Clinical Problems in DENTISTRY 50 OSCEs and SCRs for the Post Graduate Dentist
John Laszlo
Copyright © 2013 by John Laszlo. Library of Congress Control Number: ISBN: Hardcover Softcover Ebook
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Rev. date: 11/05/2013
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Contents Preface Chapter 1 Exam Expectations Introduction The Exam Structure The MFDS Themes The MJDF OSCEs Preparation for Exams Failure Exam techniques should reflect clinical ones. The Four Clinical Domains Exam Domains in Greater Detail 1. Information Gathering 2. The Candidate to Actor Interaction 3. Conveying Information 4. Clinical Issues Key Elements of an OSCE Consultation Unpalatable truth and dishonesty Giving and Taking in the Examinations Relevant Information in the OSCE History Taking in the OSCE Communication and Empathy Empathy Is Not… Breaking Bad News From the Theatrical to the Practical Words and Language The Marking Scheme for the Examinations Don’t Memorise Anything in This Book References for Exam Expectations Further Reading for Exam Expectations Chapter 2 Medical Emergencies Introduction References Medical Emergencies Introduction Further Reading to Medical Emergencies Introduction Medical Emergency 1
Background Information Introduction The Steps Towards the Answer Post-Emergency Care Further Notes to Medical Emergency 1 Prevention References to Medical Emergency 1 Medical Emergency 2 Background Information Introduction Patient with Difficulty Breathing Responding to This Medical Emergency Points to Note Common Causes of This Medical Emergency Further Notes to Medical Emergency 2 References to Medical Emergency 2 Further Reading to Medical Emergency 2 Medical Emergency 3 Background Information Introduction Answers to This OSCE Signs and Symptoms You Will See An Emergency Presentation of This Condition The Importance of a Medical History Document Your Findings Further Notes References to Medical Emergency 3 Further Reading to Medical Emergency 3. Medical Emergency 4 Background Information Introduction Answers to this Medical Emergency Heresy or Orthodoxy: An Examiner’s Comment Facts to Consider Adult Basic Life Support References to Medical Emergency 4
Medical Emergency 5 Background Information to This Question Please Take Note of Patient Notes Introduction Further Notes on Medical Emergency 5 Recognition of the Clinical Signs References to Medical Emergency 5 Medical Emergency 6 Background to This Emergency Introduction Procedures to Follow Further questions and answers about this emergency Further Considerations of this Medical Emergency Additional Details. Anaphylactic Reactions Initial Treatment References to Medical Emergency 6 Medical Emergency 7 Background Information. Introduction Beginning a Difficult Consultation Procedures to Follow Point to Note Further Notes to this Medical Emergency. Adult Choking Treatment Paediatric Choking Treatment References to Medical Emergency 7 Medical Emergency 8 Background Information Introduction Answers to this Medical Emergency. Three Questions Further Notes to this Medical Emergency. References to Medical Emergency 8 Further Reading Medical Emergency 9 Background Information
Paediatric Basic Life Support Introduction The Procedures in This OSCE Public Expectations Paediatric Basic Life Support References Medical Emergency 9 Medical Emergency 10 Background Information Introduction The Devil is in the Detail The First Procedures to Follow From Angina to Cardiac Arrest Further Notes Adult Automatic External Defibrillation References to Medical Emergency 10 Further Reading on Medical Emergencies Chapter 3 Medical Matters Introduction Medical Matter 11 Background Information Introduction Medication Lists in the Exams First Thing to Do Medication and Side Effects ASA Grading of the Patient The Answers Prescribing Treating Further Notes to this Medical Matter. References to Medical Matters 11 Further Reading Medical Matter 12 Background Information Introduction Developing Your Answers Reasons for the Answer
A Lack of Information Further Notes to this Medical Matter. References to Medical Matters 12 Further Reading Medical Matter 13 Background to This Case Approach to the subject Medical and Social Considerations Answers to this Medical Matter. Management Options Treatment Options Further Notes to this Medical Matter. References to Medical Matters 13 Medical Matter 14 Background Information Introduction Structured Answers Medication history History Taking Bleeding Tendencies: Cirrhosis and Caput Medusa Clinical signs of liver disease Further Note to this Medical Matter. References to Medical Matters 14 Medical Matter 15 Background Information Introduction Initial Answers. Further Answers. Clinical Recommendations Further Note to this Medical Matter. References to Medical Matters 15 Further Reading Medical Matter 16 Background Information Introduction
The Complaint Answer to this Medical Matter. Intra-Oral Signs The Differential Diagnoses The Case Management Pain Questionnaires References to Medical Matter 16 Further Reading Medical Matter 17 Background to the Case Introduction Answers Further Note to Medical Matter 17. References to Medical Matters 17 Further Reading. Medical Matter 18 Background to the Case Introduction Answers to this case Appropriate Questions A Revealing Clue Continuing the Dialogue Going After the Details Further Answers Specialist Tests Definitive Treatment An Important Clinical Consideration References to Medical Matters 18 Further Reading Medical Matter 19 Something to Wake You Up A Re-introduction Answers to This Medical Matter. Chewing Over the Information The Deficiency State Clinical symptoms and signs
Critical Differences Management Answer Further Notes References to Medical Matter 19 Medical Matter 20 Background Information Just As a Reminder Introduction Formulating and Presenting Your Answers The Answers to This Medical Matter. More Answers The Pause Don’t Learn the Reference Intervals Further Notes : Anaemias in Real Life References to Medical Matter 20 Further Reading for This Medical Matter. Medical Matter 21 Background Information Introduction Answers Consider the Capacity then Consent. Cervical Lymph Nodes Silver Linings Further Notes to This Medical Matter. References to Medical Matter 21 Further Reading Medical Matter 22 Background Information Introduction Answers Further Notes to this Medical Matter. References to Medical Matters 22 Further Reading Medical Matter 23 Background Information Introduction
Answers Metabolic Considerations References to Medical Matter 23 Further Reading Medical Matters 24 Background Information Introduction to the Case Answers Points to Note References to Medical Matter 24. Further Reading Medical Matters 25 Background Information Explaining and Describing Introduction Answers to This Medical Matter Clinical Signs in Introduction Access to Information Further Notes to This Medical Matter. References to Medical Matters 25 Further Reading Chapter 4 Ethical Examples Introduction Where Do Ethics Belong? The Hidden Curriculum Serving the Profession Ethics in the Exams The 2013 GDC Guidelines Consideration of These Oaths References to Introduction Ethical Examples Ethical Example 26 Introduction Answer Parental Responsibility Closing Statements Further Considerations
The Legal Aspects References to Ethical Examples 26 Further Reading Ethical Example 27 Background Information Introduction Answer Further Notes to This Ethical Example. The SPIKES Protocol White Patches and Smoking Management of the White Patch References to Ethical Examples 27 Further Reading Ethical Example 28 Background Information Introduction Sharps injuries The Answers Further Notes to This Ethical Example References to Ethical Example 28 Further Reading Ethical Example 29 Background Information Introduction Point to note Answers Further Notes to This Ethical Example. References to Ethical Examples 29 Further Reading Ethical Example 30 Background Information Introduction Considerations in Your Answers The Answers Further Notes to This Ethical Example References to Ethical Example 30
Chapter 5 Clinical Cases Introduction Clinical Case 31 Introduction Points to Note The Answer The Medical History The Dental History Determining the Nature of the Problem The Dialogue in This Clinical Case. Discussion of Solutions Further Notes to This Clinical Case References to Clinical Case 31 Further Reading Clinical Case 32 Background Information Introduction Non-Accidental Injury Answer Child Abuse and the Exams Dental Trauma References to Clinical Case 32 Further Reading Clinical Case 33 Background Information Introduction Answer Testing Required Management of the Condition Further Notes to This Clinical Case Diagnostic Features References to Clinical Case 33 Further Reading Clinical Case 34 Background Information Introduction
Answer Additional Radiographic Findings Further Notes to This Clinical Case. Parallax views References to Clinical Case 34 Further Reading Clinical Case 35 Background Information Introduction Answers 1. The First Steps to Take 2. The Early and Intermediate Treatment 3. Those Who Should Be Notified 4. Possible Complications Arising 5. The Management of Complications Further Notes to This Clinical Case Five Rules of 5’s. References to Clinical Case 35 Further Reading Clinical Case 36 Background Information Introduction Points to Note Answers 1. The Brief set of Histories Relevant to This Patient Points to Note 2. Explain the Options for Treatment 3. Common procedural complications and answers Further Notes to This Clinical Case. The Risks from Extraction References to Clinical Case 36 Further Reading Clinical Case 37 Background Information Introduction Answer
1. Greeting and Opening the Consultation 2. Open Questions and Body Language 3. Reflecting Back to the Actor/Patient 4. The Histories 5. Candidate’s Considerations of the Complaint. 6. Giving an Explanation 7. The Specific Problem 8. Initial Treatment 9. Further Specialist Treatment Further Notes to This Clinical Case. Further Reading to Clinical Case 37 Clinical Case 38 Background Information Introduction Answers for Clinical Case 38. Point to Note Concerns with Pre-Medication. Points to Note Points to Note Points to Note Further Notes to This Clinical Case. References to Clinical Case 38 Further Reading to Clinical Case 38 Clinical Case 39 Background Information Introduction Answer Beginning the Consultation Focusing on the Issues Points to note Providing Answers Advice and Explanations Further Notes to This Clinical Case References to Clinical Case 39 Further Reading Clinical Case 40
Background Information Introduction Answers for Clinical Case 40. Overall Prognosis Further Notes to Clinical Case 40 References to Clinical Case 40 Further Reading Clinical Case 41 Background Information Introduction Answers to Clinical Case 41. Point to note. Further Notes to Clinical Case 41 References to Clinical Case 41 Further Reading to Clinical Case 41 Woody’s Work 42 Background to This Case Dealing with the Anxious Child Introduction to the Case Answer for Woody’s Work. Explanations Radiography and Explanations Figures from canine studies Ectopic canines guidelines 1. Leave and Observe 2. Deciduous Canine Extraction 3. Permanent Canine Extraction 4. Canine Transplantation 5. Exposure and Alignment Patients don’t really care how much you know… . . . As long as they know how much you really care. Intranasal Sedation Further Note about Woody References about Woody’s Work Some of Woody’s Work. Clinical Case 43
Background Information Introduction Answers to Clinical Case 43. Jollying the Patient Along Key Skills + Core Chores Surgical Sieves A Patient-Centred Consultation Further Notes to Cinical Case 43. The journey is more important than the destination. References to Clinical Case 43 Further Reading to Clinical Case 43 Clinical Case 44 Background Information Introduction Answers to Clinical Case 44. Minor Matters. Point to Note Points to Note Dental Record Retention Further Notes to This Clinical Case. References to Clinical Case 44 Further Reading to Clinical Case 44 Clinical Case 45 Background Information Introduction Clinical Case 45 Part 1: Answers Two Heads Are Better Than One Pemphigus and Pemphigoid Zebras, Fascinomas and Zebromas Nervous revision Further Notes to Clinical Case 45 Part 1 References to Clinical Case 45 Part 1 Clinical Case 45 Part 2 Brown Envelope—Pink Paper Answers Clinical Case 45. Part 2 Simple Questions but No Easy Answers
Breaking Bad News Further Notes to Clinical Case 45 Part 2 A Ticket to the Zoo References to Clinical Case 45 Part 2 Further Reading to Clinical Case 45 Parts 1 and 2 Chapter 6 Procedural Problems Introduction The Story So Far… Important Developments References Introduction Chapter 6 Procedural Problem 46 Background Information Smoking Cessation Introduction to Procedural Problem 46. Answers to this Procedural Problem. Addictive Behaviours and Fears Does the Patient Need Help? The Importance of a Medication History The Treatment Ladder Further Notes to Procedural Problem 46. The First Words Last References to Procedural Problem 46 Further Reading to Procedural Problem 46 Procedural Problem 47 Background Information Introduction Answers to Procedural Problem 47. A Socratic and Not a Didactic View Audit Topic Audit Methods Further Notes to This Procedural Problem. References to Procedural Problem 47 Further Reading to Procedural Problem 47 Procedural Problem 48 Background Information Introduction
The Answer Pascal, Patients, and Papillomas Further Notes to This Procedural Problem. References to Procedural Problem 48 Further Reading Procedural Problem 49 Background Information Answers Points to Note Why We Need the Guidelines Sharps! Points to Note Safety Legislation in Dentistry Further Notes to This Procedural Problem. References to Procedural Problem 49 Further Reading to Procedural Problem 49 Procedural Problem 50 Background Information Procedural Problem 50 Part 1 Introduction Answers Part 1 Further Note to Procedural Problem 50 Part 1. References to Part 1 Procedural Problem 50 Part 2 Introduction Answers Part 2 Current trends Manufacturing methods Chemical composition Consent Concepts Consent Components Consent 10 Commandments References to Part 2 Further Reading The End… (of the Beginning) Essential reading for Beryl Murray Davies.
PREFACE In the second decade of the Internet, our patients are living longer. Despite outward appearances, many are chronically ill. Advances in care pathways and modern medical treatments allow them to live robust lives. Patients, families and carers now effortlessly access electronic information and attend their appointments with a surprising degree of familiarity of the conditions they have and the treatments they wish to have. In the advent of the digital age, in response to information now in the hands of our patients, technologies were developed for clinical training with the surgical professions seeking refuge in simulation from the onslaught of widely dispersed information freely available to all. Anatomical knowledge was taken from the cadaver to the computer, dissection being demoted and digisection promoted. Vast tracts of the training syllabus were deposited in digital… dot… domains in the progressive modernisation of clinical careers. In addition to the above developments, patients with specific signs are no longer invited to attend for student clinical examinations. Professional actors recruited into OSCEs have replaced them. These days, dental students are asked to assess symptoms that an actor speaks about, rather than examining signs a patient suffers from. Today, with electronic information being readily available, there is a fundamental question whether there is a need for a book such as this. When contemplating this project last year, the advice given by Professor St John Crean of the Faculty of Dental Surgery, RCS England was; there is still a need for the clinical textbook. In contrast to evolving electronic media, the textbook is a preserved specimen, only fading ink and yellowing pages mark the passage of time. ‘When treating patients have a warm heart and warm hands’ were words given in St Andrews by Dr David Sinclair. It was my good fortune to receive his wisdom and a privilege to meet (now) Professor Sinclair and reflect on that advice, when after the passing of nearly 25 years we met once more, this time at the Faculty of Surgical Trainers annual meeting in Birmingham in 2013. That his words stand and have served so many so well in the clinic, is a good indicator that books and words frozen in time espousing warmth and humanity still have a place in clinical education. While the Internet is comprehensive and prone to mistakes, a book can concentrate and filter information, consistently condensing it into a form useful for the examination candidate and the practicing clinician. Whereas the Royal Colleges now use actors in their clinical exams, I have based this book on real people: my patients. It was the advice and example of one patient Mr Barry Harvey that set the writing process in motion. This book contains just about everything I have learned about the MFDS and MJDF exams. Although it is the work of a single author (and I own all the mistakes), some of the very best people freely gave their opinions, advice and support to this project pushing it to completion: The two Mariannes: Laszlo and Lehmann BA (Fribourg). Mrs Michelline Brannan MA (Oxon) BN. Mr Roger Farbey MBE, Helen Nield and staff of the BDA library, London. Dr Adrian Bercu.
Fribourg, Switzerland. Mr Alex Leslie LLB and his staff of Radcliffes Le Brasseur, London. Mr Robert Francis QC. Serjeant’s Inn Chambers, London. Mr B Westbury, Mr S Henderson and staff of DPL, London. Professor St John Crean, Faculty Dental Surgery Royal College Surgeons, England. Dr Maria Hardman Clinic 95, Oxford. Mr Randy Smith, Miss Kay Benavides and Miss Carla Cobar, for their effort and energy in bringing this to print. All of my patients and colleagues for their appreciation, faith and trust. Your comments, criticisms and corrections are expected and they will be accepted.
In this, the 600th year of the founding of my Alma Mater: St Andrews, Scotland’s first university, I now remember one of Scotland’s finest daughters: Miss Jane Haining. I am moved to write her lasting words: “There are mountains on the road to heaven” Jane Haining was a true Christian, a teacher and a healer. She perished in Auschwitz in 1944, giving her life caring for others. She was prisoner 79476. This book is dedicated to her memory and to those below, Olim Cives. I learned from them all, their words, wisdom and lives are written into this book. Elizabeth Laszlo 4074003. Reverend Dr Jorg Rades. Dr Imre Laszlo MD Ph.D Dr Asif Omar Qureshi BSc. MD. Michael Vogel 65316 Anna Sotto Dr Gustav Milan Braun MD FACS. Dr Michael Norman Wood BDS FDS RCS (Ed).
1 Exam Expectations Introduction The aim of the Objective Structured Clinical Exams (OSCEs) in Part 2 of both the MFDS and MJDF and the Structured Clinical Reasoning (SCRs), Part 2 of MJDF, is to test your clinical competence. On entering these exams with a realistic prospect of passing, you will be expected to demonstrate contemporary evidence-based clinical knowledge delivered with appropriate professional behaviours. The level of your abilities for the MFDS and MJDF examinations should be equivalent to that of any dentist working in primary dental care or secondary hospital care with two years’ post-qualification experience. You will not be assessed to the level of a specialist for the MFDS or MJDF, but you will be expected to demonstrate a level of communication skills, clinical knowledge, understanding, and management of common conditions seen in dental patients to a level beyond that of an undergraduate dental student. In these examinations, although you will not be expected to demonstrate the knowledge and skills of a specialist, you should not forget that specialists mark your performance in the clinical scenarios presented to you. Many of you will be attempting these exams to mark completion of your foundation training and will have up-to-date knowledge both readily to hand and fresh in your minds from your undergraduate days and postgraduate tutors. Some of you will have taken one or two years’ break from study in between completing Part 1 of the MJDF and now wish to complete Part 2 of MFDS, before Part 1 expires. The time limit is set at 5 years between parts 1 and 2 of these exams.1 In doing so, you will benefit from reciprocal intercollegiate arrangements, ensuring equivalence for Part 1 of the exams. So you can take a short cut across the exams from MJDF, Part 1, to MFDS, Part 2, and save an hour or two of examination time in the process. A few of you will be taking the longer way round and stay within one track of either MFDS for the Scottish Colleges or MJDF in the English College. Having completed both exams myself, I do not know if there are advantages to be gained by cutting across the tracks. It may well be that what you gain in time to complete this key aspect of your postgraduate training you might potentially lose in the subsequent stages of your career because there was a core component that was never learnt, revised, or examined. Taking short cuts to save on the time spent taking exams could potentially mean the foundation upon which you will build your career may not be as sound as a candidate who completes all necessary steps in one track or both tracks together and therefore has all core components in place in the foundation of their careers. Those of you from outside the UK, the Middle East, Europe, and USA and further afield will be
taking these exams to demonstrate your clinical skills are worthy of recognition by your collegiate peers in the UK. You will be rewarded with membership by examination, then election to your chosen college after passing all parts for the diploma of MJDF or MFDS. In addition to all of you who are newly qualified keen, aspiring hospital specialists, there will be a few of you who are older candidates from general dental practice who for one reason or another have only now just returned to study with renewed enthusiasm and confidence. You will be attempting these Part 2 OSCEs and SCRs for the first time, having never experienced Objective Structured Clinical Examinations as an undergraduate. For you, there will be the open curriculum to learn and a hidden curriculum of new phrases and communication techniques, of which the younger candidates will have gained experience in their undergraduate days. Learning the facts and figures needed for the OSCEs is one area to master; the other is learning about the best way to convey your knowledge to the actor and the examiner in the brief time allocated in the exam. An interesting aspect of the OSCEs is the actor portraying a patient has a say in your assessment too. Actors are asked to comment on your presentation, and ultimately if you cannot perform in the OSCEs to the standard both the examiner and actor expect, you will not pass the exam. Your decision to study for the MFDS and MJDF will undoubtedly improve your clinical skills. In the exam itself, demonstrating your enhanced knowledge and a deeper understanding of dental problems beyond the level required for your undergraduate exams is not easy, but it is achievable. More than anything else, it is a worthwhile exercise that benefits your patients and yourself with a sense of professional pride when your efforts are recognised with an exam pass and the award of your diploma. The background of those who take and pass these exams is wide. Candidates from all over the world come to sit these exams in the UK. From the UK itself, there is a huge range of candidates preparing for the exams. There are recently qualified dentists in their early twenties who sail through all parts of the MFDS and MJDF at their first attempt. There are older candidates too. One middle-aged candidate who returned to study after several career breaks and having not picked up a dental textbook in nearly twenty years eventually passed the MFDS after five attempts. If you are taking more attempts than this or if you know of anyone who is taking more attempts than this, or thinking of giving up after failing, please let me know and I will send a copy of this book. Not only is this book more cost-effective than another failed exam attempt, with collegiate support and good luck we will make on the way, we might guide you towards the success that has eluded you. In 2012, I attended the BDA (British Dental Association) Conference in Manchester to listen to the candidates who had recently passed the MJDF. These newly qualified speakers were part of a presentation supported by the Royal College of Surgeons, England, Joint Faculties of Dental Practice and Dental Surgery. These young dentists were invited to discuss their experience of the MJDF and why they chose to undertake these exams. The first speaker said it gave him a sense of achievement, the second announced to the audience he wanted the letters after his name, while the third speaker told me (privately) he needed to get ahead of the competition to get his place in specialist training. If those reasons were really true, then the aphorism ‘the only thing worse than finding out your best
friend from dental school has died is finding out they did better than you’ might apply here. If that was true, then we would all be doing these and any other exam, just so we could do better than our best friend from dental school before we see our last patient and shuffle off to that great clinic in the clouds. Wouldn’t we? In putting yourself through these exams, you have shown a commitment to dentistry and a commitment to caring for your patients. Just by attempting these exams you are doing better, but not better than your best friend; you are doing better than if you decided not to continue with your studies at all. So I guess doing these exams is a way of marking your progressive improvement as a dentist. Oh, and by the way, before we get on to the exams themselves, just because the UK GDC (General Dental Council) does not presently consider the MFDS and MJDF to be registrable qualifications2 do not let this odd decision put you off doing the exams. If this GDC decision is a reason for not studying to become a member of a Royal Surgical College, then what an own goal against: your profession and your place in your profession that would be. In the bigger scheme of things, don’t forget the GDC is limited to regulating the practice of dentistry in the UK. On the other hand, the MFDS and MJDF carry significant cachet and gravitas from the UK and from the Surgical Colleges around the world to wherever candidates who have studied and passed these exams are benefitting their patients in the practice of dentistry to a higher standard than if they had never contemplated these exams in the first place.
The Exam Structure OK, with your motivation to continue studying and with whatever reason you are fuelling your desire and determination to complete your MFDS and MJDF, I guess we can now get on to the exam itself. In the MFDS, there is no requirement to treat or to actually physically examine the actors who will represent patients with common clinical conditions. In various exam questions, actors will portray the relatives of patients who have endured certain clinical situations and you will conduct a dialogue with them. In the MFDS, there are currently no medical emergency OSCEs; this is the preserve of the MJDF. At several MFDS exam sittings, I have seen anxious candidates in their last remaining minutes before being ‘condemned’ to entering the examination room, nervously looking through textbooks on how to deal with medical emergencies for an exam where there are no medical emergency questions! Of course, the decision not to include medical emergencies in the MFDS may change in time, so do be aware of the regulations and requirements for the college you will be sitting your exam in. Do not unnecessarily stress yourself and lose time in revising a subject you will not be examined on. In contrast to the MFDS in the MJDF, there are questions specifically dealing with medical emergencies; these may have actors representing patients or relatives of patients. There are also the procedural and practical medical emergency OSCEs with no actors but resuscitation manikins. In these OSCEs, you must demonstrate competence in dealing with any one of the medical emergencies presented.
Out with medical emergencies, there are further practical questions that do not have actors present. In those OSCEs, you need to demonstrate competences in a clinical technique or event, e.g. taking a biopsy or dealing with needle stick injuries. With two years of clinical work or more behind you, hopefully you will have plenty of experience of the former while little if any of the latter. It is not the purpose of this book to teach you how to become technically competent in the clinical areas of your work. Only after practice, practice, and practicing again for all the hours you have and possibly some you think you might not have, will you become a competent practitioner in the clinical skills on which you will be examined. Rather, this book presents questions from cases that commonly occur in dental practice based around those OSCEs regularly found in both the MFDS and MJDF exams. In your exam, in all MFDS and certain MJDF OSCEs with actors, an introduction with information about the case and the patient is presented to you in a booklet (which you must return at the end of the exam). In the two or so minutes you have before entering each OSCE and the ten or so minutes at the rest stations between active OSCEs, you will have time to note down and highlight any areas you feel are relevant to the exam question. During the examination with the actor, you can refer back to information you have written in the booklet. In the MFDS and MJDF exams, you are given a comprehensive and clear briefing before you enter the examination room. The only thing you have to watch out for is that you are at the correct page for the correct OSCE. If you are unsure, then ask a member of the examination staff. On the day of your exam, you will see administrative staff of the Surgical Colleges in attendance. In addition to their quite intensive workload, they do a first-class job in calming anxious candidates. You can rely on them to make sure you are at the right page, the right station, at the right time, and that you are all right. The rest is up to you and all the hard work you will be putting in between now and your exam. For now there are three essential points you should note: First, in these exams both your ability to communicate and your clinical knowledge will be examined. Second, your understanding of the clinical problem the actor portrays, how you propose to manage this with any potential issues developing or background factors you uncover is at the heart the OSCE. Third, the ability to demonstrate your clinical skills and competencies under exam conditions and not under clinical conditions is the key to passing both MFDS and MJDF. The MFDS Themes In the MFDS OSCEs, four clinical themes are examined. Depending on the theme of the question, a different emphasis is placed on these areas when assigning marks for the candidate’s performance: 1. Taking a history. This can be a medical, a dental, or a social history taken from the actor. 2. Explanations. These are a diagnosis, a prognosis, and the available options for treatment. If the actor agrees to one of the options you mention, then explaining what the procedure entails for them with the benefits and the risks involved will be expected from you. The advantages and disadvantages in proceeding or not proceeding with your options must be given in balanced
terms. 3. Investigations. The results of any previous investigation or test should be interpreted and then communicated to the actor. In the OSCE, such test results will be given to you in the exam handouts and these are also provided in the introduction to each case. 4. Managing Patient Concerns. The enquiries or concerns of the actor representing a patient or their relative need to be addressed in the OSCE. Such exam questions frequently deal with consent issues: consent for a procedure, the management of a nervous patient or relative (most likely the parent of a child), encouraging or motivating the actor portraying a patient to take an appropriate course of action or to undergo some form of treatment. Lastly, management could mean informing the actor or patient of a course of action that is needed but which is neither ideal nor expected, such as giving test results or the breaking of bad news. At present, the MFDS has a defined theme order from OSCE No 1 to OSCE No 10 as follows: OSCEs 1-2: History taking. OSCE 3: Investigations. OSCEs 4-6: Managing patient concerns. OSCEs 7-10: Explanations. Please note this order may change in the future. The MJDF OSCEs In the MJDF exam, there will be a mix of the above themes with practical skills OSCEs, including (as mentioned above) the medical emergencies. The skills station OSCEs will cover the entire range of dental clinical activities. The only real preparation for the practical MJDF OSCEs is as stated above: to practise, practise, and practise every day while in clinic. While you practise the clinical skills necessary for the MJDF, do not neglect to keep your theoretical —and evidence-based knowledge up to date. In many ways, some of the MJDF OSCEs are as much an exercise in multitasking as they are a test of your clinical competencies. In contrast to the MFDS in the MJDF, there is no defined order determining the type of OSCE that will appear. So after completing a practical question, you may enter a medical emergency and then a dialogue question and so on.
Preparation for Exams On one revision course a while ago, I met a candidate who had decided to take several months’ break from work to concentrate on the exams. On balance, this isn’t a great idea for several reasons: 1. You will not have an income and the exams do cost money. 2. You will not be in practice dealing with patients. 3. Your clinical skills might become degraded with absence from the clinic. 4. You will not be regularly practicing the techniques needed to pass the skills OSCEs in the
MJDF. 5 . In taking this amount of time off, you will be isolating yourself from your colleagues professionally, academically, and perhaps socially too. Taking a week or even a month off before the exam and getting some rest is a good idea. Taking several months off is a bad idea. Do carry on working and develop good professional relationships with your patients. Treat every patient as if you were being examined in an OSCE. By doing so in addition to giving them the best standard of care, you are also mentally preparing yourself for your exams. In doing so, I cannot see any harm in letting your real-life patients know you are studying for your postgraduate exams. I did. Most will be quite pleased to know they are in the care of a dentist studying for higher qualifications. From experience, I can tell you that patients are more than supportive, forgiving, and accepting when things do not go as well as expected or you have to give them your bad news. Patients are also very good at giving feedback too. However, if you want the support and feedback from your patients, you have to let them know what you are studying for and why you are studying for these exams. Let’s not forget it is important to let your patients know when you will not be in the clinic to look after them. Don’t just abandon them when you will be at a revision course or sitting your exams. Failure If you do not pass an exam, patients are so supportive and do give you encouragement, feedback and insight from their perspective too. One candidate told me that the best words of advice received after failing did not come from a tutor or colleagues but came from a patient: ‘Och dinnae wurry aboo’ it. Dinnae gee up gee it an aer’ go. Ahll ah ways come ti yee wi mah nashers.’ (Do not worry about this failure; do not give up and give it another go. I will always come to see you with my teeth.) For some of you now entering an exam your preparation comes after failure. Joining a study group will help to highlight the areas you need to concentrate on more and the areas where you have already reached the required standard to pass. Attendance at and learning with a study group is an efficient use of your time and can consolidate your approach to the exam. Exam techniques should reflect clinical ones. In working towards the MJDF, remember there are practical OSCEs too. So when you write out a patient’s prescription or are suturing your patient’s sockets, if you are in the mindset: that you are working under exam conditions, when sitting the MJDF exam, it won’t feel at all odd, for example; to be talking to the practice biopsy pad you are suturing and asking it in front of an examiner: ‘This won’t take too long. You will let me know if you are in any discomfort?’ If you don’t do this in the exam, then the examiners will probably think you don’t do this in real life either and you treat your patients with the same lack of respect you give to the practice pad. Do let the
examiners know you would check the medical history, have used both topical and local anaesthetic, so there will be no pain or discomfort while you cut and suture and remember to place a tissue orienting suture for the histopathologist too. Do not forget to advise that you will take the sutures out (if necessary) and give the results of the sample you have taken in one to two weeks time.
The Four Clinical Domains In both the MFDS and MJDF exams despite the differences previously outlined, the assessment of the candidate is broadly similar. There are four domains on which both the examiner and the actor will mark you, and these are your abilities to do the following: 1 . Gather relevant and necessary information. You need to demonstrate the clinical skill to exclude the improbable and concentrate on the possible information relevant to the OSCE. 2. Interact with the actor. How well can you relate to the actors? In my experience, there is a wide variety of actors, just as there is a broad range of patients. For some actors, their not being on the red carpet to the Oscars and having to settle for the blue carpet in the OSCEs is almost an unbearable insult to their talent. In contrast, other actors are very kind and considerate, wanting to do everything to help you pass, sometimes to the consternation of an examiner trying in vain to control the actor with a hard stare (nice use of body language). 3 . Convey information. Nothing impresses the examiners more than simple things said simply. Please do not pluck the most complicated wordage out of your preconscious mind to convince the actor and the examiner you really know what you are talking about. You really will not convince them of anything. Speech is silver, silence is golden. Use the power of the pause3 and allow the actor time to speak. Actors in the main love the sound of their own voice, so do not deprive them of the pleasure. After all, that is what they are getting paid for. This pause will give you time to put a few choice words of your own into the OSCE. 4. Deal with clinical issues. There isn’t any getting away from the fact you have to know your facts and you have to attend the exam with all the facts in your head not in your mobile phone. Guidelines change and the Internet is a good source of accessing the information needed in your revision. However, whatever else you do in the exam, please do not tell the actor to look up the data they need on the Internet and leave it at that. Rather advise them of reputable web sites to access information, e.g. NHS Choices, Cancer Care UK, Resuscitation Council UK. If doing so, you must cite the data, the source and the date you accessed it. Homework, Information, and Consent 1. In the real world, with real patients, I always give them homework to do. This usually involves looking up something or other on the Internet or reading an NHS Patient Information Leaflet I give them. 2. Web addresses of something they ought to know are a good source of information, and my patients go online before we meet again in a week or so and come back with questions. 3. If they have not done their homework, then the patient will not know the facts, and therefore, the
consent process might not be valid. In-cranio is better than in-silico In contrast to the real world in the MFDS and MJDF, you will not be meeting with the actors again (unless you are coming back for the re-sit). So in an exam, telling the actor all the information is available online, when you don’t know the answer (even though some 85% of patients have access to the Internet4), might not get you many marks from the examiners. For these exams, you are not allowed to take any electronic device into the exam. Nor can you realistically rely on last minute knowledge chaotically crammed into your short-term memory bank for recall if needed. In an OSCE, candidates who utilise this method of revision often present a mass of jumbled facts in a tangled knot and in doing so end up breaching one or all of the four clinical domains listed above. Although we have moved from the days of in vivo examinations with real patients to in vitro practical simulations, to pass these examinations, a substantial amount of data has to be well learnt and systematically processed in order to be dispensed efficiently and appropriately when needed. In the exams, there will be a marking schedule to note down the results you achieve in the four OSCE domains, you will be assessed as being competent or not competent, and your grades will be added together. As mentioned above, depending on the theme of the exam question, a different emphasis or weighting will be attached to each of these OSCE domains.
Exam Domains in Greater Detail In 1994, Chambers5 first noted the issues of competencies and their importance in dental training. If we go through the exam domains again in more detail, by knowing what is expected of you, your ability to achieve competence in the domains can be achieved through focused revision. 1. Information Gathering In the OSCE, you should be able to recognise and react to concerns raised by the actor. For example, these concerns can be about the appearance and the function of dental work. When taking a history, you should have an understanding of background social issues facing the patient portrayed in the OSCE. These might include any past or future events likely to impact on the decisions any patient or dentist engage in and when deciding on the best treatment option to pursue. In the OSCEs, you need to have an appreciation for factors that might not be presented in the introduction. You will need to gather relevant information to build as full a picture of the patient’s background as possible. With regard to the MFDS and MJDF, a candidate who is not competent does not gather relevant information and does not appreciate those factors that are relevant but hidden. You have to ask the correct question to uncover information which is not written in the introduction, which might influence dental treatment. Only through appropriate questioning in the history taking will you be able to uncover these factors. A favourite in the exam is the forthcoming wedding or other life-changing event, which the actor is planning but has not told you about at any time until you ask about it. In essence, you should be able to take a focused, elegant, and precise history from the actor. You
should be able to get the actor to provide you with the information needed to come to a correct diagnosis and use any relevant data that is provided in the introduction to assist in this process. 2. The Candidate to Actor Interaction The competent candidate will show appropriate concern and empathy for the actor and the role they are playing. Developing a rapport with your actor is important. I have thought about this interaction domain a lot in the past few months. After discussing this with my senior colleagues, we kind of thought that if you have an actor acting and a dentist going along with this, then the dentist has to be kind of acting a little bit too. So this domain is about acting with the actor. The candidate who can’t act a little will not develop a rapport and will probably fail this domain. In essence, you will be able to be courteous and welcoming to the patient being played by the actor. One MJDF revision course organiser summed it up: ‘In the exam you get marks for being a human being.’ Be sensitive, show empathy, and be able to assist the actor in the telling of the story they wish to portray. From your time in the clinic, you will have gained significant experience of non-verbal communication skills, so use them. Also, be aware of the actor’s questions, doubts, and fears, while showing respect for the ideas and expectations of the patient being played by the actor in the OSCE. Do not forget the patient played in the OSCE has a right to autonomy and confidentiality too. Acting and acting up Please do not over-egg the pudding or corpse the actor out of your OSCE; it is so easily but inadvertently done. Before sitting my MFDS a while back, I did think about taking some acting classes (on the recommendation of a friend and colleague). For those candidates who do not feel confident, then this is a worthwhile option; there is no shortage of ‘resting’ (i.e. currently unemployed) actors who give classes. Attending these classes is cheaper than getting your practice in during the OSCE. 3. Conveying Information The competent candidate will give clear explanations and provide options that are appropriate solutions for the problems portrayed. When giving the options, start with the simple things, and before moving to the next option, ask if the actor has any questions. Use this opportunity to clarify any misunderstandings. Give the actor the information in lay terms about what each option means and what it involves. The comparative costs should be borne in mind too. While you don’t need to specifically give a cost to each option, it is immensely helpful to give relative costs, i.e.: ‘Option one is less expensive than option two, and we will move to option three, the most expensive, which involves more work than the first two choices you have.’ This is probably all you need to say, and if the actor then asks for finite costs, you can possibly say that definite costs will be provided in a treatment plan.
The candidate who cannot give a structured set of options from simple to complex with relative costs is not competent. Using technological terms and jargon is not acceptable. The use of jargon If you find yourself using jargon, as I have done, then say to the actor or your patient: I am sorry, we dentists do tend to use our own language, what I mean is… (try to use clear terms to explain, then finish by asking). Does that make it clearer for you?’ The response of ‘Yes, you have explained that very well. I would like to ask you about…’ is the actor’s way of telling you that you are back on track and the examiner can move along without marking your performance in an adverse way. In conveying information, in addition to financial costs, there is another cost in terms of the time needed for you and the patient to complete an agreed treatment plan. In the information gathering domain, any time constraints imposed by social obligations will play a part in the options you and the actor will choose to follow. From this, you can see that clinical domains and social domains interact and cannot be treated in isolation. In essence you will be able to explain a problem, explain the options, and then negotiate with the patient a solution they are happy to accept; that is, you will gain consent from the patient being portrayed in the OSCE. You will be able to use appropriate language and clinical skills to deliver information about treatment outcomes both good and bad to the actor. Checking the actor’s understanding at each stage of the information delivery process is a significant part of the conveying information domain. 4. Clinical Issues In having all the facts in hand, you should realise the limitations imposed upon you by your level of experience and legislation. One issue to be addressed is referral to a specialist for complicated treatment options. In referring a patient, you need to be able to explain why you need to do so. Any further investigations providing information that will guide treatment or open further options need to be mentioned. The candidate who does not accept the limitations in their clinical abilities and does not appreciate the clinical issues is not competent in this domain. While the domain of candidate to actor interaction is a bit nebulous and subjective, the domain of clinical issues is not. Clinical issues are not so much about not knowing what you don’t know; it’s more about knowing the limits of what you do know. Although changing continually, for the time being when you sit your clinical examination, accept that clinical issues are cast in stone and you have to be clear about what you can and cannot do within the rules of dentistry in the UK. For the older experienced candidate who will not have too much difficulty developing a rapport
with the actor, the candidate to actor domain should not be too difficult, but the clinical issues domain may prove to be bothersome if you have not read the latest guidelines. Implants in the actor’s head Some candidates for the MJDF have been placing implants successfully for many years; however, do remember the following: The level of your abilities for the MFDS and MJDF examinations should be equivalent to a dentist in primary dental care or secondary hospital care with two years’ post-qualification experience. So even if you have lots of experience in this area and a postgraduate diploma too, referral to a hospital specialist is the preferred route for the actor and certainly not the casual or cavalier: ‘Here is my business card. I can give you a great set of cheap abutments tomorrow and have you fitted up with a nice dazzling-white film star smile in a few days. I’ve been doing patients for years now, with very little bother, and as I’ve met you here today I’ll give you a great price too… How does that sound? Any questions? No? Good, here I’ll just scribble a few things for you to sign with a deposit to pay today, OK?’ Rather, it is more appropriate to explain something along the following lines to the actor: ‘Although I do have experience of placing implants, I feel that a referral to my senior hospital colleague for treatment planning and advice in the first instance would be an appropriate option. I would be happy to write the referral letter, to give you a copy and provide you with any further information. I would like you to have options and to make the correct choice with your dental treatment from one of these options. Please do ask me if there is anything you are unsure about.’ In essence, you will be able to devise an effective evidence-based treatment plan, arrange follow-up, and review the dental care where indicated. A range of treatment options needs to be discussed with the patient. This should include and start with preventive care. Sensible use of your resources with time available for the treatment should be considered in your discussions guiding the actor towards the most appropriate dental treatment for ‘their patient’. In presenting your options in the examination, you will be aware of the current legal and social frameworks and the constraints these and evidence-based guidelines impose on your treatment planning and treatment options.
Key Elements of an OSCE Consultation You will see that the above four domains overlap and should not to be dealt with in isolation from each other. The OSCE clinical consultations of the MJDF and MFDS will include the following key elements essential to any dental consultation in real life: 1. Taking a history from the actor . This will be the medical, dental, and social histories from which you will be able to derive all relevant data to provide options and shape your treatment plans. 2 . Explaining findings to the actor. This could be the data from test results or explaining the
findings of a radiograph, i.e. saying to the actor: ‘This is your X-Ray and this is what we have found.’ (Note use of term X-ray and not radiograph.) 3. Explaining a diagnosis to the actor. This is an explanation in lay terms of a condition they are portraying. In addition to the diagnosis, you will have to explain the prognosis. In other words, given the information you have and the knowledge of the condition the actor is portraying, can you explain how their care will progress and the disease will regress? Lastly, what do you intend to do with the actor in a proposed plan of action? 4. Planning the treatment for the actor. Using both the facts you have read from the introduction and those you have learnt from the history taking from the actor, together with the skills you have acquired in your clinical training, how will you form and present a suitable plan of treatment? Simple plans presented simply work best Please remember that an elegant treatment plan with simple effective solutions proven to work from clinical evidence is a more appropriate answer in these exams and in real life than a complex experimental solution with inherent risks of failure and limited chance of success. 5. Discussing options with the actor. These are the appropriate solutions to deal with the case as presented. You will have questions to answer, and these could range from the perfectly sensible to the implausibly risible. For example, one question that seems to work its way into the OSCEs is whether: ‘Silver fillings cause cancer, yes or no? Can you replace them all with white ones please?’ Whatever else you do, keep a straight face and give evidence-based answers, citing where necessary publications to support the choices you give. 6. Explaining a treatment procedure in detail to the actor . If you have experience of the treatment in question, then great; this type of OSCE is a gift. If not, then pretending you do just won’t work in the OSCE. With certain treatments, although you might not have the experience, you will probably have sufficient knowledge to assist the actor in coming to a decision on whether they will proceed with a course of action or not. In the OSCE, explaining the complexities of a treatment in lay terms is all that is required. 7 . Giving the information needed for consent. This really just follows on from the previous section on explaining a treatment. Consent is a legal and clinical concept that is dynamic, and we will return to consent in detail in the cases of Chapters 4 and 6. For now, please know this: Consent is a principle of clinical law and ethics. Before any competent patient undergoes treatment, permission to treat must be obtained. The times of imposing dental treatment on patients have long gone with the ‘trust me I am the dentist’ approach to care.6 In the exams and in real life too, the patient has the final word on whether a proposal becomes a plan and a plan becomes an action resulting in dental treatment. 8 . Motivation of an actor portraying a patient. This is a somewhat subjective area, and only through experience will you learn those techniques that work and those that might not in any given clinical situation. In the examinations, you should only use those techniques learnt in behavioural sciences and accepted by your colleagues and the profession as a whole. The patients
represented by actors do come with their own modes of overcoming fear of the dentist or developing strategies to motivate themselves to accept dental treatment. Some of these are inappropriate, e.g. taking an excessive level of alcohol or other substances before attending. In the exam and in real life, you will be able to identify these behaviours and deal with them appropriately. 9. Breaking bad news to the actor. This could be anything from telling the actor you lost the biopsy sample on the way to the hospital to telling the parent of a child you or one of your colleagues took the wrong tooth out from their only child (yes, really). Unpalatable truth and dishonesty Best to tell the truth and apologise. Explain what you need to do to correct the mistake and carry on with the OSCE. In real life and in the exams, telling things to the patients and actors that are not strictly the truth is dishonest. It is easier to tell the unpalatable truth early than having the truth dragged out of you under cross-examination. 10. Managing an emergency. This has not been a part of the MFDS OSCE syllabus, but it does regularly appear in the MJDF OSCEs and can be anything at all. So it is best to be up to date with all of the latest Resuscitation Council UK Guidelines on dealing with medical emergencies. The next chapter will cover these in detail.
Giving and Taking in the Examinations Relevant Information in the OSCE In the examinations, your ability to give information to the actor can only come after taking a history, using terms they can understand. This is another one of the keys to passing the OSCE or any clinical exam. The taking of a history combined with the practical elements of a clinical exam is interwoven in the practice of dentistry. However, in the MFDS and MJDF exam there is no actual physical examination of a patient as there are no patients; there are only actors. This makes for an interesting experience for a candidate who is used to both history taking and clinical-examining, often at the same time in order to come to a diagnosis. In one diet of the MFDS exam, an actor with the most unbelievably bad breath was present in an OSCE, and this OSCE had nothing to do with halitosis. It became clear after a few questions in the taking of a history that the bad breath was an ‘incidental finding’. If faced with a situation like this, remember that such clinical signs are not part of the exam. The discord candidates faced here was an examiner sitting in an OSCE seemingly oblivious to this clinical sign. Do not be tempted to enquire if the actor and examiner both have anosmia.7 As interesting a subject as anosmia is, it is slightly outside the domain of the MFDS and MJDF. In addition, do not ask if either you or the actor is at the wrong OSCE. Rather, concentrate on the taking of a history so you can deal with the theme and topic as detailed in the introduction. Taking a verbal history is the only tool at your disposal. I suppose one analogy is if you are used to
looking at the world with both eyes. Can you imagine closing one and then gathering up the information you need to walk about the street without either bumping into other things or other people or missing a sign or signal? It kind of works, but your depth perception is a little bit messed up until you can interpret what you see with your one open eye and then you can function quite well. History Taking in the OSCE Well, I think you might say the clinical questions in the MFDS and MJDF are like looking at the world with one eye shut. So until you sit your exam, get lots of practice in taking histories before reaching out to examine the patient. I attended one revision course, and one statement from this course stuck with me: ‘Three quarters of all diagnoses can come from a good history.’8 I do not know if this figure is precisely correct, where it comes from, or if there is a study to prove this. Despite all that, let’s just say it feels right. Perhaps what is more appropriate would be to say that if you can take a good history, then an accurate diagnosis should follow from this. In an OSCE, due to a constrained 10 minutes, history taking is something that needs an almost rigid structure. It needs you to do the following: 1. Bring out relevant facts from the actor. 2. Assemble the facts into an order. 3. Process the ordered facts obtained for relevant information. 4. Gather up the information and use this to determine what the actor is portraying. In real life and in the OSCEs, history taking needs a structure, but it is not a mechanical process or a physical science. History taking is more a social art form held within a structured professional conversation.9 It is an art form because it needs to suit the individual dentist and individual patient. Some dentists are truly (possibly intentionally) atrocious at history taking as they are more focused on other areas of dentistry. Some patients are not so good either at providing a history. There can be areas of a patient’s personal life which is not so easy for them to discuss. There can be language problems too. For example in the UK, there is a significant proportion of patients whose first language is not English. In Switzerland, there are four languages: French, German, Italian, and Romansh. Despite this in both the UK and Switzerland, dentistry is successfully undertaken despite a perceived possible barrier of language. Both verbal and visual communication skills are used in history taking, and with the actors in the OSCE, there is no difference. Using visual in addition to verbal expressions of understanding is important and must be used in addition to an open objective and critical history taking technique.
Communication and Empathy In communicating with the actor, from the very start of the OSCE you should be working hard at developing a rapport. On entering the exam room and faced with the actor and the examiner, you have
to begin by assessing the mental and emotional state the actor is portraying. The empathy you display in the OSCE is important, and we will return to empathy in the OSCEs in Chapter 3. Just for now, I would like to begin by saying empathy is complicated but not impossible to get your head around. The MFDS and MJDF are not examining psychology; they are examining your ability to be a good human being in the dental clinic. Empathy Is Not… The important thing about empathy is that it is not about feeling sorry for someone’s predicament or getting upset about what is happening to your patient. For sure, there have been desperately upsetting things I have seen in the dental clinic. As your career reaches into the future, you will experience the uplifting highs and overwhelming lows that caring for patients and clinical practice will bring you in equal measure. Anyway, now back to empathy. Clinical empathy for the MFDS and MJDF questions has the following parts to it: 1. You have to understand the patient (as portrayed by the actor), the dental problem, and the situation they find themselves in. 2. With the patient’s situation, you have to have a feeling for how they see themselves in relationship to you so you can understand and anticipate the feelings the actor will display during the OSCE. 3. You have to acknowledge the emotions displayed and communicate your acknowledgement back to the actor so the examiner can see you doing this. 4. The last piece of clinical empathy is to act on the understanding you have so you can benefit the patient as portrayed by the actor. This aspect of the MFDS and MJDF exam is firmly in the artistic domain. If you approach the OSCEs in a flexible way and you are prepared to concede some points in the discussions that follow from the history, then the unreasonable and unrealistic expectations the actors are sometimes instructed to portray will be quite easy to deal with as you underpin your negotiation with rapport. From history taking, through diagnosis to the treatment plans you propose, above all else, a flexible approach is needed. If the MFDS and MJDF was a strictly mechanical enterprise with no artistic flexibility, then it would not accurately reflect real life. If there were only rigid structures to be followed without thinking, then history taking would not be the art form it so truly is. So do allow yourself and the actor to have some freedom to explore your role and theirs during the OSCE. These exams aren’t life and death events, but in being flexible, don’t corpse the actor. Around the artistic flexibility, there has to be a structure too. There has to be some planning, forethought, and you can’t be too avant-garde in your manner while undertaking the OSCEs. While an independent and individual style may work really well in some dental clinics, please do bear in mind that Royal Surgical Colleges are still ‘ever-so-establishment’. The modern performing arts have not reached from the stages of RADA to the surgical theatres of the RCS.
OK, so moving on now. While engaging with the actor, you need to demonstrate to the examiner a structured conversation in which your intention is to get the actor to communicate their symptoms and attitudes to treatment. Furthermore, you will need to allow the actor sufficient space to talk about their symptoms with you.10 When this information is coupled to the clinical signs depicted in the introduction to the OSCE or any radiographs, photographs, or test results, you should be able to gain a complete understanding of the problem presented. From this point, you should be able to answer any questions the actor may throw at you, and then you ought to be able to complete the OSCE. On entering the exam room, do greet the actor/patient appropriately and courteously. Although you may have never met the actor before, or if you have done so in a previous exam, do follow the protocols. If, for example, the introduction states the patient is returning to you for test results, then don’t introduce yourself as if you have never met before. In the play you are now part of, the patient met you two weeks ago and is returning, try something like this: ‘How nice to see you again and thank you for coming back to the clinic to see me. We now have your test results. Would you like to see them with me?’ Of course, the actor might then say something like: ‘Oh yes, that would be a good idea. I have been a bit nervous about this for the past few days.’ Your response can be: ‘Yes, I can see getting these results is troubling you. Would you like me to carry on?’ In responding like this, you are showing both awareness and insight into the attitude of the patient the actor is portraying. The actor should be allowed to tell the patient’s story without interruption. Sometimes the actors do get carried away a little bit, especially if the part they are playing involves some drama; the lost test result is a favourite. Don’t blag it or tell the actor some old work of fiction you think they want to hear. I have seen actors go postal when candidates try to bluff their way out of the lost test results OSCE. Stick to the facts; what you know about their case and what you know about your professional responsibilities are all you have to demonstrate through effective communication. The wrong tooth being extracted is another commonly recurring nightmare OSCE. As most of you preparing for the MFDS and the MJDF are at the early stages of their careers you will not have had the misfortune to be involved (in one way or another) with taking the wrong tooth from a patient. For those of you who have experienced this disaster, then an honest reflection on why such an incident occurred is helpful in preparing for such an exam question. Breaking Bad News Lastly, that old chestnut—the breaking of bad news. This type of OSCE, unlike the lost test, will always turn up sooner or later. What is bad news to an actor might seem like an everyday event for you. One example is providing options for treatment for the patient immediately after they suffered dental trauma right before an upcoming social event. If the injuries mean the teeth cannot be saved, you have
to advise the patient played by the actor that they have to wear dentures for several months, as saving teeth broken off at the gingival margins with root fractures is just not possible. Repairing teeth broken after a patient has bitten a piece of toast is, I suppose, your daily bread and butter. For an actress playing the young bride-to-be (getting married tomorrow, you’ll know this if you take the time to ask), the fracturing of upper incisors might come across as nothing less than a catastrophe. So treating the scenario with the respect the actress expects is a necessity. From the Theatrical to the Practical Of course, it is a bit difficult to be the candidate in such an OSCE talking to an actress, who with an intact dentition is rabbiting on about her front teeth being broken when clearly they are not. You just have to go along with the theatricals and get to the practical of history taking and giving options. In real life things are different; of course they are. In real life, patients allege they break teeth on toast. In the exam diets, toast is never implicated; it is always something more exotic. They’ve fallen over a kerb stone (which brings the prospect of compensation and some dough coming their way). In the OSCEs, if you cannot demonstrate the empathic skills and professional conduct that you would in the dental clinic in real life, then it is difficult for the examiner and actor to award you sufficient grades to pass the OSCE. Clinical questions, such as the ones dealing with giving bad news, can become a bit melodramatic and you have to be able to gently bring the actor back to your reality, just as you would do with a real-life patient. As with real-life patients, some actors are very good at delivering the necessary facts for you, whereas others will truly inhabit their characters growing within them. These actors may need to be kept on a tight lead to keep them from rambling off into the darker recesses of their character’s life. An actor who is accommodating will need little inspiration in the OSCE, while the more reticent and hesitant actor will need some encouragement to deliver the facts for you to use. Most actors are helpful doing their work well, not being carried away with themselves. However, there was one diet of the MFDS, where an actor played the part of a chain smoker who was just not willing to stop smoking. All efforts on the part of the candidates to get him to accept a smoking cessation policy were met with refusals, to the point where he crossed his arms, bowed his head to the candidate (passive aggressive behaviour is always difficult to deal with), and refused to communicate further with the candidates. It is really difficult to talk to the top of someone’s head when they refuse to maintain eye contact. I cannot say I knew what all that behaviour was about, other than in real life; you will get characters like this and you will have to deal with them (professionally). Back in the clinic a few days later, I did see a patient who was an actor in real life (nice inversion there) who smoked everything and was similarly not interested in abstaining from some of the things he smoked. While he didn’t consider cutting back on the use of tobacco, when it was suggested that testing for use of drugs while driving was increasingly being used by various UK Police Forces he did reconsider his smoking habits. I suppose that was one result. The relevance to dentistry is you will meet all kinds of patients in the exams; be prepared to meet them in real life too!
Do take a thorough, comprehensive all-inclusive history from the actors and do be prepared to ask about both recreational and prescription drugs. History taking does need to be adapted to the patient being played by the actor. The history has to be from the actor with appropriate input from the candidate directing the course and destination of the conversation. Some actors will portray patients who are confused, nervous, or aggressive; in fact, you’ll get the full shooting match in the OSCEs. From the moment you walk into the OSCE, work on developing your rapport and clinical empathy with the actor. Make adjustments to your method in the exam based on your assessment of how the actor is responding to you and your approach. The expression of unreasonable and unrealistic expectations is commonly seen in dental clinics and in OSCEs. The exam candidate and dentist who can modify the actor’s or the patient’s expectations will succeed in providing treatment that is accepted and an exam performance that is acceptable to the actor and examiner. Words and Language In the OSCEs just as when you are at work, the actor or patient should be allowed to tell their own story in their own words, while your choice of words should be appropriate to the situation. In using language, do be professional, but do not use complicated technical terms to explain your ideas to the actor. Periphrasis, circumlocution, and verbiage is just flannel, waffle, and (my favourite), blether. That’s a good Scottish word, so here are some more Scottish expressions: ‘Nae bletherin or Haud yer weesht.’ The English equivalent is ‘Keep a still tongue in a wise head.’ In other words: No jargon . . . in the OSCEs. There is a risk in using complex verbiage that the patients either don’t understand what you’re babbling on about or the patients themselves start banging on using terms they haven’t got a clue about or what their real meanings are. After a few minutes of this, no one will understand what the other person is trying to say so: Best to keep things really simple and to the point. Don’t interrupt the actor when they are in full flow. However, you shouldn’t allow the actor to lead you a merry dance up their garden path. Be prepared to guide them along your path while telling their story to get the information you need from them to answer your OSCE question. Your questions should be open, and a non-judgemental approach has to be used. Sensitive questioning is important, and please don’t use phrases or pass comments which can be seen as critical or judgemental by the actor playing the patient.
The advantage of using free or open questions is that it allows the patient or the actor to use their own words, phrases, or expressions to tell you about the problem they have. If you are doing this in the clinic, then you will already know your patients are taking an active role in the dental consultation. Your patients are most likely not nervous around you and have confidence in your operating skills. If you can do this in the OSCEs, then the actors will similarly develop and display confidence in your history taking skills. Do listen to what is being said; listen attentively, responding to information with acknowledgement, and listen actively, building on the information provided, taking important facts to ask your next questions as you put together the necessary details to complete the OSCE.11,12 Following your friendly professional introduction, begin your history taking with open questions. Although the use of closed questions is not ideal, it can be useful to bring the actor into the area you wish to explore. In the nicest possible way you are bringing the actor into your spotlight, keeping them there as you question them, getting them to describe in their own words the reason for their attendance. The use of closed questions is good to prevent the vague actor or the actor playing a vague patient from letting their character wander around their stage and your subject. In the OSCE and in a real-life consultation, such questions do restrict the actor’s ability or patient’s necessity and their opportunity to talk. In the OSCEs, it is really important to hold back, to not interrupt, and to allow the actor to tell you their story. There are other forms of question which you may also consider using, and these are leading questions. However, such questions can be unhelpful for two reasons. Firstly, it might send a message to the examiner and actor that you aren’t really attending the exam to listen, but rather you are attending to tell everyone about the things you want to talk about. Some of these things might have little relevance to the OSCE or have no bearing on treatment which the actor or patient expected to receive. Secondly, by asking leading questions you might suggest an answer the actor will then give you. Such compliance of the actor or a patient can then be easily exploited, leading the whole exam question into a direction it ought not to go. In the OSCE just as in a dental clinic, an actor or a patient may feel obliged or even constrained into providing you with an answer they think you want to hear. In this regard, if leading questions are extensively used, an enforced compliance may result. In the OSCEs, your goal is to use the opportunity provided in the exam to demonstrate your clinical competence. The opportunity here is to allow the actor to completely act out the role of the patient. From your performance, the actor and examiner will be able to see that outside of the exam, when you are at work, you allow your patients the freedom to tell their story. From the patient’s story, you will have all of the information, not constrained by closed or leading questions, to provide the options for treatment and answer any further questions that may arise.
The Marking Scheme for the Examinations In assessing your performance in the consultation OSCEs, both the actor and the examiner provide input into a marking scheme, and the following aspects of your performance will be graded whether you are above the standard required, you meet the standard required, or you are below the standard required to pass the exam question:
1. You have delivered a professional introduction in the correct manner to the actor. 2. Your actual physical position with regard to the actor was appropriate, i.e. you faced them at the same level. 3. The patient’s background was checked. That is, social, medical, and dental details were assessed to the correct and appropriate level with relevance to the question asked. You only need to take a history. If this was actually asked in the question, i.e. if the question is one on history taking, then do take a full history. In doing so, where the following data was not provided in the introduction, you acquired knowledge of the actor or the patient’s: a. Medical history b. Dental history c. Family history The questions you asked and the information you gained were of relevance to the question being asked. 4. You began the OSCE by asking the actor to describe their patient’s problem in their own words 5. In questioning the actor, you did so in a way that allowed them to tell their story. 6. In the OSCE, you guided the actor along the story of their patient and did so without unnecessary interruptions. 7. In the OSCE, you didn’t use dental terms which the actor may not have understood. Or if you had to use such terms, then you checked to see the actor understood after you explained the meanings of any terms you used, which may have caused confusion. 8. Your use of questions was appropriate, using open questions at the start of the OSCE, and as the exam progressed, your questions became more focused and closed as you approached the end of the OSCE. 9. You made an assessment of the actor or patient’s motivation and their expectations of what the treatment might give them. 10. You provided appropriate answers to questions. The answers you gave were based on data provided in the introduction to the OSCE, with information obtained from the actor and combined with the latest evidence determining how you clinically practice. 11. You asked the actor at all relevant points during the exam: if they understood your questions, if they understood your answers, and if they understood your proposals for treatment. After the above was completed, you asked if there were any further questions. 12. The OSCE was completed in the same way you began, with a courteous and professional departure from the exam room. The above criteria in the examiner’s marking sheet are then scored and added together to give a global rating for the candidate in each of the questions. These scores are then added to give an overall
exam score. In the MJDF exam, a series of statistical analyses are conducted to determine the pass mark and pass rate for each of the exam diets. Each exam diet is assessed to determine both objectivity and continuity with previous exams. For those sitting the MJDF, if certain questions were answered more easily while others proved to be more difficult a weighting factor is applied to the marks given for these questions to balance out the overall score. In the MFDS exam, 7 out of 10 OSCE questions have to be passed, with no fails in the following domains: a. Information gathering b. Dentist-patient interaction c. Conveying information d. Clinical issues. Again, there may be some statistical analysis of the results generated by the candidates to ensure consistency and continuity of exam standards across the exam diets. Some two to three weeks after you sit the examinations, the results will be posted online on the web site of the colleges. These results are given with your exam number only, so your results can be anonymously checked. For those of you who pass, you can move on to build on your success. For those who fail, I hope this book provides a useful source of ideas and encouragement not to give up, but to have another go at the exams. As mentioned above, some of you will pass first time while others will take a few attempts to reach the required standard. If you have the desire, the determination and the discipline to do so, whether this is your first or final attempt at these exams, reaching the standard to pass is achievable.
Don’t Memorise Anything in This Book The idea for writing this book was not for you either as an exam candidate or as a casual reader to study and mindlessly memorise all the data contained between the covers. That is not the purpose of this work, and anyway, given human nature, there will be mistakes, for which I accept full responsibility. If you are memorising in neutral rather than engaged in forward focused learning, these errors will pass unnoticed and into your clinical work. Rather than memorising facts, I want you to enjoy reading this work and pass your thoughts and comments to your college tutors, colleagues, and friends. In anticipation of this, I look forward to your criticism, and I hope this work proves to be a useful addition to those books you already have read and are using in your exam preparations. Lastly, we need to take a step back for a moment from the exam and look at the task ahead of us as members of a profession.
1. This book should benefit you as an exam candidate. This book should play a part in raising your standards for both the exam and the clinic too. 2. If this is true, then this work and other contributions in the field should raise the standard and the pass mark for the exams. 3. If this happens and the overall standard of candidate rises, then those who set these exams will have their work cut out to keep ahead of the tide of dentists with higher standards as new questions will have to be set and new marking schemes devised. 4. Currently, the MFDS and MJDF are two different exams. The MFDS has a focus on clinical communication skills, whereas the MJDF demands demonstration of both communication and technical skills. Both exams utilise the OSCE as the method to examine candidates. The MFDS and MJDF are equivalent exams carrying the same weight. This weight is the future of those dentists whose careers start from this foundation level exam. However, from experience I can tell you these exams are really two distinct entities and any profession having such a partition in its foundation cannot be stable. 5. If we can unify the foundation and begin to build with higher standards, it should follow the level of care we as an entire profession—candidates, examiners, clinicians, colleagues, and the colleges—can achieve, for our patients will rise too, and that more than anything else is what this book is about. Of course, I could wish you all good luck, but in these exams, in your careers, and in life you make your own luck. Onwards and upwards to the questions. References for Exam Expectations 1. The Royal College of Surgeons of Edinburgh. MFDS Examination Frequently Asked Questions. 2010. [Online] Available from: http://www.rcsed.ac.uk/examinations/exam-details-page.aspx? calId=22f4c11a-7d1e-4b1d-acf6-b84e173c3d29_and_locid=48 [Accessed 14 February 2013]. 2. Pocock I. MJDF and the modern dental career. Br Dent J. 2007;203:5-6. 3. Hershey T. The Power of the Pause: Becoming More by Doing Less. Chicago: Loyola Press 2009. 4. Meyer UA. How genomics will change personalised medicine. Presentation at Swiss Clinical Trials Organisation Conference, Zurich, 14 June 2012. 5. Chambers DW. Competencies: a new view of becoming a dentist. J Dent Educ. 2004;5:342-45. 6. Baergen R, Baergen C. Paternalism, risk and patient choice. J Am Dent Assoc. 1997;128(4):48184. 7. Scully C, Porter SR, Greenman J. What to do about halitosis. Brit Med J. 1994;308:217-18. 8. Savarrio L, Thomson D. Lecture In MFDS Revision Course. Royal College of Physicians and Surgeons, Glasgow, 12 and 13 April 2011. 9. McCartan B, McCreary C. History Taking and Examination. In Mossey PA, Holsgrove GJ,
Stirrups DR, Davenport ES. Essential Skills for Dentists. pp. 1-18. Oxford: Oxford University Press 2006. 10. Cameron R. Acting Skills for Life. 3rd Edition pp. 26-30. Toronto: Dundurn Press 1999. 11. Rogers C, Farson RE. Active Listening. Chicago University Industrial Relations Center 1975. 12. Hargie O. Skilled Interpersonal Communication: Research, Theory and Practice. 5th Edition pp. 177-208. East Sussex: Routledge 2011. Further Reading for Exam Expectations 1. UK Committee of Postgraduate Dental Deans and Directors. Standards for Dental Educators. Oxford: COPDEND 2013. [Online] Available from: http://www.copdend.org//data/files/Downloads/COPDEND_Standards_high_resolution.pdf [Accessed 15 June 2013]. 2. COPDEND. A curriculum for UK Dental Foundation Programme Training. Oxford: COPDEND 2006. [Online] Available from: http://www.mjdf.org.uk/mjdf-examination/docs/gpt_curric.pdf [Accessed 17 June 2013]. 3. European Commission Advisory Committee on the Training of Dental Practitioners Report and recommendations on core knowledge and understanding—prerequisites to achieving clinical proficiencies (competencies). Document XV/E/8011/3/97-EN Brussels European Commission. 4. Quality Assurance Agency for Higher Education. Subject benchmark statements: dentistry. Gloucester: Quality Assurance Agency for Higher Education 2002. [Online] Available from: http://www.qaa.ac.uk/Publications/InformationAndGuidance/Pages/Subject-benchmark-statementDentistry.aspx [Accessed 4 April 2013]. 5. General Dental Council. The first five years: a framework for undergraduate dental education, 3rd Edition. GDC 2002. [Online] Available from: http://www.gdcuk.org/Newsandpublications/Publications/ Publications/TFFYthirdeditionfinal1%5B1%5D.pdf [Accessed 8 July 2013].
2 Medical Emergencies Introduction This chapter covers the medical emergencies that will be examined in the MJDF OSCEs. If you are not sitting the MJDF and are only studying for the MFDS, then you can go straight to Chapter 3, ‘Medical Matters’. MFDS and Medical Emergencies It is important that you know the areas you will be examined on. It is essential not to waste time and nervous energy right before an exam by fearfully reading a subject area that will not come up. At present, medical emergencies are not examined by the Scottish Colleges. This situation may change in time, so you must keep up to date with the requirements of the college where you intend to sit your exam. Notwithstanding this, it is imperative that you maintain proficiency and currency in dealing with the emergencies that unfortunately will present in dental surgery. Today, thanks to the advances in health care, there are many more patients living with chronic medical conditions who would have died without the complex care and medication they receive.1-3 However, for them to remain alive carries a significant risk of morbidity and mortality.4 Collapse and emergency is a cause of concern and anxiety not only for these patients but also for all those involved in their health care.5 In the UK, the General Dental Council (GDC) has mandated that every 5 years 10 hours of training and revision of the medical emergencies are needed. It has been estimated that 0.7 medical emergencies will occur in the UK per dentist per year.6 However, given the move away from sole practitioners towards group practice where in excess of five dentists, specialists, and hygienists all work together, if we simply multiply this figure by the number of operators in one site, then this figure cannot be considered in terms of being a fraction any longer per surgery. In simple terms, if you work in a group practice, for every year that you practise a medical emergency that you and your colleagues will have to deal with will arise every few months. In examining these medical emergencies, the MJDF OSCEs are more practical than theoretical. The first thing that hopefully jumps out at you is that the marking scheme mentioned in the last chapter does not apply in many of the medical emergency scenarios as communication plays a secondary role to your demonstration of practical skills. The second thing is that rather than sitting and reading about medical emergencies you have to get off your chair, get away from this book, and practise them. In 2005, in a study based in a London teaching hospital, Hamilton commented on the poor knowledge and skill retention of cardiopulmonary resuscitation (CPR) training found in medical and nursing staff. This had previously been documented for over 20 years in a literature search of the subject.7 Of
further note is the 2000 paper from West, noting the unsatisfactory level of knowledge and skills in basic infant-life support in paediatric nurses chosen at random.8 Both studies concluded that CPR knowledge and skills could be improved with frequent training, using multiple and practical methods.7,8 In the MJDF revision course, one method of improving the retention of CPR skills comes down to three things: practise, practise, practise. I agree, but do so with different methods and means available. Studying, revising, and practicing with colleagues is more productive than on your own, and nowhere is a group effort more usefully applied than in training and retaining your medical emergency skills. If you are ever called upon to use these skills in real life, you will most likely have to do so with a hastily assembled and rapidly growing group of alarmed colleagues and bystanders helpfully professing their expertise. So if you practise your medical emergency skills in a group, when you find yourself part of another group you will be able to effectively deliver your skills to the patient promptly and properly. In such circumstances, it is imperative that you work with the means you have to provide emergency treatment using the latest techniques for the patient in your care. There are 10 medical emergency OSCEs in this chapter. In the cases where they are applicable, the UK Resuscitation Council has kindly allowed their algorithms to be reproduced for your education and training. In permitting their use, I am grateful for the opportunity to incorporate their life-saving work in this chapter. On one hand, I know their inclusion will benefit both you and your patients. On the other hand, as prepared and as ready as you will be to deal with medical emergencies, having witnessed mortality associated with cardiac arrest outside of a hospital environment, I sincerely hope that CPD and the OSCEs are the only place you will ever need to demonstrate your skills in this area. References Medical Emergencies Introduction 1. Lichtenberg FR. Why Has Longevity Increased More in Some States than in Others? The Role of Medical Innovation and Other Factors. Manhattan Institute for Policy Research 2007;4. [Online] Available from: http://www.manhattan-institute.org/html/mpr_04.htm [Accessed 20 April 2013]. 2. Baker D, Fugh-Berman A. Do new drugs increase life expectancy? A critique of a Manhattan Institute Paper. J Gen Intern Med. 2009;24(5):678-82. [Online] Available from: doi 10.1007/s11606009-0954-4 [Accessed 20 April 2013]. 3. Lichtenberg FR. Do new drugs save lives? J Gen Intern Med. 2009;24(12):1356. [Online] Available from: doi 10.1007/s11606009-1101-y [Accessed 20th of April 2013]. 4. Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: updating the cost of illness model. J Am Pharm Assoc. 2001;41(2):192-99. 5. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great
Britain. Part 3: perceptions of training and competence of GDPs in their management. Br Dent J. 1999;186(5):234-37. 6. Girdler NM, Smith DG. Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation. 1999;41:159-67. 7. Hamilton R, Nurses’ knowledge and skill retention following cardiopulmonary resuscitation training: a review of the literature. J Adv Nurs. 2005 Aug;51(3):288-97. 8. West H. Basic infant life support retention of knowledge and skill. Paediatr Nurs. 2000;12(1):347. Further Reading to Medical Emergencies Introduction 1. Sutton RM, Niles D, Meaney PA, et al. Low-dose, high-frequency CPR training improves skill retention of in-hospital paediatric providers. Paediatrics. 2011;128(1): e145-51. 2. Wik L, Thowsen J, Steen PA. An automated voice advisory manikin system for training in basic life support without an instructor: a novel approach to CPR training. Resuscitation. 2001;50(2):167-72.
Medical Emergency 1 Background Information On a busy Monday morning, a new patient in pain has just been added to your day list. The patient is an apparently fit and healthy male aged in his mid-30s who both smokes and drinks. He tried to contact many dentists over the weekend, but could not get an appointment. He has been in some pain for some time and has just been added to your list as an emergency appointment. The medical history has just been completed today and there are no contraindications to dental care. The patient is not a regular dental attender. He has helpfully written on the history form that he is scared of the dentist and ‘hates going to the dentist’. Introduction You have not treated this patient before. The patient in this scenario looks pale and exhausted. In the actual OSCE, the actor portraying the patient may already be seated and there might not be a dental chair. You enter the exam room and the actor takes one look at you, then slumps forward in the chair. It is clear he is losing consciousness. Question Demonstrate how you would deal with the above emergency if it occurred in the dental clinic. Points to consider in this case 1. This OSCE deals with a common medical emergency that perhaps all dentists have faced in clinical practice at some point in their careers. 2. This question is designed to test both your approach to a medical emergency and your response when you have discovered or decided on the nature of emergency you have been presented with.
3. The actor in this question will react to both your words and your actions, so you must demonstrate a systematic, practical, and effective approach to managing all the medical emergencies you might see in dental practice. 4. The examiners will mark you on both your words and your actions. 5. As the scenario develops, be prepared for other medical emergencies that may follow from the one that initially presents. The OSCE will last 10 minutes. The Steps Towards the Answer This is a practical OSCE, so you have to participate in the events that unfold: 1. Check for danger. Make sure you and any bystanders are safe (even though the background to this question states this is in your workplace, do not assume there is no danger). After checking and making sure everything is safe, then approach the actor/patient and assess for a response. Do this by gently shaking one or both of the actor’s shoulders and ask, ‘Are you all right?’ and be prepared to repeat this if necessary. 2. If there is no response, then shout for help. As mentioned above, this OSCE may develop into another medical emergency and be ready for this. As in real life, expect the unexpected and be prepared to deal with it. If the actor responds to you, then try to find out what is wrong by immediately going to the medical history. Ask if there are any medical problems the patient has or does he currently take any medicine. The actor is only barely responsive, his speech being slow and slurred. To your questions on the medical and medication history, the answers confirm the information in the introduction and there is nothing of note. You must check the following: Airway. Check if the mouth and nose are clear. Breathing: Check for chest movement, listening for breathing sounds. The actor then slumps forward and loses consciousness. There are no airway obstructions and he is still breathing. In the OSCE, the actor will be unresponsive. Indicate to the examiners your intention is to lie the patient flat in the dental chair or lie the patient flat on the floor. If your assessment is correct and approach appropriate, the actor will comply; that is, they won’t resist your intentions and actions to reposition them. If this was a simple faint, then raising the actor’s legs will initiate a rapid recovery. You must remember to keep the airway clear and loosen any clothing around the neck. This is important in the OSCE and real life too. Tell the patient and the examiners that if recovery is delayed, you will administer the following: 3. Oxygen at 10 litres per minute and continue to assess the patient for other causes of loss of
consciousness. In a simple faint, the patient will rapidly recover in a matter of a few seconds only. However, you must maintain the actor in this position as you would with a real patient. Although loss of consciousness in a faint lasts seconds, you must maintain the patient in the position to assist return of blood flow from the extremities for minutes. With the patient lying flat, with raised legs, when he has regained consciousness continue with your taking of the medical history. Remember in this OSCE, you are treating a new patient and going through the medical history is essential. If laying the patient flat and raising the legs results in recovery, you can now be certain the cause of loss of consciousness was a simple faint. Post-Emergency Care Advise the examiners and the actor you will record this event, attempt to identify and record the possible triggering factors, and so try to prevent this from happening again to this patient. Finish the OSCE by completing the medical history and state you will make an entry in the patient notes of the dental phobia and the fainting episode. Advise the examiners, when the patient returns, you will treat him in the supine position. Also mention you will complete the care of the patient for the condition he has attended for today and only discharge the patient from your care when he is well enough to go home, with an attendant carer if necessary. Also do check that the patient is not hypoglycaemic: Ask the actor if he has had anything to eat today and if necessary provide something sweet to eat or drink. Ensure the environment you discharge him to is safe and do review the social history on this visit: In this case, the patient is not a vulnerable adult, but a childhood history of dental phobia has resulted in the faint you have treated today. With this OSCE and when dealing with a faint in real life, your aim is to treat the patient and prevent further episodes from occurring. After the actor has recovered, in the remaining time in the OSCE, the examiners may ask for more information on the background to this emergency: Further Notes to Medical Emergency 1 1. Simple faint or vasovagal syncope may affect up to 2% of dental patients.1 Although recent papers cite a lower prevalence than this: In a small hospital-based study, the most common emergency was vasovagal syncope, and the total number of all emergency events was 1.8 per hospital dental surgeon per year. 2 A larger practice-based study demonstrated a similar number of emergency events, with vasovagal syncope at 1.9 per general dental practitioner per year.3 2. Vasovagal syncope or fainting is caused by reduction in blood flow to the brain (inadequate cerebral perfusion). In a faint, there is a reflex action mediated by the autonomic nerves leading to widespread vasodilation in the splanchnic and skeletal blood vessels. The resulting bradycardic
reflex causes loss of consciousness.1,4 3. You might be asked in the OSCE to give the signs (your observations) and symptoms (the patients account) of a faint. They are the following: a. Patient feels light-headed and dizzy. b. You will see pallor and sweating. c. The pulse rate has slowed down. d. There will be nausea and possibly vomiting. You won’t be expected to deal with vomiting in an OSCE, but you will be expected to deal with it in the clinic and it does happen. e. The last sign of fainting is the first one you were confronted with in this OSCE, and that is, loss of consciousness. 4. Some patients are more prone to fainting than others. It has been noted that young fit males are prone to fainting either before or after dental or other injections.1 In this OSCE, a faint has occurred as a result of pain and the emotional stress or fear of the dentist. In a recent paper, it was noted that one-third of all dental patients have fear and anxiety associated with dental visits,5 the principal fear being that of ‘the needle’, and this fear can be a transgenerational problem. (We will return to explore this again in Clinical Case 39.) In truth, fainting is a complex physiological problem,6 and fear of the dentist adds another dimension to this complexity. Fainting in the dental practice may be an aspect of a blood-injection-fear phobia, within the DSM IV TR.7 In the most up-to-date analysis of this problem, a survey of 11,213 families revealed fear of the dentist was prevalent in 0.4% of this sample with 13% of these patients experiencing dizziness or fainting.7 The confounding evidence from this study was that those patients who were frightened of the dentist avoided dental attendance, whereas those who reported fainting did not! So blood injection injury phobia may be a clinical entity, with one paper reporting on a case resulting in profound sinus arrest.8 From the above, we can see that although fainting is a common and simple emergency to deal with, it is complex, may be part of a wider recognised clinical entity, and may have serious consequences. Prevention One way to deal with fainting is to be aware of the initiating factors or triggering events and to address these. In the Handbook of Cognitive Behavioural Approaches to Primary Care, Watling (2010)9 gives a good overall account of the faint in a clinical environment and the technique of applied muscle tension (AMT). Dental patients at risk of fainting could be instructed in this technique to reduce the risk of a faint occurring. This technique essentially involves advising a patient to tense and relax the leg arm and torso muscles with a periodicity of 15 to 20 seconds in sets of 5 repetitions. The patient prone to fainting is trained in this technique before a dental attendance with mastery of this technique being noted within 1 week (i.e. before the patient returns for his next appointment!).
An interesting point is AMT actually encourages the patient to tense and relax the skeletal muscles enhancing venous return and cerebral perfusion, thus lowering the risk of fainting. Other techniques such as applied relaxation (AR), although proven to be effective in phobia reduction, paradoxically reduces venous return and cerebral perfusion, which might then increase the risk of vasovagal syncope.10 Although the technique of AMT may not prevent a faint in this OSCE, it might be useful in future dental attendances and with other phobic patients too. Its clinical application will need the input of a psychologist, and you might consider referral of a susceptible patient for a specialist consultation in this regard. References to Medical Emergency 1 1. Scully C. Chapter 1: Medical Emergencies. In Scully C. Medical Problems in Dentistry. 6th Edition pp. 6-7. Edinburgh: Churchill Livingstone 2010. 2. Atherton GJ, Pemberton MN, Thornhill MH. Medical emergencies: the experience of staff of a UK dental teaching hospital. Br Dent J. 2000 Mar 25;188(6):320-24. 3. Girdler NM, Smith DG. Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation. 1999 Jul;41(2):159-67. 4. Greenwood M. Medical emergencies in dental practice: 2. Management of specific medical emergencies. Dent Update. 2009 Jun;36(5):262-64, 266-68. 5. Armfield JM, Milgrom P. A clinician guide to patients afraid of dental injections and numbness. SAAD Dig. 2011 Jan;27:33-9. 6. Jardine DL. Vasovagal syncope: new physiologic insights. Cardiol Clin. 2013 Feb;31(1):75-87. 7. van Houtem C, Aartman I, Boomsma D, Ligthart L, Visscher C, de Jongh A . Is dental phobia a blood-injection-injury phobia? Depress Anxiety. 2013 Aug 19. 8. Sadahiro T, Tamura Y, Mitamura H, Fukuda K. Blood-injection-injury phobia: profound sinus arrest. Int J Cardiol. 2013 Jul 22. pii: S0167-5273(13)01265-5. 9. Watling A. Chapter 21: Medical Phobias. In Di Tomasso RA, Golden BA, Morris HJ. Handbook of Cognitive Behavioural Approaches in Primary Care. pp. 472-476. New York: Springer Publishing 2010. 10. Hayes-Skelton SA, Usmani A, Lee JK, Roemer L, Orsillo SM. A fresh look at potential mechanisms of change in applied relaxation for generalized anxiety disorder: a case series. Cogn Behav Pract. 2012 Aug;19(3):451-62.
