[Type here]

1-Drunken nurse:
Good morning … how are you today?

Is everything alright with you?

I would like you have a word with you in private if you don’t mind? Let’s go to the other
room and close the door to get some privacy?

Don’t get me wrong but you don’t look right to me and I can smell alcohol in your breath
have you been drinking? If nurse says she had a drink last night with friend, you say: that is
fine to have fun and a couple of drinks with friends but what worries me is that you come to
work and alcohol is still in your system. Are you having problems at home? is there any way
I could help you please let me know you can trust me? I know it’s easier said than done but
try not to mix your personal and professional lives. By doing this you risk your registration
with the GDC you know they take these matter seriously and it will affect your career and
had a financial comeback on you.

You are a wonderful nurse, but I can’t work with you today as you are still under the
influence of alcohol it is a breach to the health and safety law and accidents can happen
easily you can prick yourself or the patient and might cause an injury to yourself or the
patient ..,

We need to keep patient confidence and trust in us, if the patient noticed that you are
drunk that is a breach of GDC principle which states we need to maintain appropriate
personal behaviour to keep public trust in us.

I would suggest that you go back home now and I will continue the treatment with a
different nurse.

I will need to raise this issue with principle dentist, tomorrow will both talk him together. if
the nurse says no please I will lose my job then you have to mention. I understand your
worry and concerns. I am really Sorry .. I am only doing my job by the GDC standards I am
obliged to raise concerns and I do feel concerned regarding your and patient’s safety.

I want to reassure you; I will be with you and am here to support and help you through this.
go home and rest for today and come back refreshed tomorrow and call me when you get
home safely.

Criteria Done
marks

1
[Type here]

1- Ask nurse if he/she is okay in a sensitive manner 1

2- Ask nurse if they can have a chat in private-ensure privacy 1

3- Ask nurse if she/he has been drinking 1

4- Suggest he/she return home and don’t work today as it is not an 3

appropriate behaviour in front of the patient

REFFERAL TO GDC-Standards for the dental team (Sep 2013)

Principle 9-make sure your personal behaviour maintains patient’s

confidence in you and the dental profession

5- Explains to the nurse that you must raise concerns locally and you 3
suggest speaking to the principle dentist together tomorrow when the
nurse is feeling better

REFERRAL to GDC- Standards for the dental team (Sep 2013)-principle

8 Raise concerns if patient is at risk

6- You offer support 1

2-Amalgam toxicity
Mr Walcott a 55-year-old medically fit patient who gives you a history of multiple
amalgam fillings placed over 10 years ago by his previous dentist. He has no fractured
restoration, no pain or sensitivity, but he is concerned about mercury poisoning and wants
his fillings replaced by a white filling

Explain how would you manage this patient and how you plan to address his concerns?

Good morning mr, my name is .,I am one of the dentist here. I understand that you are
worried about your silver filling is that correct? Are they causing you any pain or sensitivity
or do you think they are broken?

I completely understand your concerns but let me reassure you that there is nothing to
worry about. Now we do hear and read a lot about mercury dental filling and their harmful
effect but we should not believe anything unless it is evidence based.

2
[Type here]

The truth Mr, that silver filling has been used for a very long time over 150 years and are still
used safely in dentistry. These fillings have many benefits, provide long durability, easy to
place, low cost , they have the ability to fight germs and they have enough strength to
tolerate the force of a bite without breaking compared to the tooth coloured fillings

Evidence based studies showed that there is no link between fillings containing mercury
and Alzheimer disease. The Alzheimer’s Association also agrees with that and it is stated on
their website Mr, poisoning happens only with large amount of mercury, to give you an
example, did you know that Mercury, is a mineral which is find naturally in our environment
is it the earth ,water and fish that we eat.

so the effect from a dental filling is extremely small to give you a simple comparison in
numbers, the world health organisation has stated that the maximum tolerated dose of
mercury is 30microg where the release of mercury from multiple filling is 7.4microg per day
which is way below. The highest release of mercury is during placing or removing it. As they
are not broken or giving you pain, it is better to leave it as it is unless you are not happy with
the colour.

Is everything clear so far?

The food and drug administration FDA consider:

1- that silver fillings are safe for adults and children over the age of 6.

2-The amount of mercury measured in the bodies of people with dental amalgam is way
below levels associated with adverse health effect, even in those who have 15 silver
filling surfaces has been found to be far below the lowest level associated with harm.

3- all clinical studies have not found any link between these filling and health problems.

I hope I have put your worries at rest? Do you have any questions? Thank you.

if patient ask why do they not use amalgam in other countries? say that in the UK we have
safe disposal of amalgam and this is not available.

Patient instruction:

Over 10 years you had several fillings placed on many of your back teeth due to lots of
tooth decay. At that time, you had a lot of sugar in your diet and your tooth brushing was
not very good. Your dentist placed silver amalgam filling and you have since improved
your diet and brush twice a day now. You have no problems with your fillings as there is
no pain or broken fillings but you recently read in a magazine that said amalgam filling
causes mercury poisoning and Alzheimer’s disease. You want your filling changed
immediately to something without mercury and you are very worried about the poisoning
you have been exposed to over the past 10 years with these fillings.

3
[Type here]

Criteria Not
Done done

1- introduce yourself the patient and use patient’s name 1 0

2- Explain to the patient that amalgam fillings contain 2 0

mercury but there is no evidence that is causes poisoning
or Alzheimer disease

3- Show empathy to the patient that you understand their 2 0

concerns but explain that amalgam has been used for
many years over 150 and is still safely used within
dentistry today

4- Explain benefit of amalgam restoration in terms of low 2

cost, ease of application, high strength, durability
(especially compared to composite restoration) and
bacteriostatic effect.

5- Explain that mercury naturally is present in the 2

environment, so the effects from amalgam is extremely
small. The highest release of mercury is during amalgam
filling placement and removal.

6- World health organization maximum tolerated dose of 2

mercury of 30 micrograms per day, which is much more
than what is released from multiple amalgam restoration
7.4microgram per day.

7- The food and drug administration FDA considers: 3

1-dental amalgam filling are safe for adults and children

over the age of 6 years’ old(new regulation from the BDA
stat that the safe age of silver fillings has been raised to 15
years old)

2-the amount of mercury measured in the bodies of

people with dental amalgam fillings is well below levels
associated with adverse health effect

3-even in adults and children over the age of 6 who have

fifteen or more surface of amalgam filling has been found
far below the lowest level associated with harm

4
[Type here]

4-clincal studies in adults and children aged 6 and above

have found no link between dental amalgam filling and
health problems

8- Ask patient if they have any question, thank them 1

3-Bottle caries

A 3-year old patient presents to you for the first time with his mother. The child has never
seen a dentist before and has no prior experience of having dental treatment. You need to
discuss preventive advice with the parent and management options
Introduce yourself to the patient: Good morning mrs , my name is.., I am one of the dentist
and will be seeing your daughter.
Ask about patients concerns: how ca I help you today?
I am sorry to hear about that, we will do something about it but I will need to ask you some
questions to have more details of the problem is that alright?
Does your child have a high sugar diet?
How many times does your child brush their teeth?
Do you supervise your child when they brush their teeth?
Is your child bottle feed or take it when going to sleep?
Explain the condition: Unfortunately, your child has multiple early childhood tooth decay
called nursing bottle decay. the cause of this is bottle feeding especially at night, milk
contains natural sugars. During sleep saliva flow which helps in cleaning our mouth is
reduced dramatically and this increases the risk of decay.
Explain treatment:
first I want you to stop feeding your child in a bottle ideally children at the age of 6 months
should be encouraged to drink from a cup.
If you child is used to a bottle when sleeping you could replace the milk with water and
weaning them off that habit slowly.
I will remove decay and place filling in the teeth that could be saved but those that cannot
be saved will be removed. This will be done under local anaesthesia but if your child is
uncooperative we can refer her for sedation where he will be given gas to inhale to reduce
his anxiety or general anaesthesia were you child will be put to sleep. Is that clear Mrs,?

5
[Type here]

Explain prevention:To prevent decay in the future, you should reduce sugar intake, restrict
sugar to mealtime. No sugar should be consumed 1 hour before bed time and that also
includes milk and fruit juices.
You should make sure your child:
1-brushes their teeth twice a day in the morning and last thing before they go to bed and no
food should be consumed after that
2-you should use a pea size of adult toothpaste containing (1350-1450) of fluoride and soft
tooth brush they should spit the tooth paste and not rinse afterwards
3-this should be under your supervision.
I will also apply fluoride paste on her teeth 3-4 times a year to make them stronger as a
preventative measure and will be seeing her every three months to check that everything is
fine, do you have any questions? See you next appointment
. (for children giving prob, can use pea sized amount of 1350-1400 ppm toothpaste, fl
varnish 3-4 times a year, and shorter recalls along with diet etc)

Patient instructions:
You are the parent of a 3-year old child who has decay as shown in the photograph below.
You are going to see a dentist for the first time to seek treatment. The candidate is expected
to discuss the cause of the decay with you without the use of technical terms and discuss
ways in which this problem could be prevented in the future as well as treatment options.
They should also show empathy.

Marking sheet:
Not
Topics to be covered Done
done

1 Introduces themselves to parent 1 0

2 Asks what concerns are 1 0

3 Able to recognise nursing caries and explain to patient 1 0

Discusses causes i.e. bottle of milk or comforter at

4 night, lack of saliva production at night therefore 1 0
increasing risk of decay

5 Avoid use of jargon 1 0

Advise stop bottle of milk at night. Discuss alternatives

6 i.e. water in the bottle instead and gradual weaning off 1 0
bottle to cup

Discusses OHI i.e. brushing twice daily, use high

7 concentration fluoride toothpaste and supervised 1 0
brushing

6
[Type here]

8 Shows empathy throughout 1 0

Discussed treatment options i.e. no treatment,

9 1 0
restoration of teeth or extractions

Discusses management options such as treatment

10 under local anaesthesia, relative analgesia (N2O) or 1 0
general anaesthesia.

Total

Notes for examiner: Make sure candidates show empathy and explain terms in a friendly
way. Mina is happy to add more fluoride dosages for 3-year old or any other preventive
treatment if needed be.

4-Consent of extraction from patient on warfarin:

This patient mr/mrs jones on Warfarin a regular attender and is not an anxious patient. You the
dentist have to take consent for extraction of lower left 2nd premolar which is badly broken down
under LA.

● Good Morning Mrs. Jones, …, nice to see you again. your lower left tooth is causing
you trouble and I am here to explain the treatment options, is that correct?
● Mr Jones sadly that tooth is damaged beyond repaired and cannot be restored. If
you leave the tooth it might cause you further problem such as pain and infection.
That is why we are removing it.
● I have noticed that you are taking warfarin is that correct? Since when? When was
the last prick test done? What was the value? Does if fluctuate? do you have your
yellow card with you? Do you take any other medication?
● I would want to refer you back to your GP and request another blood test for the INR
1-3 day before your appointment to have the tooth taken out just to make sure
everything is fine. Is that alright?
● The treatment is done under LA and is a simple one procedure, the tooth will be
taken out in one piece but as it is badly damaged there is a small chance it might
break. If that happens we need to make a small cut in the gums and have it removed.
(Explain Local Anaesthesia and surgery)
● As you take warfarin you are more likely to bleed a bit more than others who are not
on that medication. warfarin makes your blood thinner so it can flow smoothly
around your body. Having said that I would advise you to continue taking it as the
risk from bleeding is far less than the risk of blood clotting.
To stop the bleeding, I will then apply some haemostatic package in the wound and some
stitches on top of it then ask you to bite on a gauze pack for half an hour and that should
take care of the bleeding.

7
[Type here]

● Once the bleeding stops, you will be sent home with instruction on how to care for your
wound and what to do in case of emergency
● After the procedure, there is risk of pain which you can take some paracetamol for it
avoid any ibuprofen or aspirin as it can start bleeding. Swelling is another side effect
of the procedure which should subside within a couple of day.
● Do you have any questions? Happy with the explanation?

● Thank you

Actor:

You are mr/mrs jones 60 years attending your dentist to seek explanation as to what your options
are for badly broken down tooth on the lower left side. The dentist will discuss the options of a
badly broken tooth on the lower left side. You agree with the dentist to have the tooth extracted.

You take warfarin for thinning your blood since you had a metal valve fitted 10 years ago. You had
blood check done 2 days ago and your INR results was 2.5.you attend blood clinic once a month

You would like to know the outline procedure itself. Your dentist should get your permission to
take the tooth out and it’s important that the dentist explains that you should continue take
warfarin. The dentist should also ask you to have another check 1-3 days before your extraction
appointment. if the dentist does not mention this you need to say that you will stop taking your
medication as you have done before for a previous extraction.

Criteria Done
mark
s

1- Address patient with their names 1

2- Communicate empathically 1

3- Avoid using jargons 1

4- Explain the options of 2

1-leave it with no treatment

2-extraction under LA and procedure with risks

3-confirm negotiated treatment options -Verbal consent

8
[Type here]

5- 1-check if the patient has had their INR checked and value (therapeutic range 2
2-4)

2- request patient to have INR check done with their Warfarin/anticoagulant

clinic or GP within 1-3 days of planned dental procedure

6- Advice the patient to continue with their warfarin as the risk of bleeding is 2
lower than risk of thrombosis if warfarin is discontinued (current guide line
from the Nation Patient Safety Agency and the British society of the
Haematology-Sep 2011)

7- Explain method of extraction briefly including a surgical approach. This 2

includes the fact that you will use local measures like pressure pack, sutures
and surgical to promote haemostats. Warn for pain and swelling

8- Check patients understanding 1

if INR is a score of 4 treatment should be deferred //if INR fluctuate refer to specialist.

5-Fluoride supplement:
Kevin seller is 9 years old and has mixed dentition. However, all his first permanent
molars are decayed and several of his deciduous molars are extracted because of decay.
His mother is quite worried and has come for you for advice on fluoride supplement.

Patient advice:

You are Mrs Sellers and visiting your dentist today to seek advice about fluoride
supplement for your son Kevin 9 years old. Kevin has many decayed teeth and has lost
many of his baby teeth early because of decay. He brushes once in the morning using baby
toothpaste and you don’t know if it contains fluoride or not.

Your neighbour has suggested that you give him fluoride tablets to make his teeth
stronger as the water in your area contain no fluoride (candidates must ask specifically
about water fluoridation). You need a professional opinion as you read on the internet
that fluoride can be poisonous and can cause cancer.

Good morning mrs , My name is .., I am one of the dentist here and will be seeing? How
can I help you today?

I understand that you are concerned but rest assured there is nothing you need to worry
about. I need to know more details about:

How many time does Kevin brush his teeth per day?

9
[Type here]

Do you know if there is fluoride in his tooth paste?

Do you know if there is fluoride in water in your area?

Fluorid is important for our teeth. Research has shown that fluoride reduces decay in
children and adults:
Fluoride can be taken as orally as tablets or applied topically as paste or mouth rinse. The
best way to apply fluoride on a tooth is by brushing twice a day once I the morning and
last thing before he goes to bed with fluoride tooth paste 1350 ppm. Make sure he spits
and doesn’t rinse after.

He (Children above the age of 6 years) can use fluoride rinse0.05% which contains 225
ppm of fluoride at any other different time than brushing as it can wash away or dilute the
fluoride applied by brushing and minimize the effect as tooth paste has more
concentration of fluoride than the rinse.

We can apply fluoride gel or paste which is brushed on his teeth as a preventative
measure 2-3 time annually that will help his teeth to be stronger.

The use of fluoride tablets is questionable and I would suggest the use of topical fluoride
first; tablets needs the complains of parents so there is a risk of under or over dose. There
is also the risk of fluorosis in case of over doses in children under the age of 6. These
tablets have more effect on the structure of the teeth while they are developing as Kevins
teeth are already developed the effect is minimal, so I would suggest using the topical
first.

You have mentioned you are worried about poisoning and cancer. I want to put your
thoughts at rest poisoning with fluoride will happen only if you have excessive amounts of
it and as you use it within the recommended dose for daily use it is completely safe.
clinical researches has found no link between cancer and fluoride.

Do you have any question? Thank you.

Criteria Done
marks

1- Introduce yourself to the patient 1

2- Ask about the problem 1

3- Ask about water fluoridation in the area and Kevin’s oral hygiene 1
regime

4- Explain why fluoride is important for the teeth, fluoride disturbs the 3

10
[Type here]

process of decay by:

1-changing the structure of developing enamel, making it more

resistant to acid attack-these structural changes occur if a child
consumes fluoride during the period when enamel develops (mainly
up to the age of seven years)

2-encourages a better quality of enamel to make the more resistant

to acid attacks

3-reducing plaque bacteria’s ability to produce acid, which is the

cause of decay

5- Advice on brushing the teeth twice per day using a tooth paste 3
containing at least 1350 ppm fluoride

6- Advice on the use of fluoride rinse 2

These can be prescribed for patient aged 8 years and above for daily
us, in addition to brushing twice a day with a tooth paste containing
1350 ppm fluoride and should be used in different time of brushing to
maximise the topical effect, which relates to the frequency of
availability rinsing even with a fluoride rinse immediately after
brushing reduces the beneficial effect of fluoride toothpaste. Fluoride
in tooth paste 1000-1350ppm is at higher concentration compared
with fluoride rinses 225 ppm and is more effective if retained in the
mouth, rather than being diluted or washed away by rinse

7- Fluoride varnish 3-4 times a year 2

8- Fluoride tablets: 2

It is recognised that fluoride tablets or drops require the compliance

of parents and this may include under or over use. There is a risk of
fluorosis if children aged less than six years old take more than the
recommended. With this in mind other sources of fluoride may be
preferable and therefore considered first

9- Answer question about poisoning (only excessive amounts) and 2

cancer (no risk of cancer)

10- Avoid jargons 1

11- Ask if patient has any question 1

12- Thank the patient 1

11
[Type here]

6-( white Patch ) Lichen planus/lichenoid reaction

This is Jenny Brown, a 32-year-old legal secretary. She is not known to your practice and
has come in today complaining of a sore patch on the right side of her mouth, which has
become increasingly uncomfortable over the past week. She is obviously very distressed
and asks you to have a look.

On examination, you see an erythematous area with irregular white striae on the buccal
mucosa opposite the lower right first molar. There are no ulcers. The LR6 has a large
occluso-buccal amalgam. The occlusion is sound and the remainder of the oral cavity is
completely normal. Assuming you have performed an adequate examination, complete your
history and explain to the patient what you think the likely diagnosis is, and outline your
management.

Picture of patient was kept. Patient was on ibuprofen (NSAIDS) for a long time against pain
from broken hand. Patient is a non-smoker. Explain to patient about the lesion and advise
accordingly.

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

● Good morning Mrs, my name is____, I’m
one of the dentists here. I understand that you have
a white patch that is bothering you. Sorry to hear
you are having such a problem but rest assured we
will do something about it today.
Take the history of the complaint

● Site Can you tell me where is it

exactly?
● Onset When did you notice it?
● Character Is it painful? Can you scrap it
off? Any ulceration on it? bleeding or discharge?
● Radiation Do you have the lesion on both
sides of your cheeks? Do you have lesions in other
parts of your body?
● Treatment Have you had any dental

12
[Type here]

treatment near that area recently? When was that? Is it your first filling? did you have the
same reaction before?
●Trauma Do you think you have bitten your check? Do you think the filling has a Sharp
edge?
●Are you suffering from any medical condition such as systemic lupus atheromatous?
●Are you on any medication, either prescribed or over the counter
●Do you smoke?
● Do you have alcohol?

●From what you have described your lesion, it seems like what we call lichenoid reaction
which is like an allergic reaction of your body to the silver filling you had recently. What I
would advise is to have the silver filling removed and will put a temporary filling in place
and will follow up with another appointment next week t to check if it has healed.

●I would advise you to avoid spicy and hard food. (if patient smokes or drinks alcohol
patient should be encouraged to stop it as it can aggravate the condition)
● I would recommend the Use of difflam mouth wash to numb the painful areas and help
with discomfort
●I will also refer you to your GP for a patch test to see if you are allergic to sliver fillings.
●If after a week, we see no respond I would suggest referring you to a specialist where
they will do a biopsy which they take a piece of tissue from that area and examined under
the microscope.
●I don’t see any alarming signs and I don’t think you need to worry at all but the only way
to know exactly what it is by doing a biopsy.
Do you have any question? Thank you?

In case of lichen planus:

We ask similar questions and these are points we need to cover:
The condition that you have is what we call lichen planus which is basically a skin condition
but can affect other parts of your body. It can also appear only on the lining of your mouth. It
normally affects mid aged women more than men. The cause of this is unknown, it has
something to do with your immune system but it can happen as side effect of some
medication or dental treatment. it is not an infection nor it is contagious. ((we need to change
the filling or refer you to GP to change medication))
It is usually diagnosed with the lacy white appearance that shows on both sides of your
check but to confirm the diagnosis I will need to refer you to have a biopsy where a sample
of that area is taken and examined under the microscope.
In most cases there is no cure for it but there is some medication that can dampen the
symptoms these medications have many side effects so I will need to refer you to a
specialist to be monitored closely. Having said that in some cases, it disappears
spontaneously.
Normally it is nothing to worry about but it has the tendency in 1% of the cases to turn into
something nasty.
Its important to keep meticulous oral hygiene at all times to avoid any infection to the area.
Avoid spicy and crunchy food. Smoking and alcohol can worsen the condition so avoid these
as well. Keep up with your regular check-ups so any changes in it can be detected.

Patient instructions

You are a 32-year-old legal secretary who comes in today with a red-white sore area on the
cheek opposite your first right molar. It is causing a burning pain which has got worse over
the past week, although it may have started a fortnight ago. It is made worse by spicy foods
and nothing helps to ease it. You had a large silver filling put in the tooth next to the cheek

13
[Type here]

about three weeks ago by another dentist and you think symptoms started around then. You
have no tooth ache, and you have not bitten your cheek or felt the filling as sharp.

You have no medical problems, have never taken any medication and do' not smoke. You
rarely drink.

You are concerned that this may be cancer and are very anxious. The dentist has already
performed an examination. The dentist should complete their history and address your
concerns, as well as outlining his/her management plan to you.

