ACTOR OSCE'S

1.Bleeding after extraction – patient on warfarin

Use patient’s name, communicate empathically, and avoid jargon

 Good morning Mr Jones, I’m _______, one of the dentists here today. How can I help you?
 Mr Jones I understand you are worried and concerned and I will do my best to help you. I would like to
know few details of the problem. Is that ok?

Take history of presenting complaint

 When was the tooth removed? When did the bleeding start?
 Was the extraction difficult or did it take a long time?
 Were there any stitches given?
 Did you do anything to stop the bleeding?
 Did you follow the instructions given by your dentist for the care of the wound?
 Is it bleeding a lot? Did it stop for some time or has it been continuous?

Take brief medical history

 Do you have any health problems?
 Are you taking any drugs or medication, prescribed or over the counter?
 How long have you been taking this medication (Warfarin or ibuprofen) and what is it for?
 Do you have any warning cards or a yellow booklet? Can I have a look at it?
 Was any blood tests done on the day that the tooth was removed? Was your INR checked before
extraction? Do you know the value? Does your INR fluctuate?
 Do you have any other diseases such as high blood pressure or liver or any bleeding problems?
 Did you take any pain killers after the tooth was removed? (Ibuprofen)

Diagnose, briefly explain problem and aetiology

 Mr Jones, the medicine that you are taking (Warfarin) is given to make your blood thin so that it can flow
smoothly in your body, but this may also cause wounds to bleed for longer. We check this increased
bleeding by a measure called the INR which is updated on your yellow warning card regularly. In your
case, the value was safe enough, but there may still be more bleeding compared to a normal person.
 Another reason why the bleeding is prolonged is because you were taking Ibuprofen along with this
Warfarin, which is known to increase the effect of Warfarin.
 You also failed to follow the post-extraction instructions and smoked and rinsed your mouth which
resulted in loss of the blood clot or may have delayed its formation.

Explain treatment plan to stop the bleeding

 Don’t worry, we will take care of this and the bleeding will stop. Most of the blood you see might be a little
blood mixed with a lot of saliva, so maybe the actual loss of blood might be much less than what it
appears to be.
 First I’ll check your mouth,clean it and identify where exactly the blood is coming from. I’ll then apply
some pressure with my fingers to bring the walls of the wound closer and place some stitches on top of
it then ask you to bite on a gauze pack for half an hour. The bleeding should then stop
 Once the bleeding stops, we’ll wait for an hour until you are safe to go home and I’ll explain to you how
you need to take care of the wound.
 If the bleeding still doesn’t stop after an hour, I’ll give you some medication and I might also have to refer
you to the hospital. I may also need to consult your doctor.
 Do you have any questions? Thank you Mr Jones

2.Post-extraction instructions

Use patient’s name, communicate empathically, and avoid jargon

 Good morning Mr James, I am ________, your dentist today, I’ve been told that your tooth has been
removed or has to be removed (according to the question) and I’m here to explain to you how to take care
of this wound. Is that alright?

Explain post-extraction precautions

 After the tooth is removed, we will place a piece of gauze on top of the wound and you’ll have to bite on it
for half an hour to stop the bleeding.

 If the bleeding continues after you have left the surgery, please don’t panic, because most of the liquid is
saliva which might be mixed with a little bit of blood. If you feel that the bleeding is more, fold a clean
handkerchief and place it over the wound and bite firmly and keep it pressed for 15 -30 minutes. If the
bleeding still continues please call to the surgery or the local emergency service or come back to the
surgery immediately.

 The wound is quite fragile and it gets disturbed easily in which case it might bleed again and takes longer
to heal. So, avoid touching it with your tongue or finger, avoid eating on this side for few days and do
not spit or rinse your mouth for the rest of the day.

 Brush your teeth gently for a week, it might be uncomfortable to brush around the wound, so don’t brush
that area for a day.

 Avoid strenuous exercises, hot fluids, alcohol, hard or chewy foods for rest of the day. So you may
have to eat soft and cold food such as mashed potatoes or scrambled eggs for rest of the day. Ice cream
is also allowed.

 If you are a smoker, avoid smoking for at least 24 hours as smoking delays the wound healing.

 Avoid heavy exercise or work for at least one or two days.

 The wound might be sore and slightly painful for a few days which is normal, so I’ll prescribe you some
pain killers like Paracetamol which you can take 2 tablets every 4 hours as required. If the pain is
severe, contact to the surgery. You might also have some swelling and some difficulty in opening the
mouth and it takes a few days to reduce. You may initially have some discomfort while eating but all these
problems should go away in a week.
 The area around your tooth/lips, cheek and tongue may be numb for about 2 hours after tooth removal, so
take the pain killers within 2 hours, and please be careful not to bite your lip or tongue while it is numb.

 If the pain increases or gets worse after a few days, please come to the surgery.

 After 24 hours, gently rinse the wound with warm salty water for about 15-20 seconds three times daily
after food for a few days. This helps healing and keeps the area clean.

 We will also give all these instructions in writing.

 Do you have any questions? Thank you.

3. Recurrent aphthous ulcers

Use patient’s name, communicate empathically, and avoid jargon

 Good morning Mrs Jones, I’m ________, one of the dentists here today. How can I help you?
 I understand your concern about these ulcers; I know they are usually very painful. May I have few more
details about this problem?

Take a full history of events leading up to this appointment

 Since when do you have these ulcers?
 Is it the first time you are having this or had similar problem before? How often does it happen?
 When was the last time you had this problem?
 Where exactly are these ulcers?
 Is it a single ulcer or many ulcers together? and how big are they?
 How long do the ulcers usually last?
 Has the frequency increased or decreased?
 How does the affected area look like? (red)
 Do you have any pain or bleeding from these ulcers?
 Have you noticed something in particular which brings on the ulcers or causes them to increase such as
eating some foods or taking specific medication or when you are stressed or menstruation?

Take pain history

 onset, character, intensity, site, duration, radiation, aggravating and relieving factors)
 Have you been to the doctor or taken any medicines for this problem? If yes, did the doctor ask for any
tests e.g. blood tests?

Take a brief medical history

 Are you taking any medicines for any other problem? Do you suspect of pregnancy or are you taking any
contraceptive pills? Have you recently changed pills to different brand or different pills?
 Do you suffer from anaemia? Any recent blood loss or any problems with your menstrual cycle?
 Do you have any major health concerns, allergies, tummy upset or any skin problems?
 Is anyone in your family having a similar problem?
 Do you smoke? If not, have you recently quit smoking? (Praise for quitting smoking – It is important for your health).
 Have you been stressed due to any reason lately?

Management
 Based on what we discussed, the problem you are having is likely to be common mouth ulcer which we
call (recurrent) Aphthous Stomatitis.
 It affects about 25% of the population sometime in their lives.
 It is more common in females.
 There is often a familial tendency
 There are some predisposing factors :
-hypersensitivity to food stuffs ( benzoate preservatives E210- E219)
-cessation of smoking
-psychological factors(stress)
-injury to mucosa ( accidental bittng of tongue or cheeks)
-alterations in blood factors ( decreased iron, B12 and folic acid)

 Treatment is based on identifying the predisposing factor and treating them , followed by symptomatic
relief.
 Blood tests are done to exclude deficiencies , specially if you have gastrointestinal problems, heavy
menstrual flow or are a vegan.
 Avoid foodstuff containing benzoate preservatives, and sharp foods, acidic fruits and drinsk and
chocolates.
 Drink plenty of water ,and consider using wide bore straw if discomfort is present.
 The ulcer should heal itself in a few days , but to relieve the discomfort , you can use:
 Mouthwashes: chlorhexidine ( to prevent 2ndary infection)

Benzydamine ( to decrease discomfort )

Topical steroids :hydrocortisone ( 2.5mg mucoadhesive buccal tablets)

 I may also need to refer you to your GP for a blood test as these ulcers can be due to some blood
deficiency. In your case it is probably due to (explain the reason)…or refer to GP for stress management.
 If patient coming with ulcers more than 3 weeks then say that I may refer you to a specialist called oral
and maxillofacial surgeon who may do some special tests by taking a sample of these and examining
under microscope, which is called biopsy.
 I would like to see you after two weeks to check on their healing and we will take it from there.i fthey have
not healed or worsened, I may need to refevr you to a specialist who will do more tests.

 Do you have any questions? Thank you.

4.Denture cleaning advice

Please give denture cleaning advice for an upper immediate denture and a lower chrome-cobalt denture:

1 Use appropriate greeting: hello, my name is ….., I am your dentist today and I am here today to give
you some instructions regarding your dentures
2 Explain to the patient that the immediate is a temporary measure for aesthetic purposes and a
permanent denture/bridge/implant will be given after healing: as you know , you have just some teeth
removed a place has been given to you to replace the missing teeth so you do not have to go home
without teeth, this plate is a plastic plate and it also serves as a bandage for your socket to prevent
more bleeding and promote quicker healing .
3 The denture may alter your speech at first but you will soon get used to it.
4 Please Do not take the denture out today as it serves as a bandage to stop bleeding and keeping the
blood cloth from being dislodged

5 You can take it out after 24hrs and rinse your mouth with warm salt rinses four times a day to keep the
extraction area clean and prevent infections, and also promote healing.

6 Some discomfort is usually present after extraction and when immediate dentures are placed:
-you can take a painkiller to ease the pain
- When you come back after 24hrs, we will assess the pressure spots on the denture and fix
them , this will help will the discomfort, but make sure you have worn the denture for 24hrs prior to
your appointment so we can assess the sore area and adjust the plate accordingly.