Medical Emergency 2 Background Information After being in some pain for a few days and self-medicating with an assortment of over the counter medications such as paracetamol and ibuprofen, a patient has now come in for treatment. The procedure needed was root canal treatment to extirpate the contents of an infected canal from a non-
vital tooth. Introduction In the OSCE exam, the bell rings and you enter the examination room. In addition to the actor and examiners, there is an adult resuscitation manikin on the floor and an assortment of emergency drugs and equipment laid out on a table placed to one side of the room. There are paper cups present, a brown inhaler, a blue inhaler, and other medical emergency items, including oxygen masks and cylinders. In a pile next to this assortment of equipment are some dental instruments used for root treatment with an assortment of root canal files and a container clearly marked ‘bleackh’. It is obvious that some complications have arisen during a root canal treatment session. Of note, there is no rubber dam present. There are two examiners seated, both looking at you expectantly. An actor/patient is seated facing the examiners; the actor has his back to you as you enter the examination room. Before beginning a. There seems to be quite a lot going on here, with a few possible options to consider. In contrast to the previous case, dealing with a simple vasovagal syncope, this OSCE looks more complicated. b. It has been noted that collapse and other medical emergencies in the dental clinic are a cause for anxiety.1 c. There is one thing the medical emergency OSCEs in the MJDF are good at and that is duplicating the sense of anxiety you feel as a candidate facing the unknown. d. In this scenario where do you begin? e. Begin as you would with any emergency; assess the situation and make sure it is safe to proceed. Once you are sure there are no dangers, then carry on. Question Patient with Difficulty Breathing The actor/patient turns to look at you, and he is breathing with some difficulty. He has shortness of breath; his breathing is noisy and rapid. The actor represents a patient struggling to breath. He is using his shoulders to try to get more air into his lungs. He cannot speak to you for more than a few words at a time and he seems to be confused. Ignore the manikin (and the examiners too) and concentrate on the patient. He is your emergency. Responding to This Medical Emergency The patient is still conscious. 1. Check the airway and make sure it is clear. Tell the examiners and the patient you are looking
for any obstruction or foreign body he may have partially swallowed or inhaled. Think of the obvious and common things first. Has a root instrument passed into the airway? Ask the patient: ‘Have you inhaled anything? Has something gone into your lungs or chest?’ ‘Do you have any known allergies? Are you allergic to anything at all?’ Note the repetition of the question to emphasise the urgency of your enquiry. The answer to your questions is no. The actor continues to demonstrate breathing that is becoming more noisy and rapid. In this OSCE, there are two possible options: either anaphylaxis or severe or life-threatening asthma. There are no signs of ingestion or inhalation but do not completely discount these. 2. Administer oxygen. From the table at the side of the room, take the oxygen mask and place over the actor/patient’s mouth and turn the flow to 15 litres per minute. The patient acknowledges you have done this, but there is no improvement in breathing. This will give you time to consider what is wrong with the patient. 3. Next you have two options: either administer adrenaline or salbutamol via inhaler. Examine the actor/patient’s mouth again; there is no sign of swelling of the tongue or lips and no rash or cyanosis. Therefore, administer the salbutamol inhaler. There are two inhalers provided for you: one brown and one blue. Lift the oxygen mask away from the patient’s face and give the blue inhaler. Tell the patient and the examiner you will give 2 puffs initially and up to 10 puffs from this blue inhaler through a spacer. Tell the examiners and patient you will continue to observe the patient for up to 45 minutes to assess if there is any improvement. In the OSCE, you may need to repeat these applications of salbutamol two or three times before the actor responds. After a minute or so, the patient portrayed by the actor demonstrates an improvement in breathing. Additional Questions At this stage in medical emergency, it is clear from your responses that you have correctly identified an asthma attack which is severe or life-threatening. You now have about 5 minutes left in the OSCE. So the examiners might ask: what else will you do? Do not be tempted to end at this point; you will fail this OSCE, and a fail in the medical emergency section may result in failing the whole MJDF exam. You can advise the examiners that if the patient’s breathing did not improve after multiple puffs of salbutamol, then as noted above you would consider using a spacer. If there is no spacer, then the paper cups on the table can be used. Take a cup and show the examiners how you will do this: Make a hole in the bottom of the cup and place the inhaler in the hole. Place the cup over the
patient’s mouth and administer the salbutamol, then replace the oxygen mask. If you are using a spacer, tell the examiners you will use up to 10 Puffs, and you will call for help and dial 999 as the medical emergency will not over. The patient must not be left alone during the entire event. Specifically and clearly, tell the examiners both what you are doing and why you are doing it. Advise the examiners you will continue to monitor the patient, call for help, and verify help is coming. During the remaining time in the OSCE, advise the examiners you will continually re-assess the patient and this is PABCDE protocol : Positioning, Airway, Breathing, Circulation, Definitive treatment, and Emergency care as necessary.2 Alternatively, you can state you will use the MOVE protocol: Monitoring, Oxygen, Verify help is coming, and Emergency action—salbutamol via inhaler/spacer and oxygen at 15 litres per minute. Points to Note 1. In the MJDF OSCE, the issue of positioning or posture of the conscious breathing patient is not covered, and the protocol is ABCDE, with D for disability and E for exposure. 2. In the more recent Malamed protocol,2 the ABC are acknowledged, i.e. the patient’s airway is patent, he is breathing, and he does have a circulation. 3. However, it is important to monitor the position or posture of the patient and to ensure definitive treatment, i.e. salbutamol and emergency treatment, i.e. transfer to hospital if necessary has been initiated. Only after the actor/patient is stabilised can you advise the examiners that you will account for all the root instruments, verifying they are present. If there are any missing, you will need to conduct a significant event analysis and report to the relevant body or authority. In this case, there was an asthma attack. The non-use of rubber dam during root canal treatment is indefensible. Even if no instruments were aspirated (inhaled) or ingested (swallowed), the use of sodium hypochlorite (bleach) may have precipitated this asthma attack. This medical emergency must be documented in the patient notes. Common Causes of This Medical Emergency Asthma can be life-threatening and this must be recognised. Asthma can be precipitated by anxiety, exertion, an infection, or exposure to any allergic agent (such as bleach used in a root canal treatment).3,4 Tell the examiners and the actor/patient (who has now recovered), you will document this episode in the patient’s notes and consult with the patient’s medical practitioner as a medical assessment will be needed. There are some preparations patients can buy as over-counter-medicines (OCM), which may make asthma worse, and the most common ones are the non-steroidal anti-inflammatory drugs (NSAIDS). A potentially fatal reaction in asthmatics to NSAIDs has been known for a considerable time.5
In this OSCE, after dealing with the emergency, it is important to tell the examiners you will take both a medical and a medication history. The patient attended for a root treatment. Prior to this, he had taken ibuprofen, and in the course of the treatment, some of the hypochlorite had spilled into the mouth. It is likely that a small amount being inhaled was contributory to the asthma attack. Do state it is mandatory to use a rubber dam. The use of rubber dam is commonly cited as an effective way of preventing the accidental aspiration of the small files used in root canal treatment. More common than this is the ingestion or aspiration of cleaning solutions such as sodium hypochlorite. The use of rubber dam might also be cited as a means of preventing this. Critical Signs Do recount the sign of an asthma attack you have already picked up. In an OSCE, it is a simple matter for an actor to display the signs and report the symptoms of asthma to you. In an OSCE and in the clinic, the critical signs to be aware of are as follows: 1. Breathlessness, in excess of 25 breaths per minute, laboured expiratory wheezing, and coughing. 2. If the actor/patient becomes distressed and anxious and cannot complete answers to your questions in one sentence, this is a sign of severe asthma. 3. Use of accessory muscles of respiration is a sign the asthma is severe or life-threatening. Sometimes, asthma can be part of a more generalised anaphylaxis, and in these cases you would administer the adrenaline intramuscularly.6 Also tell the examiners that asthma can be life-threatening if the breathing rate falls to less than 8 breaths per minute and the pulse rises, then drops; the patient will rapidly become unconscious, and respiratory arrest can follow from exhaustion.7 For these reasons, the order in which you respond to this emergency is first give oxygen, then the salbutamol, and finally adrenaline. From the start of your dealing with this medical emergency, if there is any doubt on what condition you are faced with you must state to the examiners you will contact the emergency services and verify they are coming; until they arrive and you hand over the patient, you must continually monitor the patient’s vital signs. Further Notes to Medical Emergency 2 This question frequently appears in the MJDF and rightly so as asthma is a common condition affecting 5% of the population in the UK.7 Its prevalence is increasing, especially in childhood in Western countries. Asthma usually begins in childhood or in early adult life.7 There are two types of asthma: the extrinsic or allergic childhood onset asthma and the intrinsic or non-allergic adult onset asthma. As mentioned above, precipitating or trigger factors for asthma can be infections of any kind (including the dento-facial infection requiring root treatment), drugs such as an NSAID (in this case ibuprofen), the anxiety and stress of attending a dental treatment. Given that all these factors are present in this OSCE, then an asthma attack is predictable. It has been noted that 15% of asthmatics can experience a significant reduction in lung function during dental treatment.7
In an asthma attack, the bronchioles in an asthmatic’s lungs become hyper-reactive, with smooth muscle constriction, mucosal oedema, and excessive mucous secretion resulting in airway obstruction that is reversible with B2 agonists such as salbutamol (the blue inhaler) and if necessary: oxygen. In the examination room in the OSCE, the presence of a brown inhaler containing a corticosteroid such as Beclomethasone or Fluticasone was noted in the introduction. Using a brown inhaler will not reverse the airway constriction and obstruction of an asthma attack and should therefore not be used in cases such as this. Their use is in the prevention of asthma only. Deaths from asthma unfortunately do still occur, and in recent studies, it is stated to be rising due to several factors.8,9 Among these factors are a failure to recognise and deal with the deterioration in clinical signs, an unwillingness among asthmatics to use steroids to prevent the condition from arising, and the adverse social circumstances of the patient. References to Medical Emergency 2 1. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 3: perceptions of training and competence of GDPs in their management. Br Dent J. 1999 Mar 13;186(5):234-37. 2. Malamed S. Emergency Medicine. A Peer-Reviewed Publication. Academy of Dental Therapeutics and Stomatology. [Online 2013]. Available from: http://www.ineedce.com/courses/1437/PDF/Emergency Medicine.pdf [Accessed August 2013]. 3. Quirce S, Barranco PJ. Cleaning agents and asthma. Investig Allergol Clin Immunol. 2010;20(7):542-50. 4. Guggenheimer J, Moore PA. The patient with asthma: implications for dental practice. Compend Contin Educ Dent. 2009 May;30(4):200-02, 205-07. 5. Stevenson SD. Diagnosis, prevention and treatment of adverse reactions to aspirin and NSAIDs. J Allergy Clin Immunol. 1984;74(4):617-22. 6. Greenwood M. Medical emergencies in dental practice: 2. Management of specific medical emergencies. Dent Update. 2009 Jun;36(5):262-64, 266-68. 7. Scully C. Chapter 15: Respiratory Medicine. In Scully C. Medical Problems in Dentistry. 6th Edition pp. 366-367. Edinburgh: Churchill Livingstone 2010. 8. Rebuck AS. The global decline in asthma death rates: can we relax now? Asia Pac Allergy. 2013 Jul;3(3):200-03. 9. Goeman DP, Abramson MJ, McCarthy EA, Zubrinich CM, Douglass JA. Asthma mortality in Australia in the 21st century: a case series analysis. BMJ Open. 2013 May 28;3(5). [Online] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657652/ [Accessed August 2013]. Further Reading to Medical Emergency 2 1. Douglas G. Chapter 6: Management of Acute Asthma in Adults. In Douglas GJ, Elward KS.
Asthma: Asthma Clinicians Desk Reference. pp. 61-70. London: Manson Publishing 2010. The data and findings in this chapter in this British textbook clearly support the research findings from the Australian studies on asthma mortality Of note is the fact that 1,400 people die every year in the UK from asthma; this is disproportionately higher than the US figure of 4,000 deaths per annum. 2. Baren JM. Chapter 33: Severe Life Threatening-Asthma. In Field MJ. The Textbook of Emergency Cardiovascular Care and CPR. pp. 527-528. Philadelphia: Lippincott Williams and Wilkins 2009. Another good source of data and techniques on dealing with this condition.
Medical Emergency 3 Background Information In this OSCE dealing with another medical emergency seen in the dental clinic, I have moved the focus away from a purely practical question found in the MJDF medical emergencies syllabus towards a dialogue-based approach found in the MFDS OSCEs. Despite this, in any examination you should still demonstrate your grasp of the theory in dealing with this condition if it presents as an emergency and a sound knowledge of the underlying condition itself. Although this OSCE deals with a condition affecting some 1% of the population and 10% of the population will have experienced at least one episode in their lives1 it is a difficult condition to simulate in a clinical exam. The figures cited agree with the UK NHS Choices web site, with half a million people in the UK affected by this condition.2 It is included in this chapter on medical emergencies for the sake of completeness. In moving the focus of this particular case away from a practical MJDF exercise to a more conversational MFDS dialogue, it should be remembered while this condition may not appear as a medical emergency in the OSCEs, it does commonly present as one in the clinic and you should be prepared to deal with it there. Introduction The subject of this OSCE is a young adult orthodontic patient of 15 years. Her mother attends with her. The patient has very poor oral hygiene and has been sent to you by her orthodontist as she cannot maintain adequate oral hygiene. This patient simply does not respond to oral hygiene instructions and seems to have no interest in anything you say. The orthodontist is busy and has referred this patient for you to deal with. The clinical note is incredible, probably telling you more about your colleague than it does about the patient: PATIENT RECORD CARD Dont have to deal with this No not have time or fundingto deal with this nonsense any more’. And wont!
Send tp dentist ASAP to deal with this child!
The chief complaint from the orthodontist is that the patient keeps breaking her orthodontic appliance and has repeatedly broken off the incisal edges of the crowns of her upper front teeth, which another
dentist has repaired with composite. Both mother and the orthodontist are not happy about the lack of progress and want you to do something. In the consultation, the patient suddenly collapses, and after a few minutes she recovers; throughout that episode, the mother dealt with the situation and did not allow you to go near her daughter. You recorded the events in the notes and the mother took her daughter home. Understandably, no progress was made with her orthodontic and dental care at that visit. The mother re-attends a week later. In this OSCE you are faced with the mother in this visit. The mother wants to know what you are going to do to help her daughter. Medical Emergency Question This OSCE deals with another common medical problem seen in the dental surgery, but which one? How this case is presented a. In such OSCEs, a commonly used device is for an actor to play the part of the parent of a patient. You will then conduct your consultations with the actor. b. In this case, an actor will portray the mother of the patient. You have to be empathic towards the mother and supportive of her daughter. Begin by expressing your concerns and start by taking a good medical history from the mother (in real life you will have input from the daughter as well). Previously, you have witnessed a collapse and would like to know more about what has caused this… Answers to This OSCE Taking a complete Medical History will reveal the patient has epilepsy. Your history must include information on a. the nature of the seizures, b. the frequency of seizures, c. the type and efficacy of medication that the patient has been and is currently taking. The mother is upset and embarrassed, eventually admitting to you her daughter has had epilepsy since childhood. She is now noticeably falling behind in school and has been a hospital inpatient as the episodes have been both frequent and severe. The mother then reveals that her partner also has epilepsy and they met through a support group. Social history to this case The information that the mother has met her partner in an epilepsy support group is an interesting aspect of the social history, revealing the patient has a good support network and that she is not in an at-risk home environment. A note should be made of this and if necessary, any contact details for the patient’s GP and support workers are recorded in the patient notes. Signs and Symptoms You Will See Signs and symptoms of epilepsy may include the aura phase or a premonition that a seizure is about to
happen, the tonic phase when the collapse or the fit happens and there may be a collapse, and then a rigid phase. Following this, there are jerking movements and the tongue and lips may be at risk of being severely bitten. Of relevance to this case is the repeated damage to the orthodontic appliance that would have occurred during the epileptic seizures. Other clinical signs are frothing of the mouth and urinary incontinence. As the latter is an especially socially problematical issue, this should be sensitively acknowledged as one of the reasons why the mother did not want you to intervene and why she immediately took her daughter home at the last visit. In your OSCE discussions with the mother, it is important to communicate your understanding and empathy of the condition her daughter suffers from. In your ‘OSCE-discussions’ do mention the above-mentioned facts, stating to the mother: Your daughter does have a common condition and we are aware of its nature, how it might present and the complications that can arise. We are trained to deal with these. We know about 1% of the adult population in the UK suffer from epilepsy and 10 % of the population have suffered from one seizure in their lifetime.1,2 Epilepsy is a complex disorder. Simply stating that it is indicative of a neurological dysfunction doesn’t help the patient; it won’t endear you to her mother and doesn’t increase your chances of passing the OSCE. Epilepsy has many forms and underlying organic, biological, and non-biological causes that go beyond the appearance of a seizure. Shorvon (2010)3 notes there are four main ways to describe epilepsy and each of these classification systems has advantages and disadvantages. These are as follows: a. Seizure type, b. Anatomical site or location, c. Associated syndrome, d. Aetiology. A practical classification from the International League Against Epilepsy (ILAE) overcomes the problem that patients may display more than one seizure pattern and there may be multiple underlying causes or no underlying cause identifiable.4 This system is as follows: a. Seizure type: generalised, focal, or unknown, with various descriptors of the seizure displayed. b. Electroclinical: according to age of onset from paediatric to geriatric. c. Syndromic or distinct constellation. d. Non-syndromic. Berg and Scheffer (2010) with the ILAE proposed a radical rethinking of the way we classify epilepsy. Although this is still a work in progress, to not make the global health care professions aware of these changes would be a disservice to the patients.5,6 In this case, childhood febrile convulsions led to the development of epilepsy. This is noted to be a common cause of epilepsy, with some 3% of children affected going on to develop epilepsy.1 This aetiology emphasises the need to take accurate, accessible, and applicable medical histories from patients or in this case their parent.
Within the details of the 2010 classification of epilepsy, different causes are identified. In this case, epilepsy developed after cerebral hypoxia or trauma during birth, with attendant metabolic disturbances. From the literature, we can see that epilepsy is more common in the younger patients between 5 and 20 years old, and there may be environmental triggers leading to the seizures. In this case, hormonal changes might be implicated,7,8 and again these factors should be raised with the mother in your OSCE discussions. The other often quoted triggers for epilepsy are bright flashing lights and the recreational drugs acquired and used by many young adults today. In your OSCE, do briefly mention that you are aware of social pressures, but be careful not to infer that her daughter is influenced by these or specifically that she is taking or using drugs. Allow the mother to raise the issue if it comes up in the OSCE, then state that a referral to her daughter’s general medical practitioner is the most appropriate way to deal with her concerns. The mother seems to be happy with your explanations and wants to know why the orthodontist has concerns about her daughter’s oral hygiene. In response, oral hygiene instruction should be provided. Mention the issue of any medication her daughter is taking such as Phenytoin and other anticonvulsants*, causing the gums to swell in response to bacteria naturally occurring in the mouth. This phenomenon has been known since 1939 but is still frequently the subject of case reports (usually from junior doctors who happen upon this clinical finding for the first time in their careers!).9 *(These are also termed AEDs or anti-epileptic drugs, this term, although in common use is not advised due to the other AEDs, the use of which we will soon cover.) The mother then asks if you are prepared to look after her daughter in the future, and now you can reassure the mother that as a dentist, you are trained to look after all your patients and if her daughter attends and has an epileptic seizure, you have the means to deal with this. The mother asks what these are. An Emergency Presentation of This Condition Your response should be to state: a. You would ensure her daughter’s safety at all times. If she has a seizure lasting more than 2 minutes, you would give a sedative drug. b. This is Midazolam and is given in an age-dependent-dose. For her daughter, this would be 10 mgs. c. This would be placed in the mouth in the cheek or administered by nasal spray. d. The decision to give Midazolam will be a joint decision with the mother and the designated practice first aider. As such, this will be a declared and managed medical emergency with an ambulance being called and her daughter being transferred to hospital. c. Oxygen at 15 litres per minute would be given, and if necessary, her daughter would be monitored until handing over to the ambulance personnel takes place.
This OSCE dealing with the medical emergency of epilepsy also touches on the immediate effects of this condition on the orthodontic treatment the patient is receiving. Epilepsy is not a condition with contraindications to either orthodontic or dental care. However, it may be the case that orthodontic appliances are modified to minimise the potential for trauma to a patient and damage to teeth or the patient, if a seizure were to occur. Finish the OSCE by reassuring the mother you will communicate your findings to the orthodontist and document in the notes that her daughter has epilepsy, but this is not well controlled. The Importance of a Medical History In this case, the orthodontist was focused on delivering specialist care and did not read the medical or social history at all. From their perspective, among the hundreds of patients seen every week; they were faced with a non-compliant patient with poor oral health and an inability to progress with treatment due to repeated appliance breakage. Taking a few minutes to read the notes can make a critical difference. Sudden unexpected death in epilepsy (SUDEP), while rare, is one of the main dangers associated with epilepsy. In the UK alone, every year between 500 and 1,000 people die as a result of SUDEP, although thankfully this is less than 1% of all people with epilepsy.2 Although the cause of SUDEP is unknown, a clear understanding of your patient’s epilepsy and good management of their care and seizures can and will significantly reduce this risk. Document Your Findings The finding of epilepsy come from appropriate clinical enquiries and an up-to-date medical history documenting the type of epilepsy the patient suffers from. Also noted will be the need to provide oral hygiene instruction to the patient at a level and language she can understand and in terms with an approach she can relate to so that a change in her attitude to receiving effective dental care can be achieved. This OSCE can end by asking the actor playing the part of the mother if there are any questions. Further Notes Epilepsy is more common in the young, the physically disabled, and the mentally impaired, with most cases arising between the ages of 5 and 20 years. Although there are no clear triggers, in many cases sleep deprivation and the anxiety of a dental visit with the bright light of the clinic can be the causative factors resulting in an epileptic seizure.1 One trigger factor not commented on in this case, but may be causative, is the effect of smell in precipitating an epileptic seizure. Certainly when discussing this subject with patients who suffer from epilepsy, an altered perception and sense of smell has been commented on during the aura or premonition phase of a seizure. Whether the characteristic smell of a dental clinic with fear of the dentist might trigger epilepsy is an unanswered question, but one worthy of your further thought and comment. One critical factor discovered in SUDEP was the post-mortem discovery that AED levels were suboptimal. 10 One question that we might ask is if a dentist or hygienist, in addition to reinforcing
oral hygiene instruction and tooth brushing advice, might also prove to be another important means of reinforcing the imperative for a patient with poorly controlled epilepsy to maintain their medication.11 References to Medical Emergency 3 1. Scully C. Chapter 13: Neurology, Epilepsy. In Scully C. Medical Problems in Dentistry. 6th Edition 2010. pp. 343-346. Edinburgh: Churchill Livingstone 2010. 2
. NHS Choices. Epilepsy. [Online] Available http://www.nhs.uk/Conditions/Epilepsy/Pages/Introduction.aspx [Accessed August 2013].
from:
3. Shorvon S. Chapter 1: Definitions and Epidemiology. In Handbook of Epilepsy Treatment. 3rd Edition pp. 1-5. Oxford: Wiley Blackwell 2010. 4. International League Against Epilepsy: Epilepsy Is Still a Puzzle Report of the Commission on Classification and Terminology. [Online] Available from: http://www.ilae.org/Visitors/Centre/ctf/documents/ILAEHandoutV10_000.pdf [Accessed August 2013]. 5. Berg AT, Berkovic SF, Brodie MJ , et al. Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 20052009. Epilepsia. 2010 Apr;51(4):676-85. 6. Berg AT, Scheffer IE . New concepts in classification of the epilepsies: entering the 21st century. Epilepsia. 2011 Jun;52(6):1058-62. 7. Zupanc ML, Haut S. Epilepsy in women: special considerations for adolescents. Int Rev Neurobiol. 2008;83:91-111. doi: 10.1016/S0074-7742(08)00005-6. 8. Cramer JA, Gordon J, Schachter S, Devinsky O. Women with epilepsy: hormonal issues from menarche through menopause. Epilepsy Behav. 2007 Sep;11(2):160-78. 9. Mohan RP, Rastogi K, Bhushan R, Verma S . Phenytoin-induced gingival enlargement: a dental awakening for patients with epilepsy. BMJ Case Rep. 2013 Apr 23;2013. 10. Hesdorffer DC, Tomson T. Sudden unexpected death in epilepsy: potential role of antiepileptic drugs. CNS Drugs. 2013 Feb;27(2):113-19. 11. Shankar R, Cox D, Jalihal V, Brown S, Hanna J, McLean B . Sudden unexpected death in epilepsy (SUDEP): development of a safety checklist. Seizure. 2013 Aug 2. pii: S1059-1311(13)00221-5. Further Reading to Medical Emergency 3. 1. Jacobsen PL, Eden O. Epilepsy and the dental management of the epileptic patient. J Contemp Dent Pract. 2008 Jan 1;9(1):54-62. 2. Martland T, Camfield C. Chapter 4: Epilepsy Beginning in Adolescence. In Appleton R, Camfield P. Childhood Epilepsy from Diagnosis to Remission. pp. 73-107. Cambridge: Cambridge University Press 2011. 3. Appleton R, Camfield P. Chapter 7: The Prevention of Epilepsy and Its Consequences. In Appleton R, Camfield P. Childhood Epilepsy from Diagnosis to Remission. pp. 133-138. Cambridge:
Cambridge University Press 2011.
Medical Emergency 4 Background Information Dentistry is a safety critical profession, and a dentist who cannot demonstrate the basics of cardio pulmonary resuscitation (CPR) is an unsafe dentist. Practise, practise, practise and do so with your colleagues and fellow students on a regular basis, before and after this OSCE. As mentioned before, in the UK, the GDC stipulate you must demonstrate 10 hours of training in medical emergencies in verifiable continuing professional development (CPD) in every 5-year cycle. In this type of OSCE, you must go through the accepted and current resuscitation procedures and do so in the correct order. Unlike the previous OSCEs where a degree of interpretation, discussion, and avenues for further thought were introduced, in this procedural and practical OSCE there is little if any room for deviation from the currently accepted protocols. Introduction The bell rings and you enter the examination room. There are two examiners and one resuscitation manikin on the floor lying face down… This is purely a practical OSCE, and the examiners take little part in the proceedings; you will have up to 10 minutes to assess and provide the treatment necessary to the satisfaction of the examiners. Critical Points in This Emergency If any of the stages in the procedure are missed out, you will fail the OSCE and risk failing the entire MJDF exam as a result. Answers to this Medical Emergency 1 . Check for danger. Do not proceed if there are any hazards. The examiners will remove any hazards you identify. 2. Check for responsiveness. Do this by shaking and shouting at the dummy. 3. Open the airway. In this instance, turn the manikin over in the accepted manner, then 1. tilt the head, 2. lift the chin and 3. thrust the jaw. 4. Check for normal breathing for 10 seconds minimum. 5. Telephone for help. The examiner will provide a telephone: Dial 999. Listen to the call being connected. In some exams, you will have to speak to someone on the telephone, and this results in a very realistic OSCE. Ask for Ambulance Service. State your name, your address including postcode (state the OSCE number you are at), your
telephone (don’t mess about trying to remember any number; give them your mobile number). State the following: I have an unresponsive patient in cardiac arrest. I am on my own now starting CPR. Send an ambulance. Please read back this data to me. 6. Now you can begin the CPR. 30 chest compressions at 100 per minute to depth of 5 cms, with both hands placed in the middle of the sternum of the manikin. In this aspect of the exercise, your depth and rate of compression will be assessed. So this needs practice, practice, practice. 2 breaths at 1 second for each breath, and again your technique will be assessed. The manikin’s chest must rise and fall with each breath. This cycle of 2 breaths and 30 chest compressions will go on until the examiners tell you to stop or the time for the OSCE ends. During this phase of the exercise, 2 breaths and 30 chest compressions, your technique will be assessed, and this gives a good opportunity for the examiners to assess how effective you will be in real life. In this OSCE, the whole exercise should only take 5 minutes; there is only one attempt allowed, and failures in this exercise are rare but do occur. In some exams, a failure in this OSCE or any medical emergency OSCE will mean you will have to do exceptionally well in the other questions to compensate to achieve a pass in the overall exam. Normally, a failure in any one of the medical emergencies will result in a failure in the exam overall. Heresy or Orthodoxy: An Examiner’s Comment Something you might wish to consider. Some examiners have stated (in revision courses for the MFDS) that CPR and medical emergencies do not have a part in their syllabus because this subject cannot be examined in an objective and realistic manner using actors.1 One deduction you might make from this statement is if a subject cannot be examined correctly, then it can’t be taught properly either… A recent study in Japan has indicated there may be some truth in the above statement and the deduction made from this. The use of robots in OSCEs testing dental students in medical emergencies revealed only a minority of students could accurately identify the medical emergency the robot was configured to portray. 2 This result agrees with the second part of the deduction (i.e. clinical teachers could do better). Notwithstanding this, the majority of students in this study stated they recognised the usefulness of the robot-patient in training and examining medical emergencies, thus agreeing with the statement of the MFDS examiner! As mentioned previously, the MFDS and MJDF are constantly evolving to meet the quite rapid and exciting developments in dentistry in the UK and Europe. Perhaps the MFDS will include medical emergencies but only when suitably configured robot-patients are available.
In the meantime, there are other examining boards and Royal Colleges, who state that training, revising, and practicing medical emergencies are an important part not only of the foundation level examinations but also of the entire lifelong practice of dentistry and will continue to be included in their syllabus. Please consider the following facts and then decide if you wish to rehearse this important part of dentistry in your revision, even if you are not going to be examined on it: Facts to Consider In the UK, annually, approximately 60,000 people sustain a cardiac arrest outside of a hospital environment.3,4 Half of this number are attended to by emergency medical services.5 In Europe, the most frequent cause of death among the population aged 65-84 is ischaemic heart disease (IHD) and cerebrovascular accidents (CVA). In the EU, an average of nearly 1 million people aged 65-84 died each year from 2001-2003 from IHD and CVA.6 There is a clear duty of those who practise dentistry to be able to deal with all medical emergencies to be competent in basic life support, in particular emergency life support (ELS) and CPR. High-quality basic life support delivered promptly will increase the chance of a successful electric defibrillation. The UK Department of Health figures for 2011 show that using an automatic external defibrillator (AED) can significantly increase the survival chances of a patient in cardiac arrest with a 1 in 5 chance of a successful outcome.7 The figures from the USA demonstrate that a rapid and effective response with an AED can result in survival of up to 50% of patients in cardiac arrest.8 It is now becoming increasingly common for dental practices to have an automatic electric defibrillator (AED), and in some examinations, you may also be asked to place and go through the simulated operation of these. It has been emphasised by the UK Resuscitation Council that an AED can be used effectively even by those with no training if confronted with a cardiac arrest.9,10 The guidelines for examinations will vary, and it would be prudent that you keep up to date with not only the UK Resuscitation Council guidelines but also the advice for examination candidates, given by the specific college you choose to sit your foundation level exam with. Failing to revise this subject is currently an option with certain colleges, but failing your patient when faced with a medical emergency of this nature is not currently an option open to anyone. Adult Basic Life Support The algorithm for this medical emergency is available online from the UK Resuscitation Council: http://www.resus.org.uk/pages/blsalgo.pdf This is reproduced below:
References to Medical Emergency 4 1. Shearer A. Lecture In MFDS Part 2 Revision Course. Royal College of Surgeons, Edinburgh, 7 and 8 July 2011. 2. Tanzawa T, Futaki K, Kurabayashi H, et al. Medical emergency education using a robot patient in a dental setting. Eur J Dent Educ. 2013 Feb;17(1):114-119. 3. Ambulance Service Association. National Cardiac Arrest Audit Report; 2006. 4. Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation. 2010 Nov;81(11):1479-87. [Online] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20828914 [Accessed August 2013]. 5. Pell JP, Sirel JM, Marsden AK, Ford I, Walker NL, Cobbe SM. Presentation, management, and outcome of out of hospital cardiopulmonary arrest: comparison by underlying aetiology. Heart. 2003;89:839-42. [Online] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767789/ [Accessed August 2013]. 6. Niederlaender E. Statistics in focus population and social conditions 2006 4-5. Eurostat. [Online] Available from: http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-NK-06-010/EN/KSNK-06-010-EN.PDF [Accessed August 2013].
7. Ambulance Quality Indicators: Clinical Outcomes, Ambulance Trusts in England—April 2011. Department of Health; 2011. [Online] Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performancedataandstatistics/Ambulanc Quality Indicator [Accessed August 2013].
8. Cave DM, Aufderheide TP, Beeson J, et al. Importance and implementation of training in cardiopulmonary resuscitation and automated external defibrillation in schools: a science advisory from the American Heart Association. Circulation. 2011 Feb 15;123(6):691-706. 9. Andre AD, Jorgenson DB, Froman JA, Snyder DE, Poole JE. Automated external defibrillator use by untrained bystanders: can the public-use model work? Prehosp Emerg Care. 2004 JulSep;8(3):284-91. 10. Koster RW, Baubin MA, Bossaert LL, et al. European Resuscitation Council Guidelines for Resuscitation 2010. Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 2010; 81.81(10): 1277-92.
Medical Emergency 5 Background Information to This Question In this OSCE you are presented with a dental practice emergency drugs box and boxes of rubber gloves. There is an oxygen cylinder and face mask too. A middle-aged healthy-looking actor portrays the patient in this exam setting. The medical history here reveals the patient has diabetes and ischaemic heart disease too. He is a regular attender at his doctor for his medication. The medicines he takes are insulin, thiazide diuretics, beta blockers, frusemide, and aspirin. Please Take Note of Patient Notes 1. I have underlined the insulin to emphasise this medication and the condition it treats is central to this medical emergency. 2. In the OSCE, a list of medication will be given, but you will not have an emphasis or text underlining guiding you towards the emergency you are faced with. 3. With medical emergencies, there is good news and bad news. 4. The good news in the MJDF is that it is unlikely you will have an OSCE dealing with multiple medical emergencies occurring concurrently, rather you will be asked to demonstrate competence in dealing with one emergency at a time (before going to deal with another medical emergency at another OSCE station!). 5. The bad news is in real life; a poly-medicated patient may present with multiple medical emergencies that you must be ready to deal with at any time concurrently consecutively or otherwise. Introduction After introducing yourself to the actor in a professional manner, the consultation can begin. The actor has a small piece of paper on to which he has carefully noted all of his medications and doses, the times he takes them and the reasons for these. Knowing about Medication
1. Most patients you see in dental practice are well informed about the (prescribed) drugs they use, being well aware of what each drug does and what their side effects are. 2. In this type of OSCE, do expect to see your actor/patient clutching a piece of paper that they will be quite keen for you to see. If you do not know what a drug does, then just ask. 3. Whatever else you do, when confronted with a drug you have never heard of or seen before, don’t nod at the actor in a knowing and yet in an unknowing way. If you do, the examiners are attuned to recognising holes in your knowledge and will relentlessly pluck away at this hole until your time runs out. 4. Just as in real life, let the patient explain things to you. Use their knowledge with yours. 5. If you are still unclear, then the UK Dental Practitioner’s Formulary (DPF) can be used. In the forthcoming OSCEs, this document will be extensively referred to. In the OSCE the actor will hand you a medication list. This list shows the patient is taking insulin and other drugs for high blood pressure, anticoagulation, and diuretics too. The patient uses a home blood glucose monitoring (HBGM) test, with blood sugar levels in the normal range. This was taken one hour prior to the appointment. Just as you are going through this list of medications, the actor tells you he has a headache, pins and needles in his lips and tongue. He tells you that he doesn’t feel at all well… stating: ‘Sorry… I feel quite odd. I do feel dizzy, a bit queer in fact…’ Question What do the symptoms this patient is complaining of alert you to? Before the patient can explain any more, he seems to tremble, becoming confused and quite drowsy, with slurred speech; he then collapses forward in the chair and will not respond to any more of your questions. At this point, the two examiners might also be leaning forward too, but only to get a closer look at what you will be doing next. You have 10 minutes to discover what the problem is and effectively treat this patient… First thing you must do are the PABC’s of emergency first aid. This will begin to earn you some marks and give you some thinking time about the next steps you will need to take in order to pass this OSCE. There are gloves in this OSCE: Put them on. Then go through the following protocol: Posture: If the patient has collapsed, make sure he can be supported or his position is stable. If his head is forward, then gently raise his head to complete the following steps: Airway: Check there are no obstructions such as dentures or other items present. Breathing: Check the patient is breathing for 10 seconds and count these seconds out aloud so the examiners can hear you.
Circulation: You may wish to check the pulse and show the examiners you are doing this by taking the patient’s wrist and checking the pulse. Carotid pulse or wrist pulse? 1. Please do not take a carotid pulse. This is really important. 2. The taking of a carotid pulse is within the advanced life support domain. 3. In the MJDF, medical emergency OSCEs, and basic life support, a wrist pulse is appropriate. 4. In another OSCE, an examiner may stop you and state, ‘There is no pulse. Now carry on.’ In that case, you would carry on with a resuscitation manikin. In this OSCE, you will be relieved to know the actor still has a pulse; show the examiners that you know that checking the pulse is an important aspect of dealing with this diabetic patient for the following reasons: a) Long-standing diabetic patients are prone to ischaemic heart disease. b) In addition to a diabetic emergency, there could be other reasons for the collapse.1 This patient is having a diabetic hypoglycaemic episode. Working in dental practice, you are much more likely to encounter hypoglycaemia than hyperglycaemia due to its rapid onset.2 Make an initial diagnosis that the patient is hypoglycaemic and tell this to the examiners. Lie the patient flat; in the exam, advise the examiners you will do this and the actor will helpfully comply with this. Next you need to take glucagon from the emergency drugs box. Once you have identified glucagon, then the examiners will expect you to select and assemble the correct syringe and needle. Draw up the sterile saline with one needle and then administer the glucagon reconstituted in solution with a second Green needle into a practice pad. When inserting the needle, you need to inject to the correct depth (not to the needle hub please) and administer the drug at the correct rate (slowly and confidently). You are expected to inject 1 mg/1 ml glucagon into a practice-pad simulating an intramuscular injection. Do state the dose and route of administration to the examiners. Before injecting, do not forget to wipe the practice-pad with alcohol. I do not think you would fail this OSCE for not alco-wiping the pad before injection (it is a medical emergency), but doing so shows good clinical practice. The examiners will make sure you inject the rubber pad and that you do not inject the ‘collapsed’ actor/patient in a state of nervous excitement. Place all the sharps safely to one side or dispose of them immediately in a sharp safe bin. You are not finished yet. Turn back to the patient and monitor his recovery; if you have selected glucagon, then you can
proceed to the next stage of this OSCE. If you have selected any other item you will fail this question. In real life, you will add further complications to a medical emergency if you fail to identify hypoglycaemia and incorrectly administer the wrong drug. By doing so, you may endanger your patient’s life. After a few more minutes (in real life this could be 5 up to 10 minutes), the actor will now represent a patient in recovery. You should advise further monitoring is necessary and give a sweet drink or oral glucose gels. In this case, you may wish to state that you will arrange for transport to hospital (in the UK, this would be an NHS 24 facility) and inform the patient’s general medical practitioner of this episode. You need to tell the examiners you will document this medical emergency in the patient’s notes. With a hypoglycaemic emergency, there are patients who will not respond within minutes to glucagon due to absolute exhaustion of liver glycogen depot stores. Such patients are critically ill and will urgently require glucose IV and medically supervised monitoring. The attending ambulance crew must be informed of this and will undertake these measures.2 At the end of the OSCE, assuming you have completed all the above stages, you can dispose of the sharps and any other items used in the correct clinical waste bins provided for this purpose. Do not expect the examiners to do this for you; although you might not fail for not disposing of your sharps, not doing so shows a somewhat careless clinical attitude. Further Notes on Medical Emergency 5 Diabetes is a common condition affecting some 3% to 4% of the UK population; it may however only be recognised in three quarters of all cases.3 It is a leading cause of death and disability worldwide where perhaps some 246 million people are affected by this condition.3 Globally, the prevalence of diabetes for all age groups is expected to rise from 2.8% in 2000 to 4.4% in 2030. One of the key drivers in this epidemic is obesity.4 You will have seen diabetic patients as a student and in your work too. So presenting an OSCE dealing with diabetes is to be expected. You should know about this condition and what you must do when a diabetic patient presents as a medical emergency. Diabetes can be Primary Type 1 Insulin-dependent or more commonly Primary Type 2 Non-Insulindependent. Secondary diabetes can arise from another underlying condition. Diabetic control can be affected by oral infections leading to potentially fatal complications.5 Another factor destabilising diabetic control can be from the medication a patient is taking. The most commonly implicated are corticosteroids, thiazide diuretics, and even beta blockers.3,6 The clinical presentation of diabetes in these cases is more likely to be from poor drug control with an unmasking effect of these medications bringing latent or inherent diabetes into the clinical arena, rather than driving the metabolism of a healthy patient with a small diabetic risk towards actually developing clinical diabetes.6 Another form of diabetes, termed Type 1.5 Diabetes or LADA (Latent Autoimmune Type 2 Diabetes), which can affect up to 1 in 8 (12%) of all Type 2 cases of diabetes has recently been considered to be
a distinct type of diabetes.7 Diabetics with LADA often appear slim, fit and generally look healthy; they do not have the common Type 2 symptoms including the metabolic syndrome indicators of obesity, high blood pressure, and insulin resistance. Initially LADA can be controlled without insulin; however, within a few years the patient becomes dependent on insulin to control their diabetes.7,8 Of importance in LADA is the issue of ischaemic heart disease, the risks for myocardial infarct (MI) and stroke or cerebro-vascular accident (CVA), and that these can present as simultaneous medical emergencies together with a hypoglycaemic episode. If the diet can be controlled and blood sugar levels normalised, these risks are lowered.8 In this case, the actor is represented a patient who is a Type 1.5 Insulin-dependent diabetic; the medications he has been prescribed may indeed have precipitated the diabetic emergency. Other rarer forms of diabetes are maturity onset diabetes in the young and gestational diabetes in expectant mothers, both of note but not relevant to this specific OSCE. Recognition of the Clinical Signs You must recognise diabetic complications as and when they arise by the clinical signs they present with. In this OSCE, the actor initially complained of symptoms of headache and pins and needles in the lips and tongue. The actor demonstrated signs of trembling, slurring of speech, and then portrayed unconsciousness. Other signs you will not see in an OSCE but you will see in real life are the following: Patient becoming sweaty, aggressive, possibly having a seizure and finally the descent into unconsciousness. In this OSCE, the patient/actor demonstrated unconsciousness. You may have an OSCE where if you act quickly enough and the patient does not lose consciousness, the actor will respond to a sweet drink. If you fail to act promptly, then you will be expected to administer glucagon. You won’t get any more marks for administering glucagon, but you might just redeem yourself enough not to fail the question. So pay attention to the signs and symptoms both in real life and in the OSCEs. Act promptly and act properly. Lastly, you will recall the patient’s HBGM recorded blood glucose was reported in the introduction to be in the normal range (<11.1 mmol/L >8 mmol/L). Yet in this OSCE, the patient was demonstrably hypoglycaemic. The findings from the following study are of note. While a Cochrane Database Systematic Review demonstrated the efficacy of home—or self-blood glucose monitoring systems in the insulin-dependent diabetic, some questions were raised about their suitability for the non-insulin-dependent diabetic and their overall usefulness in detecting hypogylycaemia or other complications.9 Adding to these criticisms are concerns that in the absence of governmental regulation, patient funding and support, manufacturers could potentially provide obsolete monitoring systems not configured to accurately detect hypoglycaemia.10
Lastly, home monitoring has been noted to be unreliable in the past. Recently, quality control issues and counterfeit items have confounded this problem further. Be aware of these issues in real life and as options to consider in the ‘Structured Clinical Reasoning Questions’ (SCRs) too.11
References to Medical Emergency 5 1. Scully C. Chapter 1: Medical Emergencies. Managing Emergencies. In Scully C. Medical Problems in Dentistry. 6th Edition pp. 8-11. Edinburgh: Churchill Livingstone 2010. 2. Greenwood M. Medical emergencies in dental practice: 2. Management of specific medical emergencies. Dent Update. 2009 Jun;36(5):262-68. 3. Scully C. Chapter 6: Endocrinology, Pancreas. In Medical Problems in Dentistry. 6th Edition pp. 138-144. Edinburgh: Churchill Livingstone 2010. 4. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004 May;27(5):1047-53. 5. Chandu A, Macisaac RJ, Smith AC, Bach LA. Diabetic ketoacidosis secondary to dento-alveolar infection. Int J Oral Maxillofac Surg. 2002 Feb;31(1):57-9. 6. Setter SM, White JR Jr, Campbell KR. Chapter 40: Diabetes. In Helms RA, Quan DJ, Helfindel ET, Gourley DR. Textbook of Therapeutics Drug and Disease Management. 8th Edition pp. 10421076. Philadelphia: Lippincott Williams and Wilkins 2006. 7. Nambam B, Aggarwal S, Jain A. Latent autoimmune diabetes in adults: a distinct but heterogeneous clinical entity. World J Diabetes. 2010 Sep 15;1(4):111-15. [Online] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083891/ [Accessed August 2013]. 8. Diabetes.co.uk The Global Diabetes Community. Diabetes Types Type 1.5 Diabetes. [Online] Available from: http://www.diabetes.co.uk/type15-diabetes.html [Accessed August 2013]. 9. Malanda UL, Welschen LM, Riphagen II, Dekker JM, Nijpels G, Bot SD. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database Syst Rev. 2012 Jan. 18; 1: CD 005060 10. Parkin CG. Penny wise and pound foolish: will shortsighted cost reduction measures compromise patient access to promising self-monitoring of blood glucose technology? J Diabetes Sci Technol. 2013 Jul 1;7(4):979-82. 11. Palm Beach Post. Blood Money: Black, Gray Markets for Diabetes Test Strips a Big Business. [Online] Available from: http://www.palmbeachpost.com/news/business/blood-money/nSWyQ/ [Accessed August 2013].
Medical Emergency 6 Background to This Emergency Having completed the first five OSCEs, you now proceed to another examination room. What you
know so far is if this was an exam you would be about one hour into your morning exam session by now. So far it has been a busy morning with a faint, an asthma attack, a mother of a child with epilepsy, you have practised and revised your (adult) CPR and treated a hypoglycaemic episode in a Type 1.5 Diabetic patient. Although you might not see this number of medical emergencies in the MJDF, you could see any one of them and certainly will see more than one in the Part 2 exam. Introduction The data in the introduction to this case states your patient has just had a local anaesthetic, when suddenly she begins to feel unwell. If you could see the patient, you would see she has suddenly become short of breath; she is wheezing and is rapidly developing a swelling of the lips. The patient is hoarse, becoming drowsy, confused and could collapse at any time. In the exam room are boxes of gloves on a table to one side of the room. There are also some dental equipment and materials. There is a dental practice emergency drugs box next to the boxes of gloves. You enter the room and there appear to be two examiners and someone else present too. External Assessment 1. This additional person is an external exam assessor there to ensure standards in the questions are being maintained and candidates are being assessed objectively. 2. The external assessors move around from OSCE to OSCE in a random manner. 3. Treat this external assessor as you would any examiner and do not involve them in your management of this emergency case. Question Your patient has just collapsed, but there is no actor present in this OSCE, only the adult resuscitation manikin lying on the floor and the dental practice emergency drugs box open on the table, with several boxes of gloves as noted above. You have 10 minutes to use the information you have been given in the introduction to this OSCE to decide on what to do and then do it. Procedures to Follow State to the examiners you will stop what you are doing (if you were conducting a procedure in real life), and you will call for help and if necessary call 999 and ask for an ambulance. You have already completed this part of the exercise in OSCE 4. (You may wish to revise this again if you feel you are not fluent in the process.) The process: 1. Check for danger. Do not proceed if there are any hazards. The examiners will remove any hazards you identify.
2. Check for responsiveness. Do this by shaking and shouting at the manikin. 3. Open the airway. In this instance, turn the manikin over in the accepted manner then tilt head, lift chin, and thrust jaw. 4. Check for normal breathing for 10 seconds minimum. 5. Telephone for help. The examiner will provide a telephone. Dial 999. Listen to the call being connected. In some exams, you will have to speak to someone on the telephone, and this results in a very realistic OSCE. Ask for Ambulance Service State your name and your address including postcode (state the OSCE number you are at) and your telephone (don’t mess about trying to remember any number; give them your mobile number) State clearly the following: I have a patient in distress. I am on my own. I think the patient has had a severe allergic reaction or suspected anaphylaxis. Send an ambulance immediately. Please read back this data to me. After this stage return to the manikin. In this OSCE, you are told that the patient is breathing. From the clinical signs in the introduction and the brief history, what will you do now? Immediately administer oxygen. Apply the mask to the manikin or to the actor and use 15 litres per minute flow rate. Continue to look for signs which will confirm the patient either has an anaphylactic reaction or is asthmatic. Potentially, both asthmatic and anaphylactic processes are occurring together. The signs which you will look for and tell the examiner as you closely examine the manikin are a. Perioral rash. b. Swelling of lips and tongue. c. Facial flushing with clammy skin. d. Stridor and wheezing, specifically an expiratory wheeze and hoarseness. If the patient is still responsive, they will tell you they have symptoms of itching. In some OSCE cases and in revision courses, prior to simulating a collapse, the actors may report to the candidates: ‘There feels like an impending sense of doom.’ Lay the patient/actor flat, or in this case, ensure the manikin is flat and raise the legs. Absolutely consider suspected anaphylaxis rather than a severe allergic reaction if the onset of this collapse as noted in the introduction was rapid, i.e. within a few minutes.
Now you can administer intramuscular adrenaline from the dental emergency drugs box. The examiners will be checking to make sure you correctly select adrenaline and administer it in the correct dose in the correct place. Optimally, this is in the outer muscle of the thigh. In this case, read the introduction and background information to check the age of the patient. In this OSCE introduction, no age was given. Ask where the notes are or if there are any notes. You can assume this patient was an adult. You might not fail for not asking or not checking, but (this is a big but) the dose of adrenaline you give is dependent on the age of the patient. In real life and OSCEs, check the age of the patient again before you give adrenaline. These doses of intramuscular adrenaline are: Adult
0.5 ml or 500 ugms
Child over 12
0.5 ml or 500 ugms
Child 6 to 12
0.3 ml or 300 ugms
Child less than 6: 0.15 ml or 150 ugms
Source: Resuscitation Council UK Medical Emergencies and Resuscitation. Standards for clinical practice and training for dental practitioners and dental care professionals in general dental practice. December 2012 Revision.1,2 Continue to administer adrenaline at 5-minute intervals and monitor for signs of improvement in the patient’s condition. In real life, this means you will continue to administer adrenaline and to monitor the patient until they improve or medical help arrives. In the OSCE you may have time to give a second dose of adrenaline or at least tell the examiners this is what you intend to do and to continue to monitor the patient until help arrives.2 You should end the OSCE by stating you will a. Monitor the patient. b. Oxygenate the patient at 15 litres per minute. c. Verify that help is on its way. d. Epinephrine continue to give repeat doses up to 0.5 ml at 500 ugms every 5 minutes. You may also wish to consider that if there is an asthma attack precipitated by anaphylaxis, you will give salbutamol via spacer with the oxygen. Further questions and answers about this emergency
Once you have completed all these steps, the examiners may ask you some questions. These questions are an important part in demonstrating your understanding of this medical emergency. Question 1: In addition to clinical signs and patient symptoms, what sounds might you hear? Answer 1: You will hear the following sounds in the following emergency conditions: Expiratory wheeze: In asthma or chronic obstructive airways disease anaphylaxis and heart failure. Stridor: in anaphylaxis as congestion of the lungs occurs. It is also heard in foreign body inspiration, epiglottis, trauma, and angioedema. No sounds: or a clear chest in hyperventilation, pleural effusion, pulmonary embolism, and pneumothorax. In this case, the wheezing and stridor are two critical signs you must pick up and act on. Question 2: Why do you lay the patient flat and raise the legs? Answer 2: In this OSCE, you lay the patient flat to maintain and attempt to restore blood pressure. In anaphylaxis, there is hypotension with compensatory tachycardia. Raising the legs assists the heart in maintaining blood pressure, until the cardiac muscle responds to the epinephrine with an increase in rate and force of contraction. You must do everything to maintain blood pressure and flow. So lifting the legs will improve venous return and delay or prevent the onset of the critical phase where cerebral perfusion falls to a level where the patient loses consciousness and becomes comatose with a risk of brain damage. Question 3: What immunological processes are going on? Answer 3: Anaphylaxis is a Type 1 hypersensitivity reaction. A stimulatory antigen binds to IgE antibodies with mast cell degranulation releasing vaso-active peptides causing rapid and widespread vasodilation, with the resulting drop in blood pressure as noted in the previous answer.2 Question 4: You have already mentioned some clinical signs. What are the signs of anaphylaxis? Answer 4: The clinical signs are rapid onset of itchy rash/erythema. Facial flushing or pallor also noted as a circum-oral pallor, with swelling of lips and tongue being seen. Upper airway oedema and bronchospasm, leading to stridor, wheezing and hoarseness as noted in Answer 1 are also heard. Question 5: What might happen if the anaphylaxis is not controlled? Answer 5: A respiratory arrest may follow leading to cardiac arrest. If this doesn’t happen, then with critically decreased cerebral perfusion the patient can become comatose with a risk of brain damage. Further Considerations of this Medical Emergency In this OSCE, the patient is in anaphylaxis. Do not waste time in the exam or the chance of saving a patient’s life in the dental clinic by trying to figure out the cause. Anaphylaxis is a severe, life-threatening, generalised, or systemic hypersensitivity reaction. It is characterised by rapidly developing, life-threatening problems involving: the airway (pharyngeal or laryngeal oedema) and/or breathing (bronchospasm with tachypnoea) and/or circulation (hypotension and/or tachycardia). In most cases, there are associated skin and mucosal changes.1,2
The most common causes of anaphylaxis in dentistry are allergy to drugs and latex.3 In the introduction, it was twice mentioned there were boxes of gloves on a side table in the exam room. In this case, it is most likely the patient reacted to these rather than the injection of local anaesthetic. However, a significant proportion of anaphylaxis is classified as idiopathic, in which there are significant clinical effects but no readily identifiable cause; additionally, there is an age-dependent variation in this.4 Data from the UK suggest approximately 1 in 1333 of the population of England have experienced anaphylaxis.5 There are approximately 20 deaths from anaphylaxis reported each year in the UK, half of these being iatrogenic.6 However, given the nature of the condition and how it presents, this figure may not be accurate.4 Patients who are prone to anaphylaxis will often carry an EpiPen which contains 300 ugms of epinephrine. This is a median dose for use in all age groups. If you have such a patient, then do make sure their EpiPen and your epinephrine are in date and present in the surgery and not in a CQCapproved locked drug cabinet when you treat them. Additional Details. One of the co-morbidities associated with anaphylaxis is angioedema. This is an anaphylaxis reaction causing airway obstruction. There may be a hereditary component to this. There is also a rare condition of hereditary angioedema caused by an autosomal dominant deficiency of an inhibitor of the enzyme C1 Esterase. This is responsible for stopping complement cascade activation. If a patient is deficient in this enzyme, they must be supplemented with it prior to dental treatment as the consequences can be fatal.7,8 Although both conditions are rare and in all the years I have been working I haven’t seen or treated a case, nevertheless the underlying principle is the same: Make sure your patient’s medical histories are up to date for every patient every day. If you have a medical and medication history in the OSCE: Read it and use it in your diagnoses and in your treatment. In anaphylaxis and all medical emergencies, efficient use of the notes, notice of the symptoms, and responding to clinical signs is the key to treating the patient and passing the OSCE. Anaphylactic Reactions Initial Treatment The algorithm for this medical emergency is available online from the UK Resuscitation Council. From: http://www.resus.org.uk/pages/anaalgo2.pdf. This is reproduced below:
References to Medical Emergency 6 1. Resuscitation Council UK 2006 Medical Emergencies and Resuscitation. Standards for clinical practice and training for dental practitioners and dental care professionals in general dental practice. 37-38. December 2012 Revision. 2. UK Resuscitation Council. Emergency Treatment of Anaphylactic Reactions: Guidelines for Healthcare Providers. Working Group of the Resuscitation Council 2008. Reviewed 2013, with annotated links to NICE 2012 Guidelines. [Online] Available from: http://www.resus.org.uk/pages/reaction.pdf [Accessed August 2013]. 3. Scully C. Chapter 17: Allergies. Urticaria and Acute Allergic Angioedema. In Scully C. Medical Problems in Dentistry. 6th Edition pp. 414-419. Edinburgh: Churchill Livingstone 2010. 4. NICE National Institute for Health and Care Excellence. Anaphylaxis: Assessment to Confirm an Anaphylactic Episode and the Decision to Refer after Emergency Treatment for a Suspected Anaphylactic Episode. [Online] Available from: http://guidance.nice.org.uk/CG134 [Accessed August 2013]. 5. Stewart AG, Ewan PW. The incidence, aetiology and management of anaphylaxis presenting to an accident and emergency department. Q J Med. 1996;89(11):859-64. 6. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000;30(8):1144-50. 7. Atkinson JC, Frank MM. Oral manifestations and dental management of patients with hereditary
angioedema. J Oral Pathol Med. 1991 Mar;20(3):139-42. 8. Bork K, Barnstedt SE. Laryngeal oedema and death from asphyxiation after tooth extraction in four patients with hereditary angioedema. JADA. 2003 Aug;134(8):1088-94.
Medical Emergency 7 Background Information. Again, with this OSCE as with OSCE 3, the focus has moved from being a medical emergency question with an emphasis on demonstrating practical skills towards an OSCE with an emphasis on communication skills. By changing the emphasis of learning, I hope you might be more interested in this case and benefit from reading about some of the risk factors that resulted in this medical emergency. This case is presented in a slightly different format—more of a conversational MFDS exam and less of a purely procedural MJDF exercise. Notwithstanding this approach, please do not neglect to revise your practical skills when dealing with this type of emergency. Introduction On the last working day of last week, you completed a root treatment on a patient. This was a lower left first molar. The root treatment went well and you finished by preparing the tooth for a crown and took an impression to send to your laboratory. You finished by placing a temporary crown and made an appointment for the patient to re-attend in 2 weeks. However… The patient ended up in hospital over the weekend. Today her husband has come to see you about why his wife is in hospital; he thinks you had something to do with it. You have the dental notes, and all you know is you completed a root treatment on a lower left first molar. You did use rubber dam. In accordance with the best evidence-based practice, you prepared the tooth for an alloy crown, then placed a temporary acrylic crown and discharged the patient from your care; nothing untoward was noted down or remembered. Your patient went home but developed a persistent cough which became progressively more severe throughout that evening. Later that night, she appeared to be choking, and her husband took her to hospital. You enter the OSCE; you can see an actor playing the part of the angry husband and two examiners sitting righteously on either side of him. It might just be your imagination, but the examiners seem to be presiding in judgement over you in regard to some dreadful error that has befallen this man’s wife. You have 10 minutes to get yourself through this… Dealing with an uncomfortable situation Points to note 1. When faced with this type of OSCE portraying a clinical event, stay calm and don’t get drawn
into an argument. 2. It has been known for candidates waiting at rest stations to overhear an unsuspecting candidate in this type of OSCE being attacked mercilessly by the actor until they are tied up in knots completely. 3. By becoming embroiled in an argument, you might not fail the exam as a whole, but you might unnecessarily lose marks. Why let yourself get into this situation in the first place? Beginning a Difficult Consultation Start by professionally introducing yourself to the husband and acknowledge his anger. Say how sorry you are to learn of the events of the weekend. Have some well-rehearsed phrases to disarm the actor and get your OSCE back on track. Remember you are dealing with the events leading up to and after a medical emergency, but not the actual emergency itself. The following statement is a good way to begin: ‘I am sorry that this has happened. We will do everything to find out what has happened, and as soon as we find out, you will find out too.’ Perhaps this statement is the only way to begin such an OSCE. A statement such as this, although containing an apology, is not an admission of culpability. Continue by asking the husband what has happened. He tells you his wife is in hospital and he has come to see you about this. Upon further questioning, the husband reveals that his wife was coughing when she left the dental surgery, but by late evening, she was choking on something. The actor asks: If you had noticed anything, what would you have done? This is the cue from where you can begin to explain how you might deal with this medical emergency. Procedures to Follow Choking and aspiration are thankfully infrequent but hazardous complications that may arise from dental treatment.1,2 The nature of dentistry puts patients at risk of choking. Prevention is important and you had used a rubber dam throughout the course of treatment. Your notes attest to this. You state to the actor: If his wife was thought to have inhaled or swallowed something you would have encouraged her to cough vigorously to clear the airway or to cough up the object causing the blockage. Point to Note Do not use emotive terms like choke or jargon such as aspirate. Instead, use words that cannot be misinterpreted or misquoted later in the OSCE or in real-life litigation. You can go on to say there are degrees of airway obstruction, from mild to severe, but in the clinic you can state that you noticed nothing untoward. The actor then asks: What would you have done if there was an obstruction and you had noticed something?
Your answer is as follows: A foreign body could be dislodged by asking your wife to cough. If this did not work, then assistance would have been given as follows: 1. Moving the dental chair to the upright position. 2. Sitting your wife forward while supporting her. 3. With a firm slap to the upper back between the shoulders, the object should be dislodged upwards and outwards through the mouth rather than being carried down into the lungs. 4. Giving up to five blows to the back and then checking to see if this will dislodge or expel the object. 5. If this does not work, then getting your wife out of the dental chair for the following steps: 6. Standing behind, grasping both hands around the waist, and pulling upwards into the diaphragm with a fair degree of force should work. 7. Repeating this five times and then reverting to the back slap would be the next step to take. 8. At this point, if the object has not been dislodged an ambulance would be called. You can tell the husband: ‘These are the current Resuscitation Council UK guidelines for dealing with choking that I would have followed.’3 The actor seems to be satisfied that you know what you are doing, and if his wife had a problem in the dental surgery, you would have dealt with it proficiently. Further Questions However, his wife ended up in hospital and he wants to know how might this have happened? The answer to this is as follows: If a patient has an airway obstruction, then attendance at hospital will result if there is breathing difficulty and the airway cannot be cleared. When a patient with foreign body airway obstruction attends a hospital, radiographs are normally taken. We need to know the following: 1. In the hospital what tests were done? 2. If radiographs were taken, what did these show? 3. Was there a foreign body in the chest or lungs? The actor tells you nothing was seen on the X-rays and the lungs were clear. What are you thinking now? You might ask if anything was found on further examination. The actor then tells you that a tube was passed into his wife’s throat (a bronchoscope) and the hospital doctor found a tooth at the top of the lungs. The actor then takes from his pocket a
sterilisation pouch with your acrylic temporary crown and shows it to you. You can explain that this type of crown has no metal in it and therefore would not show up on the Xray. You may add that given the circumstances that have arisen, you will ask one of your colleagues to complete the treatment (fitting of permanent crown) and arrange all necessary follow-up care for his wife when she is discharged from the care of the specialists. State you will make a note of this adverse outcome and that you will contact your indemnity provider and place the full information of this incident with your practice manager and practice principle for their investigation. Ask the actor if there are any further questions and if not then you can end the OSCE by telling the actor that you will fully cooperate with any enquiry or recommendation arising from this incident, and if they have any further questions, you will answer them as openly, honestly, and truthfully as you can in accordance with a duty of candour you owe to the patient.4 Further Notes to this Medical Emergency. This type of OSCE deals with an infrequent but potentially life-threatening medical emergency. In the MFDS syllabus, you will not be asked to perform hands-on OSCE, but in the MJDF syllabus, you must be prepared to demonstrate your technical competence and theoretical knowledge in dealing with any medical emergency. Choking is a notoriously difficult medical emergency to simulate, and in attempting to do so, there is a risk of causing injury to the actor as they will be repeatedly backslapped and manoeuvred by a succession of exam candidates. Even though this medical emergency might not be examined as such in either the MJDF or MFDS, you should be aware of its potential to appear at any time in the clinic and be prepared to answer questions on it in an SCR question. In this OSCE, I have combined both dialogue and practical aspects into one scenario. Overall, when dealing with an anxious patient or their relatives, acknowledge their feelings, apologise, and move the consultation or OSCE in a direction you need to go in order to give the answers to their questions. Foreign body aspiration presents as a life-threatening emergency, more so in adults than children. Every year in the USA, some 500 to 2,000 people die as a result of foreign body aspiration, with a variety of objects being responsible.5 Nearly 27% of these deaths are caused by aspiration of dental prostheses.6 Despite a literature search, no comparable figures are available for the UK. However, the following story from nearly 90 years ago gives us a very human perspective, giving depth to the above figures: In May 1925; Miss Edith May Cooper attended the National Dental Hospital London for sedation extraction of molar teeth. During the procedure, a crown fractured from the roots of one tooth and was inhaled by Edith. Edith came round from the procedure but complained to her sister that she had difficulty breathing. She was never told about the missing tooth and was discharged from the hospital and no follow-up arrangements were made for her.
Edith developed septic pneumonia and died on 27 August 1925 in St James Hospital, London. The coroner recorded a verdict of accidental death. Edith was only 30 years old.7 Adult Choking Treatment The algorithm for this medical emergency is available online from the UK Resuscitation Council: http://www.resus.org.uk/pages/achkalgo.pdf. This is reproduced below:
Paediatric Choking Treatment The algorithm for this medical emergency is available online from the UK Resuscitation Council: http://www.resus.org.uk/pages/pchkalgo.pdf. This is reproduced below:
References to Medical Emergency 7
1. Greenwood M. Medical emergencies in dental practice: 2. Management of specific medical emergencies. Dent Update. 2009 Jun;36(5):262-68. 2. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 1: their prevalence over a 10-year period. Br Dent J. 1999;186:72-9. 3. Handley A, Colquhoun M. Chapter 2: Adult Basic Life Support. In Resuscitation Council (UK) 2010 Resuscitation Guidelines with 2013 update and NICE Accreditation. pp. 15-28. Resuscitation Council UK Medical Emergencies and Resuscitation. Standards for clinical practice and training for dental practitioners and dental care professionals in general dental practice. [Online] Available from: http://www.resus.org.uk/pages/gl2010.pdf [Accessed August 2013]. 4. Griffith R. Legal advice. Nurs Stand. 2013 Aug 21;27(51):72. 5. Weber SM, Chesnutt MS, Barton R, Cohen JI. Extraction of dental crowns from the airway: a multidisciplinary approach. Laryngoscope. 2005;115(4):687-89. 6. Tamura N, Nakajima T, Matsumoto S. Foreign bodies of dental origin in the air and food passages. Int J Oral Max Surg. 1986;15(6):739-51. 7. The Northern Advocate Coroner and Dentist. Saturday 12 December 1925.
Medical Emergency 8 Background Information It will come as no surprise that MJDF and MFDS examiners will expect you to have an up-to-date working knowledge of the medications patients in the OSCEs are taking and for you to know about possible drug interactions from the medications you might prescribe. Although such medical matters are the subject for the next chapter, this OSCE deals with the potential for a medical emergency arising from the medication this patient is taking. Introduction A well-mannered retired university biochemistry lecturer attends for an extraction of a non-vital, periodontally involved upper molar tooth. This tooth is mobile and there is an apical abscess present. The patient in this case takes the following medication for the reasons noted: 1. Aspirin 150 mgs ods after suffering transient ischaemic attacks (TIA), then a mild stroke over 3 years ago. 2. Prednisolone 5 mgs ods for Crohn’s disease which is now under control but has flared up recently. This has been taken for more years than she can remember. In this OSCE, rather than limiting the question to a practical exercise dealing with a medical emergency, the background issues of the condition that potentially might give rise to such an emergency are explored too. Questions on this Medical Emergency. 1. In this OSCE, what are the first things you need to do?
2. From the medication history, can you see any potential problems? 3. If you were to extract the molar, why might you need to take precautions and if any what might these be? 4. What emergency might occur in this case? 5. How will you deal with it? Answers to this Medical Emergency. 1. First, introduce yourself in a professional manner, going on to take a concise and relevant medical and medication history with details of the actions and interactions of the medications noted in the introduction that are being taken by the patient. In brief, the patient is being chronically medicated with two anti-inflammatory drugs; the first is non-steroidal and the second is steroidal. 2. The first thing that becomes obvious is the complication following from drug actions and possible interactions. The patient is taking aspirin; this is a non-steroidal anti-inflammatory drug (NSAID). Taking aspirin is not a contraindication to performing routine dentistry. However, you need to explain to the actor that aspirin will affect post-operative bleeding. Its mode of action is to stop platelets forming clots. In essence, you can advise the actor as follows: ‘Aspirin thins the blood. Blood itself is always in a delicate state of balance, having clots forming and then being broken down again.’ You can continue by stating: ‘The aspirin you take is to prevent unnecessary clots forming inside a blood vessel, which may then lead to another stroke or a CVA (cerebrovascular accident) occurring, which is more serious than the TIA you have already had.’ You can add: ‘However, if we take a tooth out, we do need to have a clot forming in the socket, so we might need to take extra measures to ensure any bleeding after extraction is controlled. We may need to place a suture across the opening of the socket, holding the gums tightly together to help the healing process. With aspirin, the bleeding time after an extraction will be increased.’ The patient in this OSCE is a retired biochemistry lecturer. As expected, she is interested to know more about aspirin. You can tell her the mechanism of aspirin’s mode of action is as follows: Aspirin inhibits the Thrombaxane A2 Receptor on platelet membranes. The ability for platelets to cross-link fibrinogen via activated glycoprotein 11a and 111b receptors is reduced. The bleeding time increases and clots do not form so readily in blood vessels.1 The actor might ask how long this effect can last for. You should be able to state in an OSCE that aspirin does not have a dose-dependent effect and taking even one tablet can acetylate the platelet’s Cyclo-oxygenase (COX) pathway for up to seven days. 2 So the risk of prolonged bleeding can occur even one week after taking only one aspirin tablet.3 In
this case, we have to balance the greater risk of not taking aspirin against the lesser risk of bleeding from the extraction site. This can be controlled with localised measures such as suturing or use of other haemostatic material placed in the socket. Other aspirin side effects are the potential of gastrointestinal tract bleeding and ulceration. These two side effects should be mentioned briefly before you can now move on to the other medication the patient is taking: Prednisolone is a steroidal anti-inflammatory drug used to treat Crohn’s disease. The side effects of long-term steroid administration are well known to patients. You will remember these from your Part 1 exam revision—they include osteoporosis, muscle weakness, cataracts, hypertension, bleeding or perforated peptic ulcers, diabetes, infections, mood changes or psychoses, delayed wound healing, and the last of these—immunosuppression, an intentional side effect used to control the symptoms of Crohn’s disease. Crohn’s disease is a chronic inflammatory disorder of the bowel. Hereditary factors, diet, smoking, and the use of NSAIDs (e.g. the use of aspirin in this case) have all been proposed as co-factors in the exacerbation of this disease. Bacterial species can colonise damaged gastrointestinal tract mucosa, leading to the clinical presentations seen in Crohn’s disease. 4 The clinical signs are stomach cramps, abnormal bowel habits, and malabsorption. Any part of the bowel can be affected and presentation of oral ulcers is common. There is a potential risk of drug interaction between aspirin and Prednisolone. This might result in GI tract irritation, but this is not an emergency. Such a complication would not prevent you from performing an extraction. In a recent study, the prevalence of adverse GI tract events with coadministration of aspirin and Prednisolone was found to be very low. There was only one serious complication: a Mallory-Weiss tear was seen in 1 out of 142 patients being medicated with both aspirin and Prednisolone.5 This finding should be noted in the context that this study was investigating patients with cancer, and there may have been other factors predisposing this patient to this very rare complication. Notwithstanding this, you should mention the need to communicate your concerns with the patient’s general medical practitioner (GMP). Such a measure would be prudent in this case. 3. If you wish to proceed with extraction, you must accept that almost all dental procedures are stressful for patients. Stress causes increased adrenocorticotrophic hormone (ACTH) and cortisol levels. However, patients who have been on long-term steroid medication may be unable to initiate an adequate response to stress due to steroid suppression of the hypothalamo-pituitary axis (HPA) and atrophy of the adrenal gland cortex, resulting in lowered glucocorticoid secretion.6 Thus, a dental procedure may initiate an adrenal crisis; however, this is thought to occur only when the steroid dose is greater than 10 mgs per day. 7 This group of patients may develop symptoms of fatigue, weakness, arthralgia, nausea, and orthostatic dizziness if they abruptly stop steroids.8 Two cases of adrenal crises have been reported in the literature with steroid doses lower than this level in patients undergoing general anaesthetic dental extractions.9, 10 However, in these two cases
there may have been reasons other than adrenal crises for the clinical signs seen. It is now accepted that adrenal suppression correlates well with dose and duration of steroids being taken.6 With regard to patients undergoing surgery, the picture is made even less clear as two studies separated by over twenty years revealed. In the first study, patients were instructed to cease steroid intake prior to surgery, the majority of patients demonstrating adequate adrenocortical responses despite this measure.11 In the second study, patients taking greater than 10 mgs corticosteroids underwent major surgery with no signs of adrenal crisis in the absence of supplementary measures.12 Today although there are some conflicting opinions, minor dental local anaesthetic procedures for patients receiving long-term steroid medication at doses less than 7.5 mgs Prednisolone do not warrant supplementation with additional glucocorticoids as these patients are at very low risk, if any, for developing adrenal crisis.13 In the OSCE, ask the actor if they have a steroid warning card. In response, the actor may helpfully produce an up-to-date blue card, which details that minor procedures in the dental surgery can be conducted and do not require any supplementation of the verified steroid dose they are taking. Given the condition of the tooth in this case, which is both non-vital and mobile, you should now discuss the treatment options with the patient: Any procedure should only be conducted after considering the risks and benefits to the patient and ensuring you are prepared to deal with the consequences in the surgery and afterwards too. In this case, your option would be to extract the mobile tooth, suture the socket, lay the patient flat, and allow sufficient time for recovery, monitoring the patient until they are able to sit up and be discharged. Up to 24 hours after the procedure, you should be in contact with the patient to ensure everything is all right and there are no post-operative complications. Contacting the patient later in the day is more than just a courtesy. In real life, you ought to do this if not for all your patients, then at least for the ones who present with the medical conditions portrayed in this OSCE. 4. The emergency in this case would be an adrenal insufficiency or crisis and the clinical signs are as follows: 1. Shock leading to a fall in blood pressure. 2. Pulse becoming increasingly rapid, then weak. 3. Pallor, sweating, and hypotension with hypoglycaemia weakness and confusion. 4. Loss of consciousness. 5. In an adrenal crisis the patient is laid flat, the legs are raised, and the airway is maintained. You will follow the ABC protocol (airway breathing circulation). High flow oxygen (15 litres per minute) is given and an ambulance called. The patient is monitored while being given oxygen and you will verify help is coming to transport the
patient to hospital for emergency medical care. Your ability to identify this emergency will come from taking a thorough medical history and understanding the feedback mechanism of reaction of the adrenal gland cortex in response to steroid medication.6 In the MJDF OSCE, you will be expected to identify and practically deal with a simulation of this medical emergency. As important as dealing with this medical emergency is the ability to prevent it from happening, and as noted, this only comes from an understanding of the mechanism of actions that corticosteroids have on the adrenal glands. Three Questions It is essential to review medical and medication histories when you are with a patient to ensure they are being treated to the best of your abilities. As your experience of clinical work and examination techniques grows, medical emergency cases can be revised by answering three questions: 1. Which potential complications might arise? 2. What can be done to prevent them? 3. How can you deal with them in an emergency? The numbers of retired doctors, dentists, and biochemistry lecturers is increasing and you will meet them in both OSCE and in real life too. If you can demonstrate to them that you know what you are doing and why you are doing it, then you should be able to prevent this type of medical emergency from occurring in the dental clinic. Further Notes to this Medical Emergency. 1. Concise answers to pertinent questions are essential in an OSCE. Your answers should be delivered convincingly and not defensively. So know your stuff. 2. In this OSCE, the actor plays the part of a retired biochemistry lecturer, and in your revision, you can have some fun demonstrating your superior knowledge of biochemistry with your study partners and tutors. 3. However, in the exam and the clinic, nothing is more impressive to an examiner or a patient than precise and concise answers elegantly delivered with no jargon. 4. This is important in the MFDS OSCEs. After all, the actors don’t know one end of the COX pathway from the other, but the examiners certainly do and you don’t want to lead them a merry dance up any pathway. 5. Answers that are common sense and factual in the clinic are also likely to be acceptable and justifiable in an exam. References to Medical Emergency 8 1. Vane JR, Botting RM. The mechanism of action of aspirin. Thromb Res. 2003 Jun 15;110(56):255-58.
2. Greenstein A, Greenstein B. Section 42: Non-Steroidal Anti Inflammatory Drugs (NSAIDs) Mechanisms. In Concise Clinical Pharmacology. pp. 84-85. London: Pharmaceutical Press 2007. 3. Rainsford KD. Chapter 7: Pharmacology and Biochemistry of Salicylates and Related Drugs. In Rainsford KD. Aspirin and Related Drugs. pp. 265-452. London: Taylor and Francis 2004. 4. Marrollo M, Armuzzi A, Zannoni F. Chapter 1: Etiology. In Tersigni R, Prantera C. Crohn’s Disease: A Multidisciplinary Approach. pp. 1-29. London: Springer-Verlag 2010. 5. Koomanan N, Ko Y, Yong WP, et al. Clinical impact of drug-drug interaction between aspirin and prednisolone at a cancer center. Clin Ther. 2012 Dec;34(12):2259-67. 6. Edwards CR, Baird JD, Frier BM, Shepherd J, Toft AD. Endocrine and Metabolic Diseases, Including Diabetes Mellitus. In Edwards CR, Bouchier IA, Haslett C, Chilvers ER. Davidson’s Principles and Practice of Medicine. 17th Edition pp. 706-719. Edinburgh: Churchill Livingstone 1995. 7. Bell NH. The glucocorticoid withdrawal syndrome. Adv Expl Med Biol. 1984;171:293-99. 8. Byyny RL. Preventing adrenal insufficiency during surgery. Postgrad Med. 1980;67:219-28. 9. Cawson RA, James J. Adrenal crisis in a dental patient having systemic corticosteroids. Br J Oral Surg. 1973;10:305-09. 10. Broutsas MG, Seldin R. Adrenal crisis after tooth extractions in an adrenalectomized patient: report of case. J Oral Surg 1972;30:301-02. 11. Kehlet H, Binder C. Adrenocortiocal function and clinical course during and after surgery in unsupplemented glucocorticoid-treated patients. Br J Anaesth. 1973;45:1043-48. 12. Bromberg JS, Baliga P, Cofer JB, Rajagopalan PR, Friedman RJ. Stress steroids are not required for patients receiving a renal allograft and undergoing operation. J Am Coll Surg. 1995;180:53236. 13. Gibson N, Ferguson JW. Steroid cover for dental patients on long-term steroid medication: proposed clinical guidelines based upon a critical review of the literature. Br Dent J. 2004 Dec 11;197(11):681-85. Further Reading 1. Resuscitation Council UK 2006 Medical Emergencies and Resuscitation. Standards for clinical practice and training for dental practitioners and dental care professionals in general dental practice. 11 Appendices Section ii Adrenal Insufficiency, pp. 34-35. December 2012 Revision. 2. Scully C. Chapter 1: Medical Emergencies, Managing Emergencies. In Scully C. Medical Problems in Dentistry. 6th Edition pp. 16-17. Edinburgh: Churchill Livingstone 2010.
Medical Emergency 9 Background Information An important skill to develop when you sit any OSCE is the ability to go from one question to the next
and not dwell on your performance in the previous question. Focusing on the job to be done and the patient in hand is also an important clinical skill. When you are about to treat the next patient you should be thinking about the data generated in the history you are taking and not what you did to the last patient. While sitting at a rest station, looking over the introduction to the next question, it might seem like you have two questions which are the same and you are just about to enter an OSCE you have (seemingly) already completed. In OSCE 4, we dealt with the medical emergency of myocardial infarct and cardiac arrest. This was an MJDF practical OSCE and not an MFDS conversational OSCE. In this OSCE, we will revisit this medical emergency. My reasons for going over cardiac arrest again are that basic life support skills can deteriorate in as little as a few weeks to months after completing a revision course1 (see references 7-9 in the introduction to this chapter). Basic life support skills and paediatric life support skills show degradation in under six months.2 The more often you go over this material in different ways, the more skilled you will become in dealing with this type of OSCE, but more importantly, you will also have acquired and retained the skills necessary to deal effectively with this type of medical emergency in real life. Paediatric Basic Life Support Medical emergencies can happen at any time in a dental practice and the practice of paediatric dentistry has been stated to be no different.3 From 1996 to 1999, in the UK there were 8 deaths in dental practice of which five were children; all had received general anaesthetic (GA).4 It is shocking to reflect that these deaths followed the 50 recommendations from the 1990 Poswillo Report to reduce morbidity and mortality associated with general anaesthesia in dentistry. In 2000, following the death of Darren Denholm, aged 10, in an Edinburgh dental practice, the report ‘A Conscious Decision: A Review of the Use of General Anaesthesia and Conscious Sedation in Primary Dental Care’ was published. Despite GA no longer being an option for dental practices, patients still request referral for this procedure or for sedation. For this reason, the findings of the 2000 report must not be confined to history. If we consider some of the findings in detail, investigations and inquiries into the deaths were critical of the standard of care provided in fundamental areas such as pre-operative assessment, blood pressure, oxygen, the start of resuscitation, and transfer to specialist critical care.4 Today these fundamental areas are critical measures we must take to ensure the safety of all of our patients, not just those we refer for GA. With the publication of the 2013 GDC Standards for the dental team (specifically Principle 7: ‘Maintain, develop and work within your professional skills’, Standards 7.1 to 7.3)5 and the mandatory continuing professional development to demonstrate 10 hours of training in medical emergencies in every 5-year cycle,6 paediatric emergencies are now thankfully rare in dental practice.2 Notwithstanding this, there is a duty of care for all dental professionals to be able to competently deal with medical emergencies in both adults and children.7 This OSCE is a purely practical exercise, which will be within the MJDF syllabus. So if you are studying for the MFDS, never treat children or live in some strange world where children don’t exist;
you can skip this OSCE. Otherwise and for all of us, we need to practise the procedures in this OSCE and do so frequently. Introduction You enter the examination room and there are two examiners and a paediatric resuscitation manikin on a table in front of you. A child patient has collapsed and has stopped breathing in the middle of a treatment session. The child’s medical history notes and dental records are on a table to one side of this room. These notes appear to be incomplete with no details of what treatment has been provided. Question You have 10 minutes to deal with this emergency. In every paediatric medical emergency, an immediate effective response is critical. The Procedures in This OSCE 1 . Check for danger. Do not proceed if there are any hazards. The examiners will remove any hazards you identify. 2. Check for responsiveness. Do this by shaking and shouting at the paediatric manikin and shout for help. If no response then 3. Open the airway. In this instance, turn the manikin over in the accepted manner, then: tilt head, lift chin, and thrust jaw. 4. Check for normal breathing for 10 seconds minimum. If there is no normal breathing then 5. Give 5 rescue breaths. Check for signs of life: Response to stimulus, normal breathing, or spontaneous movement. Check for gagging coughing or choking. Check for a carotid brachial or groin pulse. If there is none, then proceed to: 6. Give 15 chest compressions. These are given at 100 per minute to a depth of 4-5 cms. 7. Give 2 rescue breaths. 8. Give 15 chest compressions. Continue this cycle for 1 minute then after one minute: 9. Telephone for help. The examiner will provide a telephone. Dial 999. Listen to the call being connected. In some exams, you will have to speak to someone on the telephone, and this results in a very realistic OSCE. Ask for Ambulance Service. State your name, your address including postcode (state the OSCE number you are at), your telephone (don’t mess about trying to remember any number; give them your mobile number). Clearly state the following:
I have an unresponsive child in cardiac arrest. I am on my own giving CPR. Send an ambulance now. Please read back this data to me. The cycle of 2 breaths and 15 chest compressions will go on until the examiner tells you to stop or the time for the OSCE ends. Further Point If the examiner tells you that the child is now breathing normally, then place the manikin in the recovery position. Monitor, administer oxygen, call for help, and verify it is coming. Continue to monitor for any signs of abnormal breathing and resume compressions and breaths if necessary. Continue to assess for signs of abnormal breathing and signs of airway obstruction. Clear these as necessary. In this phase of the exercise (2 breaths and 15 chest compressions), your technique will be assessed, giving a good opportunity for the examiners to consider how effective you will be in real life. In this OSCE, the whole exercise should only take 5 minutes; there is only one attempt allowed, and failures in this exercise are rare but do occur. As stated previously, in some exams a failure in this OSCE or any medical emergency OSCE will mean you will have to do exceptionally well in the other questions to achieve an overall pass in the exam. Public Expectations There is a public expectation that automatic external defibrillators (AED) should be present in every health care environment. The dental surgery is a health care environment.3 The GDC at 37 Wimpole Street, London, has an AED on the wall to the left of the entrance. Even though the GDC itself is neither a health care environment nor public, they are clearly telling you: If you don’t have an AED in your surgery or you don’t know how to use one and something goes wrong and you need one, then we would like you to spend some time with us. You might then find yourself at the GDC with a pair of barristers attached to you, but only more intimately than you would have stuck a pair of defibrillator pads to your patient. All dentists should consider the use of an AED to be an essential component of both adult and paediatric basic life support. AEDs can be used safely without any training. These machines use voice prompts to instruct on the sequence of events to follow. In children, the need to use an AED is a rare event indeed. If in an OSCE or real life you are faced with a situation where you have to use an AED on a child, ensure the correct attenuated settings are used.4 8. To date, I am not aware that there has been an OSCE where an AED formed a part of the questions on medical emergencies. However, given their effectiveness of increasing patient survival with CPR, it
would be short-sighted if any exam candidate were not to anticipate their use in an OSCE or real life and to not prepare for their use in either of these settings. Paediatric Basic Life Support The algorithm for this medical emergency is available online from the UK Resuscitation Council: http://www.resus.org.uk/pages/pblsalgo.pdf. This is reproduced below:
References Medical Emergency 9 1. Saor J, Monsieurs KG, Balance JHW, et al. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 9. Principles of education in resuscitation. Resuscitation. 2010;81:1434-44. 2. Rice S, Moore R, Summ L, Crean S. Paediatric Emergencies and the Dental Team. In Training Supplement from FDS Education Paediatric Basic Life Support: An Updated Guide for the Dental Team. p. 6. London: Royal College of Surgeons Faculty of Dental Surgery 2010. 3. Hosey MT, Welbury RR. Chapter 16: Medical Disability. In Paediatric Dentistry. 4th Edition pp. 350-352. Oxford: Oxford University Press 2012. 4. Report by a Group Chaired by the Chief Medical and Chief Dental Officer. A Conscious Decision. A Review of the Use of General Anaesthesia and Conscious Sedation in Primary Dental Care. UK Department of Health 2000. [Online] Available from: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prodconsum dh/groups/dh digitalassets/@dh/@en/documents/digitalasset/dh 4019200.pdf [Accessed August 2013]. 5. General Dental Council. Principle 7: Maintain, Develop and Work within Your Professional Knowledge and Skills. In Standards for the Dental Team. pp. 63-67. London: General Dental
Council 2013. 6.
General Dental Council CPD. [Online] Available from: http://www.gdcuk.org/Dentalprofessionals/CPD/Pages/CPD-for-dentists.aspx [Accessed August 2013].
7. Resuscitation Council UK Medical Emergencies and Resuscitation. Standards for clinical practice and training for dental practitioners and dental care professionals in general dental practice. December 2012 Revision. London: Resuscitation Council (UK). 8. Tang W, Weil MH, Jorgenson D . Fixed-energy biphasic waveform defibrillation in a paediatric model of cardiac arrest and resuscitation. Crit Care Med. 2002 Dec;30(12):2736-41.
Medical Emergency 10 Background Information We are almost at the end of this section on the common medical emergencies that you are expected to be able to deal with as a foundation level dentist. In this OSCE, we will now note some of the differences between two types of cardiac emergency: the cardiac arrest already covered in OSCEs nos 4 and 9 and angina pectoris which we will now deal with. Both emergencies frequently occur in the UK. Heart disease is very common with (as stated previously) an estimated 60,000 CPR episodes occurring annually in the UK outside of a health care or hospital environment.1,2 Angina pectoris affects 1% of adults with a rising prevalence as the population ages.3 The British Heart Foundation Compendium of Health Statistics gives a detailed analysis of the figures for heart disease in the UK. In the latest edition, (data from 2010) of note: 1.9% of men and 1.0% of women (all age groups) in the UK suffered from angina and just over 285,000 new cases were recorded, the incidence of angina being 37.9/100,000 men and 21.0/100,000 women.4 The signs and symptoms of angina are variable, the severity of the condition being dependent on the extent of coronary artery narrowing. Despite such variability, classically angina has unmistakable symptoms.3 Patients frequently describe the pain of angina like they are being choked or strangled. The pain can spread to the left arm or the left jaw, but on stopping exercise or resting, this pain will go away. Angina has a mortality rate range of 2.8% to 6.6%.5 (In an MJDF OSCE or SCR, I think it would be permissible to give a figure of approximately 5%, as this is within the range of annual angina mortalities.) The clinical symptoms and signs of angina can be initiated by physical exertion, notably cold weather or emotional upset. A patient’s fear or anxiety of the dental practice environment commonly provides the stimulus necessary to initiate an episode of angina pectoris. This OSCE is presented as both a practical and a theoretical exercise. Introduction
The patient is a 55-year-old bus driver who smokes and drinks. These habits—his being overweight, a carbohydrate-rich diet, and a lack of exercise—are clearly contributory to the problem that will unfold in front of you. The patient takes statins to lower his cholesterol and one 75 mg aspirin daily; he has a history of chest pain but only on exertion. The bell rings and you enter the examination room; there is an overweight middle-aged gentleman who has come in to see you about his loose and discoloured teeth. He has already received a treatment plan and would now like to discuss the options with you. In this OSCE, there are some clinical photographs and radiographs. These show, respectively, extensive gingival recession and bone loss. There is also a detailed report from a periodontal specialist, which is summarised as stating many teeth are now un-saveable and an extraction and immediate partial denture plan would be the best option to follow. Understandably, the patient is upset with this recommendation following a private consultation for which he has paid a considerable sum. The patient is both frustrated and upset, insisting he wants to have ‘veneers fitted’ and does not think he should lose any teeth. He tells you that he vehemently disagrees with the opinions of the specialist and would like you to go through the findings with him in this consultation. The Devil is in the Detail 1. In this type of OSCE, there could be a significant amount of clinical data presented as photographs, radiographs, and 6-point periodontal pocket charting and so on. 2. Among this wealth of data somewhere, almost hidden, you will find an updated medical history. In this form, the medication history reveals the patient to have been prescribed sublingual Glyceryl Trinitrate (GTN). 3. This detail is crucial to how you will complete the OSCE. 4. The paradox with such detailed notes is the most important information is buried among less safety critical data. 5. In the MJDF exams, the medical emergency OSCEs might appear anywhere among other less safety critical OSCEs. The knowledge that the patient takes GTN will help to eliminate other causes of the symptoms the actor will describe to you and help you to focus on the emergency. Question In the middle of the discussion on dental treatment (during which you should display empathy towards the patient), the actor suddenly stops talking; he will just about cry out that he has a severe stabbing pain in his chest. The patient will be in considerable distress, indicating to you the pain he has is now spreading into his jaw and along his left arm too. The patient looks frightened. To one side of the room on a table, there is a dental practice emergency drugs box. The First Procedures to Follow 1. You must remain calm and reassure the patient. 2. Stop any further discussions on dental treatment and now focus on the medical emergency.