Drugs that cause lichenoid reaction you can find reference in pink book page 436.
Gold salt
Antimalaria that end with quin
Metformin
Penicillamine
Alloupril (which is an anti-uric acid)
Triacyclic anit depressants
Methyl dopa (antihypertensive for pregnant women)
Anti-hypertensive drugs (ACE captopril Ramipril, Betal blocker atenolol and
propranolol,Diuretics Thiazide)
NSAIDs
Mnemonic: GAM PAT MAN
Management is the ; V 4B 3S =increase vegetable intake , benzydamine mouth wash,biopsy
,beclomethasone and blood test, avoid spicy food, avoid smoking and have a salty mouth
rinse

14
[Type here]

7-Avulsed tooth:
You receive a phone call from a mother of a 10-year-old boy. She tells you that her son has been
playing rugby at school and collided with another player. As a result, he has knocked his upper
central incisor. She is very distressed and would like your advice as to what she should do.

Patient instruction:

You are anxious mother of a 10-year-old boy. Your son has been in an accident at school whilst
playing rugby and his upper tooth has been knocked out. You are very distressed and need advice.
You are willing to put the tooth back into the socket if instructed to do so

Criteria

1- Reassure the patient 1

2- Ask the mother briefly what has happened, how, any loss of consciousness 1

3- Take a brief medical history. Candidate needs to be brief as time is essence. 1

Candidate should ask about cardiac status, bleeding problems, allergies and
tetanus status

4- Ask where the tooth is? Does she have the tooth? If so where is the tooth and 2
is it stored in a medium? i.e milk or isotonic solution is the crown intact?

5- Explain to the mother that the tooth needs to be replanted and is best to do 3
as soon as possible as it will give the tooth better prognosis.

Ask if she is happy to do this and reassure that they will be talked through
this.

Ask to inspect the root and gently remove surface debris.

Ask them to replant the tooth into the socket ensuring that they have the
correct orientation. i.e maximum bulbosity of the crown facing the front

6- Get patient to bite on gauze /handkerchief to ensure that the tooth is sitting 2
correctly in the socket and advice to come to your practice soon

Good morning, ______ speaking, the dentist for today. How may I help you?
I’m sorry to hear that, please calm down I will guide you through the steps to help your child.
How is your son now?

● 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?
● Do you have the tooth with you?
● Is it intact or broken? If broken, have you got the pieces? Is there any chance your child
may have swallowed it?

15
[Type here]

● Is it on your hands or stored in a medium?

● the best thing to do now is to place the tooth back into the hole where it was originally
placed. The sooner this is done the better is the outcome of prognosis.
● 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 wider shinny part that normally shows in the mouth, not the root
which is the long pointy part of the tooth.
● If the tooth is dirty, quickly rinse it with milk or water. (tap water can be used)
● Do not wipe it, scrub it or use soap.
● 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 which is the wider part of the tooth, with the smooth convex
surface facing you, place the tooth in the hole.
● Ask the child to gently bite on a piece of gauze or clean handkerchief to seat the tooth
correctly to the level of the other teeth.
● Is it done? yes, say. fantastic!

● Now, come to the practice to see me as soon as possible so I will do further treatment.

● If patient is reluctant to do it and prefers to come to see you advise to put the tooth in milk
or water don’t let it dry out and come to the dental surgery as soon as possible.

● Thank you, see you soon, bye.

There is a pilot osce where a four-year-old child have an intrusion injury of his upper A,
tell the parent to calm down this is a very common thing that happens in children it
happens in around 60%. Inform the parent that you need to take an xray to see if the
permanent tooth germ is injured. In most of the cases all we need to do is monitor the tooth
it might push out again this will take something between 1-6 months. If the tooth doesn’t
push out and we find that the adult tooth is at danger of damage, we need to have the tooth
taken out. The trauma might cause irritation to the centre of the tooth and the tooth will
undergo death and can be a source of infection we will need to do some treatment for the
centre of the tooth we call this pulpectomy when the centre of the tooth is shaped and a
body friendly filling is applied. Or we can remove the tooth a place a space maintainer
which are hooks and bands to prevent the back teeth from pushing into that space and that
will put him under the need of more complicated treatment in the future to.

8-Repeated x-ray for broken file:

You have noticed that during endo treatment, part of the endodontic file has
separated and is in the root canal.in order to localise its position you have now
taken a periapical radiograph which has not covered the full extent of the broken
file and tooth. Now you must let the patient know what has gone wrong with the
radiograph and take his/her permission to [take a second radiograph. ‘[
Patient is not happy about this as another radiograph is needed since the first one
was not correct. Patient has undergone radiotherapy in the past for medical illness
and does not want to be radiated as this can be harmful to the body.

16
[Type here]

Council and reassure the patient about the low risk regarding the dose of
radiograph giving reasons to support your answers.

Actor instructions:
Your dentist has taken a radiograph as he/she has separated a piece of instrument
within your tooth. You are not happy about taking x-rays as it causes harm to the
body. You have had radiotherapy in the past (5 years ago) for medical illnesses
and it was not pleasant experience.
You have read in the newspaper that too much radiation causes cancer; dentist
wants to take a second radiograph as the first one has not covered the full extent of
the broken instrument.
Good morning mr, my name is .., I am one of the dentist here and will be seeing
you today.
From your note, I gather that you had an x-ray to check the broken file,
unfortunately the x-ray we took for you has come up with poor quality. It does not
show the entire tooth as it seems the film has moved a bit when in your mouth. To
finish your treatment effectively, I will need to know exactly where the broken piece
of the instrument is. I will need to take another radiograph.is that okay with you?
I apologies for this mrs, and understand that this might be concerning and
distressing but let me reassure you that the radiation you will be exposed to from
this second x-ray is very little and the risk of cancer is minimal one in one million.
I understand your fears as you had radiotherapy in the past. To put your mind at
rest radiation for radiotherapy are meant to kill abnormal cells which is very different
from radiation for x-ray which don’t penetrate as deep, these only take pictures of
teeth to give you a comparison with numbers the amount of radiation from
radiotherapy is 60000 micro Sievert whereas the radiation for a dental radiograph is
1-8 micro Sievert. So, Mr, the amount of radiation received from the second
radiograph is extremely small. Risk of cancer is minimum it is 1-2 in every 2 million
-20 million so you can see the risk is minute.
We get more radiation from natural resources, including the soil, sun light and from
our general environment such as watch TV or lap top. Studies suggest that we are
exposed annually to 2700MSv of radiation every year which is equal to 350 x-rays
and what you will receive from the extra x-ray is equivalent to a returned flight from
London to Spain.
Per the ionisation radiation regulation states the general population should not be
exposed to more than 1000MSv of radiation a year which is equivalent to 125
dental x-rays.
Mr, we work in patient’s best interest and take all the precautions to reduce the
amount of radiation. we do not take any x-rays unless it is necessary, using modern
equipment which are checked every three years , faster films and we localized the
x-ray area so risks are kept as small as possible.
I hope I have put your worries at rest and explained clearly that it is safe. I do
apologies for this again,
are you happy to give me consent to take the radiograph?

Criteria Done
marks
1- Greeting and professionalism/introduce yourself 1

17
[Type here]

2- Handle the situation and apologies for the error in the radiograph 1
3- Explain the reasons for the error in the radiograph 2
4- Explain about dental x-ray and how its different from radiotherapy 2
5- Give explanation on back ground radiation 2700MSv per year and 3
exposure from periapical is only 1-8.3 MSv or less or 2 day of back
ground radiation
6- Give comparison flying distance- short haul return flight from London to 3
Spain (within Europe) as equivalent to pair of periapical
7- Give annual limit of effective dose-1mSv for public according to the 1
IRR99

18
[Type here]

8- Give the dose constrain of 0.3 mSv/per annum for public according to 1
the IRR
9- Get consent from the patient for the second radiograph 1
10- Communication skills-display empathy and understanding 1
Total 17
Mill Sievert = 1000Micro Sievert
2700 Micro Sievert it includes all the annual radiation public exposure
including dental and medical radiograph.

9-Explaining radiograph finding (supernumerary teeth)

A patient present to you for a regular check up with his mother. The child just had a dental
radiograph. You need to discuss with the parent the normal radiographic findings, any
unusual findings and mark it on the radiograph, the approximate patient age as well as
management and treatment option.

19
[Type here]

Good morning mrs, my name is, I am one of the dentist here and will be seeing you.

How can I help you today?

Sorry to hear about that I understand your worries but I want you to be rest assured we
will definitely do about it, but first let me explain to you the findings on the radiograph.

There is a lot of information we can get from the radiograph for example your sons
estimated age he around 10 years old? He’s teeth is a mixture of milk and adult teeth.

One of his front adult tooth is not out yet if you see that white bit there, it has been
obstructed by the presence of an extra tooth (or a retained milk tooth), some people like
your son they have extra teeth which also have different shapes and locations, usually
this is an inherited condition.is that clear?

To know the exact position of that tooth I will need to request an upper occlusal standard
radiograph which will give us more information about the actual position of the tooth in
his jaws and it will help us in deciding the right treatment plan. Are you following me mrs?

The treatment option he has, we remove the extra tooth to see if the adult tooth pushes
out spontaneously, it is done under LA but if your child is uncooperative I can refer
him/her to have it done under sedation where he breaths a mixture of gases which
reduces his response to pain or general anaesthesia where he is put to sleep. The other
treatment option is to refer him to an orthodontist who will try to slowly pull out the
tooth using wires and braces and arrange his teeth. is that alright? His teeth will have
rearranged but it is a long expensive treatment

20
[Type here]

I will still be seeing him for regular check-up and maintain good oral hygiene.

Do you have any questions?

Thank you

Criteria Done
marks

1- Introduce yourself to the patient 1

2- Ask what are the concerns 1

3- Able to identify the patients age from the dental radiograph any age from 8-10 1
years is acceptable

4- Able to explain radiographic findings to the parent: radiograph is in mixed 1

dentition, presence of primary and permanent teeth

5- Able to recognise un-erupted left central incisor and supernumerary tooth and 1
explain to parent

6- Avoid use of jargons 1

7- Able to ask for more radiographs: upper standard occlusal or periapical 1

radiograph for parallax technique

8- Show empathy through out 1

9- Discussed treatment plan primary and supernumerary tooth removal, possible 1

exposure and bond of the permanent incisor

10- Management option LA, IS, GA 1

TOTAL 10

Parallax tech: SLOB/ same lingual opposite buccal

Horizontal parallex in which two periapical radiographs are taken or a periapical and
standard occlusion
Vertical parallex in which one DPT and one standard occlusion
Type of supernumerary teeth: prevalence is 0.8% in primary dentition and 2% in secondary
dentition occur more in premaxillary region. Affecting males more than females. If found in
primary teeth it follows 20% in secondary.
Aetiology :theories include offshoot of dental lamina

21
[Type here]

Divided according to shape or position page 67 pink or 361 Eric:

Shape (conical/peg shaped/, tuberculate/barrel shaped/, supplemental, odontome)
Position:( mesiodens , distomolar, paramolar)

10-Bleeding after extraction patient is on warfarin and ibuprofen

OSCE:
Candidate instruction
You are an emergency dentist attending Mr Jones in your practice who had an extraction of
UR6 carried out at another dental practice 9 hours ago. He presents with persistent bleeding
from the socket.

Please take appropriate history to determine the cause of the bleeding.

Actor's props
Anticoagulant clinic record book (yellow book), box of propranolol, box of warfarin, box of
ibuprofen, gauze pack, written instructions after extraction, paper work (consent, ITA)

Actor's (patient) information:

Full Name: Mr Victor Jones
DOB: 22/11/44 (66 years-old)
Address: 1 Lame Street, Palmers Green NZ11XC

Dental history:
● Brush twice daily (afternoon and before going to bed)
● Flosses every evening at 10pm, visits dentist every 6months
● Diet: Low sugar (1 tsp in a cup of tea twice daily)
● Last dental treatment: extraction of an unrestorable tooth UR6
● Doesn't wear denture.
● Never had filling or extraction before in life.
● Happy with smile & appearance of teeth.

Medical history:
● Atrial fibrillation, mild osteoarthritis, hypertension (well controlled), visit GP for repeat
prescription only when necessary.
● Allergic to shell fish (rash) and taking warfarin 5mgs (INR 2-3), propanolol 10mgs,
ibuprofen 200mgs
● Visit anti-coagulant clinic every week (last visit was yesterday and INR was 2.9).
● Family history: nil

Social history
Marital status: Widow with no children and lives alone in a flat.
Smokes 5-10/day for the past 35 years and is not interested in quitting.
Alcohol: teetotal
Occupation: Retired Civil Worker

Patient instruction
You are the above named patient and had an extraction done 9 hours ago at another
dentist. Since the extraction you have been bleeding (oozing out of the socket) but with no
pain. You have tried biting on gauze for 30 mins and did it twice but in vain.

22
[Type here]

You are very annoyed and frustrated. You have already smoked 2 cigarettes, 4 hours after
the extraction and rinsed your mouth thrice with cold water to get rid of the bad taste inside
the mouth. You have been taking Ibuprofen for the last 4 days as your joints are hurting.

The dentist gave you the written and verbal instructions and as far as you know you tried
following them. Your INR was taken yesterday afternoon and it was 2.9.Usually your INR
stays within the range of 2-3.

You couldn’t eat anything since then and you are concerned about the blood loss and would
like to know the likely cause of the bleeding.

Only give the yellow book and list/boxes of medication if candidate asks for it. You will also
have some paper work & gauze, just give everything with above.

Some people will start talking about the treatment but you may need to drag them back to
the cause of the bleeding as the questions specifically ask for finding out the cause of the
bleeding socket.

You need to ask them:

● Why am I bleeding continuously?
● Is it because of rinsing/smoking that I am bleeding?
● Am I bleeding because of warfarin?
● Am I bleeding because of Ibuprofen?
● Have I lost a lot of blood?
● Do I need to stop taking warfarin/ Ibuprofen?

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

● Good morning Mr Jones, my name is _______, one of the dentists here. How can I help
you?
● Sorry to hear you are having such a problem, Mr Jones I understand you are worried and
concerned and I will do my best to help you but first I need to know few details of the
problem.
Take history of presenting complaint
● When was the tooth removed?
● Was the extraction difficult?
● Were there any stitches given?
● when did the bleeding start?
● Did you do anything to stop the bleeding?
● Did you follow the instructions given by your dentist on how care for your wound? Did
you smoke or rinse after the tooth removal?
● Is it bleeding a lot?
Take brief medical history
● Do you have any health problem such as high blood pressure or liver or any bleeding
problems?
● Are you taking any drugs or medication, prescribed or over the counter?
● Did you take any pain killers after the tooth was removed? (Ibuprofen
● Do you have any warning cards or a yellow booklet? Can I have a look at it?
● Was your INR checked before extraction? Do you know the value? Does your INR
fluctuate?

23
[Type here]

Diagnose, briefly explain problem and aetiology

● Don’t worry. Most of the blood you see might be a little blood mixed with a lot of saliva, so
the actual loss of blood might be much less than what it appears to be. The bleeding is
caused because of delay in the formation of the blood clot which works as a plug to stop
the bleeding.

● 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 measure this with 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
person who doesn’t take the medication.
● The main 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. I would suggest
you stop taking it and go back to your GP they can prescribe you some safer pain killers.
● You mentioned that you have smoked and rinsed your mouth and that has disturbed the
blood clot where the healing process starts.
Explain treatment plan to stop the bleeding
● I will apply a dressing and place stiches , will also give you a gauze to bite on for half an hour
until bleeding stops I will see you tomorrow to check that everything is fine. If you have any
other problem with it contact us as soon as possible
● Do you have any questions?
● Thank you Mr Jones

24
[Type here]

11-Oral submucosal fibrosis:

25
[Type here]

On Examination, you notice blanching and stiffening of the buccal mucosa on the right
side of the mouth causing limitation of mouth opening. Discuss the possible diagnosis, risk
factors and management of this lesion with the patient.

Actor:

You are Mr Patel, 46 years old attending a dentist appointment for the first time, for a
check-up. During the medical history you admitted chewing betel quid once on most days.

On examination your dentist has noticed a white, stiff area along the inside of your right
cheek, where you normally chew the pan. You are unaware of this lesion but have noticed
some pulling in the area on a wide mouth opening.

The dentist needs to establish what is the likely diagnosis of this lesion, which is
submucosal fibrosis. If he/she correctly diagnoses the problem then he/she should inform
you of the probable causative factor (the pan) and briefly explain the predisposing factors
and risk, encouraging you to quit this habit. He/she should then refer you to a specialist
for further investigation.

Good morning Mr Patel, my name is, I am one of the dentist and will be seeing you today.

Mr Patel, looking at the results of your examination show that you have a white lesion inside
your right check. Are you aware of that?

Can you tell me if you have limitation in opening your mouth?

Do you chew pann? How long have you been doing that?

Do you smoke do you have alcohol?

Do you have any medical condition?

26
[Type here]

I am afraid, you have a condition called Oral sub mucous fibrosis is a progressive,
irreversible disorder that affects the inner part of the mouth causing the muscle to lose its
elasticity and becomes stiff and that is why you are having limitation in opening your mouth
widely.

There are many causes for this condition, its incidence increases in certain population such as south
east Asia, middle east and south Africa. Can be associated with vitamin deficiency or excessive
consumption of spicy food or genetic.in your case Mr. Patel, the main cause is you regular chewing
of pan for long period of time.

Unfortunately, this condition is incurable and I will need to refer you to a specialist for further
investigation. It can extend to other areas such as the pharynx, larynx and esophagus affecting your
speech and eating ability, is that clear so far?

Meanwhile, as you wait for your referral, I will strongly advise you to quit the betel chewing as this
can also make your asthma condition worse because of the chemicals. The same should go for
smoking and avoid alcohol intake too. You should continue with your oral hygiene measure brushing
twice a day to keep the area clean to avoid any infection of the patch. I would also recommend use
of chlorohexidine mouth wash as it helps to fight the bacteria.

I would also advise you to do some stretching of the muscles of your mouth by keeping your mouth
open you should do it frequently and for longer times, this is very important as it can spare you the
worst effect of limited mouth opening.

I do not want to frighten you but it does show warning signs It has a small chance 5-8% to turn into
something sinister. the only way to tell is by doing a biopsy. Do you know what a biopsy is? They
take a piece of tissue from that patch and examine it under the microscope and that is the only way
to get a definitive diagnosis. Is the explanation clear Mr. Patel? Do you have any questions?

Thank you

Criteria Done
marks

1- Introduce yourself to the patient and address patient with their name 1

2- Communicate empathically 1

3- Diagnose and explain sub mucosal fibrosis without using jargons 1

4- Discuss the likely cause betel quid chewing and one more of the following 2
factors:

● Prolong vit deficiency

27
[Type here]

● Genetic predisposition and increased incidence in certain part of the

world including south-east Asia, middle east and south Africa

● Excessive consumption of spicy food

● Immunological process

5- Explain there is no regression or cure for the existing lesion 1

6- Inform patient of the pre-malignant nature of this disease (risk of malignant 1

transformation 5-8%) and the possibility of it worsening the existing asthma

7- Give advice on chewing cessation and enforcement of oral hygiene measures 1

8- Advice the patient to do muscle stretching exercises, which must be frequent and 1
prolonged, that’s important to spare the patient the worst effect of limited
mouth opening

9- Offer referral to a specialist for further investigation (biopsy) 1

10- Close consultation appropriately, check for understanding, ask for questions 1

TOTAL MARKS 11

12-Periapical abscess (swelling on the gums)

28
[Type here]

Mrs Victoria Crane has come to you for the first time as an emergency appointment, she has
a painful swelling above her upper teeth.

Investigate what is wrong and how the swelling can be treated.

You will need to arrive at diagnosis and explain this to the patient and also present various
treatment options.

Actor brief

You are Mrs Crane, 45 years of age, medically fit and well. Recently, you noticed a swelling
under your upper lip, which has been there for 3 days and has now become very painful
(throbbing). You were unable to sleep the night before because of pain.

You are a very busy with your sister’s wedding in three days which you why you did not
attend the dentist earlier.

Only provide this history of trauma if the candidate asks: a few months back, your 3-year-
old son hit you in the tooth with his head. You were in severe pain for 2 days afterwards and
took pain killer but decided against seeing the dentist because the suddenly disappeared
after that)

You are not keen on starting any treatment and just need antibiotic (the candidate should
refuse) but you keep insisting.

Criteria Done
marks

1- Introduce yourself 1

2- History of chief complaint 2

3- Brief medical history 2

4- Brief dental history 2

5- Diagnosis explained (PA Abscess) 2

6- Offered incise and drain 1

7- Offer access cavity and pulpectomy 1

8- Treatment option RCT and Extraction with immediate denture 2

9- candidate refuses to give antibiotic and explains about NICE guideline 3

29
[Type here]

10- Ask if patient has any questions 1

11- Thank the patient 1

12- Actor to comment on empathy, simple explanation and treatment option 2

TOTAL 21

Good morning Mrs Crane, my name is , I am one of the dentist here. How can I help you
today?

Sorry to hear you are suffering such a problem but rest assured we will do something about
it but I need to know more details about the problem.

Can you tell me exactly where is the swelling? Since when have you noticed it? Is it
becoming worse or better?

Can you describe the pain for me? How long does the pain last? Have you taken any pain
killers did it help?

Does it radiate to other places?

Does it interrupt your sleep?

Do you have any temperature? Did you have any treatment on that tooth? Any history of
trauma?

Any boil or blister? Any salty taste? Swelling?

Do you suffer from any medical condition? Any allergies?

