT should be carried out within 2 weeks in CLOSED APICES)
(trauma case)
What treatment would you undertake at this next review?
- removal of splint
- extirpate and dress with CaOH
- refer to paeds specialist urgently
3 images of the patient are shown. The pt is unable to raise their eyebrows, smile or close eyes on the entire LHS.
What is the provisional diagnosis?
Bell’s Palsy -
there is no indication of any LA involvement.
(facial paralysis case)
What are 3 other differential diagnoses?
- stroke
- ramsay hunt syndrome (facial paralysis caused by varicella zoster in the facial nerve)
- lyme disease (bacterial infection from ticks)
- melkersson rosenthal syndrome (neurological disorder; recurring facial paralysis, swelling of face or lips, fissured tongue).
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management of ectopic canines6
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management of impeded maxillary incisors5
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extraction of first permanent molars6
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dental anomalies and treatment options36
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DBOH prevention15
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anaesthetic options14
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PR & safeguarding6
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diet advice8
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implants7
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perio13
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denture design45
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toothwear management2
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management of edentulous spaces7
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denture faults17
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fixed pros faults9
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avulsed tooth management12
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endo scenarios - (apexification needed)7
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oral surgery24
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oral diag31
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ortho15
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general25
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practice questions53
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gill barker’s contribution37
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examine dental29
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SDCEP prescribing54
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radiology1
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preqcribing quiz9
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BDS5 OSCE50