3. Ask the actor/patient if this has happened before. Gasping and struggling to breathe, the actor replies: ‘Only once, when I was out walking.’ 4. Your ability to calmly reassure the actor/patient that you will effectively deal with the problem is essential if you are to effectively manage his condition. Ask if he has taken any medication for this pain. The patient tells you he does have medicine, but he didn’t bring it with him today. 5. pecifically, you wish to find out if the patient has previously used GTN (noted in the dental records). In this OSCE, the patient/actor may have a GTN spray or you may need to identify this in an emergency drugs box. In this OSCE, you will need to administer this medication to the actor. 6. There are two forms of GTN you might use; if the patient/actor didn’t forget to bring his medication (tablet form 0.5 mgs GTN), then administer this, instructing the actor to place one tablet under the tongue. Or if the actor has a spray form of GTN or you access the emergency drugs box, then administer one to two doses (each application: 400 ugms), aiming the spray under the tongue, then getting the actor to close his mouth and breathe in through the nose. 7. It is essential that you continue to monitor the patient in this OSCE. If the symptoms do not improve or despite GTN administration they worsen, you must be prepared to go to the following steps. 8. Immediately call for help. 9. Provide oxygen by mask at 15 litres per minute. (This will be provided for you to use.) 10. Repeat the GTN. 11. Give one aspirin 300 mgs tablet; instruct the actor to chew this tablet. 12. Call 999 for an ambulance. In the OSCE, clearly tell the examiners you are doing these things. From Angina to Cardiac Arrest The examiners may provide you with a telephone. The protocol is as follows: 1. Dial 999. Listen to the call being connected. In some exams, you will have to speak to someone on the telephone, and this results in a very realistic OSCE. Ask for Ambulance Service. 2. State your name, your address, including postcode (state the OSCE number you are at), and your telephone (don’t mess about trying to remember any number; give them your mobile number). 3. Clearly state the following: I have a patient with cardiac chest pain. I am on my own. I have already given GTN, aspirin, and oxygen. There is no improvement in his condition. Send an ambulance now.
Please read back all of this data to me. 4. Continue to monitor the patient’s level of consciousness and their pulse. Be prepared to go to the next level of basic life support, which is the CPR exercise in OSCE 4, or to use an AED. As this OSCE develops, be prepared for the recovery of the patient too. The patient does not improve and is becoming unresponsive; he is now losing consciousness. If the OSCE develops this far, you will be given a resuscitation manikin to work on. 5. Open the airway by tilting the head back and thrusting the jaw forward. 6. Assess for breathing for a minimum of 10 seconds and count this aloud. 7. You are advised the patient is not breathing. Check: airway breathing and circulation again. Make sure help is coming. 8. Commence CPR at 30 chest compressions and 2 breaths in addition to the oxygen already being given. 9. Again, shout for help. In response, you are given an AED. 10. Attach the AED pads to the resuscitation manikin. An assessment of whether shock is advised will be made. 11. If no shock is advised, then resume CPR 30 chest compressions and 2 breaths for 2 minutes. 12. If shock is advised, then keep clear until the shock is delivered, then resume CPR 30 chest compressions and 2 breaths for 2 minutes. This process should be continued with re-shock and CPR until help comes and handover to the emergency team can be completed. You will provide full data to them on the steps you have taken and medication you have given so far. The OSCE has now run its course and is complete. Further Notes You will have noted from the history presented in the introduction that the patient has only ever experienced one episode of chest pain before, when walking. This is stable angina; that is, the coronary arteries cannot supply sufficient blood to the heart under physical exertion, but under normal sedentary circumstances; there is adequate blood flow to the heart muscles. In this scenario, the patient/actor is now portraying potentially unstable angina; although there is the stressful environment of the dental consultation, there is no physical exertion. In this scenario, you must recognise from the medical history the potential for unstable angina to present itself and to deal with it by going through the above protocol. In real life by being empathic and supportive, you will gain the trust and respect of the patient and reduce the stress they are under. By displaying empathy in the OSCE, you will reduce if not eliminate any stressors portrayed and gain the support of the actor. If in the earlier stages of this OSCE, any one
of the measures proves successful before a medical emergency develops and the actor/patient recovers; you must state you will document this episode in the patient’s dental notes and liaise with the patient’s GMP before discharging the patient from your care. Chest pains in dental patients Most patients who suffer cardiac chest pain in the dental surgery will have a previous history of heart disease.3 From the medical history, you must determine what, if any, medication is being taken. In most cases, the patients will both know and state they have angina. In this OSCE, the patient/actor was in distress and unable to confirm the condition he (possibly) knew he had. If a patient uses medication to control angina, then they will have brought it with them, or in this OSCE, it can be found in the emergency drugs box. As noted, classically the pain of angina pectoris is described as a band of crushing pain across the chest often radiating to the mandible and to the left arm, but you must be aware there are variations.3,4 The pain of a myocardial infarct, although similar to angina, is more severe, and most importantly for this OSCE, it is not relieved by GTN. If this is the case, then you must go straight to the basic life support protocol. A myocardial infarct (MI) will present with symptoms of severe crushing chest pain; the clinical signs are pale, clammy skin and shortness of breath with no relief from GTN use. These symptoms and signs are all that need to be acknowledged in an OSCE to determine the actor is portraying an MI and not portraying angina. In real life, there may be other signs and symptoms in addition to the above; nausea and vomiting may also be seen. In the medical emergency OSCEs, a medical emergency will be just that. However, in real life, chest pains may not be of cardiac origin. Non-cardiac chest pains are chest pains lasting for less than 30 seconds and are variable in their location. A pain originating from the lungs can be sharp, well localised, and worse on breathing in. Interestingly, those pains that ease when physical exercise eases or stops altogether can also be the classic exercise transabdominal pain (ETAP or stitch) and are often seen in late patients running to their appointments. But (and this is a big but) such pains may also have a cardiac origin, and care must be taken not to discount such pains as just being a sign the patient is unfit and out of shape. If the pain is from a skeletal muscle (as opposed to a cardiac muscle), then palpation of the affected muscle will reveal it to be tender.6 In many patients such as the actor in this OSCE, a poor diet can lead to gastric problems, reflux, and oesophagitis which commonly presents as a chest pain too. One confounding picture can emerge in such patients by application of GTN. The pain will ease as GTN also acts on the smooth muscle of the oesophagus, reducing any painful contractions.6 Nevertheless, it is vitally important to eliminate MI and angina in any patient (or actor) complaining of chest pain. If this cannot be done with any confidence in real life or in an OSCE, then treat all chest pain as that of cardiac origin until you or an appropriately qualified person can absolutely prove otherwise. Adult Automatic External Defibrillation
The algorithm for this medical emergency is available online from the UK Resuscitation Council: http://www.resus.org.uk/pages/aedalgo.pdf. This is reproduced below:
References to Medical Emergency 10 1. Ambulance Service Association. National Cardiac Arrest Audit Report; 2006. 2. Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation. 2010 Nov;81(11):1479-87. [Online] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20828914 [Accessed August 2013]. 3. Scully C. Chapter 5: Cardiovascular Medicine, Acquired Heart Disease. In Scully C. Medical Problems in Dentistry. 6th Edition pp. 107-108. Edinburgh: Churchill Livingstone 2010. 4. British Heart Foundation Health Promotion Research Group Coronary Heart Disease Statistics. A Compendium of Health Statistics. London British Heart Foundation 2012. [Online] Available from: http://www.bhf.org.uk/publications/view-publication.aspx?ps=1002097 [Accessed August 2013]. 5. Jones M, Rait G, Falconer J, Feder G. Systematic review: prognosis of angina in primary care. Fam Pract. 2006 Oct;23(5):520-28. 6. Greenwood M. Medical emergencies in dental practice: 2. Management of specific medical emergencies. Dent Update. 2009 Jun;36(5):262-68. Further Reading on Medical Emergencies 1. US Department of Health and Human Service. Chapter 1: Overview Diagnosis of Unstable Angina.
In Clinical Practice Guideline 10: Unstable Angina: Diagnosis and Management, pp. 14-20, 1994. 2. Plowman SA, Smith DL. Chapter 15: Cardiovascular Disease Risk Factors and Physical Activity. In Exercise Physiology for Health Fitness and Performance. 4th Edition pp. 454-470. Philadelphia: Lippincott Williams and Wilkins 2013. 3. Scully C. Chapter 1: Medical Emergencies. In Scully C. Medical Problems in Dentistry. 6th Edition pp. 3-18. Edinburgh: Churchill Livingstone. 2010. 4. Greenwood M. Medical emergencies in dental practice: 1. The drug box equipment and general approach. Dent Update. 2009 May; 36 (4): 202-211. 5. Greenwood M. Medical emergencies in dental practice: 2. Management of specific medical emergencies. Dent Update. 2009 Jun;36(5):262-68. These articles are well written, to the point containing what you need to know for your GDC CPD in medical emergencies.
3 Medical Matters Introduction Today, increasing numbers of patients are taking increasing numbers of medications. The patient’s doctor or dentist will prescribe many medications, while other drugs are obtained as over-the-counter medicines (OCMs). In addition to these sources of drugs, many patients continue to smoke, to drink, and to use drugs recreationally. If we look at this pattern and then consider how it applies to dental patients, it makes for an interesting set of factors that MFDS and MJDF candidates have to contend with in the course of revision and in examination. As ever, what is more important than tackling these problems portrayed by actors in an examination is your ability to apply a good working knowledge of these factors to the patients you will see in the dental clinic. The OSCEs can be as realistic or as artificial as you want to make them. My experience is that thorough revision of the subjects covered in the OSCEs will enable you to build a broad foundation of knowledge you can use while working in the dental clinic. In time, you will find that many clinical patterns portrayed by the actors in the OSCEs really do appear in patients. After a few years of working in dental practice, you will discover clinical signs and symptoms in your patients will remind you of the OSCEs for which you are now studying and on which you will soon be examined. By reading not only around the subject matter, but into the subject matter too, you will gain a greater insight into the mechanism of actions of drugs, how they interact with other drugs, and ultimately how they affect the patient. In Chapter 2, we looked at ten of the common medical emergencies that you would be expected to deal with in the dental clinic and in the MJDF exam. In that chapter, learning the current practices and demonstrating the correct procedure to use in each scenario is the key to passing all of the questions on the medical emergencies. In this chapter, the ability to identify the drugs patients are taking, those medications a patient or an actor might ask you to prescribe and the interaction with those medications you might appropriately prescribe is the key to passing these questions. There are also OSCEs and clinical cases where no medication is being taken. In these questions, it is important to identify common and not so common conditions that need referral for management and treatment by a specialist. In this chapter, there are 15 questions. Some of these questions have been developed from OSCEs frequently appearing in the MFDS and MJDF exams while others are based on real patients. You will see that in many cases the level of detail given is greater than that required to answer a 10-minute OSCE. There are two principal reasons for giving you this level of detail. First, in the MJDF exam in addition to the OSCEs, you will have structured clinical reasoning (SCR) questions, and the depth and detail given here is sufficient to answer not only the OSCEs but also the questions the examiners will ask you in the longer and more meticulous SCR questions.
Second, one criticism of existing test-books for dental OSCEs is they contain questions and answers with lists of facts but no development of the subject itself. The patient as a person and their personal, social, and medical circumstances have not been expanded upon in any detail, and as such, there might be a lack of realism in the way the patient is presented. It has been mentioned to me that such books are very good at preparing a candidate to answer an exam question but perhaps not so good at preparing a candidate to answer a patient’s questions in the clinic. In this chapter and others, I have tried to develop both questions and answers, giving the patient some depth as a person. In doing so, I hope the cases are interesting enough to grab your attention, motivating you to read around and into the subject, not only in anticipation of your impressing the examiners in the SCRs with your knowledge but raising your clinical standards too. As with the previous chapters, the list for references will be at the end of each case. Again, it is hoped you might find some time in your studies to look up and read these. Rather than challenging you with a long list of references, I have chosen the most up-to-date and pertinent references from which these cases can be developed further as you prepare for the SCRs.
Medical Matter 11 Background Information In writing about medical matters, I was thinking, what is the best way to begin this chapter? With every new patient you treat, there will always be the initial effort of trying to recognise the complexities of drug action and interaction, resolving to learn the processes involved, trying to fit them into a larger picture, making your understanding of the clinical case work for you and finally work for the patient. Sometimes your attempts will reward you with success. Then you can distil the facts necessary to convince your colleagues and patients in terms they understand so they know that you know what you are talking about! At other times, your efforts lead nowhere other than back to where you began, very much like Ulysses.1 At times like these, the end point of trying to find an explanation is impossible and the more you try to find answers to questions the more confusing the clinical picture becomes. Answers to your questions become indefinable and evasive. When this happens, stand back, take stock, and take the following view: ‘Chaos in the middle of chaos isn’t funny but chaos in the middle of order is.’2 Pause and introduce order in your search, eliminate the chaos and confusion, then carry on. The last patient from a Saturday morning emergency clinic is as good a case as any, to be the first in this chapter on the medical matters facing you and your patients. Introduction A 60-year-old retired farmer and his wife have both come to register for dental treatment, having just
moved into the area. You have finished examining the wife. You ask the husband to come into the clinic. The husband slowly makes his way to the dental chair; he looks exhausted. He tells you he has a pain in the upper right lateral incisor. Other than having an allergy to penicillin, the patient had been fit and well up to last year. An acute episode of shortness of breath resulted in hospital admission where he was treated with high dose IV steroids to reduce what was thought to be an acute severe asthma attack. After 48 hours and no reduction in symptoms, a 12-lead ECG was undertaken, revealing no abnormalities in his cardiac electrical activity. Finally, after a few more days, echocardiography was completed and a grossly enlarged left ventricle and features consistent with chronic cardiomyopathy were discovered. He is now taking the following medication while awaiting a suitable donor for heart transplant: 1. Aminophylline 225 mgs. 2. Salmetrol
50 mgs.
3. Ramipril
2.5 mgs.
4. Frusemide
40 mgs.
5. Digoxin
1.25 mgs.
6. Ivabradine
5 mgs.
Medication Lists in the Exams a. When faced with a complex medical history and a long list of medications, but only a short time to take these into consideration, it helps to know why patients are taking the drugs they take. b. Between now and sitting your MFDS and MJDF, try to note down the lists of medications your patients take. c. Read up and revise these drugs from the British National Formulary (BNF), either hard copy or online. d. The BNF is available online from the WHO HINARI organisation e. This is accessible by registering with
[email protected] First Thing to Do In an OSCE, before a clinical examination, the first thing to do would be to take a brief medical history, medication history and a dental history. For both the patient and you, time is important, so make the history taking a brief exercise. You discover the pain in the upper right incisor has been keeping the patient awake at night, and he complains of feeling a swelling in the area under the right eye. He does not have an elevated temperature and there are no swollen lymph nodes. The second thing to do is to work out the actions of the drugs being taken and ask if there are any other drugs the patient is taking that have not been noted. Medication and Side Effects Aminophylline 225 mgs. This is a bronchodilator containing xanthine and is given to patients who
have severe asthma. There may be increased heart rate and increase in plasma concentrations of erythromycin.3 Salmetrol 50 mgs. This is a long-acting beta 2 adrenoreceptor agonist. It acts in the same way as salbutamol (you will find this in the emergency drugs box), but it has a slower onset of action and is longer in duration than salbutamol. A patient taking this may have nausea and dizziness.4 Ramipril 2.5 mgs. This is an ACE inhibitor. These diminish the conversion of angiotensin l to angiotensin ll. This is used in heart failure and is generally well tolerated. However, there may be arrhythmias, angina, and chest pain associated with this drug.5 Frusemide 40 mgs. This is a loop diuretic to reduce pulmonary oedema from left ventricular failure. This drug acts very quickly, taking effect in one hour and complete effect within six hours. However, there are complications with chronic use, and these are prostate enlargement, liver and kidney damage, all of which can counter the intended drug effect.6 Digoxin 1.25 mgs. This is a well-known cardiac glycoside. The effects of this drug are an increase in the force of ventricular contraction but a reduction in the electrical activity from the AV node. You should note that this dental patient who is taking digoxin does have heart failure. In those chronically medicated with digoxin, there are several complications; fatigue, weakness, and further arrhythmias are all possible.7 Ivabradine 5 mgs. This drug is used as an anti-anginal. In this patient who has left ventricular failure, Ivabradine is given to lower the heart rate when beta blockers are not well tolerated.8 Question in this case: How will you treat this patient and what treatment options might you consider? ASA Grading of the Patient Now you have the basic knowledge of the actions of the medication the patient is taking, you will clearly see he is not well. Before proceeding any further and certainly before you might consider any treatment, an ASA grading of the patient would be important. If asked in an OSCE or an SCR about this system, then the answer is: It is a risk stratification scoring system. Its full description is the Physical Status Classification of the American Society of Anaesthesiologists. It is reproduced below:9 ASA 1: Normal healthy patient with no medication. ASA 2: Patient with mild systemic disease, including conditions, e.g. asthma, pregnancy, or epilepsy. ASA 3: Patient with severe systemic disease but not incapacitating, e.g. uncontrolled hypertension, recent myocardial infarct, or severe asthma stroke or uncontrolled diabetes. ASA 4: Patient who has a condition which is a constant threat to life, e.g. cancer, unstable angina arrhythmia, or recent stroke. ASA 5: The moribund patient not expected to live longer than 24 hours. First described in its current form in 1963,10 the past 50 years have seen modifications and additions
to the ASA classification. However, despite some criticisms of consistency between the different specialties in health care and specialists within the same discipline11, 12 together with the results of a recent study demonstrating only a statistically moderate agreement in the reproducibility of classification,13 the ASA system remains the standard by which dental patients can be pre-operatively assessed in the UK. Patients graded ASA 1 and 2 can be treated in general dental practice. ASA 3 may require hospital support and ASA 4 and 5 are hospitalised patients, requiring emergency or palliative dental care. The patient in this OSCE is graded ASA 3. Having a toothache because of the upper right lateral incisor needs to be placed into perspective with the other issues facing him and his family. Returning to the question, so far you will have: 1. Interacted and communicated with the patient to 2. Gather the necessary information to 3. Form clinical options for appropriate treatment to 4. Communicate these to the patient to 5. Gain consent to accept an appropriate treatment plan. The Answers With this patient, the options for treatment are limited but not out with the remit of a general dental practitioner to undertake without the need for referral to a specialist. The upper right lateral incisor presents with the signs of an infected and inflamed pulp. The sensible options are to restore or extract the tooth depending on how broken down the crown is and how much support remains in the root. You can present the options to the patient in terms he can understand, giving the pros and cons for each option. If the tooth is not periodontally involved and the crown is not extensively decayed, then root treatment with two to three clinical visits across two to three weeks is the most appropriate way to proceed. It would be inappropriate to treat this patient without adequate pain control. With respect to the cardiac condition and the medication, you must state in an OSCE that you will use local anaesthesia and this will not contain adrenaline. Given the patient’s history of allergy to penicillin, the potential for interaction with other antibiotics, and the lack of evidence for their effective use to treat pulpal and periapical localised infections, you can advise the examiners of the following options you might pursue in this case. Antibiotic treatment is not indicated in this case; rather, a more appropriate option is to remove the infected material from the tooth followed by conservative restoration of the crown. Draining the infected material from the pulp chamber, with recall to complete the root canal treatment, is the most sensible way to proceed if the patient wishes to keep his tooth.
If the patient does not wish to keep the tooth or there is extensive loss of periodontal and bone support, i.e. it is mobile and badly broken down, then extraction is the most appropriate alternative option. Prescription of an antibiotic and passing the patient on to a long waiting list is neither clinically correct nor indeed ethically acceptable.14 Upper incisors are easy enough to treat; access to the canal is not difficult. So all attempts should be made to encourage the patient to retain the tooth unless it is hopelessly mobile and broken down. When you have presented your options to the actor/patient, then ask if there are any questions. In real life, many patients will readily accept whatever you have to say to them and most will not question your clinical judgement. You really do have to be the guardian of the options you give and how you present them. Please do not give inappropriate options in the OSCE or in real life. Failing an exam is one thing, but to fail your patient is to fail as a dentist. In an OSCE such as this, in both MJDF and MFDS, the actor would be keen to ask for antibiotics, and potentially they may even ask for erythromycin. Given the patient is allergic to penicillin, you might think a prescription for erythromycin to be appropriate; if so, please note the interaction of erythromycin with Aminophylline from the list of medications the patient is taking. Prescribing Interestingly, if you see that there is no prescription pad at the OSCE station, you might just be reminded by its absence not to offer a prescription. More importantly, you must give valid reasons why you are not going to prescribe, and you must do so in a way that is acceptable to both the patient/actor and to the examiner. By doing this, the actors and examiners will know you are relying on up-to-date evidence on which you are basing your clinical decisions.14 If you can present your thoughts in a convincing and empathic way to the patient, this type of OSCE should present no problem for you. Treating In questions like this, all you have to do is take a good drug history and then work towards presenting your treatment options. These are root treatment or extraction with a non-adrenaline containing local anaesthetic. Avoid prescribing antibiotics unnecessarily if at all and review the patient within a week for signs of resolution of the symptoms. Further Notes to this Medical Matter. As stated, this OSCE was based on a patient attending for an emergency appointment. After finishing writing up the notes, the patient was contacted to let him know of our thoughts on how his dental treatment should proceed. Our conversation soon got round to the cardiomyopathy and what could have caused this. It was odd that a fit and well man of 60 years old, who had led an active farming life, should ‘suddenly’ develop this condition. The patient’s diet for some 47 years had consisted of meat from game he had shot on his 1,500-acre farm. His farm, both land and animals had been repeatedly treated with a variety of pesticides and
herbicides for decades. The patient’s exposure to these chemicals many of which were organophosphate derived had not been on an occupational level but more on an industrial scale. It may well be that accumulation of chemicals from both diet and work had eventually resulted in the cardiomyopathy.15, 16 These observations will be passed to the specialists looking after the patient, and while he waits for surgical treatment, we await the findings of further investigations into the effect of the chemicals the patient had been exposed to. References to Medical Matters 11 1. Essex C. Ulysses syndrome. BMJ. 2005;330:1268. 2. Walker M. Steve Martin: The Magic Years. p. 185. New York: SPI Books 2001. 3. BMA Royal Pharmaceutical Society BNF 64. Section 3 Respiratory system 3.1.3 Theophylline p. 186. London: Royal Pharmaceutical Society; 2012. 4. BMA Royal Pharmaceutical Society BNF 64. Section 3 Respiratory system 3.1.1 Salmetrol pp. 183-184. London: Royal Pharmaceutical Society; 2012. 5. BMA Royal Pharmaceutical Society BNF 64. Section 2 Cardiovascular system 2.5.5 Ramipril p. 121. London: Royal Pharmaceutical Society; 2012. 6. BMA Royal Pharmaceutical Society BNF 64. Section 2 Cardiovascular system 2.2.2 Furosemide pp. 87-88. London: Royal Pharmaceutical Society; 2012. 7. BMA Royal Pharmaceutical Society BNF 64. Section 2 Cardiovascular system 2.1.2 Digoxon p. 83. London: Royal Pharmaceutical Society; 2012. 8. BMA Royal Pharmaceutical Society BNF 64. Section 2 Cardiovascular system 2.6.3 Ivbradine pp. 135-136. London: Royal Pharmaceutical Society; 2012. 9. Scully C. Chapter 2: Medical History and Risk Assessment. In Scully C. Medical Problems in Dentistry. 6th Edition pp. 19-20. Edinburgh: Churchill Livingstone 2010. 10. Dripps RD. New classification of physical status. Anesthesiol. 1963;24:111. 11. Bernard PA, Makin CE, Hongying D, Ballard HO . Variability of ASA physical status class assignment among pediatric sedation practitioners. Int J Adolesc Med Health. 2009 AprJun;21(2):213-20. 12. Aronson WL, McAuliffe MS, Miller K. Variability in the American Society of Anesthesiologists Physical Status Classification Scale. AANA J. 2003 Aug;71(4):265-74. 13. Cuvillon P, Nouvellon E, Marret E. American Society of Anesthesiologists’ physical status system: a multicentre Francophone study to analyse reasons for classification disagreement. Eur J Anaesthesiol. 2011 Oct;28(10):742-47. 14. Crighton A. Antibiotic stewardship. Br Dent J. 2011;211:443. 15. He X, Li C, Wei D, Wu J, Shen L, Wang T . Cardiac abnormalities in severe acute dichlorvos poisoning. Crit Care Med. 2011 Aug;39(8):1906-12. 16. Shewale SV, Anstadt MP, Horenziak M, et al. Sarin causes autonomic imbalance and
cardiomyopathy: an important issue for military and civilian health. J Cardiovasc Pharmacol. 2012 Jul;60(1):76-87. Further Reading 1. Malamed SF. Prevention. In Medical Emergencies in the Dental Office. 6th Edition pp. 15-58. St. Louis: Mosby 2007. 2. Little JW. Ischemic Heart Disease. In Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the Medically Compromised Patient. 7th Edition. St. Louis: Mosby 2007. 3. Malamed SF. Know your patients. J Am Dent Assoc. 2010 May; 141:3S-7S.
Medical Matter 12 Background Information While the previous case was taken out of the dental clinic, this next OSCE is from the MFDS syllabus. By this stage of your revision and clinical training, you will already have developed an interest in the reasons why patients are being medicated. The list of interactions and side effects of their drugs should be noted, and these can be found in the BNF, as mentioned previously; this is available online. I remember this OSCE from the examination and it was straightforward, but it did require an up-todate knowledge of the latest guidelines. The point to note is that you do have to be up to date and know the requirements for the examining body whose exam you choose to take. The guidelines for this OSCE changed a few weeks before I sat the exam, and it did catch a few people out. If you are up to date with your clinical skills and knowledge, then this OSCE should be quite enjoyable. A good way to revise drug actions, interactions, and their side effects is to take a comprehensive medical and medication history for every patient you see. Together with your dental nurse and the patient (with their lists of medications on paper), go through such lists until you have covered every drug. The time you spend on the clinic doing this is time well spent and will strengthen your revision for the exams. Introduction You enter the OSCE examination room to be faced with a middle-aged lady. The actor/patient has attended for an extraction of a tooth that has been causing her discomfort for some time and she would like this extraction to be completed today. She does have a relevant medical history with items of note. In this OSCE, not much clinical information is given, and you will have to develop a dialogue with the actress to elicit the relevant information enabling you to make the appropriate clinical decisions so the appropriate care for your patient can be undertaken. Question Can you extract the patient’s tooth today? Developing Your Answers
You will need to take a thorough medical history. In completing this for this patient in this case, you must determine the presence and extent of the following medical problems: 1. Liver impairment: Either yes or no. 2. Alcohol intake: Is this above the recommended level? Alcohol is the most common drug of abuse. The recommended safe limit for alcohol use is 14 Units for women and 21 Units for men per week.1, 2 An Alcohol Unit (AU) is equivalent to 10 ml of pure ethanol. This quantity is present in one standard bottle of beer, a glass of wine, or a measure of spirit. Moderate alcohol use is 1 AU for women and 2 AU for men per day. Anything above 5 AU per day is defined as alcohol misuse. In determining a patient’s alcohol intake, you should be aware of the inherent problem that patients frequently miscalculate their alcohol intake.3 3. Kidney impairment or failure: Either yes or no. 4. Disorder of clotting. If present in this case, what is the nature of such a disorder? 5. Are there any medications the patient is taking? This question should reveal all medications the patient is taking and why she is taking these. There could be any combination of the drugs routinely prescribed for those who are on anticoagulant medication. In this OSCE, you must identify these and focus on the ones that may give cause for concern if it is your intention to go ahead with an extraction today. 6. Importantly in this case, the patient is taking warfarin and has done so after an aortic valve replacement a number of years ago. 7. The patient is allergic to penicillin. With all dental patients who are taking warfarin, you must know the following: a. The target INR and the acceptable range for the condition the patient has (see below). b. If you are planning an extraction, the INR has to be less than 4.0. c. At the time of the extraction, the British Committee for Standards in Haematology recommends the INR is 2.0 or less.4 d. The date the INR was last taken. If you are planning an extraction, the INR must be within 72 hours of the procedure. e. You can approach this by asking the patient if they take their blood thinning medication (warfarin) and then ask the patient what number was last noted in their Yellow Book (Anticoagulation Record) and you must ask: ‘When was this last recorded?’ For a dental patient, this has to be ideally on the day of the procedure, certainly not more than three days pre-procedure and most usually within a day of the procedure. For a patient with an artificial heart valve, the INR target is 2.5 to 3.0 and INR range is 2.0 to 4.0
(depending on which valve has been replaced and which design of artificial valve was used).5-7 In this OSCE, the patient then reveals she always has a stable INR; she can’t remember the number precisely, but this was taken last week. Can she go ahead and have her tooth out? Reasons for the Answer The answer is no. Unfortunately not today, and you have to explain the reasons for this. These are as follows: 1. We have to ensure there is a safe balance between the ability to stop the bleeding after an extraction and excessive bleeding if the INR exceeds 4.0. 2. Despite the INR being reported by the patient as being stable, we still need the documentary proof that it is and what is the precise level of this stability. You can suggest in the OSCE that the patient sees her GMP and has an INR taken, and if this is in an acceptable range, she can re-attend today with the documentary proof, and given the circumstances, you can then proceed with the extraction as requested. The actor/patient then asks if she can have some antibiotics for the pain. The first trap is forgetting she is allergic to penicillin. You might well consider prescribing another antibiotic. In those patients on warfarin, there are a few interactions you must know about. First and foremost, metronidazole will interact with warfarin and should be avoided. Excessive bleeding can occur. The warfarin dose may have to be reduced by up to one-third, and this can only be authorised by the patient’s GMP or anticoagulation clinic. 8 In the OSCE, you must tell the actor this. Second, an alternative to metronidazole is erythromycin. This causes unpredictable effects with warfarin. In one case study, a grossly elevated INR was seen after topical use of an ointment containing erythromycin.9 Again, you must tell the actor of this risk too. The real trap within the trap is the question the actor asked: ‘Can she have antibiotics for the pain?’ Antibiotic medication is not analgesic medication, and we have to maintain antibiotic stewardship.10 The patient/actor then helpfully asks if she can stop taking warfarin. Can you go ahead and extract the tooth today? Your response to a persistent actor is to tell her as she has an artificial heart valve she as at a high risk of developing blockages in her blood vessels (thrombo-embolic event), which can lead to serious complications. You might mention these are: Strokes, also known as transient ischaemic attacks (TIA) or cerebrovascular accidents (CVA), when affecting blood vessels of the brain. Blockages or pulmonary embolisms affect blood vessels of the lungs. Blockages in veins returning blood from the skeletal extremities, mostly the lower limbs can cause deep venous thrombosis (DVT). All of these can result in permanent disability or death. If the
patient continues to take the warfarin, these risks are avoided. However, if the patient stops taking warfarin, the risks for the above noted morbidities associated with drug cessation greatly outweigh the benefits of reduced bleeding from a dental extraction. The actor/patient then goes on to mention she really is in pain, and if you can’t take the tooth out, if you are not going to give antibiotics, can you at least give her something to take the pain away? Your response to this question is: The safest and most effective treatment you can give would be paracetamol for a few days up to 3.0 gms per day for one week until the INR can be checked and an extraction completed. You must avoid both aspirin and NSAIDs such as ibuprofen and diclofenac as these irritate the stomach lining and may cause bleeding, which in this anticoagulated patient would be a serious complication.11 A Lack of Information In this MFDS type of OSCE, very little information is actually given to you in the introduction and you have to elicit information from your dialogue with the actor. It is important to develop an empathic approach in order to gather the information you need to enable you to make the correct clinical decisions. At the same time as being empathic towards the actor, you cannot be sympathetically swayed by their requests for antibiotics to take their pain away. If you were to suggest that you might prescribe antibiotics, you would fail the OSCE and possibly the entire exam as this would show a lack of understanding of current clinical concepts. Further Notes to this Medical Matter. The INR is the ratio of the patient’s prothrombin time to a reference prothrombin time. Normal INR is 1.0 warfarin, which antagonises the vitamin K dependent clotting factors: 2, 7, 9 and 10 together with the proteins: C, S, and Z.12 A diet high in vitamin K can lower the INR. Alcohol can inhibit warfarin but may have the opposite effect in patients with liver disease.12,13 Warfarin prolongs both the prothrombin time and the activated partial thrombin time. The onset is from 8 to 12 hours reaching a maximal dose in 36 hours, persisting for 72 hours. In this case, in this OSCE, pain control should be limited to paracetamol. Codeine is rarely used in dental anaesthesia, and dihydrocodeine should only be considered for second line pain relief when other drugs are unsuitable. In a dental patient taking warfarin, such as this case, there is no indication for routine prescribing of antibiotics as they will interfere with the pharmacokinetic binding of the drug. Warfarin has a low therapeutic index with a 99% protein binding level. Metronidazole, amoxycillin, and erythromycin all cause secondary haemorrhage as the plasma concentration of warfarin can rise dramatically when warfarin is displaced from binding sites into plasma. Even a reduction in binding of 1% will cause a doubling of the free active warfarin available, and this can result in catastrophic bleeding.8,9,14 Compare the above interaction with the administration of aspirin. This NSAID interferes with the pharmacodynamic activity of warfarin. The antiplatelet activity of aspirin irreversibly acetylates
platelet membranes for up to one week and can interact with the anticoagulant effect of warfarin to enhance its effect. This interaction is an additive synergistic effect that is greater than the sum of the two drugs working in isolation. References to Medical Matters 12 1. Bellis M, Harkins C. Know your limits. Nurs Stand. 2011 Feb 16-22;25(24):22-3. 2. Scully C. Chapter 34: Substance Dependence. In Medical Problems in Dentistry. 6th Edition pp. 685-691. Edinburgh: Churchill Livingstone 2010. 3. Govier A, Rees C. Reducing alcohol-related health risks: the role of the nurse. Nurs Stand. 2013 Aug 14;27(50):42-6. 4. Perry DJ, Noakes TJ, Helliwell PS; British Dental Society. Guidelines for the management of patients on oral anticoagulants requiring dental surgery. Br Dent J. 2007;203(7):389-93. 5. Cannegieter SC, Rosendaal FR, Wintzen AR, van der Meer FJM, Vandenbroucke JP, Briet E. Optimal oral anticoagulant therapy in patients with mechanical heart valves. New Engl J Med. 1995;333:11-7. 6. Torn M, Cannegieter SC, Bollen WL, et al. Optimal level of oral anticoagulant therapy for the prevention of arterial thrombosis in patients with mechanical heart valve prostheses, atrial fibrillation, or myocardial infarction: a prospective study of 4202 patients. Arch Intern Med. 2009 Jul 13;169(13):1203-09. 7. McLeod CJ, Gersh BJ. Optimal anticoagulation therapy in patients with valvular heart disease or atrial fibrillation. Arch Intern Med. 2009 Nov 23;169(21):2032-33. 8. Seymour RA. Drug interactions in dentistry. Dent Update. 2009 Oct;36(8):458-69. 9. Parker DL, Hoffmann TK, Tucker MA, Gerschutz GP, Malone PM. Elevated International Normalized Ratio associated with concurrent use of ophthalmic erythromycin and warfarin. Am J Health Syst Pharm. 2010 Jan 1;67(1):38-41. 10. Crighton DA. Antibiotic stewardship. Br Dent J. 2011 Nov 25;211(10):443. 11. Wright V. Historical overview of non steroidal anti-inflammatory drugs. Rheumatology. 1995;34 Suppl 1:2-4. 12. Scully C. Medication and Dietary Interactions with Warfarin. Chapter 8: Haematology. Anticoagulant Treatment. In Medical Problems in Dentistry. 6th Edition pp. 194-195. Edinburgh: Churchill Livingstone 2010. 13. Holbrook AM, Periera JA, Labiris R, et al. Systematic overview of warfarin and its drug and food interactions. Arch Intern Med. 2005;165:1095-106. 14. Juurlink DN. Drug interactions with warfarin: what clinicians need to know. Can Med Assoc J. 2007;177:369-71. Further Reading
1. Baxter K, Preston CL. Stockley’s Drug Interactions: A Source Book of Interactions, Their Mechanisms, Clinical Importance and Management. 10th Edition. London: Pharmaceutical Press 2013.
Medical Matter 13 Background to This Case In this OSCE, we will deal with an elderly retired patient. He used to work in the electronics industry, soldering components together. He developed asthma and was medically retired. The patient has gastric ulceration and reflux and has been in pain from the upper left quadrant for a few weeks. He wears an old plastic denture (Kennedy Class ll). This replaces some teeth in the upper right quadrant. The patient has broken this denture a few times and has repaired it himself at home. He also attended with a non-registered dental technician who has made some repairs to this contraption. Due to fear of the dentist, he is an irregular dental attendee. The patient is taking the following medication: 1. Salbutamol inhaler. 2. Fluticasone Propionate. 3. Omeprazole. He also smokes and drinks socially. Approach to the subject The subject of this OSCE can be commonly found in both the MFDS and MJDF exams. Your approach to answering this question might differ in accordance with the exam you are preparing for. If you see such a question in the MJDF, a more structured approach will be expected and the actor and examiner will ask you specific questions. You will need to know this subject in considerable detail to answer the questions that are put to you. In the MFDS, less data is provided in the introduction. You will need to develop a dialogue with the actor to elicit the information you need to answer the question. The focus on your answers to the question will depend in which of the MFDS themes this OSCE has been placed. To remind you, the MFDS exam themes are: a. History taking. b. Providing explanations. c. Investigations. d. Managing patient concerns. Question In this OSCE, we will focus on the history taking, gathering information on the medication and the impact that asthma might have on the treatment options available.
Medical and Social Considerations The patient is elderly and dentally phobic; thus, he is an irregular attendee. He is a smoker and takes medication for asthma. These are important points to note, as they are connected with the condition with which the patient has attended. These may influence the treatment you might choose for him. Answers to this Medical Matter. Dental phobia, once established, is a difficult condition to unravel. In the undergraduate dental curriculum, the paediatric dental syllabus often contains the lectures on dental phobia. In this OSCE and perhaps in real life too, transferring paediatric dental techniques to an elderly dentally phobic patient is about as useful as a chocolate teapot. Rather than do this, acknowledge the fear the patient has and understand there may be some resistance to accepting your options for dental treatment. The actor/patient may demand extraction of the tooth or teeth that are causing pain and may insist on being ‘put to sleep’ for this. Do not focus your efforts in this OSCE by trying to impress the examiners with your knowledge of behavioural modification techniques. If you do and are lucky, you might succeed in putting the examiner to sleep. In this OSCE, the patient is fearful of the dentist but is open to listening to the options you give. The phobia has resulted in irregular attendance, and the patient now only attends when in pain. He smokes too, and it is an accepted fact that smokers, when under stress, will increase their tobacco intake and do so quite considerably. You may wish to mention smoking cessation very briefly but do not open this up as a focal discussion for this OSCE. We will return to smoking cessation in Chapter 6, ‘Procedural Problem 46’. Given the patient is dentally phobic and a smoker, in this OSCE and in real life too, you can guess these are promoters for asthma. If you consider the patient is elderly and has asthma, you can assume the patient is a chronic asthmatic with intrinsic asthma. Attacks are not initiated by allergic reactions; rather they are initiated by emotional stress and in this case by smoking and gastro-oesophageal reflux too.1 The smoking and fear of dentists will initiate, promote and increase the susceptibility towards clinical asthma and the risk of an asthmatic attack in the dental clinic. The medication the patient is taking will have oral side effects too; if we deal with the medication in the order it was given, this will reveal some of the problems the patient is experiencing: Salbutamol inhaler. This bronchodilator is a selective B2 agonist and may cause increased heart rate. In dental patients, it is better to avoid adrenaline containing local anaesthetic, which may cause arrhythmias. There are possible complications from dry mouth too.2 Fluticasone Propionate. The patient takes this as an inhaler and has been doing so for some time. Therefore, we can anticipate there is a risk of adrenocortical suppression. Orally, we might also see oropharyngeal candidal infections and rarely the condition of Angina Bullosa Haemorrhagica can present in those who are taking corticosteroids.3 Omeprazole. This medication is used to inhibit stomach acid production by blocking the proton
pump in the gastric parietal cells. Side effects are quite strangely vomiting, which seems a little counterproductive. Other oral side effects noted are taste disturbance and dry mouth.4 It can now be seen from the social, medical, and drug history the possible reasons why the patient has developed some of the problems he reports in this OSCE. From the history given, the patient wears a plastic denture, which he has repaired himself. There are economic reasons why patients choose to repair their own dentures. Importantly in this OSCE, repair with commercial grade adhesives and further work in a non-registered laboratory will most likely result in the patient’s exposure to cyanoacrylate cements and acrylic monomers which are two agents known to cause asthma.5,6 In the OSCE, the actor/patient should be notified of this. A dental history should now be taken on the nature and source of the pain in the upper left quadrant. There is likely to be acid erosion from the gastric reflux and in patients with asthma, there is a greater risk of periodontal inflammation. In this OSCE, the gastric reflux has caused erosion resulting in the pain the patient is feeling and the periodontal involvement has resulted in mobile teeth. The partial upper denture might be trapping acid from the stomach. This together with the chemicals noted above are responsible for the asthma the patient now presents with. Management Options The management options will be determined by the level of anxiety displayed by the patient. Although the patient felt the need to request a general anaesthetic, this is best avoided as it may result in further complications. These are lowered O2 and increased CO2 levels, potentially causing pulmonary oedema with an increased risk of pneumothorax.5 Intravenous sedation with benzodiazepines might cause respiratory depression; therefore, relative analgesia with nitrous oxide is preferable for the patient of this OSCE. Routine dental treatment can cause a significant decline in lung function in many asthmatics, so it is important to lessen the fear by reassurance and empathy and delicately approaching the care of this patient type.1,5 Treatment Options Further investigation of the pain from the teeth will lead you to the correct treatment options which may be: Conservative: restoration of the dentition and denture. Surgical: extraction and replacement of the partial upper denture with a more hygienic design (perhaps cobalt chrome), which is less likely to promote further asthmatic episodes. The last aspect of this OSCE you may wish to discuss is the patient’s alcohol intake and social drinking. You will need to establish the amount of alcohol consumed and determine if this is contributory to the gastric reflux. Referral to the patient’s GMP with any concerns you have would be important to ensure your thoughts and concerns are dealt with appropriately.
The OSCE can be completed by asking the actor/patient if there are any further questions and answering these as necessary. Further Notes to this Medical Matter. Asthma is a common condition. So you will see asthma questions in the MJDF exam, possibly the MFDS exam too and definitely in real life. Up to 1 in 20 people in the UK have asthma. Broadly speaking, there are two types of asthma; these are the extrinsic type affecting children, caused by allergens, such as food, some medicines, NSAIDs, and notably penicillin. Some 75% of children with asthma will improve by adulthood. The second type in this OSCE is intrinsic asthma, which is not solely allergy mediated. In this form emotional stress, acid reflux can combine with an initiator (the cyanoacrylate and monomers from the denture), resulting in asthma.1,5,6 Acid erosion from gastric reflux in an asthmatic can be treated effectively, but care should be taken as the fluoride varnishes we see and use in the clinic contain colophony which may also cause asthma and other allergic reactions. From the introduction, you will have noted the patient as being medically retired. The patient worked in the electronics industry. Solder flux contains high concentrations of colophony, and in this case, industrial exposure to this resin was the initiator of his asthma.7,8 In the MFDS exam, there have been questions on allergy to Polymethyl methacrylate (PMMA), specifically describing a mucosal reaction to partially cured PMMA. However, this is an extremely rare event.9 What is more common, is the risk of a patient with asthma becoming a medical emergency and your ability to deal with this will be tested. (Remember Medical Emergency 2 dealt with that eventuality). Your ability to effectively deal with any emergency comes from practicing a series of procedures, whereas your appropriate treatment of an asthmatic patient comes from your understanding of the underlying condition itself. References to Medical Matters 13 1. Scully C, Chaudhry S. Aspects of human diseases. 8. Asthma. Dent Update. 2007;34:61. 2. BMA Royal Pharmaceutical Society BNF 64. Section 3 Respiratory system 3.1.1 Salbutamol pp. 182-183. London: Royal Pharmaceutical Society; 2012. 3. BMA Royal Pharmaceutical Society BNF 64. Section 3 Respiratory system 3.2 Fluticasone propionate pp. 193-194. London: Royal Pharmaceutical Society; 2012. 4. BMA Royal Pharmaceutical Society BNF 64. Section 1 Gastro intestinal system 1.3.5 Omeprazole p. 57. London: Royal Pharmaceutical Society; 2012. 5. Scully C. Chapter 15: Respiratory Medicine. Asthma. In Medical Problems in Dentistry. 6th Edition pp. 365-367. Edinburgh: Churchill Livingstone 2010. 6. Lozewicz S, Davison AG, Hopkirk A, et al. Occupational asthma due to methyl methacrylate and cyanoacrylates. Thorax November. 1985;40(11):836-39. 7. Burge PS, Edge G, Hawkins R, White V, Newman Taylor AJ. Occupational asthma in a factory making flux-cored solder containing colophony. Thorax. 1981;36:828-34.
8. Burge PS. Colophony hypersensitivity revisited. Clin Exp Allergy. 2000;30:158-59. 9. Jagger D, Harrison A. Chapter 2: The Painful Denture. In Complete Dentures: Problem Solving. London: BDJ Books 1999.
Medical Matter 14 Background Information This question, like OSCE 11, is another real-life case, which caught my attention. I thought both cases are worthy of your attention and further detailed study. For this OSCE, I have transposed the patient from the dental clinic into an exam setting. The case will be described as it might appear in an OSCE. You might well see such a case in the MFDS, where this would make a good history taking OSCE, whereas in the MJDF, you might be asked to answer the structured questions following a history given in the introduction. Introduction The patient in this case, despite ill health, still works as a company director for a medical equipment manufacturer. You will probably have used, or more specifically, you and your patients will have sat on one of his products. If you are doing some revision in the clinic right now between patients, spare a thought for him and the reasons contributing to his poor health. You enter the exam; the actor/patient in this case is a 60-year-old man. The patient is slouching in the dental chair and appears to have a healthy suntan, but a swollen abdomen. Today he is attending for a routine dental exam, needing no dental treatment other than scaling and cleaning. He no longer drinks alcohol and has never smoked. In contrast to the previous patient, this gentleman has been a very regular dental attender. His dental history is straightforward with some amalgam fillings in the occlusal surfaces of posterior quadrant upper and lower teeth and some Class V Glass Polyalkenoate fillings in the buccal and labial surfaces of anterior teeth. He has no dental problems that he is aware of. However his medical history is interesting: The patient has had a history of psoriatic arthritis, for which he has taken methotrexate for several years but has now stopped taking this. He has Maturity Onset Diabetes Mellitus, which is being controlled with Metformin 850 mgs bds. The patient’s blood pressure is being controlled with Lisinopril 10 mgs ods and Amlodipine 5 mgs ods. Spironalactone 100 mgs ods completes the list of medication being taken. Structured Questions 1. What is psoriatic arthritis? 2. What effect will psoriatic arthritis have on dental treatment? 3. How is this condition treated and what impact might this treatment have on the patient?
4. Is there anything in the patient’s appearance and data in the medical history that might cause you some concern? 5. Why are the medications being taken and what further complications can arise? Structured Answers Given the time constraints of the OSCE, around 10 minutes or so, the questions you might be asked can be gauged from the medical history; the answers to these should be succinct and precise. 1 . Psoriatic arthritis (PA) is a joint disorder which can particularly affect the lower spine and sacroiliac joints. (This explains why the patient is slouching in the dental chair.) In this form of arthritis, there are no immune abnormalities. When PA is compared to rheumatoid arthritis (RA), in PA we find RF (Rheumatoid Factor) which is an IgM antibody complex directed against abnormal IgG leading to complement activation and an inflammatory destructive process in the patient’s joints. Whereas in PA, the arthritis is seronegative, but still it is erosive and in addition to the lower back, the knees can be affected too. The Temperomandibular Joint (TMJ) is very rarely affected in PA or indeed in any of the other arthritides.1,2 Psoriasis associated with PA displays a symmetrical pattern affecting the skin of the extensor surfaces of the arms and legs, and the scalp can be affected too. So in a dental clinic consultation, you can easily see these signs.1-3 2. As stated above, PA of the TMJ is rare, so dental problems are limited to the oral mucosal lesions which may be seen. Such intra-oral clinical signs are also rare; but might include Geographic Tongue (EM or Erythema Migrans). A diagnosis of oral psoriatic lesions can only be considered when we also see cutaneous psoriasis too.4 The appearance of intra-oral lesions, as well as being rare is variable, from translucent plaques to that of EM. One impact on dental treatment may be that the oral lesions delay other treatment until the lesions heal. However, perhaps the biggest impact on dental treatment is from the medication the patient needs to take for PA, followed by the effect of PA itself on the lower spine, making it difficult or uncomfortable for the patient to sit comfortably in the dental chair. 5 Lower back support would be needed when this patient attends as he has done today for an exam. In the OSCE and in real life in a case such as this, do make sure you and the patient are both sitting comfortably. 3. Treatment of PA: The cutaneous lesions can be treated with coal tar soaps eg: Dithranol and in some cases UV light therapy might be useful too. In some patients with PA, this form of treatment might explain the appearance of a healthy suntan (but this is not the reason in this case). The general management of PA is with NSAIDs. The latest treatment regimen of PA is with anti-TNF agents but previously, this patient was being treated with methotrexate, which also causes oral ulcers. 6 There are other complications arising from methotrexate, which will be revealed below. 4. The patient is slouching in the dental chair, possibly because PA has affected the lower spinal vertebrae, making it difficult for him to sit upright. The pronounced abdominal distension and the patient’s skin colour should give you cause for concern. The skin colour is definitely not a result of UV treatment. In this case, the patient has not been treated with UV. In an OSCE and in real life
when faced with a patient whose skin colour is darker than normal, the prospect of liver disease and all the attendant complications must be considered. 5. The medication the patient is taking: a . Methotrexate. This is a DMARD (disease modifying anti-rheumatic drug) used to treat moderate to severe rheumatoid arthritis. There are risks of abnormalities in the patient’s white cell, red cell, and platelet counts. There are mucosal and gastrointestinal side effects with renal and liver toxicity resulting, if the dose and patient response is not closely monitored.6 b. Metformin. This is a biguanide anti-diabetic drug. Biguanides (of which Metformin is the only one available in the UK) exert their action by decreasing gluconeogenesis and increasing the peripheral utilisation of glucose. The patient has Type 2 Diabetes. So Metformin works by increasing the output of the patient’s remaining and functioning pancreatic Islet of Langerhans cells. Metformin is the first drug of choice in the overweight diabetic patient where diet alone has failed to control the diabetes. Metformin is therefore used in the diabetic patients for glucose and weight control. There are side effects of decreased vitamin B12 absorption too and we might see urticarial rashes in the patient. (We would need to be careful if this patient presented with urticaria to clinically differentiate this from Psoriasis.) Liver toxicity is also a complication arising from Metformin.7 c . Lisinopril. This is an angiotensin converting enzyme (ACE) inhibitor. These diminish the conversion of angiotensin l to angiotensin ll. This drug can be used in heart failure (remember the ACE inhibitor from OSCE 11); in this case, the drug is used to reduce hypertension. However, the side effects are (very rarely) dry mouth and, interestingly, psoriasis. There is a risk of renal impairment too, but with respect to this patient, hepatic enzyme levels can become elevated and ACE inhibitors present another risk factor for liver toxicity.8 d. Amlodipine. This drug is a calcium channel blocker. These drugs work on the conducting cells of the myocardium and on vascular smooth muscle cells too. With application of this drug, the heart rate and force of contraction diminish as does the muscle tone of systemic and coronary vasculature. The side effects are dry mouth, taste disturbances, and with respect to this patient, arthralgia and back pain are commonly seen. Rare complications are pancreatitis and liver toxicity, and jaundice might then be seen clinically.9 e. Spironolactone. It is an aldosterone antagonist (Aldosterone is the mineralocorticoid produced in the adrenal cortex from angiotensin ll). Aldosterone acts on the juxtaglomerular apparatus of the kidneys causing sodium retention, potassium excretion with resulting fluid retention, vasoconstriction, and thirst is commonly seen. As with the other drugs this patient is taking, Spironolactone may cause liver toxicity too.10 Spironolactone is used to treat the oedema and ascites caused by cirrhosis. In this patient, liver failure has followed from cirrhosis. Medication history From the medication history, with a good working knowledge of the drugs patients are taking you can gain a tremendous insight into the patient’s health and well-being or in this case more precisely and
unfortunately their ill-being. When a patient presents in an OSCE or in real life who takes Spironalactone and there is no history of heart disease, you must acknowledge the fact that there is a serious underlying medical problem. History Taking This case deals with a patient who has psoriatic arthritis. His general medical practitioner provided treatment for several years for this condition with methotrexate. This drug as noted above is a DMARD which affects the immune response and may require up to 6 months of administration for a therapeutic response to be noted. In this case, the patient was given methotrexate, not for weeks or months but for many years, and the only thing being monitored in this time was the clinical immunological response of PA to the drug (which in any event is associated with seronegative arthritis). From the history given, there was no monitoring of liver function or blood counts in all this time. The patient was given methotrexate for many years, and today, only after years of clinical use and review, do we now know this drug causes many complications, most of which can be avoided by dose and patient response monitoring. Certainly, the patient was not monitored closely enough (if at all) and the drug dose altered accordingly. Cirrhosis resulted. The patient’s liver, despite an incredible regenerative capacity, is now irreversibly damaged. The healthy tan noted in the introduction is in fact jaundice and the swollen abdomen is ascites; both are clear clinical signs of the degree of liver damage.11 In addition to irreversible liver damage, the other complications arising from methotrexate use are an altered blood count, pulmonary toxicity, and pleural effusion. Our patient displays most of these complications. With respect to clinical dentistry, it is incredibly important to note that one of the first signs of methotrexate toxicity is oral ulceration which is indicative of methotrexate-related gastrointestinal pathology.6 In this case, the patient was suffering from PA. Methotrexate use caused cirrhosis and liver failure, with all the attendant complications we see in the clinical signs noted in the brief history. Also included is diabetes, which followed from altered liver function. Excess levels of proteins and carbohydrates in the diet are converted to fat by the liver. The liver turns glucose into glycogen and converts it back to glucose when required, thus maintaining stable blood sugar levels. Liver disease can lead to bleeding tendencies too. Most blood clotting factors using vitamin K as a metabolite are made in the liver. Bleeding tendencies result if these factors are not adequately produced to balance the naturally occurring clotting breakdown process. Thankfully, in this real-life case, the patient did not require any dental treatment, with the prospect of further interventions to control any bleeding. Bleeding Tendencies: When the synthesis of blood clotting factors is depressed, then relatively excessive fibrinolysis will result in an increase in the patient’s INR as the PT and APTT increase. With chronic bleeding, we will see anaemia, and further physiological hepatic stress results as the liver’s metabolism increases to produce more clotting factors. Cirrhosis and Caput Medusa
In the early stages of liver disease, due to the regenerative potential of hepatocytes, the patient may remain asymptomatic for many years. Notwithstanding this, cirrhosis is potentially and frequently fatal. When the portal circulation is obstructed, hypertension can cause venous back flow with the classic clinical sign of the Caput Medusa. These are distended blue veins radiating away from the umbilicus. This sign might not readily avail itself to us in the dental clinic. Nevertheless, asking the patient about any other signs on their body might reveal this striking clinical sign in some patients with cirrhosis. With portal hypertension, we will also find splenomegaly, resulting in thrombocytopenia, and this will exacerbate the bleeding tendency. Lastly, in the cirrhotic patient, we have the risk of the classic Mallory-Weiss tear, with rupturing of oesophageal varices; the resulting bleeding is uncontrollable. Theoretically, if a dental patient’s airway is irritated, excessive coughing and postural pressure on the oesophagus may precipitate such an event.12 The other medications being taken by this patient are to manage the ensuing complications arising from the effects of chronic liver failure and cirrhosis. Further complications we might see are disturbed metabolism and an increase in sex steroids leading to gynaecomastia and testicular atrophy. Clinical signs of liver disease There are other clinical signs which were not present in this case, but in the MJDF and MFDS OSCE; you may be given clinical photographs showing the classic hand signs. If you look at your patient’s hands in the clinic, you will see these signs: Finger clubbing Opaque nails Palmar erythema Dupuytren contracture. Commonly seen facial signs associated with liver disease are: Spider naevi (angiomata or fine broken subcutaneous capillaries). Other signs on the body are Swollen ankles Scant body hair or loss of hair may be a symptom the patient complains about. Further Note to this Medical Matter. In any patient who has compromised liver function, any further medication has to be provided with a high degree of caution and regard as to how it will affect the action of drugs already being taken by the patient More importantly, we need to know how the drugs we might prescribe will interfere with the reduced liver function. Administration of any broad spectrum antimicrobial needs careful thought, as further reduction in the patient’s GI tract flora may result in even lower vitamin K availability. Hepatotoxic analgesics such as paracetomol should be avoided and we should also consider lowering the dose of local anaesthetics we provide.13
This case is not so unusual, but it is a case in point for three reasons: 1. The patient presents with two conditions: psoriatic arthritis and liver failure. The first is life altering; the second is sadly iatrogenic and life limiting. 2. The earliest signs of methotrexate induced liver failure can be seen in the mouth. It is vitally important to take an up-to-date drug history and to correlate any signs and symptoms we see in the dental clinic with the medication a patient is taking. Please do not assume that just because a patient is chronically medicated the dose is correct and current. It cannot really harm anyone to question the medication a patient is taking. 3. To not do so when the sign’s that harm is being done is a clear act of omission and clinical negligence. References to Medical Matters 14 1. Ritchlin C. Psoriatic disease—from skin to bone. Nat Clin Pract Rheumatol. 2007 Dec;3(12):698706. 2. Amherd-Hoekstra A, Näher H, Lorenz HM, Enk AH. Psoriatic arthritis: a review. J Ger Soc Dermatol. 2010 May;8(5):332-39. 3 . Bruce IN, Psoriatic Arthritis: Clinical Features. In Hochberg MC, Silman JS, Smolen ME, Weinblatt M, Weisman M. Rheumatology. 3rd Edition pp.:1241-1252. Philadelphia: Mosby 2003. 4. Helliwell PS, Taylor WJ. Classification and diagnostic criteria for psoriatic arthritis. Ann Rheum Dis. 2005;64 (suppl II): ii3-8. 5. Scully C. Chapter 16: Rheumatology and Orthopaedics. In Medical Problems in Dentistry. 6th Edition pp. 398-399. Edinburgh: Churchill Livingstone 2010. 6. BMA Royal Pharmaceutical Society BNF 64. Section 13 Skin 13.5.3 Methotrexate pp. 750-751. London: Royal Pharmaceutical Society; 2012. 7. BMA Royal Pharmaceutical Society BNF 64. Section 6 Endocrine system 6.1.2.2 Metformin pp. 442-443. London: Royal Pharmaceutical Society; 2012. 8. BMA Royal Pharmaceutical Society BNF 64. Section 2 Cardiovascular system 2.5.5 Lisinopril pp. 119-120. London: Royal Pharmaceutical Society; 2012. 9. BMA Royal Pharmaceutical Society BNF 64. Section 2 Cardiovascular system 2.6.2 Amlodipine pp. 129-130. London: Royal Pharmaceutical Society; 2012. 10. BMA Royal Pharmaceutical Society BNF 64. Section 2 Cardiovascular system 2.2.3 Spironolactone pp. 89-90. London: Royal Pharmaceutical Society; 2012. 11. Lewis JH, Schiff E. Methotrexate-induced chronic liver injury: guidelines for detection and prevention. The ACG Committee on FDA-related matters. American College of Gastroenterology. Am J Gastroenterol 1988;83:1337. 12. Weiss S, Mallory GK. Lesions of the cardiac orifice of the stomach produced by vomiting. J Am Med Assoc. 1932;98:1353-55.
13. Scully C. Chapter 9: Hepatology. In Medical Problems in Dentistry. 6th Edition pp. 234-252. Edinburgh: Churchill Livingstone 2010.
Medical Matter 15 Background Information The previous OSCE, which went into some detail, was based on a real-life case. Due to the complex nature of the subject matter, exam questions have to be structured to prevent both examiner and candidate travelling in any number of directions. I have not yet seen a case dealing with liver pathology in the MFDS or MJDF syllabus. It is most likely that a question dealing with liver disease will turn up eventually. Given the importance of the liver in the greater scheme of things, it might be unwise for an exam candidate not to revise this subject. The following OSCE is intentionally short, to the point and is based on another case I saw (yesterday) so I am writing this up while all the details are still fresh in my mind. Again, this case is based on the pathology of an organ system very close to the oral cavity, yet seldom examined to any great detail in the MJDF and MFDS syllabus. After you have read this OSCE, I hope you will see the importance of revising your anatomy and pathology. Introduction The patient is a pleasant lady in her mid-forties; she is seated as you enter the exam room. She has a walking stick and her right arm is lying across her lap; her right hand is curled upwards and closed. She greets you and asks if you can complete a dental examination for her. She seems to have a very slight speech impediment. She tells you she has just finished a course of orthodontic treatment. As she smiles, you can see that she has a well-aligned dentition, but the gums appear a little swollen, red and look noticeably dry. The patient tells you she has promised herself for a long time that she would have a straight set of teeth and after all that she has been through in the past few years, she indeed did go ahead and have ‘braces’ to correct her malocclusion; she is now happy with the results of the orthodontic treatment. Taking a Medical History In this OSCE, take a medical history from this patient. 1. In taking a medical history, do note down anything of relevance with the medication the patient is taking or the condition she presents with, which may affect the dental treatment you provide. 2. Try to develop a full and inclusive history and asking the patient directly about any operations or illnesses is a good way to begin. Given that time is of the essence in an OSCE but not (so much in this case) in real life, then developing a good rapport with the patient is important. 3. In this case the patient attends with her teenage son (who also requested a dental examination). It is important to respect the mother-son relationship, and when taking a history, you have to be careful that your questions are both appropriate and structured to gain the information you need. You might ask if the mother is happy for the son to be present during the history taking and dental examination.
One way to begin after your professional introduction is by asking: ‘Thank you for coming to see me today. I’d like to know a little more about you. Please could you tell me about any visits to doctors or dentists you have had… ?’ If there is anything I don’t pick up, perhaps your son can help to fill in the blanks.’ Open the consultation and involve the son who should actively participate in the consultation (if his mother is happy for him to do so). The response was: ‘Oh yes, well… now you ask…’ So the medical history will be revealed to you: The patient was generally fit and active until a few years ago when she attended her GMP (general medical practitioner) with a severe headache. At this visit, the GMP noted nothing other than the patient had been out partying a day or so before her attendance and had drunk some alcohol. So the doctor sent her on her way with some advice on responsible drinking and limiting her alcohol intake to 14 units a week. How appropriate and useful was that advice? This might provide a salutary lesson in never jumping to the obvious conclusion initially, then discharging your patient without taking a comprehensive history from them. The headache did not abate and the patient then attended an NHS 24 hour centre. Nothing was noted in that consultation either and the patient was again sent on her way but advised to re-attend with her GMP or the hospital if the symptoms did not ease, which they did not. A day or so later, the patient attended the AE unit at her local hospital still complaining of the headache. The junior doctor on call observed that the patient was dragging her right foot and had slurred speech. Initial Questions. 1. What are your thoughts now? 2. What possible investigations might have been completed in the hospital? Initial Answers. 1. Patients do present with headaches in the dental clinic. Your job in the OSCE and in real life is to use both your knowledge and clinical experience of the signs, symptoms and causes of head and neck pain to exclude any dental causes and where necessary refer to a medical (neurological) specialist for treatment. Notwithstanding this, you have to be able to identify the common causes of pain, to list them and exclude or include in your differential diagnosis as necessary the following: a. Pain from pulpitis referred or not. b. Sinusitis. c. Temporomandibular joint/myofascial pain or the TMJ Pain Dysfunction Syndrome. You must be able to differentiate the above from the following:
a. Trigeminal neuralgia and other neuralgias. b. Giant cell arteritis c. Chronic idiopathic or other atypical facial pain. None of the above commonly occurring OSCE subjects was the cause of the headache. The clinical sign of the patient dragging her right foot and slurred speech is both sinister and very worrying. 2. Further investigations would be urgently needed in this case and these are; testing of the cranial nerves followed by MRI and CT scanning. It might now come as no surprise to learn from the outcome of these tests, that the patient was diagnosed with a brain tumour. This was identified as a benign meningioma exerting pressure effects as it grew in the left motor cortex. Meningiomas are the most common primary brain tumour (about one-third of all intracranial tumours are meningiomas; they arise from the Arachnoid Villi 1,2) Each year, about 4,700 people in the UK are diagnosed with tumours of the central nervous system (CNS). Meningiomas make up nearly a quarter (25%) of all primary brain tumours. They are most likely to be found in middle-aged or elderly people. Meningiomas are more common in women than in men.3 This tumour was successfully treated with surgical resection and radiotherapy. However, there were some complications following the procedure; an infection developed. The patient was given antibiotics and steroids to reduce the inflammatory response. Finally, a cerebroperitoneal shunt was placed which is still present and working. A period of recovery with physiotherapy and speech therapy followed from the complications of the brain surgery. Today, some 2 years later, the patient is taking the following medications: Baclofen 10 mgs ods. Oxcarbazepine 300 mgs bds. Aspirin 75 mgs ods. Further Questions. 1. What do these drugs do? 2. What are the possible oral side effects that you might see? 3. What interactions may arise with drugs you might prescribe to treat this patient? Further Answers. 1. The drugs being taken are as follows with the following actions: Baclofen is a skeletal muscle relaxant used to treat severe chronic muscular spasticity. In this case, the spasticity resulted from the effects of the meningioma and surgical damage to the left motor cortex. Baclofen both inhibits spinal cord transmission and depresses the output from the CNS too.4 Oxcarbazepine is used to control epilepsy. In this case there was no epilepsy; however, following the surgery there were partial seizures. We can see from these two drugs the potential interaction
between anti-epileptic and muscle relaxant medication. In this case, these effects were thankfully not seen.5 Aspirin is an anti-platelet NSAID. In this case, it is used to prevent cerebrovascular accidents or other cardiovascular disease events. Specifically, it is being taken to prevent possible blockage of the cerebro-peritoneal shunt.6 2. The oral side effects of the drugs that might be seen are as follows: Baclofen: The oral side effects are dry mouth and taste disturbances.4 Oxcarbazepine: The oral side effects of Oxcarbazepine are sore throat, blistering rashes, and mouth ulcers.5 Aspirin: There are few if any oral side effects; however, gastrointestinal irritation and bleeding may occur.6 3. The interactions of these drugs with others you may prescribe are as follows: Baclofen: There are no drugs in the British National Formulary that interact with Baclofen; nevertheless, please note the following: Oxcarbazepine: Oxcarbazepine causes a lesser degree of hepatic enzyme induction than Carbamazepine and so a lower antagonistic effect of Baclofen is seen; that is, the dose of Baclofen required to control the spasticity is less than if Carbamazepine was used. With this combination, there is a lower risk of hepatotoxicity too.5 (Please refer to the previous OSCE for the relevance of this.) Aspirin: This is a drug which is extensively protein bound; if other drugs given to a patient are also extensively protein bound, then aspirin can displace these drugs, increasing their therapeutic effect.6 With this patient, there are no such drugs, however, in another OSCE or in real-life cases there may be medication the patient is taking which have a high protein binding and we have to be aware of this and the interactions which will follow. Additionally, many of the antibiotics dentists prescribe which inhibit the hepatic cytochrome enzymes (e.g. C.P.450) can increase the level of plasma Oxcarbazepine, leading to drowsiness and confusion.7 Clinical Recommendations 1. In this case, a benign intracranial meningioma was discovered and operated on. Damage from the lesion with post-surgical complications resulted in the patient presenting with the clinical signs she has. The history of seizures meant the patient was not allowed to drive a car and therefore the son attends with his mother to take her to and from the dental appointments. 2. The clinical presentation of the spasticity in the right hand meant the patient had to relearn all necessary skills with her left hand including tooth brushing. Without specially adapted devices, now commonly available, flossing would be almost impossible for her. Although the patient has completed a course of orthodontic fixed appliance therapy, tooth brushing and oral hygiene need to be reinforced and alternative means of inter-proximal cleaning now need to be explored.
3. Oral hygiene suffered with a decreased ability to clean the teeth. When this problem is coupled with a dry mouth caused by the medication, the results are those appearances described in the introduction to this case. 4. The treatment recommendations for this patient should now be simple and corrective rather than complex and alternative. Remember, the patient has only just completed a complex orthodontic treatment plan and possibly the oral health might have been overlooked during this time. Fixed appliances are difficult to clean if effective oral hygiene instruction is not given and reinforced. 5. A referral should be made to the practice hygienist and follow-up appointments planned to monitor the improvement in oral hygiene. Further options might be to co-ordinate patient care with an occupational therapist eg: modifying toothbrush handles and flossing devices and together with a neurological specialist: monitoring of the medication the patient is taking. Further Note to this Medical Matter. With respect to the son, the maternal history of meningioma should be noted in his medical history. Although it has not been conclusively proven that there is a familial tendency, the natural history of meningioma is complex and not yet fully understood.8, 9 If not already completed, then the family doctor should be notified of your findings and observations. References to Medical Matters 15 1. Claus EB, Morrison AL. Chapter 4: Epidemiology. Section ll Anatomy and Pathology. In De Monte F, McDermott MW, Al-Mefty O. Al-Mefty’s Meningiomas. 2nd Edition. New York: Thieme Publishing 2011. 2. Central Brain Tumour Registry of the United States 2009-10. CBTRUS Statistical Report: Primary Brain and Central Nervous System Tumours Diagnosed in Eighteen States in 2002-2006. Hinsdale, IL. Central Brain Tumour Registry of the United States 2009. 3.
Meningioma in Macmillan Cancer Support. [Online] Available from: http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Brain/Typesofbraintumours/Meningio [Accessed August 2013].
4. BMA Royal Pharmaceutical Society BNF 64. Section 10 Musculoskeletal joint diseases 10.2.2 Baclofen pp. 685-686. London: Royal Pharmaceutical Society; 2012. 5. BMA Royal Pharmaceutical Society BNF 64. Section 4: Central nervous system 4.8.1 Oxcarbazepine pp. 290-291. London: Royal Pharmaceutical Society; 2012. 6. BMA Royal Pharmaceutical Society BNF 64. Section 2: Cardiovascular system 2.9 Aspirin p. 156. London: Royal Pharmaceutical Society; 2012. 7. Seymour RA. Drug interactions in dentistry. Dent Update. 2009 Oct;36(8):458-69. 8. Adamson DC, Rasheed BA, McLendon RE, Bigner DD. Central nervous system. Cancer Biomark. 2010;9(1-6):193-210. 9. Ostrom QT, McCulloh C, Chen Y. Family history of cancer in benign brain tumor subtypes versus gliomas. Front Oncol. 2012 Feb 28;2:19.
Further Reading 1. Renton TF. Chapter 66: A Pain in the Head. In Odell EW. Clinical Problem Solving in Dentistry. 3rd Edition pp. 311-316. Edinburgh: Churchill Livingstone 2010. A good account of the things to look for inpatients with intracranial problems presenting as extracranial symptoms in the dental clinic.
Medical Matter 16 Background Information Following from the previous headache, I would like to look at another OSCE based on a patient referred to me by my colleagues. I picked up this interesting case and again I have adapted the clinical information into an OSCE. However, this time, instead of focusing on the background causation, I would like to concentrate more on the enquiries and investigations needed to uncover the reasons behind the presentation of the headache. Introduction The medical history reveals: The patient is a 50-year-old lady who has recently had a hysterectomy, suffers from mild asthma, and is allergic to penicillin. She does not smoke and drinks only 1 to 2 units of alcohol per week. The Complaint There is a history of one year of pain from the upper left quadrant. The pain is localised to this area and does not radiate anywhere else. This is worse at night and throbbing in nature. Eating, brushing, hot and cold foods all aggravate the pain. Multiple dental visits have been completed, but no treatment has been started. In addition to the oral pain, there has been a sharp shooting pain in the left eye. This is associated with redness and watering which started at the same time as the oral pain. The intra-oral exam reveals the gingival tissues in the upper left molar area are tender. The tongue has a whitish patch of depapillation in the midline dorsum with clearly defined edges. Question to this Medical Matter. What history do you need to take and what questions will you need to ask? Answer to this Medical Matter. The history should focus on the pain the patient complains about. The medical, social and of course drug histories should all be noted too. The pain history should be laid out logically and in sequence from start to finish. In this OSCE, for just now, set aside the medical history and the social history; they are given above and we will return to these in detail. The drug history is not relevant in this case. One sequence of questions useful for taking a pain history is set out below, with the answers given for this case: 1. When did the pain begin?
One year ago. 2. Did anything precede the onset of pain? No one identifiable event, although the first attack was slow to develop. 3. Severity of pain? Give the patient a scale of 1 (mild and not noticeable) to 10 (unbearable and all consuming). The patient reports the pain is at level 5-6. 4. Timing? The pain is continuous and lasts 2 to 3 hours and occurs 2 to 3 times per night. 5. Character? When describing the pain, I have used the McGill Pain Questionnaire.1, 2 This will provide a series of words you can use to take your history of pain. The pain was described as: Shooting, sharp, wrenching, sore, frightful, and annoying. 6. Location? Deep in the intra-oral upper left quadrant. 7. Factors affecting the pain? Eating, tooth brushing, touching the teeth, pressure and biting, prolonged chewing, opening, and yawning all seem to make the pain worse. 8. Relief? What has the patient done to make things better for themselves? Taking paracetamol in ever-increasing doses. 9. Associated factors? Disturbances in salivation and excess tear flow from the left eye with redness too. There is some nausea and visual aura in the form of flashing lights. 10. The impact of the pain? Fatigue, concentration is impaired, and sleep affected. Feelings of anxiety, depression, and unhelpful intrusive thoughts are all noted too. With the information gathered from the pain history, what will you do next? In the MFDS and MJDF OSCEs you explain that having addressed the pain the patient presents with, you will now take notes of the social and family history. In the OSCE, this would be a concise exercise to confirm what is written in the introduction, that there are no factors likely to be causative of the problems the patient has initially presented with. Even if there are no obvious social or familial issues in real life in the dental clinic, do not omit to take a comprehensive social and medical history
from this patient and indeed from all your patients. From this point, you might conduct a clinical examination on the patient. In both the MFDS and MJDF examinations, performing a clinical examination is not part of the syllabus. Therefore, you would only explain to the actor and examiners that you would include a physical clinical examination of the patient in your overall scheme of investigation. You should concentrate on the issue of the clinical presentations as described above, and there may be photographs provided in the exam to support the information given in the introduction. Intra-Oral Signs If you could examine the patient intra-orally, you would see a midline depapillation of the tongue with clearly defined edges. You can be certain this is atrophic glossitis and possibly Median Rhomboid Glossitis. Once thought to be an anatomical abnormality, this is now known to be a form of chronic atrophic candidosis often seen in those who smoke (not this case) and those with a haematinic deficiency.3 The patient is post-menopausal; recently she has had a hysterectomy and uses an inhaler for asthma. Although the menopause is rarely associated with serious physical or medical complications, emotional disturbances and psychological disorders are not uncommon. Depression and paranoia may develop.4 The Differential Diagnoses From the pain history you have taken and the description of the findings in the exam, you can be fairly certain that this OSCE does not completely describe orofacial pain and there is an underlying cause of a dental nature, a deficiency state, or an infection which is causative of the pain the patient presents with. At this stage in the OSCE, you should present your differential diagnoses: 1. Referred pain from an oral candidal infection presenting as Median Rhomboid Glossitis. 2. Possible haematinic deficiency leading to atrophic glossitis and the clinical presentation of the tongue as noted. 3. Post-menopausal atypical facial pain and oral dysaesthesia. 4. The increasing use of paracetamol may be causative of blood disorders, e.g. leucopenia, neutropenia, and thrombocytopenia. Liver damage can also result and this may play a part in the signs and symptoms the patient presents with.5 5. There may of course still be a dental cause of the pain and this has to be ruled out before we proceed with further investigations. The Case Management Both MFDS and MJDF are not specialist exams and management of a case such as this would need to be referred to a hospital specialist for treatment. It is important to state this is what you intend to do in the OSCE. Is it enough to state to the examiners and actor you would refer and then leave it at that? No, possibly not in real life and certainly not in the OSCEs either, as you would be faced with an
awkward silence. It is necessary to expand on what you will request in the referral letter. In the MJDF, there are several specific OSCEs dedicated to writing out requests and these can be referral letters and prescriptions for medications or for laboratory work too. In the clinic and in revising for exams, you will have more than enough opportunity to develop your own methods of writing out a referral. In the MFDS, the writing out of a referral letter is not part of the examination syllabus. With an OSCE such as this one, it is important to state the clinical findings, to request the investigations you need in order to develop the differential diagnoses and possibly a definitive diagnosis too. Possible investigations In this case, the possible investigations might be: 1. Full blood count 2. Serum iron and ferritin levels 3. Vitamin B12 and folate levels In asking for these, you should be able to identify the accepted normal levels and interpret reasons for the results. (We will return to blood tests in the following OSCEs.) In this case, you should refer to a restorative consultant to rule out any dental causes, and if dental causes can be conclusively eliminated, together with the results of the blood tests, we might then be able to assign the symptoms to either: A. Oro-facial pain syndrome or: B. Deficiency state. With both diagnoses above, the treatment is also in the domain of a specialist. The purpose of this OSCE is to present another real-life headache, to go through the history taking, eliminate the improbable and focus on the possible reasons for the headache. Although medication and drug interactions are not responsible for this patient’s pain, we are fairly certain that an underlying physiological or chemical imbalance is. The task of an MFDS/MJDF candidate in an OSCE or the GDP in real life is to present a case to an examiner or a senior specialist, respectively, enabling them to pick up the case and continue the care for the patient. In the MFDS and MJDF OSCEs, many of the examiners are specialists in the subjects they will examine you on and will expect you to present the OSCE to them in the same way you would do with a patient in their clinic. The next most beneficial thing we might do in practice is to treat the candidal infection in the tongue, but we must not forget to manage the underlying cause of this infection too. Finally, the most important thing we must do is to address the patient’s paracetamol use and to restrict if not eliminate its unabated use due to the very real risk of ensuing liver damage. A referral letter must include your concerns of this. Pain Questionnaires
In this case, the following were used in the clinical assessment. In your clinical work and when undertaking revision for your exams and in the OSCE itself, you might find these helpful: 1. The McGill Pain Questionnaire is a series of 20 sets of words which are identified by the patient as being descriptive of both the quality and intensity of pain they have.1 2. Hospital Anxiety and Depression Scale (HADS). This measures both anxiety and depression on linear scales.2 3. Brief Pain Inventory (BPI). This measures two aspects of the patient’s pain: how much pain the patient is in and how much this pain interferes with their quality of life.2 By using these diagnostic tools, the impact of the pain on the patient’s life can be evaluated and reported in the referral letter. The specialist reading your referral will have a better understanding of the difficulties facing the patient if you can use such pain questionnaires, presenting data in a recognised and accepted format. A concise and pertinent referral letter helps you to help the patient. It also creates a good impression with your senior colleagues. References to Medical Matter 16 1. Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975;1:277-99. 2. Melzack R, Turk CD. Chapter 1: The Measurement of Pain and the Self-assessment of People Experiencing Pain. In Handbook of Pain Assessment. 3rd Edition pp. 3-18. New York: Guilford Press 2011. 3. Scully C. Oral and Maxillofacial Medicine: The Basis of Diagnosis and Treatment. 2nd Edition pp. 196-198. Edinburgh: Churchill Livingstone 2008. 4. Freeman EW, Sammel MD, Lin H, et al. Symptoms associated with menopausal transition and reproductive hormones in midlife women. Obstet gynaecol. 2007;110(2 Pt 1):230-40. 5. Provan D. The Patient, Section 11: Poisoning. Paracetamol (Acitaminophen) Poisoning. In Oxford Handbook of Clinical and Laboratory Investigation. 3rd Edition pp. 677-679. Oxford: Oxford University Press 2010. Further Reading 1. Cawson RA, Odell EW. Section 2: Soft Tissue Disease, pp. 170-277. Section 3: The Medically Compromised Patient, pp. 278-357. In Essentials of Oral Pathology and Oral Medicine. 6th Edition. Edinburgh: Churchill Livingstone 1998. A good basic text. Rather than going out and buying the latest edition, online resellers stock copies of this text. It is reasonably priced and readily available. In the past decade, there have been some changes, but few are of a level critically examined at the MFDS or MJDF level. 2. Scully C, Felix DH. Section 5. Oral White Patches. In Oral Medicine Update for the Dental Practitioner. pp. 20-27. London: BDJ Books 2006.
A well-illustrated smaller reference source useful to answer both patient and examiner questions and a good source of discussion in your revision group tutorials.
Medical Matter 17 Background to the Case Continuing from headaches, this case concerns another neurological problem and is based on another real-life patient. For this OSCE, I have introduced structured clinical questions as you would find in the MJDF exam. Cases like this might be examined in the MFDS and in the MJDF, not so much because it is interesting but more so because the problem is quite common. Introduction A pleasant 67-year-old lady attends with you as an emergency dental patient, having broken a heavily restored lower left second molar. The patient is a regular attender with your senior colleague. The first thing to do with any patient you see for the first time is to update both the medical and medication histories. The patient hands you her list of medication, which comprises the following: 1. Macrogol oral powder ods/bds po 2. Levodopa 50 mgs tds 3. Cabergoline 1 mg tds 4. Prucalopride 1 mg 5. Amantadine hydrochloride 100 mgs ods 6. Selegiline hydrochloride 1.25 mgs ods Questions 1. What do these drugs do? 2. From the answers above what condition might the patient have? 3. How might this disease classically present and what signs will you see in the patient? 4. What are the oral effects of this condition? 5. What may cause the disease? 6. What interactions may occur with these drugs? 7. What oral side effects may be seen with these drugs? 8. Is there any risk to you from the condition the patient has? 9. How would you treat this patient? 10. Are there any other treatments you might consider or refer the patient for? Answers
1. The list of medication a patient presents to you is a gold mine, revealing a tremendous amount of useful information. In the MJDF, you will have access to the BNF. An ability to rapidly go through this text and identify the drugs a patient is taking is a most useful clinical skill. The drugs prescribed in this case were reviewed from the British National Formulary, September 2012, edition 64. 1. Macrogol is an inert polymer acting as an osmotic laxative; it increases the amount of water in the large bowel, by fluid retention and drawing water out from the body.1 2 . Levodopa is the amino-acid precursor of dopamine; it acts to replenish depleted muscular dopamine. Dopamine is a catecholamine monoamine neurotransmitter and hormone playing a major role in reward-driven behaviour patterns.2 3. Cabergoline is an ergot-derived dopamine receptor agonist. It is used together with a dopamine precursor to lower the dose of (in this case) Levodopa required.3 4. Prucalopride is a peripheral serotonin receptor agonist. Serotonin (5 HT hydroxytryptamine) is a monoamine neurotransmitter. Most of the body’s 5HT is located in the GI tract where it regulates gut motility. In the brain, 5HT is involved in the control of mood, appetite, and sleep; other functions such as memory and cognition are controlled by 5HT too.4 5. Amantadine hydrochloride is a weak dopamine agonist. Amantadine both blocks dopamine reuptake and increases its release; the net result is there is more dopamine available.5 6. Selegline hydrochloride is a monoamine oxidase B (MAOB) inhibitor which has the effect of reducing Levodopa end-dose deterioration. MAOB is an enzyme located on the outer membranes of mitochondria, which preferentially metabolises on the Dopaminergic neurones. Of interest is monoamine oxidase A (MAOA), also located on mitochondrial outer membranes which metabolises (by deamination) noradrenaline, 5HT, and dopamine.6 2. With the exception of the first drug on the list, the others provide a huge clue to the medical condition the patient has. The answer is the common, serious, and relentlessly degenerative brain disorder of Parkinson’s disease. Parkinson’s disease is the second most common neurodegenerative disorder after Alzheimer’s disease with an estimated prevalence of 0.3% in the general population. The risk of developing Parkinson’s disease increases with age, with a prevalence of 1% in those over 60 and 4% in those 80 years and older. 7 Many studies have reported higher risk for Parkinson’s disease and younger age of onset in males.8-10 This chronic disorder affects the brain’s basal ganglia with decreasing levels of dopamine being produced.11 In the dental clinic, we may see patients with the classic mask-like face of patients literally in the grip of Parkinson’s disease. 3. This patient presented in the clinic with a slow shuffling gait, was slightly stooped over, and spoke in a very soft voice. My colleague who has cared for the patient for several years advised that the patient has quietly persisted with her life with some good days and some bad days. There are
problems with balance and coordination, muscle rigidity, and the classic pill rolling of the hands seen so often in patients with Parkinson’s disease. Of particular importance is that GI tract motility will slow down as it has done in this patient. So another hidden clue from the medication history that this patient has Parkinson’s disease is their use of laxatives. 4. In contrast to the abundance of medical literature providing commentary on the systemic and social consequences of Parkinson’s disease, there is a relative paucity of dental literature documenting the oral impact of this condition. Nevertheless, there are profound dental implications of the dyskinesia associated with Parkinson’s disease, the altered saliva flow, and taste disturbances seen with this condition.12 The oral signs of Parkinson’s disease are drooling from hypersalivation, a stooped cervical posture, and movement disorders: either a deficit or an excess, making dental examination difficult. Secondary oral effects follow from the medication, and Levodopa causes an alteration in secreted saliva quantity, but not quality or composition.13 5. Parkinson’s disease is idiopathic, there is a possible familial pattern and first-degree relatives are 3 × more likely to develop the condition. There is an early onset form of the disease with genetic mutation.7 Parkinsonism is the expression of clinical signs shared by Parkinson’s disease. The causes may be CVA, head injury (especially those who box/recreationally fight), those patients taking dopamine receptor blockers, and other similarly acting drugs. Severe early onset Parkinsonism has been seen in recreational drug users and especially in the farming community and rural-isolated communities. Females who have had hysterectomies with no HRT are at higher risk of developing Parkinson’s disease than those undertaking HRT; although this result is based on scientific data and not clinical or epidemiological evidence, it is worthy of our consideration.14 6. The drug interactions from the medication really start with the first drug: Macrogol: Other medication should not be taken one hour before or after this drug due to the impaired absorption seen. So the first interaction is that of timing of medication. Prucalopride also has the same interaction. The Levodopa and Cabergoline are given together to reduce their doses if taken individually; this is a synergistic interaction. However, hypotension may result if drug control is not strictly controlled.3 Cabergoline and Amantadine do not interact with the other drugs the patient is taking, but Cabergoline plasma levels may become raised with use of a macrolide antibiotic, e.g. erythromycin, due to elevation of the Cyt. P450 enzyme activity. Cochrane review of Amantadine. In 2003, a Cochrane review determined there was inadequate evidence to support the continued use of Amantadine in the treatment of Parkinson’s disease. Specifically, due to lack of evidence in that review, it was impossible to determine whether Amantadine is a safe and effective form of treatment for levodopa-induced dyskinesias in patients with Parkinson’s disease. 15 Therefore, it is somewhat surprising to see it still being used some 10 years later by the patient in this case.