Unfortunately, Mrs Crane, you are suffering a localized infection at the tip of the tooth what
we call preapical abscess. It might have been caused by the trauma that you had few
months ago which has irritated and infected the nerve of the tooth. as it has not been
treated the infection has spread to the underlying tissue and causing pus collection and that
is why you have the swelling.
To relive you from pain today, I can do a small cut in you gum to allow the drainage of pus
or make an opening into the tooth and have the nerve taken out and then seal with a
temporary filling, I will also prescribe you some painkillers and that should take care of the
pain
The treatment option you have is either have a root canal treatment, the other option is to
have the tooth taken out and we can replace it with an immediate denture which you can
wear straight after that so you will not be left a gap.
I understand your concerns but as you have no fever it is not recommended by the national
institute of care and health excellence guidance to give antibiotic unless there is a severe
infection or fever and I don’t see that you have any of those. The best way to relieve you

30
[Type here]

from pain is by allowing the drainage of pus from that area to release the pressure that is
causing you pain.
Do you have any questions?
Thank you

13-Facial pain (TMPDS):

Candidate instruction
This is Michael Brown, a 22-year-old chemistry student. He has come to see you because of
pain in his face. The pain is associated with area in front of his ear. It is mainly on the left-
hand side but can occur on the right as well. The pain is worse in the morning and at the end
of the day. It also gets painful when he eats some meals and sometimes he will wake
because of the pain. He has visited his dentist in the past who have investigated his teeth
and have found no dental pathology. He has had a click in his jaw for the last 3 years and
occasionally feels his opening is limited but can open mouth fully.

Take a concise history and explain to the patient what you think the likely diagnosis is, and
outline your management plan to him.

Patient brief
Your name is Michael Brown. You are a 22-year-old chemistry student. You have been
experiencing pain on left hand side of face. It is centred just in front of your ear on left but
occasionally you have noticed it on the right side as well, but not as frequently. The pain is
worse in the morning and at the end of the day. Eating also exacerbates the pain and
occasionally it will wake you up from sleep.

The pain began 6 months ago at the time when you were diagnosed with Non-Hodgkin’s
Lymphoma. You recognise that you grind your teeth at night. NSAIDS or antibiotics have not
helped. The symptoms are not related too hot, cold or sweet foods or drinks. There has been
no injury to the area or jaw and there was no previous history of it.

There are no other medical issues of medications being taken.

You are waking up early in the morning since the Non-Hodgkin’s Lymphoma diagnosis and
you’re a petite is poor and deteriorated. Your mood does vary during the day and you have
less energy than normal. You recognise you have been stressed since the diagnosis and
treatment for the condition.

You also know that your mouth has been dry and that a white line has appeared on your
cheeks on both sides, and you have noticed your tongue has small indentations along the
side.

Your dentist has not found any other causes after investigations on your teeth involving X-
rays and applying something cold to each tooth. You also remember something to do with
"small electric current".

You have had a click for the last 3 years and although you an open your mouth fully,
occasionally it feels it gets restricted/limited in how far it opens.

31
[Type here]

● Good morning Michael, my name is_____, I’m one of the dentists here. I understand that
you have pain on the side of your face,
● Sorry to hear you are suffering such a problem, I want to assure you we will do something
about it but I need to know more details about it?
● When did you first notice the pain?
● Does it radiate to other areas?
● Do you grind your teeth? Do you have any sensitivity?
● Did you have a trauma in that are?
● Did you take any pain killers for it? did it help?
● Did you seek any treatment for it?
● Are you currently seeing your GP for any medical condition(arthritis) or do you take any
medication?
● Sorry to hear about your recent diagnosis, how are you coping with it?

Explanation to the patient and Management

Michael it is likely that you may be suffering from TMPDS. This is a very common condition
which affects your jaw joint and muscles in one or both sides. This could be because your
teeth are not meeting together properly.

Stress and depression aggravates this condition because of grinding. for the discomfort to
disappear you need to relax. As you are going through a stressful time I would suggest
referring you to counselling for stress management and they can prescribe you
antidepressants. you need to be patience and give the treatment time to work.

Regarding the treatment, you need to follow my advice by relaxing your jaw. For this you
need to:

● Stick to a soft diet and try to avoid hard food

● Apply heat to the area and try to massage the area gently

● I will give you some pain killers that helps you with relieve the pain

● I will give you some leaflets that explains some jaw exercise relaxations it will help
you with the muscle ache

I will be seeing you on a regular basis and if after a month if the pain still exists. I will
give you a night guard which is basically a plastic plate that goes on top of your teeth
and keeps them apart and that will decrease the pressure on your muscles. If after a
month that doesn’t help I will refer you to a specialist for further test and treatment, is
that alright? what can the specialist do you cannot? they are qualified to do further
treatment such as injecting some medication there to help reduce the inflammation
inside your joints do surgery.

Is that clear so far? Do you have any questions? Thank you

32
[Type here]

33
[Type here]

14-Trigeminal neuralgia:
You are a dentist in a general practice. A 63-year-old female patient presents to your
surgery. She is very distresses and complains of a recent onset of intense facial pain. You
need to take a through pain history, provide a differential diagnosis and discuss further
management.

34
[Type here]

Examiner instruction

Examiner will play the anxious patient in the absence of an actor. Candidate needs to
demonstrate the ability to be empathetic to the patient, take a through history of the
present complaint and explain the differential diagnosis

Actor instruction

You are the distressed patient, you have had a two-week history of intense, stabbing pain
located in the region of your right cheek. The pain is so intense, electric shock or stabbing in
nature, lasts seconds, is triggered by touching the area, washing face, applying make-up.
You cannot stand the area to be touched, sometimes even eating moving your mouth can
bring the pain. The pain his affecting your life, cause you to stop all activity until pain is
resolves. The pain does not radiate anywhere, it very well localized over your right cheek.
You are medically fir and well, have not recently had any dental work performed, have not
felt otherwise unwell and have never had symptoms like this previously. You would like to
know the cause of this pain.

Criteria Done
marks

1- Candidate reassures patient 1

2- Ask about the location of pain and if it radiates 1

3- Ask about how long the patient has experienced this pain. Ask about the duration 2
and frequency of episodes of pain

4- Ask the patient to describe the pain, severity (use pain score) 2

5- Ask the patient if there are any precipitating factors/relieving factors. Ask if 1
analgesics have been used and if they have helped

6- Discuss if the patient has experienced symptoms like this before, if they sought 1
any other opinion about this

7- Discuss with patient a deferential diagnosis of trigeminal neuralgia (most 1

likely)/persistent idiopathic facial pain? Post herpetic neuralgia

8- discuss referral to oral maxillofacial/oral med clinic/GP 1

TOTAL 10

Good morning Mr/Mrs , my name is , how can I help you today?

35
[Type here]

Sorry to hear you are suffering such a problem we will do something about it but I need to
know more details about the problem,

Site:

Can you point exactly where is the pain?

Onset:

Since when has the pain started?

Have you had it before or is it the first time?

How long does the pain last?

How often do you have it?

Is there anything that triggers the pain? Is there anything that makes it feel better?

Did you take any pain killers for it? did it help?

Character:

Can you describe the pain for me?

How sever is the pain can you give it a score one been least painful and 10 being the most
painful?

Radiate:

Does it spread to another area?

Associated symptoms:

Does it affect your sleep?

Any itchy skin? Did you have a painful rash in that area recently?

Treatment:

Have you had any dental treatment recently?

Have you sought medical advice for it?

Are you generally fit and well?

36
[Type here]

Thank you for the information Mr/Mrs, facial pain is associated with a couple of condition
that share some similar symptoms and these are:

1-is trigeminal neuralgia: this is a condition affecting a major nerve called trigeminal nerve
that supplies your face. The cause is unknown, I am inclined to this because of the
description of pain which happens in one side only, stabbing pain to the slightest touch. It
happens after age of 50 due to compressions on the nerve which happens for various
reasons, and it start sending pain messages to the brain and the pains can be of great
severity.

2-idiopathic facial pain: is also a condition of continuous long lasting pain that spreads to
other side of your face

3-post-herpetic neuralgia: which is another type of facial pain related to areas of the face
which has been affected previously with a virus that stays in the body for long time.

Now I would like to refer you to a specialist were further test will be done to make a proper
diagnosis of the condition.is that alright with you? The specialist will prescribe you some
medication called carbamazepine and they will perform some blood test to make sure your
liver is fine and its safe to have the medication. Is that clear, mr? in the mean time I would
advise you to avoid the trigger factors such as

Do you have any other questions?

Thank you.

15-Lip laceration by a colleague:

You are approached by a colleague who informs you that while working on a patient, his bur
slipped and cut the patients lip. There is some bleeding and slight discomfort. However, the
patient did not experience any pain. Explain how would you proceed from here with regards
to patient management and risk management.

Criteria Done
marks
1- Advice colleague to stop working and inform the patient of injury 1
2- Assess the injury, how deep is it, is there any breach of the skin, advice patient on 1
the extent of injury and on plan of management
3- Management of bleeding using a pressure pack, local aseptic agents, suturing 1
4- Advice patient of possible problems, risk and complication and their likely 1
management. (pain, swelling, bleeding, infection, scarring)
5- Continue or defer dental treatment (discuss with patient) 1
6- - if injury is sufficiently deep to require more very basic suturing, consider advice and 1
possible referral to maxillofacial unit. (do not send patient to hospital before calling
the team)
7- Make a detailed record of the incident in the patient’s note along with photographs, 1
list of witnesses and discussions with patient
8- Record incident in practice’s / department’s accident record logbook or fill incident 1
form

37
[Type here]

9- Inform patient of practice’s complaint policy and his right in case he would like to 1
make a complaint
10- Inform dental indemnity provider 1
11- Carry out regular audit for incident analysis and record it in practice clinical 1
governance folder
12- Ensure regular training for the team to minimise frequency of accidents. 1
TOTAL 12

● Frist of all I don’t want you to panic, this was an accident, and can happen to anyone no
matter how careful you are.
● tell me what happened?
● Is there any laceration to the skin?
● Did you inform the patient?
● I understand you are distressed, you have a professional duty towards the patient. You
should go back to the patient, stop treatment and apologize for this mishap and explain that
it happened by accident; reassure the patient that you are going to take care of him.
● Check the patient’s medical history to see if he has any bleeding problems. Assess the
depth of the wound.
● Try to stop the bleeding by applying pressure with gauze if it is superficial, give sutures if it
is relatively deep. If any redness or swelling apply cold pack. Remind them about possible
risks of infection and scarring.
● If it is deep and you cannot control the bleeding, refer him to the maxillofacial unit and
before sending him make sure they are informed before he goes.
● After you have treated the laceration, arrange a follow up appointment. If sutures are
placed, they may need to be removed after one week.
● if it is a minor wound discuss with the patient if they are happy to continue the treatment or
prefer to defer it to another time.
● Note down the details of the accident and the steps you have taken in the with some
photographs of the injury in the Accident Book and the patient’s notes. Ask your nurse to
sign it and ask the patient to countersign it.
● If the patient is unhappy and wants to make a formal complaint, explain their right and
complaints procedure policy in our practice.
● Call up your indemnity provider and take their advice on this matter.
● We do carry regular audits for incident analysis and I would recommend we carry out more
training for the team to minimise the frequent of these accidents.
● Is there anything else you want to know?
● Thank you.

16-Needle-stick injury:
While cleaning up after the last patient, and with the patient still on the premises your
nurse has sustained a needle stick injury through her glove from a used dental needle.
Explain to the examiner what stages you would go through to comply with health and safety
law and current guidelines.

● Stop the treatment and calm the nurse and reassure her that that the risk of infection
is low and we will follow the practice protocol for needle stick injury for her/his peace
mind.

38
[Type here]

● Will assess the wound, if there is any breach of the skin? How deep is the injury? Is it
bleeding? if the needle went into the nurse’s blood vessels.
● Will ask her to remove the gloves, wash the injured area with running water and soap
● Not to suck or scrub the wound and encourage bleeding by apply pressure around
the injured area
● Explain to the patient wat has happed in private. Assess patient risk factor, if his
medical history up to date. And advise them their full cooperation would be of great
help and the information they give is confidential
● Patient will be given a confidential risk assessment questioner about (HIV, Hep
B,Hep C) and ask if they were prepared to give blood sample so that appropriate
post exposure prophylaxis is given to the nurse.(if patient is HIV aske about if he is
controlled any change in his medication recently and blood examination)
● If the patient is high risk, we will arrange for the nurse to urgently to attend local
occupational health department within an hour. for advice and further management
e.g. prophylaxis and virology
● I will make a record of the incident in the practice accident logbook and report it via
RIDDOR if the donor blood is from a high-risk patient.
● Maximise the use of sheath holders and single use disposable syringe system.
● Ensure that everyone in the surgery has their Hep B immunisation status is up to
date.
● Ensure there is regular training for the team and regular auditing of incident forms in
order to minimise frequent accident.

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

39
[Type here]

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. single injury indicate a risk of 300 HBV infections (30% risk), 30 HCV infection (3% risk) and
3 HIV infections (0.3% risk) per 1,000 respective exposures

40
[Type here]

The patient in front of you has attended for a restoration on the upper left first molar tooth.
Having administered a buccal infiltration, whilst attempting to re-sheath the local anaesthesia
needle, you suffer a needle-stick injury. Act out in front of the patient how you would manage
this situation, and describe to the examiner (where necessary) the sequence of events and
actions which you would follow in managing this accident, in both the short and long term.

Criteria Done
marks
1- Reassure the nurse that the risk of infection is minimal, but you are required to follow 1
the practice protocol for needle stick injury for her/his peace of mind
2- Assess the injury: how deep is it, is there any breach of the skin, has the needle 1
interred the patients’ blood vessel, is the injured area bleeding
3- Remove the glove, wash the injure area with running water and soap, do not scrub or 1
suck on the wound, encourage bleeding by applying gentle pressure to the punctured
area
4- Explain what has happened to the patient in an area that ensures privacy. Assess the 1
patient’s risk factor: medical history forms up to date. Advise them their full
cooperation would be of great help and any information entirely confidential
5- Ensure that the patient is asked to complete the confidential risk assessment 1
questionnaire (HIV,HepB,HepC) and ask if they would be prepared to give blood
sample so that appropriate post exposure prophylaxis may be offered to the nurse
6- If high risk, arrange for nurse to urgently attend local occupational health department 1
(ideally within one hour) for advice and further management, eg prophylaxis, virology
7- Record the incident in the practice department’s accident record logbook and report 1
via RIDDOR if the donor blood is from high risk patient
8- Maximise usage of devices such as sheath holders and single use disposable syringe 1
systems
9- Ensure that Hepatitis B immunisation status is up to date for everyone in the practice 1
10- Ensuring regular training for the team, and regular auditing of incident forms in order 1
to minimise frequency of accident

The centre of disease control and prevention (CDC) guidelines acknowledge that there is no
active PEP for HCV, only recommendations intended to achieve early identification of
chronic disease and, when detected, referral for evaluation of treatment options. According
to the CDC identification of acute infection with HCV may not necessitate active
intervention.[25] However, there is some evidence that treatment with interferon alfa-2b may
be beneficial preventing chronic hepatitis
CDC guidelines generally recommend a PEP protocol with 3 or more antiviral drugs, when it
is known that the donor was HIV positive; however, when the viral load was low and none of
the above noted risk factors are met

17-Acute apical periodontitis for a patient on

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

41
[Type here]

No relevant medical history except Osteoporosis and has no allergies. He/she has been medicated
with bisphosphonate (Fosamax) 10 mg orally taken once daily since 2000.
A LR6 has a large MOD composite restoration and missing a mesioligual cusp. IT has negative
response to warm gutta percha, ethyl chloride spray, electric pulp testing. However, the tooth has
tenderness to percussion and pressure over it apices
An otherwise mildly restored dentition, no periodontal diseases and excellent oral hygiene.
Patient instruction:
You are Mr/Mrs Scholes a 75-year-old patient of this dentist. You are attending a non-emergency
appointment relating to your lower right first molar. The tooth was restored by this dentist
approximately 5 years ago with a large white filling. A part of this tooth fracture 6 months ago but it
did not cause you any problems so you have been monitoring it. In the last few day, however, the
tooth started to cause spontaneous, long lasting pain which has disturbed your sleep. The pain is not
worse with hot and cold, but mainly biting. The pain spreads to your right ear, not associated with
any swelling and is temporarily alleviated with simple pain killers.
You have no relevant medical history except Osteoporosis and you have no allergies. You have been
medicated with bisphosphonate (Fosamax) 10 mg orally take once daily since 2000. You have read
that this medication can limit what the dental procedure you can have.
You would like specific details in:
1-what exactly is the problem
2-what the options are for the tooth
3-what are the chances of getting osteonecrosis of the jaws
4-should you stop taking your medication
5-the advantages and disadvantages of the root canal treatment
6-where antibiotic can help or not,

● Nice to see you again Mr Scholes, how are you today?

Form you notes I gather that your tooth Mr Scholes is badly broken. unfortunately, you have
a condition called acute periapical periodontitis. As your tooth is broken it has caused death
of the tooth, as it has not been treated, this has also irritated the area around the tip of the
tooth root and that is why you are pain on biting.is that clear Mr Scholes

The option to relieve you from pain is either:

● To have a root canal treatment, where the centre of the tooth is cleaned and a filling
is put in place. The advantages of this treatment is that you will save the tooth and
there is a success rate of 90%. However, the disadvantages are that it is a long
treatment requires several appointments and a cap might need to be made to cover
and protect the tooth and that incurs further cost.
● The other option is to have the tooth taken out and have a replacement in the future.
As you are on Fosamax and you have a very slight risk of developing MRONJ which is
basically death of the jaw bone, because of the medication you are taking the blood flow to
your bone is reduced so your wounds might not heal and your bones become infected and
visible in your mouth. it is a painful condition it is estimated that one in every 10-100 in those

42
[Type here]

who are on injection and one in every 10000 in those who are on tablets. It is advisable to
avoid any trauma or injury to your jaws however it is entirely your choice.
Stopping the medication will not reduce the risk as the medication stays in your system for
very long time. also the risks from stopping it outweighs the benefits.is everything clear so
far?
● So what would you like to do Mr Scholes?
● If you still prefer the tooth to be taken out, we will make the tooth removal as atraumatic as
possible to avoid triggering bone death, you must maintain a good oral hygiene and follow
the post extraction instruction carefully to care for your wound afterward.
● I will be seeing you on a weekly basis for 4 weeks to check the wound is healing properly
and if there is any abnormality I will have to refer you to a specialist
● If patient asks about antibiotic? No you will not need them as there is no evidence that it
will reduce the risk of ONJ. Is everything clear so far?
● 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.

Criteria Done
marks
1 Use appropriate greeting 1
2 Explain to the patient that the LR6 Acute Apical Periodontitis and thus needs 1
extraction or RCT
3 Explain to the patient that they are on oral bisphosphonates so she is at very slight 1
risk of Osteonecrosis of the jaw.
explain what is osteonecrosis,
explain why extraction is best avoided whenever possible. The incidence of ONJ in
the general population is unknown. Estimates of ONJ patients taking bisphosphonate
range from 1in 10,000 in those on IV bisphosphonate and 1 in 100,000 in those on
tablets per year exposure from Scottish guidelines
these incidences are different in scully page 388 IV bisphosphonate is 1 in every 10-
100 and oral tablets is one in every 10000-100000

4 Explain that stopping medication does not reduce the risk of ONJ 1
5 Explain advantages of root canal treatment e.g. maintain the tooth and relatively high 1
success rate
6 Explain disadvantages of root canal treatment e.g. several appointments, longer 1
appointment and the tooth will need cast restoration

43
[Type here]

7 If patient prefers extraction, then candidate should explain that it will be done as 1
traumatic as possible and the patient needs to maintain superior oral hygiene and
needs to strictly follow the post extraction instruction given
8 In case of extraction patient will need to be reviewed weekly for 8 weeks, if there is 1
any sign of inappropriate healing then the patient will have to be referred to a
specialist
9 When patient is asked about antibiotic the answer is no as there is no evidence it 1
reduces the ONJ(new name is medication related osteonecrosis of the jaw MRONJ)
10 Check patients understanding 1
11 Talk empathically and does not use jargon 1
12 TOTAL

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
for less than 5 years.

● 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) medication
is for over 5 years
● 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

44
[Type here]

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 weekly for 8 week.

If surgery sites fail to heal within 8 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.
Other scenarios for this case is patient WILL START bisphosphonate so treatment plan will
change preferred is extraction of a poor prognosis toot.
Patient who has radiotherapy to head and neck will have risk of OSTEORADIONECROSIS
to the jaw extraction should be avoided RCT is best option. However if patient will start
treatment in few weeks best option is extraction of poor prognosis teeth.

If patient is taking medication for less than 5 years patient is low risk if more than 5 years patient
is high risk.
Patient on denosumab ONLY for any length of time he is at low risk.
If patient comes with small lesion of MRONJ refer to specialist for monitoring, OHI, antibiotic and
antibacterial mouth wash if it is a large lesion refer for surgery .

18-Post- Extraction Instructions:

• Good morning Mr. James, my name is…. I am one of the dentists here and will be seeing
you, how are you today? I’m here to explain you how to take care of the wound.is that
alright?
• After we remove the tooth there is a hole that is left behind, this is filled with blood
which becomes solid and works as a plug to prevent further bleeding and that is where
healing takes place so you need to take care of this clot as is it very delicate and can be
dislodged very easily. This is done by:
• not spiting or rinse your mouth for the rest of the day. avoid touching the wound with
your tongue or finger.
• Do not smoke or take alcoholic for rest of the day.
• avoid eating on this side for 3 days. And stick to a soft and cold diet for rest of the day.

45
[Type here]

• After 24 hrs., rinse your mouth gently with warm salty water for three times daily for 3
days.
• If brushing is uncomfortable around the wound, use chlorohexidine mouth wash for that
area until you can resume brushing remember a clean wound heals better than a dirty
one.
• If the bleeding continues after you have left the surgery, don’t worry, most of the time it
is only a mixture of saliva with a little blood. However, if you feel that the bleeding is
more, fold a clean handkerchief and place it over the wound and bite on it firmly for 15 -
30 minutes. If the bleeding continues please contact us immediately.
.
• The wound might be sore and slightly painful for a few days which is normal, so I’ll
prescribe you some pain killers which you can take when you have any pain. You might
also have some swelling it takes a few days to reduce. If the pain increases or gets worse
after a few days, please come to the surgery.
• The area around your tooth/lips, cheek and tongue would be numb for about 2 hours,
please be careful not to bite your lip while it is numb to avoid any injuries to it.
• You might also need to take a day off work.
• We will also give this information in writing.
• Do you have any questions?

