MJDF Oral Medicine and Surgery

Question 1

A 60-year-old male smoker presents with a non-healing white patch on the ventral surface of the tongue that cannot be rubbed off. Biopsy shows moderate epithelial dysplasia. What is the most appropriate management?

Accepted Answer

Complete surgical excision with clear margins, smoking cessation counselling, and regular long-term follow-up with clinical and histological surveillance

Answer

A leukoplakia with moderate dysplasia on a high-risk site (ventral tongue) in a patient with a major risk factor (smoking) requires surgical excision to obtain clear margins. The malignant transformation rate for dysplastic leukoplakia is approximately 5-18% over 5 years, with higher rates for moderate/severe dysplasia, ventral tongue/floor of mouth location, and continued tobacco use. Post-excision management includes smoking cessation, regular clinical review (initially 3-monthly), and repeat biopsy of any recurrence. Leukoplakia can recur at the same or different site.

Question 2

What is the difference between an odontogenic keratocyst and an orthokeratinised odontogenic cyst, and why is the distinction clinically important?

Accepted Answer

The odontogenic keratocyst (OKC) has a parakeratinised lining with a high recurrence rate (25-60%) and association with Gorlin syndrome; the orthokeratinised variant has a lower recurrence rate (<5%) and no Gorlin association, making conservative treatment more predictable

Answer

The distinction is crucial for prognosis and management. The OKC (parakeratinised type) has a thin, uniform parakeratinised epithelium with a corrugated surface, palisaded basal layer, tendency for satellite cysts and daughter cysts in the wall, high recurrence rate (25-60%), and association with Gorlin-Goltz syndrome (PTCH1 mutation). The orthokeratinised odontogenic cyst has an orthokeratinised lining with a prominent granular layer, recurrence rate below 5%, and no Gorlin association. Treatment of OKC may require peripheral ostectomy or Carnoy's solution application to reduce recurrence.

Question 3

A patient presents 48 hours after extraction of a lower premolar with increasing pain, swelling, trismus, and a temperature of 38.5°C. There is fluctuant swelling in the buccal sulcus. What is the diagnosis and management?

Accepted Answer

Post-extraction abscess with subperiosteal collection — incision and drainage under local anaesthesia, copious irrigation, antibiotics (amoxicillin plus metronidazole), and review within 24-48 hours

Answer

The triad of increasing pain, fluctuant swelling, and pyrexia at 48 hours post-extraction indicates a localised post-extraction abscess. The fluctuance suggests pus collection requiring surgical drainage. Management: local anaesthesia, incision through the most fluctuant point, blunt dissection to break down loculations, copious irrigation with saline, consider placing a drain, prescribe antibiotics (amoxicillin 500mg TDS plus metronidazole 400mg TDS for 5 days), analgesics, and review within 24-48 hours. If trismus is severe or there is any sign of spreading infection, hospital referral is warranted.

Question 4

What are the clinical features and management of oral candidiasis in a patient using a corticosteroid inhaler for asthma?

Accepted Answer

Pseudomembranous candidiasis (white patches that can be wiped off leaving erythematous mucosa) or erythematous candidiasis on the palate/dorsal tongue; managed by advising spacer use, rinsing mouth after inhaler use, and prescribing topical miconazole oral gel or nystatin suspension

Answer

Inhaled corticosteroids deposit on the oropharyngeal mucosa, causing local immunosuppression that predisposes to oral candidiasis. It typically presents as pseudomembranous candidiasis (removable white plaques) or erythematous candidiasis (red patches on the palate or tongue). Prevention: use a large-volume spacer device (reduces oropharyngeal deposition by 80%), rinse the mouth with water after each inhaler use, and practice good denture hygiene. Treatment: miconazole oral gel 20mg/mL (2.5 mL QDS for 7-14 days) applied after rinsing, or nystatin suspension 100,000 units/mL. Systemic fluconazole is reserved for refractory cases.

Question 5

What is the recommended protocol for managing an avulsed permanent incisor in a 10-year-old child who presents within 30 minutes of the injury with the tooth stored in milk?

Accepted Answer

Replant the tooth immediately: rinse gently with saline (do not scrub the root surface), replant into the socket, apply a flexible splint for 2 weeks, prescribe antibiotics and tetanus check, begin root canal treatment 7-10 days post-replantation

Answer

According to the International Association of Dental Traumatology (IADT) guidelines, for an avulsed permanent tooth with a closed apex, replanted within 60 minutes with the tooth stored in appropriate medium (milk, saline, Hank's balanced salt solution): gently rinse the root surface with saline (do not scrub or remove attached PDL cells), replant into the socket, apply a flexible (passive) splint for 2 weeks (using orthodontic wire and composite), prescribe systemic antibiotics (doxycycline 100mg or amoxicillin if under 12), verify tetanus immunisation, and initiate root canal treatment 7-10 days post-replantation (before splint removal) to prevent inflammatory resorption.

MJDF Part 1 Practice Test

MJDF Part 1 Practice Test

MJDF Oral Medicine and Surgery