Lastly, Selegiline: Interestingly, this drug can antagonise the anti-Parkinson effects of methyl dopa, and concomitant use with Prucalopride should be avoided due to the potential rise in 5HT levels being seen. If the patient’s 5HT levels are elevated, then the clinical signs of restlessness, agitation, tremor, vomiting, and diarrhoea will all be seen. 7. The oral side effects seen from the drugs above will be mucosal ulceration, dry mouth, and muscle tremors in the masticatory muscles. The complex patterns of drug actions and their interactions in a disease such as Parkinson’s can lead to a multiplicity of oral signs. The clinical picture will not be that clear; as wide a spectrum of responses can be seen in a population of patients as they can be seen in one patient with Parkinson’s disease. Medication side effects. In an OSCE, if you are asked for the oral side effects of neuro-modulatory drugs such as those listed in this case, then the following most common signs should be mentioned: a. Dry mouth, leads to: b. Taste disturbance, leads with lack of saliva to: c. Oral ulceration. A patient with a sore mouth might also have: d. Clenching, bruxism, and muscle tremors too, leading to: e. A headache. I think in an OSCE when asked about the oral side effects from most drugs patients take, then the above sequence often applies and can be given in your answer. 8. Parkinson’s disease is a non-transmissible illness. However, there are theoretical co-factors involved in the disease process that may present a risk to you as a health care professional. One cofactor is infection with Helicobacter pylori which may be transmitted in saliva. It is not clear whether dental staff are at risk; nevertheless, dentures do provide a reservoir for this bacterial infection, and patients with Parkinson’s disease do unfortunately drool saliva.16 9. A patient with Parkinson’s disease is still a dental patient and a human being and you must not treat them in any way which is different from any other patient. For sure, they will have bad days and they will have good days when the balance swings from disease progression to drug suppression and back again. The Parkinson’s patient may be unresponsive and have a blank expression, but they are still intelligent and cognizant and this must not be forgotten. Empathy and sympathetic handling of your patient is really important. If the patient becomes anxious, frightened, or worried, then an increase in lip and tongue tremor might be seen, making work with sharp instruments and drills both difficult and dangerous. Levodopa may cause hypotension, so the patient has to be carefully lifted into and out of the dental chair. The epinephrine in dental local anaesthetics may interact with Levodopa to cause tachycardia, hypertension, and arrhythmia; therefore, using local anaesthetic without adrenaline might be considered appropriate in this case and other Parkinson’s disease patients.
10. The salivary drooling is both socially stigmatising and troublesome. The use of botulinum toxoid, injected into the major salivary glands, significantly reduces salivary flow. Although botulinum toxoid is very popular in the area of cosmetic practice, its application in this case would need a specialist as the neurovasculature in the parotid gland (Pes anserinus of CN Vll) and submandibular gland (mandibular and glandular branches of the facial artery and lingual nerve) may be transected by insertion of needles.17 Further Note to Medical Matter 17. With an increasing elderly population, Parkinson’s disease is now more common and you will see more cases in the dental clinic. Therefore, at some point expect to see an OSCE dealing with this or other geriatric condition. The MFDS exam utilises actors, so it would be most unlikely and perhaps improbable to have an actor presenting with this condition. In contrast, the MJDF OSCE and SCR questions use a structured approach to this type of case. Therefore, you may be given a full set of dental notes with a drug history, and the examiners may ask you to go through these and work through a systematic line of enquiry. Alternatively, in the MJDF or MFDS an actor may portray a relative or a carer wishing to discuss in some detail the impact of this disease on their family member. Indeed in the MFDS, the use of actors portraying a patient’s relative is a commonly used device, and the information about a medical condition, which they may be at risk of developing themselves, should be thoughtfully and sympathetically delivered using language and terms they can understand, relate with and respond to. This OSCE is representative of a real-life case in the dental clinic. Perhaps the most important aspect of this exercise is to demonstrate your ability to identify the drugs, their uses and side effects and to separate the clinical signs you can ascribe to a disease process from those arising from the medication. You will need to work around the clinical problems as they are presented to you while developing answers to any questions the examiner or actor may have. As mentioned before, if you can enter the OSCE with a good working knowledge of the drugs a patient is taking with an awareness of the effects and side effects, then this type of case shouldn’t be too problematic for you to solve. References to Medical Matters 17 1. BMA Royal Pharmaceutical Society BNF 64. Section 1 Gastro-intestinal system 1.6.4 Macrogol pp. 72-73. London: Royal Pharmaceutical Society; 2012. 2. BMA Royal Pharmaceutical Society BNF 64. 2012. Section 4 Central nervous system 4.9.1 Levodopa pp. 309-310. London: Royal Pharmaceutical Society; 2012. 3. BMA Royal Pharmaceutical Society BNF 64. Section 4 Central nervous system 4.9.1 Cabergoline pp. 307-308. London: Royal Pharmaceutical Society; 2012. 4. BMA Royal Pharmaceutical Society BNF 64. Section 1 Gastro-intestinal system 1.6.7 Prucalopride p. 77. London: Royal Pharmaceutical Society; 2012. 5. BMA Royal Pharmaceutical Society BNF 64. Section 4 Central nervous system 4.9.2 Amantadine hydrocholide p. 314. London: Royal Pharmaceutical Society; 2012.
6. BMA Royal Pharmaceutical Society BNF 64. Section 4 Central nervous system 4.9.1 Selegeline hydrochloride pp. 312-313. London: Royal Pharmaceutical Society; 2012. 7. de Lau LM, Breteler MM. Epidemiology of Parkinson’s disease. Lancet Neurol. 2006;5(6):52535. 8. Baldereschi M, Di Carlo A, Rocca WA, et al. Parkinson’s disease and parkinsonism in a longitudinal study: two-fold higher incidence in men. Neurology. 2000;55(9):1358-63. 9. Haaxma CA, Bloem BR, Borm GF, et al. Gender differences in Parkinson’s disease. J Neurol Neurosur Psychiatry. 2007;78(8):819-24. 10. Wooten GF, Currie LJ, Bovbjerg VE, Lee JK, Patrie J. Are men at greater risk for Parkinson’s disease than women? Journal of Neurology, Neurosurgery and Psychiatry. 2004;75(4):637-639. 11. Scully C. Chapter 13: Neurology. Movement Disorders. In Medical Problems in Dentistry. 6th Edition pp. 329-331. Edinburgh: Churchill Livingstone 2010. 12. Lobbezzoo F, Naeije M. Dental Implications of some common movement disorders. Arch Oral Biol. 2007;52:395-98. 13. Tumilasci OR, Cersósimo MG, Belforte JE, Micheli FE, Benarroch EE, Pazo JH. Quantitative study of salivary secretion in Parkinson’s disease. Movement Disord. 2006 May;21(5):660-67. 14. Dye RV, Miller KJ, Singer EJ, Levine AJ. Hormone replacement therapy and risk for neurodegenerative diseases. Int J Alzheimer’s Dis. 2012;2012:258454. 15. Crosby N, Deane KH, Clarke CE. Amantadine in Parkinson’s disease. Cochrane Database Syst Rev. 2003;(2): CD003467. 16. Nielsen HH, Qiu J, Friis S, Wermuth L, Ritz B. Treatment for Helicobacter pylori infection and risk of Parkinson’s disease in Denmark. Eur J Neurol. 2012 Jun;19(6):864-69. 17. Naumann M. Hypersecretory Disorders. In Moore P, Naumann M. Handbook of Botulinum Toxin Treatment. 2nd Edition pp. 343-359. Oxford: Blackwell 2003. Further Reading. 1. Toulouse A, Sullivan AM. Progress in Parkinson’s disease: where do we stand? Prog Neurobiol. 2008;85:376-92. An interesting review article on the treatments and developments in Parkinson’s disease.
Medical Matter 18 Background to the Case The previous OSCEs were based on real cases, some who have come as everyday patients, others seeking a second opinion, and a third group referred by colleagues. This next case is right out of the MFDS. The actress who plays this part gets to be the same patient for every exam, but despite being the same character in every exam, every time she appears, she has something else wrong with her! One of the advantages of playing the part of a patient is the actress doesn’t actually suffer from the
disease. One of the disadvantages of being a candidate is that if you see the same actress two or more times, they will not have the same condition as the last time you met. OK, let me introduce you to this case: Introduction The patient is a pleasant lady who is in her late sixties and is a regular dental attender. She doesn’t need any dental treatment, but she has developed a painful burning sensation in the mouth a few months ago. Her jaws ache and she is tired; her son has returned from active service in the army. He is unemployed and has been living at home for over one year. The patient is trying to make ends meet and is struggling to keep things going. She appears tired and pale. Question for this case Please take a history and detail any investigations you might consider to establish the cause of the symptoms this patient suffers from. Points to consider In this OSCE in the MFDS, you will have 2 minutes to read the above information, collect your thoughts and structure your meeting with this actress and the examiners. 1. The social history is given and may have an impact. Do not dwell too long on this but do include this in your observations and causations. 2. The dental history is given and I think it is fair to suggest that you might acknowledge this but do not go into too much detail in the OSCE. 3. In contrast, the medical history needs to be developed further and a clue is that we are dealing with a symptom, not a clinical sign and no test results are given. 4. You do have a paucity of information but the answers will come from the actress if you can do the following: 5. Use appropriate questions in your dialogue with the actress to develop your answer to this OSCE. With this in mind, in this type of OSCE, the wrong question asked appropriately will lead you down a path away from the problem you need to solve. The right question asked inappropriately leads nowhere, whereas the right question asked appropriately will guide ou towards the answers you need to pass the OSCE. The patient has burning mouth syndrome (it actually says so in the introduction). I’ve underlined burning for you, but it won’t be underlined in your MFDS or MJDF OSCEs, so accept this is what the actress is portraying. Please do not go looking for some obscure and rare condition; the examiners will not be pleased. Candidates will tell you this from experience and experiences in the MJDF and MFDS can be costly. Answers to this case Once all the professional introductions are complete, you might go on to ask the actress about the pattern of the pain by asking the following sequence of questions:
a. Does the pain start during the day and go on? ‘No.’ b. Does it start on waking and go on throughout the day? ‘Yes, it is non-stop and relentless.’ c. Does the pain just come and go? ‘No, it’s from morning to night and it wakes me up too.’ The actress is describing the most common form of burning mouth syndrome; the pain is present on waking and lasts throughout the day. From here, you have to establish if there are any localised causes resulting in this presentation. d. Asking if the patient has dentures may reveal: ‘Yes, I have dentures, but I do not actually use them.’ (She may carry them around in her handbag all day before putting them back in the glass of water by her bed every night.) e. Asking if the patient wears dentures provides you with an answer that she wears them for weddings, funerals, and the lunch club. f. Asking if the patient uses dentures provides you with the answer that she does, but finds them uncomfortable when she is at the lunch club. You might then consider if candidosis is a co-factor in the presentation of her burning mouth. Candidal infection often has an underlying cause, and systemic causes should now be investigated. Appropriate Questions Asking the patient about her drug use may provide you with a retort of ‘Who do you think I am?/Who do you think you are asking me such a question about drugs?’ Alternatively, asking the patient about her use of prescribed medications and if so which prescription drugs has her doctor given her to use would be more precise, appropriate, and less likely to earn you a rebuke and cost you the OSCE. The patient advises you that she does not take any medications prescribed or otherwise. A Revealing Clue The actress/patient will be quite keen to tell you: ‘I am quite fastidious about my diet and all the pills doctors give you these days. Well, really, do they do any good? Food isn’t what it used to be and it’s so expensive now… with my son staying at home too.’ If you can develop a rapport with the actress, then she’ll practically tell you what is going on. From the above, she might as well have the answers you need to pass the question written on her forehead.
If you can grasp what she is telling you, then go on to ask about her diet. Continuing the Dialogue An open question about the patient’s diet is important. Ask about the quantity then the quality of food. Ask if she is eating enough and then about what she is eating: a. How are you finding your meals? Are you eating enough and regularly? ‘Well, I don’t eat as much as I used to and I don’t seem to be able to finish my meals.’ The above is an enlightening answer and one of the keys to unlocking this case. a. Are you having enough greens? ‘Yes, I am. I do like my greens and all my vegetables too.’ b. How about fruit? Are you getting your five a day? ‘Oh yes, the local shops are very good.’ c. How about meat? ‘No, I’m not having any of that. You just don’t know where it comes from and what is in it these days, and it’s so expensive I have to look after my son as well, so we are just eating what we can.’ These answers reveal the patient has a specific dietary deficiency. This knowledge coupled with the symptoms the patient presents with should lead you towards vitamin B12 deficiency being a possible cause of the burning mouth syndrome in this OSCE. Vitamin B12 is found in liver, meat, eggs, and milk, precisely the sources of vitamin B12 the patient has not been eating. The body can store vitamin B12 for up to 3 years, so deficiency is rarely caused by poor intake alone. There are other factors involved.1 Uncovering vitamin B12 deficiency in the OSCEs for MFDS and MJDF is only the start of the story. You have to work a little harder for your supper if you want to crack this OSCE in all the forms it might take… Going After the Details 1. Vitamin B12 deficiency readily results from mucosal malabsorption and not dietary deficiency. 2. Defective intrinsic factor production in the stomach is responsible for the inability of this patient to resorb vitamin B12 in the terminal ileum. 3. This condition can be a result of specific antibodies against gastric parietal cells or the intrinsic factor they produce. 4. Decreased gastric acid production is also seen, and atrophic gastritis might explain why the actress/patient claims to be eating less. 5. Vitamin B12 deficiency is rare in younger people, although those who follow a strict vegan diet may be more at risk.2 In older people, around 1 in 10 people above the age of 75 are affected.2-4 In the NHS Choices web
site (www.nhs.uk), it is claimed pernicious anaemia is the most common cause of vitamin B12 deficiency affecting 1 in 10,000 people in Northern Europe.2 Although Scully (2010) gives figures of 1 in 1,000 of the North European population and 1% of females over 70 being affected.1 I think it is important to know the precise figures as the NHS Choices web site is designed to inform patients, whereas Scully writes to educate you the dentist. A survey investigating the projected prevalence of nutrient inadequacy in Europe suggests figures much higher than the NHS data, with dietary deficiency and not pernicious anaemia in the aged population being the critical factor in developing this condition.5 In a Finnish cross sectional population study, nearly one-third of the study group showed borderline B12 levels with 2.6% demonstrating clear B12 deficiency.6 The European figures for nutrient inadequacy correlate well with the population-based cross sectional analysis of the well-known UK Banbury study.4 6. In the USA, 5% of those over 50 have low vitamin B12 levels.1 So this is a common condition not just affecting the UK and Europe and not something cooked up by the MFDS or MJDF examiners to confuse you. You now have to present your findings and clinical knowledge to both the actress and examiner in a language they can understand. In doing so, try to use simple terms, not complex terminology; remember, no jargon in the OSCEs Further Answers Explain to the actress and the examiners there are two possible reasons for a burning mouth: 1. The patient is not getting enough vitamin B12 or other vitamins. (Don’t forget that you can only provide a provisional diagnosis prior to any definitive test results coming back to you, so do not exclude other possibilities.) Or: 2. Vitamin B12 and other vitamins in the diet, although plentiful, are not being absorbed by the patient. The following complications should be mentioned but in a patient—or actor-centred OSCE, with the time constraints, it is not possible (or necessary) to go into great detail. The following details will most likely be examined in the SCRs of the MJDF. A lack of vitamin B12 leads to accumulation in the body of methyl-malonic acid from absorption of homocysteine. If not corrected, neurological damage leads to spinal cord degeneration and eventually paraplegia if the deficiency or malabsorption is not addressed. It is therefore crucial to test for vitamin B12 deficiency and to grasp that the burning mouth the patient is complaining of is one of the earliest symptoms of this process. With further progression, there is an increased risk of carcinoma of the stomach. Macrocytic anaemia and neurological symptoms develop in 10% of those with vitamin B12 deficiency.1 In the OSCE, explain to the actress there are a few tests to be completed to confirm your preliminary
diagnosis and you will refer the patient to a hospital specialist for this. In the MFDS, there is no requirement to ask the examiner for a syringe and needle while asking the actress to roll up her sleeve. All you have to do is explain the procedure to the examiner and actress. Specialist Tests a. A blood test is required to look at the effect the vitamin B12 deficiency is having on the patient’s blood cells. Explain to the actress that a small sample of blood will be taken and looked at in a hospital laboratory. b. A test specifically looking at how much vitamin B12 is being absorbed and used will be needed. This is the Schilling Test. You do not have to go into the finer details about the test, other than to explain this procedure is completed by specialists in hospital and not in general dental practice. The test itself takes a day to gather up information on how much vitamin B12 contained in a drink the patient is given is processed by their body, then passed out.1,7,8 A patient might ask further details on this test and you can explain that they are given a drink containing vitamin B12 with a marker and as they urinate (use the word ‘pee’: I think that would be appropriate in the Royal College Exams!), the levels of ‘marked’ or ‘labelled’ vitamin B12 present are then measured. This test is common and painless and the results are needed to help in treating the condition the patient has. In addition to the burning mouth, there will be other neurological symptoms from vitamin B12 deficiency too. Other simple clinical tests which might be performed are using a tuning fork to establish if the patient can detect the vibrations emitted. This test is simple but not on its own definitively diagnostic. A specialist would perform diagnostic test such as this. Even though a dentist would be in an ideal clinical position to place the tuning fork on the mastoid processes and other areas, in general practice; testing for such vitamin B12 induced neuropathies is not usually done. If you were to perform such tests, then any observations you make must be documented and communicated to a specialist for interpretation of your clinical findings. The final part of this OSCE would be to ask the actress if she has any questions. The actress may ask: If she does have the condition you are suggesting, then what treatment can she receive? The answer you give will depend on the test results and the input from the specialists and senior medically qualified colleagues. Acknowledging the question but deferring the answer is the best way to deal with this in the OSCE. In reply, state to the actress: ‘At this stage the diagnosis is only provisional and this is the best answer we can give you’
You would be doing really well to reach a definitive conclusion within 2 minutes, reading an introduction and then 10 minutes with a patient in the presence of an examiner. Definitive Treatment Treatment (if the diagnosis is confirmed) is to rebuild the depleted vitamin B12 stores with intramuscular injections of Hydroxycobalamin (1 mg pds every three days), then monitor the patient’s response to this with a three-monthly review and dose adjustment as necessary.1,2 Finish the OSCE by acknowledging the patient is under considerable social stress at home. Add that you will refer for the investigations as discussed and you will examine, investigate and treat the candidal infection of the dentures. An Important Clinical Consideration A normal appearance of the tongue with burning mouth is often the first sign of vitamin B12 depletion and deficiency. Blood tests are important, but normal haematological results can be misleading in the early stages of this condition. The burning sensation is the first clinical sign of neurological impact from vitamin B12 deficiency. In other more developed cases, the tongue may show signs of depapillation and red patches. The candidosis can be both aggravated and precipitated by the underlying deficiency and treatment of the clinical sign should follow treatment of the condition’s source. References to Medical Matters 18 1. Scully C. Chapter 8: Haematology. Vitamin B12 Cobalamin Deficiency. In Scully C. Medical Problems in Dentistry. 6th Edition pp. 208-211. Edinburgh: Churchill Livingstone 2010. 2. National Health Service. Anaemia Vitamin B12 or Folate Deficiency. In NHS Choices. Your Health Your Choices. [Online] Available from: http://www.nhs.uk/Conditions/Anaemia-vitaminB12-and-folate-deficiency/Pages/Introduction.aspx [Accessed July 2013]. 3. Clarke R, Grimley Evans J, Schneede J, et al. Vitamin B12 and folate deficiency in later life. Age Ageing. 2004 Jan;33(1):34-41. 4. Hin H, Clarke R, Sherliker P. Clinical relevance of low serum vitamin B12 concentrations in older people: the Banbury B12 study. Age Ageing. 2006 Jul;35(4):416-22. 5. Roman Viñas B, Ribas Barba L, Ngo J. Projected prevalence of inadequate nutrient intakes in Europe. Ann Nutr Metab. 2011;59(2-4):84-95. 6. Loikas S, Koskinen P, Irjala K. Vitamin B12 deficiency in the aged: a population-based study. Age Ageing. 2007 Mar;36(2):177-83. 7. Devalia V. Diagnosing vitamin B-12 deficiency on the basis of serum B-12 assay. BMJ. 2006;333(7564):385-86. 8. Snow CF. Laboratory diagnosis of vitamin B12 and folate deficiency: a guide for the primary care physician. Arch Intern Med. 1999;159(12):1289-98.
Further Reading 1. Mitchell L, Mitchell DA, McCaul L. Chapter 11: Medicine Relevant to Dentistry. In Oxford Handbook of Clinical Dentistry. 5th Edition p. 490. Oxford: Oxford University Press. 2010. A good source of data to refer to when in the clinic treating patients in deficiency states. 2. Delivering Better Oral Health. Section 4: Healthy Eating Advice: An Evidence-based Toolkit for Prevention. 2nd Edition. London: Department of Health 2009. A good publication from the DOH with information for patients on dietary advice.
Medical Matter 19 Something to Wake You Up If you are by now bimbling through your revision with your brain firmly in neutral, remember that unfortunately some candidates do fail exams. Yes, failures do occur, and sometimes candidates returning to resit the exam will be faced with a familiar face in a familiar case. This next case does look familiar. The actress from the previous OSCE has returned once more and she still has that burning mouth. She had that case of vitamin B12 deficiency, so this should be easy as the information from the previous OSCE is still fresh in your mind… A Re-introduction The patient is a pleasant lady who is in her late-sixties and is a regular dental attendee; she doesn’t need any dental treatment, but she has developed a painful burning sensation in the tongue a few months ago. Her jaws ache and she is tired. Her son still lives at home; he is still unemployed and has been there for over one year. (I think you get the picture.) The patient is trying to make ends meet and is struggling to keep on top of things. She still looks tired and pale. Question for This Case Please take a history and detail any investigations you might consider necessary to establish the cause of the symptoms the patient has. You will have 2 minutes to read the above information, collect your thoughts, and structure your reunion with this actress and the examiners. Point to consider in this Medical Matter 1. The social history is more or less the same as before and may again have an impact. Do not dwell too long on this, but do include this in your observations and causations. 2. The dental history is not so relevant, so once more do not go into too much detail in the OSCE. 3. Again, as with the previous case, the medical history needs to be developed further, and a clue is that we are once more dealing with a symptom and not just clinical signs. There may be some test results and you do have to ask further detailed questions to eliminate previous causes and develop some new ideas. Answers to This Medical Matter.
Be wary of a familiar case; no two questions will be repeated exactly in two sittings of the MFDS/MJDF exams. For sure, the cause will be different from the last time you met the actress and you will have to work just as hard to get the answers you need. Begin in the usual manner, you might consider using the following opening statements as part of your professional introduction: ‘How nice to see you again! /You’ve come back for your six-month check-up?/How have you been since the last time we met?/ Is your son still at home?’ The answer you receive is as follows: ‘Yes, he is and I have had this terrible pain. I did go for some tests, but there didn’t seem to be anything wrong with me… I just don’t know what to do now…’ Note the information that she has been for some tests, but they were negative and build upon this in the answers you give. So now, the pain history can be taken, it is very much like before with no difference. The open question you begin with might be as follows: ‘Can you please tell me about this problem you are having?’ a. Does the pain start at some point during the day and go on? ‘No.’ b. Does it start on waking and go on throughout the day? ‘Yes, it is non-stop and relentless.’ c. Does the pain just come and go? ‘No, it’s from morning to night and it wakes me up too.’ The actress is once more describing the most common form of burning mouth syndrome; the pain is present on waking and lasts throughout the day. From here, you have to establish if there are any localised causes and eliminate any dental causes of the pain. In this OSCE, there are none. Asking the patient about her medication reveals there are no medications the patient is taking. But she does like a drink of alcohol. On further questioning, you find out that she is drinking about 20 sometimes 30 units of alcohol a week. Remember the recommended level is 14 units per week for women. As you have developed a good working relationship with the actress, she then leads you towards the dietary questions again: ‘What about my food? Do you think I might be eating something that doesn’t agree with me?’ An open remark and question about the patient’s diet is important. Once again, ask about quantity, then quality: Ask if she is eating enough and then about what she is eating:
a. How are you finding your meals? Are you eating enough and regularly? ‘Well, I don’t eat as much as I used to, but I suppose I am getting older.’ This is important, and again, you have to build on this answer. a. Are you having enough greens? ‘No, I am really off my greens and have been for a few weeks now.’ b. How about fruit? Are you getting your five a day? ‘No, I can’t take fruit. They are so bitter and painful. I have terribly painful tongue when I eat fruit.’ The above is another big clue about what might be happening here. c. How about meat? ‘Well, now that you ask, I do have my roast on Sunday. Friday is always fish and my meat pies on Wednesday at the pensioner’s lunch club,’ the actress adds: ‘Do you think I might be overdoing the meat? I mean too much of a good thing and all that?’ The actress will of course deliver this with a degree of satisfaction; indeed the examiners, although they aren’t meant to, may nod in approval at that. Chewing Over the Information 1. You do have enough information to work with. The patient eats more than enough meat. 2. So it follows she most likely will not have vitamin B12 deficiency, neither this nor malabsorption from pernicious anaemia. 3. The tests mentioned above were not questioned further initially, but we should not forget about these and shall return to them shortly. However, the actress still has a burning mouth and she is sitting in front of you, so you now have to develop your OSCE in another direction; you will have about 6 or 7 minutes left to find out what is going on. The patient portrayed in this OSCE does actually have a deficiency state, and we know this from looking at both the symptoms and her diet. What exactly is she trying to tell you she is deficient in? Well, she doesn’t seem to be eating any greens and is suffering from a burning tongue. The Deficiency State The answer should be clear: folic acid deficiency Folic acid is present in greens, especially spinach, sprouts, and asparagus. In addition to the source, the following differences between folic acid and vitamin B12 are important to consider: Folic acid is absorbed from the proximal small intestine (the duodenum and jejunum), whereas vitamin B12 is resorbed from the terminal ileum. The human body does not store folic acid, but can have three months’ depot stores of vitamin B12. Notwithstanding these differences, the clinical picture of
vitamin B12 and folic acid deficiencies might appear similar at a first glance:1,2 The similarities are burning mouth, specifically soreness of the tongue.1,2 There are changes in the blood cells produced in the bone marrow, with macrocytic anaemia from impaired DNA synthesis. On closer consideration, the fundamental differences are the following: In an adult case of folic acid deficiency, there will not be a neurological impact such as that seen with vitamin B12 deficiency; however, accumulation of homocysteine does lead to cardiac pathology and ischaemic heart disease. In a prenatal case, for the foetus a deficiency in folic acid can lead to neural tube defects and an increased risk of cleft lip and palate.1,3,4 In this case, given the age of the patient, this is not a consideration. However in an SCR, be prepared for a line of questioning exploring the extremes of age in some detail. Language and Communication 1. In an MFDS OSCE, the actress will want to know about what is causing her ‘sore mouth’, whereas in an MJDF OSCE, the examiners would like to know about the ‘aetiology of glossodynia’. 2. For both exams, do not forget about using appropriate language and communication skills. Use simple elegant terms to put your points across to the actress and reserve the technical terms for the examiner. 3. In both the MFDS and MJDF, there may also be some clinical photographs for you to look at. Remember, clinical photographs are used in the examination as a means of providing you with the information you will have acquired if you were to perform a clinical and intra-oral examination of the patient. Clinical symptoms and signs Of importance with folate deficiency: There will be glossodynia in the early stages, but there are no clinically visible abnormalities, so clinical photographs in this case will have limited value. Later on, as the condition develops, there will be atrophic glossitis and depapillation. Angular cheilitis is also seen, but this is rare and it is only seen if the deficiency is exceptionally severe.1,3 As mentioned, folic acid is not stored in the body, so unlike vitamin B12 deficiency, dietary deficiency is responsible for the symptoms here. There are other co-factors too, and the reported alcohol intake may contribute to nutritional malabsorption. In other cases, but not in this one, malabsorption may be caused by Crohn’s disease or gluten enteropathy. It is important when taking the medical history to exclude these causes.1,2 Folic acid deficiency leads to anaemia, and the definitive test is to look for low red cell folate levels. In this case, the patient is just about telling you what is wrong with her: ‘I did go for some tests, but there didn’t seem to be anything wrong with me…’ This was the Schilling test, and it was normal; that is, the vitamin B12 absorption is within normal limits. However, the patient has presented with clinical symptoms, so folic acid deficiency must now be considered. Critical Differences
In real life, it is critically important to differentiate between vitamin B12 deficiency and folic acid deficiency.5 If the former condition is confused with the latter and you give folic acid or do nothing, then irreversible neurological damage can follow with spinal cord degeneration and eventually paraplegia. In the latter, neurological damage will not occur, as subacute spinal cord degeneration does not take place. Nevertheless, as noted above, raised homocysteine levels may predispose to ischaemic heart disease in the patient. While you may not need to go into this level of detail with the actress in the OSCE, you should be aware of these complications when identifying and differentiating these specific deficiencies in either an OSCE or the dental clinic.1-3 Management Question Once you have presented your findings to the actress and examiner, she will then ask how you propose to manage the condition. Management Answer Once more, the answer will depend on the test results; with normal Schilling test and low red cell folate levels, folic acid deficiency can be confirmed. Treatment with folic acid at 5 mgs per day PO for up to four months will restore the blood folic acid to normal levels.1,2 This case is managed by referral to medical specialists and not by your treatment in the dental clinic, which is interesting as the first symptoms of either vitamin B12 malabsorption or folate deficiency will often be seen in the dental clinic with the patient who presents with burning mouth syndrome. Further Notes Appropriate and prompt referral is the key to managing this case, but in mentioning to the actress that you will refer, you have to explain why, giving some background information on your reasons for doing so. An understanding of the role vitamin B12 and folic acid play in the presentation of symptoms is important too. If the patient or actress attends with blood test results, then you should be able to interpret these and provide an explanation to the patient. With test results, the reference values are given, so you will be able to identify those results lying outside the normal range.6 With vitamin B12 malabsorption and folic acid deficiency, a macrocytic anaemia is seen with a raised MCV. Additionally, you might see a reduction in both white and red cell counts, with platelet numbers being reduced too.1,4 This is pancytopenia. If the bone marrow of a patient with these deficiencies was to be sampled, then atypical non-maturing erythroblasts will be seen in greater numbers. The other potential cause of malabsorption and deficiency in this case is the possible tendency to excess alcohol intake as reported by the patient/actress.7 Referral to the patient’s GMP with a request for test results and alcohol counselling should resolve these issues. References to Medical Matter 19
1. Scully C. Chapter 8: Haematology. Anaemia. Folate (Folic Acid) Deficiency. In Medical Problems in Dentistry. 6th Edition pp. 204-211. Edinburgh: Churchill Livingstone 2010. 2. McNulty H, Pentieva K, Hoey L, Strain J, Ward M. Nutrition throughout life: folate. Int J Vitam Nutr Res. 2012 Oct;82(5):348-54. 3. Elmadfa I, Meyer AL. Vitamins for the first 1,000 days: preparing for life. Int J Vitam Nutr Res. 2012 Oct;82(5):342-47. 4. Wallingford JB, Niswander LA, Shaw GM, Finnell RH. The continuing challenge of understanding, preventing, and treating neural tube defects. Science. 2013 Mar 1;339(6123). 5. Lu SY, Wu HC. Initial diagnosis of anaemia from sore mouth and improved classification of anemias by MCV and RDW in 30 patients. Oral Surg Oral Med Oral Pathol Oral Radiol Oral Endod. 2004;98(6):679-85. 6. Snow CF. Laboratory diagnosis of vitamin B12 and folate deficiency: a guide for the primary care physician. Arch Intern Med. 1999;159(12):1289-98. 7. Cravo ML, Gloria LM, Selhub J, et al. Hyperhomocysteinemia in chronic alcoholism: correlation with folate, vitamin B-12, and vitamin B-6 status. Am J Clin Nutr. 1996;63(2):220-24.
Medical Matter 20 Background Information Interpretation of test results is an important part of any dental treatment. In the previous two OSCEs, the patient/actress attended with similar clinical symptoms from two different causes. In this OSCE, examples of which you will find in both MFDS and MJDF exams, a patient returns to you with test results. You have to interpret these results and explain their meaning to the patient and the examiner, formulating a plan of action or treatment based on your interpretation. Just As a Reminder In the MJDF OSCE, the examiner or the actor will ask structured questions, whereas in the MFDS a more fluid, open, and dynamic style of examination determines that you will take the lead and guide the patient/actor through the OSCE in a dialogue. In both the MJDF and MFDS exams, interaction, information gathering, and conveying relevant facts in a language everyone can understand, while having a good grasp of current clinical issues, is all you have to do. This sounds easier than it is, so you have to practise, practise, and practise. Just to add a little pressure in the exam, you will have 2 minutes to acquire the necessary information from the test results and 10 minutes to distil the data without using jargon, into information the patient can understand. In general, in OSCEs but especially in this one, where test results are provided for you, nothing is more impressive than your ability to deliver precise answers in unpretentious language. Introduction
OK, here we go with this OSCE, and you will have the test results to hand before you enter the exam room. The patient was referred for blood tests after complaining of a sore mouth. A colleague has requested these results. However, your colleague has had to attend a CPD course today, and now you have to deal with their patient. The patient is a pleasant lady in her mid-50s and has had a painful burning sensation in her tongue for some time and has now developed mouth ulcers too. This patient does look pale, and she also complains of being tired and gets a little breathless on exertion, so she hasn’t been taking regular exercise for the past few months. Despite this, she has had no serious illnesses or operations, takes no medication, drinks sparingly, and does not have a personal or family history of any GI tract illnesses. Blood Test Results 1. Erythrocyte sedimentation rate ESR 20. Normal range: <20 mm/min 2. Platelet count 152. Normal range: 150 to 400 × 10 9/L 3. White blood cell count WBC 7.7. Normal range: 4 to 11 × 10 9/L 4. Mean corpuscular volume MCV 74. Normal range: 80 to 100 fL/L 5. Mean corpuscular haemoglobin MCH 10. Normal range 11.5 to 16.5 ugms/L (Adult female range) The actress is sitting anxiously, waiting for you as you enter the exam room with her results. By now you have already had a quick look at the test results and would have noticed a few anomalies and made a few notes. Most if not all patients when attending to receive test results will be nervous and apprehensive, and in both OSCE and real life, you have to portray a confident professional manner. Formulating and Presenting Your Answers 1. No one likes to receive or deliver bad news; being defensive can be taken as a sign by the actress that you are about to give bad news or a sign by the examiner that you don’t know what you are going to talk about. 2. All the actress/patient knows is that she has a painful burning tongue and mouth ulcers. You have the test results, and the examiner knows the answers that he or she wants you to deliver. 3. As we develop a differential diagnosis, excluding the improbable, narrowing our search for answers down to the possible, towards the delivery of a definitive diagnosis, patients often have thoughts moving in the opposite direction. Patients may think they do not have some common condition with a plausible explanation. Rather, they might begin thinking, while waiting two or so weeks for their results, they have a rare and serious condition. Although the cause may seem irrational and improbable to us, with access to the Internet anything becomes possible. Some patients will develop these thoughts to the extent they catastrophise while waiting for the results
of a test; that is, they will give greater weight to an adverse outcome no matter how unlikely this may be.1,2 4. Presenting test results, especially results of a blood test to a dental patient, is a relatively rare event in general dental practice. You need to recognise the process of cognitive distortion or catastrophisation and respond to the actress or patient in appropriate ways if they begin to display anxiety and adverse emotions before receiving their test results. 5. In the undergraduate curriculum and MFDS/MJDF revision courses, developing empathic responses are suggested as a possible way for you to deal with an anxious patient. However, empathy has many forms. Specifically in this type of OSCE, while you do not need to identify the mental state the patient displays (this is cognitive empathy), you must be able to respond to and display appropriate emotions to the situation portrayed by the actress; this is affective empathy.3,4 In essence, you have to display empathy and emotional intelligence to a degree that it is picked up by the actress and examiner. In this OSCE, an appreciation of the behaviour patterns of a patient nervously waiting for their test results is as necessary as an understanding of basic haematology. The ability to effectively and appropriately inform the patient of the results of their blood test is the key to passing this OSCE. The Answers to This Medical Matter. After the formal introductions, approach the actress in this OSCE as follows: ‘Hello, thank you for coming back to the clinic. I have your test results here. Would you like to see them?’ The reply might be: ‘Oh yes, but I am a bit worried, I mean I have had a blood test and I am concerned about what I might have.’ This now gives you the opportunity to respond with: ‘Please let me show you the results and we can go through them together, then I would like to ask you some questions so we can give you the answers to what has been troubling you.’ The actress responds with: ‘Yes, that would really help me. It’s nothing serious, is it?’ At this point in OSCE, just take the results page out of the exam book and place the piece of paper in front of the patient so they can see the whole page of results for themselves. If you take this approach, please try not to tear the page into half as this isn’t a great way to begin your consultation, as you hand a scrap of torn test results to the actress. You continue with…
‘Serious? Why do you say that?’ The reply will be: ‘Well, I have these mouth ulcers and my tongue has been terribly sore. I was really worried.’ Acknowledging the patient’s concerns is essential: ‘Yes, I can see this is bothering you. We now have results here which I am sure will clear this up for you today.’ In the OSCEs, just taking the page of results out from the exam book and handing it to the patient kind of gives a message to the patient that these are her results and you are not concealing anything from her. Some examiners might look a bit perplexed if you do this, but that is because every other candidate has not actually done this, i.e. physically given the patient their results. Essentially, the handout sheets you have in the OSCEs are like patient notes. So there is no need for one actor or patient to see another actor or patient’s notes; maintaining privacy between question stations is perhaps just as important as maintaining confidentiality between patients. By separating the notes and handing the results to the actress, you will be reinforcing this confidentiality. You might continue with the following: ‘Yes, these results show me that there is a simple explanation why you have a sore tongue together with mouth ulcers. I would like to go through the results with you and let’s see if we can’t come up with an answer for you today. How does that sound?’ While the foregoing is the way this OSCE would begin for both the MFDS and the MJDF, the following structured questions are more appropriate to the MJDF syllabus. In answering these questions, you can usefully revise the format of delivering blood test results to an actress/patient, if this question arose in the MFDS examination. Present the test results to the patient in a systematic manner going from the top to the bottom of the test results page and pause after you give an explanation for each result, looking at the actress to see that the she is following what you are saying. More Questions 1. Once the above has been completed, what abnormalities have you outlined? 2. What is your first diagnosis from these results? 3. Might you ask for further tests to narrow your diagnosis? 4. What might be the cause of the results in the blood test? 5. How do you propose to manage this actress/patient? More Answers 1. Both the haemoglobin and MCV are lower than normal; while the ESR is normal, it is at the low end of the reference interval. The platelet count is at the lower end of the normal reference interval too.
2. From these figures, it is clear the blood test results show values for microcytic iron deficiency anaemia. In this OSCE, you do have enough information to give a diagnosis and proceed to the explanation and management phase of treatment. An explanation to the patient is best given in simple clear terms explaining the possible causes of iron deficiency. Despite your confidence in giving explanations, you might ask for further tests to determine why there is insufficient iron in the patient’s blood. Broadly speaking, the two main reasons for this result are as follows: a . Acute haemorrhage. Asking the patient if they have had a fall or accident or cut themselves needing a hospital visit will quickly eliminate this cause. A further test would be to take a blood screen and look for reticulocytes. Explain this in simple terms: ‘If you’ve recently lost some blood quite quickly, then we would need to look for signs that new young red cells are present in your blood. However, I don’t think this is why you are anaemic.’ The word anaemic is so common it can hardly be termed jargon, but if questioned, then be prepared to use phrases like blood loss instead. b. Chronic haemorrhage. This may not be so evident in the clinic. In contrast to the first reason, a slow loss of relatively small amounts of blood across several months may result in the patient being anaemic and the presentation of iron deficiency anaemia seen in this OSCE. In this case, the cause may be either poor diet (very rare) or menorrhagia occurring during the process of menopause. 3. Further tests that you may be asked about in the structured MJDF but perhaps not the patientcentred MFDS exam are those tests needed to identify the specific cause and effect of blood loss and iron deficiency. The more common of these tests that you should know about for the MFDS and MJDF exams are as follows: i) Serum ferritin. A drop in levels is perhaps the most sensitive indicator of iron deficiency; however, this is not a widely used test and levels may rise in acute inflammation. ii) Total iron binding capacity and transferrin. Their levels can be used to determine the early onset of anaemia as the total amount of iron available drops. As the transferrin saturation level drops below 16%, then anaemia can be diagnosed.5 iii) Marrow iron stores can be tested, as can red blood cell size and quantity and quality of the haemoglobin contained in the red blood cells. As the anaemia progresses, then more immature red blood cells will be released from the marrow into circulation and detected in blood tests. Be prepared to ask the actress/patient about both their diet (see previous two OSCEs on dietary questioning) and to ask in appropriate terms about excessive chronic menstrual blood loss. 4. The most likely cause should be dealt with first (as you will be about halfway through the OSCE by now); afterwards, briefly discuss any other rarer causes.
‘I see that your iron levels are low and given that you haven’t had this before and the timing of this happening…’ The Pause Now is a good time to introduce you to… the power of the… pause . . . In the OSCE, do not say anything but silently count: 1… 2… 3… and let the actress/patient take the lead, and she will continue with: ‘Oh yes, of course, the change. Well, yes, it is happening. Do you think that it might… ?’ You can now explain that the most common reason for low iron levels and blood loss in a patient of the age portrayed by the actress is irregular menstruation and menorrhagia during the ‘change’. You can continue with: ‘Yes, although it is outside my area of clinical experience, we find this to be the most common cause of Iron deficiency anaemia (blood loss), and this is the most likely reason you are getting the feeling of burning mouth and mouth ulcers too.’ Of course, there are other less common causes too if the patient was not peri-menopausal, such as internal bleeding from ulcers, oesophagitis, and colonic lesions. Coeliac disease is also implicated in iron malabsorption.5,6 However, the medical history given in this case is clear, and these conditions are unlikely to be causative of the microcytic iron deficiency anaemia you are investigating here. However, be prepared to deal with them in other OSCEs, SCRs, and in real life too! 5. Management of iron deficiency anaemia. If there are any dietary deficiencies, management is by giving dietary advice and referral to a dietician if necessary for this. A balanced diet of vitamin C rich sources, e.g. fruit and green vegetables, can promote the absorption of non-haem-iron. The chief sources of haem-iron are meat, poultry, and fish. Gastric acid is needed to convert ferric nonorganic complexes to ferrous organic complexes so iron can be absorbed in the jejunum. Interestingly, in contrast to the previous OSCE, alcohol can assist in the process of iron absorption as it stimulates gastric acid production.5 Conversely, a patient who has had a gastrectomy or a patient taking antacid medication may become iron deficient.5 Once the dietary issues have been addressed, referral to a GMP for administration of iron salts is indicated. Although you will not have to prescribe this in the dental clinic, you may be asked for details of these medications in the MJDF OSCE exam. These are as follows: 1. Ferrous sulphate: 200 mgs tds for three to four weeks. After this time, the dose response of serum iron is measured, and this treatment can continue for up to three to four months after the haemoglobin levels rise to ensure the iron stores are replenished. 2. Ferrous gluconoate: 250 mgs tds for three to four weeks can be prescribed if ferrous sulphate is not tolerated. In both MFDS and MJDF exams, a well-informed actress may ask if there are any side effects or
interactions with these medications. You should know that constipation or other altered bowel habits may occur. Tetracycline absorption can be reduced by iron, and similarly, ferrous sulphate absorption can be reduced by tetracycline.7 Explain to the patient, from these test results, with dietary correction and iron tablets, in three to four weeks we might expect to see the test results becoming normal. More importantly for the actress/patient, the oral ulceration and burning sensation in the tongue should also pass in a few weeks too. Finish the OSCE by asking if there are any questions or any explanations you have given that are not clear. If you have gone through all of the above in the 10 minutes in an OSCE, the actress will compliment you on both your reassuring manner and clinical knowledge. Don’t Learn the Reference Intervals Do not try to learn the reference intervals for the test results as you will be given them in the OSCE. The important point to note is the haemoglobin values for males and females are different. Male values are 13 to 18 g/dl and female values are 11.5 to 16.5 g/dl. Do make sure you are looking at the correct test results as they apply to the patient. There are OSCEs where incomplete or inaccurate test results are given so you have to be aware of this too. Of particular interest in clinical dentistry is that a sore tongue can develop before the haemoglobin level falls below the normal range. Atrophy of the tongue with colour change is only seen in later stages of iron deficiency anaemia.5 A perceptive practitioner should be aware of the significance of this clinical sign.8 Of importance is the smooth or bald tongue, eponymously known as Moeller’s Glossitis or Hunter’s Glossitis. In this condition the patient’s tongue becomes depapillated, appearing smooth and red. This clinical sign is seen in iron deficiency anaemia and with the other causes of anaemia discussed previously in OSCEs 17 and 18. So you need to be aware that this sign is not pathognomonic for iron deficiency anaemia.6 The Plummer Vinson Syndrome or Paterson Brown Kelly Syndrome of glossitis, dysphagia, koilonychia (ridging of the nails), and microcytic hypochromic iron deficiency anaemia is very rare and will most likely not be examined in the MFDS, but it may be a topic for the MJDF OSCE or SCRs. In this syndrome, you should be aware of the associated premalignant condition of the formation of a post-cricoid web material on the anterior oesophageal wall. As soon as the underlying iron deficiency anaemia is corrected, the precipitating factors for this rare condition are removed.5,8,9 A more common finding as well as oral ulceration or aphthous stomatitis is angular cheilitis and oral candidosis. Again, once the iron deficiency is corrected, then these conditions resolve often without the need to specifically treat the candidal infection. Remember that candidal infection is a disease of the diseased, and treating the cause rather than just the clinical sign will provide the cure.
Further Notes : Anaemias in Real Life In real life, the causes and effects seen in the previous three OSCEs often do not occur in isolation and vitamin B12, folic acid, and iron deficiency anaemias can develop together in one case and not in three separate cases as we have here. A 2013 study in Germany revealed that nearly 5% of a population study group demonstrated anaemias with 20% of these being iron deficiency anaemia, the incidence increasing with age.9 A literature search reveals that many recent studies have been undertaken in the developing world demonstrating the coexistence of anaemias and their causes.10,11 A recent study in Poland revealed that anaemia is still a problem in the healthy younger population in more developed countries too.12 Only in MFDS and MJDF examinations do these conditions appear more frequently than in real life but in isolation! However, as the standard and complexity of the MFDS and MJDF examinations evolves, we may soon see a compound type of OSCE or SCR with several anaemias overlapping each other but in one question, affecting one patient. Given the evidence from these studies, it would seem to be the case that deficiency in one micronutrient is associated with deficiencies in others too. In this OSCE, the actress is perimenopausal; if we are faced with an iron-deficient pregnant patient, then it is important to demonstrate knowledge of the importance of vitamin B12 folate in the development of the foetus and newborn where neural tube defects, behavioural anomalies, and other problems may arise from those deficiency states.5,13-15 When discussing treatment for this anaemia, if the actor displays signs and symptoms of multiple deficiencies, then compound treatments are available to deal with the conditions. Compound preparations may contain iron, folate, and ascorbic acid to aid absorption. Do be sure to add advice about the possible risks of dental erosion and abrasion from the tablets if chewed, but this is a minor point. References to Medical Matter 20 1. Nezu AM, Nezu MC. Cognitive-Behavioural Case Formulation and Treatment Design. In Di Tomasso RA, Golden BA, Morris JH. Handbook of Cognitive Behavioural Approaches in Primary Care. pp. 201-222. New York: Springer 2010. 2. Watling MA. Medical Phobias. In Di Tomasso RA, Golden BA, Morris JH. Handbook of Cognitive Behavioural Approaches in Primary Care. pp. 472-473. New York: Springer 2010. 3. Ogle NT. Theoretical Perspective on Empathy. In Chapter ll: Review of the Literature. Cultivating Empathy among Undergraduate Students through the Implementation of Personalization Exercises. pp. 17-21. Ann Arbor: UMI Proquest LLC 2008. 4. Davis MH, Measuring individual differences in empathy: evidence for a multidimensional approach. J Pers Soc Psychol. 1983;44:113-26. 5. Scully C. Chapter 8: Haematology. Anaemia. In Scully C. Medical Problems in Dentistry. 6th Edition pp. 202-208. Edinburgh: Churchill Livingstone 2010.
6. Corazza GR, Valentini RA, Andreani ML, et al. Subclinical coeliac disease is a frequent cause of iron-deficiency anaemia. Scand J Gastroenterol. 1995 Feb;30(2):153-56. 7. Campbell NR, Hasinoff BB. Iron supplements: a common cause of drug interactions. Br J Clin Pharmacol. 1991 Mar;31(3):251-55. 8. Chi AC, Neville BW, Krayer JW, Gonsalves WC. Oral manifestations of systemic disease. Am Fam Physician; 2010;82(11):1381-88. 9. Eisele L, Dürig J, Broecker-Preuss M. Prevalence and incidence of anemia in the German Heinz Nixdorf Recall Study. Ann Hematol. 2013 Jun;92(6):731-37. 10. Bhardwaj A, Kumar D, Raina SK, Bansal P, Bhushan S, Chander V. Rapid assessment for coexistence of vitamin B12 and iron deficiency anemia among adolescent males and females in Northern Himalayan State of India. Anemia. 2013;2013:959605. 11. Pasricha SR, Shet AS, Black JF, Sudarshan H, Prashanth NS. Biggs, BA. Vitamin B-12, folate, iron, and vitamin A concentrations in rural Indian children are associated with continued breastfeeding, complementary diet, and maternal nutrition. Am J Clin Nutr. 2011 Nov;94(5):135870. 12. Szczuko M, Gutowska I, Seidler T, Mierzwa M, Stachowska E, Chlubek D. Risk of anaemia in population of healthy young people inhabiting a region in central Europe. J Nutr Metab. 2013; 2013: 646249. [Online] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736460/ [Accessed October 2013]. 13. Brito A, Hertrampf E, Olivares M. Folate, vitamin B12 and human health. Rev Med Child. 2012 Nov;140(11):1464-75. 14. Ströhle A, Wolters M, Hahn A. Nutrient supplements—possibilities and limitations: part 2. Med Monatsschr Pharm. 2013 Jul;36(7):252-66. 15. Elmadfa I, Meyer AL. Vitamins for the first 1,000 days: preparing for life. Int J Vitam Nutr Res. 2012 Oct;82(5):342-47. Further Reading for This Medical Matter. 1. Mitchell L, Mitchell DA, McCaul L. Oral Manifestations of Haematological Disease. In Oxford Handbook of Clinical Dentistry. 5th Edition pp. 432-434. Oxford: Oxford University Press 2010. A good overview at the MFDS level may be a bit thin for the MJDF SCRs. 2. Department of Health. Section 4: Healthy Eating Advice. In Delivering Better Oral Health. An Evidence-based Toolkit for Prevention. 2nd Edition. London: Department of Health 2009. Everything the Department of Health wants you to know to tell your patients. 3. Quince TA, Parker RA, Wood DF, Benson JA. Stability of empathy among undergraduate medical students: a longitudinal study at one UK medical school. BMC Medl Educ. 2011 Oct 25. [Online] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219554/ [Accessed July 2013].
A great study showing that men are less empathic than women. No surprises there. Although cognitive empathy does not decline, men become less affectively empathic as they progress throughout their undergraduate studies than women do. While the results are statistically significant, the authors do not know how practically significant they are. Perhaps the reason the authors couldn’t figure out a practical application is that Cambridge, where the study was undertaken, doesn’t have a dental school. If you plan to pass the MFDS and MJDF then read this paper!
Medical Matter 21 Background Information The previous three OSCEs were based on questions seen in the MFDS examinations. You will commonly see examples of this type of OSCE in many test-books and in revision courses for both MFDS and MJDF syllabus. Simple explanations for the clinical presentations provide the answers to the questions posed by the actors and examiners in these exams. This OSCE is based on a patient who trundled in to see me for some basic dentistry. We ended up seeing each other and nearly everyone else in his family for the next five years! To date, I have not yet seen an example of this type of case in the exams or revision texts. Yet the foundation grade dentist and the general dental practitioner with no postgraduate training will regularly treat patients such as the case described here. The link between this OSCE and the previous three OSCEs will become clear as we progress through the clinical details of this case. I have moved this OSCE away from an MFDS style of question and answers with dialogue, towards the MJDF structured series of questions you will find in that exam’s OSCEs. The level of detail explored in this case is fairly deep and thorough. By going through the questions and the answers in this case to the level provided, you should be well prepared to answer questions in this subject not only for the MJDF OSCE, but for the SCRs too. The format in which the subject matter has been explored with an oral presentation leading to a systemic condition, leading back to another oral presentation, is intended to encourage you to think and read further into and around not only this case but also the others coming up in the following OSCEs. Introduction The patient is a 30-year-young adult with Down’s syndrome and Eisenmenger’s syndrome too. He attends with his mother and carries his oxygen tank with nasal supply. He suffers from asthma and takes a salbutamol inhaler. In the past, he has used a steroid inhaler, but this is infrequent and has not been needed for some time. The patient does have moderate learning difficulties and relies on his family for support. His mother tells you that at night she can hear him noisily grinding his teeth. He has attended several times and enjoys his visits to the dental practice. He looks forward to chatting to the trainee dental nurses, and they oblige by making him cups of tea with extra sugar. The patient is happy to attend and does enjoy his food, resting his oxygen tank on his well-filled tummy.
Obesity is not yet a concern, but something his mother is aware of, taking steps to control his diet. The oral hygiene is not that good with bleeding gums, plaque, and calculus covering one-third of the lower incisors both labially and lingually. The lips and gums appear dark red/blue and the lower lip is terribly cracked. The tongue appears swollen with deep grooves and fissures. The lower incisors are somewhat mobile. There is no decay, but there are enamel lesions on the premolars and molars. Questions 1. In this case, why is it important to take a medical history? Which conditions might the patient frequently suffer from and can these affect dental treatment? 2. What is Down’s syndrome? 3. Can a patient with Down’s syndrome consent for dental treatment? 4. Can you note some of the common clinical features, both extra-oral and intra-oral, of this syndrome? 5. Do these present any problems for the patient in receiving dental treatment or the dental practitioner in giving dental treatment? 6. From the information in the introduction are there any other dentally relevant issues you have noticed? How may these impact on dental treatment? 7. Please note the treatment you can give to this patient, where do you begin? 8. Are the any other reasons the patient may have cracked lips and how might you address this problem? 9. What is Eisenmenger’s syndrome? 10. What clinical signs are seen in this syndrome? 11. What are the dental implications? 12. How can the clinical conditions be dentally managed or treated? 13. Recalling the haematological issues with the previous OSCE, what further treatments may be necessary for this case? 14. Which other medication might be used and are there any oral side effects from this? 15. Thinking laterally, which other medication normally contraindicated for use in patients with cardiovascular diseases might find a particular use in this case due to a favourable benefit—risk ratio in this case? Answers 1. Having completed the appropriate clinical introductions, you can proceed to take a medical history. Every time every patient attends for dental treatment, the medical history must be updated. In this case, the patient’s mother will have completed a medical history form on his behalf. In the OSCE, you should briefly go over this again and specifically ask if there are any medications the patient is taking which there may be from time to time or any procedures which the patient has to
undergo. Specifically, URTIs (Upper Respiratory Tract Infections) should be noted as these may preclude dental treatment from going ahead. Any patient who needs supplemental oxygen and suffers from asthma will be at risk from complications from common viral colds. 2. Down’s syndrome or Trisomy 21 is the most common of all malformation syndromes affecting up to 1 child per 800 births in the UK. (In several texts and online sources, the range is from 1 in 650 to 1 in 1,000 live births.) It is commonly known that older mothers are more likely to have a baby with Down’s syndrome. However, as older mothers do have fewer children, three-quarters of Down’s syndrome children are born to younger mothers. The relative risk rises from 1 in 1,000 at age 30 to 1 in 100 at age 40 and higher as the age increases.1 Down’s syndrome is caused by complete or partial DNA replication, specifically, trisomy of chromosome 21. The replication of DNA is from the long arm of the chromosome 21, and interestingly there is a wide range of how much DNA is replicated and in which cells this replication event occurs. So Down’s syndrome represents a huge range of penetrance and expressivity of this condition. This is significant as not all your patients who have Down syndrome have a similar phenotype. Some 92% of Down’s syndrome cases have an extra chromosome 21 in all cells. The most common cause (88%) is from chromosomal non-dysjunction of maternal DNA, and this explains the common pattern of increasing incidence with maternal age.1 3. With Down’s syndrome, the degree of expression or severity of the syndrome will determine whether a patient can consent for treatment or not. In this case (but not all patients with Down’s syndrome), the patient can consent for an examination. However, any actual treatment for this patient will need the assent and permission from the mother or other legally appointed guardian. Consider the Capacity then Consent. In this OSCE, it is important to demonstrate that you are continually assessing whether a patient has the capacity to consent to examination and/or treatment. As mentioned previously, a common device used in the MFDS is to employ an actor portraying a relative of the patient, and you will communicate your knowledge and understanding of the condition to them as they literally act as advocates. For sure, there are actors who have Down’s syndrome, but I don’t know if the Royal Colleges would engage someone specifically with this condition to portray a patient with the condition. Capacity to consent for treatment must be in accordance with the Mental Capacity Act 2005. At each visit, mental capacity must be assessed in relation to the proposed treatment. In the coming chapters, we will return to explore consent in greater detail. 4. Down’s syndrome has readily recognisable features easily noted in the dental clinic. The individual features and their prominence vary from patient to patient. The more interesting features to look out for are iris white spots (Brushfield spots) which are of no dental relevance, but do look for them, and pointing them out to your patients shows your interest. It also shows you have been reading around the subject too. Patients with Down’s syndrome often have multiple mobile and tender cervical lymph nodes. These are dentally relevant and are indicators of dental infections. Cervical Lymph Nodes
No dental exam on any patient would be complete without examination of the cervical lymph nodes. Interestingly, patients with Down’s syndrome are at greater risk of leukaemia in childhood, but thankfully, this association did not apply in this case. Intra-orally there is no macroglossia, but there is poor motor control and thrusting of the tongue with speech and swallowing problems. In patients with Down’s syndrome, the forward posturing of the deeply fissured tongue gives an appearance of macroglossia. The classic class lll skeletal pattern in Down’s syndrome with poor oral seal and mouth breathing contributes to drying out of the fissured lips that now appear cracked and very painful. 5. With painful cracked dry lips, the patient’s desire to brush the teeth is now almost non-existent. The lower incisors are spaced, so they accumulate plaque, and therefore calculus develops more readily. The potential to develop candidal infection is increased due to a decreased neutrophil function. Antibody and complement levels are diminished in patients with Down’s syndrome too. 2 The cracked lips may become super-infected with both fungal and bacterial species simultaneously. Although not in this case, but in other patients with Down’s syndrome, angular cheilitis is commonly seen. 6. The patient’s mother has heard her son noisily grinding his teeth at night. This bruxism would be the primary cause of tooth mobility in the lower incisors. The poor oral hygiene is secondary to this and promotes if not accelerates further mobility of the lower incisors by a process of periodontal destruction. Please do not forget with Down’s syndrome the patients often have shorter rooted teeth, so with compromised periodontal support and a susceptibility to periodontal disease, the teeth will become more mobile more readily.3 Silver Linings a. Perhaps the only two silver linings around this cloud of dental misery are firstly, although the molars have short roots, they do have shallow fissures, and secondly, patients with Down’s syndrome have been noted to have a lower caries prevalence than the general population.1,4 b. Nevertheless, in this case the trainee dental nurses are doing their best to overcome this inherent advantage with the generous addition of sugar to the endless supply of tea and buns the patient has come to expect from his dental visits. c. This behaviour should be monitored and moderated. As a dentist, it would be your responsibility to do so. 7. Treating the cracked and dry lips is the first thing to do to gain ease of mouth opening for an exam. Petroleum-based cream or beeswax preparations should be applied before you begin treatment. The angular cheilitis can be treated with Fusidic acid based topical cream. Miconazole gel can also be applied. One interesting link between this case and the three previous OSCEs is that underlying factors predispose patients to angular cheilitis, and these are deficiencies of vitamin B12, folic acid, and iron.
In this case from reading the introduction, you will know there are no dietary deficiencies. 8. Whereas patients with Down’s syndrome do have an increased incidence of coeliac disease, they do not have an increased incidence of Crohn’s disease. 5 There may be other reasons for the appearance of the cracking of the lips as described in the introduction. The patient has nasal oxygen and this is taken 24 hours per day; the oxygen is delivered via a small bore tubing into nasal cannulae. You need to ask the patient and his mother how frequently these tubes are cleaned. Are they cleaned at all/ever? Although these questions are outside the remit of clinical dentistry, they are nevertheless essential questions which must be asked, for the following reasons: The patient’s nostrils and these tubes are a good source from where Staph. aureus species can thrive and then contaminate the fissures of the tongue and cracks in the lips, leading to colonisation and a resident infection. Application of Mupericin cream to the nostrils should solve this problem. Regular cleaning and replacement of the oxygen tubes is also important. In the absence of infection, perhaps the most obvious reason for the lips cracking is the desiccant effect of constant oxygen flowing over and around them. The application of barrier creams can limit this damage to the lips. 9. Eisenmenger’s syndrome is a condition closely associated with Down’s syndrome. Of those patients with Down’s syndrome, some 40% to 50% have some form of cardiovascular defect. 6 In other words, 1 in 1,200 to 1 in 2,000 of all live births in the general population will have a cardiovascular defect. In Eisenmenger’s syndrome, there is a septal defect between the left and right ventricles where the diameter of the defect exceeds 1.5 cms. Through this defect, blood will flow from the left to the right side of the heart, bypassing the systemic circulation. With exposure of the pulmonary circulation to high-pressure blood flow, damage to the delicate vascular structures is seen, with resulting fibrosis, scarring, and blockage of the capillaries in the lungs. Following this, there is increased vascular resistance in the pulmonary circulation, and so blood pressure builds in the right ventricle, firstly to match and secondly to exceed the blood pressure in the left ventricle. Right ventricular hypertrophy develops and blood flow is reversed from the right ventricle back through the septal defect to the left ventricle. Systemic venous blood mixes with oxygenated pulmonary blood in the left ventricle, bypassing the pulmonary circulation to re-enter the systemic circulation once more.7 A congenital ventriculo-septal defect, pulmonary hypertension, and reversal from a left-right to a right-left shunt define the Eisenmenger’s syndrome.7 10. In a patient with Eisenmenger’s syndrome, there is de-oxygenation of blood flow in the systemic circulation. Compensatory overproduction of red blood cells occurs, placing an increased physiological stress on the marrow and the liver. More immature red cells are released into the circulation, with further build-up in red blood cell breakdown products. This is the process of physiological or secondary polycythaemia. Hyper-viscosity in the poorly oxygenated blood results in venous stasis and increased capillary pressure. Abnormal coagulation is seen due to venous stasis, and subsequently excessive bleeding
occurs due to increased blood pressure from damaged capillaries as less pliable immature red blood cells congest capillaries in almost any area of the systemic and pulmonary circulation with a haemodynamic pressure increase rupturing the delicate endothelium. The above processes occurring in Eisenmenger’s syndrome explain why the lips, gums, and tongue in the patient appear dark red or even blue. The increased physiological demand for red blood cell production not only creates hyper-viscose blood it also creates an increase in demand for iron too.8 11. Of note and importance in patients with Down’s syndrome with cardiovascular defects (remember this could be around half of all patients with Down’s syndrome), a deficiency in iron is contributory to the emergence of the angular cheilitis and appearance of the tongue. None of the above conditions and complications precludes dental treatment from going ahead in general dental practice. In the OSCE and with patient care in the dental clinic, despite the altered immune response, decreased neutrophil function, and cardiovascular defect, it is important to demonstrate that antibiotic cover is not needed in cases such as this. Nevertheless, there is a risk of bacterial endocarditis, and it is the responsibility of the carer to identify such a problem if it occurs and to refer immediately for treatment. 12. After the issue with the painful cracked lips has been addressed, the poor oral hygiene must be treated with either a hygienist or a dentist providing oral hygiene instruction with scaling and cleaning. However, the need for periodontal treatment must be ongoing to prevent relapse and accumulation of plaque and calculus again, especially in the lower incisors. The mobility of the teeth is exacerbated by the nocturnal bruxism, and provision of a bite guard may be an option as would securing the mobile teeth with a wire splint bonded on to the teeth with composite. The posterior teeth might be fissure sealed, and further investigation of the dento-alveolar structures can be achieved by use of a panoramic radiograph. On examination, no teeth were damaged or excessively worn with the bruxism, so keeping the teeth under observation and restoring as necessary would be the most conservative and appropriate option. The need for extensive restorative work in the future can be avoided by good dietary advice and oral hygiene instruction. These measures should be given for all patients and especially those with Down’s syndrome and cardiovascular problems too. 13. As stated above, the medications the patient is taking should be assessed, but generally these do not interfere with dental treatment. The additional procedures the patient needs should be noted, and this is venesection to reduce hyperviscose blood. Ultimately, this leads to low iron stores, and these have to be replenished in the same manner as the previous OSCE 20, namely: 1. Ferrous sulphate: 200 mgs tds for three to four weeks. After this time, the dose response of serum iron is measured, and this treatment can continue for up to three to four months after the haemoglobin levels rise to ensure the iron stores are replenished. 2. Ferrous gluconoate: 250 mgs tds for three to four weeks can be prescribed if ferrous sulphate is not tolerated. 14. Diuretics may be taken by those patients with Down’s syndrome and Eisenmenger’s syndrome to
control both pulmonary and systemic hypertension. The oral side effects such as dry mouth can exacerbate the conditions described above, especially when we consider that the patient is mouth breathing too and already has painful dry and cracked lips. 15. In a patient with Down’s and Eisenmenger’s syndromes, the other medication that might be taken to open up arterioles and reduce the pulmonary artery hypertension are GMP-specific phosphodiesterase type 5 inhibitors. An example of this is Sildenafil citrate which very effectively opens and maintains patency in both pulmonary and systemic arterioles.9 It is interesting to note that this medication in its other guise is contraindicated in those with cardiovascular disease due to the unfavourable risk-benefit ratio. Nevertheless, in those patients with Down’s syndrome and Eisenmenger’s syndrome, the ratio favours more benefit than risk and therefore it is cleared for use. Further Notes to This Medical Matter. Almost all of you, at some time in your undergraduate and foundation grade clinical work, will have treated a patient with Down’s syndrome. The main purpose of this question is to encourage you to think around and into the subject matter in greater detail than that required for a routine clinical exam or an OSCE. In doing so, you will be well prepared to deal with this subject in the SCRs, and the next time a patient with these syndromes attends for treatment, you will have a greater understanding of the systemic processes at work behind the clinical presentations you see. References to Medical Matter 21 1. Scully C. Down Syndrome (Mongolism or Trisomy 21) General Aspects. In Medical Problems in Dentistry. 6th Edition pp. 620-621. Edinburgh: Churchill Livingstone 2010. 2. Lee SR, Kwon HK, Song KB, Choi YH. Dental caries and salivary immunoglobulin A in Down syndrome children. J Paediatr Child Health. 2004 Sep-Oct;40(9-10):530-33. 3. Frydman A, Nowzari H. Down syndrome-associated periodontitis: a critical review of the literature. Compend Contin Educ Dent. 2012 May;33(5):356-61. 4. Mahoney EK. Chapter 6: Down’s Syndrome. In Odell E. Clinical Problem Solving in Dentistry. 3rd Edition pp. 27-32. Edinburgh: Elsevier, 2010. 5. Malt EA, Dahl RC, Haugsand TM, et al. Health and disease in adults with Down syndrome. Tidsskr Nor Laegeforen. 2013 Feb 5;133(3):290-94. 6. Chung EM, Sung EC, Sakurai KL. Dental management of the Down and Eisenmenger syndrome patient. J Contemp Dent Pract. 2004 May 15;5(2):70-80. 7. Selzer A, Laquer GL. The Eisenmenger complex and its relation to the uncomplicated defect of the ventricular septum: review of thirty-five autopsied cases of Eisenmenger’s complex, including two new cases. AMA Arch Intern Med. 1951 Feb;87(2):218-41. 8. Wood P. The Eisenmenger syndrome or pulmonary hypertension with reversed central shunt. Br Med J. 1958 Sep 27;2(5099):755-62. 9. Sun YJ, Yang T, Zeng WJ. Impact of sildenafil on survival of patients with Eisenmenger syndrome.
J Clin Pharmacol. 2013 Jun;53(6):611-18. Further Reading 1. Smith DS. Health care management of adults with Down syndrome. Am Fam Physician. 2001 Sep 15;64(6):1031-38. A good overview on what you need to do and know with Down syndrome or T21 cases. 2. Scully C. Chapter 5: Cardiovascular Medicine, Valvular Heart Disease. In Medical Problems in Dentistry. 6th Edition pp. 121-124. Edinburgh: Churchill Livingstone 2010. A brief description of the patho-physiology of cardiac diseases, useful for the MJDF SCR questions. 3. British Association for the Study of Community Health. Delivering Better Oral Health: An Evidence-based Toolkit for Prevention. Section 2: Principles of Tooth Brushing. pp. 17-18. London: Department of Health 2010. The data and evidence for giving tooth brushing instruction to patients.
Medical Matter 22 Background Information Cases such as the previous one dealt with a common genetic condition, resulting in a syndrome with quite striking difficulties that the patient and his carers have to deal with, overcome, then just get on with being alive. In contrast, as if life itself was not enough of a challenge, there are some patients who are not satisfied with their lot and take it upon themselves to request modifications to their appearance with surgical and non-surgical cosmetic or aesthetic procedures. There are many dentists who blissfully, if somewhat misguidedly, oblige such patient’s desires, without much thought as to what they are doing or why they are doing it. Then there are those patients who don’t need the assistance of the medical or dental profession in their quest for perfection and decide to self-medicate with various drugs, and finally when things don’t go according to plan or unforeseen complications arise, only then will they seek our help. In contrast to the previous patient who was quite happy with the cards he was dealt with to play the game of life, this next case (also based on a patient I treated) was far from happy with the cards he had been dealt. He decided to have the deck loaded in his favour. This case was interesting enough for inclusion in the Faculty of General Dental Practice (FGDP) portfolio. If you are on the Fellowship pathway for FFGPD, then you will need to gather cases for presentation as this form of assessment is no longer part of the MJDF syllabus. Introduction The patient in his mid-thirties is a confident athletic-looking male of large build displaying well-
developed musculature. The patient has advanced male pattern baldness. He works nights as a doorman in the pubs and clubs in town. During the day, he is a collector. Previously, a colleague has seen the patient. His reason for re-attendance is to repair a lower molar he has broken. The dental history reveals that a lower right first molar, although previously filled, has now broken while the patient clenched his teeth during certain weightlifting exercises. The tooth has broken several times and has been repeatedly filled; every time the conservative treatment fails, another more extensive plastic restoration is placed. Even though the patient is happy to re-attend for the repair work, this is the first time with yourself, and you detect a little dissatisfaction in his demeanour. In the course of your consultation, the patient discloses that he is taking the following medication: 1. Stanozolol 50 mgs ods PO and 50 mgs IM ods. 2. Testosterone Cypionate injected intramuscularly on a weekly basis. 3. Dianobol (Methandrostenolone) taken orally. 4. Decadurabolin (Nandrolone) taken orally on monthly cycles at various doses. 5. Sumatriptan 50 mgs ods PO. 6. Atenolol 50 mgs ods PO. 7. Doxazosin 1 mg ods PO. 8. Bendroflumethiazide 2.5 mgs to 5 mgs three times weekly. 9. Isotetretinoin 20 mgs ods PO for 2 months duration. In contrast to the previous OSCE, I have placed this case in the MFDS syllabus with points to consider and notes in your dialogue with the actor/patient. The answers to the questions are of sufficient detail for those needed in the MJDF OSCE and SCR questions too. Questions 1. Please take a medical and dental history from this patient. 2. Why might the actor/patient be defensive and resist giving you the information to compete a medical and medication history? 3. How might you gain the confidence or compliance of the actor/patient to agree with your need to take a medical and medication history? 4. If you look at the substances the patient is taking, how would you broadly classify these? 5. What possible unintended side effect might be seen from some of these drugs? 6. With the side effects noted, how might some of the medications work to counteract these, and do these drugs used secondarily have any oral and dental side effects in themselves? 7. Why would a restoration repeatedly fail in this patient?
8. Are there any additional factors contributing to failure in this case? 9. Are there other contributory factors resulting in failure, i.e. not coming directly from the patient? 10. From your reasons given for the failure, what might you consider to be a more appropriate restoration? Which investigations might you carry out and why? 11. Before treating this patient, how would you assess him medically? 12. From this assessment, is this patient well? 13. As a result of your medical assessment, is there anything you would do differently with this patient when compared with others you might treat in the dental clinic? 14. Are there any indirect risks to the patient and yourself from the patient’s drug use? 15. If restoration is not possible, what other options and precautions might you need to take? Answers 1. In this OSCE, begin in the usual manner with professional introductions. After this, the first task to be undertaken is updating the medical history and drug history. Begin your taking of a medical history by asking about the following: Heart, cardiovascular system, gastrointestinal tract, and genito-urinary tract. Then move on to the musculoskeletal system. It is important to question whether there is muscle tenderness as this might be implicated in the development of the headaches the patient has been complaining of. Continue your history taking by asking the patient about their: Operations and Illnesses, then finish by asking about any medications the patient might be taking. Make this medical history gathering a brief but inclusive ‘net-casting’ exercise, demonstrating your professional approach to patient care and as a ‘catch-all’ to gather up any further data to include in your treatment planning. In this OSCE, the medical history is completed with enquiries about drugs the patient may have selfprescribed. Patient’s retort. Somewhat unsurprisingly, the patient responds with a retort that he can’t see what this has to do with dentistry, and as you are just the dentist and not even his usual dentist, why do you need to ask all these questions. ‘My dentist doesn’t ask these questions. He just gets on with it. Why do you need to know about anything I am taking?’ 2. In both the OSCEs and in the dental clinic, you will commonly experience this type of response from actors and patients. In OSCEs, this can be a retort to a badly phrased question on your part. In response, focus on the task set in the examination. Put your question another way and continue to acquire the information needed to come to a diagnosis. In the dental clinic, there are three reasons
for a patient to respond in this manner: a. The patient is a confident outgoing Type A personality and wants to take control of the consultation to do things his way. b. The patient is not used to your thorough and methodical way of doing things, as his previous dentist has not engaged in the process of information gathering. Rather, the emphasis then was on patient-practitioner interaction, treating the signs and symptoms but not addressing or treating the underlying causation. c. The drug history is something the patient initially did not want to reveal as it was considered an irrelevance by him. In fact, in this case, it is anything but an irrelevance and is central to the causation of the patient’s attendance. 3. Your response to the initial reluctance to open questions and data gathering for the medical history would be to state: ‘I do appreciate that you might not have been asked these questions before. As this is the first time I am seeing you and you have returned to the surgery a good few times for the same treatment, I really would like to understand if there is anything else going on which might lead to repeated failure of the filling you have had.’ In response to this, the actor/patient should relax a little. You can continue by again asking about the medical and medication history: ‘Perhaps we can begin by asking about any medication or drugs you are taking. I really do need to know about these. In learning more about you, I have to tell you all the information you give me is confidential and will not be released to anyone else.’ 4. We can see the first four drugs are taken recreationally or are self-prescribed, and these are a mixture of anabolic and androgenic steroids: 1. Stanozolol 50 mgs ods PO and 50 mgs IM ods 2. Testosterone Cypionate injected intramuscularly on a weekly basis 3. Dianobol (Methandrostenolone) taken orally 4. Decadurabolin (Nandrolone) taken orally on monthly cycles at various doses. The drugs in the second group are prescription medicines provided by the patient’s GMP: 5. Sumatriptan 50 mgs ods PO 6. Atenolol 50 mgs ods PO 7. Doxazosin 1 mg ods PO 8. Bendroflumethiazide 2.5 mgs to 5 mgs three times weekly 9. Isotetretinoin 20 mgs ods PO for 2 months duration. The first group of drugs are non-prescription recreational substances. In assessing these, we have to be aware there is no control over their quality and quantity. Rather than going through these drugs in
this first group one by one, I think it would be sufficient to answer: The patient had acquired these for his recreational use. These drugs are a mixture of androgenic and anabolic steroids used in various experimental combinations to build skeletal muscle mass and reportedly reduce body fat. The patient’s GMP prescribes the second group. These are prescribed to counteract unintended side effects from the first group of drugs. 5. When the patient attended, it would be fair to say that his experimentation with anabolic and androgenic steroids had achieved a fair degree of success. However, the side effects of this patient’s recreational pharmaceutical experiment had been to cause headaches, hypertension, acne, and gynaecomastia. Points to Note. a. All of these symptoms were eventually reported by the patient in the taking of a medical history. b. As noted above, the patient’s previous dentist considered these signs and symptoms to be dentally irrelevant. c. By working through the answers to this OSCE, you will see that these signs are especially relevant to dentistry. 6. If we go through the list of prescribed medication, we can see how these might work to eliminate or reduce the side effects of the recreational drugs the patient is taking. The oral side effects are noted too. 1 . Sumatriptan is an anti-migraine drug. Although contraindicated in severe or uncontrolled hypertension, this drug is being used in this case to reduce cluster headaches. There do not appear to be any direct dental side effects; however, muscle tremor has been reported, and liver and renal toxicity are issues with high doses of this drug.1 2. Atenolol is a cardio-selective beta adrenoreceptor antagonist. In this case, the use of Atenolol was twofold: to control the systemic hypertension caused by drug-induced patho-physiological increase in skeletal muscle mass from steroid use and to reduce the onset of migraine and cluster headaches. As with Sumatriptan, hepatotoxicity may arise with higher doses.2 Of importance and note with dentistry, the use of a cardio-selective beta blocker in this case coupled to a hypertensive patient will contraindicate the use of epinephrine containing dental local anaesthetics. Other than this interaction, there do not appear to be any oral or dental side effects. 3. Doxazosin is an alpha adrenoreceptor blocking drug. In this case, it is used to treat hypertension. In a thirty-something-year-old male, hypertension is unusual; the cause is most likely to be a side effect of the anabolic and androgenic steroids and the anaerobic exercises the patient subjects himself to. The side effects of Doxazosin that may be aggravated by the group one androgenic drugs are gynaecomastia, impaired liver function leading to hepatitis, weight gain, and alopecia. There do not appear to be any oral and dental side effects of this medication or interactions with commonly prescribed antibiotics for dental needs.3 4. Bendroflumethiazide is a thiazide diuretic used to treat hypertension. It can very effectively
lower blood pressure with minimal doses. In higher doses, hepatic impairment may occur. With the other drugs this patient is taking, this should be considered. Bendroflumethiazide used in this case is to reduce the oedema resulting from the use of anabolic steroids. The anabolite Methandrostenolone characteristically causes fluid retention and thus the hypertension seen in this case. With regard to the Doxazosin, the hypotensive effect of Bendroflumethiazide will be enhanced when used in conjunction with this adrenoreceptor antagonist.4 Possible dental side effects are dry mouth and altered saliva flow. 5. Isotretinoin is a topically applied preparation for acne. In severe cases, the drug can be taken orally. This patient is taking Isotretinoin as a result of the acne caused by increased sebaceous gland activity which results from the androgenic steroid use. The pattern of acne following androgenic steroid use presents across the upper back, shoulders, and forehead; only rarely are peri-oral areas affected. So there should be minimal exposure to the oral tissues from this medication.5 7. It might be sufficient to state the restoration failed because the functional loads placed on the material used exceeded the material’s ability to resist the compressive loading placed on it. If we explore this answer to a detail as might be required to answer an MJDF SCR, rather than an OSCE, we have to look at the material used and the effects of the drugs in group 1 (listed above) and conduct a full intra-oral examination. Even though in both MFDS and MJDF intra-oral examinations are not conducted, there is sufficient information given in the introduction of this case to guide you towards the reasons for repeated failure. In the introduction, it was stated that a lower right first molar, previously filled, had broken when the patient clenched his teeth while performing certain weightlifting exercises. From basic material sciences, we know that any metallic cast restoration (gold or non-precious alloys or cast porcelain/glass) will be more durable than any plastic material (amalgam or composite or Glass Ionomer). We know that the tooth was filled and has repeatedly failed. In an OSCE, further questioning of the actor/patient would be necessary, and one question we might ask is: ‘Have any of your other teeth broken?’ From appropriate questioning, it was revealed that there were multiple failures of the natural and restored dentition too. If the patient was sitting in front of you, evidence of clenching might be seen from well-developed masseteric muscles which were tender. If you could examine the patient intra-orally, you would see faceting of the molar dentition that is indicative of bruxism. The hypertrophy of the masseteric muscles results from anabolic steroid use, while androgenic steroids taken will be implicated in the mandibular prognathism.6 This combination of increased muscular activity with mandibular growth, creates adversely directed inter-arch forces exerted in directions incompatible with the long-term survival of any plastic restoration.
8. Despite the above, it is debatable to state that masseteric hypertrophy is solely responsible for the repeated failure of the restoration in this case. Even with hypertrophic masticatory muscles exerting their forces during chewing and clenching, the actual forces developed against teeth may not be significantly more than those developed by normal non-enhanced musculature. The failure in this case was caused when these forces were directed along pathways not within the normal envelope of mastication; that is, parafunctional activity might be implicated here. It was stated in the introduction: ‘The patient clenched his teeth while performing certain weightlifting exercises’. It was during these extremes of exertion that parafunction and failure occurred. Therefore, both prognathism and masticatory muscle hypertrophy were contributory to the dental failure as was the inappropriate use of a plastic restorative material. The other factors involved in failure, in addition to the mechanical overloading are repeated cycles of smaller forces directed against the restoration. One side effect of anabolic and androgenic steroid use, with added Sumatriptan medication is muscle tremor. 1 This may promote failure of a restoration if small micro-forces are directed against the teeth in a chronic manner. 9. A further contributory factor in restoration failure may have (surprisingly) been the patient’s forceful and quite strident personality. Unreasonable demands may have been placed on the previous dentist to come up with ‘instant’ solutions to the problem of failure. Rather than taking a step back to assess why the restoration may be inappropriate or inadequate, the previous practitioner simply acceded to the patient’s demands for immediate solutions, resulting in (almost) immediate failures yet again. 10. After the first failure, it would have been more opportune to advance the dental care of this patient using a cast restoration. In this case, an advanced conservative solution is needed. Should the failure of the restoration involve the root structures then endodontic treatment or extraction would be indicated. The first investigation needed is periapical radiography limited to the tooth in question. In this case, due to multiple restorative failures, it would be quite in order and within the FGDP guidelines to use a panoramic radiograph to identify any further failures and the extent of the problem in the upper and lower jaws. An added benefit from the panoramic view is to identify the vital neurovascular structures and to note their displacement with the degree of mandibular growth caused by the drug-induced prognathism.7 11. On one hand, the patient presents to you as an athlete (of sorts.) On the other hand, with the medication prescribed to control the side effects of the drugs being taken, although he may look the picture of health, he is not. You will recall from OSCE 11 the use of the ASA system 8 to assess a patient, and here once more is the system for you to consider with this patient: ASA 1 Normal healthy patient with no medication. ASA 2 Patient with mild systemic disease, including conditions, e.g. asthma, pregnancy, or epilepsy. ASA 3 Patient with severe systemic disease but not incapacitating, e.g. uncontrolled hypertension, recent myocardial infarct, asthma which is severe, stroke, or uncontrolled diabetes.
ASA 4 Patient who has a condition which is a constant threat to life, e.g. cancer, unstable angina, arrhythmia, or recent stroke. ASA 5 The moribund patient not expected to live longer than another 24 hours. 12. If the patient did not partake of extreme physical exercises and was hypertensive, I would place him at ASA 3. Given the recreational exercises, it is possible he may even be ASA 4. From this assessment, clearly the patient is not a well man. Point to consider In the press and medical literature, there have been a few cases of anabolic steroid using strength athletes who have died from cardiovascular complications following or even during physical exercise. This is not the same as the Sudden Cardiac Death Syndrome seen in endurance athletes, where the hypertrophic cardiomyopathy occurs in genetically predisposed athletes and is a primary response to exercise challenge.9 In this case, the hypertrophy is a response to anabolic and androgenic steroid use, placing unduly severe systemic resistance on the heart muscle. The hypertrophy of the heart muscle is a response to both patho-physiological stress and pharmacological exposure to these drugs too. With the combination of recreational activity, an underlying hypertension and the medication being taken, you can confidently assess this patient as being: ASA 4. 13. In the dental clinic, you might consider treating him in the same way as you would an elderly frail grandmother. In essence, this patient’s heart is so overworked that it might fail at any time. In the dental clinic, the use of epinephrine containing anaesthetics would be contraindicated. Lying the patient flat in the dental chair might be contraindicated due to the pressure on major vessels supplying blood to and from the heart. You might consider treating him in the seated position or indeed referring him for specialist care. 14. The other risks to the patient are from his use of recreational drugs. In the steroid using fraternity (and indeed the steroid using sorority) it is known that steroids taken orally cause more harm to the liver than the intramuscularly applied variety. It is quite remarkable to note this level of medical understanding is common knowledge among recreational drug users. So there has been a move towards using injectable androgenic steroids (Testosterone Cypionate) and away from oral anabolic steroids (Dianobol and Decadurabolin) Needle supply and exchange programmes do exist, so the risk of acquired infections such as hepatitis B and C are minimised but not eliminated. The paradox is that athletes no longer share needles, but they might share the vial from which the drug is taken. So the risk is still present. Of course, the application of universal cross-infection control measures in the dental clinic mean the risk for you is the same for this case as it is for all cases you treat. However, a patient who has taken drugs to the extent described in this case is at risk of hepatotoxicity; the added perils of acquiring hepatitis B or C only add to the potential hazards. 15. If the tooth cannot be restored, then extraction is another option. Given the hypertension and hepatotoxicity, then expect the patient to have an abnormal coagulation profile. Be prepared to state in the OSCE that if extraction is needed, in addition to using a non-adrenaline containing anaesthetic,
haemostasis would be better achieved with sutures and haemostatic agents placed in the socket. As always, provide the patient with all the realistic and available options for treatment that you can complete and ask if there are any questions, complete all necessary investigations or arrangements for referral, and clearly state in an OSCE you are doing this and give your reasons for doing so. Further Notes to this Medical Matter. In the introduction, it was stated: ‘He works nights as a doorman in the pubs and clubs in town. During the day, he is a collector’. One way to build a rapport with this patient was to ask about what he specifically collected. I do remember asking if he collected stamps or coins or whatever else people collect these days. His response was: ‘Coins? Don’t talk daft. I collect debts.’ Injecting humour (as opposed to other things) was the way to overcome the patient’s preconceptions about what dentists need to know in order to safely and successfully treat patients. With this start to the consultation, we treated the problem he attended with by restoring the tooth with a non-precious alloy, cast metal crown. I finished our treatment by advising him of the risks of anabolic steroids and that he should consider further input from his doctor. The patient agreed with me on this point and offered the following response: ‘Oh yeah, steroids are terrible for you. I agree, I am getting off them next week… I’ll be on growth hormone and insulin…’ If I catch up with the patient again before I finish this book, then I will certainly write up another OSCE about the vices of insulin in non-diabetics and growth hormone in oversized adults. References to Medical Matters 22 1. BMA Royal Pharmaceutical Society BNF 64. Section 4 Central nervous system 4.7.4 Antimigraine drugs. Sumatriptan p. 282. London: Royal Pharmaceutical Society; 2012. 2. BMA Royal Pharmaceutical Society BNF 64. Section 2 Cardiovascular system 2.4 Beta adrenoceptor blocking drugs. Atenolol p. 100. London: Royal Pharmaceutical Society; 2012. 3. BMA Royal Pharmaceutical Society BNF 64. Section 2 Cardiovascular system 2.5.4 Alpah adrenoreceptor blocking drugs. Doxazocin p. 113. London: Royal Pharmaceutical Society; 2012. 4. BMA Royal Pharmaceutical Society BNF 64. Section 2 Cardiovascular system 2.2.1 Thiazides and related diuretics. Bendroflumethazide p. 85. London: Royal Pharmaceutical Society; 2012. 5. BMA Royal Pharmaceutical Society BNF 64. Section 13 Skin 13.6.2 Oral preparations for acne, oral retinoid. Isotretinoin p. 756. London: Royal Pharmaceutical Society; 2012. 6. Gebhardt A, Pancherz H. The effect of anabolic steroids on mandibular growth. Am J Orthod Dentofacial Orthop. 2003 Apr;123(4):435-40.
7. Pendlebury ME, Horner K, Eaton KA. Section 2: Use of Ionising Radiation, 2.2. The Use of Panoramic Radiography in Selection Criteria for Dental Radiography. 2nd Edition pp. 11-29. London: FGDP 2004. 8. Malamed SF. Know your patients. J Am Dent Assoc. 2010 May;141:3S-7S. 9. Shabana A, El-Menyar A, Gehani A. Sudden cardiac death in athletes: where do we stand. Crit Path Cardiol. 2013 Sep;12(3):161-69. Further Reading 1. Scully C. Chapter 33: Sports, Travel and Leisure, Pets. In Medical Problems in Dentistry. 6th Edition pp. 668-671. Edinburgh: Churchill Livingstone 2010. The following are all useful sources of information on the behaviours displayed by bodybuilders and steroid users when in the clinical environment. 2. Pope HG, Kanayama G, Ionescu-Pioggia M, Hudson JI. Anabolic steroid users’ attitudes towards physicians. Addiction. 2004;99(9):1189-94. 3. Kanayama G, Barry S, Hudson JI, Pope HG. Body image and attitudes toward male roles in anabolic-androgenic steroid users. Am J Psychiat. 2006;163(4):697-703. 4. Cohen J, Collins R, Darkes J. Gwartney D. A league of their own: demographics, motivations and patterns of use of 1,955 male adult non-medical anabolic steroid users in the United States. J Int Soc Sports Nutr. 2007;4:12. 5. Shapiro H. Adjusting to steroid users. Druglink. 1992;7 (5): 16-7. 6. Kay EJ, Tinsley SR. Chapter 8: Assertiveness without Aggression. In Communication and the Dental Team. London: Stephen Hancocks 2004.
Medical Matter 23 Background Information I was kind of wondering where to go with this OSCE, and I thought this case was a nice one to follow from the last patient. This OSCE is closely based on the work for a patient and the treatment we did for him over two years. We are still looking after him, so the story is not over yet. Last thing yesterday, I did a try-in of a nice cobalt chrome partial upper and lower set of dentures. With the consent of the patient, he would like you to learn from his story for both your benefit and that of your patients too. A case like this is both thought-provoking and motivating. The public have a perception that dentists are always trying to take things away from patients: sugar from their diets, teeth from their mouths, and money from their wallets. On the other hand, we know that we try to put things back into our patients and their lives with varying degrees of success and the odd failure too. Read this OSCE and see if you can spot what was missing, well done if you can. Everyone involved in the care of this patient from the hospital consultant down to myself missed it first time around.
It only took me the best part of a year to realise what essential detail was missing from the patient’s life for so many years and which was contributory to the problems he had endured. Introduction The patient is a 56-year-old ex-serviceman happily married with a son and daughter. He has just had his first book published, and as you read this, he is furiously typing away at his second. He now walks with a stick and a leg brace on the left leg and rarely if ever gets out. There is curvature of the spine with loss of height. He does appear pale and very frail. The patient spends most of his time at home indoors, finding it difficult to get out and partake of social and sporting activities. Due to the traumas of surgery described below and the resulting complications, he lost his driving licence. There is a complex surgical and medical history. Several years ago, an elective procedure to correct a hiatus hernia regrettably resulted in hospital acquired methicillin-resistant staphylococcus aureus (MRSA) infections and further emergency surgery to correct the destructive effects of these complications. Some 10 years of inpatient hospital care ensued with catastrophic weight loss following surgical resection of over half of the small intestine. The resulting malnutrition with even further weight loss, chronic dehydration, and further complications then followed: Scarring and constriction of the oesophagus and gastrointestinal tract and a non-healing, chronically infected, and ulcerating surgical incision in the anterior abdominal wall after ever-increasing resection of the infected abdominal muscles were unavoidable. A colostomy and parenteral nutrition was required, and long-term admission to a teaching hospital for years of care followed. Not unsurprisingly, in this time the oral hygiene suffered terribly, and many teeth were lost due to periodontal disease and decay from the high carbohydrate diet the patient needed just to maintain his weight. Other complications arising were pathological fracturing of several vertebrae, fractures to the lower limbs on weight bearing, osteomalacia, and osteoporosis with nerve involvement and a permanent left foot drop. Recently, the patient has attended a Medicine for the Elderly Clinic to have intramuscular vitamin D injections. The patient eventually attended our dental practice, requesting some teeth to be fixed and a new set of dentures so he could eat properly after several years of not being able to do so. The drug history revealed the following medication being taken: 1. Cyclizine 50 mgs tds PO 2. Cophenotrope 2.5 mgs qds PO 3. Codeine phosphate 30 mgs qds PO 4. Quinine 200 mgs ods PO 5. Calcium salts 1.25 gms ods PO. Questions
1. Why are these drugs being taken? What are the possible oral and dental side effect and interactions? 2. In the drug regimen, what is the principal difference in rationale in the administration of these drugs in comparison to the previous OSCE? 3. From the introduction, the history of surgery and the medication being taken, what dietary problems does the patient have? 4. What is osteomalacia? What is osteoporosis? What are the differences? 5. Do these directly contribute to the dental problems the patient is having? 6. How might your dental management of the patient begin? 7. Given the history from the introduction, how might you proceed with care of this patient? 8. What are the risks and complications the patient presents with? 9. How would you medically grade this patient on the ASA scale? 10. Are there any risks for the patient in extracting teeth? If so, what are these and how might you deal with them? 11. What complications from the medications may have adverse dental effects? 12. What measures might you take to minimise the adverse effects of the medication the patient is taking? 13. Is there anything from the history and the introduction that would cause you to be vigilant in your clinical conduct? 14. What must you do to safeguard this patient and reduce if not eliminate any risk to his health when in your care in the dental clinic? 15. After working through the questions and answers, have you spotted what the patient is missing that he needs? Answers 1. As with the previous OSCEs, it is helpful to go through the drug history to find out if there are any systemic or dental side effects or any interactions with drugs you may commonly prescribe as a dentist. The drugs, their purpose, side effects, and interactions are as follows: 1. Cyclizine is an antihistamine with a minimal sedating effect, but nevertheless there is a sedating effect. So operating machinery and driving may be contraindicated while this medication is being taken. However, in this case, Cyclizine is not used as an antihistamine; it is used as an antiemetic to prevent nausea and vomiting, which are side effects of the other medications being taken. One side effect of Cyclizine which is absolutely dentally relevant is dry mouth. Gastrointestinal disturbances and psycho-motor impairment also occurs. In this case, this drug is being given with antimuscarinic drugs, and the effect of these drugs will be enhanced by
Cyclizine. 1 2. Cophenotrope is an antimotility drug containing diphenoxylate hydrochloride and the antimuscarinic: atropine sulphate. It is used to reduce bowel movement to assist in rehydration following ileostomy or colostomy. Diphenoxylate is useful in reducing the effects of acute diarrhoea. The oral side effects are nausea, vomiting, and dry mouth. In higher doses, constipation and dizziness occur, but these are controlled with the Cyclizine. 2 The antimuscarinic effects of atropine sulphate reduce diarrhoea, urination, gastrointestinal motility, and vomiting. Many drugs have antimuscarinic effects, and combined use of two or more of these can increase the dentally relevant side effect such as dry mouth. In this case, the synergism of atropine and Cyclizine will result in decreased salivary flow and the dry mouth. 3. Codeine phosphate is useful in this case to reduce GI tract motility as outlined above; it is also beneficial in the control of mild to moderate pain caused by the wedge fracturing in the vertebrae and the nerve involvement in the lower limbs. The side effects are the same as those mentioned above for diphenoxylate hydrochloride. Additional side effects seen are abdominal pain, malaise, and painful muscle fasciculations. 3 4. Quinine is a skeletal muscle relaxant used in this case to control painful nocturnal muscle cramps. The underlying cause of the leg cramps is most likely to be dehydration and electrolyte imbalance. The codeine may initiate a skeletal muscle tremor and painful fasciculations. With lowered potassium and calcium levels following from malabsorption after multiple GI tract resections, it is easy to understand why this patient is at risk of suffering muscle cramps. 4 Side effects of quinine are more or less the same as those for the above noted medications, and these are nausea, vomiting, and fatigue if the dose is not tightly controlled. Interestingly, these side effects may be masked by the Cyclizine, so monitoring of drug levels is important. 5. Calcium salts are taken orally to supplement the low calcium absorption. It is used to prevent or reduce the further skeletal degradation from osteoporosis. Of dental relevance is that patients on calcium supplements have a reduced ability to absorb fluoride. Some antimicrobials, antivirals, and bisphosphonates also have reduced absorption potential with patients taking calcium salts. In this case, there are no interactions from the use of calcium salts, and the antibiotics with the greatest interaction effects are not routinely used in dentistry, except tetracycline. 5 2. The drug regimen in this case is palliative. Palliative medication is not curative, but rather it is to control pain and other symptoms to provide the best quality of life for the patient and his family. In palliative care, the numbers and doses of drugs should be at the lowest possible level with which to achieve the best possible results. With the trauma of surgical complications this patient faced and their life-long after-effects, even
taking the medications listed above with the frequently seen, side effects can prove to be an ordeal. The treatment in this case is truly a multidisciplinary exercise, with the input of the dentist being only a small but quite essential and active element of the total care package. Therefore, it is important to bear this in mind when discussing the treatment for and with the patient. In the OSCEs for the MFDS and MJDF, communication of your understanding of the medication and possible treatment intentions with the examiners (or other care providers in real life) is essential. This OSCE demonstrates a diametrically opposite approach in the drug regimen to the previous OSCE. The multiple medications being given in that case were to control the complex effects of those drugs taken voluntarily for recreational purposes. Quite simply the patient in the previous OSCE has a choice. He wants to take the drugs whereas the patient in this OSCE does not; he needs to take the medication. 3. With surgery and GI tract resection of the small intestine malabsorption is the main complication. The process of digestion of food starts with salivary enzymes, and the dry mouth caused by the medication is where the clinical problems really begin. The weight loss follows from an inability to absorb sufficient nutrients from a diminished diet. Adequate amounts of iron and folate in the duodenum and vitamin B12 in the terminal Ileum are similarly not absorbed. Dietary fats are poorly utilised and the fat soluble vitamins: A, D, E, and K, will be reduced (but not entirely eliminated) too. In this case, there is a concept of the short bowel syndrome resulting from surgery. Vitamin and mineral deficiencies lead to pathological fracturing from osteomalacia.6 4. Osteomalacia is the skeletal abnormality caused by lack of calcium and phosphorous. Calcium absorption is reduced because of lack of vitamin D from the malabsorption state in this case. This patient also had to endure a period of parenteral nutrition, and systemic osteoporosis occurred. Osteoporosis is the loss of absolute bone density; it is a natural process of ageing, but in this case it is caused by lack of calcium. With hospitalisation and lack of regular exercise, the descent into osteoporosis would have been fairly rapid. 5. The upper and lower jaws are affected by these processes. However, pathological processes affecting bone metabolism (although they may well have been contributory) did not cause the degradation in dental and periodontal condition. Neglect of oral hygiene while the patient was hospitalised for many years would have been the principal cause of the poor state of the dentition the patient presented with. 6. From an understanding of the above, the dental management of the case begins with the dentist instituting good oral hygiene advice. The dietary advice has to be under the control of a dietician familiar with the issues of a case like this one. The next stage of care once adequate oral hygiene is re-established, is to negotiate with the patient the best way forward, to provide basic conservation and then, finally, the dentures he has requested. 7. With a history of life-changing complications following elective surgery, the patient is
understandably cautious about embarking on any health care procedure. Both the history and his apprehension have to be accepted in the dentist-patient interaction you will have in a case like this. In an OSCE, your ability to successfully empathise with the patient will gain you some of the marks needed on your way to passing the question. In the dental clinic, patience, empathy, and insight are needed to make this case a success. The initial management begins by making the patient feel comfortable and that he can trust you to do the right thing. Explain to the patient that simple steps with no risk or low risk to his dental health is the path you wish to follow to build his confidence in your professional abilities to restore his oral health. 8. The risks and complications the patient presents with are surprisingly not so multifarious. For sure, there is osteoporosis, and restricted mobility is an issue. With dental access in the UK being almost universal, entry to the dental surgery and the dental chair itself will not present a problem. The patient should be seated and made to feel comfortable. He has to be comfortably seated as the rate of treatment progression will be slow but hopefully rigorously methodical. Support should be given to the cervical and lumbar spine due to the painful wedge fractures. 9. In this case, there is no cardiovascular pathology. In contrast to the previous OSCE which was graded ASA 3 or even ASA 4, this case is ASA 3. Possibly as the long-term healing progresses and the patient adapts to the short bowel syndrome, then the symptoms will become milder and the patient may attain an ASA 2, but this is clinical conjecture. For the duration of dental treatment, the patient is graded as ASA 3, and there are no real risks to the patient from conservative treatment. 10. If extractions are planned, then care must be exercised due to the potential for fracturing of the jaw. Even if we successfully extract un-saveable teeth in the most atraumatic manner, we may still see an extended bleeding time if the clotting factors are affected by the malabsorption. Suturing the sockets and using haemostatic agents would be indicated as a matter of course in this case. 11. The medications the patient is taking will cause a dry mouth. 1-5 This may increase the risk of demineralisation, and the patient is at risk of developing dental cervical Class V lesions. If we are to prescribe dentures, then the lowered saliva flow will result in lowered adherence of the denture to the mucosa, and so retention of the upper denture will be affected. In designing the dentures, these factors have to be considered and the placement of clasps should be utilised. The teeth upon which clasps are to work have to be both sound and stable, so any active decay has to be removed and the teeth restored. 12. Application of topical fluoride should be considered in addition to high concentration fluoride toothpastes and fluoride containing mouthwash. In this OSCE, do be sure to tell the examiners that with the calcium salts being prescribed, the ability of the patient to absorb fluoride will be diminished,5 so topical application is an important route of fluoride application. In addition to this, the medication, specifically, the opioid medication the patient is taking, will reduce the salivary flow rate, so mouthwashes and artificial saliva may be useful too. In this case, there were no oral ulcers or other complications of malabsorption seen (as discussed in the previous OSCEs dealing with deficiency states). In essence, although medically complicated the patient was quite a simple case to treat.
13. The patient had suffered for many years from the effects of health care associated (or acquired) infections or HCAI. These are an increasing global concern, especially with the increase in antibiotic-resistant bacterial species.7 In this case, repeated surgical site infections and wound infections resulted in significant morbidity to the patient. Bacterial species associated with these infections can arise from the patient, from another patient, or from a health care worker. The bacteria of the oral and nasal environment are a good source of pathogens to initiate such infections. Promotion of the infection is seen in malnourished patients and in those who have endured an extended stay in hospital, with drains, sutures, and central lines. This patient has had just about all the risk factors for a further HCAI. 14. Before beginning to treat this patient, the following precautions must be followed: 1. Follow the latest HTM 01 05 Best Practice guidelines for hand and surgery hygiene, no excuses and no reasons not to. 2. Avoid touching wounds, your nose, or any other non-dentally relevant surface. 3. Use appropriate alcohol-based cleaning agents for cleaning the hands correctly in the prescribed manner (there is an MJDF practical OSCE on this!) 4. When hands are soiled visibly, use soaps with antimicrobial properties to remove all contamination. 5. Prevent skin cracking with moisturiser and keep all cuts/abrasions/wounds covered while in the clinic. There are certain specific organisms implicated in antibiotic resistance, and the most documented is the MRSA (methicillin-resistant Staphylococcus aureus).8 These are broadly: HA MRSA (hospital acquired) or: CA MRSA (community acquired). Other common species are the Kleibsiella, Pseudomonas aeruginosa (found in hot tubs, spas, and swimming pools), Enterococci, and the Clostridium deficile. All of these are commonly found in and around dental surgeries, and you will be familiar with their names from your undergraduate BDS microbiology days. In truth, the species involved are no more infective than the Staphylococcus aureus carried by one in five people in the general population.9 However, if these species can enter into the wound of a susceptible patient, or if there is a species with genetic switching or uprating of the expression of certain Leukocidins, then the virulence of these organisms can be unremitting and deadly. With specific relevance to the dental clinic, water line contamination with active biofilm-based bacterial species has to be eliminated and this patient in common with all dental patients, should not be exposed to the risk from non-compliant water lines. In the MFDS you will most likely not have to go to this level of detail, however all of the above is fair game in the MJDF SCRs which are less patient or actor led and more structured. So even though this chapter is all about the medical issues and drug interactions of patients, the risk of HCAI is still a safety critical medical and medication issue. Despite all of the above risks, the patient is still quite determined to attend for treatment. 15. OK, so what is missing in the patient’s life that he needs a little more of?
We know he has been in hospital as an inpatient for the greater part of 10 years, and we also know he now attends a Medicine for the Elderly Unit for intramuscular vitamin D. (The patient isn’t best pleased about that, given his age: 56; this is not by any stretch of the imagination: elderly.) We also know he is pale and very frail. For the past 10 years, the patient has been an inpatient in hospital, and now his mobility is very restricted, so he doesn’t get out very much. He is getting calcium and vitamin D, but no one has prescribed… sunlight. Well done if you picked this up from the introduction. Metabolic Considerations Sunlight is needed to convert the precursor in the skin 7-deyhdrocholesterol into vitamin D. A paucity of sunlight leads to osteomalacia and the problems seen here. Even in this case with a decreased ability to absorb the precursors from the diet, there remains in this patient a residual conversion activity of cholecalciferol present in fish, eggs, and milk products in the diet to convert 25hydroxycholecalciferol in the liver to the active form: 1, 25 di hydroxycholecalciferol in the kidneys. In this case, the liver and kidneys were not affected by the traumas of surgery and HCAIs. However, one critical risk of injecting vitamin D is the risk of hypercalcaemia and kidney failure. In a patient such as in this case, sunlight is more than beneficial; it is an absolute requirement to healing and health. With the patient’s improvement in health, he recently passed an aircrew medical and was successful in gaining an Royal Air Force Association Flying Scholarship presented to him by HRH Prince Faisal of Jordan and ACM Sir Stephen Dalton at the Royal International Air Tattoo, Fairford in July 2013. I hope the patient’s medical consultant finds the revelation of the missing sunlight suitably illuminating and gets round to passing this patient fit enough to get his driving license back. References to Medical Matter 23 1. BMA Royal Pharmaceutical Society BNF 64. Section 4 Central nervous system 4.6 Antihistamines. Cyclizine p. 257. London: Royal Pharmaceutical Society; 2012. 2. BMA Royal Pharmaceutical Society BNF 64. Section 1 Gastro intestinal system 1.4.2 Antimotility drugs. Co-phenotrope p. 59. London: Royal Pharmaceutical Society; 2012. 3. BMA Royal Pharmaceutical Society BNF 64. Section 4 Central nervous system 4.7.2 Opioid analgesics. Codeine phosphate p. 270. London: Royal Pharmaceutical Society; 2012. 4. BMA Royal Pharmaceutical Society BNF 64 Section 10 Musculoskeletal and joint diseases 10.2.2 Skeletal muscle relaxants. Quinine p. 687. London: Royal Pharmaceutical Society; 2012. 5. BMA Royal Pharmaceutical Society BNF 64. Section 9 Nutrition and blood 9.5.2.2 Phosphate binding agents. Calcium salts p. 634. London: Royal Pharmaceutical Society; 2012.
6. Seetharam P, Rodrigues G. Short bowel syndrome: a review of management options. Saudi J Gastroenterol. 2011 Jul-Aug;17(4):229-35. 7. van Kleef E, Robotham JV, Jit M, et al. Modelling the transmission of healthcare associated infections: a systematic review. BMC Infect Dis. 2013 Jun 28;13:294. 8. Chatterjee SS, Otto M. Improved understanding of factors driving methicillin-resistant Staphylococcus aureus epidemic waves. Clin Epidemiol. 2013 Jul 4;5:205-17. 9. Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev. 1997;10(3):505-20. Further Reading 1. Scully C. Chapter 27: Dietary Factors and Health and Disease. In Medical Problems in Dentistry. 6th Edition pp. 606-608. Edinburgh, Churchill Livingstone 2010. 2. Scully C. Chapter 16: Rheumatology and Orthopaedics. In Medical Problems in Dentistry. 6th Edition pp. 383-388. Edinburgh: Churchill Livingston 2010. 3. British Association for the Study of Community Health. Delivering Better Oral Health: An Evidence-based Toolkit for Prevention. Section 3: Increasing Fluoride Availability and Section 4: Healthy Eating Advice. London: Department of Health 2010. 4. Greenwood M, Meechan, JG. Chapter 3: Gastrointestinal System pp. 13-17. Chapter 8: The Musculoskeletal System pp. 39-45. In A Clinical Guide to General Medicine and Surgery for Dental Practitioners. 2nd Edition. London: British Dental Association 2010. 5. Department of Health. Decontamination Health Technical Memorandum 01-05: Decontamination in Primary Care Dental Practices. Appendix 2: Hand Hygiene Policy. 2nd Edition. London: DOH 2013.
Medical Matters 24 Background Information I was back in the clinic today and working with my colleague who, with some tutelage and guidance, has just passed his LDS RCS. We decided to include an OSCE dealing with some of the subjects we have discussed in clinic together. I hope that with the correct approach and answers in this case if you face this type of question in an exam you will not have too much difficulty in passing. I have based this question not specifically on the question in any exam, but on my own clinical experiences of treating patients who for one reason or another have fallen through cracks in the floor of our society. These patient’s do not just disappear, and we have more than a duty of care to look after them. Introduction to the Case A 36-year-old female patient attends your dental clinic, complaining of loose upper and lower
dentures. The dentures are plastic or PMMA (Polymethyl methacrylate), only recently prescribed by another dentist in general practice. These dentures were provided immediately after the patient has had teeth extracted. Now these dentures are not well retained at all. Appearing underweight and pale, the patient also reported having recurrent lesions on and around her lips, but these are not present in this examination. However, if you could see the patient, you would see there are red, ulcerated, infected, and very painful lesions at the corners of the mouth. She complains that she cannot eat at all with her new teeth, and they are, she states: ‘Rubbish and I wish I had my own teeth back. I cannot get on with these new teeth.’ There is a history of fear of the dentist, and the patient requested a complete clearance. Prior to this request, there was poor oral hygiene and irregular dental attendance on her part. The medical history reveals a history of drug abuse with heroin, cocaine, marijuana, and almost any form of injectable, ingestible, or inhalable drug having been taken since the patient was 16 years old. The social history is one of abuse, and the patient not being in regular nine-to-five employment, she states to you: ‘I make my living from five to nine and not nine to five.’ The medical history form is incomplete with regard to HIV, HBV, or HCV testing, and the patient declines to provide any further data on this subject, what she smokes or if she smokes. The medication being taken is methadone, and the patient was on an oral methadone maintenance programme (OMMP) for several months and now takes Buprenorphine. In an empathic and supportive consultation, she tells you that she wants to get off the drugs, get a job, and sort herself out as her child has been taken into care, and she wants to look after her daughter who is now 6 years old… In this case, you need to continue from the initial consultation, working through the following structured questions. Questions 1. Take a full medical history; include any drugs or medication the patient is taking. 2. Do you need a complete medical history before starting any dental treatment? 3. What is an OMMP and what is the rationale for its use in this case? 4. What are the clinical signs you will see from the drugs the patient is taking? 5. What are the risks to the patient from their drug use? 6. Are there additional risks for the patient that may lead to consequences that are more serious? 7. Can you list the sequence of clinical signs and symptoms seen in withdrawal from the drugs the patient is taking? 8. Can you give more detail on how an OMMP might work?
9. Can you give more details of the two medications the patient used in her recovery from drug use? 10. In taking a relevant dental history from the patient are there any issues you should be aware of? 11. Are there any oral signs or side effects from the medication the patient is taking? 12. What is the most likely reason for the lesions on the patient’s lip and how can these be treated? 13. What are the causes of the lesions at the corners of the mouth and how can these be managed? 14. Why are the dentures loose and can you manage the patient’s concerns about this? 15. Can you give some possible treatment options for treatment to the patient? Answers 1. The taking of a medical history is accomplished in the same way as any of the previous OSCEs and in the same way you would take a medical history in the dental clinic from any one of your patients. Upon entering the examination room for the OSCE, introduce yourself in a professional manner and advise the actress/patient who you are and what you are about to do. Begin in your usual way, by asking about the following: heart, cardiovascular system, gastrointestinal tract, and genito-urinary tract. Move on to the musculoskeletal system. Then ask about any operations or illnesses the patient has or has had or are planned. Finish with any medication the patient is taking. Points to Note a. Make this medical history an exercise in information gathering which clearly demonstrates your professional approach to the care of this patient. b. If the medical history is achieved in a no-nonsense matter of fact way, it can pave the way for the rest of the OSCE question or dental consultation to proceed quite easily. c. If the medical history is undertaken in a haphazard manner, missing out essential items, you will struggle to get the full picture to pass the OSCE or if this is a real-life case: to treat the patient effectively. d. An empathic, well-paced, and steady approach is essential to gather up any further information you might use in treatment planning in the OSCE. e. You can complete the medical history with enquiries about any drugs or medication the patient may have self-prescribed. f. With this case, it is so important not to be judgemental. An empathic and calm manner is crucial, so you can gain as much relevant information as possible. g. When asking questions, such as the patient’s risk behaviour for smoking, drinking, and drug taking among other items, don’t forget the power of the pause… and to stop after each question is
asked. h. After stopping, look at the actor or patient to see if they understand the question. Ensure they comprehend what you are asking. i. Take down accurate notes and reflect any answers back to the actor or patient. j. Get the actor or patient to repeat anything you do not understand. In taking the medical history, the patient reveals that she had frequently injected drugs, but now has stopped this and has been prescribed methadone for several months and latterly Buprenorphine. You need to ask the following question: ‘Can you tell me a little more about the drugs you take?’ The reply is clear: ‘I don’t take them any more, but I used to do Horse and a few lines of Charlie.’ If you don’t understand the terms the patient is using, then ask; in the OSCE and in real life, other terms will be provided. As with many things in life if you do not ask, you will not get. Horse or H refers to heroin, while lines or Charlie refers to cocaine… 2. Some of the answers the patient gives will be evasive, and it might prove difficult to establish a full history of the medication and drugs the patient is taking. The dilemma you face in this OSCE and indeed in real life is: In which direction do you proceed when you don’t have the full facts of the medical and drugs history? If you do not proceed with treatment on the pretext you do not have all the information, then this might be seen as an abandonment of your duty of care. If on the other hand, you do proceed and there is an adverse incident with harm being caused to the patient, then this is negligent. Even if harm did not result, it might be seen as unethical to begin to treat a patient if you do not have the full facts of a medical history to hand. For sure, there are many courses of dental treatment just like this case; for whatever reason, the patient chooses not to inform the dentist or cannot inform the dentist of all the information needed. In this situation, there is not much you can do other than document fully in the patient notes and to state in an OSCE: Under the circumstances as complete a medical history as possible was taken. After doing so, you can proceed with the options for treatment and treatment itself, which in view of the limited information may be a compromised or suboptimal treatment. Quite simply with incomplete information, the treatment provided will be limited to alleviating symptoms and correcting any problems. 3. The patient portrayed in this OSCE was previously on an OMMP. As stated in the introduction, an OMMP is an oral methadone maintenance programme; following this phase of recovery, the patient moved on to Buprenorphine. These two drugs are used to manage and to reduce the dependence on illicit opioids the patient was taking. Patients taking these medications have to be in a supportive
environment for more than three months until compliance is achieved.1 A supportive setting would involve professional input from social workers, psychologists, together with your medical and nursing colleagues. The environment can be a secure inpatient short term one for up to one month or a community-based location for three months. The rationale for using methadone and Buprenorphine is to minimise the morbidity and mortality associated with opioid withdrawal. By providing opioid substitutes, the patient ideally does not need to resort to or revert to harmful or criminal behaviour patterns to maintain their drug use.2 4. Although an actor will not display the signs in an OSCE, in the dental clinic the key signs of opioid use are as follows: Warm and flushed skin, a dry mouth, and constricted pupils. In an OSCE, an actor may portray the following signs: Diminished mental faculties, drowsiness and a general inability to concentrate on essential tasks. Patients who are dependent on opioids suffer from constipation, respiratory depression, and various infections due to neglected hygiene. The patient’s general health suffers and poor diet leads to malnutrition. Perhaps the classic and often cited sign of opioid abuse are the infected needle tracks in the skin. 5. In those patients who are intravenous drug users, there is a risk of acquiring HBV, HCV, and HIV from re-using contaminated needles. More common than these viral infections and perhaps more critical is the risk of a right-sided bacterial endocarditis, developing if viable cutaneous bacterial species are injected. This hazard coupled with the respiratory depressant effect of an opioid frequently results in the patient suffering lung infections and pneumonia with scarring of the lung tissue being common sequelae. 6. Other risks are from the nature of the drug being taken. Heroin bought on the street is contaminated and mixed with inert filler material and other drugs. Embolism, thrombosis, infarction, abscesses, and necrosis of vital organs and limbs are all too commonly seen. For all of these risks, most deaths in opioid users will occur from drug overdose, as those addicted to heroin will be habituated to the presence of the drug in their nervous system with increasing doses being used to derive the same results. Cessation of drug use is difficult due to the highly addictive nature of the drug. The patient has stated they have used a mixture of drugs: Horse or H (heroin), lines or Charlie (cocaine). So abstinence and ultimately cessation will be a complicated affair in this case. 7. Untreated withdrawal from opioids is an unpleasant process. In a few hours, the patient will show signs of: Excess flow of saliva, tears, sweat, and other secretions. After one day, the signs are:
Persistent yawning and restlessness; the patient’s pupils will be dilated; muscle tremors, vomiting, and goose flesh are also seen. After one to two days, these signs will peak, then subside. By one week, the remaining signs of: Weakness, insomnia, and muscle tremors may go on to last for months. Withdrawal risks a. In opioid users who are in poor health, the morbidity associated with a sudden unsupported withdrawal is particularly severe and may prove to be fatal. b. For this reason, those users who wish to diminish or cease their opioid dependence need medical, psychological, and social support. c. In this type of OSCE, treating the actor or patient in an empathic non-judgemental manner is crucial to the success of the exam question. This approach is vital in real life with dental treatment and when supporting the patient while they are in your care during their recovery. d. To treat such a patient in a non-supportive manner may drive them away from care and back to illicit drug use once more. 8. In this OSCE, the patient is on an OMMP. In this treatment, methadone is used as the initial substitute therapy to achieve stabilisation. The patient is maintained on a constant dose of this drug. In this time, the patient’s health should improve as their reliance on methadone diminishes. Only after careful consideration and monitoring of compliance in a supportive environment will the patient then move to a diminishing dose of methadone or move to another drug in this case: Buprenorphine. Although the withdrawal symptoms from methadone and Buprenorphine occur later than with heroin, the symptoms last for longer, and for this reason, an accelerated withdrawal programme may result in non-compliance and relapse. Complete and successful withdrawal can take up to three months. Certainly if this example was not an OSCE but a real-life dental case, you would be able to note the patient’s progress on their path to sustained abstinence as the signs of opioid dependence and then withdrawal might be seen. These signs are weight gain, mood stabilisation, and an increase in mental functioning. 9. The details of the medications the patient is taking in this programme are as follows: Methadone. This is a long acting opioid agonist with a sedating effect. For this reason, it is the first drug of choice in a managed withdrawal programme as the sedative effect can counter any anxiety the patient may experience during withdrawal. The drug is taken orally in a syrup formulation with a high sugar concentration. This high sugar concentration contained in this syrup will cause problems for the dental care of the patient.3 Buprenorphine. It is an opioid receptor partial agonist; interestingly it has both agonistic and antagonistic actions. It is less sedating than methadone and is preferred for those patients who have passed the maintenance phase and are in the withdrawal phase of recovery. With a less sedating
effect, patients can begin to participate in more activities too, e.g. seeking and keeping work. There are fewer drug interactions with Buprenorphine and the withdrawal symptoms are milder than methadone.3 Points to document in Medical History a. When you took the medical history, it is important to verify the actor is not portraying a patient who is either pregnant or breastfeeding. b. If this was the case, these issues must be documented and raised with the other health care professionals in the support team caring for the patient. 10. The dental history of this case is the patient is partially dentate. There are very few dental complications in opioid dependent patients. However, pain control with non-opioid analgesics is just about impossible, and referral to a specialist sedation clinic is the preferred route if minor oral surgical procedures are to be undertaken. In the OSCE, do mention this option and that referral for a general anaesthetic is another option, but this carries the risk of additional complications. If necessary, you will consider a hospital referral if the patient cannot accept treatment as an outpatient in a general practice or as a day case patient in a sedation clinic. Pain control with Opioids a. Patients on methadone and Buprenorphine are often in respiratory depression and response to CO2 in blood is diminished. b. The patient on an OMMP or Buprenorphine has diminished pain tolerance and patients can be irritable and perceived as being aggressive. c. In a case like this, the actor may indeed ask for medication for pain. You may consider the options available, but providing opioid analgesics to a patient on an OMMP or Buprenorphine is not one of them, unless you intend to upset everyone in the support team looking after the patient. d. In an OSCE dealing with a patient on OMMP or other recovery programme: Do not ever mention opioids for pain control; you will also upset the examiners if you do. e. Such requests for pain control are ideally dealt with by stating an urgent referral to a specialist in special needs dentistry may be the most appropriate way to manage the dental problems the patient has. 11. There are no specific oral or dental side effects of opioids, their withdrawal or maintenance therapy. However, the chaotic lives that opioid-dependent and recovering patients sometimes lead mean that oral hygiene is seldom a high priority for them. Often there is dental neglect and advanced periodontal disease; their diet can be more opportunistic than balanced, with high sugar intake and infrequent meals. Caries is seen, and as mentioned and of importance to this OSCE: methadone hydrochloride contains high sugar concentrations. The syrup base of the drug causes caries, while the methadone itself is responsible for xerostomia seen in patients on maintenance therapy.3 Buprenorphine similarly causes xerostomia; taste disturbances and muscle fasciculations are seen. If
the muscles of mastication are involved, then painful spasms of jaw muscles result. 12. Even though the lesions on the lips are not currently present, they should be investigated and treated. Points to Note a. In the MFDS and MJDF OSCE, the actor will not present with clinical signs as noted in this case; there will be clinical photographs to aid in your answers and your forming a diagnosis. b. In questioning the actor/patient, the symptoms associated with the clinical signs should be noted and commented on in the OSCE. c. The lesions are not currently present but they are recurring, and the most likely reason for such a presentation can be quickly determined by asking the patient or actor if they get cold sores. In this case, the answer that they do would be a positive finding. Recurrent infection with the herpes simplex virus causes the herpes labialis noted but not currently seen in this case. A note should be made of this working diagnosis and the actor or patient informed of the need to topically apply Aciclovir during the prodromal phase of infection. You can inform the actor: ‘When there is a tingling or a burning sensation before the lesions appear on the lips you can apply a cream. This medicine is available without prescription and is very helpful in clearing up but not curing the cold sores.’ Topical application of an antiviral is an accepted treatment as there are no interactions with methadone. In systemic antiviral treatment, the methadone concentration should be theoretically reduced due to the risk of drug interaction.4 13. In contrast to the viral infection of herpes labialis, caused by HSV (herpes simplex virus), the painful lesions at the corners of the mouth are most likely to be caused by a combined bacterial and fungal infection. As mentioned in the previous answer, in the MFDS and MJDF OSCE, there will be clinical photographs to support any comments the actor will make about conditions they are portraying. Again, symptoms associated with any clinical signs should be asked. There are several underlying reasons for the presentation seen, and these should be investigated. The lesions at the corners of the mouth are most likely to be angular cheilitis or angular stomatitis. They are classically uncomfortable, red, and consist of deep macerated fissures at the corners of the mouth that are infected with and colonised by yeast or fungal infections. Candidal species combined with bacteria staphylococcal species, e.g. Staph. aureus and Streptococcal species e.g. beta haemolytic bacterial species Str. Pyogenes are causative organisms in this clinical condition. Angular cheilitis is frequently associated with denture stomatitis. In this OSCE, the actor has dentures but is complaining she cannot use them. Denture-related stomatitis is a chronic form of atrophic candidosis. Patients with this condition do not complain due to it being asymptomatic, and therefore, it is often simply not noticed by the patients.5
There are several underlying causes for these lesions. These causes are as follows: 1. Iron deficiency anaemia is implicated in a patient’s predisposition to infection with candidal species. Given the potential for irregular diet and dietary deficiency in this case, this cause should be fully investigated. (Please refer back to and revise OSCEs 18, 19, and 20.) 2. The dentures which are infrequently used or not being worn will mean there is often no support or inadequate support of the lips. An over-closed and reduced antero-posterior and reduced vertical dimension of the lips will mean the skin folds at the corners of the mouth can become colonised with fungal species from a reservoir both in the oral mucosa and in the denture itself.6,7 3. The macerated skin folds are then susceptible to infection. There may be a dry mouth or altered salivary flow from the medication; this might add to the problems of angular cheilitis. Barrier ointments can be applied to the infected skin around the mouth. The causes do need to be identified. State to the actor: ‘While we investigate the reasons why you are getting the problems around your mouth, I would like to prescribe some medicine to treat this for you.’ In the OSCE, advise the actor you will provide a prescription for the following: Miconazole oro-mucosal gel. This is applied to the lips and to the denture at night (you need to tell the actor to remove the dentures at night). In some cases and in OSCEs (but not here), patients wear dentures throughout the day and throughout the night too. Porous, cracked, or worn PMMA in the denture is a source of candidal species. The Miconazole gel should be applied four times a day for five to seven days and most importantly for two days after the lesions have healed. Fusidic acid cream. This is applied to the corners of the lips three to four times daily until the lesions heal. This is a narrow spectrum antibiotic used to eliminate the staphylococcal species implicated in angular cheilitis. Given the patient is now taking Buprenorphine, the antifungals we can prescribe will be restricted to topical application of Miconazole. Other azole drugs could potentially interact with both Buprenorphine and methadone if given systemically. If the presentation of herpes labialis and angular cheilitis becomes more florid and topical treatments do not work, then referral to a specialist should be considered. Presentation of these conditions that are resistant to topical medications should raise the spectre of the patient being immunocompromised. If this is the case, then many of the systemically used antivirals will significantly interact with the methadone and Buprenorphine.4 For MJDF and MFDS level examinations, it is sufficient to be aware of these drug interactions. If the patient is taking systemic antiviral medication and on an OMMP, then the input of a specialist is warranted. 14. Dentures becoming loose are a common finding in many if not all denture wearing patients. In this case, the most likely reasons are as follows:
1. The dentures are poorly adapted to the mucosa. 2. There is no retention to the mucosa, due to a poor seal around the mucosal surfaces, or the mucosa is drier than normal or has an altered surface due to inflammation from candidal infection. 3. The dentures are broken. Don’t forget this is a common reason dentures do not fit properly, are not worn, or if they are they are not used with any degree of success. Most candidates and textbooks seem to miss this common reason out. Conversely, just because a denture is broken does not mean it will not be worn. Remember: Plenty of patients persevere with perforated plastic plates in their palates. 4. Although patients wear and use broken dentures, we do have to advise them of the benefits of either repairing or replacing them. 5. There are occlusal interferences from the opposing teeth or opposing denture destabilising the dentures. The methadone and Buprenorphine cause reduced salivary flow. 3 Therefore, the ability for negative pressure to develop or the suction between the mucosa and the PMMA is reduced to a level where the denture is repeatedly dislodged either during mastication, speech, or as a result of the muscle tremor or fasciculations following methadone or Buprenorphine treatment. The patient portrayed in this OSCE may have chronic atrophic candidosis and the palatal mucosa would be affected. Limited adaptation of the mucosa to the PMMA surface then does not permit adequate retention. In the lower denture, these factors are not so critical for stability or retention. One factor affecting both upper and lower dentures is the degree of bone remodelling following extraction and the placement of immediate replacement dentures. These factors combined with the reduced salivary flow from the OMMP and Buprenorphine might explain why the dentures are not being worn with any degree of success. Explanations and management a. In this OSCE you need to explain to the actress/patient that their medication reduces saliva flow. b. Frequent and regular intake of water should be able to offset this side effect of the medication they are taking. c. Also explain that in the first instance, the dentures they were given are only temporary and adjustments to their fitting and biting surfaces are needed. d. Then go on to advise the patient of the further options for treatment. e. The options can be chair side reline of the denture, adjustment of biting surfaces, and then possibly provide a copy of the adjusted and relined dentures. Eventually, a new upper and new lower denture will be needed to be provided in the coming months and years. 15. Further treatment options will be determined by the ability of the patient to attend for treatment and their ability to maintain good oral hygiene. If the patient cannot disclose further medical data
and discuss adverse habits such as smoking or drinking, then advanced restorative work such as implant supported crown and bridgework cannot be considered. Conventional tooth supported crown and bridgework cannot carry any long-term prospects of success. Failure rates for such work would be higher than acceptable in a patient who smokes and has poor oral hygiene. The medical problems the patient presents with and the medication that is taken are clearly contributory to the dental problems the patient has presented with. Even with limited information on the medical history, there is still a tremendous amount of dentistry that can be accomplished for this patient. However, this treatment would be basic. Placing dentures, either full or partial, together with regular hygiene is basic dentistry, but it can do so much to improve the oral health of a patient. In explaining treatment options to the patient, the continued recovery of the patient from drug dependence, through Methadone maintenance and on to Buprenorphine withdrawal, will determine the dental treatment options that will be available for the patient. As the dose of Buprenorphine diminishes, so too will the side effects. Salivary flow rates will increase, and with new dentures, the previous problems of poor adhesion to the mucosa and retention of the dentures will diminish as the patient both physiologically and functionally adapts to the new dentures. In time, future options such as implant borne prostheses can be discussed; all options should be kept open and discussed with the patient in future appointments. Information overload I think it is easy to become overwhelmed with information in an OSCE. The short answer why the denture is not retained is that diminished salivary flow from methadone use results in a failure to develop a mucosa to denture seal. So the denture drops down in a dry mouth. Not so much in an OSCE but in an SCR, other treatment issues will be explored, and these will come to the forefront of your treatment discussions. Without becoming overwhelmed, it is important to deal with these too. When dealing with patients in real life, it is difficult to pick out specific elements of a case, to isolate them and address these while ignoring other aspects of dental care. In contrast to this, in the MFDS, this is precisely what you need to do in the OSCEs. This approach might seem a little artificial. Then again most examinations are, especially those using actors, which are artificial in every respect. In this OSCE, fifteen questions focussed on separate areas or topics that might be explored in your exam were asked and answered for you. In the MFDS and MJDF exam, you will only be asked to focus on one topic, and this will be given in the introduction to the case. I hope in this OSCE I have covered most areas for your revision and that presentation of this case in several areas and with considerable detail proved to be helpful in your revision and for your examination performance. As mentioned, in real life, when looking after a recovering patient, unlike the MFDS and MJDF OSCEs, several issues will run concurrently, and these can span the whole spectrum of dental, medical, and social themes. In my experience, success in treating a recovering patient and concluding
their case successfully comes from knowing when you can help and knowing when to let the patient help themselves. The ability of knowing when to refer, or if you like; when to defer to the patient’s support team is probably the most important thing you can do. References to Medical Matter 24. 1. National Institute for Clinical Excellence. NICE Technology Appraisal Guidance 114. Methadone and Buprenorphine for the Management of Opioid Dependence. NICE: London 2007 and review 2010. 2. Arora A, Williams K. Problem based review: the patient taking methadone. Acute Med. 2013;12(1):51-4. 3. BMA Royal Pharmaceutical Society BNF 64. Section 4 Central nervous system 4.10.3 Opioid dependence. Methadone hydrochloride, buprenorphine pp. 323-326. London: Royal Pharmaceutical Society; 2012. 4. Morris DJ. Adverse effects and drug interactions of clinical importance with antiviral drugs. Drug Saf. 1994 Apr;10(4):281-91. 5. McIntyre GT. Oral candidosis. Dent Update. 2001 Apr;28(3):132-39. 6. Farah CS, Lynch N, McCullough MJ. Oral fungal infections: an update for the general practitioner. Aust Dent J. 2010 Jun;55 Suppl 1:48-54. 7. Thomson WM, Brown RH, Williams SMN Z. Dentures, prosthetic treatment needs, and mucosal health in an institutionalised elderly population. Dent J. 1992 Apr;88(392):51-5. Further Reading 1. Scully C. Chapter 34: Substance Dependence. In Medical Problems in Dentistry. 6th Edition pp. 684, 698-700. Edinburgh: Churchill Livingstone 2010. 2. Scully C. Chapter 3: Perioperative Care. In Medical Problems in Dentistry. 6th Edition pp. 48-50. Edinburgh: Churchill Livingstone 2010. 3. Jagger D, Harrison A. Chapter 3: The Broken Denture pp. 9-13. Chapter 5: The Dirty Denture pp. 17-21, and Chapter 6: The Problem Denture pp. 21-25. In Complete Denture: Problem Solving. London: BDJ Books 2003. 4. McCord JF, Grant AA. Chapter 3: Pre-definitive Treatment: Rehabilitation Prostheses pp. 9-14. Chapter 11: Specific Clinical Problem Areas pp. 65-72. In Clinical Guide to Complete Denture Prosthetics. London: BDJ Books 2009. 5. Greenwood M, Meechan JG. Chapter 13: Skin Disorders Part 1 pp. 65-70. Chapter 14: Skin Disorders Part 2 pp. 71-75. In A Clinical Guide to General Medicine and Surgery for Dental Practitioners. 2nd Edition. London: BDJ Books 2010. 6. BMA Royal Pharmaceutical Society BNF 64. Section 4.7.2 Opioid analgesics pp. 268-274. London: Royal Pharmaceutical Society; 2012.
7. Kay EJ, Tinsley R. Chapter 1: Relationships with Patients Why Bother? Chapter 3: Meeting Each Other pp. 21-32. Chapter 10: Other ‘Special’ Patients 117-126. In Communication and the Dental Team. London: Stephen Hancocks 2004.
Medical Matters 25 Background Information In dentistry, you will notice patterns. Depending on where you work, whether you are in a hospital or in a general dental practice, if you are in the UK, Europe, the Middle East, or the USA or wherever you happen to be preparing for your MFDS or MJDF, you will see patterns. Look around you and look at your patients, and you will see not only patterns, but associations in the conditions your patients present with. These associations can be in behaviours, e.g. children who don’t sit in the dental chair and refuse to open their mouths. Rather than the patient not doing what they are told, it might be equally probable the problem lies with the practitioner not doing something the patient or parent expects them to do. Other repetitions might present in a noticeably increased number of patients who attend with a similar problem. If you are inclined to investigate such associations, their causation may be quite surprising. Recently, while working for a few months in a rural practice in the UK, several patients were noted to be on a medication for a specific endocrine problem. These patients were adults, mostly of pensionable age and were not related to each other. I have based this OSCE on this group, particularly one of the patients from this group and some of the clinical problems he presented with. Just like OSCE 23, it would be interesting to see if you get to what the problem is before we get to the end of the case. The purpose of this OSCE is to emphasise (once more) not only how important it is to take a medical history and to look at all the information you have in the medical history form, but to examine the patient thoroughly as well. In the MFDS, a manual examination of the actor is not part of the syllabus. In contrast, in the MJDF, there are certain practical OSCEs to complete. Again, even though these are practical questions, it is not expected that you will conduct an actual physical examination of the actor/patient. In the exam, clinical photographs are presented to represent the clinical signs a patient has. Combining these with the symptoms mentioned to you, with appropriate questioning of the actor, you should be able to build a clear picture of the background to the problems your actor/patient presents with. For both MFDS and MJDF, it is important to demonstrate that you know how to conduct a full examination of the patient’s head and neck and to demonstrate that you know the signs and symptoms of head and neck abnormalities that you need to act upon. Explaining and Describing 1. In both MFDS and MJDF exams, you may well be asked by an actor or the examiners how would you undertake a clinical examination. 2. One answer is to use the techniques you will have developed and found to be appropriate for
yourself and your patients. 3. It is crucial that you are able to describe to both the actor and the examiners who are observing and marking your performance exactly how you would conduct a clinical examination. 4. You must do this using simple terms using language they can understand. 5. If you have limited experience of examining a patient’s head and neck and less experience of conveying information to patients or actors, then before you go any further: 6. Get your head out of this book. 7. Go to the clinic. 8. Get some practice in with your colleagues and tutors in your study group. 9. For every long-winded methodological scientific explanation of a condition, there are simple ways of explaining things. 10. In simplifying things do not go too far. Before we go into this OSCE, I’ll leave you with this little gem I recently overheard from an examination candidate: ‘If we can’t give your son a local anaesthetic, we will send him to hospital to be put to sleep.’ The actor replied: ‘Put to sleep? . . . What do you mean put my son to sleep? You mean put to sleep like our pet dog?’ Please practise your communication skills. Introduction Another retired teacher presents to you, having just had a root treatment completed on the lower left second molar. The patient was referred to an endodontic specialist after his regular dental practitioner struggled to gain access to the root canals. The previous dentist also noted the patient had conspicuous facial muscle twitching and felt it to be in the patient’s best interests to refer to a specialist to undertake this work, as the delicate nature of root treatment could not be completed due to the repetitive twitching of facial muscles and an inability to access the canals. The specialist completed the root treatment satisfactorily and recommended that a crown should be placed on the tooth. The patient returned to his dental practitioner who could not perform crown preparation again due to the patient’s muscle twitching, and the patient has now come to see you for this work. The patient has also recently attended his medical practitioner and was prescribed vitamin D and calcium supplements. (Compare this with OSCE 23). A revealing medical history A few years ago, the patient underwent thyroidectomy after being treated with Carbimazole for well over a year before this. The other medication the patient remembers taking was Levothyroxine and
then sodium iodide, just before his surgery. The patient had also been treated with beta blockers in the past until the thyroidectomy. After the surgical procedure, the patient is now taking daily oral thyroxine. Despite being fit and active, the patient has (as noted above) recently been given vitamin D and calcium supplements by his medical practitioner. When the patient speaks, he does so with a voice that is somewhat hoarse and strained. On presentation in this OSCE, there is no sign of any twitching of the facial muscles. The clinical examination shows a heavily restored and temporarily filled lower right second molar. Several other teeth are also extensively restored, mostly with amalgam fillings. Given the patient’s age this is not surprising. Interestingly, the lower right second molar has no opposing maxillary tooth. Despite the tooth being non-functional, the patient was keen not to lose any more teeth, having had a few extractions in the preceding years. The root treatment is radiographically ideal, well condensed laterally, filled to the apices of all canals, and importantly, there is no post-procedure sensitivity. The periodontal condition is good with BPE (basic periodontal exam) of 1 in all sextants. The patient regularly attends the hygienist and generally keeps good oral health, responding well to oral hygiene instructions. The patient being a retired chemistry teacher now wants to know if the extensive use of mercury amalgam has anything to do with the thyroid problems he has had. He is well read and is keen to discuss the lymphatic drainage of the head and neck and the proximity of the thyroid gland to the various cervical lymph nodes, having spent many hours of his retirement in the local library on the Internet extensively reading on this subject. The patient then adds that many of his friends have used the same dentist for many years, and all now seem to be on some form of thyroid medication. He wants to know: Is there a connection between the extensive dental treatment, restoration with mercury amalgam fillings, and thyroid problems? Questions for This Medical Matter 1. Take a brief history of the relevant clinical signs and symptoms, noting down the relevant details that you might need to know to manage this case. 2. What are the specific clinical signs you need to note down from the condition this patient has? 3. Although the cause has not been firmly established, what might the common causes of this condition be? 4. Is this condition likely to be benign or malignant? 5. How might the condition be managed and what are the reasons for such management? 6. Explain how you would conduct a clinical exam of the neck. 7. Can you list the signs you will look for and the likely causes? 8. Take a drug history and explain the relevance of the medication the patient is taking. 9. With the medication the patient is taking, what are the clinical effects, side effect, and oral effects seen?
10. From the introduction, the patient speaks in a hoarse and strained voice. Why might this be so? 11. Can you describe the innervations of the neck and thyroid gland? 12. Following the thyroidectomy, which state is the patient now in and what clinical signs need to be investigated? 13. Are there any dental implications from the condition the patient is in or the medication he is taking? 14. From the introduction what other clinical sign has been noted that the patient has had? 15. In addition to the thyroid glands and nerve supply, are there any other glands, tissues, and structures in the neck you must be aware of? What are these? What is their function? 16. Is there anything from the previous answer that might explain why root treatment could not easily be completed or is there another explanation? 17. From the introduction, you have read that the actor/patient is keen to know about the lymphatic drainage of the head, neck, and thyroid. What can you tell him? 18. Can mercury from dental fillings affect the function of the thyroid gland? Points to Note a. When answering questions like this, a good medical history is essential. b. In this question, the nature of the medical problem was already provided in the introduction. c. In this OSCE (unlike a dental clinic) unless the question specifically asks you to, you do not need to go through the entire medical history again; you only need to recount the specific problem from the introduction. Answers to This Medical Matter 1. From the introduction, the important points to note down are two years ago the patient underwent thyroidectomy after being treated with Carbimazole for well over a year. In the UK, Carbimazole is the most used drug to treat hyperthyroidism.1 2. Although in this case the cause of the hyperthyroidism was not established, we should be aware of the clinical signs to look for in our patients. Enlargement of the thyroid gland shows as a swelling of the anterior triangle of the neck. This enlargement of the thyroid is commonly known as goitre. Other common signs are retraction of the eyelids and protruding eyes (exophthalmos); if a patient wears glasses, ask for them to be removed to look at the eyes. Additionally, weight loss, tremor, and muscle weakness are seen. The cardiovascular system is affected too, with tachycardia and atrial fibrillation being commonly
seen. In an OSCE, clinical photographs would be present for you to comment on, and from these, you could point out any clinical signs you may wish to comment on. 3. The causes of hyperthyroidism could be in response to physiological stress, the side effect of medication, the autoimmune condition of Grave’s disease, or an adenoma of the gland itself producing an excess of thyroxine, resulting in the clinical signs described above. 4. Most swellings of the thyroid are benign, and you might advise the actor and the examiners of this and that less than 5% of thyroid swellings are from primary or secondary malignancies which affect the thyroid gland.2 5. The most common reasons for surgery are that the swelling of the thyroid might obstruct the airway with laryngeal obstruction, also affecting the patient’s voice and ability to swallow. 6. Even though you are not going to undertake an actual examination, you should let the actor know what physical examination of a patient’s neck involves. Advise them this can be completed while they are seated, requiring no special instruments or procedures; with just your hands gently feeling around their voice-box. Before palpation (touching the patient), tell them you are looking for any clinical signs which might help you to understand the problem a patient presents with and that examination is a simple task. An examination initially involves no more than looking at their neck. If possible, get the patient to turn their head to the left and look for signs, turn their head to the right and look for signs, then look straight ahead with the head up and then down, while again you look for clinical signs. Ask the patient to face you and observe the neck for any signs during speech, breathing, and swallowing too. 7. In the MJDF exam, you might introduce the information that in a neck examination any signs in the neck are noted according to whether they are any one of the following 9 S’s: 1. Single (can be infections or thyroid nodules) or 2. Several (can be lymph nodes). 3. Shape (describe the edges as diffuse or defined). 4. Size and 5. Site (anterior or posterior triangle of the neck, bounded by the sternocleidomastoids). 6. Stays in one place (can be abscesses or the submandibular salivary gland) or 7. Swallowing moves the swelling up or down (the thyroid glands, nodes, and ducts). 8. Solid (can be thyroids and associated structures) or 9. Sack like (can be cysts). Point to Note
a. In the MJDF OSCE as noted above, a clinical photograph might be provided, and in this case you might see a surgical scar. b. You must confirm with the actor that this relates to the thyroidectomy completed two years previously and not due to other procedure. c. Remember to reassure the actor that in their case the condition they present with is most likely to have been benign. 8. The patient had been prescribed: Carbimazole as an antithyroid medication to control the activity of the gland. Levothyroxine as a blocking replacement regimen. Sodium iodide and propranolol are both used as a pre-surgical regimen to stabilise the patient’s thyroid gland activity. 9. There are significant oral and dental side effects from all these drugs. As a dentist, you must be aware of these and look out for them in your patients and in the actors portraying the symptoms associated with them in your postgraduate exams. The medications, indications, and clinical signs are as follows: Carbimazole: This anti-thyroid medication can result in swelling of and soreness in the throat from infection and upper respiratory tract infections (URTI) from a Carbimazole-induced bone marrow suppression, resulting in diminished white blood cell count. If a patient in the dental clinic or an actor in an OSCE is taking Carbimazole and complains of sore throat, then this is a possible sign of bone marrow suppression, and specialist referral to alter or cease the dose of Carbimazole being taken should be sought. The bone marrow suppression causes mouth ulcers and taste disturbances, and these side effects should be noted if seen in the clinic or are mentioned in an OSCE.3 Levothyroxine: This was used pre-surgically, and the side effects can be similar to those arising from hyperthyroidism as noted above. Interestingly, use of Levothyroxine will accelerate the metabolism of propranolol used in this case pre-surgically.4 Sodium iodide: This medication may result in increased salivary flow rates, salivary gland swelling (seen in the neck if the submandibular salivary glands are affected), laryngitis, bronchitis; URTI’s and goitres are seen too. The sodium iodide was delivered as a radioactive isotope of Iodine-131 and is useful in patients where there is cardiac disease as a result of hyperthyroidism. Propranolol: This was used as an adjunct to the radioactive Iodine-131. Propranolol is a noncardio-selective beta blocker for the pre-operative preparation of a patient for a thyroidectomy. This medication will work very quickly to reverse the effects of the thyrotoxicosis by blocking the beta adrenoreceptors in the vasculature of the thyroid gland. Essentially, this results in less blood flow both into and out of the gland. Therefore, the influence of an overactive thyroid is reduced as are the effects on a patient’s heart as propranolol acts on the myocardium too. Very rarely, dry eyes and a dry mouth might be seen as the effects on the thyroid will similarly reduce blood flow to the major salivary glands too.5
10. The patient speaks in a strained or hoarse voice, and there are several reasons for this; as mentioned previously, there may have been enlargement of the thyroid gland encroaching the larynx. There may also have been upper respiratory tract infections (URTIs). The patient did undergo thyroidectomy, and a risk of this procedure is damage to the nerves supplying the larynx. 11. The nerve supply to the larynx comes from the tenth cranial nerve or the vagus nerve. This exits the base of the skull through the jugular foramen passing inferiorly in the carotid sheath between the internal carotid artery and internal jugular vein to give off the recurrent laryngeal nerve (RLN) at the level of the aortic arch on the left side and subclavian artery on the right side. These two RLNs then ascend in the neck in front of the arteries they have looped around, with the left RLN being longer than the right (as it has to pass under the aortic arch). Both RLNs ascend in a groove between oesophagus and trachea, throwing out branches to the vessels of the heart in a cardiac plexus. The oesophagus and trachea are well supplied by the RLN branches. Then finally, the larynx itself receives its supply from RLN anterior and RLN posterior branches. All muscles of the larynx are supplied by the RLNs except the Cricothyroid which receives its supply from the superior laryngeal nerve (SLN). The RLN enters the larynx itself with the inferior veins and arteries of the larynx to supply the muscles controlling the patient’s voice. The RLNs pass behind the thyroid and are easily damaged during surgery. The shorter right RLN being more midline than the longer left RLN is more frequently compromised. Unilateral nerve damage causes hoarseness; bilateral nerve damage causes an inability to speak with breathing difficulties too. Point to note: Clinical sign not to ignore. a. Of importance and with respect to the spectre of throat cancer, it is the left RLN which is more commonly invaded by a tumour from the lungs or mediastinum, and the tumour spread in the left RLN results in hoarseness. b. This tumour spread can also pass along the lymphatic system of the neck too (more about this later). c. In this case, unilateral nerve damage to one of the RLNs from surgery has resulted in the hoarseness heard in the patient’s voice. In this case, thankfully there was no throat cancer. For both MFDS and MJDF and in the dental clinic, a thorough understanding of the anatomy of the neck and the consequences of common pathologies are essential to passing the exam and not failing your patient. 12. Following the thyroidectomy, the patient became hypothyroid. This can be deduced from the medication he is taking. (Some 30% of patients who have had a thyroidectomy become hypothyroid.6) The clinical signs of hypothyroidism are not often seen. The common signs of weight gain, hair loss, oedema in face and legs, decreased mental capacity are all seen. Interestingly yet again, hoarseness is another sign of hypothyroidism. In the clinic if any of these signs are present,
they need to be investigated further. 13. The patient has been maintained in a euthyroid state with thyroxine for quite some time, and there are dental implications from this condition you will need to discuss in the OSCE: Treatment with local anaesthetic carries little risk, and the normal precautions regarding dose limitations for all patients should apply here. However, there is a risk of causing a myxoedematous coma if dental sedatives are used. Given the theoretical risk of ischaemic heart disease in a patient who has been rendered athyroid and is medicated to a euthyroid state; it might be prudent to use non-adrenaline containing local anaesthetics, but this is more a theoretical rather than a practical concern. 14. In this case, the other clinical sign is twitching of the facial muscles. Although this sign was not evident during presentation of the patient, it should be mentioned as it is of some relevance to the case. There are several causes of twitching of the facial muscles, and the most likely reason for this sign can be found from the introduction to the case. Clinical Signs in Introduction a. In an OSCE, it would be both inappropriate and rare to have an actor display clinical signs such as facial twitching. b. Often clinical signs are noted in the introduction for you to acknowledge and use when answering questions on the case. You must acknowledge in an OSCE, everything in the introduction is there for a reason. 15. When the thyroidectomy was performed, there was damage to one RLN.7 Another common complication of this surgical procedure is the removal of the parathyroid glands. Their accidental removal results in hypoparathyroidism. In most cases, this is transient as any remaining parathyroid tissue in the neck will undergo compensatory hyperplasia. However, this may take some time. The parathyroid glands are located behind the thyroids, so if there was damage to one RLN also approaching the thyroids posteriorly, it is quite likely there was removal of parathyroid tissue too. These glands produce parathyroid hormone (PTH), and together with vitamin D, these control the level of calcium in a patient’s plasma. PTH opposes the action of calcitonin (produced in the thyroid gland in parafollicular cells it acts to reduce blood calcium levels). PTH acts on the small intestine to increase calcium and phosphate absorption and on the kidneys to decrease calcium excretion while increasing phosphate excretion too. Calcium and phosphates are released from bones as osteoclastic activity increases under influence of PTH. Alkaline phosphatase and hydroxyproline levels rise. This can be detected in the patient’s urine with simple laboratory tests. In hypoparathyroidism (from gland removal), the opposite of the above effects will occur. Plasma calcium levels will drop, and aberrant contractions of skeletal muscles will be seen.
The patient will complain of symptoms of tingling and numbness in the arms and hands, and of relevance to this case: Twitching of facial muscles is seen. If any region supplied by the facial nerve is gently tapped, then the twitching noted above will result. It is most likely that during the examination conducted by the previous dentist, this twitching of the facial muscles known as Chvostek’s sign was elicited, possibly unintentionally, as the facial nerve would have been stimulated during a dental examination.7,8 The patient then received treatment for the hypoparathyroidism in the form of calcium and vitamin D supplements. So when the actor presents the patient as portrayed in this OSCE, there will be no sign of any muscle twitching due to the plasma calcium levels being normalised once more from compensatory hyperplasia of any remaining parathyroid tissues, together with the corrective effects of calcium and vitamin D supplements. 16. The root treatment was referred to a specialist due to difficulty in accessing the canals. Pulp stones and osteodentin formation occluding canals is a classic sign of hyperparathyroidism and not hypoparathyroidism. The most likely reason for canal obstruction in this case would have been age-related change and sclerosis of the canals. In hypoparathyroidism of a congenital and not an acquired nature, osteodentin deposition is seen with canal obliteration. In this case, natural ageing of the teeth over many years results in thin tortuous root canals. These are not easily amenable to instrumentation as secondary post-eruption dentin and reactive tertiary dentin is produced by odontoblasts retreating into the pulp chambers and root canals with ever decreasing diameters. It was this physiological process, the muscle irritability and twitching which would have been the main reason for referral to an endodontist in the first place! Access to Information a. Patients with increasing frequency (possibly due to Internet access) ask pertinent and interesting questions. b. If I don’t know the answer to a question, I tell the patients that I don’t know. c. The, I will either call them with an answer or have the answers for them at their next visit. d. There are also those ‘goldeny’ nuggets from the Internet that patients present to you for evaluation. e. In the OSCE exams, you don’t have the luxury of reviewing the actor to tell them you have found the answers to their questions. If the actor asks questions you don’t know the answer to, then tell them something like this: ‘That’s an interesting and thought-provoking question, but in the time we have I would like to concentrate on the issue you have presented with today.’ This response seems to work, then you can move on. f. Whatever else you do, do not spin out a work of fiction to pass the time, as that is all you will
pass. 17. The lymphatic drainage of the thyroid is multidirectional, and this is to be expected as the thyroid is a highly vascularised organ. The immediate drainage is to the prelaryngeal, pretracheal, and the paratracheal lymph nodes which accompany the RLN (see above). From here, drainage is into the mediastinal lymph nodes. All lymphatic drainage from the head and neck is into the deep cervical nodes, then into the jugular lymphatic trunk, which joins the thoracic duct on the left side and the internal jugular vein or brachiocephalic vein on the right side. Although the lymphatic system draining the mouth, head, and neck is complex, there is no direct lymphatic connection from the floor of the mouth to the thyroid gland itself. 18. The question the patient or actor asks is an interesting one. This originated from the thoughts the patient had that mercury amalgam from an extensively restored dentition may have interacted with the iodine being metabolised by the thyroid gland. There is no evidence in the literature that such a phenomenon might actually occur although the hypothesis that it may is theoretically plausible given the proximity of lymph nodes and vessels in the neck and the reactivity of mercury with iodine. In truth and in fact borne out by clinical evidence, there is little to support the patient’s hypotheses; however, there are some recent papers investigating a link, and some correlations have been established.9,10 In the MJDF SCR, you may wish to include this as a discussion topic. Point to note: Defending your position. a. It is important in OSCEs and in the SCRs, to defend your position with clinical evidence, established knowledge, and accepted facts. b. The actors, just like real patients, can be ever so persuasive in attempting to convince you otherwise ie what they believe carries more weight than what you know. c. I think the lesson here is to be sure of your facts, but do not come across as defensive when defending them. Further Notes to This Medical Matter. Do you think it is unusual that the previous dentist referred the patient for a root treatment but did not remark on the twitching of the facial muscles or hoarseness of the voice? That dentist set aside clear clinical signs and concentrated on the task in hand—to refer the patient for a dental problem. In the narrow confines of the MFDS and MJDF, referral with no regard for clinical signs is not ideal, and it might not be so good either in the broad expanse of the real world dental clinic. Often clinical signs are thought to be an embarrassing or sensitive business for a patient; in this case, the twitching of the facial muscles and hoarseness of the voice were completely ignored for fear of causing unintended offence or alarm to the patient. In another case I became aware of, the hoarse voice of a patient’s husband wasn’t commented on or noted for six months by another dentist. The patient came to see me when her previous dentist was on holiday, and I carried on with her routine dental care. On asking how her husband was doing, the patient replied to me:
‘My husband died of throat cancer last month… he was fifty three.’ The whole story came out: how the previous dentist would only do a scale and clean every now and again and did not really examine the head. With specific relevance to this case, the neck was never examined in all the time her husband was under the care of that dentist. From this OSCE, you will see there are many reasons why there may be alteration or hoarseness in a patient’s voice: From an URTI, to nerve damage, to an endocrine imbalance. It is striking to note that this most obvious and simple of clinical signs is seldom if ever picked up in the dental clinic. Hoarseness in a patient is a clinical sign crying out to be referred. I began this OSCE by mentioning the occurrence of patterns. The interesting pattern in this case was that many patients in a rural clinic all attending the same dental practices were on thyroid medication. The patient asked if there is a connection between his dental treatment and the thyroid problems. The answer is most likely not. After I looked at the medical history forms of the patients in this group; all had one thing in common: All the patients had attended with the same medical practitioner. I eventually met the doctor (when he attended for dental treatment). He mentioned that as part of his (thorough) examination of the patients, he did thyroxine and TSH testing on his patients. The figures in the UK general population are quite striking: Some 15% of patients display clinical signs of thyroid nodules and 5% of all patients, i.e. one-third of those with clinical signs, do have a detectable abnormality of thyroid function. So it seems this doctor was being meticulous in his practice. The figures are surprising; this means that in an average day a dentist in general practice in the UK might see between one and two patients with clinically detectable thyroid anomalies. So when something is found on clinical examination, referral for laboratory testing follows, and with a positive result, medication to correct the condition follows. In my search for reasons why this pattern of thyroid problems should be so, I looked at the diet of the patient, and all were healthy and balanced. Being a rural practice, there was a ready supply of fresh vegetables and meat slaughtered on the local farms. On discussing the patterns of this OSCE with a rural-based colleague who rides horses, she mentioned that horses also suffer hoarseness too. This is also from damage to the equine RLN. The causes of equine RLN injury are multiple; often it follows from musculoskeletal injury after exertion. The cures range from surgery to retirement of the animal from racing, being relegated to a companion status animal. Phenylbutazone is an NSAID commonly administered to these horses to treat RLN injury. Some 8,000 horses are slaughtered in the UK every year for human consumption. It has been known for many years that Phenylbutazone can affect the metabolism of the thyroid gland.11 Although measures are in place to prevent horses medicated with Phenylbutazone from entering the
human food chain, less than 2% of the UK equine stock’s medication status is actually monitored. This chapter began with the case of a farmer who had developed cardiomyopathy, probably because of his exposure to chemicals used in the farming industry. This chapter ends with this OSCE and the consideration that one drug used in the farming industry particularly in equine veterinary practices in quite small levels may be implicated in an endocrine problem commonly seen in rural dental patients. Although it is perhaps beyond the scope of this book to look further into these patterns, they are interesting, and if anything sparks your interest, then it is sure to make your learning and revision more enjoyable, if not more worthwhile when you examine and treat your patients. References to Medical Matters 25 1. Franklyn JA, Boelaert K. Thyrotoxicosis. Lancet. 2012 Mar 24;379(9821):1155-66. 2. Hu MI, Vassilopoulou-Sellin R, Lustig R. Chapter 5: Thyroid and Parathyroid Cancers. In Pazdur R, Wagman LD, Camphausen KA. Cancer Management: A Multidisciplinary Approach. 11th Edition. London: UBM Medica 2008. 3. BMA Royal Pharmaceutical Society BNF 64. Section 6 Endocrine system 6.2.2 Antithyroid drugs. Carbimazole p. 455. London: Royal Pharmaceutical Society; 2012. 4. BMA Royal Pharmaceutical Society BNF 64. Section 6 Endocrine system 6.2.2 Antithyroid drugs. Levothyroxine p. 454. London: Royal Pharmaceutical Society; 2012. 5. BMA Royal Pharmaceutical Society BNF 64. Section 2 Cardiovascular system 2.4 Beta adrenoceptor blocking drugs p. 100. London: Royal Pharmaceutical Society; 2012. 6. Scully C. Chapter 6: Endocrinology. Thyroid Gland. In Scully C. Medical Problems in Dentistry. 6th Edition pp. 153-159. Edinburgh: Churchill Livingstone 2010. 7. Christou N, Mathonnet M. Complications after total thyroidectomy. J Visc Surg. 2013 Sep;150(4):249-256 8. Athappan G, Ariyamuthu VK. Images in clinical medicine. Chvostek’s sign and carpopedal spasm. N Engl J Med. 2009; 360 (18). E 24. [Online] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19403899 [Accessed September 2013] 9. Ursinyova M, Uhnakova I, Serbin R. The relation between human exposure to mercury and thyroid hormone status. Biol Trace Elem Res. 2012 Sep;148(3):281-91. 10. Gallagher CM, Meliker JR. Mercury and thyroid autoantibodies in U.S. women, NHANES 20072008. Environ Int. 2012 Apr;40:39-43. 11. Morris DD, Garcia M. Thyroid-stimulating hormone: response test in healthy horses, and effect of phenylbutazone on equine thyroid hormones. Am J Vet Res. 1983 Mar;44(3):503-07. Further Reading 1. Scully C. Chapter 6: Endocrinology. In Scully C. Medical Problems in Dentistry. 6th Edition pp. 153-159. Edinburgh: Churchill Livingstone 2010.
2. McMinn RMH, Hutchings RT, Logan BM. A Colour Atlas of Head and Neck Anatomy. 6th Impression. London: Wolfe Medical Publications 1990. 3. Food Standards Agency. Horse meat investigation. Advice for consumers. Enforcement and regulation. London: Food Standards Agency 2013. 4. Abiodun MO, Bird R. Havard CWH, Sood NK. The effects of phenylbutazone on thyroid function. Acta Endocrinol. 1973;72:257-64. 5. Stock CJR, Nehammer CF. Endodontics in Practice. London: BDA Books 1992. 6. Scully C. Chapter 37: Eponymous and Acronymous Diseases and Signs. In Scully C. Medical Problems in Dentistry. 6th Edition p. 720. Edinburgh: Churchill Livingstone 2010.
4 Ethical Examples Introduction How do you feel after reading the first three chapters of your test-book? By this stage in your exam preparation, you will have begun to get a feel of the subject matter and of the level of clinical knowledge that you need to develop and demonstrate in your MFDS and MJDF exam questions for the OSCEs and for the SCRs Where Do Ethics Belong? A good few months ago, while in the depths of winter, I had in mind the idea to include a chapter on the laws and ethics of dental practice, as these subjects are examined at the foundation level of postgraduate dentistry. The dilemma I faced was: Where does such a chapter belong? Either at the beginning, then the whole focus of the book would be on law and ethics, or at the end, then the chapter might remain unread. As a reader, you might just plough through this book question by question, in preparation for your clinical exams, ignoring such a chapter if it was placed either at the beginning or the end of your book. The aphorism ‘if you want to hide something then place it right in front of you’ might apply to this dilemma. So, rather than concealing this chapter at the beginning or at the end of the book, I hid it right in the middle, where you cannot help but stumble across it. The first three chapters of this book dealt with the format of the MFDS and MJDF clinical exams, the common medical emergencies, and then some clinical problems with frequent drug interactions you might encounter in the exams and in examining patients. The clinical subjects in these areas are derived from accepted knowledge and evidence-based dental practice. So I guess you just have to plough your way through these subjects until you reach the end of the book or the required standard or hopefully both together. Behind the evidence-based practice of clinical dentistry lies a dynamic framework of concepts based not only on the law as it applies to health care but also the accepted standards of professional behaviour you will have to adhere to in your everyday life while at work and outside work too. The Hidden Curriculum The recent September 2013 publication of the UK GDC’s Nine Standards for all GDC registrants sets out the principles expected from all members of the dental team, except dental practice managers who curiously still remain unregistered as an entity. Behind all of the published rules and defined regulations lies a kind of nebulous hidden curriculum that some of you will have absorbed while
growing up around dentists, doctors, and health care professionals in your close family and friends. For those who have not grown up with dentists, doctors, or health care professionals milling around their childhood, this hidden curriculum comes out while you are at dental school. By the time you have reached graduation you should have absorbed enough of it or have been saturated to the extent you can fit right into your first job in the same way as anyone else regardless of their background. OK, now back to ethics and law. I reached a compromise. I thought I would place this chapter of questions dealing with ethical and legal concepts immediately after writing about some of the important and essential stuff you have to learn. You cannot get away from medical emergencies, so this has to come first. Today, the GDC requires you to demonstrate verified continuing professional development in this subject. After that essential chapter, you ought to learn about some of the medical conditions and drug interactions now being seen with an increasing frequency in your patients. Before getting on to the more clinically oriented subjects that you will already have learnt and practised for some time both as an undergraduate student and as a foundation level dentist, comes this short but important chapter on ethics and law. In arranging your book in this way, I hope that thinking about some of the ethical and legal concepts supporting your practice of dentistry might provide a framework to support your revision while reading the chapters that follow. Serving the Profession A few days ago, while discussing this book with a patient who is a senior police officer, we both came to an interesting conclusion. Today there are more and more restrictions placed upon us, not directly by the professions we have chosen to serve in (my underlining and my emphasis) but indirectly by adjoining bodies that society has repeatedly assembled around our professions to oversee the regulation of our professions and professional activities. Although we serve in our respective professions in the police service and the health service, we also have to serve this assembly of adjoining organisations and the very society that has placed them there. Only by first observing the rule of their laws can we then begin to serve our patients. In the UK, among the more prominent adjoining organisations are the Care Quality Commission (CQC) that independently regulates all health and social care services in England and Wales and the Professional Standards Authority (PSA) that oversees and regulates not only the GDC but eight other health care regulators in the UK. I mention this as the GDC, in response to audit and review from the PSA (formerly the Council for Health Care Regulation and Excellence (CHRE)), has stipulated that the teaching of law and ethics should now, like medical emergencies, be a mandatory component for the continued training of all those in the dental team. The GDC have also decided to get involved in the behaviours of pre-registrants too. If these behaviours result in convictions which are likely to impact on a future registrant’s fitness to practise, then the GDC will retrospectively investigate and summon a prospective registrant to answer some
questions they may have about their future fitness to practise. Ethics in the Exams So professional behaviours will be assessed in both MFDS and MJDF exams. While attending a recent conference, I was speaking to a vice dean of one of the Royal Colleges. While discussing this book, he told me of one candidate he had examined recently. The candidate was doing rather well. Towards the end of the exam, the actor then hinted helpfully about consent for a procedure. ‘Is there a form I need and can I take it away and read it?’ the actor (supportively) asked. The candidate’s response was striking: ‘No, you don’t have to read it, just sign it.’ For those of you who will remember the physiology of the jaw opening reflex, the toxic stimulus provided by this reported answer provided sufficient output from the trigeminal motor cortex to cause my jaw and that of the vice dean to simultaneously drop into slightly open positions at the recounting of this tale. For those of you who can’t remember the TMJ and its innervation, here is a great reference you can use in your revision: McKay Yemm and Cadden BDJ 1992.1 That exam candidate was asked to come back for another attempt at the MFDS. On the return visit, (I was told), rather than snatching defeat from the jaws of victory, a more enlightened view on the importance of the issues of consent was demonstrated. Teamworking, recognition of your professional limitations, and your approach to the responses the actors and your patients provide are as important in the examination for which you are now preparing as they are for the career you will be pursuing. With this, there is both bad news and good news. The bad news is in the MFDS and MJDF exams; clinical scenarios and problems can be based around any area of clinical practice in which you might find yourself. The good news is these scenarios and problems will be limited to the two-year postgraduate level of clinical experience. The 2013 GDC Guidelines With respect to ethics and law, in 2013, the GDC published a new set of guidelines, replacing the previous 2005 Standards Guidance.2 All registrants involved in the practice of dentistry had to keep to six principles of the practice of dentistry in the UK. Up to September 2013, these were: 1. Putting patients’ interests first and acting to protect them. 2. Respecting patients’ dignity and choices. 3. Protecting the confidentiality of patients’ information. 4. Cooperating with other members of the dental team and other health care colleagues in the interests of patients. 5. Maintaining professional knowledge and competence.
6. Being trustworthy From September 2013, the nine new principles are:3 1. Put patients’ interests first. 2. Communicate effectively with patients. 3. Obtain valid consent. 4. Maintain and protect patients’ information. 5. Have a clear and effective complaint procedure. 6. Work with colleagues in a way that is in patients’ best interests. 7. Maintain develop and work within your professional skills. 8. Raise concerns if patients are at risk. 9. Make sure your personal behaviour maintains patients’ confidence in you and the dental profession.3 Rather than remark on the previous guidelines, the new standards deserve some comment. At a glance, the principles seem very good. However, a closer look at Principles 3 and 8 reveal some inconveniences: 1. Consent can only be valid, so rather than stating in Principle 3: obtain valid consent, a more appropriate principle might be: obtain and maintain consent, thus reflecting the dynamic ongoing nature of consent. (We will return to consent in Chapter 6.) 2. Principle 8: Raising concerns if patients are at risk. OK, and if a colleague is a risk? A more appropriate wording might be: raise concerns if anyone is at risk. If there is to be greater awareness of patient’s rights, then there has to be an awareness of the dental professional’s rights too. In 2005 and again in 2013, the GDC (kind of) decided that the Hippocratic Oath (sort of) officially now applies to the practice of dentistry in the UK. Here is the Ludwig Edelstein translated version of the Hippocratic Oath: ‘To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it— without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but to no one else. I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.
I will not use the knife, not even on sufferers from stone, but will withdraw in favour of such men as are engaged in this work. Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves. What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about. If I fulfil this path and do not violate it, may it be granted to me to enjoy life and art, being honoured with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.’ 4,5 For sure, over the years the Hippocratic Oath has been translated, but if we look at the way we practise our clinical skills today, very little has actually been lost in translation down all the generations and across all of the countries where clinicians work. In addition to translation, the Oath has been modified many times and in several different countries. One of the most significant revisions was the Declaration of Geneva, first drafted in 1948 by the World Medical Association. 6 Over the years, this declaration too has been revised. The Physician’s Oath of 1948 was codified in the Declaration of Geneva with an amendment being made by the 22nd World Medical Assembly in Sydney Australia in 1968.7 Consideration of These Oaths While there is currently no legal obligation for dental students to swear an oath upon graduating, at some point in your career, if you have not done so, then in a moment of quiet personal reflection you might consider the weight of the words in the declaration. The initial rationale of the Physician’s Oath was a response to the atrocities committed by many dentists and doctors willingly working in the Nazi regime of Germany. (An example of this and the relevance to dentistry is given in Chapter 6.) Notably, this oath requires the physician not to use clinical or medical knowledge contrary to the laws of humanity. This document was adopted by the World Medical Association only three months before the United Nations General Assembly adopted the Universal Declaration of Human Rights (1948), ensuring the security of the person. I feel the Physician’s Oath is appropriate to the work of anyone in the dental profession, and application of these principles during your revision and in your examinations for the MFDS and MJDF will reward you in clinical practice as you serve your profession and patients. The Physician’s Oath as incorporated into the Declaration of Geneva is as follows: 1. I solemnly pledge myself to consecrate my life to the service of humanity. 2. I will give to my teachers the respect and gratitude which is their due; 3. I will practice my profession with conscience and dignity;
4. The health of my patients will be my number one consideration; 5. I will respect the secrets that are confided in me, even after my patient has died; 6. I will maintain by all the means in my power, the honour and the noble traditions of the medical (dental) profession; 7. My colleagues will be my brothers and sisters; 8. I will not permit considerations of religion, nationality, race, gender, politics, socioeconomic standing, or sexual orientation to intervene between my duty and my patient; 9. I will maintain the utmost respect for human life; even under threat, I will not use my medical knowledge contrary to the laws of humanity; 10. I make these promises solemnly, freely and upon my honour. In the UK, we now practise dentistry not as individuals but as teams, and all those who are directly involved in clinical dentistry in the UK are registered with the GDC. Interestingly, for nurses registered with GNMC (General Nursing and Midwifery Council) there is a pledge that is close in ideals to the oaths noted above. In addition to this, I think it is important to remember that in the MJDF OSCEs there are senior dental nurse practitioners who will examine you in some of the practical OSCEs, for example certain aspects of clinical waste disposal and your knowledge of the legislation on sharps and sharps’ injuries. So it can be useful to reflect on the structures in place governing not only our functions but those of other dental team members too, with the morals and ethics in the pledges they undertake to observe. The nurse’s pledge or Nightingale Pledge was named after Florence Nightingale and is a modified version of the Hippocratic Oath. Predating the Physician’s Oath, this pledge was created in Detroit 1893 and is a statement of the ethics and principles of the nursing profession.8 The 1935 revision to the Nightingale Pledge reflected an expansion of nursing’s clinical work to those activities covering public health and other areas of clinical practice such as (perhaps) dental nursing. By including an oath to become a ‘missioner of health’ dedicated to the advancement of ‘human welfare’, these additional clinical activities were covered in this oath. Here is the Practical Nurse Pledge for you to consider: ‘I solemnly pledge; To adhere to the code of ethics of the nursing profession; To co-operate faithfully with the other members of the nursing team and do carry out faithfully and to the best of my ability the instructions of the physician or the nurse who may be assigned to supervise my work; I will not do anything evil or malicious and I will not knowingly give any harmful drug or assist in malpractice.
I will not reveal any confidential information that may come to my knowledge in the course of my work. And I pledge myself to do all in my power to raise the standards and prestige of the practical nursing; May my life be devoted to service and to the high ideals of the nursing profession.’ Just before we get to the OSCEs in this chapter, if we can once more consider the need to regulate the regulators, those organisations appended to our profession whose rules we have to observe. Why is there a need for such regulation? The words of Robert Francis in 2013, subsequent to the publication of the report bearing his name, provide not only an answer but also a searing indictment against UK health care regulators’ failure to maintain standards: ‘The events at Mid Staffordshire Hospital ‘happened under a regime in which everyone was under a professional duty not to harm their patient. And where did all that get anyone?’ 9,10 While there remains no legal requirement to undertake any oath, still some 98% of American and nearly 50% of British medical students swear some kind of oath either at entry to or graduation from university.11 Since 1992, there have been recommendations that medical ethics form part of the core curriculum and that graduates undertake an oath or affirmation to observe an ethical code of conduct.12 More recently, the limitations and criticisms of such oath taking led a group of London medical students to compose a declaration at their graduation, marking an explicit commitment to ethical behaviour.13 Among such behaviours are adherence to the four principles of Beauchamp and Childress of Autonomy, Beneficence, Non-maleficence, and Justice.14 Despite concerns about oaths and initiatives to compose declarations, there is evidence to suggest oath taking may strengthen one’s resolve to behave with integrity in extreme circumstances.12 In 2013, the words of Robert Francis QC told us about the failings in regime and regulation in the UK NHS, and there are now formal responses to his report from the regulators, although at this time the GDC have not yet responded. The words of Francis are underpinned by the research of Fischer and colleagues on the effects of different forms of regulation in health care. They found that rule-based regulation tends to erode values-based self-regulation, producing professional defensiveness and contradictions which undermine rather than support good patient care.15,16 The role of managers and clinical leaders can be crucial in achieving positive changes in practice; however, one danger is that managers may seek simple solutions over evidence—leading them to adopt management techniques that are ineffective or damaging.17 One form of value-based self-regulation is the undertaking of an oath or a declaration; perhaps it is time that managers are registered and regulated by the GDC and like ourselves they too have to undertake an oath or affirmation of their commitment to patient care. References to Introduction Ethical Examples 1. McKay GS, Yemm R, Cadden SW. The structure and function of the temporomandibular joint. Br Dent J. 1992;173(4):127-32.
2. General Dental Council. Standards Guidance for Dental Professionals. London: GDC 2005. 3. General Dental Council. Standards for Dental Professionals. London: GDC 2013. 4. Edelstein L. The Hippocratic Oath: Text, Translation and Interpretation. Supplements to the Bulletin of the History of Medicine. No. 1. Baltimore: Johns Hopkins Press 1943. 5. Orr RD, Pang N, Pellegrino ED, Siegler M. Use of the Hippocratic oath: a review of twentiethcentury practice and a content analysis of oaths administered in medical schools in the U.S. and Canada in 1993. J Clin Ethic. 1997;8 (Winter):377-88. 6. World Medical Association, WMA. WMA Declaration of Geneva. WMA 2013. 7. Tarbell CA. For the Sick. In Detroit Courage Was the Fashion: The Contribution of Women to the Development of Detroit from 1701 to 1951. pp. 80-81. Detroit: Wayne State University Press 1953. 8. Maxwell AC, Pope AE. The Florence Nightingale Pledge. In Practical Nursing: A Text-book for Nurses and a Handbook for All Who Care for the Sick. p. 17. New York: G.P. Putnam’s Sons 1910. 9. Lintern S. Francis presses government on criminal sanctions. Health Service Journal, 14 May 2013. 10. Robert Francis QC. Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust January 2005-March 2009. The Mid Staffordshire NHS Foundation Trust Inquiry. 11. Hurwitz B, Richardson R. Swearing to care: the resurgence in medical oaths. BMJ. 1997;315:1671-74. 12. BMA. Medicine Betrayed. London: Zed Books; 1992. 13. Sritharan K, Russell G, Fritz Z. Medical oaths and declarations: a declaration marks an explicit commitment to ethical behaviour. BMJ. 2001 Dec 22;323(7327):1440-41. 14. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 1st Edition. New York: Oxford University Press 1989. 15. Fischer MD, Ferlie E. Resisting hybridisation between modes of clinical risk management: contradiction, contest, and the production of intractable conflict. Account Org Soc. 2013;38(1):3049. 16. McGivern G, Fischer MD. Reactivity and reactions to regulatory transparency in medicine, psychotherapy and counselling. Soc Sci Med. 2012;74(3):289-96. 17. Saïd Business School. Oxford Report on Health Care Managers’ Limited Use of Management Research. University of Oxford; 29 May 2013.
Ethical Example 26 Introduction The mother of a child patient for whom you have been undertaking routine preventive dentistry comes
in to see you. In the OSCE, the child will not be present. One year ago, you saw the patient. After noting the child’s mouth was very crowded, you referred the patient (then aged 12) to your orthodontic colleague. At that time, you were instructed by the orthodontist to extract the lower left first premolar (tooth number 34). This procedure was to allow the second premolar (35) to erupt into the mouth, so fixed appliance orthodontic treatment could begin. You completed this extraction as requested under local anaesthetic. The child then returned to the orthodontist to commence treatment with fixed appliances in the upper and lower arches. After the experience of extraction with local anaesthetic, the child was apparently traumatised and returned after one year for a routine check-up. Your orthodontic colleague noted that tooth 34 was still actually present. The mother then asked for a referral to extract the tooth 34 under a sedation procedure as she thought her child could not tolerate another local anaesthetic extraction. A referral letter was sent to a sedation clinic signed by both the practice manageress and the orthodontist, and so another lower left premolar was extracted by an oral surgeon under sedation on the basis of that referral letter. A radiograph was taken, and your patient now aged 13 has no premolars in the lower left quadrant because of your earlier extraction and that of the oral surgeon. Her remaining teeth in this quadrant are: the lower left six, the lower left three, and the lower incisors. (These are teeth: 36, 33, 32, 31.) Question The mother is angry and upset. The theme of this OSCE is to manage the concerns of the mother within an ethical framework following extraction of the wrong tooth. Points to Note a. This OSCE is based on questions appearing in the MFDS exam. b. The extraction of the wrong tooth is an unfortunately common occurrence. c. In this OSCE, you do not need to break bad news; both the mother and daughter already know has happened, but not why it has happened. Answer The way to begin answering this question is as follows: As time in the OSCE is of essence and you have met the mother before, you do not need to go through all of the formal introductions. Make your professional introduction as brief as possible and then get straight into the answer itself. Begin by re-introducing yourself and apologise for the error. Explain to the mother that you will investigate the reasons for the adverse clinical outcome. One good statement to use in such situations is:
‘I wish to apologise for the mistake which has occurred. Although I am unable to explain the reasons why this has happened, I can, however, assure you that as soon as I find out, you too will find out.’ The actor portraying the mother tells you she is confused, being both angry and upset. She tells you she thought so highly of you and your colleagues and now you have let her and her child down. You can continue by repeating and reaffirming your commitment to continue to care for her child— that you will write to your colleagues who are involved and that a comprehensive investigation into why the error occurred will take place. Patient complaints 1. In an OSCE as in real life, this approach demonstrates both openness and honesty. This OSCE is not the place to excuse or explain what has happened. 2. In this OSCE, which deals with managing concerns, you have to be aware of the time limits in the UK to respond to a patient complaint. The substance of this OSCE is a clinical complaint; that is the reason the mother is attending today. 3. Complaints do not have to be written; they can be verbal too. Following your apology to the mother, you should advise her of the measures in place to respond to her complaint. Time to Respond 1. Patients, parents, or the legal guardian of the patient have six months from learning of the error to make a complaint, but this has to be within twelve months of the error. 2. A written acknowledgement has to be sent within two working days to the parent or legal guardian. An investigation has to take place and a written response sent to the patient within ten working days of the original complaint being made. 3. In this OSCE, you advise the mother that you will respond in accordance with the times set out above. In this OSCE and in real life, it behoves you to be open and honest with the actress playing the mother. Do not attempt to add incorrect information, provide assumptions, or conceal information from her at any stage of your dealings with her. By clearly stating the above time limits, this helps you to create a framework and a basis whereby the mother and her child can move forward. When dealing with the aftermath of an incorrect extraction, presenting a supportive framework goes a long way towards calming the initial anger and hostility while bringing a parent round to accepting suggestions for ways in which to move forward with the care of their child. Above all else, in the OSCE, do reassure the mother with the following: ‘That the patient, her child, is at the centre of this and everyone involved in the dental clinic will not lose sight of this.’ Of course, it is a predictable and unpleasant reaction to try to find, firstly, a reason and, secondly,
someone to blame for the events as described here. In this OSCE, you do not have to accept the blame. Indeed, you should not do so. If the actor playing the mother becomes accusatory or angry, then reiterate your apology and commitment to cooperate with the mother, using the correct procedures to resolve the initial issues. By apologising, you are not accepting responsibility, but you are clearly empathising with an actor portraying a parent in a state of emotional shock. The unnecessary loss of a tooth through an administrative error as described in this OSCE is a truly catastrophic event for all concerned. Do not forget the question of this OSCE is to manage the concerns of the mother as expressed by the actor and to do so in an ethical manner. The mother then asks the following question: ‘What will happen with the dental care of her child now that a permanent tooth has been mistakenly removed?’ In continuing with the OSCE, you might state: ‘That a responsible person will be appointed to coordinate the continuing care for her child.’ As you are present in this consultation or OSCE, you might ask if she may agree to you to being the person she can communicate with and coordinate the further care of her child with other specialists. In doing so, again you are not admitting responsibility or liability for what has occurred, but you are stating your commitment to continue caring for her child. You might also suggest that: ‘Given the age of her child (as the upper and lower jaws are still growing) you need to seek further specialist opinions for the best way forward.’ Continuing, you can explain: ‘The information you find (for her) will be independent, so the most appropriate unbiased options can be discussed, and from these, an ideal solution can be found and followed.’ The actor will of course display some resistance to your suggestions and maintain a stance of displeasure and hostility. In the OSCE, you have to firstly accept and then acknowledge these signs. In OSCEs and in real life, I have found the following comment to be helpful: ‘I can see this is not easy for you and I would like to say that this is not easy for me either and I truly find this to be difficult, but I can see a way forward with the care of your child.’ Initially, you need to mention that you would like to bring in as much support as needed. This will be how her child might continue with (what is essentially now an altered) orthodontic treatment plan. You should mention that despite the mistake that has happened the best way forward is to continue with the orthodontist who has started the treatment plan, but you would like to bring in other opinions to support the mother with her decisions. At this stage, do ask if there are any questions.
The actor may then ask: ‘How can anyone plan treatment as her child is missing a healthy tooth?’ Advise the actor that you will ask for an independent opinion from an orthodontic specialist who is not associated with the practice. Continue by advising that you see the treatment continuing in three stages and these are as follows: 1. The immediate short term for the next year up to two years and depending on the information we receive this might mean continuing with orthodontic treatment. The space which is now present between the first molar and canine can be closed, or the space can be maintained. Explain if the space is to be closed, then the orthodontic treatment will continue as the fixed appliances (use the term ‘braces’) are already in place. Not unsurprisingly, the actor playing the mother tells you she isn’t happy to have the space closed up and feels that a big biting tooth (the molar) being next to the lower eye tooth (the canine) doesn’t seem to be right somehow. You should respond by acknowledging these concerns and repeat to the mother that: ‘I do agree with you that this doesn’t sound ideal, but this is only one option and we should now consider the other options too. Could we go on to discuss other options for treatment?’ The actor will acknowledge this suggestion, and you can now go on to discuss the other options. 2. If the space is to be maintained, then in the short term a bridge can be placed, and this will be done when the orthodontic treatment is finished in one year’s time. Explain to the mother a bridge is made by your technical colleagues in a laboratory. This consists of a tooth attached to the teeth in front and the tooth behind the one which was taken out. You should advise the actor/patient’s mother that you would like to use a bridge that is attached in place, and the teeth in front and behind will hold this new ‘bridging-tooth’ with glue. At this stage, the actor may ask you: ‘Is it the case, bridges cut down healthy teeth and they don’t last forever?’ The actor may also say to you that bridges are not real teeth and her child will now have even more complicated treatment to correct this (unforeseen, unplanned, and unfortunate) extraction. You explain to the mother that the type of bridge you wish to use is a bridge held in place by being glued to the teeth both infront and behind the one taken out and very little if any enamel (explain this is the tough outer coating of the tooth) will be removed or disturbed in the process. Clinical pictures and radiographs If there are clinical pictures, models, or radiographs present, you can use these to illustrate the point you are making. If the molar teeth have been restored, then you may also tell the actor that the part of the teeth which have been filled will once more be filled and there will be little if any further disruption of her child’s teeth. 3. You should go on to say that bridges are a medium-term solution.
The actor may then ask you what do you intend to do after this medium term. In the longer term, a more permanent solution would be to provide a dental implant to restore the missing tooth. Dental implants Given the recent problems and publicity with other forms of implant and cosmetic procedures, for the absolute avoidance of confusion, you need to use the term ‘dental implant’. You can go on to explain this involves referral to a hospital-based specialist and a surgical procedure. A dental implant would be placed when at the age of over 21 the jaws of her child have stopped growing and the dentition is stable. You should state this will be over seven years into the future, and if this is the route the mother wishes to follow, then you can arrange for the necessary arrangements to be put in place to facilitate this. At every stage of managing the concerns of the mother, you have to briefly pause to check that the information you are giving is understood and ask if there are any questions. Pause to ask questions, pause when you are answering questions, and pause before moving to the next stage of the process. The actor may ask what is involved in a dental implant. In managing the concerns of the mother, you should again state that this procedure will only be undertaken when her child has fully grown and might be completed by a specialist dental surgeon in hospital. There are of course specialists in practice who undertake these procedures, and again you would be prepared to provide all of the information necessary so the mother can, in the future, make the correct decision for her child. The actor states that she is not sure how to proceed and she would like to discuss this with both her partner and her child. You can answer this point by advising the actor playing the mother that you agree with her wishes to involve her child in the decision-making process. As the mother, she does have the responsibility to decide what now happens to her child. Parental Responsibility 1. You should be aware that the mother does have the responsibility for the care of her child. From a legal point, if the mother is not married to her partner, even if he is the natural paternal parent of the child, or if the partner is of the same gender, this partner may provide input and advice to what will happen to the child. However, they have no right of responsibility for the care of the child. 2. In this OSCE, you do not need to and indeed ought not to go into the specific legality of who has responsibility for the care of the child in this case. If you do so, you will be a long way off subject and you might incur the wrath of an angry actor. 3. Currently in the UK, the position is as follows: Parental responsibility rests with the mother or the natural father if married to the mother at the time of birth of the child. Parents who have legally adopted a child or any authority or persons with residency orders where the child lives with them also have parental rights. 4. If the natural father is not married to the mother, then he has no parental responsibility.
5. Parental responsibility can be granted by court order, an agreement with the mother, or as a condition of a will. I feel it is important to introduce this aspect of UK law. Some of you may be studying for the MFDS and MJDF in revision courses outside the UK and will be sitting for qualifications in your own exam centres. Possibly, there will be variations in the legal framework in different countries, and perhaps it would be prudent to know in which country your examination will be taking place. You have to be up to date and aware of the law as it applies not only where you will be taking your exams but where you will be practicing dentistry too. Closing Statements Do be sure to ask if there are any further questions from the actor. Usually, if you have managed to cover the areas described above, there should be no further questions. In some OSCE scenarios, the actor may insist that they will be threatening legal action. Do not be alarmed if such expressions are made; you should almost expect this. Maintain a professional and polite approach and advise the actor that you and your colleagues will cooperate with the mother, her family, and legal advisers to gain the best outcome for her child. One statement I have found to be reassuring for a parent and supportive of your commitment to continue dental care for a child is to say to the actor: ‘It is my sincere hope that in the final analysis, we can all learn from this quite horrendous mistake, so no other child will go through what your child has. If this means further study and critical examination, then this will happen with measures to stop this from ever occurring again. I would like for us to stay in touch and to keep you updated on the information we learn. ‘I think with this situation we find ourselves in the words of Lionel Bart are fitting:1 I can’t promise you today that I can make things any better, but by working together, we can at least make things less bad.’ I think this would be one acceptable approach to managing concerns. I have based this OSCE on both an MFDS exam question and what really happens in the dental clinic. By combining both in this case, you will gain an insight into what will be expected of you in an MFDS or MJDF OSCE. Further Considerations Managing concerns and dealing with the aftermath of an incorrect extraction is unfortunately a common problem and one I hope you will not have to deal with in real life. In the MFDS and MJDF OSCEs, the actors do portray realistic behaviour patterns. Having seen both real life and OSCE cases such as this, you might be forgiven for thinking the actor really was the parent of a child who suffered an incorrect extraction. An elective extraction involving two or more practitioners will mean that the information passed between the parent and practitioner, practitioner and practitioner in one clinic, and then practitioner and specialist in another clinic is most likely to be the source of the error that led to the wrong tooth being taken out. The best practice would be to write the referral letter or instruction in both clear
language and in symbol form, clearly noting the correct tooth to be taken out.2 In this case, the premolar was extracted earlier and in haste. The orthodontist did not check the computer record, the paper record from one year earlier, the radiographs, or the child’s mouth. The mother understood incorrectly that another tooth had to be taken out, and from the previous performance, she asked that a sedation extraction would be undertaken instead. The introduction of the mother’s wishes for the care of her child and third party involvement, in this case the practice manageress, then a fourth party, the sedation specialist oral surgeon, provided all the elements contributing to the extraction of a wrong tooth. A Significant Event Analysis Whenever a serious clinical incident occurs, a significant event analysis or SEA is conducted, this revealed the following: 1. The records were not checked by the orthodontist. 2. The parent and practitioner were not in direct communication with each other during the referral process. 3. The referral letter was signed, sealed, and stamped (endorsed with the dental practice stamp) by the practice manageress. 4. The sedation specialist then followed the instructions as written by the practice manageress and did not look in the mouth or at a radiograph taken immediately before the procedure to check if the referral was correct. 5. The sedation specialist assumed (incorrectly) as the official stamp of the dental practice was used to endorse the extraction request that everything was in order. The Legal Aspects The extraction of a wrong tooth is treatment without consent. In law this is an assault. In the UK, as outlined above, there are time limits and a framework within which complaints are managed. In this case, the mother will receive a letter in 2 days, and an investigation with results and recommendations within 10 days (if in practice) or 20 days (if in hospital) is then sent to the mother. If following this the mother is not satisfied, then an independent review panel is convened to investigate with responses being sent to both parties. In this OSCE based on real events, a letter was sent to the mother with an apology and explanations. A referral letter was sent to a hospital-based orthodontist for an independent treatment plan to be followed. The reason for this was: 1. The orthodontist involved wanted a surgical solution: implant treatment at age 21. 2. The sedation specialist involved wanted an orthodontic solution: Close the space between the lower left 6 and lower left 3. As no consensus could be achieved and there was a risk that both parties were losing sight of the fact that the patient, a child, must come first, a referral was made, and the recommendation of an
orthodontic consultant based in hospital was followed. The child continued with orthodontic care. When this phase of treatment was completed, a minimal preparation bridge was placed. In the future, if a replacement resin retained bridge or replacement with a conventional bridge would not be suitable, then an implant will be placed by a surgical specialist. The mother did not resort to legal action against those involved in the care of her child. I think this was the best all of those involved could hope for in this situation. The final analysis and recommendation to avoid administrative errors from developing into adverse clinical events was to do the following: Check the patient record cards. Check with the patient or parent. Check in the patient’s mouth. References to Ethical Examples 26 1. Stafford D, Stafford C. Fings Ain’t Wot They Used T’ Be: The Lionel Bart Story. London: Omnibus Press 2011. 2. Henderson SJ. Risk management in clinical practice. Part 11. Oral surgery. Br Dent J. 2011 Jan 8;210(1):17-23. Further Reading 1. General Dental Council. Standards Guidance. Standards for Dental Professionals. May 2005. 2. General Dental Council. Standards Guidance. Principles Complaints Handling. May 2006. 3. Brennan M, Oliver R, Harvey B, Jones G. Chapter 7: Ethics of Team Working in Practice. In Ethics and Law for the Dental Team. 1st Edition pp. 73-94. Knutsford: PasTest 2006 (Reprint 2009). 4. Kay EJ, Tinsley SR. Chapter 11: Decisions in Dentistry: Whose Responsibility? In Communication and the Dental Team. pp. 127-135. London: Stephen Hancocks 2004. 5. Gahan MJ, Lewis BRK, Moore D, Hodge TM. The orthodontic-restorative interface 1. Patient assessment. Dent Update. 2010;37(2):74-6.
Ethical Example 27 Background Information Taking another question from the MFDS, I remember this OSCE quite well. It should be quite straightforward to complete within the allocated time. Whereas one candidate easily completed the question, with the actor briefly showing them a hint of a smile (usually a good sign) and the examiner
nodding approval, the next candidate struggled to control the same OSCE. With a deteriorating situation and the actor getting quite irate at the candidate’s efforts to dig their way out of the turmoil they had gotten into, those at the rest stations looked up as the candidate’s torment continued unabated until the bell rang. While this might be an unusual occurrence in the MFDS and MJDF, patients do occasionally get upset and angry, perhaps rightly so if you try to flannel them with jargon or talk at them with something that is not quite right. An example might be not being upfront and honest with a patient about things that have not quite gone according to plan. The well-known American, Michael Tyson, famous for among other things, in a social commentary once said: ‘Everyone has a plan until they get punched in the face.’ Messing up a simple OSCE where all you have to do is tell the truth is like getting a punch in the face. At best, you will be left waiting for the bell to ring, to take the actor out of your misery. At worst, your whole exam plan could be on the ropes. Introduction Last week, your colleague decided to perform an incisional biopsy in a patient’s buccal mucosa as there was a small white patch there. The patient is a 36-year-old secretary who smokes but wants to give up; she drinks socially. The patient has re-attended this week to learn of the results of the biopsy. Between last week and your colleague, the results of the biopsy have not returned. You have phoned the hospital department dealing with the biopsy, but they have no information on either the patient or the biopsy. Question The biopsy sample is lost and you have to manage the patient’s concerns. You enter the OSCE, and the actor is sitting there pleasantly smiling as you now have to give the news that the biopsy cannot be found. Answer The first thing you have to do is introduce yourself to the actor as you would to any patient you meet in the clinic for the first time. Then you might wish to ask how the last week has been for the patient. Empathy and biopsies 1. This is a good way to buy some time as you plan how you are going to deliver your news to the patient. Remember that having a biopsy is often an uncomfortable procedure. 2. From start to finish, the whole process of taking a biopsy can be uncomfortable for the patient. 3. Administering the local anaesthetic before the biopsy procedure is uncomfortable, and following the procedure, if silk sutures were used (less so now), then these will need to be removed either today or in the next few days.
4. If resorbable sutures were used (more common), then these can become an irritation in the mouth as they accumulate food debris. In reply to your question, the patient tells you that last week was bearable and the wound healed well, but above all else, they are anxious and nervous about receiving the news. The actor states they have a real fear they may have oral cancer. The actor implores you to tell them the results of the biopsy. ‘Please tell me the results of the test. It’s not cancer, is it?’ Your response should be to give the information to the actor in small pieces. You might wish to state the following: ‘I am glad to hear the last week was bearable and that you are healing well.’ Continue with: ‘I do appreciate your concerns and thank you for re-attending again today, this time with myself. My colleague who you saw last week isn’t here today, and somehow we don’t seem to have the results of your biopsy (the procedure you attended for last week).’ ‘I am sorry that this has happened.’ Now you should pause and wait for the response. The response should be both a visual and verbal one. The colour instantly drains from the face of the actress, while her expression goes from quite personable and pleasant only a moment before to blank, then angry and getting worse with every passing second… ‘What! What? What do you mean: You? Yes, you! You don’t seem. Seem? To have the results… ?’ The actor exclaims this, while being just ever so slightly on the loud side of speaking with an accusatory tone. The actress may precisely reflect your carefully chosen words back to you: ‘You don’t seem to have the results?’ She might add the following for good measure for you to concentrate your efforts at recall: ‘Well, either you do or you don’t, which is it?’ In an OSCE, sometimes you have to roll with the punches and accept the point: ‘Yes, you are correct. I do not have your results today and I do not know today where your results are. However, I will endeavour to find out where your results are, and as soon as I find out the result, you too shall find out the results of your biopsy.’ That is perhaps the best you can do. This might take the wind out of the actress’s sails until you can get on to the other things you need to talk about in the OSCE. The actress will continue her onslaught, but in a different manner; sidestepping your defence, she
carries on: ‘I’ve been worried sick, sick. All of this week: sick. Seven solid days of sickness and for this wasted journey here today.’ The actor will really be in her element now, in full flow. You will have these OSCEs when it seems the actor is in control and you are just a passenger going along for the ride. ‘I can see you are upset. If I was in your position, I would be quite upset too, and this really can’t be easy for you.’ The only way to proceed is to acknowledge the distress caused by the loss of the biopsy, explore the concerns and feelings, then encourage any questions the actor may have. ‘I know this is difficult. Do you have any questions you wish to ask me today?’ It is the way to take control of the OSCE and to show you wish to get the most out of this consultation for the patient. The actress then changes tack slightly: ‘I am worried about cancer. I am sorry if I seem to be harsh, but I am worried. It’s just that my best friend has had cancer, and I am worried I might have it too. I am sorry if I seem to be angry. I don’t mean to upset you.’ Your response is as follows: ‘I can see this is difficult and you need not worry as you haven’t upset me. Sometimes it’s good to get things out and thank you for being so open with me.’ This is one possible answer to respond to the concerns, helping the actor or a patient to prioritise the next options they may wish to take. In this OSCE, the actress continues: ‘I need to go for a smoke. I need a cigarette. I do that every time I get stressed. I know I shouldn’t and I do want to stop though.’ One useful reply to this comment from the actress was to suggest the following: ‘Look, I know this isn’t a consultation about smoking cessation. I haven’t asked if you want to stop, but there are ways we can help. We can advise you on the benefits of stopping. We can assist you in stopping and arrange for you to attend a stop smoking Service clinic.’ In this answer, you are alluding to the five A protocol of smoking cessation: The underlined words: asking, advising, assisting, arranging, and attending, are the basis of this protocol which we will return to in OSCE 46. You can now reassure the actress and guide her back to the subject matter of the OSCE. In real life, there will be powerful and persuasive characters in the dental clinic. Their consultations need to be focused on concise interactions and may require a firm approach to achieve this. You might continue this consultation with the following:
‘We need to get back to your lost biopsy. I will investigate what has happened and I can assure you we will find out. There might be a simple explanation for this. However, the difficulty we face together today is that I cannot tell you anything about the results of a test if I do not have the test. ‘It would be grossly unfair and quite incorrect if I were to tell you something I do not know.’ Limiting your answers 1. In stating this to the actress, you are not giving any detailed information. 2. Premature advice and reassurances should not be given until the patient’s concerns are clearly identified or you have the data to hand. 3. The actress then asked what would happen next. Your response is as follows: ‘I would hope we will find the biopsy. My experience tells me we will. If not, then we will ask you to come back again and then my colleague who saw you last week may wish to take another sample. The sample taken last week was only a small piece. There remains more of the area to look at, but we will only do this should this be necessary. If it is, then I do apologise for having to give you this bad news today and for the thought of you having to go through another procedure which really cannot be pleasant for you.’ In cases such as this, it is helpful to state to the patient or the actress that all stages of the procedure of transport of her sample from the clinic to the laboratory will be tracked and monitored. In this case, you might add that an investigation will take place to locate the biopsy and why it has gone missing today. It is important to agree an action plan and then the follow-up. The actress should be in agreement at this stage of the OSCE; drawing to the end of the OSCE, you might state: ‘What I can tell you is that whatever the result is, we will deal with the news together and we must stay in touch.’ Draw the OSCE to a close by asking: ‘Do you have any questions for me?’ Follow-up strategy 1. In stating the above, you are agreeing an action plan and follow-up care. 2. You are ensuring the patient has ongoing support, care, and access to information. 3. All of these are important for a patient and important for the examiners to see and hear you doing this in the OSCE. In this type of question, it is important to not end until you have checked it is OK to end the interview. The response from the actress is ‘No, I don’t have any questions and thank you. You have explained things to me and I would like to come back to get my results and talk about the smoking.’ With that, the actor will relax, smile, and you can leave the OSCE and join the other candidates at the
rest station. Further Notes to This Ethical Example. In some OSCEs, you will go through the entire subject matter well within the allocated time and finish early. This is nothing to worry about and you probably haven’t missed anything out. Of course, there will be other OSCEs where due to the subject matter time is critical and you will have to pack a lot into the 10 or so minutes allocated. The purpose of this consultation was to manage the concerns of a patient after the results of a biopsy taken a week previously were not (yet) available. Although you have to manage concerns in this OSCE, there is also an element of breaking bad news here too. What is bad news to a patient might not be bad news to you. There are ways of delivering bad news and a format to be followed. The SPIKES Protocol One format I find useful is the accepted SPIKES protocol:1 As follows: 2 1. Setting. Check that the location you are giving the news to the patient or actor is suitable for the news they are going to receive. In an OSCE, it invariably is, as you wouldn’t be asked to give bad news if it wasn’t. 2. Perception. Check the degree of understanding the patient or actor has. It is important to know the level at which you will deliver the news to the patient. 3. Invitation. Ask the patient if they would like to know about the information you have. Would they like to receive this now? In this case, the information that the results of a biopsy could not be given was something the actor or patient was not expecting and this can come as quite a shock. In this OSCE, the object was to deliver the correct information. 4. Knowledge. It is important to ask the patient how much do they know about the condition they have. In this case, the patient knows there was a white patch on the cheek mucosa, but it would be inappropriate to pass any comment on the nature of this, and so in the OSCE as in real life, no information can be given. Of course, should the actor want to know about white patches and their possible causes and potential consequences, then you would have to be in a position to tell them about this condition (see below). 5. Explanation. Acknowledging and responding to concerns to help the actor or patient deal with them is important, and questions should be encouraged. In this case, you have to be able to explain to the actor the steps you will take within the health care environment to locate their biopsy if possible. If this cannot be done within a certain period of time, then you should explain the measures to be taken to correct any problems; in this case, another incisional biopsy would be needed. 6. Summary. This is the strategy to end the consultation to recap everything and to have an exit and a plan. Do not leave the actor or the patient with nothing. In this case, a further appointment will be made, with an investigation into what has happened, and if necessary a second sample will be
taken. Additionally, the issue of smoking cessation was touched on and left with the actor to take up if they wish to do so. White Patches and Smoking The patient smokes and has a mucosal white patch; these are two important facts given in the introduction. It would be easy in this OSCE if you were to focus on these two issues, but the subject of this OSCE is a lost biopsy and the object of this OSCE is to deliver the news to the actor that the results cannot be given as the patient’s biopsy is lost. There are several reasons for a white patch to be seen in the mouth, and white patches are commonly seen. If you have such an OSCE, and the actor asks: ‘What might be the possible cause of a white patch?’ then the common reasons you can explain to the actor are follows: 1 . Trauma, which can be thermal or chemical, from hot food and drink or the patient placing an aspirin tablet against the cheek mucosa. 2. Infection, from a long-standing fungal infection with candidal species. 3 . Common diseases of the skin are seen in the mouth too; this can be Lichen Planus and other conditions such as both Discoid and Systemic Lupus Erythematosus. 4. If there is no known cause of a white patch in the mucosa other than the use of tobacco, this is termed: leukoplakia. 5. The last reason for a white patch in the mouth is that it can actually be neoplastic. It is important to tell the actor or the patient concerned about cancer that in certain of the causes and conditions there is a risk of malignancy arising. The degree and extent of neoplasia can be a cellular change, from a dysplastic peri or pre-cancerous alteration in the histology of the mucosa, through cancer in situ where the basal membrane has not yet been breached, to actual cancer itself causing the white patch. In an OSCE and in the dental clinic, it is important to provide information suited to the patient’s needs and to do so while offering advice and reassurance. As I recall, the candidate who received a serving in this OSCE advised the actor of results of the lost biopsy (that he had never seen). Or rather, he was telling the actress what he thought she wanted to hear. This particular response is extraordinary and in many ways as indefensible as the exam candidate in the introduction who believed consent to be a clinical irrelevance. In delivering false information to the actress, this candidate would have breached the OSCE domains of clinical issues and perhaps conveying information too. Both of these are unethical behaviours. To pass the MFDS, a candidate needs to pass all four domains in addition to 7 out of 10 of the OSCEs. In this type of question, do not give too much dental and medical information, unless it is asked for, and avoid premature advice and inappropriate reassurances until the concerns are clearly identified and, as mentioned, you have the data. Moving away from the MFDS to a more structured technical or
procedural OSCE as found in the MJDF, the following information might be usefully given to the examiners: 1. Some of the common conditions causing mucosal white patches do have a potential to be premalignant. 2. Lichen Planus is not premalignant, but the comparatively rare variant of Erosive Lichen Planus is, with a 1% potential to become malignant.3,4 3. Leukoplakias have a 5% potential to progress to carcinoma.3,4 4. However, this depends on where in the mouth the lesion is and if the patient smokes. 5. If they do not smoke, there is a greater risk of malignant transformation in this idiopathic leukoplakia, and if the lesion is in the floor of the mouth, then the risk of malignancy can be up to 25%.3,4 Management of the White Patch The site of the lesion has to be recorded and photographed. The age, health, and other factors all have to be documented too before deciding on what you will do next. If there is a rough or sharp edge of a tooth or a restoration which needs to be smoothed off, then taking a history in the OSCE, together with any clinical photographs, may help you to reassure the actor, patient, or examiner. If we return to the patient portrayed in this OSCE, the patient is a smoker. Then, as reported by Pindborg in 1980, 60% of white patches will disappear if the patient can stop smoking.5,6 Above all else, remember when giving advice to an actor or a patient, regardless of whether the biopsy is lost or found, it is nearly impossible to predict the behaviour of leukoplakia with any degree of accuracy. References to Ethical Examples 27 1. Bailea FW, Buckman R, Lenzia R, Glober G, Bealea A, Kudelka PA. SPIKES: a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2010;5(4):302-11. 2. Kaplan M. SPIKES: a framework for breaking bad news to patients with cancer. Clin J Oncol Nurs. 2010 Aug;14(4):514-16. 3. Mitchell L, Mitchell D, A, McCaul L. Chapter 9: Oral Medicine White Patches. In Oxford Handbook of Clinical Dentistry. 5th Edition pp. 410-411. Oxford: Oxford University Press 2010. 4. Scully C. Chapter 22: Malignant Disease. Cancer Prevention. In Medical Problems in Dentistry. 6th Edition pp. 518-519. Edinburgh: Churchill Livingston 2010. 5. Pindborg JJ, Reibel J, Roed-Peterson B, Mehta FS. Tobacco-induced changes in oral leukoplakic epithelium. Cancer. 1980;45(9):2330-36. 6. Pindborg, J. Oral Cancer and Precancer. London: John Wright 1980. Further Reading
1. Sandbank S, Klein D, Westreich M, Shalom A. The loss of pathological specimens: incidence and causes. Dermatol Surg. 2010;36(7):1084-86. 2. Ptacek JT, Eberhardt TL. Breaking bad news: a review of the literature. JAMA. 1996;276:496502. 3. Taylor C. Telling bad news: physicians and the disclosure of undesirable information. Sociol Health Ill. 1988;10:120-32. Three good papers to read to give you further knowledge on breaking bad news. 4. Goodger NM, Odell EW. Case 57: Oral Cancer. In Odell EW. Clinical Problem Solving in Dentistry. 3rd Edition pp. 269-277. Edinburgh: Churchill Livingstone 2010. A good example with illustrations of an oral cancer diagnosis, prognosis, and treatment—well worth reading.
Ethical Example 28 Background Information The previous two questions were based on clinical cases and questions seen in MFDS OSCEs. This next case is a procedural MJDF exercise. Even if you are only sitting the MFDS, please do not leave out this question on your way to the next OSCE. I will try to include information and advice I have found helpful for both clinical practice and in preparation for the MFDS exam too. One interesting but not so recent development in UK dentistry is the idea that dental teams should be formed and team working should be positively encouraged. So far and certainly conspicuous by its absence in the MFDS, there are no OSCES dealing with dental team members or their activities in the clinic. To date, this seems to be the sole preserve of the MJDF. The registration of dentistry in the UK now encompasses apparently all those involved in clinical care or rather direct clinical care. Despite this, there are three categories of dental team members who are not subject to training, accountability, or regulation as other team members are. These nonregistered dental team members do play a safety critical and vital role in the functioning of a dental practice and team; they are as follows: 1. Dental engineers, who turn up with variable frequency and an assortment of tools to mend your equipment and leave just before or after causing another problem to arise or after your realisation that the settings they have set on your compressor or suction pump are not what you wanted. If you are not a practice owner or perhaps if you are, if this happens, then just tell the: 2. Practice Receptionist, who has access to all the telephone numbers of everyone who is anyone to do with where you work. Often the receptionist was once trained as a dental nurse but now no longer works as a nurse and is no longer registered with the GDC. Despite this, they know more about dentistry than the newly qualified dentist does, but less about their duties than the senior associate. This is the dentist who is about to leave the practice and set up on his own with your patients and your staff. When things go wrong, the associate will always complain to the:
3. Practice Manager, who has even more control over everyone than the practice receptionist. The practice manager can access all the patients’ confidential details too. These people are sometimes the practice principal’s wife or worse than that for everyone the practice principal’s mother-in-law. For those of you who do not work in general dental practice or have at one time during your vocational training or foundation grade years, I am sure you look back with happy memories as you now gaze around the hospital to see similar characters, also not trained, not accountable, nor registered going about their business. Their job is to make sure you do yours. A year ago, I did speak to the chief executive of the GDC and asked her why we the registrants should have non-registrants directly involved in controlling the care we give to patients. Despite the findings of the Francis Report, I am still waiting for her answer… Introduction In this OSCE, we will deal with the pre-registered trainee dental nurse who has suffered a needle stick injury. As you enter the OSCE, the actress who is playing the trainee dental nurse jumps up from her chair and explains she has injured herself while removing a local anaesthetic needle from a syringe. She has stabbed herself in her finger with a needle used on the last patient. This last patient is noted to be positive for hepatitis B and has a history of intravenous drug use. No other testing for other blood borne pathogens has been conducted on this patient and the medical notes are not updated. Sharps injuries 1. Many candidates read about this particular OSCE before sitting the MJDF thinking this particular question will not come up in the exam, but it does with a predictable frequency. 2. Possibly in the same way you think: ‘I am not going to have a needle stick injury this year’, although unfortunately most of you will sooner or later. 3. In this respect, there are only two types of dentist on the GDC register. Those who have already had a needle stick injury and those who are about to have one. The Questions 1. Demonstrate the immediate actions necessary to deal with a needle stick injury either with yourself or a member of staff. 2. What are the vaccination and immunisation protocols currently recommended? 3. What is the difference between immunisation and vaccination? 4. How many needle stick injuries occur every year in Europe? 5. What legislation is in place to limit this number? 6. What new legislation is being planned to further reduce this figure?
7. In the OSCE, what are the next steps you will take with the injured trainee nurse? 8. What are the next practical steps you will take in the OSCE? 9. After these practical steps in the clinic, how will you determine whether there is a risk to the trainee nurse from contracting a blood-borne infection? 10. Following a risk assessment, if there is thought to be a risk to the trainee nurse what are the next stages? 11. If you need to take a blood test from the trainee nurse, can you do so? If you need to test the patient’s blood, can you also do so? 12. What is the current UK-recommended protocol for PEP? 13. What are the risk factors for acquiring a blood-borne pathogen from a needle stick injury? 14. Assuming the trainee nurse has immunity to HBV, what are the relative risks with respect to HIV and HCV? 15. When the immediate steps dealing with the needle stick injury are completed, what must you do next and is there legislation governing this? If so, what is it? The Answers 1. The immediate actions you must take are to instruct the actor portraying the nurse to rinse the injured finger under running water. Advise them not to scrub, but to let the blood flow out and gently squeeze any blood out of the wound. After this step, ask if she has completed her immunisation for hepatitis B. The answer should be yes, and this document can be verified once all the immediate actions are complete. 2. All staff in the dental surgery, regardless of registration status, should have demonstrated vaccination and immunity to hepatitis B. This document has to be checked before they are allowed to work in the clinical environment. For hepatitis B, immunity is demonstrated with hepatitis B anti-surface antibodies in excess of 100 mIU/ml. 3. In answering this question, consider that vaccination and immunisation are not the same. Vaccination is the process of being exposed to a specifically prescribed antigen to create immunity. Immunisation is the process whereby the body’s immune-system responds to an antigen to generate antibodies conferring resistance to infection. Immunisation is proven with a test demonstrating specific host antibodies in excess of a certain level. As mentioned in the previous answer, hepatitis B immunity is demonstrated with hepatitis B antisurface antibodies in excess of 100 mIU/ml. 4. In Europe, there are over 1 million needle stick injuries every year.1 5. In 2010, there was a pan-European directive to make it a legal requirement that employers deal in an appropriate manner with needle stick injuries with their staff. In May 2013, these directives became law in the UK.
6. In the UK, from 2013 onwards it became the responsibility of the HSE (Health and Safety Executive) to move the legislation governing sharps and their safe disposal in dental clinics from risk assessment to risk control to attempt to reduce this number further. 7. In this OSCE, the trainee dental nurse should already be fully immunised against hepatitis B before being exposed to any contaminated sharps. There should be documentary evidence to prove this. If not, the trainee nurse must now attend an occupational health department in the local hospital. Instruct the actor of the requirement to attend the OH department in the local hospital as soon as possible. Once there, she will need to consult with occupational health specialists to effectively deal with the injury and the possible consequences. Advise the actor this may mean counselling, testing, and medication. In addition to this attendance, the UK DOH (Department of Health) recommends universal source testing for HBV, HCV, and HIV. 8. The needle and local anaesthetic cartridge used on the patient has to be examined for any signs of blood or aspirant fluid from the patient. Explain to the examiners in the OSCE you would do this with forceps, such as Spencer Wells, and do so while wearing gloves. Your reasons for doing this are to assess how much of the patient’s blood was aspirated into the cartridge and re-injected into the trainee nurse’s finger. This procedure forms part of a risk assessment in conjunction with the occupational health specialist who will decide on the next steps to take. In the OSCE, the needle and cartridge should then be securely contained in a sealed sharps safe box. 9. The patient on whom the needle was used should now be identified. With consent, their medical practitioner needs to be contacted so their serus status with regard to HCV and HIV can be determined. If the patient proves to be seronegative, then this might be less problematic than if the patient was proven and recorded to be seropositive for HCV and HIV. However, if the patient was noted to be seronegative, the date of the last test should be noted. If this test was undertaken a considerable time before the needle stick injury, given the patient’s risk factors, then another test may be needed as they may at the time of the injury be seropositive for HCV and HIV. 10. Following a risk assessment with the Occupational Health Department in the local hospital, postexposure prophylaxis (PEP) with various anti-retroviral medications is provided within 24 hours of the injury and no later than 72 hours after the injury to reduce the risk of seroconversion and acquiring HIV. Even if the source cannot be proven to be positive, it may be the case that following a risk assessment PEP is started. 11. Following the initial injury, there has to be a baseline blood test of the recipient to ascertain they are seronegative and are immune to HBV. Repeat testing after several weeks is needed to determine that no seroconversion has occurred. a. The UK DOH recommends that the source patient should provide a sample of blood for HIV and HCV testing within 8 hours and no longer than 24 hours of the injury.
b. This is to reduce the need for post-exposure prophylaxis should the source prove to be negative. If the patient declines this testing and even if there is sufficient material aspirated in the cartridge, this cannot be tested for HIV due to current legislation. The results of testing could be linked to a named person, and if this person did not give permission to be tested, doing so would constitute an assault (but not a battery) Essentially if there is no consent, there can be no testing. 12. Currently in the UK, the regimen for PEP is: 245 mgs Tenofovir with 200 mgs Emtricitabine ods PO. 200 mgs Lopinavir and 50 mgs Ritonavir bds PO. This regimen is started and continued for 4 weeks. After 12 weeks following the cessation of PEP or 16 weeks from the date of the needle stick injury, an HIV test is conducted on the trainee nurse to determine the serus status with regard to HIV.2 13. The risks of acquiring any blood-borne pathogen depend on several factors. Among these are the quantity of infected material injected and the quality of material injected; the risk of seroconversion increases with an increase in viable pathogen load in increasing amounts of blood, saliva, or gingivo-crevicular fluid. 14. In this OSCE, you have to advise and reassure the actor that the relative chances of contracting HIV are quite small when compared to those of acquiring hepatitis B and C. If the trainee nurse does have immunity to HBV, then the greater risk is from acquiring HCV rather than HIV. The average risk of HIV acquisition is 3 per 1,000 injuries from known sources of the virus, whereas the risk of HCV acquisition is 3 per 100 injuries from known sources of the virus.3 Points to Note 1. In the UK some 0.4% of the UK population between the ages of 15 and 59 are infected with HCV. In those patients who are intravenous drug users, this figure is between 3% and 42%.3 2. In the four months following a sharps injury, the trainee nurse portrayed in this example will certainly require counselling and most likely treatment with PEP. 3. The actor should be informed of this necessity during the OSCE. 15. The last task you have to complete in this OSCE is to document the incident in accordance with the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 Act (RIDDOR 1995). This is a 1995 statutory instrument of the Parliament of the United Kingdom. It regulates the statutory obligation to report deaths, injuries, diseases, and ‘dangerous occurrences’ that take place at work or in connection with work. Specifically, there are three separate clauses in RIDDOR, each dealing with hepatitis, the absorption through the skin of any substance, and admission to hospital for treatment. So it is quite clear this incident has to be reported and appropriate measures taken. At the start of this OSCE, it was noted that in 2013 legislation has moved from risk assessment to risk
control. With specific regard to needle stick injuries, it is known that most of the injuries occur during the recapping process. The new regulations state an employer must replace unprotected sharps with those incorporating devices to reduce or remove the risk of accidental injury. Just as this book is going to press, these new regulations will be going through UK Parliament. The manufacturers and suppliers will be working to improve the design of dental syringes so they fall into line with the latest risk control regulations. Further Notes to This Ethical Example One reason this OSCE is repeatedly seen is because there are so many needle stick injuries. The fact this OSCE is not seen in the MFDS might cause some concern. The communication skills so necessary when dealing with patients and breaking bad news are equally important in this scenario, when advising the trainee nurse of what lies ahead for the next four months and perhaps the rest of her life. James Wise, a faculty tutor for the MJDF RCS England exams, succinctly stated in an MJDF revision course in 2011: ‘These days you don’t die of HIV. You die with it.’4 For sure the regulations will change; risks will be reduced but not perhaps completely eliminated. I had my first needle stick injury as a dental student, and my last sharps’ injury was while extracting a wisdom tooth from a friend’s son last year. Both of these were low-risk events. In the intervening years, I have treated many patients who carry the viruses mentioned in this OSCE, but so far have not had a needle stick injury while doing so. The reason this OSCE is in the ethical examples chapter is that up to April 2014 an HIV Positive GDC registrant could not practise dentistry in the UK. The reason given was patients were thought to be at risk of contracting HIV during invasive, exposure-prone procedures. The entire practice of dentistry is by definition invasive. In the mid-1990s, in a series of publications Aneez Esmail and Sam Everington wrote that if we wish to have an equitable health service for our patients, surely we should start by having an equitable health service for the practitioners.5,6 If a registrant refuses to treat someone on the basis that they have hepatitis C or HIV, this is specifically disability discrimination, and not only would the GDC take an interest in this type of behaviour, but so too would a civil court where unlimited damages could be awarded. It seems interesting that the GDC’s actions in this respect might be viewed as a form of disability discrimination against its own registrants with HIV. Possibly in defence of the GDC’s previous directive, it could have been argued the GDC is protecting the public from risk. If an HIV positive registrant (even unintentionally) infected a patient, then the GDC would have been remiss in its duty to protect the public. Thankfully, such an outcome never arose, and with the advent of improved infection control measures (HTM 01 05) and high activity anti-retroviral therapy (HAART), the position of the UK DOH and
GDC became untenable as there was no scientific evidence to continue their discriminatory policy. From April 2014, Public Health England will initiate a programme to register and monitor those HIV positive health care workers who wish to return to practice.8 Where does this leave the trainee dental nurse with the needle stick injury from a high-risk source? Surely there is a duty to control the risk with the 2013 legislation? One principle in law is that of Tarasoff and the duty to inform. However, this principle only applies if there is actual knowledge, and by withholding this knowledge, if harm results, then those who are in a position to prevent harm and did nothing by withholding are culpable.7 However in this OSCE, in this case, we do not know the answer to the following three questions: 1. Is the source patient HCV and/or HIV positive? 2. Does the source material contain viable viruses capable of causing harm? 3. If so, is their viral load of such a level to cause infection in someone accidentally injected with their blood or other oral fluid? Consequently, in the absence of answers to these questions, the principle of Tarasoff does not apply to this case. For the trainee dental nurse, it is the occupational health specialists who have to make the decision on how best to proceed. The ethical duty of the dentist is to gather all the data necessary, so the most effective decisions can be made for the trainee nurse. References to Ethical Example 28 1. Himmelreich H, Rabenau HF, Rindermann M, et al. The management of needlestick injuries. Dtsch Arztebl Int. 2013 Feb;110(5):61-7. 2. Hamlyn E, Easterbrook P. Occupational exposure to HIV and the use of post-exposure prophylaxis. Occup Med (Lond) 2010 Aug;57(5):329-36. 3. Palmer GD. Chapter 31: Ouch. In Odell E. Clinical Problem Solving in Dentistry. 3rd Edition pp. 145-149. Edinburgh: Churchill Livingstone 2010. 4. Wise J. Part 1 MJDF Revision Course. Royal College of Surgeons of England; 2011. 5. Esmail A, Everington S. Racial discrimination against doctors from ethnic minorities. BMJ. 1993 Mar 13;306(6879):691-92. 6. Esmail A, Everington S. General Medical Council. Complaints may reflect racism. BMJ. 1994 May 21;308(6940):1374. 7. Gavaghan C. A Tarasoff for Europe? A European Human Rights perspective on the duty to protect. Int J Law Psychiat. 2007 May-Jun;30(3):255-67. 8. Dental Protection. HIV-infected Health Care Worker Regulations— ‘Victory for Human Rights’. [Online] Available from: http://www.dentalprotection.org/uk/newsnevents/pressrelease/HIV-victory-for-human-rights [Accessed September 2013].
Further Reading 1. Scully C. Chapter 20: Immunodeficiencies HIV Infection and AIDS. In Medical Problems in Dentistry. 6th Edition pp. 451-459. Edinburgh: Churchill Livingstone 2010. A good illustrated overview of the issues in this case. 2. General Dental Council. Principles of Patient Confidentiality. In Standards Guidance for Dental Professionals. London: General Dental Council. May 2005. Now superseded by the following standards guidance. 3. General Dental Council. Principle 4: Maintain and Protect Patient’s Information, Standard 4.2. In GDC Standards for the Dental Team. pp. 34-43. London: General Dental Council 2013. 4. Health and Safety Executive. Health and Safety (Sharp Instruments in Healthcare) Regulations 2013: Guidance for Employers and Employees. London: HSE HMSO 2013. [Online] Available from: http://www.hse.gov.uk/press/2013/hse-sharps-regulations.htm [Accessed July 2013]. From a legal point you have to both know and act on the information contained in this document. 5. Health and Safety Executive. Blood-borne Viruses in the Workplace: Guidance for Employers and Employees. London: HSE HMSO 2013. [Online] Available from: http://www.hse.gov.uk/pubns/indg342.pdf [Accessed July 2013]. Again another essential text you must read, not just for the MJDF exams, but you should be aware of the scope and extent of the legislation as it applies to you in the workplace.
Ethical Example 29 Background Information A patient who lives in a local residential home comes to see you in general dental practice with her nurse-carers. Although she has no physical disabilities, her appearance is striking. Due to selfharming behaviours, including pulling her hair out, her hair is now shaved by her carers. This measure reveals many deep scars in her scalp in various stages of healing. She is on a complex regimen of medicine for mental illness. As a result of her medication, she is withdrawn but does communicate with you through body language and some minimal verbal statements. Her eye contact with you is very limited and strained. A diagnosis of psychosis, specifically schizophrenia, has been made and she will be in long-term residential care, possibly for the rest of her life. When she leaves her residential care home, she only does so in the company of two carers. The medications consist of a complex regimen of benzodiazepine-controlled release tablets and Risperidone at 1 to 2 mgs per day. There are other medications being taken, but the carers cannot provide you with these details at this visit. There are oral side effects of these drugs, and these are dry mouth, tremor and hyperactivity of the masticatory muscles (in line with tremor of the skeletal muscles), and difficulty in swallowing. The patient is noted to be allergic to penicillin. On questioning her carer, on previous dental visits, the patient received a prescription for metronidazole and was sent on her way again without an
examination or treatment being undertaken. While sitting in the dental chair, the patient drank the mouthwash, then asked for some more. An extra-oral exam revealed the masseters to be tender and the patient was clenching her teeth. An intra-oral examination was conducted, and the oral hygiene was noted to be: ‘not too bad’. A basic periodontal exam (BPE) revealed the upper and lower buccal sextants were graded at 2 (no pockets greater than 3 mm but some plaque retention factors present); these were overhanging margins on restorations. The anterior sextant was graded at 1. There was some gingival bleeding on probing; no pockets, no calculus, and no overhanging margins present. Additionally, intra-orally there were wear facets on the molar teeth and signs of palatal enamel erosion on all the upper teeth. There were some Class V buccal cavities present too. Introduction Can you manage the concerns of both the patient and her carers by answering the following structured questions on the examination, management, and treatment that you might consider appropriate for this patient? Point to note In the MFDS and MJDF OSCEs, the device commonly used when presenting the clinical scenario of a patient as described above is for an actor to represent the carer while clinical material such as study models, photographs, and dental records will ‘represent’ the patient. Very much as in real life with a patient who is profoundly ill, very little communication with the patient actually occurs. Questions 1. How will you introduce yourself to this patient and her carers? 2. How might you build on your introduction to the patient? 3. What key skills are important to continue the rapport you are developing with the patient and her carers? 4. Can you list and detail the types of questions and order you might use them in a consultation as presented in this OSCE? 5. The carers are qualified nurses. Should you use technical terms with them? If so, give your reasons for doing so. If not, then why not? 6. In addition to verbal communication what else is important to develop and use in this OSCE? 7. Depending on whether you are sitting the MFDS (Scottish Colleges) or the MJDF (English College) can you detail the regulations and legislation in place to protect the patient depicted in this OSCE? 8. Define mental capacity. 9. Describe the circumstances or conditions whereby capacity can be diminished or lost.
10. How can you determine if a patient has capacity? 11. Can you list the four questions you would need to ask a patient to assess if they have capacity? 12. Who can assess whether a patient has capacity or not? 13. For MJDF candidates working in England and Wales, can you detail the five core principles of the Mental Capacity Act 2007? 14. If you have any concerns about a vulnerable patient, what must you do? 15. When previously attending, the patient was not examined or treated, only receiving a prescription for antibiotics, is this appropriate? 16. Does the patient drinking the mouthwash give you cause for concern? 17. What must you do before considering any elective treatment for this patient? 18. What are the most likely causes of pain the patient is having? 19. What treatment might you consider giving at this first visit? 20. With relevance to the medication or treatment logbook the carers have, what must you do on this visit? Answers 1. Introduce yourself to the patient first and then the carers as you would to anyone coming to see you in a professional capacity. The medical history is taken, and any further information on the medication the patient is taking should be noted. If the medical history is incomplete, this may impact on any elective treatment you may wish to give. It is important in the first visit to assess the patient to determine if they are in pain or discomfort and if possible to treat this. Point to Note When someone who is in care comes to see you, they will be accompanied by their carers, who will have a folder containing details of the medications the patient is taking. As discussed in previous OSCEs, such data on medication provides a wealth of information on the medical condition your patient will have. Therefore, it is important for you to assess this data for patient care. 2. In this OSCE, building the relationship with the patient and with her carers is central to the consultation. Although the patient is medicated, you have to build a relationship with her, ensuring her needs are included and fully dealt with in the interview. Most importantly, verbal and nonverbal clues have to be picked up and acted on. Although eye contact is restricted and the patient medicated, you should be able to gather enough information to make informed and reasonable decisions to then treat the patient. 3. The following are some of the key skills you will need to use to begin an OSCE consultation such as this one. a . Actively observe and listen before saying or doing anything; assess the patient and the
relationship she has with her carers. It is important to observe the carers. Specifically, do the carers care? b . Help the patient to communicate. Facilitate this by making sure they are comfortable and relaxed. c. Respond sensitively to the patient’s actions and any remarks or demands they make. Be empathic towards both the patient and her carers. 4. The method and order of questions in this OSCE consultation are as follows: 1. Use open questions to begin with when making inquiries about the patient from the carer in the OSCE. 2. Use screening questions to ask about the patient. 3. Focus on any of the issues or concerns with specific questions. 4. Reflect your observations back to the patient. 5. Finally close down the questions to clarify any points you are unclear about. Point to Note After the introduction, the following question is one way to continue the OSCE: ‘It sounds like you might have a small problem. Would you like me to check this out for you today?’ In addition to the above questions, a negotiating style of question is helpful too: ‘Can I ask you about the food and drink in your diet?’ Finally use a summary of the issues you have discussed to end the consultation. 5. Your language should be clear and appropriate in this OSCE as in all the others so far: DO NOT USE JARGON, even with the carers, who may be qualified as medical nurses and are your health care colleagues. Just use simple language; if you use jargon with them, misinterpretation can lead to confusion later on. 6. The non-verbal communication you use is just as important as the verbal communication, eye contact (when possible), body posture, manner, and physical contact are all essential skills to develop, continually improve on, and demonstrate their use to the examiners in this type of OSCE. It is also vital to respond appropriately to the patient’s ideas and their expectations, to answer any questions the carer may ask, and to allay any doubts or fears arising from discussing dental treatment. Although non-verbal communication is important, it is best to aim for a dialogue; while you might not achieve this in real life with the patient, you will have a dialogue with the carers and therefore you will have a dialogue in the OSCE. In your consultation, the first thing to note is the patient is a vulnerable adult and there are specific legislations in place to protect or safeguard vulnerable adults. 7. It is important to conduct the OSCE in line with the regulations, as you would do in the dental clinic.
A vulnerable adult is any person over the age of 18, in need of support or care services by reason of mental illness or physical disability (or both) and who is at risk from significant harm or exploitation.1 In England and Wales, the Care Quality Commission is responsible for maintaining essential standards in dental clinics. While the CQC does not safeguard those attending a dental clinic from risk of abuse, it does stipulate that safeguarding measures must be in place. (Outcome 7 of the CQC standards) Regulations in Scotland In Scotland there is no CQC, and this is of relevance for those of you taking the MFDS for the Royal Colleges in Glasgow and Edinburgh. In Scotland, a dentist treating a vulnerable adult has to comply with the 2000 Adults with Incapacity (Scotland) Act. 2 In this legislation, a patient who has been assessed by their medical practitioner to have incapacity will need a certificate attesting to this. Such a certificate should be presented to you before you examine or treat a patient. This certificate will detail the remit of any exam or emergency dental treatment which can be conducted by you on this patient. If the treatment plan changes significantly, e.g. a. The need to perform elective dental treatment or: b. The need to sedate a patient with no capacity. Then additional documentation must be obtained beforehand. It should be noted this only applies to patients in Scotland. In England and Wales from 2007, the Mental Capacity (2005) Act applies to all those involved in the care of those who lack some or all capacity to make decisions for themselves.3 Of importance to both Scotland and England, is the test of whether or not a patient that has capacity can actually be undertaken by the dentist. However, only a doctor can assess incapacity and thereby issue certification attesting to this. If we take the legislation as a whole across the UK, there are two defined sets of laws operating. These are: 1. The 2000 Adults with Incapacity (Scotland) Act and: 2. The 2005 Mental Capacity (England and Wales) Act (MCA 2007). Depending on where you work in the UK and where you will be sitting your exams, you have to be aware of these laws and how they apply to you. 8. In the MJDF OSCE, you should be able to define mental capacity. Mental Capacity is the ability to make a decision. 9. There are several reasons for lack of capacity. In this OSCE, chronic mental illness means the patient cannot make decisions for herself. Those involved in accidents or other conditions resulting in unconsciousness also do not have capacity; loss of capacity can be temporary or permanent. In this case even though the patient currently has no capacity, improved treatments, medication, and re-assessment, capacity may return. Of note and with specific relevance to a dental surgery,
stressful intimidating or unfamiliar surroundings can also lead to a temporary loss of capacity. 10. There is a two-stage test of capacity:4 1. Is there impairment or a disturbance in the patient’s mind or their brain? If so: 2. Does such an impairment or disturbance mean the patient cannot make a decision? 11. In this OSCE, there are four specific questions which need to be answered before we can be satisfied the patient has capacity. 1. Does the patient understand the information given? 2. Can the patient retain this information? 3. Can the patient make an assessment of the information and reach a decision? 4. Can this decision be communicated to the dentist or other person responsible for treatment? 12. Anyone involved in the ongoing care of this patient, including carers and family members, can make an assessment of capacity, but as noted above, only a medical practitioner can make an assessment of incapacity. Testing capacity The simple test of capacity has to be carried out. From a professional point, this should be carried out every time you see a new patient and every time you see a patient who has previously been noted to have no capacity. In this case, the patient and her carers attended with an incomplete file documenting some of her medications and some of her medical condition. Nevertheless, it is still important to begin the consultation with no prejudices and no assumptions. 13. In the 2007 MCA (England and Wales), there are five core principles which must be adhered to: 1. A patient must be treated if they have capacity unless it is established they do not. 2. A patient cannot be treated as unable to make a decision unless all practical ways to help them to make a decision have been tried and have failed. 3. Just because a patient makes a decision which is odd or not sensible, this does not mean that they are incapable of making decisions at all. 4. Anything you do to a patient has to be in their best interests. This applies not only to patients protected under the 2007 MCA but really to all your patients all the time. 5. Before you do anything to anyone (not just patients protected under the 2007 MCA), think about the best way to do it, with the least risk, the maximum benefit, and the least impact on their future, freedom, and their rights. 14. In the dental clinic, it is important to assess the relationship between the patient and the carer. The question noted above which I always ask repeatedly is: Do the carers care? In this case based on a real patient, you might easily see the relationship between the patient and carers is a caring one. I have seen cases where there is anything but a caring relationship, and it is the
duty of anyone witnessing abuse of any kind to notify the Social Services Department and the police immediately if there are concerns. In England and Wales, there are designated Safeguarding of Vulnerable Adults (SOVA) personnel in local authorities. An AP 1 form is filed and a multi-agency approach is taken to investigate concerns raised. In this case based on a real patient, the carers really do care; the patient was in some discomfort and an appointment was made to attend with a dentist to deal with this. Perception and prejudice 1. As health care professionals, we should not approach our work with any preconceived ideas about the treatment that we might carry out based solely on a patient’s appearance, demeanour, or mental state. 2. This approach to health care provision is a two-way street, and the carers should not expect their client to receive treatment they feel they want rather than need. 3. In your work, it is important to give patients a choice and options for treatment they need and not what the carers want them to receive. 15. On specific questioning, the carer responded with the information: ‘She is allergic to penicillin and the other dentist usually gives her metronidazole.’ This statement is suggestive of inappropriate and incomplete treatment by the previous practitioner. To write out a prescription without a thorough examination shows little respect for the patient and no regard for the latest guidelines and thinking on antibiotic stewardship.5 Additionally, if you reflect on the OSCEs in the previous chapter, the risk of drug interactions with the other medication the patient is taking must be considered before you plan a course of any medication for the patient. 16. The patient drinking mouthwash is unusual, but given her medication, this was not unexpected. A dry mouth is a side effect of treatment with Risperidone. A note was made to ensure the patient had sufficient water to drink and the carers were notified of this. Patients in care environments, often on medication, and those in hospitals might also be chronically dehydrated too. 17. Before carrying out any elective treatment, a complete medical and medication history must be established and documented. The carers should be advised of this. In this first visit, an assessment should be made. 18. The pain was most likely to come from pain in the muscles of mastication from clenching coupled with dentin sensitivity from the Class V cavities. Point to Note In this case, the oral hygiene was observed and noted to be ‘not too bad’, and the carers were really trying to implement supervised tooth brushing. As a resident in a care facility, there is a possibility of a high carbohydrate diet and risks to the oral health of care recipients.6 19. The initial treatment plan should involve diet advice. On the first visit, application of fluoride varnish (the concentrations are 23,000 ppm) was applied to the surfaces of teeth affected by erosion after these teeth were cleaned and dried. Further tooth brushing instruction and oral hygiene
advice should be given to the patient and to her carers with leaflets on tooth brushing. Samples of toothbrushes and toothpaste might also be provided for the carers to distribute among the other residents, engaging them in oral hygiene measures too. Gaining trust Any patient who is relaxed in the dental surgery can agree to a consultation and dental examination, perhaps even having minimal dental treatment on the first visit. In this example, the patient can agree but not consent, and agreed to receive an examination and oral hygiene instruction. A treatment plan for fissure sealants was given to the carers and discussed then after few minutes this plan was presented to the patient. By allowing sufficient time for the patient to relax and become accustomed to the dental clinic, we can gain her trust, allowing us to undertake and complete dental treatment in subsequent visits. 20. The carers attend with a treatment logbook, so the relevant entries can be completed to detail a treatment plan. You can request a full disclosure from the patient’s medical practitioner of her medical conditions and the medication she is taking to enable you to progress with a definitive course of dental treatment. Such a disclosure may be necessary if complex treatment such as restorative work or surgical work with IV sedation is needed. Further Notes to This Ethical Example. Schizophrenia has prevalence in the UK of around 1%.7 The term schizophrenia covers many longterm mental conditions of complex origins and clinical presentations. There is little doubt that in some of its expressions it can be a disabling condition. There is a significant genetic element in the aetiology of schizophrenia. In this case, there were no social factors involved in the onset of the condition. Of specific relevance to the next OSCE, recreational drug use, especially of marijuana, PCP LSD, and cocaine, may precipitate the onset of schizophrenia. The clinical features often present themselves in young adults with hallucinations and thought disorders. There may be a lack of insight and behaviour patterns can be inappropriate. In other cases, insight may be preserved, and the chronic schizophrenic may even realise the effect they have on those around them. As the condition progresses, there could be further disintegration of personality, and social isolation often results. There may be visual and auditory hallucinations too. In more severe cases, alteration in motor function with catatonia can be seen. Coping with schizophrenia can be emotionally draining for everyone including family members who may witness the social withdrawal and degradation of a close friend or family member who may previously have been lively and the centre of attention. The diagnosis of schizophrenia can only be made by an appropriately qualified and experienced psychiatrist. Management of the condition is through antipsychotic medication; some patients require hospitalisation with many remaining significantly handicapped by this condition or from the side effects of medication.7 Most patients do show substantial improvement with medication with the intervals between psychotic episodes being marked by periods of relative normality. Nevertheless, many schizophrenics remain on antipsychotic medication for a long time.
The term: schizophrenia should never be used without a correct diagnosis or inappropriately as a comment or insult. Despite initiatives to counter its negative image, today the sad fact remains that mental illness carries a social stigma. Stigma is defined as a sign of disgrace or discredit, which sets a person apart from others. The stigma of mental illness, although more often related to context than to a person’s appearance, remains a powerful negative attribute in all social relations.8 Only a few years ago, the Royal College of Psychiatrists initiated a five-year ‘Changing minds’ plan to counter the stigma of mental illness in the UK. At the end of the initiative, there were significant reductions in the perceptions of schizophrenics as being dangerous, unpredictable, and hard to talk to (1998-2003). It is interesting to note the study by Crisp and coworkers revealed no similar reduction in the perception of drug users in this time.9 While the work of Byrne revealed that mental illness carries a social stigma,8 there are further studies revealing stigma is not only confined to a social setting but professional ones too, including health care.8,10 In this regard, labelling a patient or anyone you happen to disagree with, such as a student or a colleague with a specific mental condition or being mentally ill, would be a fundamental breach of the Disability Discrimination Act (DDA 1995). It is perceivable in the wake of the Francis Report that this may lead to professional sanctions from the GDC and referral for criminal prosecution from the CPS. Clearly, mental illness can have an impact on a patient’s oral health and on our ability to deliver care too. The challenge we face is to aim for a culture of destigmatisation and professional inclusion for all our patients and our colleagues. References to Ethical Examples 29 1.
NHS Choices Web Site. Vulnerable People. [Online] Available from: http://www.nhs.uk/CarersDirect/guide/vulnerable-people/Pages/vulnerable-adults.aspx [Accessed July 2013].
2. Scottish Government. Adults with Incapacity (Scotland) Act 2000. [Online] Available from: http://www.legislation.gov.uk/asp/2000/4/contents 3.
U.K. Government. Mental Capacity Act 2005. [Online] http://www.justice.gov.uk/protecting-the-vulnerable/mental-capacity-act
Available
from:
4. Scully C. Chapter 2: Medical History and Risk Assessment. In Medical Problems in Dentistry. 6th Edition pp. 22-25. Edinburgh: Churchill Livingstone 2010. 5. Crighton DA. Antibiotic stewardship. Br Dent J. 2011 Nov 25;211(10):443. 6. Pradhan A, Slade GD, Spencer AJ . Factors influencing caries experience among adults with physical and intellectual disabilities. Community Dent Oral Epidemiol. 2009 Apr;37(2):143-54. 7. Scully C. Chapter 10: Mental Health. Psychosis. In Medical Problems in Dentistry. 6th Edition pp. 275-277. Edinburgh: Churchill Livingstone 2010. 8. Byrne P. Stigma of mental illness and ways of diminishing it. Adv Psychiatr Treat. 2000;6:65-72.
9. Crisp A, Gelder M, Goddard E, Meltzer H. Stigmatization of people with mental illnesses: a follow-up study within the Changing Minds campaign of the Royal College of Psychiatrists. World Psychiatry. Jun;4(2):106-13.2005. 10. Schlosberg A Psychiatric stigma and mental health professionals (stigmatizers and destigmatizers). Med Law. 1993;12(3-5):409-16. Further Reading 1. Department of Health. Department of Constitutional Affairs 2005. The Mental Capacity Act 2005. Easy Read Summary. This version contains all the information you need at a level sufficient for the OSCE exams. Also available online from: http://www.thh.nhs.uk/documents/Patients/PatientLeaflets/general/MCAActEasyRead DoH.pdf 2. H.M. Government, The Mental Capacity Act 2005. Schedule A1: Hospital and care home residents: deprivation of liberty 2005. An important section of the Mental Capacity Act that you should read. Although you don’t need to know the specific act in great detail, it is nevertheless very important to know how this act determines the nature and substance of your work as a dentist. This section is particularly important for this case. 3. Brennan M, Oliver R, Harvey B, Jones G. Chapter 8: Professionalism in Practice. Ethics and Law for the Dental Team. 1st Edition pp. 95-104. Knutsford: PasTest 2006. A well-written text on your professional obligations. This is a good introduction to the issues facing you when dealing with patients who lack capacity. 4. Freeman R, Humphris G. Chapter 2: Basic Communication Skills. In Communicating in Dental Practice: Stress-Free Dentistry and Improved Patient Care. pp. 7-16. London: Quintessence 2006. Important text to read in preparation for any communication-based OSCE. 5. Bellis W. Chapter 42: Will You See My Son? In Odell EW. Clinical Problem Solving in Dentistry. 3rd Edition pp. 195-198. Edinburgh: Churchill Livingstone 2010. Another case study, this time dealing with autism in a child. Some of the issues discussed in this case are also raised in this text, with some good communication and behavioural modification strategies.
Ethical Example 30 Background Information In the preparation of this book, exam questions from both the MJDF and MFDS syllabus between 2011 and 2012 were reviewed. In this period, there were some 80 MFDS OSCEs in eight sittings of the exam. From this small sample, conspicuous by its absence, there was not a single exam question covering issues with dental team members or other dental colleagues in the workplace.
In stark contrast to this, in the MJDF OSCEs in this period, every single diet of the exam contained a question covering some aspect of dental team working. So once again, like OSCE 28, if you intend to take the MFDS, this OSCE might be of limited use in your revision. So if time is short right before your exam, then scrub this OSCE and go straight to the next chapter. After your exam, you might care to spend a few minutes reading this case, if for nothing else then from an interest point of view. If you are taking the MJDF, then reading through this OSCE will not only prepare you for the exam, but it may prove to be useful in preparation for your career and the professional relationships you will have with your colleagues. Issues of collegiate support, solidarity, and professionalism are right at the heart of some questions in the MJDF, and so they should be, as these issues lie at the heart of our profession. Introduction You are working in NHS general dental practices while studying for your MJDF exam. There are two visiting specialists who come to the surgery on a weekly basis. One is an orthodontist and the other is an oral surgeon. Your senior colleagues are hugely successful, both professionally and financially. They operate their own private practices. Many famous and wealthy patients attend for treatment with them, and your colleagues are keen to tell you about their famous ‘clientele’. Both of your specialist colleagues have an impressive list of publications and prizes they have gathered in their careers. In addition to this, they seem to have a never-ending supply of sponsored seminars to attend and invitations to lecture at international congresses. In the past few months, you notice that not all is as well as it seems and your colleague has been having some problems that are shared with you after work. You become party to information that may affect the registration of your senior colleague. The oral surgeon was stopped by a traffic police officer and found to be driving with excess alcohol. A search revealed the presence of cocaine on his person. The orthodontist has had some difficulty with a previous patient after a relationship developed and has taken to using rather a large amount of marijuana on the nights before busy NHS lists the following mornings. Already there has been a problem with one patient having an incorrect extraction (OSCE 26), and you witness the orthodontist rolling a joint and smoking it as various problems are recounted to you. The joint is then passed to you… Some Questions to Consider 1. What are your obligations to your colleagues? 2. What are your obligations to your profession? 3. What are your obligations to your patients? 4. What are your obligations to yourself?
Considerations in Your Answers In writing out this OSCE based on real people and real events, it might be useful to review the beginning of this chapter with certain words we might take from the Hippocratic Oath: ‘To hold him who has taught me this art as equal to my parents and to live my life in partnership with him…’ and those of the Physician’s Oath: ‘I will respect the secrets that are confided in me, even after my patient has died; I will maintain by all the means in my power, the honour and the noble traditions of the medical (dental) profession.’ What we can take from these words is that in addition to having a duty of care for our patients we have a duty to care for each other too. Today, the dental profession in the UK is becoming numerically larger and a little more meritocratic, whereas in a diametric opposition to this, the GDC has become numerically smaller and visibly more autocratic; for the first time an appointed chairman rather than an elected president is leading the GDC. (Although not dentally qualified, the new chairman does bring significant NHS and considerable civil service management experience to the profession.) If we can remind ourselves of two principles in the GDC publications of a duty to protect patients, if a colleague’s behaviour presents a risk: Firstly, from the previous 2005 to 2013 Guidance: Standards for Dental Professionals: 5.1 Your duty to raise any concerns you have overrides any personal and professional loyalty. 5.2 If in doubt, always raise a concern.1 Secondly, from the current 2013 Guidance: Standards for the Dental Team: Guidance 8.1.1: Your duty to raise concerns overrides any personal and professional loyalties or concerns you might have2 Then it might seem the GDC has made the Hippocratic and Physician’s Oaths unsuitable as ethical codes or points of reference for the dental professional. If we were to follow the GDC directives, we would all be running down to 37 Wimpole Street the moment a doubt arose in our minds about our colleagues’ suitability to be members of the dental profession. There are a fair few business-minded registrants who have beaten a path to the GDC spurred on by economic goals. By the end of 2012, there was a 41% rise in complaints to the GDC.3 Sometimes the GDC gets it right and bats the complaint back to the registrant-complainant and other times the GDC puts them in the ‘too difficult box’, and everyone at great expense takes a trip to London. A full case hearing can cost in excess of £100,000, and this is paid for by the registrants in the Annual Retention Fee (ARF).4 I think as adults and professionals we have to make choices, and we should make our choices from an ethical and legal framework and not because we have to blindly obey every guideline as a directive
from the GDC as if it were law itself. The obligation we have to our colleague in this case can be prised out of the ‘clauses’ of the GDC. We might start with the duty to our colleagues. Continuing from this, there is no obligation to blindly obey the directives of the regulators. In the wake of the Francis Report, it may now be our positive duty to question directives from managers and regulators, especially if they might compromise our ability to care for patients. The principles below apply equally to the professional as they do to the patient, and by applying these principles equally, we will be heading closer towards Esmail and Everington’s idea of an equitable health service for our patients by first having an equitable health service for the practitioners.5 The Answers 1. Obligations to colleagues. The work of James Childress’ and Thomas Beauchamp’s 1979 text on biomedical ethics 6 provide the source for answering the question on the obligations we have to our colleagues. You probably already know of these as the Georgetown Mantra: a. Autonomy. There is a right to self-determination to have or not have things done without consent. In this case, we should first speak with our colleague about their problems before we speak with anyone else. That is their right. b. Beneficence. We have to be kind and act in the best interests of our colleague first. We need to understand the problem and to help our colleague to find the best way forward for themselves. c. Non maleficence. We should know the limits of what we can and cannot do and don’t get into situations which are likely to cause further harm. We must help our colleague and do so with the best intentions for themselves. d. Justice. In this situation, we have to act fairly and reasonably and do so without prejudice to our colleague. If we choose to act, then our actions have to be defensible before any administration or regulation. If we choose not to act, then this too must be defensible. The actions we take or choose not to take in this case must be with respect for the person and their circumstances and not for that person’s place within a profession. The quality of our colleague’s life and how they choose to live it has to be respected, whereas the quality of their professional life and how a regulatory body wants them to lead it can have little if any bearing on how we might deal with this problem. 2. The obligations we have to the profession of dentistry We have to prevent harm from occurring. One concept of the Hippocratic Oath was to first do no harm: Primum non nocere. If we know of something which can actually harm a patient, then we have a duty to prevent that harm from occurring. In OSCE 28, the Tarasoff judgement was briefly mentioned, but it did not apply in that case.
Potentially, in this case, the duty to inform and the duty to protect patients who may be at risk from the conduct of the orthodontist most definitely apply. Therefore, the principles of Tarasoff apply here. If we look more closely at the facts of Tarasoff: This was a legal case in which the Supreme Court of California held that mental health professionals have a duty to protect individuals who are being threatened with bodily harm by a patient. The original 1974 decision stressed that the threatened individual must be warned. In a 1976 rehearing of the case by the California Supreme Court, a ‘duty to protect’ the intended victim was called for.7 The professional may discharge their duty in several ways, including notifying police, warning the intended victim, and/or taking other reasonable steps to protect the threatened individual. In this case, there are no threats and no intended victim, but there may be individuals at risk. The UK GDC has issued guidance on what to do even when a doubt exists (see above guidelines 5.1 and 5.2). The procedures one might follow are to address the issues and to approach a responsible individual or organisation experienced in dealing with problems such as drug and alcohol abuse in health care workers. In the UK, the defence organisations, Dental Protection, the Dental Defence Union, and the Medical and Dental Defence Union Scotland, are all experienced in dealing with the issue of drug and alcohol use in health care professionals and the regulatory repercussions. The obligation you have to the profession is to ensure no further harm comes to your colleague and no harm comes to patients who might be treated by a colleague who has a substance dependence, use, habit, or addiction. 3. The obligations we have for our patients. These obligations are equal to those we hold for our colleagues. If we can once more reflect on the words of Hippocrates: ‘What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about.’ The issues of what our colleagues do in their private lives outside the clinic should have no bearing on what they do while at work. However, the GDC take a rather more authoritarian view. Behaviours reflecting badly on the profession may undermine the confidence the public has in the profession. Principle 9, Standard 9.1 of the September 2013 GDC Guidelines states: ‘You must ensure that your conduct, both at work and in your personal life, justifies patients’ trust in you and the public’s trust in the dental profession.’ 2 If a colleague has a habit which offends the sensibilities, that is their business. However, in this case there is a habit. This habit involves the use of a drug that might affect both their sensibility and their
ability to do their job safely. Therefore, it now becomes every responsible person’s business to do something about it. When it comes to professionals who are regulated by appointed councils in the UK, the same freedoms enjoyed by society as a whole cannot be applied to the regulated professional, if risks are present and harm could result from specific behaviours. Mandatory drug testing has already been introduced across all the uniformed services and in the aviation industry too. It will only be a matter of time before these measures are applied right across the entire health services from the appointed regulators. In a recent article on alcohol and drug use among dental and law students in the UK published in the British Dental Journal in 2006, significant numbers of respondents to a questionnaire reported drug use. Over half of law students and nearly half of dental students reported cannabis ‘experience’ with smaller numbers reporting the combined regular use of cannabis and class A drugs such as cocaine.8,9 The authors of that study expressed an opinion for a future role for regulators such as the GDC and the SRA (Solicitors Regulatory Authority) to become proactive in prevention of drug use among their registrants. I would agree with this opinion and suggest that not only do we, as professionals, owe a duty to prevent harm from occurring to our colleagues and patients, in this regard, so too might the GDC. 4. The obligations for yourself. There is an obligation to look after yourself too. If you are offered to partake in any activity you don’t feel comfortable doing, then don’t do it. The Oxford defence I think the following explanation from an Oxford university student offered in defence does not apply in this case: ‘When I was in England, I experimented with marijuana a time or two, and I didn’t like it. I didn’t inhale and never tried it again.’ (William J Clinton, Rhodes Scholar at Oxford University) In this case, the oral surgeon who was arrested for driving with excess alcohol will face sanctions at both the GMC and GDC and the consequences for their career will be disproportionately greater than for someone who has no professional regulatory responsibilities to worry about. There is nothing more you can do other than offer mitigation and a character reference on behalf of your colleague in a magistrate’s court and at the GDC when these cases are heard. For your orthodontic colleague, support guidance and referral to the appropriate bodies is all that can be done. Your obligation for yourself is to carry on working and to pass your exams. There is only one thing less bad than learning from your own mistakes and that is learning from someone else’s. Here, I intentionally state less bad not only to reiterate the words of Lionel Bart but to emphasise a point: That it is bad to make a mistake, whoever makes it, and there is nothing better
about your colleague and not you having made the mistake. Further Notes to This Ethical Example In the UK, aside from alcohol, marijuana is the most commonly abused drug. It can be smoked, added to food or brewed up in tea, concentrated as a resin, or added to tobacco or other drugs. The active ingredient is D9 THC (delta 9 tetrahydracannibinol), which binds to receptors in the brain. D9 THC can influence memory, perception, and concentration. It has a detrimental effect on fine motor control too. As you have experienced, these are all the attributes needed in any area of dentistry and even more so in orthodontic treatment involving the very fine detailed work of fixing appliances to a dentition developing in a child’s mouth. The marijuana in circulation today is a hybridised variant of those species originally not inhaled by Clinton and others in the 1970s. The short-term adverse effects include memory lapses, learning difficulties, distortions in perception, and an inability to solve problems. The long-term problems associated with its use are depression, anxiety, personality disorders, and schizophrenia which can all be precipitated in those who are susceptible (please refer back to OSCE 29). The smoking of marijuana is commonly found in patients and frequently among those who are dentally phobic. Of note is that smoking marijuana lowers the oxygen-carrying capacity of blood and affects both blood pressure and heart rate too. There is a significant increase in risk of myocardial infarct in the one hour following inhalation of marijuana, and with its use comes the increased risk of respiratory illnesses and associated clinical signs such as increased coughing, and eventually the risk of airway obstruction is seen. The concurrent use of marijuana with tobacco may lead to an increased risk of malignant lung disease. Marijuana has been implicated in oral cancer too. The immunosuppressive activity of D9 THC results in candidal infections, although this may be an indirect result of reduced salivary flow from exposure to tobacco and cannabis smoke. If a patient is pregnant and smokes marijuana, effects are seen in the newborn child. Abnormal responses to visual stimuli, tremor, and a characteristic high-pitched cry are commonly seen. As the affected child grows, neurological anomalies and poor development follow. Children and adolescents exposed to marijuana often display behavioural problems with poor performance of motor tasks, poor language comprehension, and deficits in attention and memory. The common perception is that marijuana is an almost harmless drug with minimal long-term side effects. The truth borne out by the above is it is anything but. A patient of mine who is a preacher in a local community summed this up more eloquently than any textbook on the subject: ‘Marijuana is a drug which seemingly opens many doors, but they don’t close. People who smoke it find themselves in places they don’t want to be and then can’t leave’ So you are offered a joint?
You have choices. Last year, I went flying with a pilot who flies aerobatics in the British Team. After he had gone through his competition routine, standing on the ground that had been spinning and rolling above our heads for the previous half an hour, I asked what started his aerobatic career, his reply was both spontaneous and insightful: ‘The first fix was free. Someone offered me a flight, then I was hooked.’ References to Ethical Example 30
1. General Dental Council. Standards Guidance. Standards for Dental Professionals. Principles of Raising Concerns. May 2006. [Online] Available from: http://www.gdcuk.org/Newsandpublications/Publications/Publications/StandardsforDentalProfessio [Accessed September 2013].
2. General Dental Council. Standards for the Dental Team. pp. 78-83. London: General Dental Council 2013. [Online] Available from: http://www.gdcuk.org/Dentalprofessionals/Standards/Documents/Standards_for_the_Dental_Team__web_PDF.pdf [Accessed September 2013]. 3. Lewis K. A Word from the Director. In Riskwise UK. Risk Management from Dental Protection. Issue 45. p. 3. London: Dental Protection 2013. 4. Senior solicitor and head of department at leading London-based law firm who wished to remain anonymous. 5. Esmail A, Everington S. Racial discrimination against doctors from ethnic minorities. Br Med J. 1993;306:691-92. 6. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th Edition. Oxford: Oxford University Press 2009. 7. Roth LH, Meisel A. Dangerousness, confidentiality, and the duty to warn. Am J Psychiatry. 1977;134(5):508-11. 8. Fox K. Research summary alcohol and drug use among dental and law undergraduates. Br Dent J. 2006;201:576. 9. Barber W, Fairclough AA. Comparison of alcohol and drug use among dental undergraduates and a group of non-medical professional undergraduates. Br Dent J. 2006;201:581-84.
5 Clinical Cases Introduction This chapter has 15 questions dealing with cases you will see and treat in your work, whether it is in a general dental practice or a hospital post. These questions are representative of the OSCEs you might find in both the MFDS and MJDF exams. The scope and detail of the questions in this chapter will be at a level you ought to complete quite comfortably with some further study. As with the cases in the previous chapters, in this chapter, references and suggestions for further reading are given after the answers to the questions for each OSCE. In providing suggestions for further reading, it is not intended that you must read all of these, but rather you can see where to go if you need more information in addition to the answers already given. By revising the subjects contained in this chapter, hopefully without having to read too many of the suggestions for further reading, when you come to sit the MFDS or MJDF, you will tackle the questions in your exam quite comfortably. Completing this chapter and others in this book together with further revision texts will mean that you will be approaching the exams with the confidence of having built up a broad working knowledge of data to use as necessary in an OSCE or an SCR when required. However, the MJDF and, especially, the MFDS are not just about demonstrating your intellectual capacity or how much knowledge you can take on board, carrying it in your head to deliver in an exam. In addition to knowledge, the OSCEs and SCRs are also about demonstrating self-assurance in your clinical skills while under examination. The ability to demonstrate a cool, confident manner when dealing with the actor and calmness under pressure from the examiners is also needed to pass the exam. Reading through the previous four chapters will benefit both your knowledge and self-assurance to tackle the MFDS and MJDF. By completing the final two chapters of this book, you will definitely be raising your confidence and increasing your knowledge to a level needed to pass your exams. As a dental student and then as a foundation grade dentist, you may have found some subjects more satisfying to learn than others. Perhaps you were swayed by the opinion of a dental school lecturer or key opinion leader to follow one career path over another. Alternatively, you may have been determined to overcome one particularly challenging aspect of dentistry, consistent success at which had eluded you while you were a student. For some of you, this may have been the mysterious nature of how to make full dentures fit the patient comfortably and stay in place while they were speaking, eating, or doing nothing and for their lower dentures not to wobble about, while the upper denture stayed up. This aspect of dentistry owes more to inexplicable art than it does to modern science.
One dean of a dental school knowingly informed us as students: ‘There is more to assembling a wee model plane than making a denture.’ For this statement to be true, his wee models had to be of an amazingly high degree of complexity and accuracy, and every denture case he observed must have had healthy, retentive, and well-formed alveolar ridges (like those of the fully dentate). His patients must have taken to dentures like ducks to water. As dental students, we never got to see either his models or his patients’ model dentures. (He was a professor of oral pathology.) I think, such comments as his were, and still are, awkward to reconcile. However, I have included his example of academic and professional prejudice in the hope that if you are swayed towards one career path over another, it will be for the right reasons. Until the time comes when you choose to head off into a specialty, please treat every subject you learn and every patient you see with the same degree of enthusiasm and respect. Other areas of dentistry students either take to or avoid are children and orthodontics. Some dentists in practice avoid these two as if they were the devil’s own work. Some who are either orthodontists or parents might strongly agree, while others who are parents or orthodontists might vigorously disagree. Then there are oral medicine, oral pathology, and oral surgery. From those three specialties, some of you will be keen to carve out careers as dental surgeons, whereas others will become dental physicians. There are bound to be areas of dentistry you just cannot get your heads around and areas you just think are incredible and give you that reason to get up and go to work every morning and to revise for your exams every evening. In revising for exams, it is just the same. You will find the prospect of working through some subjects about as appealing as wading waist deep in mud with boulders tied to your ankles, in contrast to the sprint of revising subjects you both enjoyed learning and excel at clinically. One key element in achieving success is to attain a balance of the entire range of subjects you need to study in the syllabus. In the weeks leading up to the exam, as you complete the last round of revision, those disciplines you were previously weak in should be brought up to the same standard as those subjects in which your strengths lie, and further gains across all the syllabus should be consolidated by now. So here are 15 OSCEs dealing with general dentistry as I have found them in the MFDS and MJDF. Unlike the overall layout of this book and chapter order, these questions are in no particular order, because when you sit your OSCEs and treat your patients in clinic you never know who and what you will see next.
Clinical Case 31
Introduction An elderly man having no natural teeth comes to see you. He does have full upper and full lower dentures though. He has been wearing dentures for many years with some degree of success. The previous dentures that were worn successfully were replaced a number of weeks ago, but now the patient cannot get on with them at all. The new dentures are a copy set of dentures made by a dental technician. The new dentures are painful to wear, so the patient takes them out to eat. As a result, his diet has suffered considerably and he is now losing weight. The patient attends with yourself to see if you can help with the problem. There is nothing in the medical history that is contributory to the problem he has presented with today. If you examine the patient intra-orally, you will see the mucosal surfaces where the dentures fit are red and oedematous. These lesions are limited to the denture-bearing areas of the upper and lower dentures. Points to Note 1. In both the MFDS and MJDF OSCEs, you will have an actor with whom to discuss the case and clinical photographs as a substitute for a clinical examination. 2. You may or may not have an example of the dentures present in the exam. If you did, then they would be a useful ‘prop’ for the actor as he recounts his problems to you. 3. In the MJDF OSCE, the actor and the examiner will ask a series of structured questions, whereas in the MFDS OSCE, a more fluid dialogue is expected with a candidate-led approach to solving the problems as presented. 4. In a dialogue, there will be little, if any, input from the examiners, who will observe your interaction with the actor. 5. In addition to clinical photographs and a denture, there may be other items of relevance such as a laboratory invoice, the importance of which you can consider in your answers. The Question Provide explanations to the patient on the possible causes of the problems he is facing and possible measures you will take to cure the problem. The Answer To begin with, introduce yourself in a professional manner and explain who you are. Go on to say that you will deal with the problem in this visit and provide explanations for the trouble the patient has. Ask the actor what the problem is and display empathy while doing so. The patient cannot use the dentures and his diet has suffered; this cannot be easy or dignified for him and you have to communicate your concern about this to the examiners and the actor too. The taking of a medical history should be brief. Do not spend any more time than necessary to confirm that the patient has no relevant medical history and nothing implicated in the condition they have attended with today.
The Medical History Unlike real life where a patient of the age portrayed by the actor is likely to have a relevant medical and medication history, in this case, like an MFDS OSCE, the medical history has not been entirely removed but has been reduced to a level where you need only ask to confirm that there is no relevant medical history. Although this might detract from the realism, this contrived arrangement enables you to focus on the theme and topic of the OSCE. The Dental History The dental history you take has to be quite detailed and it should confirm that the patient has been edentulous for a number of years. The problems have only started after the new dentures were fitted a few weeks ago. On this basis, you can proceed to ask the actor the relevant questions you will need to, so you can come to a diagnosis to explain their problem to them. Given there are no underlying medical problems with the patient and he has successfully worn dentures for several years, the problem is most likely to be with the new denture. At this stage in the OSCE, you can reassure the actor that the problem is not with him but with the new dentures he has. The actor may confirm this by stating to you that he just cannot get on with the new dentures. Determining the Nature of the Problem In both orthodontics and periodontics, there are indices of treatment needs (the IOTN and the CPITN) but with prosthodontics, there is no such universally accepted index. We need to ask a set of questions so that we can determine what the problem might be. The further questions you need to ask now have to concentrate on the common problems found in patients who use full dentures. One thing I find useful in cases like this is to go through a list of questions to eliminate the irrelevant and improbable, to concentrate on the plausible, and then finally narrow this down to the possible. The Dialogue in This Clinical Case. You might start by asking questions about the extra-oral conditions to eliminate other causes. The following dialogue in this OSCE is numbered in a series of questions and answers. 1. Are there any problems in the head and neck area at all since you have been given these dentures? ‘No, the only pains I get are in my mouth.’ 2. Are there any pains or problems with the muscles when eating or biting? ‘No, as I can’t wear the dentures, I haven’t been able to eat very much with them.’ 3. When you were able to have the dentures in your mouth, did you get any clicking or other noises from your jaw joints? ‘No, my jaws have been all right with no such noises.’ The answers given to these questions eliminate the possibility that the actual shape and size of the denture are incorrect. Dentures that are not prescribed to the correct OVD (occluso-vertical
dimension) or are incorrect antero-posteriorly, frequently cause pain in the masseter and temporalis muscles.1 Pain caused by this problem will increase as the day progresses. In this case, the denture was prescribed to the correct OVD and there were no complications in the TMJ (temperomandibular joints) as a result of an incorrect denture prescription. Points to note. a. In contrast to the previous OSCEs, where we started with open questions, the following are quite well defined and closed questions. b. As we are now focused on one area of the patient problem as reported, we can get straight down to these questions, having already established that there are no other contributory underlying medical or dental issues. 4. Overall, are you happy with these new dentures? ‘Not at all.’ 5. Do the dentures stay in place? ‘Yes, they do.’ 6. Despite the problems reported, are you happy with the appearance? ‘Yes, generally I am.’ 7. Can you tell me what happens when you wear the denture? ‘The dentures are painful. I have to take them out.’ These four questions demonstrate that the denture stays in place and the patient is happy with the way they look. But they cause pain when placed in the mouth. The patient has had these dentures for a few weeks only and has not had problems before. 8. Are there any other areas of your mouth affected? ‘No, everything else seems to be all right.’ 9. Can you tell me a little about the pain you are getting? ‘There is a burning, almost like an itching sensation.’ 10. Other causative factors need our consideration. There might be problems with the mucosal and occlusal surfaces of the denture. We can now advise the actor in lay terms: ‘If we could examine the denture in the mouth to see the biting and fitting surfaces, then we can gain further information that will help towards our explanation for you today.’ Points to Note a. As mentioned above, in the MFDS and MJDF OSCE’s, there are several devices used to prevent you from laying your healing hands on the actors. b. In this case, the ‘patient’ may have left the denture at home or the examiner may helpfully hand
you a clinical photograph showing (as mentioned above) the red oedematous mucosal areas covering the fitting surfaces of the upper and lower dentures. You can thank the actor for providing the clinical photographs and say to them how much this really helps you in your search for answers for them. (It’s not every day your patients come in with their own intra-oral photographs!) You might then ask the following question: 11. Are there any areas of the mouth that are painful? ‘No, there is pain all around the mouth. There is not one area I would say is more painful than another, it’s just a burning itching pain.’ This answer is revealing. It confirms that there is something in, or on the denture that is affecting the mucosa. The clinical photographs show a red oedematous area limited to the fitting surfaces of the upper and lower denture. 12. While you are busy studying the photographs, looking for further clues, the actor asks you: ‘Do you think I might be allergic to these dentures?’ The importance of questions a. Actors, like real patients, will question you and sometimes these prompt you to think about other possible causes for the problems they present with. b. Your answers should be based on the clinical evidence you have built up from your questions. c. The examiners need to see you giving answers that competently and confidently convey the relevant clinical information to the actor. You can state to the actor that: ‘Allergic reactions are very rare, nevertheless, we should not rule them out in your case. Given the fact you have successfully worn dentures for many years, there is no change in your medical history, and these new dentures are very similar to your old ones, an allergic reaction is unlikely.’ You can add: ‘As I recall (from the introduction), the new dentures were a copy of the old dentures.’ These new ones were made by a technician. The only problem with the old set was the teeth were worn.’ 13. The actor confirms this and adds: ‘Yes, I saw an advert in the local paper and decided that as the price was right, I would get myself another set of teeth. The dental mechanic took my old ones and made these ones from them in a few days.’ (Older patients might refer to dental technicians as ‘mechanics’; this term reflects their generational use of language.)
14. The actor continues… . ‘But I just can’t get on with them. I thought I would though, as they seem to be an exact copy with newer teeth.’ This further information should guide you towards the problem. The oral mucosa does not display contact sensitivity reactions in the same way the patient’s skin would with a contact dermatitis.2 Nevertheless, the mucosa is both red and oedematous. There are no signs of ulceration from friction, and we know the fitting surfaces are well adapted and the OVD is correct. A technician made the denture on a tight budget, and we have to be suspicious of the quality of the product that was supplied. Notwithstanding this, we should not jump to conclusions (just yet). Medical devices regulations in the UK a. The dentures as supplied come under the Medical Devices Directives Regulations. b. As a Medical Appliance, there should be a statement of manufacture and the technician who provided the denture should be registered with the GDC as either an RDT (registered dental technician) or CDT (clinical dental technician) c. CDTs will take impressions and construct dentures, and RDTs will construct dentures to the prescription of a dentist or a CDT. 15. We might ask the actor for the contact details of the technician: ‘Could you tell me who made these dentures? I think the best way forward is to talk to them on your behalf to see if we can find out more about why these new dentures should be causing problems.’ The most likely reason for a denture problem as described is uncured Polymethyl methacrylate (PMMA) resin causing a reaction in the patient’s mucosa. The actor presenting as the patient should be advised of this and that an allergic reaction in the mouth is rare.3 Discussion of Solutions The way forward with this case is to concentrate on the most likely causes as follows: a. Contact the technician to advise them of your concerns. (Unless proven otherwise, assume they are GDC registrants and treat them as fellow professionals.) b. Explain to the patient that uncured resin (monomer or uncured PMMA) is the most likely cause of the reaction. If the denture can be cured again without causing its distortion or breakage, this may be the best way forward.4 c. Advise the patient that without examining the denture, it would be difficult to be sure, but given the clinical presentation and the history, this is the most likely explanation for the problem. If they can return to the technician and ask them to cure the denture again, this might be one sensible solution. d. If you are going to ask the patient to do so, then you have to be sure that the technician is GDC
registered as a CDT or an RDT and at the time of manufacture of the denture, they were working to a prescription from a CDT or a dentist. Also ensure that there is documentation to support the denture as a medical device. Ask if there are any questions. The actor may ask if anything else is likely to cause this problem. You can then advise that the problem of uncured resin in a denture would seem to fit the picture as presented. One other problem seen with uncured resin could be that the presence of microscopic holes (or porosities) in the denture fitting surface may mean yeast-like growth can become established in the denture. Explain that this yeast-like infection called candida may also be responsible for the problem the patient has, as the extent of the redness seems to be limited to the surfaces of the denture. If this is the case, then cleaning and curing of the denture should solve this problem, and healing of the gums ought to follow. Explain that simply cleaning the denture with denture cleaner will not remove active Candida from deep within the surface of the denture. (Some denture cleaners, although having good antibacterial activity, have limited antifungal activity.)5 16. The patient then asks: ‘Can I get some medicine if I have a fungal infection? Is this something you can give me?’ You can explain to the actor: ‘If there is infection with candidal species then taking a sample from the denture surface and from the roof of your mouth and sending this to a laboratory should confirm if this is one of the causes of your problem.’ 17. You can continue with the following explanation: ‘If it is, then we can give you a cream to apply, but we should take things one step at a time and getting in touch with the technician would be the best way forward. Then we can go on to do the other tests if this measure does not help you. How does that sound?’ The actor should agree at this point, and you can end the OSCE. Further Notes to This Clinical Case 1. Since 1998, it has been a requirement for all dentures manufactured in dental laboratories in the UK to comply with the European Union Medical Devices Directives and for laboratories to be registered. Changes were made to the Medical Devices Directive in 2010 that outlined key legal requirements for all dental appliances and not just dentures. Patients should now have access to information about where their appliances are made. The UK Government’s Medicines and Healthcare products Regulatory Agency (MHRA) oversaw these changes.
The MHRA, and not the GDC, enforces these directives. However, the GDC requires all registrants to keep up to date with these legal requirements. 2. The provision of satisfactory complete dentures requires a team approach involving the patient, the technician, and the dentist with whom the final responsibility rests for the success or failure of the appliance. 3. The technician must follow a CDT or dentist’s prescription exactly. Where it is practical, the technician should be involved in the surgery where the patient can be seen and the technician can gain an understanding of the clinical problems. The dental nurse can also assist the patient with selection of shade, shape, and set-up of the denture teeth. The patient’s comments have to be encouraged at this stage, noted, and acted on. 3. In this OSCE, a dental technician was responsible from start to finish for the dentures and the problems which resulted. If this technician is GDC registered as an RDT or working under the prescription of a CDT, then as a dentist you can still advise and amend the denture to help the patient. If the technician was not registered, the patient should be advised of this and the GDC should be informed. As a dentist you cannot and must not become involved with the illegal practice of dentistry. 4. The issue of candidal infection in dentures is more common than reaction to uncured PMMA resin. Classically, this is seen as redness of the palate following the fitting surface of the denture. It is a common condition seen in many users of full upper and full lower dentures. The common factors predisposing to denture stomatitis are: a. Patient keeping dentures in at night b. Poor denture hygiene c. Trauma to the mucosal surface—In this case, the trauma may have been chemical degradation of the mucosal surface by uncured PMMA monomer acting as a cofactor in Candidal infection and colonisation of the mucosa and denture. d. There may be systemic or metabolic deficiencies as discussed in the OSCEs of Chapter 3. In this case, an inability to use the dentures may have resulted in diet alteration with a high carbohydrate diet and further predisposition to infection and colonisation with Candida. If following smear or swab sampling of the mucosa, the patient is found to be suffering from a Candidal infection, then the appropriate measures you need to take are as follows: denture cleaning and soaking overnight in a hypochlorite cleaner, elimination of any systemic factors, and lastly, topical application of Miconazole gel to the denture fitting surfaces and the affected mucosa are all helpful. In this case, there were no underlying systemic conditions or cofactors. So the case is relatively easy to deal with. One theme running through the OSCEs is that common things happen commonly, and so you can expect to be examined on them. I have seen one question on PMMA sensitivity in 80 OSCEs in the MFDS
exams but none in the MJDF exams, and in clinical practice, I have so far not had to deal with such a problem. I think, therefore, this question might not come up again any time soon; however I hope the procedure of going through the questions in this OSCE will help you to eliminate the improbable and bring your focus to bear on the possible. References to Clinical Case 31 1. Monteith B. The role of the free-way space in the generation of muscle pain among denturewearers. J Oral Rehabil. 1984 Sep;11(5):483-98. 2. Chaudhry SI, Odell EW. A Sore Mouth . In Odell EW. Clinical Problem Solving in Dentistry. 6th Edition pp. 159-162. Edinburgh: Churchill Livingstone 2010. 3. Giunta J, Zablotsky N. Allergic stomatitis caused by self-polymerizing resin. Oral Surg Oral Med Oral Pathol. 1976 May;41(5):631-37. 4. Pfeiffer P, An N, Schmage P. Repair strength of hypoallergenic denture base materials. J Prosthet Dent. 2008 Oct;100(4):292-301. 5. de Andrade IM, Cruz PC, da Silva CH, et al. Effervescent tablets and ultrasonic devices against Candida and mutans streptococci in denture biofilm. Gerodontology. 2011 Dec; 28(4):264-70. Further Reading 1. McCord JF, Grant AA. Chapter 2: Clinical Assessment pp. 3-8. Chapter 9: Technical Aspects of Complete Denture Problems pp. 53-57. In A Clinical Guide to Complete Denture Prosthetics. London: BDJ Books 2000 (Reprint 2009). 2. Jagger D, Harrison A. Chapter 2: The Painful Denture pp. 5-9. Chapter 6: The Problem Denture pp. 21-25. In Complete Dentures: Problem Solving. London: BDJ Books 1999 (Reprint 2003). 3. Scully C, Felix DH. Chapter 6: Red and Pigmented Lesions. In Oral Medicine Update for the Dental Practitioner. pp. 28-34. London: BDJ Books 2006. 4. Davies SJ, Gray RJM. Chapter 5: Good Occlusal Practice in Removable Prosthodontics. In A Clinical Guide to Occlusion. pp. 47-56. London: BDJ Books 2006. 5. Cawson RA, Odell EW. Chapter 12: Diseases of the Oral Mucosa: Infective Stomatitis. In Oral Pathology and Oral Medicine. 6th Edition pp. 170-180. London: Churchill Livingstone 1998.
Clinical Case 32 Background Information OK, so now we will go from the previous case that is relatively rare to one that is quite common. Dental trauma is something that does happen to our patients, and I have seen dental trauma questions come up repeatedly in the MFDS and MJDF exams. This topic is extensively covered in the revision course run by the faculties in the Royal College of Surgeons in London, Edinburgh, and Glasgow.
In the MJDF, as mentioned previously, there is a structure to the OSCE. The examiners and actors will ask you specific questions. In contrast to this, in the MFDS, the consultation is more dynamic, being led by the dialogue between the candidate and actor. The examiner plays little, if any, part in the proceedings. In this OSCE we will deal with dental trauma to a child. As mentioned, dental trauma features extensively in both the MFDS and MJDF, and almost certainly, you will have an OSCE on this topic. Points to Note 1. I have seen more trauma in the OSCEs than I have seen in general practice in the same period in the past few years. 2. This topic will be examined, so it has to be a revision priority. 3. Learn this subject inside out as best you can. 4. In doing so, not only will you have increased your chances of passing the OSCE, but you will also benefit the child and their parent who come to see you in the clinic after suffering dental trauma. In the OSCE, you will not have an injured child present for obvious reasons, and various methods will be used to represent the child or create a scenario, where for one reason or another, the child cannot be present. However, you will have to deal with a parent or carer distressed by the events which they will recount to you. Introduction The mother of a child attends your surgery; the family are regular patients of yours. Her child is nearly 5 years old and has fallen at home this morning. She is concerned as the front upper teeth are now loose. One of them may have been knocked out, but she is not sure. Her husband is at home with the child, who is now sleeping. The mother who works night shifts didn’t want to disturb the child and on the way round to work she thought she would come to see you for some advice. Non-Accidental Injury 1. In this OSCE, the topic is Trauma to the Primary Dentition; there are no other issues associated with this exam question. 2. I write this for your guidance, having seen one exam candidate launch into a forensic investigation of the actor playing the mother on the subject of child abuse. 3. While a high level of suspicion is commendable, especially following the recommendations of the 2003 Laming Enquiry and Report, please be assured that in the MFDS and MJDF OSCEs, you will not be expected to deal with this subject. 4. This critically important subject may come up in the MJDF SCR. 5. Nevertheless, these issues remain fundamentally important, and in the clinic, while treating
patients, we must never forget that children are at risk. Question Provide explanations to the mother for the incident as described in the introduction. As with the previous OSCE, this case is being presented and answered as it might appear in the MFDS. Answer As with all OSCEs, introduce yourself professionally and politely to the actress playing the mother; she is worried and nervous. (Remember you collect marks in both the MFDS and MJDF for being a human being.) In the MFDS, you need to develop a rapport, show appropriate concern and empathy in a professional dentist-parent interaction. You then need to find out about the accident—when it happened, how long ago, and where it occurred. Did the mother see the child fall? The actress tells you: ‘She slipped from her chair. She was rocking back and forward on it and banged her mouth on the kitchen table. She didn’t fall, she slipped and knocked her front teeth on the table.’ You should acknowledge any distress and encourage the actress to go on and tell you more about the accident and ask if this has happened before. The actress continues: ‘Yes, she has fallen a few times, but this time one of her front tooth is loose. At school, she has had all the usual bumps and knocks in the playground. It’s the school holidays now, so I’ve been working nights and looking after her during the day. ‘I am so tired. I can’t wait until the kids are back at school so I can go back to day shift again. ‘I didn’t see her slip, but I heard her screaming afterwards. She was holding her mouth. There was blood everywhere.’ You can go on to ask if there were any other injuries, and the mother then tells you there were none. Most importantly, you need to ask if there was dizziness, nausea, vomiting, or loss of consciousness. If any of these symptoms are reported, then you should insist that the child attends an Accident and Emergency Department as there is a risk of other head injuries, specifically intra-cranial trauma, and her child needs an urgent assessment. Thankfully, in this case there are no other symptoms and you are dealing with a caring, concerned, and overworked mother of a child with a common dental injury to the deciduous teeth. Go on to ask the mother about any past medical or dental attendances and take a brief medical and dental history. Maintain your focus
1. Again, this OSCE is not one on history taking. 2. While not forgetting to take a brief history, do not make the taking of a history the focus of your answers. 3. If you do so, you may run out of the time necessary to explain dental injuries to the mother. In response to your questions on the medical and medication history: The actress tells you that her child is healthy, but she does get a little breathless and her doctor is looking at testing her child for asthma. There is asthma in the family, and while her husband smokes, he only does so outside under her strict orders. While this information may seem totally irrelevant to the theme you are being examined on, it further reinforces the picture of concerned and caring parents. So you can go on to ask about medications and vaccinations, specifically tetanus. Even though the accident was indoors at the kitchen table, children of all ages are notoriously well known for exploring the world at large using their mouths to assess and test a variety of naturally occurring animals, minerals, and vegetables. The mother tells you: ‘Yes, she has had all her usual medicines, and her tetanus is up to date. We made sure of that as she is always in the garden (when she isn’t falling off her chair indoors).’ You can review the information given so far and reassure the mother: ‘Thank you for giving me this information, which is helpful. I think although this is a worrying event for you I would like to check that your child is healthy and the accident this morning at home has only loosened some milk teeth. You said that the teeth are loose and one might have been knocked out?’ The actress acknowledges this and tells you her child is healthy, but one of the teeth was getting loose before the accident and another may have been knocked out; she tells you she might have swallowed it or ‘breathed it in’ and she is worried about this. You can put the actress at ease by letting her know: ‘The injured teeth are the milk teeth. We can be sure of this, given the age of your child. As your child had no other injuries to the head, the chances of any further complications outside the mouth are low. The teeth affected will be replaced with adult teeth in a few months, or up to one year. Adult teeth will come into the mouth to replace the milk ones.’ You should mention now that inhaling a tooth is a rare event, and if so, then this usually results in coughing and breathing difficulties. You can ask if there were any coughs, difficulties in breathing, or choking. The actress informs you there were none of these problems. You do need to accept that her child is asthmatic and the breathing difficulties you wish to know about are any unusual ones appearing after
the accident. At this stage in the OSCE, you might like to advise the actress that you want her to know what you might do next. One way to do this with respect to the mother’s work commitment is to ask: ‘I can see this has been a difficult and tiring day for you, and I think we need to talk about what we should do next. Do you have time for me to go through a few things with you now before you get off to work?’ The actress tells you that she would like to know more. Information given in this part of the OSCE has to be given in small amounts without use of technical terms. It is also important to avoid giving premature advice and reassurances to the mother until her concerns have been clearly identified. ‘There will be some things we need to do. First, we need to know where the missing tooth is. As I have mentioned, it is unlikely to have been inhaled. It may have been swallowed, and if so, it should pass through in a few days. Another answer to where the tooth is, it might have been pushed up into the gum, and if so, we need to find out if this has pushed up against the adult tooth. Lastly, the tooth may have been lost outside the mouth as the roots holding it in place would have disappeared as the adult tooth is coming down.’ Check to see if this information has been acknowledged by the actress, then go on to mention the following: ‘I think it might be a good idea to bring your child in to see me. Can we do that?’ The mother might appear a little concerned at this. You can mention that as she is a regular attender, this is nothing more than a check-up and you might like to take an X-ray picture to find out if the missing tooth is still in the mouth and to check if there is any damage to the other teeth. In the OSCE, mention that as the accident happened today, perhaps we could extend the clinic opening time and if her child and husband could attend later on, we might get some more answers for her today. The mother then asks what might happen next. You should advise her, ‘Only after a thorough examination can we know what will happen to the remaining milk teeth and the adult teeth.’ It is also important to state that injuries to the milk teeth should be reviewed every three months for the first year up to when the adult teeth appear in the mouth (eruption). It is important to mention that any work we do to the teeth depends on the extent of the injuries to the milk teeth. If there are minor breaks to the enamel (explain this as the tough outer coating), these can be filled up with a tooth-coloured material. If any damage involves the nerves of the teeth, then more cooperation of her injured child is needed. Such injuries can be dealt with too. Mention that if the primary tooth is badly damaged or pushed into the gum, it is sometimes better to remove it. So the adult tooth can be spared from having any problems in the future.
However, if we review regularly we can wait to see what happens. Sometimes if a tooth has been pushed into the gum it will re-erupt, but if there is damage to the other teeth we have to wait to see what will happen in the coming months. In response to the information you give the mother, the actress then tells you: ‘I think I will get my husband to bring our child in to see you today. In the future, what signs might I see in the teeth if they have been damaged?’ In answering this, you can mention that following trauma to milk teeth, a grey discolouration in the coming days and weeks will be seen. The pulp may still be alive, and this colour change may reverse. If the tooth stays grey or gets darker, this means the pulp has died, and we have to decide when we need to take the milk tooth out. If a yellow colour is seen, it might mean the tooth has healed itself by blocking off the pulp with more tooth material. Lastly, advise the mother of the risk of damage to the adult teeth and repeat that we really ought to make a thorough examination with X-rays of her daughter. Only if there are specific questions on this should you then advise the mother of the risk to the adult teeth. If there are no questions, then avoid giving premature advice or reassurances until it is wanted, concerns are identified, or you have the results of further investigations. Ask the mother if there are any further questions and do insist that her husband brings the child in for an assessment today. The mother tells you she will ask her husband to bring the child in and then asks if she will be all right to eat her food as normal. You can end the OSCE by saying: ‘I think given the fact your child’s teeth will be a little sore, a soft diet should help matters for a few days. When we see your child later today, I will give full advice and instructions on what to do next.’ Lastly, it is always good practice to provide contact details, in the OSCE and in real life to advise that you need to follow up this case. Tell the actress you look forward to seeing her child later today with her husband and advising them in due course of the most likely outcome following this visit and the visit planned for later today. Child Abuse and the Exams One paradox of the MFDS and MJDF OSCE is that non-accidental injuries (NAI) to children or child abuse has, to date, never been covered as a subject in these exams. Therefore, as a candidate pressed for time in revision, you might consider saving yourself some time and bother, cut a few corners, and not revise this subject.
I would like to include a few facts and figures on this subject; reading the following will not take too much of your time. a. In a review of 80 OSCES examined for MFDS RCS Edinburgh and MFDS RCPS Glasgow between 2011 and 2012, there was not one scenario dealing with the subject of child abuse. b. Yet, children who are the victims of non-accidental injury are seen in dental clinics. c. In the UK, the NSPCC (National Society for Prevention of Cruelty to Children) give some interesting statistics on their web site (2012): d. Approximately 50,500 children in the UK are known to be at risk of abuse right now. The latest available figures show that there were 50,552 children on child protection registers or the subject of child protection plans in the UK.1,2 e. In the text Paediatric Dentistry 3rd Edition, Wellbury noted that every week in the UK 2 to 3 children die as a result of abuse or neglect.3 f. Over half of children who suffer any form of NAI or abuse will have oro-facial injuries too. g. Often, the parent or carer cannot easily explain these signs in the clinic. If you have suspicions this has occurred in the clinic, you must contact the local authority, the NHS, the NSPCC, or the police. The Laming Report in 2003 referred to in the introduction to this OSCE and the Laming Review of Child Protection in 2009, came after the enquiry into the circumstances leading to the abuse, the neglect and the deaths of two children in North London. These children were Victoria Climbie and Peter Connelly. In both of these cases, oro-facial trauma and significant signs of child abuse were missed when these children were medically examined. The last few months of Victoria Climbie’s eight-year-life were noted in the report to be particularly horrific. She had lost one of her front teeth and become so withdrawn, the words of one from her community are for anyone reading this, more than just poignant; these words are painful and distressing: ‘She had forgotten how to smile.’ Even if non-accidental injury is not going to be examined in the MJDF and MFDS and it is not high on your list of priorities right now, the role of the dentist is still in the forefront of child protection. Dental Trauma Now on to some less sombre clinical issues of paediatric dental trauma. The adult incisors develop crypts located palato-superiorly to the deciduous incisors. In this case, the impact to the permanent dentition at 5 years old should have little effect on the enamel of a permanent tooth. By this age, the enamel and crowns are complete. If the deciduous teeth were intruded into follicles of the permanent successors, then trauma to the root
structures of the permanent teeth may result in dilacerations. This is an abnormal curvature or bending of the root caused by trauma. As the permanent teeth erupt, they may erupt into a non-ideal incisor relationship with the lower incisors. Be sure to advise the parents attending that following any radiographic examination and review, in the future: Orthodontic treatment may be necessary. Traumatised primary teeth should be radiographed and reviewed regularly. This is essential to detect any sign of pulp pathology, periodontal problems, or involvement of the permanent teeth. There is a wide range of dental injuries in primary teeth. If the injury involves the pulps or roots, then extraction is the treatment of choice. Teeth with minor injuries can be restored, but successful dental treatment depends on the cooperation of the child. The following range of injuries are seen in primary teeth in order from minor to serious: 1. Concussions usually go unnoticed until the tooth becomes discoloured and the parent brings the child in to see you. 2. Subluxations should be treated with a soft diet for 1 to 2 weeks until the tooth becomes firm again. 3. Extruded primary teeth should be extracted as soon as possible. 4. Lateral luxations should be allowed to realign, but this depends on the direction of luxation. Generally, if the primary crown is moved labially, the root may affect the permanent tooth, so the tooth should be extracted. Conversely, if the crown is displaced palatally, the root is pushed away from the permanent successor and this can be left to realign. 5. Intrusions are the commonest injury, and teeth may re-erupt. Radiography and review are needed. Recall should be on a weekly basis for a month, then monthly for six months until re-eruption occurs. If there is no re-eruption, then the primary tooth must be extracted. If the tooth becomes ankylosed, then the eruption path of the permanent successor is deflected and ectopic eruption of the permanent tooth may occur. 6. Avulsions are seen and the tooth is then lost. No attempt is made to replant a deciduous tooth, the parents being advised that to do so may harm the permanent tooth, that is the risk to treat outweighs the benefit to leave alone. Please note the following complications seen after trauma to primary teeth: 1. Pulp death should be suspected whenever the colour change becomes permanent and periapical swelling with radiographic changes is seen; extraction is then needed. 2. Pulpal obliteration is also commonly seen. A yellow, opaque, or discoloured crown is indicative of this problem; the tooth should exfoliate normally, and other than observation, no treatment is necessary.
3. Injuries to secondary teeth are also common with intrusions causing the most problems. In this case, even though the permanent crown is more or less complete, there may still be enamel defects. Root anomalies are more likely to be seen. These are seen clinically as disturbed eruptions and altered incisal relationships. References to Clinical Case 32 1. Radford L, Corral S, Bradley C, et al. Child Abuse and Neglect in the UK Today. London: NSPCC 2011. 2. Incidence and Prevalence of Child Abuse and Neglect. July 2013. [Online] Available from: http://www.nspcc.org.uk/Inform/research/statistics/prevalence and incidence of child abuse and neglect wda48740.html [Accessed September 2013] 3. Hunter ML, Rodd HD. Chapter 3: History, Examination, Risk Assessment and Treatment Planning. In Wellbury RR, Duggal MS, Hosey MT. Paediatric Dentistry. 3rd Edition pp. 39-62. Oxford: Oxford University Press 2005. Further Reading 1. Wellbury RR, Duggal MS, Hosey MT. Paediatric Dentistry. 3rd Edition. Oxford: Oxford University Press 2005. 2. Wellbury RR, Whitworth JM. Chapter 12: Traumatic Injuries to Teeth. In Paediatric Dentistry. 3rd Edition pp. 257-294. Oxford University Press 2005. 3. Crawford PJM, Aldred MJ. Chapter 13: Anomalies of Tooth Formation and Eruption. In Wellbury RR, Duggal MS, Hosey MT. Paediatric Dentistry. 3rd Edition pp. 297-298. Oxford: Oxford University Press 2005. 4. Scully C. Chapter 25: Age and Gender Issues. Children. In Medical Problems in Dentistry. 6th Edition pp. 571-573. Edinburgh: Churchill Livingstone 2010.
5. Laming WH. The Victoria Climbie Inquiry. London: HM Stationers 2003. [Online} Available from: http://webarchive.nationalarchives.gov.uk/20130401151715/https://www.education.gov.uk/publicat 5730PDF.pdf [Accessed September 2013] It would be very useful for you to read the Introduction, the Dedication, and then the following: Chapter 10: North Middlesex Hospital with the recommendations of Lord Laming. Chapter 11: Health Analysis Section 11:9 on the importance of note taking. Chapter 18: Recommendations, specifically the Health Care Recommendations from 64 to 90. 6. Laming WH. The Protection of Children in England: A Progress Report. UK Government House of Commons Stationary Office 2009. [Online] Available from: http://dera.ioe.ac.uk/8646/1/12 03 09 children.pdf [Accessed September 2013] It would be very useful for you to read the introduction and the following:
Chapter 6: Improvement and Challenge, pp. 61-73, is useful to learn the importance of serious case reviews.
Clinical Case 33 Background Information If you ask candidates who sat the MFDS not that long ago, many will vividly remember this OSCE for all the wrong reasons. When this OSCE ran in Edinburgh, it was like watching the stage version of The Prime of Miss Jean Brodie1 with Dame Maggie Smith in the lead. I mention Dame Maggie as her father was a consultant pathologist at Oxford University, while one of my school teachers in Edinburgh was Robin Spark, whose mother, Dame Muriel Spark. wrote The Prime of Miss Jean Brodie. This novella was based on a teacher at James Gillespies High School, Edinburgh where one was quite literally sent for one’s sins. The actress in this MFDS OSCE played the part of a stern ‘old-school’ retired teacher. She was getting into the character quite well and letting only a few candidates slip through her hawkish clutches. In the middle of the morning session, one hapless candidate entered her room, with the following results: ‘How dare you! I am a retired schoolteacher, and I always, always have been addressed by my correct title and you will do likewise, is that clear?’ She was overheard berating one candidate who addressed the character by her first name. ‘I do apologise. May I call you by your title then?’ the candidate retorted. The examiner was trying his best to conceal his amusement behind a marking schedule. The familiarity of acquaintance does, unfortunately, breed contempt, so be warned, I think the candidate did quite well to recover from their contempt to pass the exam. The dentist-patient interaction is important; don’t trip yourself up by forgetting this. There are just as many marks available for being respectful as there are for knowing your stuff. Introduction A sixty-something retired schoolteacher attends the general dental practice where you work. Over the past few years, she has developed dryness and soreness in the mouth and throat. This was first noticed a few years ago; the problem was only during term time, when teaching, but it disappeared during the holidays. The patient put this down to dealing with the rigours of being exposed to children and the stresses this entailed. On retirement, the problem resurfaced once more, and the patient eventually attended today to seek some answers to the problem which is now bothering her on a daily basis. This OSCE has appeared in the MFDS exam; the subject matter has also been examined in the MJDF OSCEs and in the MJDF Structured Clinical Reasoning Exams too. So it will be fairly well covered and rightly so as it is a common condition. You will see patients with this condition in the dental clinic.
As with the first two OSCEs in this chapter, I have based the answers to this question on an MFDS type of dialogue. Question In this OSCE, please take a history from the patient. Answer Firstly, suitably introduce yourself to the retired schoolteacher as you would to any retired professional. After this begin by asking an open question: ‘Good morning, and thank you so much for attending today, Miss Brodie. You look just spinningly lovely this morning, and it is nice to see you again. Now what seems to be the problem?’ Whatever else you do, do not call her Jean (just yet, if at all) and do not say she looks well if she clearly does not. Do apply a bit of the charm but do not pile it on in the same way you would load an upper impression tray with alginate. Actors get upset if you ham it up or over-egg the pudding. The actress answers as follows: ‘I seem to have a dry sore throat and a dry sore mouth too. In the past, it was only during term time, and I thought it was due to all the talking and shouting at the children. I thought I might have picked up bugs from those horrible creatures, but I did love them. I spent my prime, forty years, as a teacher, you know. The dryness and the pain… it would go away, but now I have it every day. Maybe that’s the legacy I have from my teaching days.’ Reply by acknowledging the problem and, as always, show empathy and some concern too. ‘Thank you for telling me about that. I can see this is really troubling and causing some concern. It’s not a problem that we can ignore, and we have to do something about this. Can I ask some questions about how you have been?’ The actress replies to this with an invitation: ‘Yes, of course you can. Please do, and you can call me Jean, if you like.’ This shows you have developed a rapport and are putting Miss Brodie at ease. You can go on to ask the further questions you need to when taking a history. ‘Thank you, I appreciate that… Jean. Tell me, do you keep well? The actress replies, telling you she has the usual lot of aches and pains in her joints. Jean tells you it’s just part of getting old, but she isn’t worried by these as she has had these pains for some time. You should pick up on this information and reflect this back to the actress: ‘When you say aches and pains, Jean, can you tell me a little more about them please?’ The actress tells you that she has joint pain in her hands and feet; at this point she helpfully adds for you:
‘I do go to see the rheumatologist at the hospital, and he has been treating me for a while now. It is not my usual common or garden variety of doctor. He, as you probably know, is a specialist, a practitioner skilled in the ways of senior medical men. More qualified than the common or garden variety of general doctors—certainly, without wishing to belittle you, more qualified than you. Maybe one day you too might become a specialist. Would you like to do that with your career and these exams you are taking?’ The character will add that patronising rejoinder with just a hint of a knowing smile. Once a schoolteacher, always a schoolteacher and Jean would like to take some control of the OSCE now and give you some advice for your career. Do not rise to the bait and bring Jean back to the OSCE as follows: ‘Thanks, I’ll take that as a compliment and a measure of the confidence you have in my clinical skills, that one day I too might be a specialist. Hopefully, after successfully passing these exams (with your help, Jean,) I can begin my journey to that great goal. Anyway, tell me, does your specialist provide you with any medication?’ The actress replies by telling you she has had arthritis, specifically rheumatoid arthritis for some time now and she is taking medication for this. Medication and medical history a. If anyone in an OSCE tells you about a medical condition, do be sure to ask in more details about that condition and do not forget to ask about any medication being taken for it. b. As in Chapter 3, you have to develop a drug history in conjunction with the patient’s medical history. On asking, a list of medication is given to you for consideration: The list of medications is as follows: 1. Leflunomide at 10 mgs ods PO (disease-modifying anti-rheumatic drug or DMARD) This has been taken for 4 months at this small dose.2 2. Eterocoxib at 30 mgs ods PO (non-steroidal anti-inflammatory drug or NSAID) This has been taken for 6 months at this small dose.3 Additionally, the patient has self-medicated with: 3. Acitaminophen (paracetamol as an OCM) taken at 500 mg irregularly when the pain is severe.4 From this list, you can advise the patient of the following information: ‘We know the medication you are taking is to reduce the body’s response to the rheumatoid arthritis you have. I think it is also prudent to advise you of the side effects these medicines can have. Has the specialist told you about some of these?’ The actress looks a little surprised at this question; after all, a practitioner skilled in the ways of senior medical men should know about these things, should he not? You can advise Jean that among the documented side effects of these medications are the following:
a. A dry mouth b. Taste disturbances c. Oral ulceration When you mention these signs, the patient then tells you she does have a dry mouth, but she doesn’t think this is related to the medicines. After all, she has had a dry mouth and a dry throat for some time now, certainly well before she started taking these medicines. Again, this is really important information for you to grasp. Dehydration is a common cause of dry mouth, and you can ask Jean if she is drinking enough; if only to exclude this cause, you should ask this question. You should then ask about any other signs she might have noticed: ‘I do get what feels like grit in my eyes, but I know it isn’t and well, I don’t know how to put this across to you as you are a junior in service, and this is embarrassing, but well…’ Personal information When a patient is about to tell you something quite personal, your body posture, your eye contact, and your manner are really important to assist the patient in being able to provide the information you need. The actress hesitates, and then continues… ‘Well, it’s down below. It’s women’s trouble. I don’t want to say any more, but its women’s trouble, and you aren’t to know more about these things or to mention them again. Is that understood?’ Your reply has to be empathic (to the highest degree of empathy you can summon up). Leaning forward, you might suggest: ‘Jean, thank you for sharing this confidential medical information with me. I think I might be able to provide you with some answers today.’ At this point, it is useful to screen the information you have and repeat the important items back to the actress. You might carry on with: ‘You tell me you have rheumatoid arthritis and the specialist has given you medication for that. We now know the soreness and dryness in the mouth, eyes, and elsewhere is not a result of taking this and you are drinking enough and you don’t take any other medication.’ The actress interrupts with: ‘Yes, but no one must know about down below. It is not to be spoken of. Anyway, I have come here today to ask you about my dry and sore mouth, and you want to talk about other things. Is there a connection?’ You can reassure the actress that the condition which she has reluctantly spoken of will not be spoken of again. So far, you have a good grasp of the medical background. You can now begin to put things in place and go to the next stage of this OSCE.
Further Questions and Examination Explain to the actress that there may be a connection between the dry mouth and eyes and the arthritis, then ask if she would like you to expand on this. The actress agrees. You can explain if you were going to examine her today you might like to look at the lymph nodes in her neck feeling the salivary glands for swelling and then finally, the mouth itself. If you could examine the patient, the initial findings you might see are: 1. drier than normal alveolar mucosa with a reddish glazed appearance, 2. a tongue which is red, fissured, and dry, and 3. a palate appearing very red and dry. If you could carry out a further intra-oral exam, the findings you might see are: 1. Plaque and calculus between the teeth and cervical caries with many Class V lesions present. 2. In this case, neither the lymph nodes nor the saliva glands are swollen. From these findings, it is clear that the patient has xerostomia or reduced saliva flow; you can advise the actress of this: ‘Jean, from the information you have given me, your reduced saliva and tear flow is most likely to be linked to your rheumatoid arthritis.’ You ask the actress if the connection with the mouth, the eyes and the rheumatoid arthritis has been mentioned before. The actress tells you she received so much information from the specialist. Some of this sounds familiar to her, but she tells you the hospital doctor spoke in such technical terms and elaborate details that she couldn’t make head or tail of what he was saying after a short while. ‘Is there another name for this condition I have?’ The actress will usefully ask you. You might reply as follows: ‘Yes, there is. It is called Sjögren’s syndrome. This is common, and perhaps it is one of the commonest medical disorders causing reduced saliva flow (or xerostomia). Although you meet the criteria of having this condition, the symptoms you present with are a little inexact for me to make a definitive diagnosis. To do so will require some tests.’ The actress will continue as follows: ‘Tests, I have given my students many tests. Are you going to give me a test here?’ Explaining tests in the exam a. This is another really important question. b. Invariably in an OSCE, when asked if you are going to do the tests here, the answer is most likely to be, no. c. However, in this case, one simple test you can describe in an OSCE that requires no expensive equipment is to ask the patient to sit for 10 minutes to collect all saliva in a graduated cup to assess its quantity and quality.
d. If you collect less than 2 ml of saliva in this time and /or the saliva is a thick viscid liquid, then the patient has xerostomia.5 e. In the MFDS and MJDF, you wouldn’t get many marks for walking in and handing the actress a polystyrene cup from the rest station and telling her that you would like her to spit into it for the duration of the exam, while you lecture her on xerostomia and its likely causes. Although xerostomia is one of your clinical findings, it is not a diagnosis and therefore, not the answer to this OSCE. Testing Required Although this case is about taking a history, it is important to state that several tests will be needed to reliably establish a diagnosis of Sjögren’s syndrome. You can advise the actress that most tests will be undertaken in a hospital by specialists. You can tell the actress: ‘These specialists are practitioners who, as you know, are skilled in the arts and are senior dental and medical men, more qualified than the common or garden variety of general dentist. Certainly more qualified than I am.’ You are then asked what these tests might involve; at this point, you can mention the simple saliva collection test. The results of this test can be documented and sent to the hospital in a referral letter, where the following tests might be conducted. You can explain the following in an OSCE: 1. Saliva testing. Saliva from all of the mouth or saliva isolated from a major gland, that is the parotid, can be assessed in more detail. ‘Any saliva collected can be tested for any bacterial or fungal infections. This is called culture testing. One of the major salivary glands, the parotid, can be stimulated to produce saliva with citric acid, and the amount produced can then be measured.’ 2. Blood tests. A blood picture and specific parts of the patient’s blood will be looked at, for example antibodies and red blood cell (erythrocyte) sedimentation rate (ESR). The tests indicate whether there is an inflammatory process occurring. Although antibody tests are not helpful in diagnosis, you can explain they are really useful in mapping out how the disease might progress or how potential complications may occur. You can explain this to the actress as follows: ‘An erythrocyte sedimentation rate (ESR) test is used to see whether there is inflammation in the body. This works by timing how long it takes for red blood cells to fall to the bottom of a test tube. The faster they fall, the more likely inflammation is present. This test is often used to aid diagnosis in conditions associated with arthritis. Along with other tests, the antibody test and ESR can be useful in confirming whether you have an infection in your body.’ 3. Blood sugar level test to eliminate diabetes as a cause of the dry mouth. Urine samples can also be used in the first instance to check a patient’s sugar levels. 4. Imaging of the salivary glands with X-rays and radio-opaque dyes is a useful means of assessing
how much of a gland is affected. 5. Biopsies and tissue sampling. The small minor saliva glands present in the gums can be looked at; to do this, a small sample a few millimetres in diameter is taken usually after a local anaesthetic is applied so the patient feels minimal discomfort as this is done. The larger glands can be sampled too, but this is less common. 6. Eye tests. As the eyes are affected too, a simple test in which filter paper is placed on the eyelid is used to see how much tear flow occurs (the Schirmer test). Point to Note The Schirmer test has been noted to be unreliable and would only be completed by an ophthalmologist. Other more detailed eye examinations might be needed to support any findings. After providing details of these tests, you can carry on with the OSCE as follows: Management of the Condition You can begin to summarise your findings and ask if there are any questions. The actress says there are none. Do not end the OSCE just yet; even though the exercise was one of taking a history, it is important to give some advice on the management of the condition the patient has attended with. Although you cannot control or treat the underlying condition; Sjögren’s syndrome, which is secondary to the connective tissue disease, it can be managed in the dental clinic. It is important to let the patient know that any remaining saliva gland function and residual saliva flow has to be preserved. Point to Note A common theme running through all areas of dentistry is that: It is better to preserve what is present than replace what is absent. In this case, replacing saliva is not as beneficial as maintaining the flow rate of saliva. Maintaining a good intake of water with frequent drinks throughout the day is useful. Stimulating saliva flow with sugar-free chewing gum is good, and it is important to communicate with the patient’s specialist and general medical practitioner to reduce or avoid using those drugs that further reduce saliva flow. There are drugs which can be used to stimulate saliva flow rate. One such drug is pilocarpine. However, its use is challenging, with side effects and drug interactions being common (see below). Lastly and perhaps the most dentally relevant aspect of this OSCE: With reduced saliva flow rate, there is altered taste sensation, so patients often add more salt and more sugar to the diet. Increasing the salt intake will affect the patient’s renal and cardiovascular system with resulting hypertension. Of specific dental relevance is the observation that increasing the sugar intake against a decreasing saliva flow rate results in the Class V carious lesions often seen in the xerostomic patient and noted in this case.
These carious lesions have to be treated. If the lesions are arrested and self-cleaning then, toothbrush instruction, application of fluoride varnish, and diet advice is given. If the lesions are carious, then caries removal (which can be achieved atraumatically with a spoon excavator) is advised and GPA/ GI (Glass Polyalkenoate/ Glass Ionomer) materials are used to restore teeth affected by these lesions. Further progression of carious lesions can be prevented with the above measures and diet advice should be given. Saliva substitutes (from clinical experience) are costly and not well liked by the patients. After giving your advice, provide a concise summary of the important points including the patient’s concerns in an action plan to give reassurance and guidance for the future as follows: ‘So, Jean, now to summarise: You have a condition with a name and this is Sjögren’s syndrome. This is secondary to your rheumatoid arthritis. Although I am fairly certain you have this condition, confirmation will require referral to a hospital specialist. It is important, in the meantime, to maintain your ability to produce saliva and to keep your mouth as clean and healthy as possible. We need to look at your diet, and it would help to reduce the sugar you take. Although I haven’t asked you this, if you do take sugar in tea and coffee, consider reducing or stopping this and use a sweetener instead. ‘Any questions so far?’ The actress should agree and with no questions, and you can continue: ‘Teeth that need to be filled can be restored. A visit to the hygienist will help by cleaning and giving you instructions on how to keep things clean. We also need to get you to come back if there are any pains or swellings in the salivary glands. With reduced saliva flow, you are at risk of a condition whereby bacteria from the mouth might enter the glands and cause problems. If you have any pain or swellings, then please immediately come back to see me and we need to refer you to the specialist for this.’ At this point, ask if there are any questions. If there are none, then continue: ‘As you have mentioned, there are other areas involved such as the eyes, and we need to make sure no problems arise with those. The condition you have carries a risk of lung and pancreas involvement too. The tests you will have with the specialist should help us to identify if these organs are affected. I do need to advise you that there is a future risk of developing something called a lymphoma.’ At this point stop and ask the actress if she would like you to explain what this might mean for her. If she asks, then explain the following to her: ‘Lymphoma is a form of cancer of certain cells in the saliva glands. Often this progresses very slowly and is localised to and limited within the gland. With early detection, it can be treated.’ At this point, pause again and check to see the actress understands, then offer reassurance to the actress in this manner: ‘It is most certainly the case as you don’t have swellings in the gland this complication is not present. The most important thing is that you have attended today, and I have been able to take a history from which we can plan the way forward. I think it is important that you continue to re-attend with myself
and with the specialists so together, we can manage this condition for you.’ With that you can end the OSCE. Further Notes to This Clinical Case 1. Sjögren’s syndrome is a distressing condition. It affects more than just the eyes and the mouth as you have seen from the dialogue above. A patient attending with this condition may be in considerable discomfort. Empathy and understanding are so important in your history taking, your assessment, and your management of the condition. Sjögren’s syndrome is an autoimmune exocrinopathy, a disorder where there is destruction of the patient’s excocrine gland tissue, and as stated above, these are not limited to the eyes and mouth only.5,6 Sjögren’s syndrome is the commonest disorder causing dry mouth. It mostly affects females in their middle ages, so the history of the character in this OSCE fits this pattern. Some 3-4% of adults in the UK have this condition. Some 90% of all cases are middle-aged to elderly women.5,6 Sjögren’s syndrome can be: 1. Primary Sjögrens syndrome: where there is no attendant connective tissue disease; notably, in the primary disease, there is often salivary gland swelling. Sometimes, Raynaud’s phenomenon is seen with this phenomenon. These patients are seronegative for the antibodies commonly associated with secondary Sjögren’s syndrome. 2. Secondary Sjögren’s syndrome: where the patient has an accompanying connective tissue disease such as rheumatoid arthritis, mixed connective tissue diseases, or systemic lupus erthythematosus (SLE), often presenting with the classic malar butterfly rash. In those patients with the secondary form, other glands are less severely affected, the mouth can be less dry, and salivary gland swelling is rarely seen. With reduced saliva flow, the patient can suffer from opportunistic infections in the mouth. In the tests above, it was noted that testing for candida would be undertaken. Often, a dry mouth is not sore. It is possible that the pain noted was a result of candidal infection. Testing saliva for candida is useful, as is taking a mucosal smear if the clinical presentation is inconclusive. The results of any testing will be discussed with the patient by the specialist who undertakes the tests. Diagnostic Features In a biopsy, where there is Sjögren’s syndrome, an inflammatory lymphocytic infiltration of the gland with acinar and cellular destruction is seen among other areas of normal glandular tissue. The results of sialography of a major salivary gland affected by Sjögren’s syndrome show integrity of the major ducts. The minor ducts are absent with multiple scattered foci of contrast medium. This picture is similar to chronic non-specific sialadenitis, but in Sjögren’s syndrome, the distribution pattern is uniform across the whole gland. Whereas in sialadenitis, it is limited to one or two lobes of a gland and the contrast medium can be concentrated in patches. The incidence of lymphoma in Sjögren’s syndrome is 5% with just under half of these being a mucosa-associated lymphoid tissue lymphoma or MALTOMA.3,7
Other tests used in diagnosing Sjögren’s syndrome are antibody testing. You should not have to go into too much detail about these tests in the MFDS and MJDF OSCEs. Although in the MJDF SCRs, you may wish to discuss these tests. Specifically, there are serum auto-antibodies, and these are the antinuclear antibodies: SS-A Robair and SS-B Lattimer antibodies, both common and diagnostically helpful.8 These auto-antibodies are involved in cellular apoptosis by activating specific enzymes, resulting in salivary gland cell destruction. In summary, Sjögren’s syndrome is a common condition often remaining undiagnosed as its presentation is variable and involves multiple organs and systems. The eyes, the mouth, the GI (gastro-intestinal) and GU (genito-urinary) tracts are all involved. These involvements and clinical presentations can be consecutive or concurrent. Many patients have gone undiagnosed for considerable periods of time with serious complications such as ocular scarring leading to blindness and development of lymphomas, as noted above. Regular dental recall and thorough examination are needed in all patients but especially those middleaged females who are in the main group of cases affected by this condition. There are two medications that may be useful for patients with Sjögren’s syndrome: 1. Pilocarpine, which is a parasympathomimetic drug. In addition to treating Sjögren’s syndrome, it is useful for patients who have had radiotherapy following head and neck cancer. The problems with pilocarpine are quite complex. Given that one of the causes of a dry mouth is dehydration, pilocarpine can cause excessive sweating, resulting in further dehydration. It cannot readily be used in those patients with asthma and chronic obstructive pulmonary disease as excessive secretions further increase airway’s resistance. There is also an increased urinary frequency so the effects of dehydration are exacerbated by this. Visual disturbances have also been noted, and pilocarpine interacts with beta blockers to cause cardiac arrhythmias. On balance, it might seem that the side effects and risks could be greater than the potential benefits.9 2. Hydroxychloroquine, which is a DMARD that suppresses the immune responses in rheumatoid arthritis. As a result, the disease processes affecting the salivary glands are slowed down too. Associated problems of muscle and joint pain are reduced; however side effects of hepatic and renal impairment and the potential for retinal damage limit the potential for widespread use of this drug in treating Sjögren’s syndrome.10 References to Clinical Case 33 1. Muriel Spark DBE. The Prime of Miss Jean Brodie. London: Macmillan 1961. 2. BMA Royal Pharmaceutical Society BNF 64. Section 10 Musculoskeletal and joint diseases 10.1.3 Leflunomide pp. 668-669. London: Royal Pharmaceutical Society; 2012. 3. BMA Royal Pharmaceutical Society BNF 64. Section 10 Musculoskeletal and joint diseases 10.1.1 Eterocoxib pp. 658-659. London: Royal Pharmaceutical Society; 2012. 4. BMA Royal Pharmaceutical Society BNF 64. Section 4 Central Nervous system 4.7.1 Paracetomol pp. 265-266. London: Royal Pharmaceutical Society; 2012. 5. Scully C. Chapter 18: Auto Immune Disease. The Connective Tissue Diseases. In Medical
Problems in Dentistry. 6th Edition pp. 429-431. Edinburgh: Churchill Livingstone 2010. 6. Hatron PY. Sjögren’s syndrome: diagnosis and systemic manifestations. Rev Prat. 2012 Feb;62(2):221-24. 7. Paliga A, Farmer J, Bence-Bruckler I, et al. Salivary gland lymphoproliferative disorders: a Canadian tertiary center experience. Head Neck Pathol. 2013 Jul 3. 8. Hernández-Molina G, Zamora-Legoff T, Romero-Díaz J, et al. Predicting Sjogren’s syndrome in patients with recent-onset SLE. Rheumatology (Oxford). 2013 Aug;52(8):1438-42. 9. BMA Royal Pharmaceutical Society BNF 64. Section 12 Ear, nose and oropharynx 12.3.5 Treatment of dry mouth. Pilocarpine hydrochloride pp. 725-726 London: Royal Pharmaceutical Society; 2012. 10. BMA Royal Pharmaceutical Society BNF 64. Section 10 Musculoskeletal and joint diseases 10.1.3 Hydroxychloroquine sulphate pp. 667-668. London: Royal Pharmaceutical Society; 2012. Further Reading 1. Escudier M, Brown J, Odell E. Case 64: A Pain in the Neck. In Odell E. Clinical Problem Solving in Dentistry. 3rd Edition pp. 301-306. Edinburgh: Churchill Livingstone 2010. 2. Shirlaw PJ, Odell E. Case 7: A Dry Mouth. In Odell E. Clinical Problem Solving in Dentistry. 3rd Edition pp. 33-36. Edinburgh: Churchill Livingstone 2010. These are two cases dealing with Sjogren’s syndrome, presented with illustrations too. 3. Soames JV, Southam JC. Diseases of Salivary Glands. Sjogren’s Syndrome and Related Disorders. In Oral Pathology. 2nd Edition pp. 241-246. Oxford: Oxford University Press 1993. A good account of the histopathology of Sjogren’s syndrome in salivary glands.
Clinical Case 34 Background Information Now for a question on restorative dentistry, just to reassure you this is a straightforward OSCE. However, you do have to go through the necessary steps in a systematic manner to get the result you need. In my review of 80 OSCEs of the MFDS examination, a restorative question always appeared in every exam. In the MJDF, restorative questions also come up. Restorative dentistry is the most common theme in all the OSCE questions, and the type of restorative question that appeared more than any other was that dealing with failing or failed restorations, broken instruments, or just about anything that did not quite go according to plan. So in your MFDS and MJDF revision, do cover this subject. By doing so, when you come to sit your exam, you will increase the chances of making things go according to your plan. If we can remind ourselves of the words of wisdom from Dr Michael Gerard Tyson LHD*, they apply once more to this case: ‘Everybody’s got plans until they get hit.’
*Dr Tyson’s post-nominals refer to his LHD or Litterarum Humanorium Doctor. He received this from the Central State University of Ohio. In this case, LHD does not refer to Local Health Department. We might remind ourselves that in his illustrious career, Dr Tyson would have referred several patients to such departments. OK, without any further ado, here is an OSCE where things have not gone according to plan. By the way, as most of the previous OSCEs have been modelled on the MFDS dynamic interaction, I thought I would present this one as an MJDF OSCE where there is more structure and the questions are answered separately. Introduction In this OSCE, the actor portrays a trainee barrister, who is a patient of one of the senior dentists in the clinic where you work. Your senior colleague always seems to attract the patients who will go for the big-ticket items in dentistry. When I say ‘big-ticket items’, I mean all the costly cosmetic treatments and non orthodox or mainstream dentistry. Your colleague’s patients are always smiling; they are always happy; nothing is too much bother, never any bother at all, in fact. On the other hand, while all this loveliness is going on, you get all the problem cases to deal with. You do not particularly agree with the way the senior dentist does things. Their dental work and complex pricing plans seem to be geared up to financing all the finer things that life and money can bring. You are still paying off student loans and setting money aside for your MFDS and MJDF exams. Just before your senior colleague dashed out the door, to the amusement of the nurses, she told you to buy yourself a new car. The weather is sunny and pleasant. (It usually is in the early summer as you attend for your Part 2 MFDS in Edinburgh or Glasgow.) With the nice weather, your senior colleague has, on the spur of the moment, decided to take a few days off with their ever-so-attractive newest partner who has just been handbagged round the clinic for all to see. In this case, you have to complete a root treatment; the tooth in question is an upper first premolar, and from the notes you can see that the root canals were stated to be multiple and curved. Stuck indoors to tidy up someone else’s mess, and exams to revise and pay for. You are thinking why couldn’t you just have been born five years earlier? By now you would have your own dental practice, not have to bother with this ‘CPD-nonsense’ and studying for these exams too; in fact you could have been just like your senior colleague. Life just isn’t fair, is it? Let me tell you: No it isn’t, and while we are at it, envy is a terrible thing too. At least one day you will have a partner more reliable than the car you currently drive, and you will get there by following as straight a path as you can. Question
While looking at the radiographs, you think you can see a broken instrument stuck near the apex of the root canal. In this OSCE, go through the steps and procedures to deal with this fairly common eventuality. Answer 1. Introduce yourself to the actor in a professional manner and explain that your senior colleague has had to take some time away from the clinic and you have been asked to complete any treatment in their absence. Then ask if this is OK with the patient. Points to Note a. In order for the OSCE to proceed, the actor has to say this is OK. b. Now you can begin to explain your findings from the radiograph. 2. Before doing so, initially briefly go over the treatment the patient has already undergone and verify their details are correct in the notes, that the relevant clinical data you have is accurate, and that the radiograph is of the tooth in question and from this patient. 3. Ask the patient how they have been since the last visit. This question should be an open question and the patient reports that there have been no problems. 4. Explain to the patient that there seems to be a broken instrument within one of the canals and you can see this from the X-ray. Present the X-ray to the patient and go through the orientation of the radiograph, pointing out where in the mouth the tooth is and on which side, relate this to the picture you present. Point out the crown, the roots, and adjacent teeth also. Additional Radiographic Findings From a periapical radiograph or other appropriate view, you can also determine bone level and thus remaining periodontal support around the tooth. If there is additional relevant information you can see from the radiograph, you have to include this when presenting your findings in the clinic to a patient and in an exam to an actor or examiner. Such information such as restorative overhangs, incorrect margins, calculus, or other presentations should be noted, presented to the patient, and documented in the notes. The item that you need to notify the patient about is the presence of a broken section of a delicate root canal file in one of the canals. You can now point this out to the patient. 5. In this OSCE, the patient will exclaim with great theatrical posturing that they were not told of this and how can such a thing happen? The actor will ask the leading question. ‘After all, your colleague is a specialist, are they not?’
Points to Note a. The first thing you have to ask is, In this OSCE, why is the actor/patient taking your word for this? After all, it is no secret you don’t really get on with your colleagues. b. Now you have the perfect opportunity to really put them in their place; after all that’s what they seem to spend most of their time doing to you. c. Don’t do any of the above and remember: You have to be professional at all times. 6. Apologise to the patient for any distress that giving this information may have caused them. Notwithstanding this distress, continue your explanation of the problem. Check to see that the patient understands your explanations. Complete this part of the consultation by advising the patient that you will make a note of your findings in the patient record cards. Do state that it may be the case that this incident is documented in the patient notes, but at this time you do not have all the notes to hand (in the OSCE’s you most certainly will not) and that you will find out why the patient was not advised of this occurrence at the correct time. In the meantime, you need to take another radiograph. Ask the patient if you can take another X-ray. 7. The patient agrees to have another radiograph taken but asks why this should be necessary as you have clearly pointed out the broken instrument in the canal. 8. You can advise the patient of the options for treatment and that either you can take an X-ray, or if the patient is referred to a specialist or returns to your colleague, then invariably more X-rays will need to be taken to determine the following: a. Is there really an instrument broken in the canal or is this just an artefact of the film? b. If there is a broken instrument, then film artefacts are not duplicated in subsequent radiographs. Also, another radiograph taken from a different angle either to the front or to the rear, when compared to the first view, should help you to determine in which of the canals the root instrument is broken, that is a parallax comparison can be made. c. Explain to the actor that the tooth being treated has two canals; one is nearer the palate and the other nearer the cheek. By taking a second X-ray, the exact canal in which the instrument is broken will be known. By gaining this further knowledge, the options for treatment will be made clearer in due course. 9. The actor is concerned that if a broken instrument is left in the canal, then this instrument, mentioned by you to be a delicate root canal file has probably been in and out of many patients’ mouths before being ‘implanted’ without their knowledge into their head. The actor then goes on to mention the risk of infection and further disease that might follow from this. 10. You can reassure the actor that all root canal instruments are single-use only on one patient, and this has been so since April 2007, following guidelines from the UK Department of Health.1-3 The instrument which is now broken was never used in any one else’s mouth. In the MFDS OSCE, you should be able to quote the Scottish regulations, and this is the 2004 Chief Medical and Chief
Dental Officer letter 2004 21.4 In England, in the MJDF, you should be able to quote the HTM 01-05 Document Section 1-17-19 on Prion Decontamination.5 The actor seems to be relieved at this, but then points out that the instrument is a disposable item and they are not happy that they will be stuck with a disposable item in their mouth; after all their tooth is not a disposable item. 11. You agree and might concede this is a fair point from the actor/patient. You can ask the actor if they would like you to explain some of the options to resolve the problem they are now aware of, and they agree. As mentioned in answer 6, you need to document this clinical incident in the patient notes and to locate in which canal the root fragment is broken. After doing so, the options for treatment are as follows: 1. Going to completion of the root treatment and filling the canals, incorporating or ‘incarcerating’ the instrument in material used to seal the root canals. As there is currently no pain, there is no urgency in making a decision; nevertheless, a decision has to be made. 2. Another choice is to attempt to remove the instrument. If so, referral to a specialist may be appropriate as the chances of success are fairly high. You can provide the actor with the following figures: Successful instrument removal is noted to be almost 80%.6 Instrument breakage and retention, although not frequent, does occur in the region of 2% to 6% of all root canal treatments. But this depends on the endodontic system used and the experience of the operator.7 So there are accepted procedures to follow if this occurred, as it has in your case. 3. If the actor chooses to accept a specialist referral, then this should be noted. 4. Advise them in the OSCE, that a referral letter will be written out today. You can then ask if they wish to have a second X-ray taken to provide further information to go with this referral. 12. The actor then agrees to be referred, but if a second X-ray is taken, they are worried this unnecessary exposure to radiation may increase the risk of developing cancer. Again you should concede that if the instrument did not break, then a second exposure may not have been necessary. However, in a course of root treatment, several radiographs, possibly up to three or four, are necessary, and the overall risk of developing cancer is very remote from one additional exposure. If the patient remains concerned after your explanation, then referral without taking a radiograph is an option. Explain to them that the specialist may have alternative means of locating a broken instrument other than taking an X-ray. You can explain that they do, for instance, have microscopes and other instruments to locate the instrument visually. You should agree with the patient not to take an X-ray but to refer to a specialist endodontist.
13. If a specialist referral is accepted, then ask the patient if there are any questions. If there are none, then continue to explain that there are a few points you wish to explain. Again, do repeat that you are sorry this has happened. Apologising to a patient does not imply any culpability on your part or that of a colleague. Go on to explain that there may be some complications in the future and that referral to a specialist does not mean the instrument will be removed or the roots successfully filled. The decision on whether to complete the treatment has to be that of the patient after receiving all necessary opinions and options. The chances of success in the hands of a specialist, although still favourable, are lower than if there was not a broken instrument present. 14. In summarising, you can state that in any treatment, there is no guarantee of success and in referring to a specialist you wish to keep all options open for the patient, but success cannot be guaranteed. 15. Complete the OSCE by summarising your findings as follows: a. There is a broken instrument in a root canal, and the patient is in the middle of treatment. b. With the patient’s agreement, you are referring to a specialist endodontist for an opinion on whether to remove the instrument or go to completion. c. Success cannot be guaranteed, the notes will be written up with a copy of the referral letter including today’s findings which will be sent to the patient. d. You will discuss the matter with your colleague on their return. You can now ask if there are any questions. The actor mentions that they were under the impression that your colleague was a specialist and point out the appointment card which states your colleague has a Master’s degree in Root Treatment and they have a special interest in this type of treatment. The actor mentions that as a trainee barrister they feel they have been misled by this misrepresentation. You can only apologise and state that you will bring this matter to the attention of your colleague and the practice owner too. At this point, you can thank the patient for bringing this additional matter to your attention and politely end the OSCE. Further Notes to This Clinical Case. 1. In this OSCE, as in real life, you cannot allow your professional relationship (or lack of) with a colleague get in the way of your professional relationship with a patient. It would be so tempting to let the patient know about how you are treated and how you disprove of your colleague’s conduct and so on. All of this is totally irrelevant; the patient only turned up to get a root filling completed, and your duty is to ensure that happens in the most efficient way possible and deal with the added information of the broken instrument in the canal. 2. When presenting the radiograph to the patient, it is important to understand the need for a second
radiograph and the principle of parallax views to locate an object in the third dimension. In this case, that dimension is of depth, that is: Is the broken instrument in the palatal or the buccal canal? A second view is needed, but it is important to know the direction from which the first view was taken. In an OSCE, if you are given two views, then you should be able to deduce the location of the object you will be questioned on. In this case, it is a broken instrument; the other favourite is the ectopic unerupted canine being either palatally or bucally displaced. Parallax views The principle of parallax viewing is: The object which is further from a reference point moves with the viewer, while that which is nearer than a reference point moves in the opposite direction. In dentistry: The mnemonic to remember is: SLOB: Same for Lingual. Opposite for Buccal. In other parallax views detailing canals, you can apply this principle to vertical or horizontal planes. The reference point you choose can be another tooth or a crown or the characteristic feature of a radio-opaque filling. 3. The last point of this OSCE was the use of specialist titles. This won’t apply to you just yet as the MFDS and MJDF are foundation level qualifications. If you are not on the GDC Specialist List, you are not a specialist. Adopting advertising and letterheads saying that you have a special interest coupled to further qualifications in a specialist discipline is just cutting it a bit fine. If things don’t go according to plan, then the GDC will apply their ‘special interests’ to you. If that happens, then in comparison to the GDC, a meeting with Dr Tyson LHD doesn’t seem that bad after all. References to Clinical Case 34 1. Department of Health Economics and Operational Research Division. Risk Assessment for vCJD and Dentistry. London: Department of Health 2003. 2. Webber J. Draconian advice. Br Dent J. 2007; 202:706. 3. NHS Scotland: Sterile Services Provision Review Group: Survey of Decontamination in General Dental Practice 2004. 4. CMO/CDO Letter CMO(2004) 21: Important information for all General Medical and Dental Practitioners, and others engaged in local decontamination of surgical instruments. 5. Department of Health. Health Technical Memorandum HTM 01-05. Decontamination in Primary Care Dental Practices. London: DOH 2013. [Online] Available from: http://www.idscuk.co.uk/docs-2013/HTM 01-05 2013.pdf 6. Hülsmann M, Schinkel I. Influence of several factors on the success or failure of removal of fractured instruments from the root canal. Endod Dent Traumatol. 1999 Dec;15(6):252-58.
7. Madarati AA, Hunter MJ, Dummer PM. Management of intracanal separated instruments. J Endod. 2013 May;39(5):569-81. Further Reading 1. Whaites E. Essentials of Dental Radiography and Radiology. 4th Edition. Edinburgh: Churchill Livingstone 2007. Although reading this whole test is recommended for the MFDS and MJDF, the following sections are particularly focused on this OSCE: Part 4: Radiography. Section 10: Periapical Radiography. pp. 97-124. Part 5: Radiology. Section 25: Development Abnormalities. pp. 299-322. 2. Stock CJR, Nehammer CF. Chapter 11: Endodontic Problems. In Endodontics in Practice. 2nd Edition pp. 87-94. London: BDA Books 1992. Essential reading for anyone considering doing any endodontic treatment. Now a bit dated but still a good starter textbook, many of the procedures and preventive measures were published in this book over twenty years ago! 3. Torabinejad M, Shabahang S. Outcomes of nonsurgical retreatment and endodontic surgery: a systematic review. J Endod Am Assoc Endod. 2009;35(7):930-37. A good read on the options to consider, when things don’t go according to plan.
Clinical Case 35 Background Information I was wondering what subject we can cover in this OSCE, and on 5th May, I had this little notion firstly nagging then knocking its way out of my head and into the book for you to consider. Nevertheless, before we get to this notion, let us consider another dental trauma case. You have already covered trauma to the deciduous teeth. So now I think it might be an idea to cover trauma and injuries to the permanent dentition in an older child. As mentioned in OSCE 32, dental trauma OSCEs feature extensively in both MFDS and MJDF exams. In the former exam, one examiner passively observes a dynamic flowing dialogue between you (as the candidate) and the actor (as a parent or guardian). In the latter, both actor and two examiners will ask a rigid and clearly defined set of questions. While they are doing this, there may be a practical task relevant to the OSCE to complete. Such questions can be on the methods you are using to complete a practical task or the materials you have selected to do so.
If you are not good at multitasking (roughly 50% of all the candidates, i.e. men) or you find back seatdentists (like back seat-drivers) an annoyance, now might be a good time to get some practice in, or attend some form of counselling to increase your ability to answer absurdly annoying questions while attempting mentally challenging problems requiring good manual dexterity. Introduction A young schoolgirl aged 12 and an adult who identified himself as a teacher from the local school a few hundred yards down the road have just run into the surgery to see you. It is in the middle of your lunch break. The teacher tells you that the child has been playing football at school. She has been elbowed in the face (accidentally) and two of her teeth have been knocked back into the mouth. You can only see one tooth. One upper central incisor appears displaced and is very loose. The other one is in a damp bloodstained towel held by the teacher. As you can imagine, there is a fair amount of blood on the child’s face; the lips appear swollen, and the child is crying and noticeably upset. The teacher is almost (but not quite) beside himself and he seems to be in a state of shock. It was all he could do to gather up the tooth and the child and bring them both to you. He tells you he found the tooth on the tarmac in the playground and the accident has only just happened about 15 or 20 minutes ago. Questions 1. What are the first steps you will take to manage this situation? Can you detail the examinations you will carry out? 2. What will be your early and intermediate treatment of the injuries? 3. Who should be notified of the incident? 4. What are the possible complications which may arise from this injury? 5. How will you manage the possible complications? Answers In this type of OSCE, you don’t have to go through the usual polite and professional introductions. The actor playing the teacher knows you are a dentist; that is why he has attended with the child. In the MJDF, this type of OSCE has appeared a few times. The device used to represent the child will be clinical photographs and perhaps a set of teeth in a Phantom Head. You will have to do some work on this while answering questions from the examiners. If this OSCE appears in the MFDS exams, then only the actor playing the part of the teacher will be present, and you will work through the OSCE with the teacher. The examiners will observe your interaction, communication, and use of clinical knowledge as you manage the situation. 1. The First Steps to Take A medical history is taken from the teacher (and the child if possible or present in real life). It would be appropriate to ask if the child attends the dental practice and to ask their name and age so their parents can be contacted immediately. It might also be advisable to ask if the teacher has not done this
already. It is important to make sure that the parents know what is going on and for them to attend the surgery as soon as possible. After this, you need to ask the teacher the following: 1. Are there any issues in the medical history, specifically any conditions such as epilepsy or other underlying illnesses, which may have been contributory to the accident? 2. Does the child have an up-to-date tetanus? 3. Did the teacher see the accident? 4. Of importance, did the child become dizzy, or vomit, or lose consciousness? 5. Are there any other injuries or symptoms, for example to limbs, noted by the teacher or breathing difficulties now noticed? The teacher then advises you that he was supervising children in the playground during lunchtime and he saw almost everything. The child was elbowed in the face in a game of football, and the injuries resulted from this. He confirms that there were no other consequences or loss of consciousness. Although he cannot exclude other conditions, you will need to make a decision on how to proceed with limited background data. Explain to the examiners and the actor playing the teacher that you would need to examine the child, making them as comfortable as possible while assessing the extent of their injuries. This must be completed before any decisions are made regarding dental treatment. You can explain that a clinical examination in these circumstances consists of the following: Extra-oral examination Look for any deformity in the dento-facial area and any abnormalities in the ability of the child to open and close the mouth. (It is most likely you will see abrasions and lacerations to the upper and lower lips, which will be swollen.) You should advise the actor portraying the teacher and the examiners that any examination in these circumstances will be difficult. Despite this, a gentle palpation of the head, neck, and face area is achievable. If you suspect any maxillofacial fracturing, then you should refer to a hospital Accident and Emergency Department. Intra-oral examination The soft tissues, including the tongue, cheeks, and gingival tissues need to be carefully examined for signs of injury. Gentle palpation of the gingival tissues and gums are needed, checking for any penetrating injuries. Bruising of the mucosa, together with linear haemorrhaging or haematoma sublingually, is suggestive of underlying bone fracture. Again, this is an indication to immediately refer to a hospital Accident and Emergency Department.
After this, the teeth are examined. A comprehensive dental examination for decay is inappropriate at this stage. However, all teeth normally present for the age and development of the child should be accounted for. Those teeth still present in the child’s mouth need to be examined, and any displacement, fractures or pulp exposures are to be noted. In this case, the upper left central incisor appears to be missing from the mouth while the upper right central incisor is noticeably displaced palatally by a few millimetres. Nevertheless, its crown appears to be intact. The molars do not need to be examined at this stage unless the degree of trauma is so severe that the blow to the face affected these teeth too. Radiographic exam If possible, periapical views or a dental panoramic radiograph would be two views to take if the injured child could tolerate these being done to them after everything else that has happened. These views might be suggested as they are the most easily achieved in general dental practice. Other views are anterior occlusal, oblique views, and two periapicals at different angulations. In this case, where there is palatal displacement of an upper incisor, a lateral radiographic view is useful to illustrate the direction and degree of tooth and root displacement. If, as in this case, there is loss of teeth and fragments of teeth, there is a risk of inhalation of these, and this has to be excluded. If we review the first steps, most importantly, if there are respiratory symptoms, an urgent referral to a hospital Accident and Emergency Department will be needed. You might also advise the actor and the examiners that a lowered radiation dose (an attenuated view) will help to discover tooth debris in the soft tissues of the facial area while not reducing your ability to identify any fractures in the dento-skeletal structures. Points to Note a. You may be presented in such an OSCE with radiographs, and these would need to be examined for any signs of dento-alveolar trauma. b. Any findings from these would be communicated to the actor/teacher and examiners too. c. In this OSCE, you might also be shown a clinical photograph which represents the tooth the teacher recovered from the playground. In this case, the picture shows a fractured tooth with parts of the crown missing. The tooth is clearly and extensively fractured. The break extends all the way down from the crown to the root of the tooth, and it appears that there is a significant proportion of the root missing from this avulsed tooth. In these circumstances, you advise the teacher: The tooth is not salvageable, and it is not going to be replanted. You can now concentrate your efforts on the dental injuries the child has. 2. The Early and Intermediate Treatment Points to Note
a. Please note that in the MJDF OSCE, you will be presented with a set of models, possibly in a Phantom Head, and the following steps will be completed. b. Whereas in the MFDS exam, as there is no practical element to this OSCE, the following steps will be explained to the actor playing the part of the teacher and there is no need to carry out any practical work. This phase of treatment of the injuries as noted above consists of the following steps: 1. There will most likely be a need to use topical, then local anaesthetic. After you have achieved anaesthesia, the displaced tooth is then atraumatically repositioned with finger pressure into line with the other teeth. If repositioning is not possible or there is fracturing of the root and alveolar bones (seen in a radiograph), then referral to a hospital for treatment under sedation or general anaesthetic is indicated. 2. A non-rigid functional splint is then used. Composite resin or orthodontic labial brackets are used to fix the splint in place. One tooth either side of the repositioned tooth is included in this splint. Again composite or orthodontic brackets are used. A lateral incisor is used in this case as the central incisor has been avulsed. A round section orthodontic wire, for example 022’ diameter is used to splint the teeth. 3. A soft diet is recommended, and 0.2% chlorhexidine mouthwash is prescribed. 4. There is an opinion that antibiotic prescription may have a beneficial effect on promoting periodontal ligament healing. However, given the latest thinking on antibiotic stewardship, you may wish to defer prescribing antibiotics.1 In a situation with a high degree of contamination and you feel antibiotics might be needed, then prescribing: Amoxycillin 250 mg tds PO for 5 days might be appropriate. If you choose to do so, then you will have to justify this clinical decision in view of the latest guidelines. 5. At the time of injury, a baseline periapical radiograph is taken to identify alveolar bone fractures, root fractures, and the involvement of any other teeth. After 2 to 3 weeks, further radiographs are taken to assess healing and other complications. 6. At review, if there are no signs of marginal periodontal breakdown, the splint will be removed. If there are signs of this phenomenon, the splint is kept in place for a further 2 to 3 weeks. 3. Those Who Should Be Notified The parents of the child involved should be notified immediately of the incident and the treatment you have completed and that treatment which you are considering. Emergency treatment conducted without parental consent is perfectly reasonable and defensible. The decision not to replant the avulsed central incisor has to be thoroughly documented. In the dental literature, there is a wealth of information on how to replant teeth. Your decision not to do so must rely on the evidence at the time of the accident and must be supported by the evidencebased practice of dentistry currently acceptable to the profession. The teacher as the immediate responsible adult should be involved with the emergency treatment you are providing. There will be various incident reports, and these will have to be completed for the
teacher, the local school’s professional regulator and the local authority. These may require some input from you, and it is possible a request will be made for disclosure of your well-written dental records and well-reported radiographs too. 4. Possible Complications Arising There is an accepted 5-year recall period during which the survival of the luxated tooth has to be assessed. The age of the child means the apex of the tooth is closed and there is just over 20% (1 in 5) chance the tooth will become non-vital. Initially, 5% of mature teeth involved in luxation injuries display a radiographic phenomenon known as transient apical breakdown (TAB). 2 This is a natural reactive repair mechanism and does not necessarily mean that the tooth will become non-vital. If the displacement and damage is more severe, the risk of other complications increases by 5 times to 25%. These other complications are: Internal root resorption, if the tooth is still vital. Or external root resorption, if the tooth becomes non-vital. Non-vital and vital teeth Just because the tooth becomes non-vital, it is still vital that the patient has a tooth! There may also be microfracturing of the displaced tooth and adjacent surviving teeth, and these are at risk from pulpal and periodontal involvement. Following an injury as described in this OSCE, discolouration of affected teeth is seen, and there are three reasons for this: 1. Maintaining oral hygiene is difficult in the days to few weeks following trauma, and debris may accumulate. This is extrinsic staining. 2. Following trauma, chlorhexidine mouthwash is often prescribed. It is an accepted fact that chlorhexidine mouthwash also adds to the process of extrinsic staining. 3. There may pulp breakdown products. If teeth become non-vital, this results in teeth becoming a blue-grey of varying shades. 5. The Management of Complications 1. The nerve tissues of teeth involved can become non-vital. So regular review and recall is needed. 2. There may be periodontal involvement of this tooth and other teeth too; if these were loosened by the trauma, regular recall and review of these are needed. 3. Fracturing at the root level of the avulsed tooth may have occurred. A displaced root fragment may be present. Depending on its size and location, extraction is an option if natural resorption does not occur. In any event, its radiographic presence or absence must be noted in the patient records. 4. The space caused by the avulsed tooth has to be restored and the immediate options are: An immediate part upper Every denture (secured with Adam’s Cribs on the upper 6s, or failing this, one of those truly exceptional spoon dentures.
In my clinical experience, I have had better results with an Every denture, rather than the spoon contraptions. The Every denture is a more hygienic design of partial PMMA denture, secured with clasps around the molars. After a few months of these interim measures, a resin-retained bridge with wings on the luxated and repositioned central incisor and the adjacent lateral incisor may be considered. Bridging design options. a. With this solution, in contrast to the current accepted thinking with anterior resin-retained bridgework of cantilevering the pontic, in this case, two wings either side of one pontic will be used to further aid in splinting of the luxated tooth. b. The teeth either side of the luxated tooth may also have suffered some periodontal injury, and these teeth will benefit from a splinting effect too. c. With such a solution, you cannot ignore the risk of decay under a partially debonded bridge retainer. d. Recall with specific examination of the retainers to ensure their continued adhesion is needed. 5. Until the child stops growing, there will be need for regular recall and attendance at the dental surgery for the next few years. At the age of 21 or so, a permanent solution such as implant placement may be considered. In the MJDF OSCE, if you have completed all the tasks and answered all the questions, the OSCE will end. In the MFDS OSCE, you should ask if there are any further questions. If not, then summarise the treatment you will have delivered and outline the complication as noted above. The further option of referral to a specialist paedodontist or endodontist should be mentioned and that comprehensive care delivery in a dental hospital may be one option to consider after the immediate and intermediate stages of care have been completed. After completing all of the above steps, you can finish the OSCE. Further Notes to This Clinical Case Dental trauma is a common occurrence. Reflecting this, questions on this subject are a common occurrence in the MFDS and MJDF. The notion that I had early one morning came about after a few interesting figures caught my attention after they had been rattling round in my head like peas in a drum. I thought I would write them down for you to consider. First I would like to give you my reasons for doing so. Revision courses for these postgraduate exams are expensive; you could fill a bookshelf with dental textbooks (which are also costly) for the expenditure of attending one of these courses. Some courses are worthwhile, others not so. From the experience of many candidates I have spoken to in preparation of this book:
Do not attend an MJDF course if you are preparing for the MFDS. Do not attend an MFDS course if preparing for the MJDF. The exams are different, and so the courses are different too. My thoughts are that if these two exams are combined, then together they will cover all the skills you need in the foundation years to be a good dentist. The MFDS is a communication-based exam, whereas the MJDF has a combination of communication and technical skills at its core. In dentistry today, you cannot have one skill without the other, and my thoughts are that until the differences between the two exams are reconciled, the two exams are not equal. In one recent MJDF revision course, a question was asked on how much do candidates need to know about the number of times a condition occurs in a population? In answer to this question, the lecturers delivered opinions varying from ‘absolutely everything must be known to the last percent’, down to ‘not at all, and don’t get stuck in a soup of syndromes and their specific statistics.’ My view (for what it’s worth, hopefully more than what you paid for this book) is that you try to travel the middle ground between these two opinions and deliver figures to the examiners and patients which are representative of the patterns you see and have read about. Such figures are important when explaining firstly, a diagnosis; or secondly, a prognosis to a patient or an examiner. Five Rules of 5’s. Without further ado, in Chapter 5, OSCE No 5, are my 5 rules of 5s: 1. In the UK, 1 in 5 children suffer trauma to the dentition. 2. Peak incidence is between 1 and 5 years old, then at 10 years, give or take 5 years. 3. 5% of mature teeth luxated have complications such as root resorption externally or internally. 4. Splinting can be up to 5 weeks for luxated teeth but no more as ankylosis may occur. 5. 5% of mature teeth survive for 5 years with no problems with 5 x this number needing RCT. Any comments, please do let me know. OK, there may have been some massaging of the figures, but they are within about 1% and one week. No one will mark you down for being in the ballpark, somewhere perhaps the child in the OSCE should not have been. But then again, if it wasn’t for her misfortune, we wouldn’t have this OSCE or the 5 rules of 5s. References to Clinical Case 35 1. Crighton DA. Antibiotic stewardship. Br Dent J. 2011 Nov 25;211(10):443.
2. Kohenca N, Karni S, Rotstein I. Transient apical breakdown following tooth luxation. Dent Traumatol. 2003 Oct;19(5):289-91. Further Reading 1. Wellbury RR, Duggal MS, Hosey MT. Paediatric Dentistry. 3rd Edition. Oxford: Oxford University Press 2005. As stated previously, this is an essential textbook for the MFDS and the MJDF exams. The following chapter is provides a good source of information. The rule of fives comes from data in this textbook. All I have done is massage the figures into more manageable bits for you to use in your exams. Wellbury RR, Whitworth JM. Chapter 12: Traumatic Injuries to Teeth. pp. 257-294. 2. Whaites E. Part 5: Radiology. Section 25: Development Abnormalities. In Essentials of Dental Radiography and Radiology. 4th Edition pp. 299-322. Edinburgh: Churchill Livingstone 2007. 3. Davenport JC, Basker RM, Heath JR, Ralph JP. Part 2: Partial Denture Design. In Colour Atlas of Removable Partial Dentures. pp. 52-118. London: Mosby Wolfe 1989. 4. Mitchell L, Mitchell DA. Chapter 3: Paediatric Dentistry, Injuries to Permanent Teeth. In Oxford Handbook of Clinical Dentistry. 5th Edition pp. 100-113. Oxford: Oxford University Press 2009 (Reprint 2010). A good source of quick reference material while on the clinic. 5. Hadden A, Eaton K, Ormond C, Holt V, Ladwa R. Section 6.1: Emergency Patient (Unplanned Visit). In Clinical Examination and Record Keeping Good Practice Guidelines. pp. 39-40. London: FGDP UK 2009. In the MJDF and MFDS, most of your examiners will have contributed to these faculty texts. Reading them will help you to give the answers your examiners are looking for.
Clinical Case 36 Background Information As modern diets seem to get softer, the problems we face as dentists seem to get harder. One problem examined in almost all the MFDS and MJDF exams is extraction of teeth. In this OSCE, I would like to look at the extraction of wisdom teeth. Today, dentists in general practice seem to be divided into two groups with regard to wisdom tooth extraction. First, those who refer patients, adopt the approach: ‘Why treat when you can refer?’ for all wisdom teeth. Second, those dentists who adopt the approach: ‘Always treat and never refer patients’ for all wisdom teeth. Somewhere between these two extremes, there is a middle ground, where an objective assessment of
the best outcome can be achieved for the patient, either in your hands or in those of a colleague. In the clinic, when faced with any safety critical procedure, being in the middle is the ideal location when assessing your patient and their choices. In the middle, you can see what is going on all around you. In front you can see the direction your patient needs to go and you can take them there with an appropriate treatment plan. Behind you, a good history from your patient will help you build that treatment plan. You cannot plan treatment unless you have a good medical and dental history to work with. There is a great old Russian saying, which, if I can remember, goes something like: ‘If you have one eye on the past, you are blind in one eye. If you forget about the past, you are blind in both.’ With just about everything we do in dentistry, if we want to do it properly, then first we need to take a good history from the patient. Introduction A 22-year-old law student is preparing for her final exams. She comes in to see you with pain from the mouth. This is not the first time this has happened to her. There have been three separate incidents in two years from the lower teeth. The pain has mostly been on the left side of the mouth, with only one episode from the right. In both the MFDS and the MJDF OSCEs, you will have a set of documents to refer to for each of the exam questions. In this case, a set of patient record cards are provided with the following information for you to consider, and they read as follows: 1. Patient is poor INFREQUENT attender in the dental clinic for treatment other than to request antibiotics for the wisdom teeth pain. 2. OPG (Dental Panoramic Radiograph) blurred. Can’t can just about see upper wisdom teeth (18 and 28) present, decayed and over-erupted. Simple? single? straight short roots, bulbous crowns. The level of the crowns has dropped below the level of the other teeth in the upper arch. 3. The lower wisdom teeth have multiple curved roots in close proximity to the Inferior Dental Canal. The crowns of these teeth are not decayed, mesio-angulated and impacted. May be some decay in teeth after all, can’t make it out 4. Operculum covering the impacted lower wisdom teeth (38 and 48). Gums inflamed with bite marks from the upper wisdom teeth. 5. Treatment: Give RX today
antibiotics as previous three visits and again requested by ot pt
‘Polishing down high spots on upper wisdom teeth with a hand piece.’ Pt VERY happy with results from today so
charge privately
The patient has now decided that all her wisdom teeth are coming out, and she wants them out in one
visit. She asks if you can do them, but ‘please do them just now’. While telling you this, she adds that her car is in for a service, and the mechanic will have her car done and dusted in an hour. ‘So could you just do the same for my teeth?’ In the OSCE, the actress portraying the patient will ask you politely, but a little too firmly, to take the wisdom teeth out. Points to Note a. There are three broad questions here with further actress/patient-led lines of enquiry to answer. b. In the answer section, you will be able to read the further information that history taking and dialogue with the actress might generate, enabling you to treat the patient appropriately and complete this case. c. Although this case is presented in a structured way such as the MJDF OSCEs and SCRs, the answers provided and the patient enquires are equally applicable to an OSCE appearing in the MFDS exam. Questions 1. Take a brief set of histories relevant to this patient. Include the social, medical, and dental aspects of history taking. 2. Explain the options for treatment. In doing so, describe the procedures with some of the issues associated with the options you have explained. 3. After explaining the options, can you describe for the patient some of the common procedural complications and answer some of the questions the actress or a patient might ask you? With the answers to the above questions, do include some of the risks and benefits of the procedures you might consider. Answers 1. The Brief set of Histories Relevant to This Patient Introduce yourself to the actress portraying the patient and explain that you will be providing her with information, so she might make a decision for her dental care today. By now, you will be well accomplished at professionally introducing yourself to the actors and your dentist-patient interaction in this regard will be well rehearsed. Next, you will need to take brief social, medical, and dental histories from the actress. If you ask open questions, the relevant information you gather will be useful in explaining the treatments you consider appropriate for this OSCE. Although this is one of three questions to answer in this case, the bulk of information you generate will be from the other two questions, so the history taking should be concise, allowing you sufficient time in the exam itself to complete the answers for the other questions. a. The social history
This reveals this patient to be under considerable stress with assignments to finish, a boyfriend she just ‘finished’ with, who now refuses to stay ‘finished-with’ and all the usual student troubles she just wishes she could be finished with as well. She has just booked her holiday flights to celebrate when she passes her exams with her first class degree her parents have assured her of getting. Your questions reveal the patient smokes up to 20 cigarettes per day and can drink any one under the table. She occasionally drinks in excess of 21 units of alcohol a week and use of drugs was denied on questioning. b. The medical history This reveals (despite all of the above activities) that she is fit and well and takes no medication but is allergic to metronidazole. Points to Note a. Whenever a patient mentions they are allergic to something or other, then the specific nature of the allergy has to be determined. b. In this case, you can ask what happened the last time this patient took metronidazole. When taking metronidazole, the following occurred: The actress tells you: ‘I was ferociously ill with the most horrid stomach upset, most likely in truth it might have had something to do with all the lawyers we went out partying with that week. I probably picked up something, rather than someone, in a nightclub.’ You can advise this actor of the well-known reaction to metronidazole when taken with alcohol and the two do not really mix.1 You must reinforce this by telling the actor that if you have to give metronidazole, she cannot drink alcohol for the duration of treatment. You can briefly go through the medical history, but this reveals no further issues, other than she is taking the oral contraceptive pill (OCP). Again, a word of caution is given to the patient: The efficacy of the OCP theoretically diminishes when used together with certain antibiotics, but this will depend on the type of OCP the patient is taking. Points to Note a. There are broadly two forms of OCP or the Pill and these are the progesterone only pill (POP) and the combined oral contraceptive (COC) containing both progesterone and oestrogen. b. There are two ways antibiotics might affect the Pill. c. These are by causing metabolic induction and thus lowering the level of hormones so ovulation can resume, or by affecting the GI tract flora needed to hydrolyse conjugated oestrogen. d. As the COC contains oestrogen, only this pill is theoretically affected by antibiotic use. As the POP contains progesterone and this does not go through liver recycling and the GI tract, antibiotics will not affect this type of Pill.2
c. The dental history This reveals the patient to be an irregular attender in the clinic where you work. However, the above dental records show that she has attended three times in two years for wisdom tooth pain from the lower teeth; the upper wisdom teeth are still present. Each time she attended she received antibiotics for this. On further questioning on the dental history, the patient informs you: ‘I pay my subscriptions to be a member of a private and exclusive clinic. Whenever I need some real dentistry then the “dental cosmetic specialist” there takes care of me. He must be good, certainly better than you are, as he is on the television as the consultant cosmetic specialist making women look younger than they are, not that I need or will ever need that.’ Points to Note a. Patients often do shop around for various non-essential dental and medical treatments. b. Such patients will only attend with their dentists and doctors in an emergency, when in pain, or after the GDC or another regulator has investigated their favourite treatment provider. c. In this case, gathering up all the data you need from the social, medical, and dental histories is important to plan the correct treatment for the patient. 2. Explain the Options for Treatment In this OSCE, the next question is to explain the options and procedures for wisdom tooth extraction. The first thing you need to do is explain the reasons for surgery and that repeatedly prescribing antibiotics for the condition she has is inappropriate. At the time, it may have been appropriate for the previous dentist to give and for the patient to receive antibiotics; currently, this is not thought to be the best way to manage a localised dental infection that has no systemic complications. While it may be thought that antibiotics can avoid a surgical intervention, the current thinking is that prescribing antibiotics do little to eliminate the cause and nothing to alleviate the symptoms of a dental problem such as this. Next, you need to explain to the actress/patient that the upper wisdom teeth are biting down on the gum covering the lower wisdom teeth and there is both infection and inflammation in the gums around the lower wisdom teeth. Despite the patient’s request to extract all teeth today, a more effective solution, given her forthcoming exams and pressing social commitments, would be to consider the following options: a. Cleaning and oral hygiene improvement You can explain that cleaning around and under the gum (or operculum) covering the impacted lower wisdom tooth is the first thing you wish to do. You do this by using a syringe (5 ml) filled with a disinfectant mouthwash. You will apply this to the inflamed gum to irrigate around and under the gum. Chlorhexidine mouthwash at 2% is used in this procedure. Referral to a hygienist for whole mouth cleaning, oral hygiene instruction, and smoking cessation
advice with yourself or referral to a smoking cessation counsellor would be the next thing to do. At this point, check with the actor to see they understand what you are proposing. In response, in this OSCE, the character tells you what she thinks of your advice: ‘Really, I have not come here for a lecture on what I already know is bad for me. I want to know more about getting the teeth taken out today. If I could just remind you that you are a junior dentist, so just get on with what you are being paid for and stick to what you know best and that is taking out my lower wisdom teeth. So come on what is keeping you?’ Points to Note a. In this OSCE, you must acknowledge and accept the actor/patient’s views, even if they are a little abrupt and condescending. b. Continue with an explanation on the procedure for extraction. c. You can go on to explain your reasons for extracting the upper teeth and leaving the lower ones for the time being. b. Extraction This would be under local anaesthesia. Extraction of the decayed and over-erupted upper wisdom teeth is the most sensible option if an extraction option is to be followed. Explain the reasons for this to the actor as follows: The upper teeth are over-erupted and non-functional. They are now biting on the gums covering the lower teeth and not the lower teeth. Being over-erupted, there is less of the root of each tooth in the upper jaw holding these teeth in the bone, so extraction should be straightforward. Points to Note: a. Before taking these teeth out, rather than just relying on the notes documenting the findings, you will need to take some X-rays. b. You can state that you will use two views left and right, for each tooth. c. In the exam state the X-ray will be positioned with an X-ray aiming device, although this information is more for the examiner than an actor or patient. From the radiographs, you can confirm the following: the shape of the roots, the condition of the teeth, their relationship to other teeth and the condition of the bones and structures of the upper jaw. From the information you already have, you can confirm with the actor that a local anaesthetic would be sufficient for this relatively simple extraction. You also need to explain the risks associated with such an extraction and these are: Breakage of roots and possibly the risk of breaking pieces of bone behind the upper wisdom teeth (the maxillary tuberosity). Explain that this may occur if the bone around the tooth is very thin. You need to explain that this bone can be as thin as a few millimetres in places. Although this is a very rare complication, you need to mention this. The maxillary tuberosity is a comparatively small bone and breaking a piece of this is not in the same category as fracturing the mandible. If the roots of the upper teeth are close to the sinus, this has to be mentioned too, and the risks of sinus
involvement should be discussed. In this case, there is no risk of this complication. The methods used for extraction can now be described for the patient. In this case, simple atraumatic elevation (with a Coupland’s chisels) and delivery with forceps can, as stated, be completed under local anaesthetic. The area of gum around the tooth is numbed with topical anaesthetic; then a local anaesthetic makes the area around the tooth numb enough for an extraction to take place. A fine instrument is passed between the socket and the tooth. This is the chisel or luxator. With some pressure, the socket is made wider and the tooth can be lifted out of the socket with some forceps. In reality, forceps are used to prevent the tooth from slipping out of your grasp and not for wrenching the tooth out of the patient’s head. To stop any bleeding, pressure is applied by biting together for a few minutes on gauze swabs. Given the patient’s quite strident and confident nature, you do feel that the extraction can be carried out with a local anaesthetic. You do have to mention other options for management and pain control. These are: Sedation, either inhalation or intravenous. In this case, as the patient has to collect her car later in the day, intravenous sedation is not appropriate, but inhalation sedation might be used. You do not need to mention (unless asked) about general anaesthetic. This is not an option provided for outpatient day care in general dental practice in the UK. 3. Common procedural complications and answers Warning the patient of pain, some swelling, and an inability to open the mouth fully for a few days after the procedure is important, as is mentioning the risk of a dry socket in the days following an extraction. As the patient is a smoker and takes the OCP, you need to explain that there is an increased risk of this happening.3 However, extractions of upper teeth are not as prone to dry sockets as lower teeth are, especially the lower wisdom teeth. Nevertheless, the patient should be advised that a dry socket is characterised by a deep pain that seems to bore deep into the jaw and is not relieved by simple analgesia such as paracetamol. If such symptoms arise, then the patient will need to re-attend for treatment to clean out and dress the sockets. Again, you can advise that antibiotics are not indicated for this problem. After delivering the above information, the patient will most likely have some questions, and these should be answered in the OSCE. The common questions asked in the clinic after proposing extraction of upper teeth, when the pain is coming from the lower teeth (with the previous dentist only prescribing antibiotics) are given and answered as follows: Question 1. ‘My previous dentist just gives me a prescription and the pain goes away, why aren’t you going to do
the same?’ Answer 1. ‘The current thinking in dentistry is that unless there is swelling, fever, and swollen lymph nodes, we do not consider it necessary to prescribe antibiotics as they have been proven to have a minimal, if any, effect on the infection, which is localised and caused by debris trapped under the gum. If we clean the gum and remove the debris, the problem should resolve.’ Question 2. ‘So if you aren’t going to give me antibiotics, what are you going to give me then?’ Answer 2. ‘A more appropriate treatment (as mentioned) is to clean out and drain any localised pus or infected material from underneath the operculum—this is the gum lying over your wisdom tooth. A hygienist can also do this and provide instruction on the means necessary to keep this area clean in the future. We might also provide you with an antiseptic mouthwash; this is chlorhexidine to help keep the infected area clean.’ Question 3. ‘Is taking out the upper teeth easy?’ Answer 3. ‘Yes, easier than trying to take out the lower wisdom teeth that are surrounded by inflamed and infected soft tissues being repeatedly bitten down on by over-erupted upper teeth. Extraction of decayed and non-functional upper wisdom teeth carry none of the risks but provide most of the benefits when compared to extraction of impacted lower wisdom teeth. In addition, there are no major nerves or blood vessels close to these upper teeth, when compared to the lower teeth.’ Complications from lower extractions a. If nerves become involved, then numbness, either temporary or permanent, can follow. b. If a blood vessel is involved, then the swelling and bruising is both noticeable and painful. c. If the swelling extends to compromise the vital structures in the parapharyngeal spaces and the airway becomes compromised, even unilaterally, then life-threatening complications can ensue. Question 4. ‘OK, then I’ll have the upper teeth out. Tell me, how sore is it going to be?’ Answer 4. ‘The pain from extraction of the upper teeth is less than lower teeth due to the ease of the procedure which does not involve cutting gum, removing bone, or placing sutures afterwards. Nevertheless, you may benefit from some painkillers such as paracetamol or ibuprofen for a few days afterwards.’ Question 5.
‘If the upper teeth are over-erupted, why can’t these teeth just be filed down, thus removing the pressure on the gums?’ Unsurprisingly, this is a common question asked by the patients. What is surprising is that some dentists ask the same question too. Answer 5. ‘Well, if we cut down the teeth by a few millimetres, then for sure, the pressure on the gum is reduced and this is what was previously undertaken. After a year or so, the tooth, which has continually erupted, will be in occlusion with the overlying gum (operculum) once more, and your trouble will return.’ ‘The other problem with this approach is that sensitivity often results with reduction or removal of enamel. Lastly, the removal of enamel makes the tooth more susceptible to decay. In this case, the upper teeth have decayed, in all probability as a result of the previous dentist’s filing (and not filling) activities.’ You might add: ‘The upper teeth are non-functional and decayed. As a result, they are now indicated for extraction.’ After all the relevant explanations are given and the questions answered, this OSCE is now complete. In this case, the patient consented to have both upper wisdom teeth extracted. This procedure was completed under local anaesthesia with post-operative instructions being given. The patient did not heed the advice regarding smoking and returned after five days with bilateral alveolar osteitis (dry sockets). This was duly treated with a proprietary iodine and eugenol dressing and the patient discharged. The patient was then scheduled for review, recall, and assessment of the lower wisdom teeth. Further Notes to This Clinical Case. Much of what you do in dentistry will be governed by rules, regulations, and guidelines. In the UK, removal of wisdom teeth was, at one stage, the most common surgical procedure undertaken.4 In 1997, the Faculty of Dental Surgery Royal College of Surgeons of England issued guidelines after it was noted that over 22% of all such procedures may have been inappropriate.5 In 2003, the 2000 NHS NICE guidelines were reviewed and citing evidence6 in part 3.1, it states: There is no reliable research evidence to support a health benefit to patients from the prophylactic removal of pathology-free impacted third molar teeth.7 So how does this apply to this OSCE? Well, there is nowhere in the NHS NICE guidelines that differentiates upper third molars from lower third molars. It just mentions: ‘third molars impacted or otherwise’. For such differentiation, you have
to go the Scottish guidelines. The SIGN (Scottish Intercollegiate Guidance Network) states: ‘3.2.7 Pain associated with the lower third molar tooth is commonly exacerbated by the upper third molar biting on the gum flap, causing pain and discomfort. If the upper third molar tooth is easy to remove and it is non-functional then immediate removal of that tooth will often dramatically relieve the pain from the area. This is particularly useful where there is likely to be delay in the surgical removal of the lower third molar.’ ‘Acute exacerbation of symptoms occurring while the patient is on a waiting list for third molar surgery may be managed by extraction of the opposing maxillary third molar.’ 8 This is the justification for the removal of the upper third molars in this case. In the MFDS and the MJDF there will be OSCEs on wisdom teeth extraction. However, most questions that come up will cover extraction of the lower wisdom teeth. Lower wisdom teeth will have more risk of complications during and following extraction than those associated with upper wisdom teeth. Some of the complications of upper wisdom teeth extraction have been noted in this case. If after radiographic and clinical assessment, you think certain risks apply, then these have to be mentioned, giving the patient a balanced view on whether to proceed with extractions or not. The Risks from Extraction 1. Fracturing of the tuberosity. This is common; however, the degree and extent of any breakage has to be put into context. 2. Tearing of gum tissue. In most cases, this will need suturing. It is common to see tearing if a fracture of the tuberosity occurs and a sharp bone fragment can split the delicate mucosa of the soft palate as the tooth is delivered. Alternatively, if elevation or a luxation technique is used and there still remains mucosa adherent to the tooth, this can be torn on delivery too. 3. Dry socket is common and needs review and local measures to resolve. Unless there is facial swelling and signs of systemic involvement, antibiotics are not indicated. 4 . Root or tooth fragment displaced into the maxillary sinus, this is relatively uncommon for extraction of upper wisdom teeth but a referral to hospital is needed if it occurs. 5. Oro-antral communication and sinus formation is quite rare, but this will need hospital attention. The patient needs to know of this risk and its treatment, that is a journey to the local hospital for assessment and treatment. 6. Extensive tearing of soft tissues involving blood vessels is exceedingly rare. The management is complicated by the fact that any vessels involved need to be sutured, and it can be difficult to close off the maxillary posterior superior alveolar arteries if they are torn. The blood flowing through these vessels is considerable, and bleeding can be quite remarkable. If there is a fractured tuberosity, the risk of vascular involvement is quite high. Finger pressure applied while injecting adrenaline in LA into a transacted artery or arteriole reduces the blood flow enough to apply sutures, stopping further blood loss. It is best not to have torn tissues
or arteries to deal with in the first place. We will return to the subject of lower impacted third molars in OSCE 38. References to Clinical Case 36 1. Jang GR, Harris RZ. Drug interactions involving ethanol and alcoholic beverages. Expert Opin Drug Metab Toxicol. 2007 Oct;3(5):719-31. 2. Seymour RA. Drug interactions in dentistry. Dent Update. 2009 Oct;36(8):458-60, 463-66, 469-70. 3. Dodson T. Prevention and treatment of dry socket. Evid Based Dent. 2013 Mar;14(1):13-4. 4. NICE (National Institute for Health and Care Excellence). Section 2: Clinical Need and Practice. Part 2.2. In NICE Technology Appraisal Guidance TA1: Guidance on the Extraction of Wisdom Teeth. [Online] Available from: http://publications.nice.org.uk/guidance-on-the-extraction-ofwisdom-teeth-ta1/clinical need and practice. [Accessed October 2013] 5. Working party report. Faculty of Dental Surgery Royal College of Surgeons of England. Current clinical practice and parameters of care. The management of patients with third molar (syn: Wisdom) teeth; September 1997. 6. Song F, O’Meara S, Wilson P, Kliejnen J, Golder S, Kleijnen J. The effectiveness and cost effectiveness of the prophylactic removal of wisdom teeth. Health Technol Assess. 2000;4(15):155. 7. NICE (National Institute for Health and Care Excellence). Section 3: The Evidence. Part 3.1. In NICE Technology Appraisal Guidance TA1: Guidance on the Extraction of Wisdom Teeth. [Online] Available from: http://publications.nice.org.uk/guidance-on-the-extraction-of-wisdomteeth-ta1/clinical need and practice 8. Health Care Improvement Scotland Scottish Intercollegiate Guidance Network. SIGN Publication No. 43. Management of Unerupted and Impacted Third Molar Teeth. Section 3.2.7 March 2000. [Online] Available from: http://www.sign.ac.uk/guidelines/fulltext/43/index.html [Accessed October 2013] Further Reading 1. McMinn RMH, Hutchings RT, Logan BML. The Mouth Palate and Pharynx. In A Colour Atlas of Head and Neck Anatomy. 6th Impression pp. 136-148. London: Wolfe Medical Publications 1990. 2. Whaites E. Part 4: Radiography. Section 17: Panoramic Radiography (Dental Panoramic Tomography). In Essentials of Dental Radiography and Radiology. 4th Edition pp. 187-206. Edinburgh: Churchill Livingstone 2010. 3. Mitchell L, Mitchell DA, McCaul L. Chapter 8: Oral Surgery. Dento-alveolar Surgery: Removal of Third Molars. In Oxford Handbook of Clinical Dentistry. 5th Edition pp. 358-363. Oxford: Oxford University Press 2010. 4. Hadden A, Eaton K, Ormond C, Holt V, Ladwa R. Section 4: Full Comprehensive Examination Clinical Examination and Record Keeping Good Practice Guidelines. pp. 21-27. London: FGDP
UK Publications 2009. 5. Dym H, Ogle OE. Oral surgery for the general dentist. Dent Clin North Am. 2012 Jan;56(1): xiiixiv. 6. Pierse JE, Dym H, Clarkson E. Diagnosis and management of common post extraction complications. Dent Clin N Am. 2012;56:75-93. 7. Henderson SJ. Risk management in clinical practice. Part 11. Oral surgery. Br Dent J. 2011;210(1):17-23. 8. Shepherd JP. The third molar epidemic. Br Dent J. 1993;174:85.
Clinical Case 37 Background Information The candidate was not getting anywhere in this OSCE. The actor had been repeating himself, but somehow, the message was not getting through to the candidate. ‘I don’t want to lose my teeth, but I don’t want to lose my teeth!’ Now with an accent, the actor continued… ‘Ahm gittin furst-ated bah tha laahhck of po o ahhgress hee-aahr. Ah doh aahn’t wahnna loo-ooess mah teee-eth. Doo yoo undaah-staahhnd me?’ If the actor carried on any more with the American drawl, he was running a very real risk of losing his teeth, but not from the condition he was portraying in the OSCE. If there was one thing more improbable than this well-fed, balding middle-aged Scottish actor pretending to be an American teenager starving in South London on a student grant, it was the impossibility he could ever, ever have been from anywhere in the United States. The theatrical divide in this OSCE of a Scottish middle-aged man being an American teenager was just too Walter Mitty to be credible. In the same way Peter Pan never ages and gets himself suspended every year in pantomime, in an OSCE, if you are ever faced with such a performance, your belief has to be similarly suspended to make this work for you. For the actor, this attempt at being a teenager was an opportunity to shine as an actor, but every silver lining has its cloud. After that performance, this character was never seen again. In appreciation of that performance, this OSCE is presented for you. In looking for the allegory, when treating patients, we have to overlook obvious clinical signs, as sometimes these can be irrelevant to the case. Instead, we have to focus on uncovering the hidden but significant details from the symptoms the patient tells us about and work out the answers from these. However, we have to ask the right questions in the right manner and in the right order to get this information.
I know the previous OSCE was quite involved. You are still probably ploughing through the SIGN and NICE guidelines now. Therefore, I’ll make this case easy, or at least easier, for you. In this case, the facts given are limited to those you might find in an introduction to an MFDS OSCE. I will work through the questions in the same way as you would for the MFDS, pointing you in the direction to get the right answers, while steering you away from answers given by candidates, which are also probable, but off the subject and, therefore, not specifically those you would give in an exam setting. Introduction A 19-year-old student who has left home for the first time and has been living on his own, comes in to see you. He really does appear thin, pale, and apprehensive. The student is concerned because the lower incisors have suddenly become loose. In the morning, he has noticed some blood in the mouth. Gaps have now appeared between the lower teeth; they feel uncomfortable while eating, and they seem to be hitting against the upper teeth. The patient does not want to lose his teeth, and this bleeding worries him. He does not smoke, but drinks occasionally and does most of the things students do after escaping from their parents for the first time. At this visit, a medical history form was completed. This form revealed no issues with the medical history, only asthma as a child and no other problems that would influence the dental condition or treatment you might give. As this is the first time you are seeing the patient, there are no radiographs and no dental notes. The only information you have is that as written above. Question In this OSCE, explain to the patient what their dental problem might be. Answer 1. Greeting and Opening the Consultation In this OSCE, you too might have to deal with cognitive dissonance. Begin by suspending any disbelief and accept the actor’s word for it. He is a teenage student, he is nineteen, he is thin, he is pale, and he is apprehensive. Now you can carry on as follows: Greet the patient and check his identity. ‘Good morning/afternoon and thank you for coming in to see me today. Can I ask for your name please?’ The actor tells you his name, which you can check against the question papers you are given in the OSCEs. The actor tells you he is a first year student at the local college. Introduce yourself professionally and explain to the student what your role will be today. In an OSCE, this is essentially repeating back the question you have been asked to the actor for the examiners’ benefit: ‘In this consultation I am going to ask some questions, and from the answers you give me, I will
then be able to explain the problem you have. How do you feel about that?’ By asking this question, you are confirming that the patient is worried. You can go on to put him at ease by an empathic and understanding manner. 2. Open Questions and Body Language Be open with your questions and your body language. Open your arms while sitting facing the actor and maintain eye contact. The student tells you he feels like he is under a lot of pressure with exams coming up and a girlfriend who has just dumped him. (If it was the patient from the previous OSCE, he is probably better off without her.) He says he is struggling with student life and now his lower teeth have become loose. You might continue by mentioning the following: ‘I can see this is troubling you, and you must have a lot to cope with right now in your studies and your private life too. I am sure there is a straightforward explanation for the dental problem you are having, and I would like to help by explaining what this problem might be,’ You can add: ‘How does that sound?’ You can ask in plain open terms what the problem is. In response, the actor tells you he does not want to lose his teeth and they have become loose over a very short period. He has suddenly noticed how loose they are. He goes on to say that only the lower ones have become loose, gaps have appeared between them, and that is why he has come to see you. He has been brushing, flossing, and using mouthwash, but despite these measures, the teeth have loosened. 3. Reflecting Back to the Actor/Patient You can then reflect this information back to the actor by repeating: ‘So in a short period, the lower teeth have loosened and gaps have appeared, and you do keep the teeth clean, by brushing, flossing, and mouth washing.’ You can ask in what period of time this has happened. The actor reveals it seems to have happened very quickly in a matter of days it seems. He is very worried by this. Acknowledge his concerns and then confirm the information from the medical history, which should have been completed at this visit. Go on to ask about any medication the patient is taking or recreational drugs the patient has used. In response, the patient states he is fit and well, does not smoke, and only drinks occasionally. He does mention that as a child, he had asthma and for this reason, he does not smoke. 4. The Histories
This OSCE is about giving an explanation. The time you spend gathering information on the medical, dental, and social histories is important, but it does not need to be as detailed as that for an OSCE specifically dealing with history taking. The medical history is clear. Importantly, there is no fever, no temperature, and no swelling in the lymph nodes. You can now go on to ask about the patient’s dental history. The dental history. Right up to attending college, the patient’s parents insisted that he regularly attended the dentist. Only a few years ago, he completed orthodontic treatment. Following this treatment, the upper and lower teeth were perfectly straight and not as they are now—loose with gaps between them. You can ask the patient when the last dental visit was. Since attending college for almost a year, there have been no more dental appointments. One point to note in the dental history: The patient is attending with loose teeth, but he is not in pain. This absence of pain is an important point to note in giving explanations and reaching a diagnosis in this OSCE. Moving from the medical history, you can continue with the social history. The social history. This reveals that the patient has an impoverished diet with breakfast missed on several occasions. Precooked and processed food is being eaten in the middle of the day, and once more, processed food replaces an evening meal. At this point in the OSCE, it is useful to summarise the information you have. You can do this by again reflecting this information back to the patient and asking if your understanding of the information is correct: ‘You are fit, well, and do not smoke. However, you are not currently eating a balanced diet. Previously you regularly attended your dentist, but now you have loose lower teeth with gaps in them’. The actor should verify this is correct. If so, you can continue and your thoughts might be the one symptom, which is conspicuous by its absence: The patient has not reported any pain. Therefore, pulpal involvement can be ruled out as a likely cause of the problem. However, if the tooth is non-vital, there would similarly be no pain, and further investigations with pulp testing and radiography would be needed. 5. Candidate’s Considerations of the Complaint. In discussing this OSCE with candidates, many candidates believed that the patient might have developed the following problems: a . Post-orthodontic relapse. There is continual trauma to the lower incisors, following from periodontal disease. Teeth may have moved into an unfavourable position. The lower incisors are now in a position of traumatic incision or traumatic occlusion.
b. Dietary deficiency. There may be vitamin C deficiency. The patient may be presenting with scurvy from the poor diet (as reported). This could be the cause of the teeth being loose and the reported blood in the mouth. c. Periodontal disease. The patient is presenting with localised aggressive periodontitis, to which he is predisposed. d. Necrotising gingivitis. Some candidates mentioned this condition in their explanations. However, in this case there is no pain, no fever, no lymph node swelling, and no characteristic metallic taste or malodour reported by the patient. Although they are under stress and may be vulnerable to this condition, the other risk factor of smoking is absent. It is unlikely the patient has this condition. e . A complex interaction of periodontal disease and social factors. This has arisen from a combination of the dental problems to which the patient is susceptible and the social stresses to which this patient has been exposed as a student, such as splitting up with his girlfriend. The problems listed above are, in essence, the differential diagnoses you will have reached from the information in the introduction and the information you have discovered from answers to your questions. In this type of OSCE, rather than going straight from the differential to the definitive diagnosis and delivering these to the patient, you need to remember: The question asks you to give an explanation and not reach a diagnosis as such. 6. Giving an Explanation In giving an explanation to the patient, it is important to find out what the patient already knows and what they need to know. The explanation for the patient needs to be organised into a general overview, delivered to the patient one piece at a time with the opportunity for the patient to ask questions. You will also need to check that the patient understands what you are saying to them after each piece of information is given. This assessment of the patient’s understanding also encourages further responses and questions. The information you give to the patient also needs to be tailored to them as an individual person. In this OSCE, information needs to be given, but the patient should not be drowned in details. Points to Note. a. If, during the exam you can draw a concise and clear diagram to illustrate a point or explain the results of an investigation to the actor, then do so, your skills in this area should be used. b. If you cannot draw at all, it is permissible to state that you will refer the patient to a web site or other sources of information to reinforce your points, but you do have to make the points clearly and verbally to show the examiner you know what you are talking about. c. Only do any of the above in summing up after all other explanations have been given to the actor/patient. In this stage of the OSCE, advise the patient that you may have some answers for their dental problem. Ask the patient if they would like you to continue. The actor should agree.
In dealing empathically with the patient’s fear of losing teeth, explain to them that brushing of teeth, flossing, and using mouthwash has not prevented the condition from arising, and these measures might not prevent the condition from progressing. In order to find out what has gone on, you need to conduct a detailed clinical examination, and this may require X-rays. The patient will then ask more details about an examination, what this involves and if this can be done in the dental clinic. Explain to the patient how you might use a standardised and graded probe, the periodontal probe either CP12 BPE WHO Probe or a Graded Williams Probe in your examination. Inform the patient, this probe will help you to find out how much gum and jawbone support has been lost from the teeth, which are now loose. The affected teeth will be charted and can be compared to other teeth in the mouth which are not loose, so the total extent of the gum problem can be discovered. Based on your findings, you might take an X-ray. Explain the radiographs you take might be one or two small ones in the front of the mouth (periapical radiographs) or a large scanning X-ray around the head (a dental panoramic view). Inform the patient the choice of X-ray you use follows from the findings of the simple probing examination. Do ensure that the patient understands that the examination consists of a blunt ball-ended probe used gently, so there is minimal discomfort and the results will help in diagnosing and treating the problem he has. 7. The Specific Problem With some confidence you can reassure the patient that the problem he has is one of gum disease. You can state in simple terms that there is an infection in the gums around the teeth. In his case, this infection is limited to the lower teeth, the incisors being noticeably affected. As there are no other medical or dental factors that have been found or mentioned, you can advise that gum disease is the most likely cause of the problem. You can state in the OSCE, that it would be difficult to categorise the gum disease without actually conducting a clinical exam, including X-rays. You need to do these things so you can learn more about the problem the patient has. However, your thoughts from what you have learnt so far today are that the patient has a form of gum disease, known as periodontal disease. (You should explain that this refers to the supporting tissues around the teeth holding them in place in the jaws.) A bacterial infection has damaged these supporting tissues. Although the disease is common and, in this case, long standing, it is likely that a combination of the stresses of student life, not having the best diet recently, together with a susceptibility to being vulnerable to this type of infection in the first place have all contributed to the problem taking their toll on his gums. 8. Initial Treatment The patient might ask if a prescription for antibiotics alone would work. You can advise him that the current thoughts are that although antibiotics may be useful, a more appropriate way to deal with the problem with or without the use of antibiotics is as follows:
A thorough cleaning around crowns of the affected teeth above the gums and around the roots of the affected teeth below the gums is needed. This cleaning would remove the source of the infection together with any infected tissues, although it will not cure the problem; it will control the problem. In addition to cleaning, the patient will need to attend for regular recall and review, to monitor their healing. You need to inform the patient that the actual physical action of cleaning and removing infected tissue is more effective than the action of antibiotics alone in removing, or at best reducing the number of bacteria responsible for the problem. You can now ask the actor/patient if there are any questions. 9. Further Specialist Treatment The question you might be asked is: If cleaning will control the problem of the gum infection, what should be done about the gaps that have appeared between the teeth? The answer you might give is: The lower teeth are affected following loss of gum support. They may have moved into positions where the upper teeth are now biting down on them unfavourably, making the problem worse than if the teeth were in thier natural healthy position or not being bitten on at all. You might mention that after orthodontic treatment was completed a few years ago, some movement of teeth back into positions the orthodontist did not leave them in is commonly seen. This is post-orthodontic treatment relapse . For these reasons, you need to mention that referral to the specialist dealing with the gum problems (a periodontist) and the specialist dealing with the position of the teeth (an orthodontist) will be needed. After a thorough clinical examination with charting of the periodontal condition and cleaning, given the problem the patient has reported with today, referral for specialist advice will be needed. Complete the OSCE by asking if there are further questions. Finally, the actor/patient asks you: ‘Will I lose my teeth?’ You can advise the patient that without the results of further examination and possibly the input of a specialist, it is difficult to state for how long the patient might be able to keep his teeth. However, as he has attended today and the teeth are still present, albeit mobile in the mouth, you can state that you will do everything to maintain and improve the condition of the gums and the teeth with the input and treatment from hygienists and specialists aiming to help him keep his teeth for as long as possible. However, given the limited information and without a clinical examination, it would be difficult to give a prognosis, let alone a diagnosis today. You can finish the OSCE by stating that you are confident that a specialist will be able to help and specialist referral should be the next stage in his dental treatment. Further Notes to This Clinical Case. The question in this OSCE asks for an explanation, not a diagnosis. A diagnosis is useful for the practitioner, whereas an explanation is useful for the patient. The patient has periodontal disease, but what is more important than labelling the condition, is to
work through the OSCE in an organised manner, put the patient at ease while doing so, and explain the disease process to the patient and what will happen next. Clinical information is deliberately limited in this OSCE as it would be in the MFDS. This limitation is intended to make you work through the consultation, acquiring clinical information, to provide the actor/patient with answers the examiner needs to hear. This is to give an explanation, not a diagnosis and not a treatment plan. In contrast to the MFDS, in the MJDF, generally more information is provided and a more structured series of detailed answers is expected from you. If this question appeared as an MJDF OSCE, you would be expected to know in some detail the differences in current classification of periodontal disease and this is a classic case of: Localised Aggressive Periodontitis. However, the patient really does not need to know this or that previously this condition was termed: Localised Juvenile Periodontitis. Both the newer and former classifications use somewhat emotive technical terms, which can cause some confusion and may even upset the actor or a patient. Anyone would be upset to know a disease they suffer from is of an aggressive or a juvenile nature. Notwithstanding this, it is important to realise that the information you can give is limited. In this case (but not in others) a diagnosis is unlikely to be based on history taking alone. The results of a clinical examination to back up the signs noted and symptoms reported are needed. In this OSCE to reach a diagnosis, 6-point pocket charting and intra-oral periapical radiography are needed too. In essence, this is a simple OSCE, so keep it simple, and the explanations should be given in terms you are confident to give and the actor, no matter how young or how old ‘their patient’ is meant to be, can understand. Periodontal disease is commonly examined in both the MFDS and the MJDF. In the last 80 questions of the MFDS, there were 5 questions covering periodontal disease in 4 diets of this exam. It is a subject that is frequently examined reflecting its prevalence in the UK among dental patients. In the next OSCE, we will return to another commonly examined subject. Further Reading to Clinical Case 37 1. Chapple IC, Gilbert AD. Chapter 6: Classification of Periodontal Diseases pp. 81-98. Chapter 7: The Initial Consultation—Screening Examination pp. 99-110. In Understanding Periodontal Diseases: Assessment and Diagnostic Procedures in Practice. London: Quintessence Publishing 2002. 2. Yip K, Smales R. Collection and Collation of Information, Chapter 4: Information Gathering and Chart Recording pp. 16-25. Corbet, E. Diagnosis of Common Dental Problems, Chapter 8: Periodontal Disease and Assessment of Risk pp. 57-71. In Yip K, Smales R. A Clinical Guide to Oral Diagnosis and Treatment Planning. London: BDJ Books 2012. 3. Scully C. Chapter 27: Dietary Factors and Health and Disease. Diet and Health. In Medical Problems in Dentistry. 6th Edition pp. 606-607. Edinburgh: Churchill Livingstone 2010.
4. Department of Health Delivering Better Oral Health. Chapter 4: Healthy Eating Advice. In An Evidence-based Toolkit for Prevention. 2nd Edition. London: DOH 2009. 5. Doubleday B. Chapter 15: Anchorage, Tooth Movement and Retention. In Mitchell L. An Introduction to Orthodontics. 2nd Edition pp. 148-160. Oxford: Oxford University Press 2001. 6. Mitchell L, Mitchell DA, McCaul L. Chapter 5: Periodontology Classification and Diagnosis. In Oxford Handbook of Clinical Dentistry. 5th Edition pp. 184-186. Oxford: Oxford University Press 2009.
Clinical Case 38 Background Information Whenever you embark on a plan to treat patients, your journey starts by wanting to do the very best. Well, we all just want to do the best for our patients. Slowly but surely, I am sure you will have had cases like this. In next to no time these good intentions run dry as a bone paving your path to perdition as your treatment plan unravels faster than you can keep things together. This next case follows from the events as we have left them in OSCE 36. In this OSCE, rather than the open dialogue required in the MFDS, I would like to work through the questions as we would for the MJDF. In this example, there are 25 questions to answer and a more rigid format to follow in completing the questions. In the MFDS, as mentioned, a more dynamic interaction is expected of you. In an MFDS OSCE, by incorporating the information below in your dialogue with the actor, the examiners should be able to see that you have a sufficient grasp of the subject to enable you to pass this type of question in that type of exam. Let us briefly go over the previous episode dealing with this patient. The patient had just dumped her boyfriend and was getting herself lined up with a first class honours degree in Law to take on the world. Before doing so, a couple of upper wisdom teeth had to come out, and there were a pair of dry sockets to deal with afterwards. Now the patient has returned all newly qualified, and despite the dry socket episode, she would like you to deal with the lower wisdom teeth… Introduction The patient is the 22-year-old student; you know her history from OSCE 36. She is now a new graduate. As you will recall, she had repeated episodes of pericoronitis from both lower third molars, and the upper third molars were extracted in a local anaesthetic procedure. She has re-attended with you and would now like her lower left wisdom tooth removed. However, given the extraction experience and the post-operative complications of dry sockets following extraction of the upper third molars, the patient would now like to be ‘put to sleep’ when the
procedure is done. She tells you that with the previous extractions, all the needles being injected with the pushing and shoving that followed really put her off having another dental experience like the last one. She remembers you telling her that extraction of upper wisdom teeth was simpler than the lower ones, and she feels that she would not be able to go through with a local anaesthetic extraction for the lower teeth. Although the lower wisdom teeth are not decayed, the previous clinical notes from OSCE 36 are relevant, and these state as follows: 3. The lower wisdom teeth have multiple curved roots in close proximity to the Inferior Dental Canal. The crowns of these teeth are not decayed, mesio-angulated, and impacted. May be some decay in teeth after all, can’t make it out 4. Operculum covering the impacted lower wisdom teeth (38 and 48). Gums inflamed with bite marks from the upper wisdom teeth. 5. Treatment: Give RX today
antibiotics as previous three visits and again requested by ot pt
‘Polishing down high spots on upper wisdom teeth with a hand piece.’ ‘The gums are still inflamed after extraction of the opposing upper teeth.’ A review of the patient record cards and consideration of the NICE and SIGN guidelines revealed multiple episodes of pericoronitis from the lower left third molar (tooth 38). These guidelines were discussed with the patient, who then elected to have this tooth removed. The lower right third molar (48) was presently symptom free and had only minor episodes of pericoronitis in the past (refer to introduction OSCE 36). Since the removal of the opposing upper third molars, there were no more problems with the lower right third molar, and this tooth was, therefore, not included in the extraction schedule. Questions for Clinical Case 38. 1. Please explain the first options for managing this patient or any patient with dental anxiety. 2. How do these techniques work? 3. Can you list some of the more common behavioural modification techniques you might use? 4. Given that you know the patient already, might these techniques work? 5. Are there alternatives you might try instead? 6. Moving on from this form of management, what might you next consider and will this work in this case? 7. What is the next level of patient management and anxiety control? 8. Are there any requirements you need to follow when considering this next option? 9. Can you give the three main types of anxiety control you might consider for this patient, their
advantages and disadvantages? 10. In which cases might you opt to refer rather than attempt treatment? 11. In discussing these options with a patient, what must you advise the patient? 12. Before beginning your procedure, what must be up to date? 13. Can you list the important parts of this? 14. Are there any other aspects that should be included, and what might the relevance to sedation be? 15. Although unlikely in this case, given the knowledge of the patient from OSCE 36, what must we ask this patient and all female patients and why? 16. Can you describe how you would explain what the procedure of IV sedation in a dental clinic involves for the patient? 17. Can you explain to the patient what the procedure of lower wisdom teeth extraction involves? 18. Following the procedure, what might the patient expect to feel, and how will you explain this to the patient? 19. What complications might there be with this procedure, and what is the current legal position in informing your patient? 20. With regard to nerve damage, when might this occur, and what factors are causative? 21. Are there any anatomical factors that play a part in making some nerves more susceptible to damage than others? 22. Which symptoms are indicative of nerve damage? What do you tell the patient and after what period of time, if these symptoms persist, is the damage likely to be permanent? 23. Are there any other options for treatment other than extraction? 24. If you choose to use this technique rather than go to complete extraction, does the patient have to consent for this? Can you describe this technique? 25. To reduce the risk of nerve damage, what might you do in practical terms when extracting lower third molars? Answers for Clinical Case 38. 1. The first line of management in this case would be to use behaviour modifying techniques such as those taught, learnt, and practised during your undergraduate years. Although these techniques were mostly on the children’s clinic, they are applicable to adult dentistry too. 2. These techniques can modify a patient’s behaviour towards dental treatment by identifying a source of fear and then working through the problem until the patient can accept dental treatment. 3. Examples of these techniques can be: tell-show-do, modelling, desensitisation, positive reinforcement, and behaviour shaping. 4. In this case, these techniques might not work so well given the patient’s age, attitude, and the fact
that a surgical procedure is indicated. Although it is useful to mention these for the sake of completeness, rather than anything else, in this OSCE, these subjects should just be stated as options that are available but not necessarily applicable or, indeed, useful in this case. Point to Note Do not spend any more time in the OSCE other than mentioning these as first-line options for anxiety control. 5. The next step would be to consider clinical hypnosis. Unless you are experienced or qualified in some approved way and have a great deal of clinical time to devote to this type of patient management, again, this might not be appropriate for this case. As you will recall, the patient is quite a strident individual with a forceful personality, and these are not good indicators for successful hypnosis. The history from OSCE 36 and the introduction above tells you that the patient might not be susceptible to either suggestion or hypnosis. 6. One consideration is preoperative medication with an anxiolytic such as a benzodiazepine licensed and approved for this specific use in the UK by a dentist. However, this option relies on an unsupervised patient taking the correct dose of the correct drug, at the correct time, prior to the operation and for this drug to be prescribed for this use by a dentist. Although you can mention pre-medication as an option, once again in an exam, you are only doing so for the sake of completeness. Concerns with Pre-Medication. a. The reality is that you might not want to prescribe a sedative drug for a patient if they are going to take it without supervision. b. You have to be cautious about even suggesting this option. In the arenas of academia or examination, such as the MJDF SCR questions, this option might be mentioned for discussion only. Whereas in the clinic, most dentists who undertake sedation are very guarded with such an option. If pre-medication is chosen, then it is under clinical supervision, while the patient is supervised in the dental clinic and awaiting treatment. c. If the patient has taken other medication or recreational drugs, the effects of oral benzodiazepine can be unpredictable; therefore, pre-medication may not be the most suitable option in this case. d. To reinforce this point, there is considerable evidence to supporting concerns that patients are not compliant in following their preoperative instructions if they are unsupervised1 7. If we were to consider using a sedative drug, it might be best practice to administer this in the dental clinic under supervision. 8. All dental sedation options require the following: a. A trained dental operator-sedationist (including a log of relevant and recent experience) supported by a dental nursing team both trained and experienced in the procedures and complications that may follow when these drugs are used.
b. In any dental sedation procedure, it is a strict requirement that the patient maintains consciousness at all times. c. The patient must be supervised and monitored during the procedure itself and in the recovery phase too. 9. The three types of anxiety control are as follows: a. Inhalation sedation using nitrous oxide. This is suitable for mild to moderate anxiety. Patient recovery is almost immediate with no after effects. In this case, the use of a nasal mask might be an obstruction to the surgical procedure. Movement of the patient’s head during the extraction may cause the nasal mask to lose its effective seal, causing inadequate sedation with the risk that a rapid loss of the sedative effect might occur during a dental procedure. In the UK, with inhalation sedation, there is no requirement to monitor oxygen perfusion and heart rate. However, in other EU states, there is a requirement to do so. Overall, this type of sedation is both simple and safe. If we were to conduct the extraction for this patient, then a more practical option would be to consider the next option. b. Intravenous sedation using benzodiazepines. There is no obstructive mask, and the dose of drug is titrated for the patient. Throughout the procedure, up to the point the patient is discharged into the care of another responsible adult, monitoring of oxygen perfusion and heart rate is needed. A chaperone is compulsory until the patient regains their capacity. Unlike inhalation sedation, the recovery phase could be several hours after the procedure has been completed. The most commonly used drug in the UK is Midazolam. This drug is introduced through veins in the dorsum of the hand or in the ante-cubital fossa. Titration of the drug with an open line to administer a benzodiazepine antagonist, flumazenil (if necessary), are requirements in addition to the vital monitoring of heart rate and oxygen perfusion. If the patient declines this option, the patient should be advised of the third choice. c. Referral to a hospital for general anaesthetic. This option is not available in the dental clinic, but there may be an opportunity in a hospital setting for outpatient general anaesthesia or day case oral surgery. If this option is chosen, the patient must be advised of the risk of complications that a general anaesthetic carries. As the risks include fatality, noted to be in the region of 1 in 100,000, a general anaesthetic is never the first choice option and that is why it mentioned last.2 An important point to consider, even when general anaesthetic is performed in hospitals with specialists, is the risk of mortality. Fatalities still occur due to unforeseen or undiagnosed underlying physiological conditions becoming clinically relevant during a GA procedure.3-5 10. In cases where there is a pre-existing severe mental impairment of a patient, even when the risks are considered, then referral to a specialist unit for general anaesthetic is an appropriate option. Nevertheless, very much in the same way that the behavioural modification techniques at the start of this list are aimed at children, the option of a general anaesthetic is also aimed at those patients whose needs are best served by specialists. 11. When discussing these options in the dental clinic, I think it is appropriate to let the patient know of your previous clinical experience and your professional thoughts on what you consider the most
appropriate means to control their anxiety might be. Points to Note a. In discussing these options in an OSCE, your own experiences will be reflected in how confidently (or otherwise) you handle the dialogue with the actress. b. In the OSCE, it is best to stick to the facts as they apply to the case and avoid a reflective account of your experiences (or lack of them) in dealing with anxious patients. c. Above all else, in the exam and in real life, base your answers on evidence from your experience or accepted facts that you have learnt and incorporated in your practice of dentistry. 12. If the use of any of the above means to control anxiety is considered, then a comprehensive and up-to-date medical history must be taken before any procedure begins. 13. Aspects of the medical history of prime importance with sedation cases and which must be considered are: a. The cardiovascular system, particularly if there has been a myocardial infarction, especially so if this was less than 6 months previously. b. Anaemias, especially, the Sickle Cell Disease or traits and Thallassaemias need to be documented. c. If there are any renal or liver problems, these can alter the metabolism of drugs used in sedation and should be considered. d. Other conditions such as thyroid disease or porphyria should be included. e. Of importance are the neurological disorders, for example epilepsy. These all need to be considered in the preoperative patient assessment. 14. Musculoskeletal problems such as cervical spondylosis, the arthritides or other connective tissue disorders need to be documented, as these may influence minor surgical work under sedation, especially with regard to positioning of the head or protection of the spinal column and airway during a sedation procedure. 15. We must ask whether or not the patient is pregnant. If she is, the stage of pregnancy should be known. Foetal respiratory distress is a potential risk during both IV sedation and a GA procedure, not directly because of the drugs used but theoretically from the postural obstruction of blood flowing to and from the uterus while the mother is being sedated. Despite this theoretical risk, there is a wealth of published evidence from cohort studies supporting the safe use of benzodiazepines during pregnancy. However, you have to be aware that there are also case-control studies demonstrating an association with birth defects such as cleft lip and palate and other musculoskeletal teratogenic effects when chronic or excess doses of benzodiazepines have been used during early pregnancy.6,7 So drug selection is of extreme importance for the pregnant patient. As benzodiazepines cross the blood-brain barrier of the mother, and they readily pass through the placenta, they can cross the blood-brain barrier of the foetus too.8 In the latter phases of pregnancy,
there are noted associations with respiratory depression and other metabolic side effects of benzodiazepine use, such as drug accumulation in the foetal adipose tissues. Points to Note a. With any form of sedation, the risk of an adverse drug interaction has to be avoided. b. This can easily be avoided by updating not only the medical history but updating the patient’s drug history too. c. This has to be done at every visit. 16. In this case, the patient chooses to have the extraction procedure conducted under IV sedation as an outpatient. It is important in the OSCE to tell the actor they will be awake during the procedure but they will have an altered perception of the passage of time. Nevertheless, they will be able to hear and to communicate with the team looking after them. The sedative is given in a vein in the arm or the back of the hand. A monitor will record pulse rate and oxygen levels at all times. In addition to the sedation drug, local anaesthetic will be given inside the mouth to numb the area around the tooth to be extracted. As the patient already has experience of extractions (Clinical Case 36), this procedure will be similar. However, with use of a sedative, the patient will feel a little light-headed and somewhat detached from what is going on, so the procedure will not cause them the same degree of anxiety as before. 17. You can advise the patient that extraction of a lower wisdom tooth will involve the following steps: a. The area around the tooth to be extracted will be numbed by injection of local anaesthetic. b. After a few minutes, the level of anaesthesia will be tested; if nothing is felt, other than a dull pushing sensation, the extraction procedure can begin. c. Initially, it is hoped the tooth may come out in one piece with use of an elevator or forceps. d. If this is not possible, then cutting the gum, exposing the tooth and some of the bone of the socket will enable the tooth to be cut into pieces with a drill. e. Any bone that is removed will be from the top and the outer side of the jaw only, thereby avoiding the potential for damage to any nerves below and to the inside of the lower jaw. f. Once the tooth is extracted, flushing the socket with sterile water enables the surgical site to be checked, making sure no bone or tooth fragments remain. g. Finally, if the area is clear, the gums will be stitched back together with two or three separate stitches. This suturing will use material that will be absorbed by the gums. h. A check-up after the extraction to see how well things are healing will take place after one week. 18. After the extraction, there will be pain and there will be swelling; this is normal following a minor surgical procedure.
You can state in comparison to the patient’s previous experience, there will be more pain and more swelling than that experienced with the upper teeth, due to the gums having to be cut and some bone requiring removal. For a few days afterwards, there may be an inability to open the mouth, but this should pass within a week. Occasionally, with the swelling, there is bruising too, and this can extend into the neck. A soft diet will be needed for a few days and some painkillers such as paracetamol may be needed at a dose of 500 mg × 2 four times per day. As with the extraction of upper teeth, if there are problems, then recall and review to deal with these issues will be necessary. In addition to discussing the procedure itself, post-operative instructions should be given to a patient who has been sedated. Briefly these are as follows: Recovery with a chaperone or other responsible person, ensuring the patient must not drive for up to 24 hours or sign any legally binding documents in this time either. No rinsing for 6 hours post-operatively; then warm salt-water mouthwashes after this time for three to four days post-operatively is beneficial. 19. The complications from lower wisdom tooth extraction can be in the following order: immediate, temporary, and permanent. a. The immediate complications are seen during the procedure; there is a risk of fracturing the mandible, transecting nerves, and severing blood vessels. b. Temporary complications are bleeding from the socket and from where the gums were cut. This is common and not necessarily a complication. Blood mixed with saliva does cause some concern, as the volume of blood loss is commonly believed by patients to be more than it actually is. Reassurance through prompt empathic communication is required to allay the patient’s questions, doubts, and fears. Swelling from haematoma and an inability to open the mouth fully almost invariably follow from a surgical extraction, and this can last for a few days up to a week. Again this is not necessarily a complication, rather a temporary and commonly expected occurrence. Review and reassurance is all that is required. The incidence of dry socket is greater with lower teeth than with upper teeth, the third molar sockets being notoriously prone to this temporary complication, and the patient should be notified of this in the consent phase before the procedure begins.9 Cleaning of the wound site and dressing usually solve this problem. If there is swelling from infection, raised temperature, or complications involving other tissues, then referral to a specialist is needed, possibly with prescription of an antibiotic regimen to reduce or remove any bacterial species involved. The current best accepted standard, if you are considering prescribing antibiotics, is to take a swab and culture for species involved in an infection so an appropriate and effective antibiotic can be used. c. The permanent complications following the removal of mandibular third molars are thankfully relatively rare. Nevertheless, they do present as a real risk, and the most frequently cited permanent complication is nerve damage. At one time, it was recommended that patients be informed of the risks where a complication with
temporary effects is greater than 5% and a permanent effect greater than 0.5%. However, adopting such a rigid approach to risk disclosure when obtaining consent, even when based on clinical evidence, may prove to be a brittle defence in law. In the UK, the 1957 case of Bolam hinged on the risks that should be disclosed to the surgical patient.10 This case resulted in a standard of Bolam reasonableness, that is the risks that are disclosed are those that any reasonable person engaged in the same field would disclose. Some 15 years later, the 1972 case of Canterbury v. Spence determined that all risks and alternatives to avoid such risks should be explained.11 In 1992, the Rogers v. Whittaker case where the 1 in 14,000 risk of blindness due to sympathetic ophthalmitis not being explained to the patient resulted in the ‘reasonable practitioner standard’ being relegated and the ‘reasonable patient standard’ now being upheld in most countries.12,13 The essence is if a patient wants to know something, they should be told. If you do not know the answer, you have to find out. Points to Note a. In the UCLAN MJDF revision course, figures are given for nerve damage following lower third molar extraction. These figures for lingual nerve and inferior alveolar (IAN) nerve, permanent or temporary damage are as below:14 i. Lingual Nerve 2.5% temporary and 1.25% permanent damage. ii. Inferior Alveolar Nerve 1.25% temporary and 0.625% permanent damage. b. As the responsible practitioner, you would advise a patient of these figures and record in the patient notes that this data was given during the process of consent for extraction. c. The truth of the matter around the risks of nerve damage from mandibular third molar extractions is more complex than the single percentages given above.15 However, in both MFDS and MJDF exams, these are acceptable figures to quote, and you could leave it at that. 20. Damage to nerves may occur at any stage of the extraction procedure. The injection of an anaesthetic drug into the nerve tissues can cause damage. An actual mechanical injury can be caused by the needle tip grazing or transecting a nerve bundle. In other cases, rather than the needle itself being the cause of damage, the chemical composition of the anaesthetic used can be responsible for the damage to the nerve too. The use of articaine, which has a greater concentration of anaesthetic and a different chemical composition from lignocaine, causes significantly more risk of IAN damage solely because of its chemical nature. You might consider restricting its use to infiltration local anaesthesia rather than block local anaesthesia.15 21. The anatomical difference between nerves themselves may result in the different pattern of nerve injuries seen during mandibular third molar surgery. The lingual nerve is injured more often than the IAN. This may be due to it having far fewer but larger fibres than the IAN, that is if one fibre is damaged in this arrangement, the impact is greater than if a single fibre is damaged in a nerve where there are multiple signals travelling in many smaller fibres such as in the IAN. From a gross anatomical perspective, the lingual nerve is not protected by a bony canal and is actually at risk
from the use of instruments used to ‘protect’ it from damage during surgery, e.g. the raggy chewedup end of a Howarth’ elevator, inserted into the lingual aspect of the mandible during a surgical procedure. Thankfully, such applications and techniques are not currently accepted best practice in the UK. 22. Aside from the considerations above, the patient has to be warned of the risk of temporary and permanent nerve damage. Such damage would present with symptoms of altered taste and sensations to the tongue, gums, lips, chin, and cheek. The patient should be warned to return to you if these symptoms occur. If symptoms persist for longer than 3 months after surgery, the risk is that damage may well be permanent and there is little, if anything, that can be done.15 Nerve damage to these branches of the trigeminal nerve is an unfortunate but a relatively rare complication of mandibular third molar removal. Thankfully, in the UK, the incidence of these injuries in relation to wisdom tooth extraction is static. By adhering to the guidelines and using correct surgical techniques, with modern imaging techniques, such as Cone Beam Tomographic imaging techniques (16) we might see a future reduction in these figures. 23. The other option, other than whole extraction, roots and all, is to consider removing the crown and leave the roots in place. This is coronectomy. So far, there have been some studies on the merits of this procedure, but these studies used very few patients. Sample sizes were all under 100, and in some studies, only single patient or very small sample sizes were used. Nevertheless, in patients where the roots are of complex form and in close proximity to the IAN canal, which is seen on radiographs to bend around the roots, coronectomy could be useful in reducing the risk of inferior alveolar nerve damage.17 24. The patient has to give consent for coronectomy as opposed to whole extraction as it is a different procedure. The technique involves using a buccal approach, and the roots should not be mobilised during the procedure. The crown is separated from the roots to the level of the amelo-dentinal junction; the surgical site is then closed with Vicryl sutures. There is still a risk of dry socket and post-operative pain and swelling, but the evidence from these studies, is the risk of IAN damage is reduced. 25. Rather than carefully selecting and undertaking cases where the risks are low and referring the high-risk cases, you can minimise the risk to the patient by preparing well and using an appropriate and minimally invasive surgical technique. 1. Approach all lower third molars buccally and avoid (if possible) the lingual areas. 2. Take good preoperative radiographs and work through the procedure with your patient and colleagues until what you are about to do is clear with everyone. 3. After this, you can decide if you want to go ahead and take the tooth out or refer. 4. If complications occur, then an urgent referral to a specialist unit in hospital will be needed as timely management at this point can reduce the risk of a temporary complication becoming a permanent one. Further Notes to This Clinical Case.
Whether you are faced with this exam question in the MFDS or the MJDF in an OSCE or an SCR, the current concepts of mandibular third molar extraction have to be followed. The SIGN and NICE guidelines, which patients can access both online and in hard copy, gives information in simple and concise terms, that you have to be aware of. The MFDS or MJDF question may ask you to manage concerns, give explanations, or in this case, go through a series of structured questions about the procedure of extraction. Most of your answer will, therefore, focus on the procedure of extraction; the other attendant issues of anxiety management, pain control, and modified surgical procedures are peripheral to answering the main question. In the MFDS OSCE, although the question is more dynamic than the MJDF, there is a structure of answering the question, and it might be as follows: 1. Introduce yourself professionally, verifying you have the correct patient for the correct procedure. 2. Use clinical communication skills of empathy and understanding. 3. In your OSCE, do not use technical terms that will baffle the actor. To do so voids consent. 4. Explain the SIGN and NICE guidelines and how they relate to the surgery you propose to do. 5. Advise the actor in clear non-emotive terms what will follow from surgery, i.e. pain and swelling. Never tell the actor: ‘The next three days will be the worst of your life…’ and leave it at that You will fail the MFDS question if you do and possibly the whole exam as this statement voids the OSCE domain of dentist-patient interaction. I can think of patients who have had immeasurably worse experiences than post-operative dental pain. Examples are ex-servicemen who have suffered traumatic lower limb amputations. 6. In the consent phase pre-surgery, warn the patient of the risks of complications and do so as a responsible practitioner advising a prudent patient. If you are following a 5% temporary 0.5% permanent level, then as a prudent practitioner qualify these figures when you are informing patients of the risks. 7. The separate risks of IAN and lingual nerve injury, their likely causes, and measures you will take to avoid or reduce the risks should be reported to the patient. 8. The need for sedation should be discussed and the reasons why you consider GA or simple LA to be either inappropriate or inadequate for the procedure must be stated. 9. Make sure the patient understands everything you have told them. 10. If there is a consent form, make sure the patient reads it, understands it, and asks any further questions, and after these have been answered, only then should they sign it. References to Clinical Case 38 1. Ravindra P, Barrett C. Compliance with pre-operative instructions for procedures with conscious sedation: a complete audit cycle. Br Dent J. 2012 Feb 10; 212 (3) E:6.
2. D’Eramo EM, Bontempi WJ, Howard JB. Anesthesia morbidity and mortality experience among Massachusetts oral and maxillofacial surgeons. J Oral Maxillofac Surg. 2008 Dec;66(12):2421-33. 3. Chicka MC, Dembo JB, Mathu-Muju KR, et al. Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims. Pediatr Dent. 2012 MayJun;34(3):231-38. 4. Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013 Aug;23(8):741-46. 5. Wochna K, Jurczyk AP, Krajewski W, Berent J. Sudden death due to malignant hyperthermia during general anesthesia. Arch Med Sadowej Kryminol. 2013 Jan-Mar;63(1):11-4, 7-10. 6. Dolovich LR, Addis A, Vaillancourt JM , et al. Benzodiazepine use in pregnancy and major malformations or oral cleft: meta-analysis of cohort and case-control studies. BMJ. 1998 Sep 26;317(7162):839-43. 7. Enato E, Moretti M, Koren G. The fetal safety of benzodiazepines: an updated meta-analysis. J Obstet Gynaecol Can. 2011 Jan;33(1):46-8. 8. Jauniaux E, Jurkovic D, Lees C, et al. In-vivo study of diazepam transfer across the first trimester human placenta. Hum Reprod. 1996 Apr;11(4):889-92.
9. Daly B, Sharif MO, Newton T, et al. Local interventions for the management of alveolar osteitis (dry socket). Cochrane Database Syst Rev. 2012 Dec 12;12 CD006968. 10. WLR Bolam v. Friern Hospital Management Committee (1957) 1 WLR 583. 11. F. Canterbury v. Spence (1972) 464 F.2d 772 (d.c. 1972). 12. Kastelein WR. Informed consent and medical liability: jurisprudence 1994-1998. Tijdschr Gezondhd. 1998;22:134-46. 13. Skene L, Smallwood R. Informed consent: lessons from Australia. BMJ. 2002;324(7328):39-41. 14. Crean St John, UCLAN MJDF Part 2 Revision Course Structured Clinical Reasoning Questions SCR A: Oral Surgery 2011. 15. Renton T. Prevention of Iatrogenic inferior alveolar nerve injuries in relation to dental procedures. Dent Update. 2010 Jul-Aug; 37(6): 350-360. 16. Umar G, Obisesan O, Bryant C, Rood JP. Elimination of permanent injuries to the inferior alveolar nerve following surgical intervention of the ‘high risk’ third molar. Br J Oral Maxillofac Surg. 2013 Jun;51(4):353-57. 17. Renton T. Update on coronectomy: a safer way to remove high risk mandibular third molars. Dent Update. 2013 Jun;40(5):362-64, 366-68. Further Reading to Clinical Case 38 1. McMinn RMH, Hutchings RT, Logan BML. The Mouth Palate and Pharynx. In A Colour Atlas of Head and Neck Anatomy. 6th Impression pp. 136-148. London: Wolfe Medical Publications 1990. A good anatomical text is essential when learning dental surgery, and this book has very good photographs detailing the critical structures of the head and neck. 2. Whaites E. Part 4: Radiography. Section 17: Panoramic Radiography (Dental Panoramic Tomography) pp. 187-206. Part 5, Chapter 25: Development Abnormalities pp. 310-313. In Essentials of Dental Radiography and Radiology. 4th Edition. Edinburgh: Churchill Livingstone 2010. This is the textbook you should refer to in your MFDS and MJDF preparation. 3. Mitchell L, Mitchell DA, McCaul L. Chapter 8: Oral Surgery. Dento-alveolar Surgery: Removal of Third Molars. In Oxford Handbook of Clinical Dentistry. 5th Edition pp. 358-363. Oxford: Oxford University Press 2010. A relevant and elegantly written chapter on this subject, it is useful to resort to while in the clinic. 4. Hadden A, Eaton K, Ormond C, et al. Section 4: Full Comprehensive Examination. In Clinical Examination and Record Keeping Good Practice Guidelines. 2nd Edition pp. 21-27. London: Royal College of Surgeons, FGDP UK 2009. An important book with guidelines to follow in the clinic when examining patients and recording data.
5. Pierse JE, Dym H, Clarkson E. Diagnosis and management of common post extraction complications. Dent Clin N Am. 2012;56:75-93. 6. Henderson SJ. Risk management in clinical practice. Part 11. Oral surgery. Br Dent J. 2012;210(1):17-23. A very well-written article on what you need to do and not do to avoid medico-legal problems from arising when considering surgery. Well worth reading. 7. Shepherd JP. The third molar epidemic. Br Dent J. 1993;174:85. Now over 20 years old, this article came out when I was a dental student. 8. Working party report. Faculty of Dental Surgery Royal College of Surgeons of England. Current clinical practice and parameters of care. The management of patients with third molar (syn: Wisdom) teeth. September 1997. This is the report from which the current UK recommendations on wisdom teeth extraction have been developed. 9. National Institute for Health and Excellence Technological Appraisal NICE TA1 Wisdom Teeth— Removal. March 2000 Updated 2011. 10. Scottish Intercollegiate Guidance Network (SIGN) 2000 Number 43: Management of Unerupted and Impacted Third Molar Teeth. Section 3: Indications for Removal.
Clinical Case 39 Background Information The next question is right out of the MFDS syllabus, appearing frequently in that exam and rightly so because this problem is commonly seen in the dental clinic. The subject matter also commonly appears in the MJDF exam too. If (hopefully when) you attend any or even many of the revision courses for your exams, cases similar to this one will be discussed. This case deals with tooth decay in a young child. The subject is easy to learn, and you will already have experience of dealing with children in the dental clinic. Be cautious, however, as the ease of learning cases such as this and the clinical experience you bring into your revision can easily lead you into a false sense of security while performing in your exam. The problem facing you is that such cases are easy to manage in real life but are notoriously difficult to present in examinations. I have added the following information to support my view that this is not such an easy subject to pass in an exam question: 1. Despite being an optimist and setting aside the legal aspects, from a behavioural standpoint, it is approximately impossible and nearly impractical to have any child poked and prodded repeatedly in a clinical exam. 2. You know this is not going to happen, and you will have to deal with some form of substitute, with which you will not be familiar or have had no experience of dealing with in the clinic.
3. As mentioned previously, the device commonly used in the OSCEs is to have an actor attend as a carer or, in this case, the mother. She then presents a series of photographs portraying her child. 4. Of course, a mother would not do this in real life. I know we live in the digital age, and every mobile camera has a phone attached so the parents actually can attend with such photographs. Seriously, when was the last time you had a concerned mother attend with pictures of, but not with her child? 5. In a previous MFDS OSCE, (Clinical Case 32) a candidate mistakenly forensically questioned the mother on why her child was not present and did social services know about this terrible state of affairs? The candidate misguidedly thought there might not be outright child abuse, but there could be a child neglect issue as a background to the main theme of the OSCE. Unfortunately, this candidate did not read the question, lost their focus, lost the plot, and lost out on passing the question. For the avoidance of doubt in the OSCEs for these exams, there is no additional, background, or hidden agenda you need to respond to. There is a question and you need to answer this in a concise structured manner to the best of your abilities. In the OSCE you are going from a clinical scenario you have competently and confidently dealt with many times in real life to one you are now facing in an examination. In the OSCE, you have to believe in the make-believe and take the information you are given in the exam at face value. The OSCE is straightforward, and the answers you give should be clear-cut. In this type of question, I think an equal emphasis must be placed on your empathic sentient abilities to do the following: 1. Inform the mother, i.e. give advice in an appropriate and acceptable way. 2. Educate the mother, i.e. ensure your information is taken in and acted on. In this OSCE, combine the above with your knowledge you have built from clinical experience and thorough revision of the subject matter. I think if you can both inform and educate a patient while keeping things simple and to the point, splitting this OSCE equally between behavioural management of the mother and clinical issues presented in photographs and case notes, then you should be able to pass this question without too much bother. Introduction A young single mother attends with you today. Her partner has permanently left home, leaving her with her daughter, who is now 4 years old. The mother does not like dentists and tells you so in quite strong terms. As the mother has had poor experiences with dentists, she has not brought her daughter in to see you; she is at nursery school, where her mother deposits her while she goes out to work. The teachers at her daughter’s school have repeatedly told the mother that they have some concerns about her daughter’s teeth. The mother tells you her child’s upper teeth are black and broken and they just came through her gums
that way. She has explained this to the teachers at nursery school. In response to this, the school nurse was notified of concerns, and this resulted in the mother being given a letter of referral to bring her daughter to see a dentist. The mother then passes you the letter. She says that she cannot read the writing in it, but the letter is clearly typed and not handwritten. It simply states that the child takes a bottle of milk to school and has teeth which are black and broken down. She does not smile very much. For the child’s sake, the teachers would like you to have a look to see what is going on in the mouth. The mother tells you that only the upper front teeth are black and broken. She adds: ‘They are her first teeth, you know. I’m only here because the nurse at school told me to come, but I can’t see its any of her business anyway.’ Question In this OSCE, explain the problem and manage the mother’s concerns about the pattern of decay her daughter has presented with. Go on to discuss the treatment options you consider to be appropriate in this case. Answer Beginning the Consultation In this OSCE, from the introduction, you can clearly see there are some real concerns with the social history that need to be taken into consideration. A single parent who struggles to look after her daughter and has limited literacy skills will need your support and care, not only as a dentist but as a human being. In this consultation, you have a duty of care not only for the child but for the mother. Begin your OSCE by adopting an empathic approach; introduce yourself professionally, but do so sensitively and acknowledge the mother’s previous dental history. Go on to tell her that you are here to find out about the problem her daughter has, give the options for treating this problem and provide advice on preventing this issue from getting worse or affecting the adult teeth. In the initial phase and introduction to the OSCE, you need to find out if there are any underlying medical conditions affecting her child or anything else you should be aware of. Do acknowledge the social constraints of a single mother taking time away from work and the impact on her daughter being taken out of nursery school to come to see you. Explain to the actor/mother that you will make this visit as productive for them as you can, especially as their free time is precious. The mother assures you there are no further medical issues. Taking a Medical History a. If no medical conditions are stated in the introduction and the question does not ask you to take a history; then do not take a full medical history (although, you would at every visit in real life).
b. In an OSCE, you can safely assume there are no underlying medical issues. c. However, you do still have to ask the question on medical history, so the examiner can see you have checked and updated this important aspect of the consultation. Focusing on the Issues Following from the initial questions, you can ask the mother: ‘What are your concerns?’ In reply, she tells you that these relate to the observations of the teachers at school and the letter of referral given to you, detailing the black and broken upper teeth. The mother advises you that only the upper teeth are like this, the lower ones appear normal. She tells you that she cannot see the teeth in the back of the mouth, so she does not know what they are like. It is important to ask if her child has been in pain. In response to this question, the mother tells you that her daughter has cried at night several times, but she gives her a dummy to suck on. During the day, she gives her milk in a bottle, and at night if she doesn’t have a dummy, she will have some milk in a bottle too. She has been doing this for quite some time now. The school her daughter goes to is the same one she went to, and she remembers when the school milk stopped when she was a child. All she wants is for her daughter to grow up with strong bones, so she gives her milk. She does know that sugar is bad for the teeth and then tells you in clear terms she does not want a lecture on: a. How to look after her daughter, she has had nothing but nagging from the teachers and the nurse at school including the letter to you and abuse from the other parents at school when she drops off and collects her daughter. She tells you that she does not need the abuse; she had enough abuse from her child’s father and her own father when they were around, she adds: ‘Thankfully, they aren’t around any more.’ b. A lecture on how sugar is bad for teeth, as she doesn’t give her child any sweets, and when she goes shopping, she asks the supermarket staff at the reduced food section for the sugar-free fruit juice and she knows its sugar-free as it costs more. c. The mother tells you she was angry when a health visitor patronisingly suggested that she gives her daughter water in a bottle at night and during the day as it will prevent tooth decay. Then the health visitor told her to tell her child not to rinse with water after brushing her teeth, because the toothpaste would be washed away. She said the teeth would not be ‘protected’ if she did that. She found all of this advice to be confusing. The actress playing the mother tells you that the advice might have been well meaning, but it was given in a condescending way that she did not need to hear right then, especially the way it was given —with a sheet of drawings and instructions she couldn’t understand or read. These were just handed to her with no explanation.
Points to note 1. Your response should be to empathically acknowledge these statements. 2. The mother is defending her right to be a parent and marking out the boundaries she feels are appropriate to this consultation with you. 3. There is nothing abnormal with this behaviour. Dentist-patient interaction a. It may be the case, in your personal opinion, that you feel such remarks and the aggressive manner in which they are delivered to be inappropriate. b. However, in this OSCE and in real life, more than anything else, we need to demonstrate the Carl Rogers concept of ‘unconditional positive regard’ to our patients. c. Allow the mother to say her piece and, in doing so, keep the peace. d. Let her get these things off her chest so you do not make the same mistakes the health visitor made. Providing Answers Go on to tell the mother that you might have some answers for her about why her daughter’s upper teeth are the way they are and ask if she would like to hear some of these answers now. The mother agrees and you can tell her in clear terms in a calm manner: ‘Even though food and drink is sometimes sold as being sugar-free, there are hidden sugars that can affect the teeth. These hidden sugars in the food cause the damage we see because even a small amount can cause decay in a child’s tooth. Continuing you might add: ‘In sugar-free foods for children, there is still some sugar present. It is a bit of slick advertising by supermarkets that they sell sugar-free products, when they should be selling sugar-reduced products.’ ‘It is better to look for tooth-friendly products with no sugar if these are available.’ At this stage, ask the mother if what you have said makes sense and ask if there are any questions. There are none. Go on to explain that, in addition to food with hidden sugars, milk has a lot of hidden sugar too, and this can cause tooth decay. The upper teeth have decayed because of the way the milk gets on to the teeth from the bottle. Milk remains on the teeth as saliva flow is less at night. This causes decay as bacteria naturally occurring in the mouth can turn the sugar in milk to acid that decays the teeth. The other issue you should notice is that the mother gets her shopping at the reduced-price food section in the supermarket. Very often, reduced-price food is processed, high in fats and preservatives, and potentially quite unhealthy. While you can point this out to the mother, do so sensitively.
She retorts by telling you that one of the supermarket workers gives her plenty of fresh fruit too, and this is also reduced in price; she reminds you that she has not come in for a lifestyle lecture. She then asks you quite calmly: ‘How many dentists do you know who have to go round and get reduced-price food? Have you ever had to do this? Lining up at night and fight for your reductions?’ You have to acknowledge this retort, you can tell the mother that you appreciate this cannot be easy for her or her daughter. The mother adds: ‘What you have said makes no sense at all, and if what you are saying is correct then why haven’t the bottom teeth gone the same way as the upper ones?’ Your answer is to tell the mother that her question is a good one and you have been asked this before. You can give the following explanation: The reason for the decay affecting the upper teeth is the way the milk comes out of the bottle. It is sucked on to the upper teeth. The tongue covers the lower teeth; whereas the lower teeth are cleaned with a continuous flow of saliva, the upper teeth are being continually coated in milk. Also while her child is asleep, the surfaces of the upper teeth dry out at night, and bacteria present in the mouth then start the process of decay on teeth covered with milk. This produces the pattern of decay to the upper teeth as seen. In essence, it is the frequent night-time drinking of milk from a bottle that is responsible for the decay to the upper teeth in her child. Carry on by stating that giving a bottle at night to comfort her child is understandable, and you can see why she would get upset with the health visitor’s seemingly unhelpful suggestions. This pattern of decay only affecting the upper front teeth does have a name, and you can ask the mother if she would like to know what this is. In real life, some mothers are keen to find out, whereas others are not and just want you to get on and help their child. In this case, the mother wants to know, so you can tell her the condition is: ‘Nursing bottle caries.’ Explaining a condition a. If you are explaining a condition to the mother, you have to be careful. This OSCE does not ask you to provide a diagnosis; it only asks you to explain and to manage concerns. b. If you choose to provide a diagnosis, then you have to qualify what you have stated. You can continue as follows: ‘Just giving out a label or a name to a condition does not really help your daughter.’ From this point, you need to continue by explaining what can be done to help her child. It is the easiest thing to hand out advice and advice sheets. In this case, the mother could not read them. It is another to give advice that is appropriate and to follow this up with practical help.
With regard to tooth brushing, the age of her daughter means that brushing has to be supervised. You can ask the mother if anyone has demonstrated how to brush her daughter’s teeth, and you can suggest to the mother that she and her daughter attend together with you in the clinic for a practical session on tooth brushing. Again, ask the mother if she feels your suggestions are helpful. If they are, then say it would be beneficial for them both to attend and you can make the time for this to happen. This time will fit into their daily commitments with the mother’s work and the daughter’s nursery timetable. This aspect of the OSCE can be expanded to take into account tooth brushing instruction and techniques. Tooth brushing instructions a. Even though this is being presented as an MFDS OSCE, in the MJDF, where this type of question has come up, a set of oversized teeth and an oversized toothbrush might be presented for you to use. b. You can now go over some tooth brushing instruction with the actress/mother using the model teeth to demonstrate a technique you feel to be important. c. Rather than baffle the actress with names and techniques, choose one technique you feel she can accept, adopt, and apply to her child. d. Explain the need to use a small pea-sized amount of toothpaste and ensure she understands the need to supervise brushing of her child’s teeth. Advice and Explanations In this OSCE, rather than explaining the benefits of either fluoride supplements (which have been shown in some cases to have poor long-term compliance)1 or mouthwashes (that are contraindicated with the under-6-year-olds due to risk of ingestion),2 simple techniques of tooth brushing, diet advice, and reducing and then limiting the use of a bottle are all that are needed. Keep things simple and move to the next stage of the OSCE when you have completed this. Despite the defensive stance of the actress playing the mother, by now you will have built up a good relationship with the character and revised some of the confusing information given previously to her by a health care visitor. A calm, understanding, and empathic approach will help to reduce or remove any confusion arising from the complicated instructions previously given in a manner perceived as being highhanded. At this point in the OSCE, you have to advise the mother what you can do with her daughter’s affected teeth and the options for treatment. Again, ask if there are any questions. If there are none, then ask if you can continue by giving advice on what we might do together to help her daughter with the decayed upper front teeth. