ADC - Australian Dental Council Minor Oral Surgery Questions and Answers — Questions and Answers
Question 1: A 65-year-old patient on long-term warfarin therapy for atrial fibrillation requires a simple extraction of tooth 36. His recent INR reading is 2.8. According to Australian Therapeutic Guidelines, what is the most appropriate management plan?
- Defer the extraction and advise the patient to cease warfarin for 3 days prior.
- Proceed with the extraction using effective local haemostatic measures. (Correct answer)
- Refer the patient to a hospital for the extraction under general anaesthesia.
- Ask the patient to halve their warfarin dose for 24 hours before the procedure.
Correct answer: Proceed with the extraction using effective local haemostatic measures.
Australian and international guidelines recommend that for simple extractions (1-3 teeth), patients with a therapeutic INR up to 4.0 can proceed without altering their warfarin regimen. The risk of a thromboembolic event from stopping warfarin far outweighs the risk of post-operative bleeding, which can be managed effectively with local measures such as packing the socket with a haemostatic agent and suturing.
Question 2: A patient presents 3 days after the extraction of tooth 46 with severe, radiating pain and a foul taste. Clinical examination reveals an empty socket with exposed, sensitive bone. What is the primary goal in the management of this alveolar osteitis (dry socket)?
- To surgically debride the socket walls to induce fresh bleeding.
- To prescribe a course of broad-spectrum systemic antibiotics.
- To provide symptomatic relief of pain while healing by secondary intention occurs. (Correct answer)
- To place a bone graft into the socket to accelerate tissue regeneration.
Correct answer: To provide symptomatic relief of pain while healing by secondary intention occurs.
Alveolar osteitis (dry socket) is a localised inflammatory condition, not a true infection, caused by the premature loss of the blood clot. The primary goal of management is palliative care to relieve the patient's severe pain. This is achieved by gentle irrigation to clean the socket of debris and placing a sedative dressing (e.g., Alvogyl or zinc oxide-eugenol pack). Systemic antibiotics are not indicated unless there are signs of spreading infection.
Question 3: During the extraction of a maxillary first molar (tooth 16), you suspect a small oroantral communication (OAC) of approximately 2mm has been created. There is no pre-existing sinus pathology. What is the most appropriate immediate management?
- Immediately refer the patient to an oral and maxillofacial surgeon for a buccal advancement flap.
- Promote and protect the blood clot with a haemostatic agent and a figure-of-eight suture. (Correct answer)
- Leave the socket open to drain and provide strict sinus precautions.
- Prescribe a one-week course of antibiotics and nasal decongestants as the sole management.
Correct answer: Promote and protect the blood clot with a haemostatic agent and a figure-of-eight suture.
For a small OAC (<2-3 mm) in a healthy sinus, the primary objective is to maintain a stable blood clot within the socket, which will allow for spontaneous healing. This is best achieved by placing a resorbable haemostatic agent (e.g., Gelfoam) and securing it with a suture (e.g., figure-of-eight) to provide a scaffold for the clot. While sinus precautions and medications are important adjuncts, the key immediate step is mechanical protection of the clot. Larger defects (>5mm) typically require surgical flap closure.
Question 4: A 22-year-old patient presents with severe pain, trismus, and swelling associated with a partially erupted tooth 38. There is purulent discharge from under the operculum. Which of the following is the most appropriate initial management for this acute pericoronitis?
- Immediate surgical extraction of tooth 38 to remove the definitive cause.
- Incision and drainage of the operculum without local anaesthesia to avoid spread of infection.
- Gentle irrigation under the operculum and debridement, with antibiotics reserved for systemic signs. (Correct answer)
- Prescribing a course of analgesics only and reviewing the patient in one week.
Correct answer: Gentle irrigation under the operculum and debridement, with antibiotics reserved for systemic signs.
The initial management of acute pericoronitis focuses on resolving the acute inflammatory and infectious process before definitive treatment. This involves local measures, primarily gentle irrigation of the sub-opercular space with saline or an antiseptic solution to remove debris and reduce the bacterial load. Systemic antibiotics are only indicated if there are signs of systemic involvement (e.g., fever, lymphadenopathy, severe trismus) or spreading infection. Extraction is deferred until the acute phase is controlled.
Question 5: A dentist identifies a 1.5 cm, indurated, non-healing ulcer on the lateral border of the tongue of a 60-year-old male smoker. The lesion is suspicious for malignancy. Which of the following is the most appropriate diagnostic step?
- Perform an excisional biopsy to remove the entire lesion and a 2mm margin.
- Use a cytological brush to scrape cells from the surface for analysis.
- Review the patient in two weeks to see if the lesion has resolved on its own.
- Perform an incisional biopsy taking a wedge of tissue from the lesion's border. (Correct answer)
Correct answer: Perform an incisional biopsy taking a wedge of tissue from the lesion's border.
For a lesion that is clinically suspicious of malignancy or larger than 1cm, an incisional biopsy is the standard of care. This procedure provides a representative tissue sample to establish a definitive histopathological diagnosis before a definitive treatment plan (often involving wide excision and specialist care) is formulated. Excisional biopsy is typically reserved for smaller (<1cm) lesions that appear benign. Delaying diagnosis of a suspicious lesion is inappropriate.
Question 6: Which of the following is a fundamental principle for designing a full-thickness mucoperiosteal flap for a surgical extraction?
- The base of the flap should be narrower than the free margin to minimise bleeding.
- The flap must be wide enough to allow for tension-free retraction and good visibility. (Correct answer)
- Releasing incisions, if used, should be placed over the mid-buccal of adjacent teeth.
- The periosteum should be carefully left attached to the bone to accelerate healing.
Correct answer: The flap must be wide enough to allow for tension-free retraction and good visibility.
A critical principle of flap design is to ensure adequate access and visibility of the surgical site. The flap must be large enough to be retracted without tension, as excessive tension can tear the tissue or compromise its blood supply, leading to delayed healing or necrosis. To ensure adequate blood supply, the base of the flap must always be wider than its free margin. A full-thickness flap, by definition, includes the periosteum.
ADC - Australian Dental Council Minor Oral Surgery Questions and Answers
A 65-year-old patient on long-term warfarin therapy for atrial fibrillation requires a simple extraction of tooth 36.
His recent INR reading is 2.8.
According to Australian Therapeutic Guidelines, what is the most appropriate management plan?