7 Healing from the extraction will continue for months, during which the bone socket will remodel and
change shape, therefore; your denture may feel loose after some time, in that case, the denture will
either need to be fixed ( relined) , or a new denture made for better comfort.

8 After every meal, please remove both your upper and lower dentures and rinse them under running
cold water, over a bowl of water to avoid them breaking should they fall, and brush your remaining
natural teeth with a brush and paste.

9 After the 1st 24hrs, you may remove your upper denture along the lower one and place them in a bowl
of water overnight, or they will dry out and change shape.
Your soft tissues (gums and palate) need to breathe and thus it is important to remove your dentures
at night.

10 Avoid:

 Using any bleaching products or acidic products to clean your metal dentures
 Using very hot water as it may damage them
 Using regular toothpaste to clean your dentures as it may damage them ( abrasive)
11 For your ACRYLIC upper denture ( plastic denture) , you can soak it in an alkaline HYPOCHLORITE
solution for 20 mins ( dentural )

12 For your lower METAL denture, you may soak it in an alkaline PEROXIDE solution for 15 mins
(stearadent )

13 Rinse dentures well after soaking

14 Check patient understands everything; see if he/she has any questions and offer a leaflet with
instructions,
If props available, please use them to demonstrate
 5. PAIN HISTORY

1.hello, my name is ---------------- , I am your dentist , how can I help you?

2. chief complaint : listen carefully to the patient so you do not have to repeat some questions regarding
information he has already given you

3. history of pain:

-site( ask patient to point out area): where is it located?can you please point out for me?

-onset:when did it start? Is it the first time? When was the first episode?

-character: can you describe the pain to me ? ( let the patient describe the nature of the pain, if he doesn’t
know, ask if it is sharp or dull ? continuous or intermittent? )

-radiation: does it radiated anywhere else on your face ?neck?head? arms?

-alleviating factors: Is there anything that helps with the pain? Painkillers?ice packs?

-temperature: do you have a fever?

-exacerbating factors: what initiates the pain or makes it worse?

-swelling: do you have any swelling in that area?

-past treatment done: have you had any treatment done on that tooth before?

-duration: how long does the pain last? How many days has it been present for?

-periodicity: how often does it reccur?

-severity : on a scale of 1 to 10, how would you grade the pain?

-effect on sleep: does it wake you up at night?

-associated factors: anything else that is associated with the pain?

6. MEDICAL HISTORY:

Hello /good morning , my name is …., I am your dentist today , I would like to ask you a few
questions regarding your medical history if that is ok ? ( always take consent before asking
medical history)

Are you generally fit and healthy?

B) Are you registered with gp?
C) Are you undergoing any treatment with your doctor/hospital/ clinic?
D) Have you visited your gp in the last 5 years for anything other than a common cold or flu?
E) I will now mention a few medical conditions , if you or any members of your family are suffering form it,
please do let me know:
Have you ever had;
1. Anaemia, asthma, arthritis
2. Bleeding tendency (following tooth extraction)
3. Chest problem (difficulty in breathing) or heart disease
4. Diabetes or depression
5. Epilepsy
6. Fits, faint
7. Gastric problem (indigestion)
8. Hormonal replacement therapy
9. Infections like herpes, hepatitis, hiv
10. Jaundice
11. Kidney problem
12. Liver problem
13. If it’s a woman of child bearing age: are you likely to be pregnant?

14. Is there anything else I should be knowing apart from this?

15. Do you carry any warning card?

DRUG HISTORY:
1. Are you taking any drugs or medications whether prescribed by the doctor or not? E.g pills, ointment,
inhalers, contraception, creams)
2. (if your not sure, ask patient why are you using this drug and what is it for?)

ALLERGY HISTORY:
1. Are you allergic to any drug or food or materials or anything in general that I should be knowing about?
2. Are you allergic to penicillin?

SURGICAL HISTORY:
1. Have you been hospitalised in the last 10 years, and if yes,what was it for?
2. Have you been refused blood donation services?

7. DIET ADVICE
Diet Sheet of a 9 year old boy

8am - Breakfast of cereal with added sugar and orange juice

11am - Jam Biscuits
12 noon - Lunch of fish and chips with tomato ketchup
3pm - Bar of chocolate
4pm - Cake with apple Juice
5pm - Bag of Toffee
7pm - Dinner of sausage roll and Baked Beans on toast
8pm - Ice cream
8.15pm - Bed

changes on the diet:

Good morning, my name is ……., I am your son’s dentist and today I am here to give you some
advice regarding changes he needs to make in his diet in order to decrease the amount of cavities
he has and preventing other teeth from being spoilt.

1. Reduce the frequency and amount of sugar

2. Reduce sugar intake to mealtimes.
3. Avoid in between meal snacking. Replace sugary snakc with healthy snacks such as
nuts , cheese, fruits, in a moderate amount.

4. Avoid certain foods with hidden sugar content eg. Cereal, tomato ketchup, baked beans
5. Avoid sticky foods like toffees, chocolates, cakes, jam, biscuits as they stick to the teeth
for a longer time
6. Can take safe snacks like cheese, peanuts

7. Carbonated drinks contain large amounts of sugar. Try substituting it with water or milk,
which is a good source of calcium.
8. Limit consumption of foods and drinks with added sugars to four times a day
9. No suger should be consumed for upto 1 hour before going to bed as salivary flow is
reduced.
10. Sugars (excluding those present in natural fruit) should provide less than 10% of total
energy in the diet or 60g per person. For children this is 33g.
11. Ensure Medications are sugar free
12. Check foods for Happy Tooth and Tooth friendly logos
13. Balanced Diet
a. Eat 5 fruits and vegetables per day
b. Eat 2 portions of fish a week

c. Cut on saturated fats, present in burgers, sausages, butter, etc

d. Eat less salt
e. Drink 6-8 glasses of water everyday
Name a Study in humans that shows the relationship between sugar and caries
(evidence for the mother )

Vipeholm study: study conducted in Sweden in mentally retarded hospital. This showed reduction
in caries when sugar was limited to mealtimes and sugar given in stick form inbetween meals
increased caries incidence significantly.
Turku sugar study: when xylitol is substituted for sucrose this reduced the caries incidence
Write down 4 forms of carbohydrates that are harmful
sucrose, glucose, fructose, Maltose.
Safer alternatives: artificial sweeteners- xylitol, saccharin, acesulfame, aspartame, isomalt,
lactitol, maltitol, mannitol, Thaumatin
 8.ORAL SUBMUCOUS FIBROSIS

Hello , my name is …., I am your dentist today , how can I help you?

Patient will complain of limited mouth opening and burning sensation in the mouth .

Take history of complaint:

-since when?

-has it increased over time?

-any treatment done for it ?

-any sore areas in the mouth? Can he locate them?

-any white patch?

-any swelling?

-ask about habits : alcohol , tobacco chewing , betel quid chewing.

Explain:

According to the history that you have given me Mr smith , I suspect that you have a
condition called oral submucous fibrosis.

Basically , it is the thickening of the tissues on the inside of your cheeks which s caused by
the chemicals released due to chewing tobacco .

It is a slow process and happens over a long period of time , other factors which may
worsen the condition are smoking , intake of alcohol and consuming spicy food as they irritate your
cheeks even more .

Unfortunately , this condition is irreversible and the damage that has been done cannot be
undone .

However , we can stop the process to limit disability ;for that , you will have to stop chewing
tobacco as it is the main culprit. You may also have to cut down on alcohol and spicy foods.

I must warn you of the ill effects if you do not stop; the thickening of your cheek muscles will
continue and spread to your throat and neck and make mouth opening , eating , oral hygiene very
difficult for you , and you suffer from asthma, It may make breathing difficult for you too.

I would like to refer you to a specialist so he can confirm the diagnosis by doing a biopsy ,
which involves cutting a small bit of tissue and examining it under a special microscope .

I will also give you some exercises to help with the mouth opening and increase flexibility.

I would like you to keep a meticulous hygiene and think about quiting tobacco; should you
need any help , we are always here to help you in any way we can .
 Do you have any questions?

Thank you

9. Lichen planus

Question : explain to the patient what lichen planus is and how you plan to manage it ?

What is lichen planus:

 it is a white patch , called lichen planus and is commonly seen.

 Some people have it on their skin, some in their mouth and others on their skin and mouth
 It can last for several years
 We do not know the exact cause but some people get similar lesions in their mouth called lichenoid
reaction ,
 Predisposing factors are : -drugs( antimalarials, antidiabetic, nsaids, anti hypertensives,gold salts)
- Dental restorative materials ( amalgam and gold )
-Graft v/s host disease
-Hepatitis C and chronic liver disease
 This condition is not infectious.

Management:

 We will have to do a biopsy, which involves taking a small sample of tissue from the patch and
analyse it under the microscope: it will give us a definitive diagnosis and remove other possible
causes of the patch.
 A blood test wil also be helpful to exclude other causes
 Any amalgam restoration adjacent to the white patch will also be replaced with a plastic filling
material (composite or GIC ) to help with the diagnosis.
 If you are taking any drugs that are likely to cause a white patch , we will take advise from your GP
and see if we can replace the drug.
 You will also need regular monitoring to make sure the patch is not increasing in size.
 Sometimes, a patch may be present on the gingiva , this may make brushing painful
 Avoid eating spicy or salty food as it may cause discomfort .
 Treatment is aimed at alleviating the symptoms and may involve :
-Benzydamine hydrochloride to numb the sore area
-Topical steroids via mouthwash or spray (bethamethasone, beclomethasone, fluticasone )
 If these do not provide relief, specialist care may be needed for more complex treatment
 10. Dry socket - pain after extraction

Explain condition, causes and management. The patient keeps saying she is in pain and asking when the
pain was going to wear off.