19-Denture hygiene advice:

Candidate instruction:
Mrs Evans has just had her upper anterior tooth removed and replaced with an immediate
acrylic denture, as well as a lower chrome cobalt partial denture for her bilaterally missing
lower molars.
Please provide this patient with appropriate post-operative instruction and denture hygiene
instruction for both prostheses.
Note patient has been given the regular post extraction instructions.//
Criteria Done
mark
s
1- Use appropriate greeting 1
2- Explain to the patient that immediate denture is temporary measure for aesthetic 1
purpose
3- The denture may alter your speech at first but you will soon get used to it 1
4- Do not take the upper denture out today as it serves as a bandage and helps to stop 1
bleeding
5- You can take it out tomorrow and rinse your mouth with warm water and salt 1
6- Some discomfort is usually present when teeth are removed and immediate denture
are placed due to:

46
[Type here]

The trauma of removing the teeth, which will go away rapidly-or you can take pain 2
killer if the pain is sever.
The dentures may have pressure spots which will be assessed and removed on your
next appointment (please make sure you wear your denture for the last 24 hours
before your next appointment so we can assess the sore areas)
7- Healing for the tooth extraction will continue for months during which the bone and
the gum shrink which will render the denture loose and in that case the denture will 1
either need relining or a whole new denture might be fabricated to better fit
8- After every meal, remove both dentures and rinse in cold water, over a bowl of 1
water in case the appliance falls and break and brush your natural teeth
9- During sleep dentures should be removed (to allow the soft tissue to rest and 1
breathe) and stored in water (if not the denture may dry out and will not fit properly
as before)
10- Avoid :
Using any bleaching or acidic products to clean your metal dentures 2
Using very hot water to clean your dentures
Using the regular tooth paste as it might damage your denture
11- For the upper acrylic denture (has no metal) you can soak in alkaline hypochlorite
solution e.g, Dentural for 20 min
For your lower metal denture, you can soak in an alkaline peroxide solution e.g. 2
Steradent for 15min
Rinse dentures well with cold water after soaking
12- Check understanding, ask if patient has any questions and offer a leaflet with all the 1
instruction
Oo0 TOTAL 15

Good morning Mrs. Evans, my name is, I am your dentist for today.
I am here to give you instructions on how to care for your denture, is that okay?
The upper plate that you have is an immediate denture it is a temporary measure to replace your
missing tooth until the healing is complete. The healing process will take months to complete.
During this time the bone and gum will shrink down. This will gradually make the denture loose.
Don’t worry if this happens, we can repair it, replace it with a new one or discuss a fixed option.
As this denture is something new to your mouth, it might feel uncomfortable. it might change your
speech at the beginning.be patient and give it a bit of time and practice and you will get used to it.
This denture will serve as a bandage over the gap where the tooth was taken out. It will help stop
the bleeding and prevent it from getting infected. So, don’t take the denture out today. You can take
it out tomorrow and rinse your mouth with warm water with some salt in it.
Are we ok so far?
You might feel some discomfort in the area. This is will be mainly due to the trauma of removing
the tooth, which will eventually go away. However, if you feel the pain is too much you can take
some pain killers which will help.
Discomfort might also be some pressure spots on the denture itself. If that’s the case, we can easily
remove these little spots next appointment. However, make sure you wear your denture for good 24

47
[Type here]

hours before the appointment as this will mark the sore spots on your gum making it easier to
remove them from the denture.
Is that clear so Far?
Always remember, you must keep your mouth and dentures nice and clean all the time. Brush your
gums, tongue and remaining teeth with a fluoride tooth paste. After every meal take both dentures
out, rinse them in cold running water.
For the dentures, 3 simple steps to clean them properly: Brush, soak, Rinse. Remember to do this
over a folded towel or a bowel of water to avoid dropping the dentures and breaking them, because
this tends to happen a lot.
For the brushing:
Do not use the tooth paste to brush the dentures as this may scratch and damage them. Just use
warm water and soap and use a dental brush to clean all the surfaces of the denture.
Remember not use very hot water as it might change the shape of the dentures and make it difficult
to fit anymore. Also, avoid using any bleaching or acidic agents to clean the metal dentures like
household bleach
For the soaking:
You have two different materials for the dentures so we are going to use two different cleaning
solutions for soaking.
For the top plastic one you can soak it in alkaline hypochlorite solution or (DENTURAL) for 20
minutes
For the bottom one with the metal parts, soak it in alkaline peroxide solution or (STERADENT) for 15
minutes.
After that, rinse them carefully under cold running water.
One last thing, for the first week I would suggest to wear the denture all the time even when
sleeping that will help you to adjust to it quickly(oxford book page 302). However, after that you
must take it out while you are a sleep. Simply because your gums need to rest and breathe when you
sleep. Take the dentures out and place them in a glass of water to avoid them getting dry as this will
make them change their shape and not fit any more.
Do you have any questions?
I hope that was not too much for you. I will give you a leaflet with all the instructions we said this will
make it easy to remember and not miss out anything.

20-Broken file in root canal:

This is Mr/Mrs black. he/she has been referred to you by your colleague who is away on
maternity leave. You have to obturator the upper right 6. As you look at the x-rays of the UR6
you come across an x-ray with a broken file. Please explain to the patient options and
management

Actor:

48
[Type here]

You are Mr/Mrs black, 61 years of age attending this dentist for the first time to get an upper right
6 tooth treated as your dentist is on maternity leave. There is a broken instrument in the tooth but
you are not aware of the broken file. As the dentist explain about it you are shocked distressed
that you were not told about a foreign object left in your tooth. You are worried about the
possible harmful effect such as cancer, infection and poisoning. The dentist should offer you
various treatment option namely refer to a specialist for the removal of instrument, completing
the treatment by trying to bypass the instrument, trying to remove it, sealing the tooth and
leaving the instrument behind or extraction and replacement options. The dentist should also let
you know that referral to a specialist does not guarantee success of file removal. The dentist
should also warn you about possible worsening of the prognosis of the tooth due to broken
instrument. You select to have your treatment completed

● 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 okay?
● 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.
● ‘’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.
● However, in case we are not able to remove the broken bit, infection and pain could be a
possible complication.

The treatment options available for you are:

● I can try to remove the broken piece of instrument if I manage to pull it out and then, I can
continue the RCT as usual. If not I will refer you to a specialist who will:
● Use special instrument to remove the fragment of the instrument.
● He will try to bypass the broken instrument or fill the tooth up to the broken piece and
monitor it
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)

● Normally success rate is high, however because the instrument left behind success rate is
reduces and there is complication, there can be pain, swelling or infection as the canal may
not be cleaned in that area but we will keep monitoring it in case any abnormality develops
I will have to refer you to a specialist to have a small surgery around the root Is everything
clear so far
● Do you have any questions? I will note what has happened in your notes ,
● Thank you, Mr Black.

criteria

Criteria Done
marks

49
[Type here]

1- Introduce yourself 1

2- Communicate empathically 1

3- Explain broken file 1

4- Show the broken file on the x-ray 1

5- Apologies on behave of your colleague and offer to find out as to why the 1
patient was not told

6- Reassure patient about their fears of cancer/poisoning and infection 1

7- Explain various treatment option 1

8- Offer a specialist referral 1

9- Warns about future complications 1

10- Thank patient 1

21-Fissure sealant:
Candidate instruction:
Sophie Adams , medically fit and well 9 years old patient attends with her mother as a new
patient to your practice. She gives a history of previous decay in deciduous first molar Ds
which require extraction by her previous dentist 6 months ago. After a full history, clinical
examination and bitewing radiographs you find that she has a caries free mixed dentition, has
a fair oral hygiene and currently uses 1000ppm toothpaste twice per day. You decide that
fissure sealants of her first permanent molars would be an appropriate preventative measure.
please explain the intended procedure to the patient and her mother including risks and
benefits and why this would particularly benefit Sophie. Please also suggest further
preventative advice.
Examiner instruction:
In the absence of an actor the examiner will play the patients mother. The candidate needs to
demonstrate the ability to fully explain the intended procedure, the benefits of the procedure,
the risks of treatment and the reasons this would be beneficial to Sophie. The candidate needs
to demonstrated the ability to empathise with the patient and mother and reassure them
regarding the procedure.
Actor instruction:
You attend with your 9-year-old daughter Sophie. You understand that Sophie has holes in
some of her baby teeth which require extraction and that her last dentist suggested fissure
sealants to protect her adult teeth. you are not sure what these are or what they involve. you
also want to know if Sophie really needs this treatment. You would also like to know there is
anything else you can do to help you can do to help Sophie’s teeth.

50
[Type here]

You have specific questions about:

What the procedure involves
The risk and benefits of a procedure
Why Sophie needs treatment
If there is anything else, you can do to protect Sophie’s teeth.
Criteria Done
marks
1- Introduce yourself and, greet the patient and mother 1
2- Empathises with the mother and does not use jargon 1
3- Fully explain the procedure:
That it is a plastic coating to seal the grooves of her back teeth 2
Placement involves:
Isolating the tooth with a cotton wool rolls to keep the tooth dry and the tongue away,
cleaning the tooth with a gel (acid etch) washing and drying of the tooth, application
of a seal (resin based fissure sealant) and setting with a light.
4- Explain the benefit of treatment: 1
Seals the groves of the molars teeth to prevent food and bacteria collecting and
causing decay, reduced incidence of decay in sealed sites.
5- Explain why the treatment is recommended for Sophie:
Recommended for patient with high risk of decay in adult teeth (decay in 2 baby 1
teeth)
6- Explain further prevention measures:
Using 1350-1500 ppm toothpaste twice a day per day 2
Advise patient to spit following brushing rather than rinsing
Full diet analysis and tailored advice could be performed
Fluoride vanish application ( durphate 22,600 ppm) 3-4 times per year
7- Ask if they have any question 1
TOTAL 10

Good morning Mrs Adams and Sophie, my name is, I am one of the dentist here, I am here
to explain the fissure sealant that Sophie will benefit from is that okay?
The benefit of FS:
Sealants are a safe and painless way of protecting teeth from decay. It forms a protective,
smooth barrier by covering all the little grooves and dips in the tooth surface and that
reduces the incidence of decay.
Basically, fissure sealant it is a protective plastic coating, which is applied to the biting
surface of the back teeth. The procedure is usually quick and straight forward, taking only a
few minutes for each tooth. First, I will need to isolate the tooth will cotton rolls. Then the
tooth is thoroughly cleaned, prepared with a special solution and dried. The sealant is then
allowed to set hard by a shining bright light onto it.
This is recommended for those with high risk of decay in adult teeth, who had 2 decayed
milk teeth. Sophie falls under this category and she will benefit for it.

51
[Type here]

The down side of it that it needs to be monitored regularly, it can wear off and might need
replacements and the procedure requires a dry field to be successful.
There are other measures that will help Sophie to look after her teeth:
By brushing her teeth twice, a day one in the morning and another last thing before she
goes to bed.
using an adult fluoride tooth paste containing 1350 ppm of fluoride.
After brushing she should spit and not rinse or swallow the tooth paste
Full diet analysis and adjustment to her diet to reduce amount of sugar she consumes
And I will be applying a concentrated fluoride gel called (durphat 22,600 ppm ) that is
brushed on her teeth 3-4 times a year to make her teeth stronger.
Do you have any questions?
Thank you

22-Oroantral fistula Osce:

Candidate instruction:
Mr/Mrs white required an extraction of his/her upper left molar. This tooth was previously
root canal filled, approximately 10 years ago and has subsequently fractured vertically. A
month ago he/she had an infection associated with the UL6 whilst on a business trip for
which antibiotic were prescribed by an emergency dentist. Mr/Mrs white decide to have the
UL6 extracted before flying for his/her next business trip. You attempt the extraction and
successfully manage to remove both buccal and unfortunately pushes the palatal root in the
maxillary sinus. You then noticed blood bubbling in the socket and took a DPT that showed
the palatal root in the maxillary sinus.
Please explain to the patient
what has happened?
The next steps in your management including further treatment options
Patient brief:
You are Mr/Mrs white, 41 years old attending the dentist for extraction of a fractured upper
left first molar which was root canal filled 10 years ago. You had an infection associated with
this tooth for the past 1 month and was given antibiotic for 7 days by dentist emergency.
You now would like to have the tooth removed before next business trip in 3 weeks. Today
rd
the dentist tried to have the tooth out and only two teeth came out completely. The 3
root has been displaced in the space above your top teeth. you had an another x-ray and
now waiting for the dentist to tell you what has happened. You are not yet aware of the
situation are not yet aware of the situation and the dentist will explain about the infected
root being displaced in your sinus. On hearing this, you get shocked and distressed. you are

52
[Type here]

now worried about possible effect of the root not being taken out such as pain, infection,
the root causing damage to the other teeth and not being able to get the root out.
What to expect from the candidate:
The dentist should be able to inform you the situation honestly and use the radiograph
taken to explain further. Procedure reassurance and explain his surgical limitation and offer
referral to a specialist oral and maxillofacial surgery unit for the removal of the tooth from
the sinus. Inform you of immediate measures she/he will take. The dentist should be able to
offer a brief explanation of what will be done to remove the tooth in the hospital. He
/should instruct the Dos Don’ts. once they have explained everything you accept their
apology and select referred for a specialist service

Criteria Done
marks
1- Address the patient with empathy and explain the situation i.e palatal root 1
pushed into the sinus
2- Apologies and informs the patient of uncommon but known complication 1
Uses radiograph to explain the situation 1
4- Explain not being able to take the tooth out 1
5- Reassure them regarding pain/infection (patient main concerns while 2
abroad), the root causing damage to other teeth
6- Explain to the patient structured immediate management: 4
Promote good blood clot by approximating gingival margins closely or
placement of physical agent in the socket to stop excessive
bleeding(surgicel), along with suturing the socket if needed
Prescribe antibiotics(amoxicillin/doxycyxline/clarithromycin) and nasal
decongestant such as Otrivine(xylometazoline)
Advise steam inhalation or saline nasal douches
Advises warm salt water rinse and OHI
Advise on analgesia and what to expect in terms of swelling and bruising
7- Discuss with the patient Do’s and Don’ts and offer written leaflet
summarising this:
Do’s Don’ts
Follow the instructions Smoke
Finish course of antibiotic Blow nose 3
Use nasal drops
Sneeze with open mouth

8- Offer a specialist referral and explains superficially what treatment will be 2

carried out by a specialist
9- Thank the patient for being understanding and enquire if they have any 1
further question
10- Actors marks: empathy, explanation of treatment option and outcomes 4
TOTAL 20

53
[Type here]

Mr White, I am sorry to inform you that as I was taking your tooth out one of the roots has fractured
and pushed into the sinus in your upper jaw. I sincerely apologise for that and want to assure you
that we will do something about it today.
it is one of the rare known risks associated with removing the upper back teeth due to root
proximity to the sinus. if you look at the x-ray you can see here that back dark area is the sinus which
is basically a hallow space used to resonate your voice it’s found in your cheek bones on both sides
of the face, and you can see that white bit is part of you tooth is pushed in it. It has formed a
communication between this area and your mouth. Is that clear Mr?
unfortunately, I can’t take the tooth out and will have to refer you to a specialist, they will take out
the root under a minor surgery and the gums will be stitched over the wound afterwards.
for today I will stitch the boarders of the wound together and will apply an agent in the wound
where to stop any bleeding. I will also give you some pain killer to deal with the pain if you have any
and I will also prescribe you some antibiotics to prevent any infection. I will also prescribe some
nasal drops to relieve any congestion. The area might be sore and will have some slight swelling and
bruising which should disappear after couple of days.
While you are waiting for your referral, I want you to follow some instructions:
1- you should not smoke as it reduces your body’s ability to heal itself and fight infections.

2- Do not blow your nose and remember to open your mouth when sneezing

3- I would advise you to brush your teeth and keep them clean and healthy and rinse with
some warm water and salt three times a day for three days to help with healing and prevent
infection

4- I would recommend inhalation of steam as that will help to relieve any nasal congestion.

There is a risk that you might develop sinusitis where you will have nasal congestion, heavy feeling
on your cheek. If this surgery is not done food and drink will pass from your mouth to your nose. The
root can cause infection and you might develop recurrent episodes of sinusitis. is that clear Mr? do
you have any question?
I do apologise again and thank you for your patience and understanding. Thank you for your time.

54
[Type here]

23-ORAL HYGIENE INSTRUCTIONS

Candidate instruction
A regular 30-year-old patient of yours Mr/Ms Rooney) has attended his/her annual check up
The patient has:
No relevant history, has never smoked and does not consume alcohol
The following teeth are present
. Mr Smith has come to your practice for his regular check-up. He is keen to improve his oral
hygiene. Please provide him with the oral hygiene instructions.

7654321 1234567

7654321 1234567
Moderate oral hygiene with obvious supra gingival and interproximal plaque. He/she also
has BPE scores of
1 1 1
1 1 1

55
[Type here]

No other clinical radiographic evidence of pathology (caries, bone loss). please obtain an
appropriate history with regard to the patient’s oral hygiene and then modify this using
equipment provided.
Patient instruction:
You are Mr/Mrs 30 years old patient of the dentist. You have been a regular attendee on
annual basis and have never required any dental treatment apart from scaling and polishing
you:
have no relevant medical history, has never smoked and are teetotal
have all your teeth present except your wisdom/ third molar teeth which were never
present
brush your teeth for about a minute twice a day with manual tooth brush
floss once in a while which causes some gum bleeding
use no mouth wash or interdental cleaning add (TePe brushes)
you have specific questions about:
what the diagnosis is?
whether you will lose your teeth?
what you need a long-term mouthwash or antibiotics?
what you can do to improve your oral hygiene?
what can you use to clean between your teeth?
what you can do about the tight spaces at the front of your mouth?
Notes for examiner
The candidate will require:
A set of upper and /lower models to demonstrated manual tooth brushing
A manual toothbrush
For the modified bass techniques, the toothbrush should be:
Held horizontally for a buccal surface and more vertically for lingual surface
Aimed at the gingival margin with the bristle at approximately 45 degrees to the long axis of
the tooth to provide subgingival plaque removal
Used in small circular motion with a roll towards the occlusal surfaces
Used in a systematic fashion e.g. posterior in anterior in each quadrant
The candidate should also instruct the actor to scrub the occlusal surfaces of the teeth and
that it will take approximately 2 minutes twice a day
Criteria Done
marks
1- Use appropriate greeting, introduces self to patient 1
2- Ask about the current regime including tooth brushing (electric or manual and duration of 1
brushing, size of head and stiffness of bristles)
3- Ask about adjuncts including inter-proximal cleaning aids (flossing, bottle brushing and inter- 1

56
[Type here]

space brushes) and mouthwash use

4- Advice diagnosis: gingivitis (reversible periodontal inflammation) NOT periodontitis 1
5- Deals empathetically with fears of losing teeth 1
6- Explain mouth wash or antibiotics will not prevent gingivitis in the long term 1
7- Show the modified bass technique with emphasis on plaque removal from tooth/gingivae 1
interface
8- Explain about proximal brushes e.g. TePe , Vision or interspace toothbrushes 1
9- Explains about proximal brushes e.g. appropriate technique e.g. loop technique 1
10- Does not use jargon and checks understanding, before closing 1
Total 10

Good morning Mr. Smith, nice to see you again. how are you today? I gather from you notes that
you are interested in more information about how to look after your teeth and gums is that correct?
, I want you to rest assured we will do something about it today.
Your gums are bleeding because you have a condition called gingivitis which is an inflammation of
the gum. The y become very red and swollen and often bleed when they are brush. Gum disease is
the main cause of tooth lose. this is cause by plaque which is a film of bacteria which forms on the
tooth surface. To prevent gum disease and decay you need to remove this layer I will give you some
instruction but first I need to know:
How many times do you brush a day? ONCE
How long do you brush your teeth each time? One minute
Do you use a manual or electrical toothbrush? Manual
Is it a soft or hard bristle?
Are you using any cleaning aids?
Mr Smith you are doing an excellent job brushing once daily. However, to remove dental plaque
efficiently, we need to brush twice a day once last thing before bed and another on any occasion
during the day for at least 2 minutes. With a medium bristle brush and a toothpaste that has
fluoride.
(we now need to demonstrate brushing! There will be props -jaw model, toothbrush, tooth paste,
dental floss, interdental brushes, mouth washes)
So if you can see here Mr smith, you need to hold the brush and place the brush head at about
45deg along the gum line, start from any side of convenience then use gentle rolling motion and
sweep towards the chewing surface do it in a systematic manner so you don’t miss any of the sides.
Are you clear so far? YES. So brush the outside, inside and the chewing surfaces. And do not scrub.
Are you clear? YES
However, Mr Smith brushing only removes 60% of plaque and what we miss is cleaning in between
the teeth. Do you use anything to clean in between teeth? I USED TO FLOSS BUT STOPPED BECAUSE
IT WAS BLEEDING!

57
[Type here]

Okay so let me demonstrate you about( loop technique) flossing as well. (taking dental floss) you
take about 18inches of floss, roll around your middle finger and leave at least an inch in between.
Gently insert the floss between 2 teeth, below the gum line and make a C shape around the tooth
you want to clean. Move your floss up down and gently remove it. Am I making sense to you? YES.
Now roll that used part with your right finger and release from the left finger to get a fresh part.
Mr Smith it is very common to see bleeding initially but this will eventually disappear and do not let
this dishearten you. Okay? YEAH
There are also bottle brushes or TEPE brushes available to clean in between teeth where there are
spaces. They come in different colour denoting different sizes. Are you following me?
So do you use mouth wash? NO.
Mouth washes help kill germs and also leaves a fresh breath. Make sure you use it at least half an
hour after brushing as we want both toothpaste and mouth wash to work efficiently. Does that
make sense to you? YES (choose the correct mouthwash)
Mouth wash and antibiotic will not prevent gum disease brushing is the most effective way to
prevent it.
I am also going to give you some tablets that disclose plaque. You just need to suck or chew on it
and it discloses the areas you may have missed so u can concentrate on those areas well. Okay?
(hand over the plaque disclosing tablets)
I know this is a lot of information. I am going to give you leaflets about everything that I have just
mentioned, so that you can take them home and give them a good read.
Do you have any questions? NO
Okay Mr Smith, thank you and have a good day!
Fluoride sodium monoflouro-phpsphate/ anticlculus
Modified bass technique: tooth brush 45 degrees with long axis of the tooth , bristles of brush
should be in the gingival sulcus with small short back and forward action with sweeping motion
towards the occlusal surface
Stillman technique: the tooth brush towards the apexes of teeth with small circular motion
Modifies stillman technique: place the brush at a 45 degree with long axis of the tooth with the small
circular movement then one stroke gently toward the occlusal surface

rd
24-Consent for extraction of a lower 3 molar
Candidate instructions
Mr/Miss Jones has had 3 episodes of pericoronitis associated with her lower left third molar,
two of which needed antibiotic prescription.

You are planning to remove her mesially impacted and partially erupted lower left third molar
under local anaesthetic. On radiograph the roots of the tooth are in close relationship to the
inferior dental nerve canal.

Please consent this patient to have the above-mentioned procedure.

Patient brief

58
[Type here]

You are Miss Jones, 33, attending you dentist to seek explanation as to how your dentist will
remove your wisdom teeth and what problems may arise after the surgery.

You would like to know an outline of the surgery itself, and also what problems will there be
after the surgery. It is important that the dentist makes you aware not only of the pain and
swelling that will follow but also the risk of damage to the inferior dental nerve and lingual
nerve. If he does mention this then you should try and establish how long the effects will last,
where will the numbness be most noticeable.

You are medically healthy, with no allergies and you are not taking any other medication

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

● Good Morning Mrs Jones, my name is_______, one of the dentists here and will be seeing
you. I understand that your wisdom tooth is causing you trouble and I am here to explain
the procedure to have it removed, is that alright?
● I understand that you are a worried and concerned but I can assure you we’ll make sure
you feel no pain during the procedure and if there is anything that makes you feel
uncomfortable or stressed please do let me know.
Explain reason for surgery
● As you know, this tooth hasn’t come out straight. Because of its funny position it has
caused problems like pain and swelling a few times. According to official guidelines from
the National Institute of Care and health 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
● the procedure will numb the area. We’ll make 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.
Post- surgical instructions

59
[Type here]

● After the procedure, the area will be sore and swollen for a few days. You might also have
some difficulty opening the mouth for a few days, and you might have to take a few days
off work.
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 for few weeks to few months. Chances of this happening
temporarily is around 10%
● Another nerve that supplies your tongue called Lingual Nerve, can cause some alteration in
taste. the probability of this happening less than 2%. however, both nerves can be
damaged permanently in less than 0.5%. (these incidences are from RCS patient leaflet)
● IAN function is disturbed in 0.5% of procedures (range
1.3 – 7.8%). Most patients will regain normal sensation within a few weeks or
months and < 2% (range 0 – 2.2%) have a persistent sensory disturbance. Reference is
odell page 116
A higher incidence of IAN injury has been reported with wisdom teeth that are
horizontally or mesio-angularly impacted and have complete bone cover. (wait for 3
months before referral)
● 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 and, we might
prescribe you antibiotics. You should follow the aftercare instruction to avoid infection and
bleeding.
● 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.

60
[Type here]

25-Consent of extraction of the upper first molar:

good morning mr/mrs, my name is, I am one of the dentist here and I am here to explain the
treatment you are having for the removal of your upper tooth.is that alright?
The procedure is a simple one done under local anaesthesia, you should feel no pain only
the pressure of the push and pull. The tooth can come out in one piece or we might need to
separate them into two pieces. There is a chance that the tooth might break and we might
need to make a small cut in the gum to have it removed.
Side effect of this procedure will have pain, swelling which should subside after a couple of
days and you can take some painkillers to deal with pain is that clear. There will be some
bleeding too which you will be given a gauze back to bite on to stop the bleeding. After the
procedure, will be instructions on how to look after your wound verbally and written.
If you look the x-ray here, you can see that darker area that is your maxillary sinus and you
can see how close the roots of your teeth are. There is a small risk that the root of this tooth
might push into that space leaving a communication formed behind. If it is a small one, it
will heal on its own however if it is a larger one I will have to place some stiches or refer you
to a specialist if it is quite a large one I will refer you to specialist as if it not closed food and
drink can escape from your mouth to your nose and it can cause infection. You must be
careful not to blow your nose. You will be given further instruction about how to care for it,
nasal drops, inhaling steam and antibiotic may be given. Are you following me mr/mrs?
Do you have any questions?

61
[Type here]

Thank you
***In case of extraction of upper wisdom risk are formation of a communication happening
between your sinus and mouth (oroantral-fistula) and fracture of the jaw (maxillary
tuberiosity)

26-Dietary advice:
Mrs Johansson has come to the hospital with Norman a 10-year-old child. Please talk to
mother, analyse and assess the diet chart provided which belongs to Norman.
1- Introduce yourself to the patient and the mother
2- Brief history about:
● diet history, feeding habits and amount of sugar consumed
● dental history, brushing. fluoride exposure,
● medical history
3- Explain the relation between sugars and decay
4- Explain why the patient has been given a diet chart to fill and highlight all sugar intake
5- Diet advice on amount/frequency/consistency/timing/hidden sugars/natural sugars/acidic item and
healthy substitutes, look for happy logo
6- Oral hygiene and fluoride advice
7- Check understanding and Thanking

Good morning Mrs Jonsson, my name is, I am one of the dentist her and will be seeing you
today. I understand that you are here to discus the dietary chart that you have been given
to fill. But first I need to know more details, is that alright?
How many times does your child brush their teeth?
Does he use a fluoride tooth paste?
Is your child fit and health? Do they take any regular medication?
I would like to thank you for thoroughly and meticulously completing the chart.
The aim of this chart so we can analyse your child’s diet, highlighting the amount of sugar
and the frequency of it. Also, it Sheds the light whether your child is having a balanced diet
which is important for their growth.
Research has shown a strong link between sugar and tooth decay. Germs in our mouth
convert sugar into acid which attacks our tooth structure and that is how decay starts the
more frequent the sugar is consumed the higher the risk of developing tooth decay.
Looking at the chart some of the sugars are obvious such as sweets, chocolate and cake.
There are other sugars which are hidden in our food which you might not be aware of such
as ketchup, baked beans and cereals.
You need to do some adjustment to his diet by reducing the amount sugar intake. Avoid any
sticky sugary food such as cakes and toffee as it takes longer to clear away. Sugary food and
drinks should be restricted to meal time. Fruit juices even with no added sugar should be

62
[Type here]

avoided because they are acidic and attacks the tooth structure too try to replace that with
plain water or milk which contains calcium which is important for their bone growth.
If you want to give your child a snack try to choose a healthy one such as fresh vegetable,
cheese or nuts. When purchasing food look at the nutritional labels on the packaging, sugar
can be hidden under different names such as glucose, fructose or lactose. Look for the
happy tooth logo which are teeth friendly food.
It is important to maintain a good oral hygiene to reduce risk of decay by brushing twice a
day once before you go to bed and in the morning with a fluoride tooth paste containing
1350 ppm. Brush for two minutes. Make sure your child does not eat anything after that and
sugars are strictly forbidden an hour before they go to bed as the saliva flow which helps in
cleaning is reduced dramatically during sleep.
Last thing if your child is taking any medication make sure it is sugar free .
Is everything clear so far? Do you have any questions? I will give you some leaflets regarding
a balanced diet and effect of sugar so you can have a read through them again.
Thank you
Mrs .Johnson bas come to hospital with Norman a 10 year old child. Please talk to mother,
analyse and assess the diet chart provided which belongs to Norman and provide diet
advice.
NB: In this station you will be given a diet chart which you have to discuss with a patient.
Usually this is a child so you have to discuss with the parent.

27-Fractured anterior tooth:

Candidate instruction:

63
[Type here]

A 40-year-old regular patient of yours Mr/Mrs Bryant attends for an emergency

appointment relating to his/her UL1. The tooth fractured earlier today at the edge of a
swimming pool and is causing pain with hot and cold stimuli but not biting .
Patient has:
No relevant medical history and has never smoked
A job marketing requiring him/her to fly abroad on the night to give an important
presentation
An otherwise unrestored dentition and excellent oral hygiene
An UL1 which has no clinical or radiographic evidence of pathology except crown fracture of
enamel and dentine only. It is positive to warm gutta percha, ethyl chloride spray and
electric pulp testing.
No clinical or radiographic evidence of caries, bone loss or fracturing of any other teeth.
Please provide this patient with options of restoring this tooth including advantages and
disadvantages.
Nice to see you again Mr Bryant? sorry to hear about your broken tooth, I know you are
worried but rest assured we will definitely do something about it today, how does that
sound? Do you have the fragment with you? If patient has the fragment an in one piece it
can be bonded to the tooth
Although you are having sensitivity I want to reassure you that the injury to your tooth is
uncomplicated. the fracture has only involved the outer layers of the tooth and not
extended to the core, so all you will be needing is a simple filling and no RCT is required at
the moment. However, this might be needed in the future because the trauma can cause
later irritation to the nerve.
I do understand because of your job aesthetic is important to you and there are some fillings
that are done at the laboratory and glues on to your tooth these provide better appearance
however due to time constrain it cannot be done.
The option you have is direct composite which is a plastic tooth coloured filling, this will
involve treating the tooth with some agent then the filling will be added and set to harden
with s special bright light. The procedure will be done under local anaesthesia and I will use
a rubber dam which is, it is a latex sheet placed over the tooth and has a metal frame
around it to prevent any saliva reaching the tooth basically it a rain coat to keep the tooth
dry.
The benefit of this filling, it is a conservative treatment as not much tooth structure needs to
be cut, it is done immediately and inexpensive. disadvantages it requires maintenance, can
absorb stains and colour is not affected with tooth whitening.
Staining can be reduced by avoiding staining food for couple of days after the procedure,
you should avoid drinks like red wine and coffee and although you are not a smoker and I
praise you for that but I just want to point avoid smoking which not only stain your filling
but your teeth too.

64
[Type here]

Do you have any question?

Thank
Criteria Done
marks
1- Use an appropriate greeting 1
2- Explain that the patient has an uncomplicated crown fracture without pulp 2
involvement
3- Explain that root canal treatment is not required as present but may be indicated in 1
the future
4- Explain that indirect restoration is not possible due to the time available and offer a 1
direct composite
5- Explain procedure including use of local anaesthesia and rubber dam 2
6- Explain advantages of composite i.e that it is minimally destructive, immediate and 2
inexpensive
7- Explain disadvantages of composite i.e that it will require maintenance, absorb 1
staining and will not change colour with tooth whitening
8- Explain that staining can be reduced by avoiding strongly coloured food post 1
operatively, not smoking in the future, avoid coffee and wine
9- Do not use jargon 1
TOTAL 12

28-Dry socket - pain after extraction:

65
[Type here]

Candidate instructions
Mrs Jones is a 65-year-old lady who has attended your surgery in pain. You removed her
UR4, three days ago and since then she has been in a great deal of pain. It started within 24
hours of the extraction and is a continuous ache which is not helped by any pain killer she
has at home. She can now see some tooth in the socket and is annoyed that you have left
some of the tooth behind. She also says that her daughter commented that her breath now
smells.

You have the picture of the patient's mouth to help you make the diagnosis.

Speak to the patient to explain what is happening and what you will do for her?

Patient instruction:
You have had an upper right tooth out your dentist, three day ago. About 24 hours afterward
you started to get pain from the socket which has been constant, aching and growing in
nature. None of the pain killer work including ibuprofen you normally take. You have been
unable to sleep and have begun to feel quite fed up. You daughter has told you that your
breath begun to smell. This morning you have looked in the mirror and have noted what
looks like a bit of bone or maybe a tooth in the socket, has the dentist left something behind
following the extraction?
You are 65 but fit and well, taking aspirin and a drug to lower your cholesterol. You smoke
20 cigarettes a day and have been smoking since extraction. You have no allergies but you
have had a similar problem in the past which was caused by a clot falling out.
The dentist will decide as what is wrong and will hopefully tell you how to have the problem
treated. Try and get him to prescribe you some antibiotics as you have heard it will help. The
dentist MUST NOT give you any as this is not correct treatment, the absence of any
systemic features which do not display.
…

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

● Good morning Mrs Jones, nice to see you again ,It is unfortunate that you have this
problem. I assure you we will do something about it. Before that, I would like to know few
details. Is that alright?
Take history of presenting complaint

● can you describe the pain? ( sever Throbbing and aching)

● Does it disturb your sleep? (Cannot sleep)
● Did you follow all the instructions given after the removal of the tooth such as not to rinse
vigorously and not to smoke afterwards?
● 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 o?
● have any major health concerns like diabetes, allergies, etc.?
(are you taking any contraceptive pills?) if patient is young
Diagnosis and basic explanation of disease and aetiology - dry socket (alveolar osteitis)
● From what we have discussed, it seems that you have developed an infection where your
tooth was removed we call dry socket. It happens in about 5 % of all extractions. Normally

66
[Type here]

when a tooth is removed, blood fills up that space and forms a mass called the blood clot.
This provides the foundation for healing.
● Dry socket occurs when the blood clot at the site of the tooth extraction has been
dislodged or has dissolved before the wound has healed. Exposure of the underlying bone
and nerves results in intense pain and infection of the bone, not only in the socket but also
along the nerves radiating to the side of your face.so that white part that you see is the
exposed bone not part of the tooth left behind.
● There are many factors that can cause this in your case as you take aspirin which cause
thinning of the blood and that prevents the clot from forming. The other cause is because
you smoked and had dislodged the clot other factors such as you have a history of such
a problem in the past and happens in lone standing teeth because they more difficult to
remove

It is more common in lower teeth, women, smokers and in difficult extractions or if any
previous history.
● What I can do today is, numb this area, clean and wash it with an antiseptic containing
Chlorhexidine. I’ll then place a dressing called Alvoygel paste in this space which will
relieve the pain. This dressing gets dissolved by itself and I will see you after 24 hours and
then a week to make sure the healing is taking place. I’ll also give you pain killers to ease
the pain at home.
● . 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
● by the national institute of clinical excellence that antibiotic is not recommended unless
you have fever. All you need is to follow the instruction I have given you.
● Thanks you.
● Do you have any questions?

67
[Type here]

29-Treatment option for an anterior missing tooth:

Candidate instruction:

68
[Type here]

1-Mr smith has lost his upper right lateral incisor (12). His concern is of an aesthetic nature.
He wants the tooth to be replaced.
Provide Mr. Smith with treatment option with advantages and disadvantages of each. Also
provide a risk assessment of the treatment option.
The information should enable, Mr. Smith to give you informed consent.
Patient information:
You are Mr, Smith aged 35 consulting your dentist to seek about treatment option and
possible treatment for your missing tooth in the upper front part of the jaw. The tooth was
removed 2 years ago and it is only now that you feel the need to have it replaced.
You would like to know all the replacement options for the missing tooth and the
advantages and disadvantages of each option. You would also like to know if there are any
associated risk with the individual treatment option.
Criteria Done
marks
1- Uses patient’s names 1
2- Provide all treatment options (including acrylic denture, chrome-cobalt denture,
resin-retained bridge, three-unit bridge, implant based crown) and explains
advantages and disadvantages of
1-removable partial denture: acrylic and Co/Cr 3
2-resin retained bridge 2
3-cantilever fixed bridge 2
4-implant retained crown
3- Describes the procedural aspects of each option briefly, and explains the risks 4
associated with each option
4- Actors appraisal marks including empathy, understanding, rapport and avoidance of 3
jargon
TOTAL 15

2-Patient lost central incisor and is. He/she is not happy about wearing removable dentures
and needs to know fixed options. The patient smokes 6 or many cigarettes a day.
● Good morning Mr smith, my name is ______, one of the dentists here.I understand that
you want a replacement for your missing tooth? I need to know more details about the
problem
● how did you lose this tooth? Did you have any replacement for it in the past?

Patient gives h/o Trauma, restored with post crown, got fractured and now using an RPD
● Are you generally fit and well? Are you taking any medication? Take a brief medical history
(esp. Diabetes)
● do you smoke?
Explain treatment options with advantages, disadvantages and risks
● I understand your concerns and I will try my best to help you. There are several treatment
options available to you and I will explain each one with pros and cons, so that you can
make your mind up.

69
[Type here]

● First you have the option of a removable plate which has an artificial tooth attached to it
this will replace your missing tooth there is a plastic one and it is the cheapest option, easy
to construct and repair and in the future more teeth can be added. the down side that it is
fragile and can break if dropped and it is removable option.
● There is another version of this which is metal, the advantage of this it is more hygienic,
stronger and less bulky the down side of it more expensive and difficult to adjust.

● The other option is sticky bridge; it is an artificial tooth attached to a metal wing which is
glued to the tooth adjacent to the gap. Advantages are it is simple and cheaper and not
much preparation is required. The disadvantage is the metal part may show through the
teeth. There is also a risk of it deboning if it happens we will have to glue it back again.

● The next option is of a bridge which consists of a cap sitting on the adjacent teeth attached
to an artificial tooth which fills in the gap. The advantages are that this lasts longer than
the adhesive bridge (8-10 years), better aesthetic and retention. The down side of that
healthy tooth tissue will need to be removed which can cause tooth death 1 in every 5. If
that happens you might need a RCT in the future.

● The last option is a single tooth implant which would be done by a specialist. A small metal
rod is placed directly in the bone and an artificial tooth sits on top of it. The advantages are
they are excellent in appearance, usually very successful long term permanent option. But
they are very expensive, long treatment and involve surgery and that is associated with risk
of complications like pain, swelling. The success of implant goes down in your case
because of smoking. So, if you opt to go for this option, you may have to stop smoking to
increase the success of treatment.

● So those are your options and we can give any, depending on your choice I will give you
some leaflet have a read through them at home and what every you decide we will take it
from there.

● Do you have any questions?

● Thank you.

Acrylic partial denture

Advantages Disadvantages
Cheap Weak material
Easy to construct and repair Non rigid
Easy to modify (addition) Must be bulky for strength
High potential for damage to soft tissue
May move during eating and chewing
May need replacement after few years

Cast partial denture

Advantages Disadvantages
More hygienic compared to acrylic dentures Expensive
Stronger in thinner section and lighter in weight Difficult to adjust
Higher thermal conductivity May require removal of tooth structure for rest

70
[Type here]

Dimensionally stable, fits better and is more seats

durable Visible metal hooks wrap around surrounding
teeth to stabilise
May need replacement after few years

Resin retained bridge

Advantages
Looks, feels and functions like a natural tooth
No need to remove from mouth for cleaning
Cheaper than dental implants
Aesthetically better than denture
Disadvantages
Expensive than denture
Adjacent tooth to be prepared
Cement may deteriorate over a period of time
allowing bacteria to seep or get deboned

Dental implant
Advantages Disadvantages
Most similar to a natural tooth, restores from Expensive.
and function in same manner. Not suitable for everyone.
Adjacent teeth don’t have to be prepared. May require additional procedure like
May decrease bone shrinkage after tooth loss. simultaneous grafting.
Preserve natural appearance and contour of the Requires more visits.
face and gums. Failure to ossteointegrate.

30-Discoloured upper right central incisor:

Mr John Brown is a 35-year-old medically fit patient. He is employed as a school teacher. Mr

Brown originally presented with a painful and discoloured UL1 5 years ago, following a road
traffic accident.

You had successfully performed root canal treatment for the tooth. Mr Brown has noted a
gradual deterioration in the colour of the tooth, and this has led to him attending today.

71
[Type here]

Explain to Mr Brown why the UL1 has discoloured. Discuss the various treatment options
available to manage his aesthetic concerns. Please outline the relevant advantages and
disadvantages for each option.

Patient instruction
5 Years ago, you were in an accident and nothing was done about your tooth. A year ago,
you noticed some pain and went to the dentist who advised you that the nerve was dead in
the tooth and suggested root canal treatment. This was done and the tooth went a little grey
which you were not too bothered about out. However, now the colour had darkened and you
would like to go through some possible options to remedy this.

● Good morning john, nice to see you again. Sorry to hear you are not happy with the colour
of your tooth rest assured we will definitely do something about it and I will explain to you
about possible treatment options. But first can you tell me if there is any pain related to that
tooth?

● this discolouration can be due to dead tissues left behind this can pass to the second layer
of tooth called dentine and can show through. It can also be due to the reflection of the
filling material used in the nerve treatment.

● we could try tooth whitening treatment (or bleaching) to the inner centre of the tooth by
removing some of the filling and applying some whiting chemical and we seal the tooth.
We can also bleach the outer layer of your teeth by applying some chemicals in a tray
which fits on your teeth. Advantage is the improvement of aesthetics and there is no
invasive treatment involved. However, disadvantage results are unreliable and sensitivity of
the teeth. There is a risk of destruction of roots of the tooth.

● If you are not happy with the results, we can go for veneers, is a thin shell made of glass or
plastic cemented on your tooth. The plastic veneers are inexpensive and easy to polish
and repair but can discolour or chip.
● Porcelain veneer on the other hand has excellent aesthetics and strength Disadvantage is
that it requires minor tooth shaping and cost.
● The last option is a crown, which is a cap glued on top of the tooth. Advantages it will
provide good aesthetic and support. 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 risk of
tooth breakage during the tooth preparation.
● Do you have any questions?
● I know it’s a lot of information to take in so I will give you some leaflets that explains the
option take them home have a read through them what every you decide we will take it
from there.
● Thank you.

Criteria Done
marks
1- Use appropriate greeting and patient’s name 1
2- Explains that the tooth has a discoloured due to loss of vitality, maybe related to

72
[Type here]

blood breakdown products or material component passing into the dentinal tubules 3
and shining through. Can also be due to excessive gutta percha in the coronal portion
of the tooth shining through
3- Internal or a combination of internal and external bleaching with GP removal tot the
cervical region of tooth. 3
Advantages-minimally invasive, disadvantages -unpredictable, risk of external
resorption
4- ● Veneer-composite resin
advantages: inexpensive, easy to polish and repair.
Disadvantages: may require minor preparation, can chip, aesthetics and strength 3
not as great as porcelain. .discolouration may shine through
● Veneer-porcelain:
advantages: excellent aesthetic,
disadvante:invasive,cost,can deboned ,challenging to repair
5- Full coverage crown- all ceramic or bonded crown
Advantages: aesthetic 3
Disadvantages: very invasive and cost
6- Ask if patient has any questions 1
7- Actors appraisal marks including empathy, understanding, rapport and avoidance of 3
jargon
8- Total marks 3
Accompanied with picture

There is a case in osces where patient wants to improve the colour of her teeth by whiting and not
adding any fillings on her teeth.

1- Introduce yourself to the patient

2- o Take history of discolouration if generalized ask about:
● when did it happen,
● red wine,
● Oral hygiene, Corsodyl mouth was,
● consumption of tea and coffee.
o If discolouration is localised ask about trauma and any treatment
3- If patient has a root canal treatment ask if there is any pain and explain the need of
radiograph to see quality of RCT treatment
4- Explain the cause of discolouration
5- Walking bleaching:
For rcted tooth, remove the GP 2mm, place GIC to protect GP, remove any stained dentine,
treat tooth with etching material to open dentinal tubules, bleaching gel and seal review
weekly

6- Explain Bleaching in surgery ((in office bleaching)):

● Start with scaling and polishing
● Apply orobase to protect gum, separate the teeth with a rubber dam, apply
bleaching solution and activate with light

73
[Type here]

● Avoid tea, coffee and smoking

7- Explain home kit bleaching:
● Impression for splint
● Give bleaching gel explain to dispense in tray, wear it for 6-8 hours remove any
access on gum
● Review weekly
8- Inside-outside bleaching:
Bleaching the tooth from inside and out combination of both
9- Ask if patient has any questions and check understanding and thank patient
Nice to see you MrX, my name is X. from your notes I understand that you have a tooth that
stained and you want to know the options you have without using any fillings on the tooth is
that right? want to know the options you have for that? I am here to explain the options you
have is that alright but first I need to know some more about the problem.
Ask about generalized or localized and follow the history taking accordingly following the
above list if not given in question, ask if patient has any pain and request a radiograph to
see the quality of RCT before offering the treatment.
The cause of the discolouration is because your tooth had a trauma and this has bruised the
tooth/ the tooth is dead and it has lost its shiny glossy experience and that’s why its looking
darker/ the nerve filling is reflecting through the colours of the tooth/ smoking, red wine,
ect.
The first option we have in walking bleaching where we will brighten the colour of the tooth
from the inside. I will place a rubber dam which is a rain coat to keep the tooth dry, then
remove some of the nerve filling and seal it with a thin layer of temporary filling to protect
the rest of it, we will use place the bleaching gel and seal it. this treatment can be repeated
twice and I will see you after 2 weeks if you are happy with the shade then we can place a
permanent white //tooth coloured filling. Advantages it is a simple cost procedure done side
of it that this treatment can irritate the tooth from inside and the tooth start to be eaten
away.
The other option is to bleach the tooth from the outside this can be done either in the
practice where we clean and polish your teeth place a bleaching gel and activate it with a
bright light advantage it is quick results but it will leave you with some sensitivity. or give
you a home kit we take a print of your teeth to make a splint which fits on your teeth and
we will give you a bleaching gel, you will need to place it in the tray and remove any access
on your gum. You must wear this splint overnight and I will see you on a weekly basis to
make sure everything is fine. Advantages it is cost effect but results are unreliable.
Last option is what we call inside-outside bleaching which is a combination of both involving
brightening the colour of your teeth from inside and out.
After any of the procedures you will need to avoid smoking, red wine, tea and coffee and
you will be left with sensitivity so we need to place a fluoride layer to stop it .is that clear?
Any question?
Vital bleaching in surgery …hydrogen peroxide 25-40%
Home kit bleaching to patient …carbamide peroxide 10%
Walking bleaching (non vital bleaching) carbamide peroxide 35%

74
[Type here]

Pink book page249

31-Recurrent aphthous mouth ulcers

Candidate instruction:
You are asked to take a history and formulate a management plan for a patient who has
come to see you regarding recurrent aphthous ulceration in a 24-year-old female called Miss
Watts.

Patient brief
You are Miss Watts, a twenty-four-year-old female who has been suffering from small ulcers
in the mouth for the last year. The ulcers are less than 1cm in size and never last more than
10 days and are associated with your menstrual cycle. You have particularly heavy periods
and changed your contraceptive pill at about the same time that the ulceration started. Do
not offer up the information about the contraceptive pill or your heavy periods unless you are
asked. You are a non-smoker, you are not under any stress, no one else in your family has
this problem and you take no other medication

Good morning miss watt, my name is , I am one of the dentists here . Am sorry to hear you
are suffering such a problem I assure you we will definitely do something about it but first I
need to know more details about the problem, is that alright?
Where exactly are these ulcers?
Since when did you have these ulcers?
Is it the first time you are having this or had similar problem before? How long do they last?
Do they heal with a scar?
Can you tell me the size of it?
Are you under stress?
Do you have a family history?
are you trying to quit smoking?
Are you a vegetarian? Do you take any supplement?
Are you pregnant? Are your periods regular? Do you bleed heavily?
Are you taking any contraceptive pills? Have you changed them recently?
Have you changed your tooth paste recently?
Do you have a tummy trouble?
Do you have any gluten allergies?
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

75
[Type here]

sometime in their llives. There are many causative factors such as stress, trauma, genetic
factors or vitamin deficiencies. (If traumatic ulcer, say this is because you accidently bit or
due to this sharp tooth).
Usually these ulcers heal on its own. If there is any discomfort during eating I would suggest
you use topical gel bonjela over the larger ones as it act as a bandage and that will reduce
irritation. I would recommend you to use benzydamine hydrochloride difflam mouthwash.
Avoid any hard and spicy foods that can cause further irritation. Take 15 ml, rinse and spit
out. chlorhexidine mouthwash is good to prevent secondary infections.
The cause of these ulcers in your case could be due to your heavy periods so, I would like to
refer you to your GP for a blood test to exclude any anaemia or vitamin deficiency and will
request they change your contraceptive pills as these ulcers have appeared at the same
time you changed your pills.is that alright?
I will see you then after two weeks to check on their healing and we will take it from there.
Do you have any questions?
Thank you.
Major : 10% in population, 10mm in size takes up to 5-10 weeks to heal
Minor:25% of the population, 2-5mm, last 1-2 weeks
Herpetiform: last for 1-2 weeks, up to 100
Mnemonic for RAU is FAST PAST //Family history, Anaemia, Stress, Trauma, Period and
pregnancy, Allergy (specially gluten), Smoking cessation, Tummy trouble
History taking:SOCRAT/ S for site, size and sum(number )/O onset, first time, how long
does it last, does it heal with a scar/ C for character any pain discomfort/ R for radiation do
you have it anywhere else in your body, A for associated symptoms any bleeding ,
discharge, alteration in sensation/ T for treatment did you have any treatment for it?

76
[Type here]

32-Incapacitated patient:

Candidates insruction:
Diane in an 80-year-old woman who lives in a nursing home. Medically she is fit and well,
but mentally incapacitated due to Alzheimer’s disease. She wears a full upper denture but
in the past few weeks she is unable to eat her meals and matron and the doctor who visits
the home have decided that her lower central incisor teeth are loose and interfering with
her biting and chewing.
You are called to the home late at night to examine and treat Diane. Whilst there you agree
that the lower central incisor is very mobile and there is danger of a possible inhalation
of these teeth. so you extract them under local anaesthesia
The next day Diane and her family come to confront you at the surgery that you should have
not put Diane through the ordeal of extracting the teeth and you should have waiting for
her son consent as he is the next of kin.

77
 [Type here]

proceed to discuss the law in relation to consent in an adult with incapacity

Criteria Done
marks
1- Where an adult patient is mentally incapacitated and needs urgent treatment,
common law and statutory law state that you should treat the patient in their best 1
interests
The patient may have expressed or implied: their wishes about this and similar
2- treatments their broader values and beliefs which could determine their own view 1
of their best interests
3- If the treatment was not urgent consider contacting:
● Anyone with lasting power of attorney family or close friends
● Anyone the patient wanted to be consulted 3
● Consider the independent mental capacity advocate service if no one else
available
4- It is the practitioner who must decide what is in the best interest if an LPA has not
been available or arranged and there is no court order or previously expressed wish 1
5- The patient’s son may be next of kin but this is not the same as having a LPA;
The next of kin’s decision is very important but not binding-good manners suggest
involving them in the patient’s care 3
The LPA can give or refuse proxy consent and broadly is binding-refer court of
protection
6- The principle is primarily stated in the mental capacity act 2005 modified by the
st 1
mental health act 2007. The full act became law in the 1 April 2009
TOTAL 10

Good morning Mr, my name is, one of the dentist here. I have been informed that you are here to
discuss the treatment your mother had yesterday is, that, right? I totally understand your concerns
and worries Mr,
First let me explain Diane’s treatment. she needed urgent treatment as her wobbly teeth was
interfering with her eating, causing her pain when biting and there was a risk of inhaling them which
put her in life threatening danger. As she is mentally incapacitated the common and statutory laws
both state that in cases like Diane treatment should be done in patient’s best interest which was
having her wobbly teeth removed.
I did put Diane’s wishes in consideration and to the best of my knowledge it is not against any of her
values or believes.
When a mentally incapacitated need treatment, it is suggesting if the treatment was no urgent I
would have considered contacting any one with:

78
[Type here]

1- Lasting power of attorney

2- Family or friend who the patient wants to be contacted

3- Or the Independent Mental Capacity Advocate Service if no one else in available.

In case where the lasting power of attorney has not been arranged and there is no previous court
order or previously expressed wishes by the patients, it is up to the practitioner to decide what is in
the patient’s best interest.
I know that you are worried about her and it is important to you to be involved in her treatment but
as you are her son you are next of kin, and your decisions are taken in good manner but it is not
legally binding as the lasting power of attorney who can refuse or give consent.
These principles are primarily stated in the Mental Capacity Act 2005 which was modified by the
Mental Health Act in 2007 and became a law on the 1 st of April 2009. Do you have any question
Mr,?

33-Chronic advanced periodontitis & need for extraction of some

teeth

.
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:
4 3 4
2 3 4*

79
[Type here]

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.

Good morning Mr Chohn, my name is., I am one of the dentist here and will be see you
today, I gather from your notes that you have problems with your gums is that correct?
Sorry to hear you are suffering such a problem, I want you to rest reassure you we will do
something about it. But first let me explain the condition you have,

Looking at your x-rays and examination we have done, you have a long lasting slow
progressing gum disease we call chronic periodontitis which is an Infection of the
supporting structure that hold the tooth in place. As the disease progresses the bone
anchoring the tooth in the jaw is lost making the teeth loose. This is the main cause of tooth
loss in adults.is that clear Mr Chohn?
I am afraid this disease is irreversible, which means there is no cure but it can be controlled
by following simple dental hygiene measures at home. Looking at your radiographs
unfortunately, the disease has progressed to a level where some of your teeth cannot be
saved and must be removed.
I do understand that this might come to you as a shock and am sorry but your teeth have no
support and might fall out by itself. we can give you a replacement which I will explain later.
The main cause of this disease is poor oral hygiene. Bacteria in the plaque causes
continuous irritation to the gum. The first line of defence against this disease is by brushing
properly
Smoking, can make the condition worse, it reduces your body’s ability to heal itself and
fight infection, I would advise you to quit smoking if you are interested, I will refer you to
the smoking cessation services they can help, what do you think Mr?

80
[Type here]

Another contributing factor that has accelerated the rate of bone loss is the lack of the
opposing teeth.

Mr Chohn to keep your remaining teeth you will need to brush twice a day to make sure you
remove the plaque layer, flossing in between your teeth and use of chlorohexidine mouth
wash. I will be monitoring you on a regular basis and will remove any hard deposit
underneath your gums.
However, if you don’t respond to the treatment I will referring you to a specialist where
more complex treatment can be done for example, they can lift your gums and clean under
them
After your gums heal we can discuss replacement of the missing teeth which could be either
a denture or an implant if you decided to quit smoking
Do you have any questions?
Thank you.

Chronic periodontitis

Criteria Done
marks
1- Introduce yourself 1
2- Communicate with the patient empathically 1
3- Explain the process of periodontal disease avoiding jargons 1
4- Identifies the bone loss clearly visible on the radiographs and indicated by 1
the BPE scores
5- Identify smoking contributory factor and offer antismoking advice 1
6- Identify lack of posterior support and overloading of the remaining teeth as a 1
contributory factor to bone loss
7- Explain the basis of treatment and describe the treatment process 1

8- Explains the need for regular monitoring and maintenance and good oral 1
hygiene
9- Discusses the long-term outcome and treatment option available following 1
loss of teeth
10- Ask the patient about understanding the explanation and offers to answer 1
any further questions before booking an appointment with hygienist
TOTAL 10

34-Anxious patient:
*Lisinopril is an ACE Inhibitor to treat hypertension

81
[Type here]

82
[Type here]

107
[Type here]

Good Morning Mr. Shah, my name is …, I am one of the dentist here and will be seeing
you. How are you today? From your notes, I gather that you are having your tooth removed
and feeling anxious about your treatment, is, that, right? I am here to explain to you the
options to relieve your anxiety during your treatment.
what makes you feel anxious? Why? Am sorry to hear about that bad experience you had
and want to assure you that we will do everything we can to deal with your anxiety and
make sure you feel no pain during the treatment. If there is anything that make you worried,
please let me know
. The procedure should not be a complicated one as the tooth is wobbly. It can be done
under local anaesthesia. We will give you an injection that will numb the tooth and you
should feel no pain only the push and pull pressure when we have the tooth taken out. If you
are worried about the injection, we can apply some gel to numb the gum first, the
advantages of this it is a quick and easy and there is no risk associated is that clear?
Other options you have is sedation you will be given some drugs that helps with anxiety and
reduces the feeling of pain, it could be given as a tablet or inhale gas or given directly into
your blood. You will be awake during the treatment and can communicate in full and follow
all instructions.
Another option is what we call general anaesthesia this takes place in a hospital, so I will
need to refer you. The procedure involves giving you some drugs to put you asleep. you will
undergo a health assessment to see if you are suitable for it. You must fast for 6 hours
before the procedure. It is also associated with side effect after the procedure such as
tiredness and vomiting and you will need to take some time off work. Is everything clear so
far?
Complication during anaesthesia can occur due to your obesity and medical condition. There
is an increased risk of chest infection because of obesity, diabetic and smoking history which
reduces you breathing activity. It also increases the risk of heart problems There is a low risk
of mortality about 3-4in a 1000,000. Are the options clear? What you like to do Mr shah? I
hope it is clear now that having the treatment under LA\ is safer and quicker but again it is
you who decide what treatment to have.
Do you have any question? Thank you very much.

35-Explanation of IV sedation:
CANDIDATE instructions
this is Miss Jones. She has had 3 episodes of pericoronitis, of her lower left wisdom tooth
two of which needed antibiotic prescription. You decide to remove that tooth which is
mesially impacted and partially erupted.
You've explained to the patient the benefits and risks of the surgical procedure, but she is
not decisive about IV sedation or General anaesthesia.
Discuss with the patient about IV sedation and general anaesthesia, with the advantageous/
disadvantageous of each.
PATIENT BRIEF

108
[Type here]

You are Miss Jones, 33, attending your dentist to remove the lower left wisdom tooth that is
giving a regular pain and swelling, already on three occasions.
You are a moderately nervous, and don't prefer local anaesthesia alone, and don't like the
idea of GA. You prefer LA and IV sedation, but not sure if it's suitable one for you, which
the dentist will mention it as an option that you'll like to have eventually. It is important that
the dentist makes you aware of the benefits and the disadvantages of all options so you can
choose the one suitable for you.
You are medically healthy, with no allergies and you are not taking any other medication.
1- Introduces him/herself. Uses patient's name and builds a rapport 2
2- Avoids jargon & Communicates empathetically 2
3- Give the options of anaesthesia and discuss {LA and IV Sedation, GA) 3
4- Name IV drugs which can be used in Conscious sedation (Midazolam & Diazepam) 3
5- What are the advantages of IV Sedation?
-Speed of sedation onset around 20-30 seconds
- Dose can be titrated against patient's response. ~ 4
-I access preserved.to use with other agents
- Administration is comfortable and shorter recovery.

6- What are the disadvantages of IV sedation?

-Establishments of IV access.
- Risk of over sedation due to rapid onset. 3
- Adverse reaction and no easy reversible possible.

7- What is the most common medication used in IV sedation? 1

Midazolam
8- What is the name of benzodiazepines reversal agent used in IV Sedation and what dose is
administrated?
Flumazenil 200micrograms over 15 seconds IV, further 100 micrograms/Min until 2
recovery, Max 1000 microgram
9- What are the indications of using benzodiazepines reversal?
-Over sedation
. - Patient who will be difficult to manage due to learning difficulty, or been larger than 2
the carer.
10- What are the contra-indications?
- Patient on concurrent benzodiazepines therapy 3
-- Benzodyazepines allergy.
- Hypothyrodisim, and myxoedam coma
11- What are the advantages of Midazolam over Diazepam?
- Water-soluble so doesn't cause pain on injection.
- More rapid recovery, a shorter half-life of 1.5-3 hrs.
-No active metabolites so no reversed sedation. 5
- More potent antero-grade amnesia than diazepam
- 2 to 5 times more potent, hence deeper sedation.

I think this can be a skilled osce . the check list is from the RCS notes. I think we need to
mention the advantages and disadvantages of GA too it has not mentioned the GA much
in this list

109
[Type here]

-. Good Morning Mr. Jones, my name is …, I am one of the dentist here and will be
seeing you. How are you today? I gather that you are having your wisdom teeth removed
and you are anxious about your treatment, is, that, right? I will explain the option you
have s to relieve your anxiety during the treatment, how does that sound?

The first option you have is IV sedation, we can give you some drugs directly into your
blood stream through a cannula on the back of your hand. This will help with your anxiety
and reduce the feeling of pain. you’ll be drowsy like you had a couple of pints but able to
communicate and follow instructions during the procedure. You will need to be escorted by
an adult. As you will be drowsy you are unable to drive or use heavy machinery for 24
hours and should not sign any legal binding documents.
The advantages of this procedure it is safe and quick onset and recovery. The disadvantages
are, that there will have a scratch to insert the needle on the back of your hand and we need
to numb the tooth as the sedation does not numb the area and you must fast for 2 hours.
or we can give you a tablet of benzodiazepine which you can take the night before your
treatment and an hour before the procedure called (oral sedation). It will help you sleep and
relax the night before and manage your anxiety on the day of procedure but the effect is
unreliable. If you ARE asked to discuss it
Unfortunately, none of these methods can be used if you are already on benzodiazepine or
allergic to any of the medications
Another option is what we call general anaesthesia, which will take place in a hospital. you
will be given some drugs that will put you to asleep and will not feel anything however, you
must undergo a health assessment to see if you are suitable for it . You must fast a 6 hour
before the procedure and need to take some time off work. Side effect is drowsiness,
tiredness and vomiting after the surgery. You will need to take some days off work and
should not sign any legal binding document. There is also a risk of death of about 3-4 in
every million although it is small this risk still exists .is everything clear so far?
● Do you have any questions? I will give you all the information so you can read them
carefully before you decide, how does that sound?

● Thank you for your time

Inhalation sedation: this is a small explanation about inhalation sedation just in case the
option we need to discuss change
You will be gives some a mixture of gases called the laughing gas to breath from a nose
piece. You will be awake and able to follow all the instruction but your respond to pain and
anxiety will be reduced.

110
[Type here]

The advantages it is a safe procedure and recovery is quick. you can resume your normal
activity afterward no need for an escort. The disadvantages you will still need the injection
to numb the tooth and area around it and if you have any breathing problem such as asthma
or even a cold this won’t be an option for you as there it causes reduction in respiration

36-Child abuse osce:

Candidate instruction:
You are a new dentist in the practice and have just carried out an examination on a 7-year-
old little girl. You have observed some bruising on her cheek and burn like wound on her
hand. She is very complaint in the chair and has attended with her mother.
On question the little girl she says she fell over and hit her face and does not know how she
got the burn. The mother is in a rush as needs to pick up her other child from school.
Explain to the examiner sitting in front of you how would you manage this situation? You
have only 5 minutes to summarise key points?
Responsibility, Recognising, Responding (stages, Informing the child and parents,
Reorganizing, Complete a reflection in your personal development portfolio.
.1- RESPONSIBILTY: 1
Explain it is a shared responsibility by many different groups of professional. It is a
co-ordinated by multi-agency LOCAL SAFEGAURDING CHILDREN BOARD
(LSCB). the decision about children are not taken by one individual but always shared
by effective inter-agency working and team discussion.
All the agencies and profession should work together to promote children’s welfare and
protect them from abuse and neglect. (working together to safeguard children, department of
health 1999
2- Explain the General Dental Council’s Standards guidance 2013 clearly states that the dental 1
team have an ethical obligation to take appropriate action if concerned about a possible abuse
of a child.
Find out about your local procedure for the protection of children and vulnerable adults. You
must follow these procedures if you suspect that a child or vulnerable adult may be at risk of
abuse or neglect (standard of dental team8.5.2 page 77
3- Recognising:
The assessment of any physical injury involves three stages:
1-evaluating the injury itself, its extent, site and any pattern
2-taking history to understand how and why the injury occurred and weather the 1

111
[Type here]

findings match the story given

3-exploring the boarder picture (e.g the child’s behaviour, the parent’s-child
interaction, underlying risk factors or markers of emotional abuse or neglect)

4- Responding -assessing a child

Assessing a child with an injury or with possible signs of abuse or neglect starts with a
thorough history including:
1-details from the child carer of any injury or presenting compliant
2-past dental history
3-medical history
4-familay and social circumstances including the household composition (particularly
in relation to unrelated adults living in the household as research indicate that children 1
living in household with unrelated adults, particularly males, often mother’s
boyfriend, are at significant higher risk of abuse and neglect)
Features of concerns would include:
1-a delay in the presentation
2-discripencies between the history and examination findings
3-developmentally inappropriate finding (does not fit with child’s age)
4-previous concerns about the child or siblings

5- Responding- what to do next

The most important thing to remember if you are faced with a child who may have
been abused is that you do not need to manage this on your own. It is important to
remember that your first duty is the child and that you have responsibility for dealing
with any injury or dental needs.
1-the first stage if you have any concerns should always discuss this with an
appropriate colleague or someone else you can trust. This may be an experienced 1
dentist, senior dental nurse, a paediatrician, child protection nurse or social worker
(see finding your local contact)
2-if having discussed it with an appropriate colleague, you remain concerned, then
you should make a referral to your local children’s services (formerly social services).
You should have identified where and how to contact your children’s service team
Referrals should be made by telephone, and should be followed up in writing within
48 hours. There is often a locally agreed referral proforma, check with your local
children services office.
6- Responding – what happens when children services receive a referral? 1
When a child is referred to children’s services, the duty social worker may ask
whether you are aware if, or inform you that, the child has been subjected to a
Common Assessment Framework (CAF). The social worker will note details of the
child and family and the concerns that are being raised.
What further action might you be asked to take?
If you have made a child protection referral, you may be asked to provide a report for
a case conference or be requested to give evidence in court.
When else might your help be requested?
You may be asked to help in the child protection process by assessing the dental needs
of children who have been abused, whether existing patients of your practice or new.
7- Informing the child and parents
It is good practice to explain your concerns to the child and their parents, inform them
your intention to refer and seek their consent. Research show that being open and
honest from the start results in better outcomes for children. There are certain

112
[Type here]

exceptions and reasonable judgment must be made in each case.

There are some exceptions, usually you should not discuss your concerns with the
parent in the following circumstances:
1-where discussion might put the child at greater risk.
2-where discussion would impede a police investigation or social work inquiry
3-where sexual abuse by a family member, or organised or multiple abuse is suspected
4-where fabricated or induced illness is suspected
5-where parents or carers are being violent or abusive, and discussion would place
you or others at risk
6-where there is not possible to contact parents or careers without causing underlying
delay in making their referral
8- Reorganising:
Safeguarding children is not just about referring them when you have concerns but
about changing the environment to ensure that the risks to their welfare are
minimised. These tips for best practice will help a dental practice to not only fulfil the
responsibilities of current legislation and ethical guidance but also take an active role
in safeguarding children: 1
1-identify a member of staff to take the lead on child protection
2-adopt a child protection policy
3-worki out steps-by step guide of what to do if you have concerns
4-follow best practice in record keeping
5-undertake regular team training
6-practice safe staff recruitment
9- Coping with aftermath
It is quite normal to have some anxiety about the consequences of making a child
protection referral. These may include fears about potential adverse consequence for
the child or family or repercussions on your dental practice or yourself. Talking it 1
through, or debriefing, with an experienced colleague maybe helpful or you may wish
to seek independent confidential counselling
10- Support for dentist
As a professional involved in a case, you may be called upon to provide evidence in
either court. In both situation, your responsibility to the court is to provide an accurate 1
and unbiased account of your findings, your opinion based on those findings and any
action that you took consequently. In a court situation, you should never venture
beyond you level of expertise or provide opinions that you are unable to back up
Odell page 167/oxford page 96
❖ If you have a examiner

1- the general dental council’s standard guidance 2013 clearly states that the dental team
have an ethical obligation to act if concerned about abuse of a child or vulnerable adults. It
is a shared responsibility between different professionals and agencies co-ordinated by the
LOCAL CHILDREN SAFEGAURDING BOARD

2-recognising an abuse by assessing any physical injury through three steps:

a) Evaluation the injury

b) understanding why and how the injury has occurred

113
[Type here]

c) Exploring the boarder picture including child’s behaviour and interaction with
their parents

We should be alarmed when there is a delay in the presentation, discrepancies between

history and examination findings, when injuries do not fit with age of the child and when
there were previous concerns about the child or sibling

3-responding to an abuse involves three phases starting with:

● taking a thorough history including:

a) Details of any injury present from the child and parent

b) Dental and medical history

c) Family and social history including any unrelated adults living in their
household

● Dentist should discuss this with a colleague. If still concerned dentist

should refer to the local children’s services by urgent calls followed by
written referral made within 48 hours.

● it is good practice to explain your concerns to the child and parents, inform
them about our intention to refer and seek their consent. You should not
discuss your concerns to the parents if that puts the child, yourself or
others at risk.

● dentist might require to give report about injury or be requested to give

evidence in court your responsibility to the court is to provide an accurate
and unbiased account of you finding.

4-reorganising: following tips of best practice to ensure that the risks to children welfare are
minimised by:
a) Name a member of stuff to lead child protection and adopt a policy

b) Follow best practice in record keeping

c) Undertake team training and safe stuff recruiting.

5-Support for dentist after a child protection referral is important. Some find it difficult to
cope with anxiety and stress after a child protection referral talking to a colleague or seeking
independent confidential counselling is helpful.
❖ If you have an actor:

1-ask the patient how did he/she get the injury? Take full history of the injury
2-reassure the child that you are here to help and support them will look after them.
Explain that everything they tell you will be confidential.

114
[Type here]

3-explain to them that they have been subjected to abuse and ask patient if they wanted
their parents to know?
4-if you are suspicious talk to a colleague
5-if concerns are met call the local children service and explain the situation to them,
make a written referral within 48 hours
6-record everything in patients notes

37-Breaking bad new to patient losing all their teeth for periodontitis:
Candidate instruction:
This fit and healthy 50-year-old lady/gentleman has come to see you as a new patient. On a
regular basis, she sees the senior partner in the practice who has had to retire for health
reasons at a very short notice. She/he has been seeing the dentist for 20 years who is a close
family friend.
She/he has come to see you to discuss bridge work to replace a denture she is wearing in to
replace her front tooth as her friend has just had one and was raving about them. She is very
conscious of her teeth and overall appearance. She/he is delighted and proud to still have
most of her teeth, something she feels is due to the care of her friend the dentist, who had told
her would go with her to the grave.
After your examination, you are faced with the reality that the patient is the victim of
supervised neglect and now requires the removal of all of her of her remaining 20 teeth. your
task is to tell her the bad news.
1- Conduct interview in a very polite fashion 1
2- Avoid the use of technical jargon 1
3- Find out what the patient already knows e.g ‘were you aware of the state of your teeth? ‘or 1
‘what have you been told?’ ‘what did you feel about your teeth?’
4- Try to determine whether the patient wants all the info in one go or e.g better to have 2
someone and come back
5- Give the information is small chunks, stop and assess before proceeding. Check 2
understanding before moving onto the next bit of information. Use of correct level
language is important
6- Display empathy but allow emotion, try and relay acknowledgement of the difficulty e.g 1
‘this must be a shock for you, I have found this difficult to tell you.’
7- Decide on way forward. Empower them to help with the decision offer them some 1
treatment direction
8- Summarise, offer contact points, early follow up. Ask do they have any question and bring
someone with you next visit

Good morning Mr Chohn, my name is..,I am the new dentist here, I gather from your notes
that you are seeking replacement to your denture is that right?

115
[Type here]

Can I start by asking you What do you think about the appearance of your teeth? do you
think your teeth are wobbly?
Looking at you x-rays and examination, unfortunately Mr Chohn, you have a long lasting
slow progressing gum disease we call it chronic periodontitis which is an Infection of the
supporting structure that hold the tooth in place. As the disease progress the bone
anchoring the tooth in the jaw is lost making the teeth loose. This is the main cause of tooth
loss in adults. Is that clear Mr?
The main cause of this disease is poor oral hygiene. Bacteria in the plaque causes
continuous irritation to the gum. It could be genetic or secondary to health problem. Sadly,
Mr Chohn, this disease is irreversible, which means there is no cure for. Are you okay Mr
Chohn, do you want me to continue or would you prefer someone with you before I
proceed.?

Looking at your radiographs unfortunately, the disease has progressed to a level where all
your remaining teeth must be removed. I understand that this might be very difficult and
has come as a shock. If we remove the teeth we will prevent further destruction to the
bone .
We’ will not pull out all your teeth at once, initially we will remove some of the most badly
affected ones. We will give you temporary dentures immediately after the extraction further
in treatment, so you are not left without teeth. is that clear so far?
After the healing process is completed we will discuss permeant treatment as dentures or
implant supported dentures, how does that sound?

Next time when you come and see me I would suggest you bring a friend who you trust and
can rely on for moral support.
Do you have any questions?
Thank you.

38-Retained upper C and impacted canine:

Ms Clara a fit and healthy lady with a class 1 skeletal pattern and class 1 occlusion has
attended your dental practice. She has a retained upper right primary canine. Radiographs
have revealed that the permanent successor is present and impacted. The radiographs have
shown overleaf. The patient and her mother wish to know the options available.

116
[Type here]

These criteria have been taken from osce for dentistry page 44
1- Introduce yourself to the patent and parent
2- Explain to the patient the diagnosis /ask about pain and swelling
3- use the radiograph to show the patient
4- Explain the treatment option:
a) Leave alone and monitor
b) Removing the permanent canine and leave the deciduous tooth in situ.
c) Extraction of the deciduous tooth and transplant of the canine
d) Orthodontically reposition of the tooth
Explain advantages and disadvantages
5- Ask the patient if they have any questions
6- Thank the patient

Good morning Mrs, my name is, I am one of the dentist here. From your notes, I gather that you are
here to discuss the appearance of your corner tooth, is, that, right? I want you to be rest assured we
will do something about it but first I will explain the treatment option available, how does that
sound?
Do you have any pain or swelling in that area?
(Looking at the radiographs here) that is your adult tooth, it is present in the bone and has not
pushed out in the mouth, we call this impaction. Thus, your baby tooth is retained in place. This
happens is about 2% of the population.
The first option is to do nothing to it. the advantage is there is no cost the disadvantages is that it
must be monitored with x-rays. There is a risk of the baby tooth falling out at some stage and you
will need replacement, a cyst might form around the adult tooth and that might dissolve the roots of
the adjacent teeth.
The other option is surgically removing the adult teeth leaving the baby tooth in place. The
advantages is that we do not need to monitor it, disadvantages it involves surgery and the baby
tooth might fall out leaving a gap which needs replacement. There is a risk of injury to the adjacent
teeth and bleeding and infection at the site of surgery

117
[Type here]

Third option is removing the milk tooth and the adult then re-implanting the adult tooth, if there is
enough space for that. There is a risk that the re-implanted tooth is not successful, the root of the
re-implanted tooth may get anchored to the bone or the root gets dissolve. Are you following me?
The last option is removing the milk tooth, surgically exposing the adult tooth and repositioning it
using braces and chain. It will give a good result and better aesthetic but it is the most expensive
option and treatment is done over a long period. Is that clear Ms Clara
All treatment can be done under local anaesthesia, sedation or general anaesthesia which I will
discuss with you next appointment. Do you have any questions?
I will give you some leaflets that explains the option have a read and whatever you decide we will
take it from there.
Thank you
This osce can be found in Kathleen fan 2.7 page 44.

39-Taking medical history:

Mr. Jonathan Watts has come to your surgery for first time, you have completed presenting
complaint and dental history, now take medical history. lo this station you will be asked to take
social history along medical history, so read question carefully
Good Morning Mr. Watts, my name is, I’m one of the dentists here and will be seeing you.
as part of the examination I’ll need to ask you a few questions regarding your health in
general just to make sure everything is fine. Is that alright?
Are you generally fit and well?
Are you under the care of a specialist or GP for any medical condition?
Are you currently taking any drugs or medication which is prescribed or over the counter?
If yes-
● What medicines is that?
● What is the Dosage?
● How many times a day?
● Since when have you been taking it?
For what condition are you taking the medication?
● Other medications/ if patient does not remember the name of medication ask for
permission to contact his/her GP

A-Do you have any allergies? If yes, what?

A- Are you anaemic?

118
[Type here]

B-Do you have any breathing problems such as asthma?

● how long have you had it?
● Are you under the care of a GP or SP? Is it well controlled?
● Record patient medication with dosage, blues inhaler /salbutamol. Brown
inhaler/hydrocortisone 200mg.

B-Do you have any bleed problems? Do you bleed excessively after a cut?
● Do you have a bleeding disorder? what is the name of it Haem A or B
● Do you bleed after a cut?
● How long have you had this problem?
● Are you under the care of a GP or SP?
● Do you visit the anticoagulant clinic?

C-Do you have any chest problems, angina or hypertension?

Angina:
● How long have you had it?
● Are you under the care of a GP or SP?
● What medication are you taking? Aspirin, statin for high cholesterol and TNG
Spray.
● Have you had any chest pain during dental treatment in the past? If yes when,
what and how was it controlled?

Hypertension:
● Ask the patient about blood pressure values
● Medication? Atenolol……….>side effect is dry mouth refer to GP to change
medication
D—are you diabetic?

Diabetes:
● What is the sugar level?
● Is he taking any medication? Is he taking tablet diet control or on insulin?

F- Have you had any fit, faints or block out in the past?
● What is the medication patient is on? gabapentin is the common medication used in
the uk and it does not cause gingival swelling
● Have you had fits or fainting?

119
[Type here]

● Have you had any increase in your medication? Possible risk of developing a ME
● What triggers the fir? (anxiety, flash lights or bright lights)
F-- Do you have a family history of any medical condition?

G-Do you have any tummy trouble(GASTRIC)e, or heart burns?

H- Have you been hospitalized in the past?

I- Do you have any blood infectious diseases such hepatitis B or C or HIV?

● When did you have your blood tested?
● Were there any changes in the medication?
Hep:
Causes damage to the liver, clotting factor will be affected so patient is at risk of bleeding.
● Which hepatitis?
● What medication is he taking?
● Any bleeding after injury?
J- Do you have any skin, eye or joint trouble?
● Any problem with the joints of the hand?
● What medication do they have?
L-Ladies
● are you pregnant?

● Are you on any contraceptive?

● Are you periods regular? Do you bleed heavily?

K-do you have any kidney or liver problems?

S- have you had steroids in the past two yers?
W- Do you carry any warning cards?
Do you have any concerns regarding your health which you would like to tell me about?
Do you smoke? How long have you been smoking? How many cigarettes do you smoke?
Do you consume alcohol? What type? And how many units per week?

120
[Type here]

40-Denture stomatitis:
a 65-year-old lady, present to your surgery with a chief compliant of dryness and
soreness and loss of taste sensation in her mouth she has recently started wearing
an acrylic upper denture. Explain the diagnosis and management:
a- not on warfarin
b- patient on warfarin

This check list is from samson’s plab

1- Introduce yourself to the patient
2- Ask the history about chief complaint:
dental history, if they have denture, denture hygiene routine? Do they wear denture at night?
medical history-diabetes, medication and steroids?
smoking
3- Give possible diagnosis and avoid using jargon
4- Give management and oral and denture hygiene instruction
Prescribe Miconazole 2% *4 time a day for 5-7 days if patient is NOT on WARFARIN
Prescribe nystatin 4 times a day if patient is on WARFARIN
5- Candidate must show empathy through out
6- Check patient understanding
7- Thank patient

Good morning Mrs/Mr, my name is, I am one of the dentist here, how are you today? From
your notes, I gather you are having some discomfort in your mouth is, that, right?
I want you to rest assured we will be doing something about it but first I need to know more
details about the problem.
Where is the soreness exactly? / on the palate
Since when have you had this problem? Is it the first time or have you had it before?
how long have you had your dentures?
How often do you clean your dentures?
do you take them out at night? Usually with night wearing patient
Do you have any medical condition such as diabetes or asthma? Diabetes, xerostomia

121
[Type here]

Are you taking any other medications? steroids cause xerostomia and to check pt is not on
warfarin
Do you smoke?

Thank you for the information its very useful, it seems that you have a candida infection
which is basically a yeast infection of your palate where your denture is in contact with you
gums. This is very common especially in denture wears and specifically females.

There are many causes for this but mainly it is due to poor denture hygiene and wearing the
denture at night. You need to clean your denture after every meal by rinsing it under
running water and use a tooth brush to remove any food debris on it and soak it in a
hypochlorite solution to keep it fresh. You should leave your dentures out at night to give
your gums time to breath from the constant pressure of wearing the denture.
For the infection, I will prescribe you antifungal cream called (miconazole gel 20 mg apply a
pea size to the fitting surface of the upper denture after food 4 times a day continue to use
7 days after the lesion has healed/ suspension called nystatin 100000units/ml 4 times daily
for 7 days. take your denture out when rinsing, retain for 5 minutes then swallow/).
I would suggest that you reduce the sugar in your diet as the candida thrives on it. you
should stop smoking as it reduces your body’s ability to heal itself that and will see you after
two weeks to see if there is any improvement.
Do you have any questions?
Thank you

41-CPR:
You arrive at your dental practice earlier than usual and found your receptionist collapsed
on the floor. There is no one else in the practice. Demonstrate and explain how you would
manage the situation on your own using the props provided.
1- Assess for danger 1
2- .Check responsiveness. Shake and shout 1
3- Shout for help [stay with patient] 1
4- Open airway [head tilt I chin lift I jaw thrust], USE SUNCTION TO REMOVE VOMIT 1
5- Check for normal breathing [up to 10 seconds] Look/Listen/Feel 1
6- ● Telephone/Summon help and get AED immediately ,and pocket mask
● Dial 999- listen to them make call
● Ask for the ambulance service (NB 999 = police, fire and ambulance)
Situation:
• I am (name)
• Calling from (address including post code)
• My contact telephone number is. ..... 5
Background:
I am calling about a collapsed person who is not breathing
Assessment:
I am suspecting a cardiac arrest
Recommendation:
• I need you to please send an ambulance and in the meantime, I am going to

122
[Type here]

start CPR on my own

Ask receiver to repeat key information to ensure understanding

7- 30 chest compressions
[heel of hand over midpoint of the chest/sternum]
• Rate at least 100-120/min 1
• Depth of compression at least 5cm
8- 2 rescue breaths
• 1 sec each
• (wait for the chest to deflate before giving 2nd breath) 1
• No more than 5 seconds’ total interruption in chest compressions
9- 30 chest compressions 1
10- 2 rescue breaths (Stop the candidate at this stage) 1
11- Ask the candidate when are they going to stop the CPR?
a) Breath normally 1
b) Signs of recovery: Speaking: opening eyes; cough. purposeful movement
Total marks 15

NOTES FOR EXAMINER

• To pass the candidates must score 15. All points must be mentioned but not necessarily in
the correct order. Failure to resuscitate patient must be graded as a failure.
• Inform candidate he has 5 minutes for the task and only 1 attempt can be made.
• Wipe dummy's mouth between students

42-Angina Pectoris:
A 75-year-old patient has undergone 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; diagnosis is unstable angina
pectoris.)

1- Use patients name, communicate empathically and avoid jargon

2- Take history of chest pain:
Site, onset, character, radiation, associated symptoms, exacerbating or reliving factors
Stable angina: last for no longer than 10 minutes, pain relived on medication and pain
exacerbated by exhaustion
Unstable angina: pain last for more than an hour, not responding to medication and pain can
start when patient is resting
3- Brief medical and social history
4- Explain the condition to the patient
5- Refer to GP immediately
6- Explain effect of condition on dental treatment
7- Patients with unstable angina or recently been admitted to hospital admission for ischemic
chest pain have higher risk and should not be considered for routine dental treatment in a
primary care.
8- Ask patient to bring their medication with them next appointment

123
[Type here]

9- Ask if patient has any questions

Mnemonic for this to remember what questions to ask is Denture StoMatitis =D;denture
hygiene and dry mouth,S;smoking,M;medical problems and medication

Good morning Mr, my name is, I am one of the dentist and will be seeing you. I have heard
that you have some chest pain and I would like to know more details about it is that alright?
s-Where exactly is your chest pain?
o-When did it start? how often do you get the pain? Is it becoming worse or more frequent?
How long does it last? What brings on the pain? how often do you get the pain? There
anything that makes it better or worse? Do you get pain when resting too?
c-Can you describe the pain for me? What do you feel exactly? How strong is the pain?
r-does the pain spread to other areas of your body?
a-do you feel anything else such as breathlessness, chocking feeling, sweating, or feeling
sick?
t-have you seen your doctor for this problem?

Are you on taking any medication that is prescribed or over the counter? What is the
medication for? How long have you been taking it? How often do you take it? Does the pain
resolve when you take it?
Do you smoke? How long have you been smoking? how many cigarettes do you smoke a
day?
Do you drink alcohol? What type? How many units do you have on a weekly basis?
Do you have a balanced diet?

Per what you have told me it seems that you might have experienced a heart problem which
we call angina pectoris. This happens when the blood vessels that feed the heart are
clogged and the heart is not getting enough oxygen to function properly. This problem is
more common in men in their mid-age, smokers, people with high cholesterol, high blood
pressure, overweight, diabetic, those who don’t exercise and people with family history of
heart attacks. You should see your doctor as soon as possible it is a serious condition and
must be treated immediately.
Your doctor will do some checks and test and prescribe you some medication. Smoking
makes your condition worse and I would suggest that you quit smoking if you are interested
I can refer you to the to the smoking cessation service where you could find a lot of help.
You should also avoid fatty food and try to lose some weight.
If you need any dental treatment in the future after your condition is stabilised we will make
sure that you are calm and relaxed and nothing causes you any stress during the treatment.
We can also give you some tablets (oral anxiolytic) an hour before you attend the
appointment which will deal with your anxiety if you have any. How does that sound? Last
thing if you have any medication such as sprays or tablets kindly remember to bring them
with you in case you need them during the procedure? Is that alright?
Do you have any questions? Thank you

43-Smoking cessation:

124
[Type here]

You are a dentist in a general practice. You are seeing a new patient who is a smoker and
patient wants advice about smoking cessation services. Please give patient advice on
quitting smoking// has smoking keratosis give advice

Smoking keratosis smokers mouth

1- Introduce yourself to the patient

2- Take history of smoking, how long, how many, are they interested in quitting?

3- ● Emphasise on stopping smoking and improving health and oral effect such as staining
of teeth and periodontal problem
● Smoking relation to heart disease, lung and mouth cancer

4- ● Advice on nicotine replacement therapy

● Offer referral to NHS smoking free services
● Advice to enlisting the help of family and friends

5- Explain NHS have one to one or group counselling and monitor their progress in future dental
appoint and provide support and encouragement

6- Ask if patient has any questions

Check list from Kathleen fan page 196

smoking keratosis is painless white patch mainly on the palate which will resolve after
quitting within several weeks.

Good morning mr, my name is, one of the dentist here, I understand that you require
information about quitting smoking is that correct?
How long have you been smoking?
How many cigarettes do you smoke per day?

125
[Type here]

How soon do you need to smoke in the morning?

Have you tried quitting smoking before?
Do you have any medical problems or any medication?
Let me explain the effect of smoking on your health in general, it increases the risk of heart
attack, stroke. People who smoke are 4 time at higher risk of developing lung and throat
cancer. Smoking is responsible for the death of more than 120000 in the UK.
Smoking also effects your oral health, it causes staining of your teeth, bad breath and gum
diseases. It also increases the risk of yeast infections in the mouth and oral cancers.
Are you interested in quitting mr ,?
I believe you have made the right choice in quitting smoking, it will beneficial for your health
general. I don’t want you to be dishearten because of your previous attempt. The truth is
that those who failed before have more chances to quit smoking in their second attempt.
You should set a date for stopping smoking, first days will be the most stressful because of
the nicotine withdrawn from your body therefore you will need friends and family support
and encouragement will help you in this mission. You can use nicotine replacement therapy
which could be either a patch or a spray and they are available over the counter. Or I could
refer you to the NHS smoking free services. They offer a one to one or a group counselling
where other people share their experience and tips. You could also find other tips,
information and support which is very helpful.
I will check your smoking status annually and we will provide you with all the support you
need. Do you have any questions?
Thank you
Smoking keratosis is a painless lesion mainly on the palate it can resolve in after quitting
smoking
44-Dry mouth syndrome:
A patient attends your practice complaining of a dry mouth. Explain the cause to the patient
and what dental complications do patient with dry mouths suffer from?

1- Introduce yourself to the patient

2- Avoid use of jargon
3- Show empathy to the patient
4- Ask patient brief history of the problem and take brief medical history and causative factor
5- Explain the condition to the patient
6- Give advice to relieve symptoms and offer saliva substitutes
7- Explain possible complications and risk of dry mouth
8- Explain briefly about preventative methods

126
[Type here]

9- Ask if patient has any question

This check list is from ore exam document
Mnemonic for dry mouth is ( MAD RAT) , M-medical condition and medication,A-associated
symptoms,D-dry eyes,R-radiotherapy and chemotherapy,A-anxiety and depression,T-any
treatment done for it

Good morning mr, my name is, I am one of the dentist here and will be seeing you, I
gathered from your notes that you are having problem with a dry mouth, is that right? Rest
assured we will do something about it but first I need to know more information about the
problem.
1.how long have you had this problem? Is it becoming worse? Is there any difficulty in
speaking or eating?
2.do you have any medical problems? Diabetic or sjorgen syndrome
3.are you taking any medication? Antidepressant amitriptyline/atenolol or propranolol for
hypertension /metformin if used for many years/ omeprazole
4.did you have radiotherapy or chemotherapy in the past?
The cause of the dry mouth is due to the reduction in salvia flow this could be (due to taking
metformin for many years/radiotherapies you had in the past which has damaged your
salivary glands/age as this is part of the natural aging process.)
I do understand that this can cause discomfort during speaking and eating to overcome this
problem I would suggest that you take the following steps:
Keep a bottle of water with you and take small sips regularly.

Increase the intake of fruit and vegetable

Avoid any hard food

Use sugar free chewing gums which stimulates salivary flow.

Use benzydamine mouth wash if there is some discomfort

Saliva is very important to keep your mouth clean and helps in preventing gum diseases and
decay. As this function is reduced in your case, you will be at high risk of developing decay,
gum disease and candida infections, so I would recommend rinsing your mouth after you
eat or have any carbonated or acidic drink and use a straw for drinking. I will also give you
some high concentrated fluoride tooth paste to help in preventing decay this is considered a
medication that should be only used by you. brush your teeth twice a day and reduce you
sugar intake.
I will monitor your condition and if it’s not helping I will prescribe you some saliva subsites
and if that won’t help I will refer you to a specialist.
I will refer you back to your GP to change your medication as it is contributing to your
problem is that alright?
Do you have any question?

127
[Type here]

Thank you.

45-Smoker want implant:

Mr James Walter is a new patient in your surgery and during history taking you find out that
he is a smoker. James has lost his upper central in an accident and wants to replace it with
an implant. Explain to the patient effect of smoking on his treatment plan and try to
convince him to quit smoking.

1- Introduce yourself to the patient

2- Ask patient about smoking, how long, how many, interested in quitting
3- Explain to the patient why implant is not a good option for the patient
4- Explain effect of smoking on success rate of implant
5- Explain the benefits of quitting smoking on health in general and oral health specifically
6- Offer referral to NHS free smoking service referral
7- Offer alternative treatment if patient refuses to quit
8- Ask if patient has any question
Check list is from exam ore document
Good morning mr, my name is, one of the dentist here, I understand that you want to
replace your missing front tooth with an implant is that correct?, I will explain the treatment
for you but fist I need to know more details is that alright?
Any medical problem? Any allergy or medication? Do you smoke??
How long have you been smoking?
How many cigarettes do you smoke per day?
Are you interested in quitting?
Let me explain a bit about the implant, is a metal rod that is placed in your bones and
covered by your gums, it can last you a life time but requires surgery and is a long
treatment. It normally has a high success rate however in your case as you are a smoker the
success rate is reduced.

Smoking reduces your body’s ability to heal itself therefore you are at a higher risk of
developing infection around implant called peri-implantitis, this cause the bone around the
implant to melt and the implant will not fix to the bone which will result in failure of the
treatment. So for a higher success rate of this treatment you need to quit smoking. Is
everything clear so far?

128
[Type here]

Smoking has an adverse effect on your health in general, it increases the risk of heart
attack, stroke, and kidney disease. People who smoke are 4 time at higher risk of developing
lung and throat cancer.
Smoking also effects your oral health, it causes staining of your teeth, bad breath and gum
diseases. It also increases the risk of oral fungal infections and oral cancers. Are you
following me?
Planning to have an implant might motivate you to quitting smoking. this will benefit your
health generally and oral health specifically.
If you are interested in quitting, you can use nicotine replacement therapy which could be
either a patch or a spray and they are available over the counter. Or I could refer you to the
NHS smoking free services.
On the other hand, if you do not want to quit I can offer you other treatment options such
as dentures or bridges we will go through them thoroughly next appointment
Do you have any questions?
Thank you

46-flabby ridge:
Mr. Adam knight is not happy with the fit of his upper denture. On examination, you noticed
that the upper ridge is flabby and only the lower anterior teeth are present. How will you
manage the patient?

1- Introduce yourself to the patient

2- Take a brief history from the patient

3- Explain the reasons of looseness of the denture

129
[Type here]

4- Explain the importance of replacing the missing lower teeth

5- Explain treatment option:

● New denture with special impression give advantages and disadvantages
● Surgery and construction of a new denture give advantages and disadvantages

6- Ask if patient has any question

7- Show empathy
This check list is from ore exam.com
Good morning Mr, my name is, I am one of the dentist here and will be seeing you today. I
gather from your notes that your upper gums have swollen up and affecting the fit of your
denture, is that correct?
Sorry to know you are suffering with such, I want you to rest assured we will do something
about it but first I need to know more details about the problem, is that alright?
Since when have you got this problem?
Is it only the upper denture you have?
Ask about teeth present in case it is not mentioned in the osce
Your denture is loose because of a flabby ridge which basically means an over growth of
your gum tissue. This has changed the shape of your jaw and your denture is not fitting as it
used to and that is why your denture is loose.
This happens in people who wear an upper denture opposing natural lower front teeth and
the missing the lower back teeth like your condition. This cause an imbalanced bit with too
much pressure applied to the upper front segment and causes the gum to undergo the over
growth.is everything clear so far?
The first line of treatment is to correct the bite by constructing a lower denture to replace
you back lower teeth in that way the bite force will be distributed equally over the jaw and
have a balanced bite. Are you following me mr?
The denture you have will not fit any more and unfortunately you must have a new denture
made which will have a better fit. You have two treatment options.
The first we take a special mould using a special technique the advantages are that it
involves no surgery is involved however the stabilization and fit of the denture might not be
good.

130
[Type here]

The other option is to have a surgery to have the tissue removed, I must refer you to a
specialist the good thing is the tissue will be removed completely however there is a
possibility of reduction in the height of your jaw and might have a reduced stabilization.is
everything clear so far?
Do you have any question?
I will give you some leaflet that explains the condition and treatment option have a read
through them and whatever you decide we will take it from there.
Thank you

47-lost biopsy:
You have sent mr James to oral and maxillofacial surgeon for excisional biopsy of a soft
swelling present between the upper centrals. You are suspecting it to be a pyogenic
granuloma. Unfortunately, the report for biopsy is lost from your surgery, maybe destroyed
with junk letters. Explain the problem to the patient.

1- Introduce yourself to the patient

2- Apologise to the patient and explain what has happened
3- Reassure the patient about the results and it was only a protocol that you had to follow
4- Tell patient what will you do next to find out the result and regularly monitor the patient
5- Explain to the patient how will you prevent this from happing in the future:
● Conduct an enquiry to find out why and how did that happen
● Conduct a audit
6- Document this is accident log book and patient notes
7- Explain patient right to make a compliant if they are not happy
8- Ask if patient has any questions
Check list from ore exam.com
Good morning Mr, my name is, I am one of the dentist here and will be seeing you. How are
you today?
I am Sorry to inform you that the report of your biopsy which was sent to us by the
specialist is lost. I want to apologise about this mishap, I assume that it has been
accidentally destroyed with the junk mail in the paper shredder.

131
[Type here]

When you had, the biopsy done the full swelling was removed and nothing is left to take
another sample so we won’t be sending you for a repeated biopsy. Are you following me
Mr?? and that is a good thing that nothing is left behind for you to worry about.
I want you to rest assured there is nothing regarding the results that you need to worry
about as it was suspected to be a pyogenic granuloma which is an innocent overgrowth of
the gum due to irritation. But we must follow a protocol where any tissue removed has to
send to be examined.is that clear Mr?
We will contact the hospital to see if they have record of the result and ask for a new copy.
If not, then it is our responsibility to take care of you we will call you on regular basis to
monitor you and see if the swelling appears again. I want to make this clear there is nothing
you need to worry about as it shows no sign of anything sinister.
We will be conducting an enquiry to see how and why did this happen. regular audit will be
conducted and measures we need to take to prevent it from happening in the future. we
will document this incident in the practice accident book log book and your notes.
I hope I have put your worries at rest and appreciate your patience and understanding. If
you are not happy you still have the right to make a formal complaint I will ask the practice
manager to contact, you to explain our practice complaint policy.is that alright?
Do you have any questions?
Thank you

48-Tooth surface loss:

A 16 year old girl attend to your practice concerned about the appearance of her teeth front
teeth. she has evidence of loss of tooth substance on her labial and palatal surfaces of her
anterior teeth.
How would you manage this patient?
Check list
1- Introduce yourself politely to the patient
2- a) Take history to determine time scale for tooth substance loss.
b) Determine the cause:
● Dietary is likely to cause erosion on the labial surface
● Gastric rex and bulimia this cause wear on the palatal surface of the upper incisors

132
[Type here]

● Attrition tooth wear by bruxism

● Abrasion tooth wear by teeth to other surfaces for example tooth brush
c)medical history involving vomiting and concerns about weight
3- Discuss prevention of further progression by:
● explaining the condition,
● the cause and removal of factors
● referral to physician for gastric problem, GI problem and stress
4- If there is sensitivity apply durphate 22600 ppm, high fluoride tooth paste concentration.
5- If mild monitor with photos and study cast
6- Give local measures
7- After controlling the condition give option for restoring aesthetic and explain why
8- Ask if patient has any question and show empathy all way through
9- Thank the patient

Check list if from Kathleen fan page 113

Good morning Ms, my name is? I am one of the dentist how are you today?
How can I help you? Sorry to hear about that rest assured we will do something about it but
first can you tell me:
Since when have you noticed the problem?
Which surface is affected? Do you have any pain or sensitivity? What do you think about the
appearance of your teeth?
How much fizzy drinks or fruit juice do you have?
Do you have any tummy problems? Have you ever vomited after a meal? Are you concerned
about your weight?
Do you think you are you stressed? do grind your teeth? any pain on the side of your face?
Any habits of biting your nails?
How many times do you brush your teeth and what type of tooth brush do you use?
Ms, your tooth is formed of three layers the outer protective layer called the enamel, acid
makes it soft and can be washed away easily exposing the middle layer which is very
sensitive. Usually your spit balance this acidity and repairs the damage but when the acids
are more frequent the repair effect is reduced.
In your case this has happened because (of the amount of fizzy drinks that you take or your
vomiting habit).
Today, I will apply some fluoride gel that will make your teeth stronger and stop the
sensitivity.
I will give you tooth paste with high fluoride note this is a medication and should be used
only by you.

I would want to refer you back to your GP to have a chat about your vomiting habit and
weight concerns which has a direct effect on the condition of your teeth, is that alright? ((if
patient is bulimic))

There are some simple steps which could help:(( if patient is having high acidic diet))
● Reduce intake of acidic foods and drinks.
● Avoid frothing and swishing drinks around the mouth.
● If you must take fizzy drinks use a wide bore straw placed at back of the mouth.
● Do not brush soon after taking acidic foods or drinks.

133
[Type here]

● Sugar free gums and cheese increase saliva and help to reduce destruction of tooth by washing
away the sugary and acidic foods and drinks
I will give you a diet chart which you need to record everything you eat and drink for three
consecutive days including a rest day to we can see where the high acid is coming from.
I will monitor you with photos and moulds and will be seeing you every three months and
after the condition is controlled then we can give you option to correct the shape of your
teeth. if patient asks why don’t you give me the options now? Because the acid will wash
away the glue we use to fix the caps to your teeth.
Do you have any question?
I will give you some leaflets that explains the condition and thank you.

49- caries on E (explain the hall technique):

Oxford pink book page 86-88

Thank you for waiting Mrs, my name is , I am here to explain the hall technique to you for
your sons decayed milk tooth, is that okay?
Does he have any pain to hot or cold or pain on biting? Tooth must be symptomless
Does your child have any medical condition or allergy? Not used with those know for nickel
allergies

1-the hall technique: This is a very simple procedure, used for decayed baby teeth stainless
steel crown which is a premade cap that is glued on his tooth to protect it. There is no need
to numb the tooth as it is a pain free procedure. need to check the tooth is symptom free.
I will place a band around that tooth for a couple of days to help with ease of placement. we
will fill the cap with some cement place it over the tooth and ask him to bite on it until it is
seated, any access cement will be removed.
2-the conventional technique: we will separate the tooth with a rubber dam which is
basically a rain coat to keep the tooth dry. The tooth must be numbed, then remove the
decay and we might need to prepare the tooth slightly all around to allow enough space for
the cap. we will choose the correct size when placing we can hear a click fit after filling the
cap with cement it is placed and the child is asked to bit on it.

134
[Type here]

The cap might be slightly high when he bites but this will be adjusted by itself after a few
weeks.
Advantages of this it has a high success rate saving the natural tooth the disadvantages that
it cannot be used in those with known nickel allergies. Is everything clear so far?

Do you have any question? I will give you some leaflets that explains everything.

Thank you
50-Amalgam high spot

Criteria
1- Introduce yourself politely to the patient
2- Show empathy and reassure patient and apologise
3- Take simple pain history,
type of filling? When did patient have it?
when did pain start? What brings on the pain?
if the patient thinks the filling is high?
4- Explain to the patient high spot, why it happens and how common it is
5- Explain you will remove it with articulating paper and review patient after 2 weeks
6- Explain that pain might continue for a while and give pain killers
7- Check understanding
8- Thank the patient

Good morning Mr, my name is, I am one of the dentist here and will be seeing you. how can
I help you today?
Sorry to hear about that I want you to rest assured we will do something about it but first I
need to know more,
Where is the pain, since when have you had it? Pain on biting? How long does it last?
When did you have, the treatment done? Do you feel you bite is high?

The pain you are having is because what we call a high spot on the filling you had recently this is
something very common let me explain it more to you. The tooth is supported in bone by a thin
layer of tissue called the periodontal ligament. When you have a filling that is too high, the tooth
gets pressed down a lot harder and it makes this ligament very tender and that is why you have that

135
[Type here]

pain. It is very common in dentistry mainly the patient is numb and cannot feel anything so the bite
might not be correct and sometimes it is difficult to identify it.
It is easy to treat, we will be grinding it down and re-checking your bite it should only take a few
minutes. For pain to resolve the healing process can take anywhere from a one day to two weeks. I
will review you after two weeks to see if pain subsides and everything is fine. In the meantime, you
can take some painkillers.
If patient is still unhappy and wants to make a compliant explain that it is patient right and practice
manager will contact him shortly.
Do you have any question? Thank you very much.

136
[Type here]

51-Child anxiety control:

Criteria
1- Greet the parent and introduce yourself
2- Show empathy and reassure the parent
3- Ask why the child is anxious
4- ask parent to support their child by:
● controlling their own anxiety
● bring the child to other appointment to get used to the environment
5- Start from simple procedures to more complex parsing their good behaviour
6- Explain to the patient show do and tell (only for young children not teenagers)
7- If fillings are needed they are done under local anaesthesia and numbing gel, safe,
quick but if child is anxious then difficult
8- Explain inhalation sedation, safe simple reduce response to pain and anxiety not
indicated if asthma or cold side effect vomiting
9- Ask if they have any question and thank them

Good morning Mr, my name is, I am one of the dentist how are you today?
I understand your worries and concerns but rest assured we will do something about it but first can
you tell me, why is he anxious? How old is he?
We will start with few simple steps to overcome his anxiety, first you have control your anxiety as
child can sense it from the parents, bring him with his sibling appointment so he gets used to the
environment.
we start with simple procedures such as examination were no scary instruments are needed, and as
he feels more comfortable we will move on to more complexed treatment parsing him through out
for his behaviour to develop a positive attitude toward his dental visits. We will introduce him slowly

137
[Type here]

through a technique called show, tell and do. Showing him the instruments we use and calling them
fancy names until he gets used to it.
if we find that he needs a filling for example and he is comfortable to have the treatment we can
have it done under local anaesthesia where the tooth will be numb and we will apply some gel to
numb the gums at the injection site, the advantages of this it is a simple one procedure it is done
here in the surgery the down side of it is the starch of the needle that he might feel.
If he is still anxious we can use a method called sedation which is basically giving him a mixture of
gases called the laughing gas to breath from a nose piece, he will be aware of what is happening and
follow all the instruction but his anxiety is controlled and pain respond is reduce but we need to
numb the tooth. It is a safe procedure and recovery is within minutes however it can be associated
with nausea and vomiting and if he has asthma or even a cold this is not suitable for him and require
a referral.
Last option is GA, this is done at a hospital set up a health assessment need to be done before, he
will be put to sleep he and must fast couple of hours before hand. Afterward he will feel tired,
nausea and vomiting is the side effect with such treatment. There is a risk of 2-3 in everyone million
it is a small risk but still exists .
Do you have any question?
Thank you

52-Radiotherapy starting after 3 weeks

you are a CDP dentist working in a dental hospital. You have seen a patient on a multi-
disciplinary cancer clinic. The patient has been diagnosed with oral SCC and will be
undergoing surgery and radiotherapy for treatment of the lesion. You are to carry out a
check-up and assess any dental needs to be carried out prior to the oncological treatment.
Please explain to the patient what you may aim to achieve in long term of dental
management associated with their oncological treatment.

1- Introduce yourself politely

2- Ask when will the radiotherapy start and on what part of the body?
3- explain you will do a compressive dental assessment and any teeth with poor prognosis will
need to be extracted prior to the radiotherapy treatment because of risk of
osteoradionecrosis
4- Infor patient about the oral side effect of radiotherapy to head and neck;
● Mucositis
● Dry mouth
● High caries
5- Give local measure to for xerostomia
6- Give local measures for high risk caries
7- If patient wearing denture examine the denture and give denture hygiene advice
8- Ask if any question and thank the patient
Check list from Kathleen fan page 283

Good morning mr, my name is, I am one of the dentist here and will be seeing you. From
your notes, I understand that you will be starting radiotherapy soon, is that right? Sorry to
hear about that how are you copping? Rest assured we are here to help if you need
anything.

138
[Type here]

When is, the treatment starting?

We will do a thorough check up of your teeth to make sure everything is fine, those teeth
that need minor filling we will treat and those which have less chances of success should be
removed to prevent any infection later on or the need to remove them after radiotherapy as
you are at a risk of developing a osteoradionecrosis which is a long standing very painful
condition where you wounds fail to heal following removal of the teeth.
radiotherapy which is a high intense dose of radiation which is used to go deep in the tissue
to kill abnormal cells. and this unfortunately can cause damage other tissue which could be
temporary or permanent. If the salivary gland which produces the spit in your mouth is
damage you might experience symptoms of dry mouth that will make it difficult to eats or
speak. I would suggested keeping a bottle of water with you all the time and taking regular
sips to keep your mouth moist, increase the intake of fruit and vegetable in your diet and try
to use a sugar free chewing gum which stimulate the release of saliva.
saliva is very important to the health of the mouth it has a cleansing effect as this is reduced
you are at risk of tooth decay. it is very important to brush your teeth twice a day with
fluoride tooth brush and tooth paste I will give you a high fluoride tooth paste of 5000ppm
fluoride this is a medication used by only you and not anyone else in your house hold. Try to
reduce the sugar in your diet and keep a meticulous oral hygiene at all time.
You might have a sore gum at times and won’t be able to brush your teeth so I will give you
a chlorohexidine mouth wash that you could use twice a day to prevent infection but you
should resume brushing when pain ease
If you have a denture make sure you clean it properly after every meal and take it out at
night to allow your gums to rest.
I will give you all the information in leaflets do you have any question?
We are here if you need any further help let don’t hesitate to contact us.
Thank you

53-anxicous mum requiring information for GA for her child

Mrs sally Baily attended your practice for the second time, her child james has a tooth ache.
You examined the tooth which is badly decayed lower left first molar which is indicated for
extraction. Mrs Baily wants the tooth out under general anaesthesia she doesn’t want to put
her child through a traumatic experience. Explain the anaesthetic options.

● Examine the following completed full dentures.

139
[Type here]

● Examine them on the models and hand articulated

● Identify eight errors in their construction.

140
[Type here]

141
[Type here]

142
[Type here]

143
[Type here]

144
[Type here]

145
[Type here]

146
[Type here]

147
[Type here]

148