Use patient’s name, communicate empathically, and avoid jargon

 Good morning Mrs Jones, I’m ________, one of the dentists here today.
May I know how can I help you today?
 It is unfortunate that you have this problem. I assure that I can do something about it. Before that, I would
like to know few details. Is that alright?

Take history of presenting complaint

 Where do you feel the pain?

 Which tooth was removed?
 Was there any difficulty in removing the tooth?
 When the tooth was removed and when did this pain start?
 Did you follow all the instructions given after the removal of the tooth such as not to rinse vigorously and
not to smoke for a week?
 How strong is the pain? Can you describe this pain to me? (Throbbing and aching)
 Is the pain continuous or does it keep coming and going? (Constant pain)
 Is there anything which increases or reduces the pain?
 Does the pain spread anywhere else?
 Has the pain been increasing?
 Have you also noticed bad breath or bad taste?
 Does it disturb your sleep? (Cannot sleep)
 Have you tried any pain killers? (No good) Or any other treatments?
 Have you had a tooth removed before, if yes, did you have a similar problem?

Take brief medical history

 Are you taking any medications for any other problems or have any major health concerns like diabetes,
allergies, etc.
 Are you taking any contraceptive pills?
 Do you smoke? When did you smoke after the tooth was removed?
Diagnosis and basic explanation of disease and aetiology - dry socket (alveolar osteitis)
 From what we have discussed, it seems that you have a problem after removal of teeth which we call dry
socket. It happens in about 3-20 % of all extractions. It is more common in lower teeth, women,
smokers and in difficult extractions or if any previous history.
 Normally when a tooth is removed, blood fills up in the empty space and then forms a solid mass, the
blood clot, on which the healing takes place.
 If due to any reason such as smoking, taking the pill or injury to this area, this mass breaks or gets
removed, the healing slows down and the bone below it is exposed to the open. This bone is very
sensitive which causes the pain and then food gets lodged and some bugs build up in this area and you
start getting bad breath as well.
 This condition is very painful but it does not have any serious consequences, the area will heal slowly but
it takes more time.
 What I can do today is, numb this area with an injection and clean and wash it with an antiseptic
containing Chlorhexidine.
 I will then place a dressing called Alvogyl paste in this space which will relieve the pain. This dressing
gets dissolved by itself. I’ll also give you pain killers to ease the pain at home.i would like to see you after
24 hrs and then :
 We’ll repeat this every other day until the pain is completely relieved, hopefully in 2 or 3 sittings. After
that you can take care of it at home by rinsing with a mouthwash or warm salt water rinses. I would also
advise you to avoid smoking for a few days.
 Do you have any questions? Thank you

11. Removal of upper molar and Oroantral communication

Question: please explain to this fit and healthy patient what removal of a grossly carious upper right
second molar under local anesthetic involves and the possible complications of extraction.

Procedure:

 The area will be numbed with local anesthetic; you may feel a sharp scratch during injection.
 You will not feel any pain but you may feel pressure and a sensation of pushing.
 The tooth may come out in one piece; however it may break as it is grossly decayed.
 A surgery may have to be done in case it does not come out with the forceps; it involves making a
small cut in the gum and removing a small amount of bone with a drill and the tooth may be needed
to be cut in piece prior to removal to facilitate it.
 This will be followed by placing a few stiches,
 Should a surgery be needed, post-operative instructions will be explained and given in writing.

Complications: use xray if available or draw tooth with maxillary sinus

 The maxillary sinus is visible in the radiograph and close to the roots of the tooth and therefore
there is a possibility of creating a communication between the mouth and the sinus.
 If the hole is very small, it may heal on its own without stitches.
 However a larger hole will need to be closed otherwise food and drink will enter the sinus and come
out of the patient’s nose.
  Closure can be carried out as soon as the tooth is removed by stitching the gum across the hole or
we can also mobilise the gum from under the cheek to cover the hole.
 You will then have to avoid blowing your nose for 2 weeks
 We may also prescribe antibiotics, nasal inhalations and nose drops post-op.
 There will be swelling and pain after the surgery and you may not be able to open your mouth fully.
 You wil have to take some time off to recover
 Do you have any questions?
 Thank you

12. impacted UL3 and retained & discoloured (ULC)

OPG and upper occlusal were given. Patient is concerned about what will happen? Will it erupt if left alone? What
will bring it down? If so how? What are the options if milk tooth is extracted?

Use patient’s name, communicate empathically, and avoid jargon

 Good morning Mr Smith, my name is _____, I’m one of the dentists here today. How can I help you?
 I can understand that this is a front tooth and you are concerned about your appearance. I’ll need to ask
you some questions to understand the problem a bit better. Is it all right?
History of presenting complaint (pain history) and a brief medical and social history
 When did you notice that this tooth is discoloured?
 Is this (milk) tooth loose?
 Have you had any pain around this tooth?
 Have you consulted any other dentist for this problem?
Explain the retention of the deciduous tooth and impaction of permanent . Estimate relative position
from X-rays provided
Show X-ray to patient for better explanation
 Mr Smith, as you can see on this X-ray, this discoloured tooth is a milk tooth which did not fall out and it
has prevented your permanent tooth from coming out into its normal position and now the permanent
tooth is stuck inside the bone.
 About 2% of all people have such a problem and most often this happens with an upper canine tooth on
one side like in your case.
 This tooth is fully formed and cannot move from its position on its own so it will not come out if left alone.

Explain treatment options

However, there are some options available to you on how we can solve this problem:
 The first option is to DO NOTHING and observe both teeth at regular interval. The advantage is that it is a
relatively simple . However, the gap may remain and the milk tooth may become loose, in which case it
will need to extracted and you will need a replacement.
 We will have to keep an eye on this area for problems like damage to the root of the nearby tooth or
maybe swelling. If one of these happens, we’ll have to remove the underlying tooth with a surgery.
 In case the milk tooth has some problems we cannot resolve, we could remove the milk tooth and take
support from a nearby tooth for attaching an artificial tooth which replaces the missing one. There are
various types of bridges and I can explain them to you in more detail later. In general, bridges provide a
good aesthetics and are fixed. However, drilling a healthy tooth may be needed which present a risk of
this tooth having some complications and needing further treatment in the future like a root canal or other
types of crown.

Explain the advantages to refer you to an orthodontist

 Another option is to refer you to a specialist (orthodontist) who could assess this problem in more detail.
Initially, he may need to take some more X-rays from different angles to locate the exact position of this
tooth. He will then suggest some more treatment options to you such as:
 Remove the milk tooth and expose the underlying tooth with a surgery for it to be slowly pulled with
braces placed inside your mouth. This works best if the tooth is not greatly displaced and you must
keep your mouth very clean when you are wearing braces to avoid decay.
 The specialist might also decide to remove the tooth below, especially when it is causing some
problems, and we might keep the milk tooth, modify it or remove it and replace it with a bridge.
 Sometimes, the specialist might even take out the tooth below and plant it in the place of the milk tooth,
this is a very complex treatment and I don’t have much knowledge on it.
 Thank you.
 Do you have any questions?
 13. Discoloured upper right central incisor

Patient has a history of trauma during sports. He Had an RCT and tooth has been filled with amalgam as a
post-obturation filling. Give a treatment plan.

Use patient’s name, communicate empathically, and avoid jargon

 Good morning Mr Smith, I’m _______, one of the dentists here today. How can I help you?
 I understand that you are here today to discuss options to treat your discoloured tooth. Is that right? I
understand that you’re worried about your appearance and can explain to you about possible treatment
options.
Take the past history of the complaint if asked to do so

o Since when has this tooth been discoloured?

o When was the silver filling done and why?
o What was treatment done before the filling?
o Have you had any pain in this tooth after the treatment?
 If the tooth is dark because of blood pigments or root treatment, explain the reason for discolouration like
this:
o This discolouration can be due to those dead tissues or blood break down products that passed to the
next layer of tooth called dentine and are showing through. It can also be due to the discoloration of the
filling material used.
Explain treatment options with advantages, disadvantages and risks
 As your tooth may look dark because of tis silver filling, we will first remove the old filling. If you are happy
with the appearance, we can give a white or tooth coloured filling called composite. Advantage is that it
will improve the appearance and is cost effective compared to other options. Disadvantage is that it can
discolour later. There is also a risk that the material shrinks or breaks.

 If you are not happy, we can try a tooth whitening treatment (or bleaching) in which we apply some
chemicals (bleaching agents) on the tooth to whiten it. We can either apply them in the surgery in a few
appointments, or we can fill up the space for the filling with these chemicals and seal it. This will be done
once a week on 2-3 appointments. We call this walking bleach and when the tooth becomes whiter, we
can give a white filling. Advantage is the improvement of aesthetics and there is no tooth preparation
involved. However, there are chances of the tooth becoming darker again later and is a disadvantage.
These chemicals are caustic, so we’ll have to be very careful in applying. There is a risk of destruction of
roots of the tooth because of the chemicals used.
(There is also a chance of sensitivity in the teeth- say this if the tooth is not RCT treated)

 If the appearance is still not satisfactory, another option is to go for something called veneers, which is
like a facing, cemented on your tooth. For doing this, we’ll first remove the front part of the tooth in a
specific shape and paste a thin shell made of porcelain or composite. The advantage is excellent
aesthetics. Disadvantage is that it requires minor tooth shaping and includes a risk of chipping off in few
cases.

 If the tooth has a large filling and does not have much strength to support a veneer, we can cut the tooth a
little more all around and give you a cap or crown which covers the entire surface of the tooth. The
advantages are: it will give strength to the remaining tooth and excellent aesthetics. But a lot of tooth
removal is involved when shaping it and it is quite expensive. As it is root treated, the tooth would be
brittle and there is a chance of tooth breakage during the tooth preparation.
 So, Mr Smith, these are your options and now it’s your choice. Before we proceed to any treatment, I may
have to take an x-ray to assess the quality of the root filling.
 Do you have any questions? Thank you .

14. DRUNK DENTAL NURSE

Scenario – You are working as a associate Dental surgeon, today your appointment diary is full and
you are going to start with your first appointment which is Root canal treatment. You smell alcohol
on the breath of your nurse who is going to assist in the treatment. What would you do?

1) Take the nurse away from the pt and ask if she has been drinking

Can you please come to the other room as I want to talk to you in private? I think you have been drinking
as I can smell alcohol from your breath. Can you please tell me is it right and what the reason is?

2) Explain the nurse about the seriousness of the matter

I want to tell you it is a very serious matter as you cannot work under the influence of alcohol, especially in
our profession as a health care provider. We have to maintain the dignity of our profession and the also the
nature of our work requires us to be in our complete senses

3) Explain the nurse that being drunk at work is against the contract

As you might know there is a clause in our employment contract that tells us about alcohol. The cause
clearly mentions that we cannot report to work under the influence of alcohol nor we can consume it during
work hours. By being drunk on work you have broken the terms of your contract of employment

4) Remind the nurse about health and safety law at work

I also want to remind you that your behaviour is against the health and safety law. This law is for your
safety as well as patient safety. If you are drunk you might not be very careful with instruments and might
injure yourself or might also accidentally prick on used needles. From pt point of view his safety is also
compromised because you are not performing your job properly

5) Warn the nurse that she is putting her registration at risk

The most important thing is your registration is at risk as the GDC has clear rules regarding working under
the influence of alcohol. The GDC in these cases usually go to the professional standards committee who
has the authority to either suspend you temporarily or permanently

6) Explain the nurse what you will be doing now

I know we are all human beings and mistakes can happen with anyone. It’s nothing personal but it’s my
duty to inform the practice manager about this incident. I am sorry if because of my complain you are going
to face any problems, I am just doing my job.

7) Inform the nurse that she can’t assist you

I am sorry I need to start the treatment with a different nurse which I think is the right thing to do under
these circumstances
 15. Avulsed tooth – phone call

Introduce yourself, communicate empathically, and avoid jargon

Good morning, ______ speaking, the dentist for today. How may I help you?
I’m sorry to hear that. How is your son now?

Take a full history of events and a brief medical history

 Before that I would like to ask a few questions to be able to guide you properly ok?
 How old is your child?
 Is there any other injury? Is he bleeding? When did it happen?
 Was there any loss of consciousness, nausea or vomiting?
 Does he have any medical problems such as heart or bleeding problems or allergies?
 Is he under any medications?
 Is he up to date with his tetanus immunisation?

 Where is the tooth now?

 Is it intact or broken? If broken, have you got the pieces? Is there any chance your child may have swollen
it?
 Is it on your hands or stored in a medium? If not, would you be able to put it in a glass of milk?

Explain how best to proceed

 As the tooth is not broken, the best thing to do now is to place the tooth back into the socket where it was
originally. The sooner this is done the better is the outcome for the tooth.
 If you are happy to do this and your son accepts it, I can give you all the instructions and guidance over
the phone.
 If you are not sure you can do it, is there anyone around you who can help?

Guidance

 Hold the tooth by the white shinny part that normally shows in the mouth, not the root which is the
elongated part of the tooth.
 If the tooth is dirty, quickly rinse it with milk or tap water.
 Do not wipe it off or use soap and don’t let it dry out.
 If the child’s mouth is dirty, please ask them to rinse their mouth with water and spit it out.
 Holding the tooth by the crown, with the smooth convex surface facing you, replace the tooth in the socket
where it came from.
 Ask the child to gently bite on a piece of gauze or clean handkerchief to seat the tooth correctly to the
level of the adjacent teeth.
 Are you able to do it? If yes say. Good!

 Now, come to the practice to see me as soon as possible so I can continue the treatment.
 Here I will assess the wound, immobilise the tooth and maybe take an x-ray.

 If patient is reluctant to do it and prefers to come to see you advise to put the tooth in milk and come to
the dental surgery as soon as possible.

 Thank you, see you soon, bye.

 16. Chronic advanced periodontitis & need for extraction of all teeth

Use patient’s name, communicate empathically, and avoid jargon

 Good morning Mr Jones, my name is _______, one of the dentists here today. How may I help you?

Take history of presenting complaint and a brief medical and social history
 When did you first notice it?
 Is the mobility increasing?
 Did you consult your dentist?
 Is there anyone else in your family with a similar problem?
 Do you suffer from any major disease like diabetes or blood disorders?
 Do you smoke? How many cigarettes a day? For how long?
 Have you ever smoked or are trying to quit at the minute?
 Are you under a lot of stress in your life at the moment?

Explain causes and risk factors –patient smokes

 After seeing your reports, I’ve noticed that your gums and bone around your teeth are coming down
and slowly losing the grip on your teeth and the teeth have become loose. It seems like you have a
long standing gum disease which has progressed slowly over many years. We call it chronic
periodontitis.
 There can be many factors that contribute this to happen such as: genetic factors, smoking, stress,
diabetes and poor oral hygiene.
 These factors increase the speed of the destruction of bone support of your teeth. There will also be
attachment loss between your gums and teeth. This can lead to some pockets to form and bacteria can
trap in those and cause more bone loss. Smokers have more bugs that cause this problem and it also
reduces the ability of the mouth to protect the gums from attack of these bugs. So stopping smoking is
very important. In diabetes, the ability of the body to respond to the attack of these bugs is also
reduced.

Explain treatment
 Unfortunately, in your case, as you can see in this X-ray, the disease has progressed to a level where
your remaining teeth cannot be saved.
 This is really sad and it might come as a shock to you that we will have to remove those teeth because if
we don’t do that, the bone might be lost even more and we might not even have enough bone to support a
denture properly. These teeth will be lost anyway, but at least we’ll be able to save the bone. You can
take your time to think.
 We’ll numb the teeth and initially remove some of the most badly affected ones. We will give you
dentures immediately after the extraction, so you are not left without teeth. We can add new artificial
teeth to this denture as we remove more teeth.
 These dentures will be temporary and will need regular adjustments on many appointments. We can
give you a permanent set of dentures later on, after complete healing takes place.
 Do you have any questions?
 Thank you.
17.Chronic advanced periodontitis & need for extraction of some teeth

Use patient’s name, communicate empathically, and avoid jargon

 Good morning Mr Jones, my name is _______, one of the dentists here today. How may I help you?

Take history of presenting complaint and a brief medical and social history
 When did you first notice it? Did you consult your dentist for it?
 Is the mobility increasing?
 Is there anyone else in your family with a similar problem?
 Do you suffer from any major disease like diabetes or blood disorders?
 Do you smoke? How many cigarettes a day? For how long?
 Have you ever smoked or are trying to quit at the minute?
 Are you under a lot of stress in your life at the moment?

Explain causes and risk factors –patient smokes

 After seeing your reports, I’ve noticed that your gums and bone around your teeth are coming down
and slowly losing the grip on your teeth and the teeth have become loose. It seems like you have a
long standing gum disease which has progressed slowly over many years and it is more
pronounced in the back teeth. We call it chronic periodontitis.
 There can be many factors that contribute this to happen such as: genetic factors, smoking, stress,
diabetes and poor oral hygiene.
 These factors increase the speed of the destruction of bone support of your teeth. There will also be
attachment loss between your gums and teeth. This can lead to some pockets to form and bacteria can
trap in those and cause more bone loss. The plaque formed in smokers has more bugs causing this
problem and it also reduces the ability of the mouth to protect the gums from attack of these bugs. So
stopping smoking is very important. In diabetes, the ability of the body to respond to the attack of
these bugs is also reduced.

Explain short term and long term treatment

 Unfortunately, in your case, as you can see in this X-ray, the disease has progressed to a level where
some of your remaining teeth cannot be saved.
 This condition is affecting some teeth more than others and if we remove the ones that are most affected,
we can then focus on saving the ones that still have some good bone support. If we don’t do that, the
bone might be lost even more, to a level that there may not be enough bone to support a partial denture,
used to replace the teeth you will lose.
 For you to be able to keep your remaining teeth for as long as possible, you’ll need to make some
changes to the way you look after them. It is important to use a soft toothbrush and to change it every
other month. Electric toothbrushes are also very good. You’ll also need to clean in between your teeth
either with dental floss or with interdental brushes or picks.
 In the process of recovering, your gums might come down a bit and this may cause your teeth to get a
little sensitive. This is normal and if it happens, please let us know so we can apply a protective coating on
them. We might also prescribe you some mouth rinses for a few days.
 The remaining teeth will be very important for you, as you can continue to use them for chewing. They
may also be helpful to stabilise future plastic or metal dentures or even support bridges.
 You will need regular professional cleaning of your teeth so we can clean the plaque below the gum level
and also remove the hard tartar that accumulate on your teeth.
 Initially, I would like you to come to see us every 3 months until we are able to control your condition. If we
see that you are recovering well, the condition is stable and you are able to keep the area clean, we may
suggest you to come every 6 months instead. However, if we see that it is actually getting worse, even
after all our efforts; we may refer you to a specialist who is more able to deal with more complex cases.
 Do you have any questions?
 Thank you.

Chronic periodontitis

Candidate instructions
Mr Chohan is a 40 year-old smoker who presents with recurrent soreness of his gums and occasional pain
on biting from several teeth which has become worse over the last few years. His radiographs are
displayed below along with BPE scores.

BPE: 434/234*

Please explain the radiographic and BPE findings to the patient and explain the nature and treatment of
periodontal disease. Discuss with the patient the long-term indications of his disease and possible further
treatment needs.

18.Pericoronitis and Consent for extraction of a lower 3rd molar

Use patient’s name, communicate empathically, and avoid jargon

 Good Morning Mrs Jones, I’m _______, one of the dentists here today and I would like to talk you through
the removal of the lower tooth which has been troubling you. I can understand that you are a little worried
but I can assure you we’ll be very gentle with the whole procedure.

Explain reason for surgery

 As you know, this tooth hasn’t come out straight. It is impacted and has caused problems like pain and
swelling a few times. According to official guidelines from the National Institute of Clinical Excellence
(NICE), when this problem happens more than once then the tooth is best removed to avoid further
complications as they tend to become worse and more frequent.

Explain surgical method

 First, we will numb the tooth by giving a small injection, you may feel a sharp scratch. You will then feel
tingling on one side of your tongue and lower lip and then the area and the tooth will go numb.
 We’ll then remove the tooth with a minor surgery which involves a cut in the gum and removing a bit of
bone around the tooth to pull it out. You will not feel any pain but you may feel some pushing and
pressure and there will be some bleeding.
 We will then close the wound with stitches which will be removed after a week. We will also place a gauze
pack inside your mouth to stop bleeding on which you will have to bite on for half an hour. If there is
bleeding after that, please call us immediately.

Post- surgical instructions

 After the procedure, the area will be sore and swollen for a few days but we will give you some pain
killers. You might also have some difficulty opening the mouth for a few days, and you might have to take
a few days off work. You have to be careful not to bite on your numb lip and avoid disturbing the wound
coz it will be quiet fragile.

Possible complications
 As the roots of this tooth are close to an important nerve called the Inferior Dental Nerve, there is a small
chance of an injury to the nerve and you might get numbness or tingling on that side which usually lasts a
few days. The probability of this to happen is (temporarily ): 10-20% but there is also a very small chance
(PERMANENT: of less than 1%) of it being permanent.
 There is also a chance of injury to a nerve of your tongue called Lingual Nerve, which can cause some
alteration in taste with 2% temporary and 0.5% to be permanent.
 We will be very careful; however, as we have to work on a small space, there is also a possibility of
adjacent teeth to be damaged during the surgery.
 As I said, we will give you pain killers for a few days to reduce the pain you might feel after the surgery
and, if there is any chance of further infection, then we might prescribe you antibiotics.
 We’ll give you all this information and all the aftercare instructions of your wound in writing.
 Do you have any questions?
 If you’ve understood me, may I have your permission to go ahead with the treatment?
 Thank you.

If you are anxious about this procedure, please don’t worry because there are methods to reduce your
anxiety and I can explain them to you in more detail later.
 19. FISSURE SEALANTS

A fit and healthy boy with high caries rate attends your clinic with his mother.

She has heard about sealants and wishes to discuss the possible benefits and the procedure for
placing fissure sealants on her son’s teeth.

1. Hello, my name is______________, I will be your dentist for the day.

2. Ask about patient’s concerns

3. Explain what sealants are:

 Fissure sealants are a plastic material that we place on the biting surface of molar teeth as
soon as they erupt to reduce the incidence of decay.
 What it does is, it blocks off all the small depressions which are hard to clean and where
food can easily get stuck and makes it easier to clean in that area.
 Statistics say that it can prevent cavities by at least 70% and 60% of surfaces treated remain
covered after 5 to 6 years.
 However, the chances of the sealant being lost are higher soon after they have been placed,
therefore they need to be checked after placement.
 Some sealants also release fluoride making these teeth more strong and resist decay
(demineralisation)
 the best time is to place the sealant as soon as the tooth erupts in the cavity and a rubber
dam can be placed as occlusal surfaces are more prone to cavities than smooth surfaces.

4.But placing sealant does not guarantee a caries free mouth , you also have to follow good oral hygiene,
take fluoride supplements if you live in a non-fluoridated area and visit your dentist regularly for fluoride
applications and regular checks .

5. In order to have caries free mouth, it is also important to eat healthy and cut down on sugary foods and
drinks.
 20. fluoride therapy
Prevention of caries in children aged 0–6 years

Advice to be given Professional intervention

Children • Breast feeding provides the best nutrition for babies

aged up • From six months of age infants should be introduced
to 3 to drinking from a cup, and from age one year feeding
years from a bottle should be discouraged
• Sugar should not be added to weaning foods
• Parents should brush or supervise toothbrushing
• Use only a smear of toothpaste containing no less
than 1,000 ppm fluoride
• As soon as teeth erupt in the mouth brush them twice
daily
• The frequency and amount of sugary food and drinks
should be reduced and, when consumed, limited to
mealtimes. Sugars should not be consumed more than
four times per day
• Sugar-free medicines should be recommended

All • Brush last thing at night and on one other occasion • Apply fluoride varnish to teeth twice
children • Brushing should be supervised by an adult yearly (2.2% F–)
aged • Use a pea-sized amount of toothpaste containing
3–6 years 1,350–1,500 ppm fluoride
• Spit out after brushing and do not rinse
• The frequency and amount of sugary food and drinks
should be reduced and, when consumed, limited to
mealtimes. Sugars should not be consumed more than
four times per day
• Sugar-free medicines should be recommended

Children All advice as above, plus: • Apply fluoride varnish to teeth 3–4 times
giving • Use a smear or pea-sized amount of toothpaste yearly (2.2% F–)
concern containing • Prescribe fluoride supplement and advise
(eg those 1,350–1,500 ppm fluoride re maximising benefit
likely to • Ensure medication is sugar free • Reduce recall interval
develop • Give dietary supplements containing sugar and • Investigate diet and assist to adopt good
caries, glucose polymers at mealtimes when possible (unless dietary practice
those clinically directed otherwise) and not last thing at night. • Ensure medication is sugar free or given
with Parents should be made aware of the cariogenicity of to minimise cariogenic effect
special supplements and ways of minimising risk
needs)
Prevention of caries in children aged from 7 years and young adults

Advice Professional intervention

All children • Brush twice daily • Apply fluoride varnish to teeth

and young • Brush last thing at night and on one other occasion twice yearly
adults • Use fluoridated toothpaste (1,350 ppm fluoride or (2.2% F–)
above)
• Spit out after brushing and do not rinse
• The frequency and amount of sugary food and drinks
should be reduced and, when consumed, limited to
mealtimes.
Sugars should not be consumed more than four times
per day

Those giving All the above, plus: • Fissure seal permanent molars with
concern • Use a fluoride mouth rinse daily (0.05% NaF) at a resin sealant
(eg those likely different time to brushing • Apply fluoride varnish to teeth 3–4
to develop times
caries, those yearly (2.2% F–)
undergoing • For those 8+ years with active caries
orthodontic prescribe daily fluoride rinse
treatment, • For those 10+ years with active
those with caries
special needs) prescribe 2,800 ppm toothpaste
• For those 16+ years with active
disease consider prescription of 5,000
ppm toothpaste
• Investigate diet and assist adoption
of good
dietary practice

Prevention of caries in adults

Advice Professional intervention
All adult • Brush twice daily with fluoridated toothpaste
patients • Use fluoridated toothpaste with at least 1,350
ppm fluoride
• Brush last thing at night and on one other
occasion
• Spit out after brushing and do not rinse
• The frequency and amount of sugary food and
drinks should be reduced and, when consumed,
limited to mealtimes.
Sugars should not be consumed more than four
times per day
Those giving All the above, plus: • Apply fluoride varnish to teeth twice yearly
concern to • Use a fluoride mouth rinse daily (0.05% NaF) at (2.2% F–)
their dentist a different time to brushing • For those with obvious active coronal or
(eg with root caries prescribe daily fluoride rinse
obvious • For those with obvious active coronal or
current active root
caries, dry caries prescribe 2,800 or 5,000 ppm fluoride
mouth, other toothpaste
predisposing • Investigate diet and assist adoption of good
factors, those dietary practice
with special
needs)
 21. TMJPDS

Use patient’s name, communicate empathically, and avoid jargon

 Good morning Mr Jones, my name is_____, I’m one of the dentists here today. How may I help you?
 I understand your discomfort. May I ask you a few details of this problem?

Take pain history – SOCRATES

 Site - Where exactly is the pain? Can you point it to me?

 Onset - When did it start? How often do you feel the pain?
 Characteristics - Can you describe it to me, what exactly do you feel when you have this pain, what sort
of pain is it? Is that becoming more frequent, or more painful than when it first started?
 Radiation - Does the pain spread to other parts of the body such as your throat or arm, jaw, stomach;
does it hurt somewhere else as well?
 Associated symptoms – Is there any noise or crepitus from the joints, does your jaw get stuck when
opening your mouth? Is there any swelling, fever or discomfort?
 Timing: How long does it last? When does it come usually?
 Exacerbating/Relieving factors - What brings it on, what makes it worse, what relieves it? Do you get
this pain when you are resting as well?
 Severity: on a scale of 1-10 how severe is the pain?
 Have you ever sought treatment for this problem?

Brief medical and social history

 Are you medically fit and well? Are you taking any medication, either prescribed or over the counter?
 Are you currently seeing your GP for any medical condition or treatment?
 Have you seen your doctor or dentist for this problem?
 Do you smoke or have smoked in the past and is trying to quit at the minute? What about your diet?
 Are you under any form of stress or hardship at the minute?
 Do you grind or clench your teeth?

Explanation to the patient and Management

 From the information I gathered, it is likely that you may be suffering from TMJPDS. This is a very
common condition which affects your jaw joint and muscles in one or both sides. It is usually a benign
muscular condition so it is not harmful and does not cause any long term damage. Symptoms come and
go, often worse when you are anxious.
 TMJPDS can be presented as clicks, crepitus, pain and restriction of movement, stiffness or locking of
your jaw joint, earache, difficulty opening and/or closing your mouth, headaches and difficulty swallowing.
Sometimes the muscles also can get a bit swollen and it may also trigger migraines.
 Most of the discomfort comes from overusing your muscles and joints such as clenching or grinding
your teeth. This is usually worse when you are worried, stressed or depressed as well as when grinding
your teeth at night. Habits such as chewing pencils, biting your nails, holding things in your mouth and
habitual chewing gum can all cause this problem as well.
 The fact that a white line has appeared on both sides of your cheeks and your tongue has small
indentations along the sides are signs that you grind your teeth at night.
 Grinding alone can be causing the pain and discomfort you are complaining about which may be worse
when you wake up or at night.
Management of the condition

The condition tends to come and go so it is important to keep the jaws apart and stress levels down to
prevent it from happening in the first place.
There are many simple and effective treatments for TMJPDS. During the acute phase, when pain is
present, it is advisable to follow a soft diet, do gentle jaw exercises, apply heat pads do relief the tension
in the muscles and also avoid opening the mouth really wide. If you wish, I can give you analgesics or even
muscle relaxants to relieve the pain and tension you are experiencing.
To prevent it from keep coming back and also protect your teeth, I would also like to provide you with a bite
splint that will keep your teeth apart and allow your jaw muscles to rest.
I would like you to return in 4 to 6 weeks for a review appointment. If there has been no improvement or if
the condition gets worse, I would like you to come back earlier so we can reassess the situation and
possibly refer you to a specialist, who will be able to try more complex treatments.

Patient’s complaint
I have been experiencing pain on left hand side of my face. It is centred just in front of my left ear on but
occasionally I have noticed it on the right side as well, but not as frequently.
History of presenting compliant

Question 1
Patient suffering from temporomandibular pain and dysfunction syndrome - take history, give diagnosis and
explain the condition.

22. Needle-stick injury

First aid
 Encourage the wound to bleed.
 Wash the area with water and soap, but do not scrub the wound.
 Cover it with a waterproof dressing.
 Stop the treatment.
 Seek urgent medical advice (for example from your Occupational Health Service), as effective prophylaxis
(medicines to help fight infection) are available.
 Report the injury to your employer.
 Fill in a RIDDOR sheet and submit to health and safety.
 RIDDOR - Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995)

Assessment of the patient

 If possible, another member of staff should assess the viral carrier status of the source patient, and hence
the likely risk of transmission of an infectious disease.
 Baseline bloods may be required from the source patient for storage and possible future testing. This will
have to be done by another healthcare professional to avoid conflict of interest, and only after proper
consent has been obtained from the patient.
 If the source patient is known to be HIV positive, or hepatitis C positive, immediate specialist advice must
be sought and antiretroviral drugs taken prophylactically as soon as possible.

What to do?

 If there is a worry that the source patient may be high risk for an infectious disease, then urgent advice
should be sought according to the local rules.
 Each primary care trust will have at least one designated specialist (often the consultant medical
microbiologist) who can be contacted for advice on post-exposure prophylaxis (PEP). Details of how to
contact them should be clearly displayed in the dental practice.
 Local arrangements should be in place at the practice to enable follow-up and prompt action to be carried
out.
 This may involve going to the nearest accident and emergency department, where you must have the
following checked:
 Tetanus status - If inadequate, a tetanus booster will be needed.
  Hepatitis B status - If previously immunised, antibody titres should be checked. If low, a booster
vaccine is needed; if very low, then immunoglobulin will be needed and a vaccine course should be
started. If not previously immunised (this should not be the case for healthcare workers in the UK),
hepatitis B immunoglobulin should be given and an active immunisation course started (first vaccine
in accident and emergency and arrangements made for subsequent doses).
 Counselling and follow-up should be arranged as necessary.

Follow-up

Ensure there is adequate follow-up of both care worker and donor. The care worker in particular will require
early involvement by the Occupational Health service. They may need specific advice about having to take
sick leave if medication is required and the possible requirement for psychological support.

Record the incident

Fill out accident book and complete critical event audit. How can subsequent events be prevented?
The incident should be recorded in the practice accident book. Details recorded should include:
 Who was injured?
 How has the accident occurred?
 What action was taken?
 Who was informed and when?
 Who was the source patient?

Further information

Risk of acquiring hepatitis B following a needlestick injury from a carrier has been estimated at 2-40%; the
risk of hepatitis C is believed to be 3-10%. The risk of acquiring HIV after a needlestick injury from an HIV-
positive source is 0.2-0.5% but may be higher if significant volumes have been injected.

23. Lip laceration by a colleague

1. A colleague comes to you saying he has lacerated the patient’s lip 5 minutes ago. How would you
proceed?
2. The hygienist injures her patient’s lip and has come to you for advice. How would you proceed?

Reassure and calm colleague down

 Calm down and tell me what happened?

 Ok, this was an accident, and such accidents can happen to anyone in our profession regardless of how
careful we are and it is very unfortunate it has happened with you, please don’t panic.
 Is the patient still in the surgery? Is he alone?
 How did it happen, when did it happen?
 How deep is the wound?
 Did you inform the patient?

Advise what to do

 I understand you are distressed; however, it is not right to run away from your professional duties towards
the patient, it is negligent and unethical. You should go back to the patient, apologize for this mishap and
explain that it happened by accident; explain that it could be due to poor visibility or poor access, and you
are going to take care of him.
 Check the patient’s medical history to see if he has any bleeding problems and give him the necessary
emergency treatment.
 Try to stop the bleeding by applying pressure with gauze, give sutures if needed. If any redness or
swelling apply cold pack.
 Reassure the patient
 If you cannot control the bleeding, take him to the Accident and Emergency of the hospital immediately.

Complaint procedure and recording of the incident

 If the patient is unhappy and wants to make a formal complaint, explain the complaints procedure.

 Inform your practice manager about the accident and the steps you have taken.

 Note down the details of the accident and the steps you have taken in the Accident Book/ the RIDDOR
sheet and the patient’s notes. Ask your nurse to sign it and ask the patient to countersign it. Also write the
referral note if you need to take him to the hospital.

 Call up your Dental indemnity provider (DDU or Dental protection) and take their advice on this
matter.

 At this time, the best thing to do is to treat the patient yourself because it is your legal and ethical
obligation to treat this patient. Also, if any problem comes up later, everyone will understand that it
happened by accident and you did the right thing and treated the patient.

 If you still feel you are not able to treat the patient, you’ll have to take the patient’s consent and if he
allows, only then I can intervene.

 After you have treated the laceration, arrange a follow up appointment. If sutures are placed, they may
need to be removed after one week.

 Is there anything else you want to know?

 Thank you.

RIDDOR - Reporting of Injuries, Diseases and Dangerous Occurrences Regulations

24. Broken file in root canal

Use patient’s name, communicate empathically, and avoid jargon

 Good afternoon, Mrs Black, my name is ______________ and I am covering for your dentist who is on
maternity leave. I am meant to be finishing the RCT today. Is that alright?

Break the bad news about broken file left in the root canal and show the broken file on X-ray to
patient

 I had a look at the last X-ray taken of your tooth and I am sorry to tell you that a piece of instrument
used to clean the root canals of your tooth was broken and is lodged inside your tooth. (Show the
patient the broken file on the X-ray).

 There is always a little chance of this to happen during this type of procedure. I would like to apologise
on behalf of my colleague and I will try to find out why you were not informed earlier.
 N.B: If the patient is worried about possible harmful effects such as cancer, poisoning and
infection: Reassure the patient by saying: ‘’I understand your concerns but there is really no need to
worry about cancer or poisoning as there is really no connection between the two. N i assure you that
these instruments are sterile.

 However, in case we are not able to remove the broken bit, infection and pain could be a possible
complication but there are ways of minimising this outcome.

Explain treatment

The treatment options available for you are:

 I can try to remove the broken piece of instrument by using a special small fine instrument (mosquito
forceps) that can be used to pull it out and then, I can continue the RCT as usual.

 If I am not able to remove the fragment of the instrument, i complete the root canal treatment, by
bypassing the piece of instrument and placing root filling material around it.

 I can also refer you to a specialist for the removal of the instrument .
 He can try several specialised methods of removal and if he is successful, he will complete the
treatment.
 He may also suggest doing a small surgery to clean and treat the tip of the tooth inside the bone. This
is done in case the treatment does not work.
 However, I must tell you that referral to a specialist does not guarantee the success of treatment.

 The last option is removal of the tooth itself and its replacement with an artificial tooth.

(Patient selects to have the treatment completed by dentist)

Warn patient about the possible complication

 The success rate of root canal treatment is usually 90%. However, in about 10% of cases,
complications can occur, during or after root canal treatment, which can lead to failure.

 In cases where we are leaving the instrument behind, there can be pain, swelling or infection as the
canal may not be cleaned in that area.

 Do you have any questions?

 I’ll make a note of this event and the explanation given to you in your records. Thank you Mr Black.

25. Dental treatment for a patient on bisphosphonates

Use patient’s name, communicate empathically, and avoid jargon

 Good morning Mr Jones, my name is _______, one of the dentists here today. How may I help you?
Take history of presenting complaint (pain history) and a brief medical and social history

 Are you currently taking medications, either prescribed or over the counter?
o Patient says he is on bisphosphonate. Find out what condition, for how long they have been taking
the bisphosphonates and the route of administration?
 Do you have diabetes or suffer from high blood pressure?
 Do you smoke or have recently stopped?
Give diagnosis and explain findings

 Mr Smith, Based on the information you provided,I gather that you have a tooth which was root canal
treated but is now painful. The reason for this pain is that there is some decay formed under the cap
which covers your tooth. Also, the root canal filling seems to be a bit short and has not worked. This
leakage under the cap may have allowed germs to gain entry and to travel to the root tip of the tooth and
cause an infection. This may happen in a few cases and it is difficult to predict.

Explain complications associated with bisphosphonates

 I understand you want the tooth taken out. However, as you take bisphosphonates I must warn you of
possible complications and inform you alternative options.
 Bisphosphonates reduce the breakdown and loss of bone. They are also used to fight tumours.
 However, they affect the capacity of the bone to heal and may cause death of part of the jaw bone. This
is a condition which we call osteonecrosis of the jaw (ONJ).
 The risk of developing it varies according to the strength and the length of time the drug has been
taken. If it is taken in the form of tablets (low dose) the risk is 1/100,000. However, in your case, as you
are taking it through injections (higher dose) the risk is 10 times higher 1/10,000.
 The risk is also increased in the bottom jaw when compared to the top jaw and also amongst smokers
and people with diabetes.
 Stopping the medication does not decrease the risk as it stays in the system for a very long time.
Another important point to consider is that the medical benefits of taking bisphosphonates far outweighs
risks.
 If we remove the tooth we might be unnecessarily triggering bone death and cause you trouble.
Present alternative option (reRCT), advantages and disadvantages
 However, there is an alternative treatment; I would like to suggest to take the crown off to enable me see
the root properly and if possible have the root cleaned and sealed again (re-RCT).
 The advantages are that you keep the tooth and avoid bone death. However, re-treating the tooth
decreases the success of treatment from 85 to 60%. This may take about 3 visits after which I will place
a new crown on it.
 If you still prefer the tooth to be taken out, I may have to seek an opinion from a specialist and find out
whether I can treat you here or whether I should refer you to a specialised service.
 To reduce the chance of you facing this situation again I would like you to maintain a good oral hygiene
and come here more often for regularly check-ups.
 If you experience loose teeth, pain or swelling in your mouth while using bisphosphonates (these
may be symptoms of ONJ), please tell your dentist and doctor about this as soon as possible.
 Do you have any questions? Thank you.

Oral bisphosphonates Intravenous/injected bisphosphonates

Alendronate(Fosamax, Fosavance) Ibandronate (Bondronat, Bonviva)
Sodium clodronate (Bonefos, Loron) Disodium pamidronate (Aredia)
Disodium etidronate (Didronel, Didronel PMO) Zoledronic acid (Aclasta, Zometa)
Ibandronate (Bondronat, Bonviva)
Risedronate sodium (Actonel, Actonel Once a
Week)
Disodium tiludronate (Skelid)

Question 1
Mr/Mrs Green attends your dental surgery taking Bisphosphonates and requires extraction of a lower
second molar. What further information you need to obtain from him. Please take the appropriate history,
explain him/her the concerns and complications of having a dental extraction under this circumstances.

Question 2
Leaky margins of crown on molar with RCT done but with periapical radiolucency. Patient on IV
bisphosphonates. Explain treatment options and associated risks.

Question 3
A 75 year old patient of yours (Mr/Mrs Scholes) attends for an appointment relating to his/her LR6. The
tooth was restored with an MOD direct composite restoration 5 years ago and has fractured a cusp
approximatelly 6 months ago. In the last few days the tooth has started to cause a spontaneous, long-
lasting pain which has kept the patient awake at night.

The patient also has:

 Osteoporosis for which he/she has been taking bisphosphoate (Fosamax 10mg) orally once daily since
2000. The patient has no allergies or any other relevant medical condition.
 The LR6 has a large MOD composite restoration and a fractured mesio-lingual cusp. It is not tender to
pressure and responds negatively to warm gutta percha, ethyl chloride spray and electric pulp testing.
 The patient keeps an excellent oral hygiene, has no periodontal disease and has a mildly restored
dentition.

Please provide this patient with treatment options followed with their advantages, disadvantages and also
risks.

Management of BONJ

Avoid extractions or any oral surgery or procedures which may impact on bone (i.e. dento-alveolar,
periodontal, periapical, deep root planing, complex restorations, implants) if there is an alternative
treatment option.

 An exception is to consider removal of teeth of poor prognosis if this will avoid extractions or other bone
impacting treatments later during the patient’s bisphosphonate therapy. In these circumstances, follow the
risk assessment and management recommendations below.

If any extraction or any oral surgery or procedure which may impact on bone is necessary, assess
whether the patient is at low or higher risk of BONJ as follows:

 the patient is at low risk before they have started taking bisphosphonates for any condition, or are taking
bisphosphonates for the prevention or management of osteoporosis.

 the patient is at higher risk if any of the following factors is present:

 previous diagnosis of BONJ;
 taking a bisphosphonate as part of the management of a malignant condition;
 other non-malignant systemic condition affecting bone (e.g. Paget’s disease);
 under the care of a specialist for a rare medical condition (e.g. osteogenesis imperfecta);
 concurrent use of systemic corticosteroids or other immunosuppressants;
 coagulopathy, chemotherapy or radiotherapy.

Advise the patient that there may be BONJ risk to enable informed consent, but ensure that they
understand that it is an extremely rare condition. It is very important that a patient is not discouraged from
taking medication or undergoing dental treatment. Record that this advice has been given.

Note: There is no supporting evidence that BONJ risk will be reduced if the patient temporarily, or even
permanently, stops taking bisphosphonates prior to invasive dental procedures since the drugs may persist
in the skeletal tissue for years. If a patient has taken bisphosphonates in the past but is no longer taking
them for whatever reason (i.e. completed or discontinued the course, taking a drug holiday), allocate them
to a risk group as if they are still taking them.

Management of low risk patients

When other treatment options are not feasible, perform extractions, oral surgery, or procedures that may
impact on bone as ‘atraumatically’ as possible; avoid raising flaps; achieve good haemostasis.

 Straightforward extractions and other bone impacting treatments can and should be carried out in primary
care. The circumstances for seeking advice from an oral surgery/ oral and maxillofacial surgery specialist
are the same as for a patient who is not on a bisphosphonate.

After carrying out any invasive treatment, review healing at 4 weeks.

If surgery sites fail to heal within 4 to 6 weeks, refer to an oral surgery/oral and maxillofacial surgery
specialist.

Note: There is no evidence supporting antibiotic or topical antiseptic prophylaxis in reducing the risk of
BONJ.

Management of high risk patients

Contact an oral surgery/oral and maxillofacial surgery specialist to determine whether the patient should
continue to be treated in primary care for any extraction or any oral surgery or procedure that may impact
on bone, or whether referral is appropriate.
 When seeking this advice, include full details of the patient’s medical and dental history, and preferably do
so by letter.

26. Pain and anxiety control for nervous patient undergoing extraction.

Use patient’s name, communicate empathically, and avoid jargon

 Good Morning Mr Jones, I’m ________, one of the dentists here today. I understand that you are a little
worried and anxious about the removal of your tooth so I would like to explain to you some methods we
can use to reduce your anxiety and make it more comfortable for you.

Explore why patient is requesting a general anaesthetic. Sympathise and reassure.

 Advise patient that the tooth is mobile and can be taken out under local anaesthetic safely and quickly in
the practice. Sedation and GA will require referral which may delay treatment

Explain Sedation
 To help you relax during the procedure we can give you some medication which makes you feel very
comfortable. We would still need to make the tooth numb. However, you will be much more relaxed.
This is called sedation and, in your case, can be done in two different ways:

Oral sedation
 In the first method, we can give you a sedative medication in the form of tablet about an hour before the
surgery, this is called; oral sedation. The medication takes a while to get into your system and then you’ll
feel sleepy for about 6 hours. This method is very simple; however, as people respond differently to the
drug, it is not so reliable. It is suitable for mild anxiety and restorative procedures but unlikely to be
sufficient for surgical extractions. It may be used in addition to other techniques if the patient is so anxious
that they may not even attend for the appointment.
Intravenous sedation
 An alternative to this is method is to deliver the medication straight into your blood stream through a fine
plastic tube into a vein on your arm or hand. This is called intravenous sedation and you will need to
 fast for 2 hours prior to the procedure. You’ll be awake during the procedure and will be able to talk
and follow instructions; however, you’ll tend to forget the experience.
 This method requires an especially trained dental team but is relatively simple can be administered in a
dental practice setting.
Post-operative instructions
 You have to be careful afterwards because this drowsiness might last for the whole day, so please avoid
driving, using public transport, operating machinery, drinking alcohol or signing important papers
on that day. You will also need to bring a responsible person to accompany you to the dental surgery
and to take care and stay with you on that day.
 Unfortunately, none of these methods can be used if you have a breathing problem such as asthma or
even common cold because the drugs involved tend to reduce your breathing ability.
General anaesthesia
 Another option is what we call general anaesthesia, which is done in the hospital. You will need o fast
for 6 hours before this procedure. You will be given some drugs by a specialist and you’ll be completely
asleep and will not feel anything. You will not be able to breathe on your own so a device will be attached
to your throat to help you breathe. The drowsiness after the procedure may last for a few days and you’ll
have to take a few days off work. You may also feel a little unwell and might vomit after the procedure.
 Before you can have it done, you will need to be assessed by a doctor for a full check-up in a pre-
assessment appointment.
 There are also risks associated to this procedure. As you won't be able to breathe on your own there is
an increased risk of chest infection or respiratory issues post-operatively due to history of smoking and
obesity. There may also be potential airway issues as the patient is obese as well as an increased risk
of hospital acquired infections.
 I must also mention that there is a risk of death of about 1/100,000 and this risk is increased amongst
smokers, and people suffering from diabetes, respiratory problems, and obesity. The drugs involved
are not as safe as sedation, so it is better to avoid it, unless completely necessary. The whole procedure
lasts for a few hours and you’ll probably get to leave hospital on the same day.
 Do you have any questions? Thank you

27. Dental treatment for a patient undergoing radiotherapy in 3 weeks

Use patient’s name, communicate empathically, and avoid jargon

 Good morning Mr Jones, my name is _______, one of the dentists here today. How may I help you?
Take history of presenting complaint (pain history) and a brief medical and social history
 Are you currently taking medications, either prescribed or over the counter?
o Patient says he is going to undergo radiotherapy.
 Do you have diabetes or suffer from high blood pressure?
 Do you smoke or have recently stopped?

Give diagnosis and explain findings

 Mr Smith, Based on the information you provided,I gather that you have a tooth which was root canal
treated but is now painful. The reason for this pain is that there is some decay formed under the cap
which covers your tooth. Also, the root canal filling seems to be a bit short and has not worked. This
leakage under the cap may have allowed germs to gain entry and to travel to the root tip of the tooth and
cause an infection. This may happen in a few cases and it is difficult to predict.
Explain complications associated with radiotherapy
 I understand you want the tooth to be saved , However, as you are doing toundergo radiotherapy, I must
warn you of possible complications :

 Common side effects of head and neck radiation therapy are dermatitis, mucosal changes,
candidiasis, loss of taste, salivary gland dysfunction, radiation caries, soft-tissue necrosis, scar
 tissue formation, and osteoradionecrosis. These side effects have important implications for care of
patients in the dental office.

 Dermatitis. Redness of the skin and local loss of facial hair are common side effects of external
beam radiation. In severe cases, the skin overlying the mandible may experience necrosis.

 Mucosal changes. The severity of mucositis is dose related. Since the maturation sequence
requires about 2 weeks, one can anticipate up to a 2-week delay between commencing radiation
therapy and the onset of mucositis. With mucositis, the oral mucosa first becomes swollen, red,
ulcerated, and potentially susceptible to infection. With-in 2 to 6 weeks post-irradiation, the mucosa
recovers, and most of the signs and symptoms resolve. Erythema and dryness are the most
common persistent changes.

 In your case, sir, it is best to have all the treatment done before you start radiotherapy so healing can take
place and we decrease the chances of bone death and osteoradionecrosis .

28. Lost Biopsy OSCE

1) Introduce yourself to the patient

2) Explain what happened

- I am sorry to say Mr James that the report of your biopsy result which was send to us by
the specialist is lost.
- I want to apologise you, I assume that the report was accidentally destroyed with other
junk letters in the paper shredder.

3) Explain to the patient what will happen now

- For your biopsy the full swelling was surgically removed so unfortunately there is nothing
left there for taking another sample for biopsy to find out the reason for your swelling.
- But please don’t worry, because the swelling appears to be innocent as I was suspecting it
to be pyogenic granuloma which is nothing but an overgrowth of your gum due to irritation.
- But still we send you for a biopsy because it is a protocol which we need to follow
- So we won’t be sending you for a repeat biopsy.

4) Explain to the patient how you will manage him

- We will try to contact the hospital where your biopsy was done to find out if they have a
record of it so that we can find the report for your swelling
- If we can’t find it then it is our responsibility to take care of you
- We will call you regularly to monitor you to see if the swelling appears again, how is the
condition of your gums
- I want to assure you that nothing to worry about it as the swelling is already removed and
we were not suspecting it to be serious

5) Explain to the patient how you will prevent this happening again
- To prevent this happening again we will do an internal enquiry to find the exact reason for
the lost report
- We will be doing audit about this problem to come up with steps to prevent this happening
again
6) Document this and advice the patient about complain procedure
- We will document this incident in our practice log book and also in your notes
- If you want to make a complain I will ask my practice manager to speak to you who can
help you further with the procedure

7) Have you got any questions?

29. Lost radiograph / Need for second radiograph

1 Introduce yourself/ be professional

2 Handle the situation and apologise for the mishap

3 Explain the reason for the error: improper film placement, patient movement , improper
developing or fixing..

4 Explain about dental xray RADIATION and how it is different from radiotherapy:

5 Give explanation on exposure from background radiation of 2700 µSv/ year and
exposure from a periapical radiograph : 1to 8.3 µSv or less ( negligible ).it is equal to 2
days of background radiation.
6 Give comparison in flying distance: the exposure from 2 iopa is equal to the radiation
received from a return flight from London to Spain ( short distance return flight form
within Europe)

7 Give annual limit of effective dose : 1mSv according to the International Radiation
Regulation 99
8 The dose constrain for the public according to IRR 99 is : 0.3 mSv /year

9 Get consent for a second radiograph

10 Explain that training and auditing will be done to minimise such mishaps

11 Communicate empathically, listen to the patient and be patient.

 30. Angina pectoris – take history and give diagnosis

A 75 years old patient has to undergo extensive dental treatment. He suffers from chest pain. Take history
and give diagnosis (h/o of angina, has GTN spray and tablets, does not use them, now gets up in the
middle of the night breathless; so diagnosis is unstable angina pectoris)
Use patient’s name, communicate empathically, and avoid jargon
Good Morning Mr White. My name is ______. I’ve heard that you have chest pain. I would like to ask you a
few questions to know more about it, is it all right with you?

Take the past history of the complaint

History of presenting illness:
 Site: where exactly in your chest you feel the pain? Can you point it to me?
 Onset: when did it start?
 Characteristics: can you describe the pain to me?
 What exactly do you feel when you have this pain
 What sort of pain is it?
 How strong is this pain?
 How often do you feel the pain?
 Is that becoming more frequent, or more painful than when it first started?
 Radiation:
 Does the pain spread to other parts of the body such as your throat or arm, jaw, stomach?
 Does it hurt somewhere else as well?
 Associated symptoms:
 Do you feel anything else when you have the pain, such as breathlessness, choking feeling, sweating
or feeling sick?
 Do you have a burning feeling or pain on breathing?
 Do you get a funny taste in your mouth?
 Timing: How long does it last? (Stable angina pain usually lasts between one and three minutes and
should last no longer than 10 minutes, whilst the pain on unstable angina lasts longer, sometimes as
long as half an hour).
 Exacerbating/Relieving factors: What brings it on, what makes it worse, what relieves it? Do you get
this pain when you are resting as well? At Night? (they may answer physical exercise (exertion), stress,
strong emotion, cold weather, large meals)

Brief medical and social history

 Medication:
 Are you taking any medication for this condition Mr White? Which one?
 Do you have to take it quite often?
 Do you have it with you all the time?
 Does the pain resolve when you take it? (this question is important as unstable angina doesn’t usually
go away when medicine is taken)
 Do you smoke? For how long? How many cigarettes a day?
 Do you drink alcohol? What do usually you have? How many of those a week?
 What about your diet?
 Have you had any injury to your chest?
 Have you seen your doctor for this problem?
Thank you Mr White!

Explanation to the patient:

 Mr White, accordingly you have told me you seem to be experiencing a heart problem which we call
Angina Pectoris (stable or unstable depending on patient’s answer to the history taking). This happens
when blood vessels that feed the heart are a bit clogged and the heart is not getting enough oxygen
from the blood for it to function properly. This problem is more common in middle-aged man, smokers,
having a high cholesterol level, high blood pressure, overweight, diabetics, those who don’t exercise and
have family history of heart attacks. You should see your doctor as soon as possible because that is a
serious condition and has to be treated immediately (if patient said he hasn’t seen doctor).
  Your doctor will do a thorough check up and some special tests and then prescribe you some
medications. You should also cut down on oily food and red meat and loose some weight and I would
suggest you trying to stop smoking. You can contact the NHS Quit Smoking Helpline.

 As far as dental treatment is concerned, we will be even more careful that you are calm and relaxed and
that any treatment that we do is painless as far as possible. Oral anxiolytic treatment may be indicated if
angina is precipitated by stress.

 Patients with ‘unstable’ angina and those with a recent history of hospital admission for ischaemic chest
pain have the highest risk, and should not be considered for routine dental treatment in primary care.

 After the visit to your doctor, please bring any medications or sprays that is prescribed to you for the
dental appointments (that’s in case patient has stable angina, if it is unstable he has to be sent straight
to the hospital as he might suffer something more serious at any time).

 Do you have any questions?

 Thank you.

Left, rather than right, lateral recovery position reduces the pressure on the inferior vena cava (the main
vein bringing blood from the lower body to the heart) in patients with increased mass or pressure in the
abdomen (e.g. pregnancy). This helps the blood flow back to the heart, to then be pumped around the body
again. Pressure on the inferior vena cava, reducing venous return (blood flow to the heart) can result in
reduced blood flow, leading to shock.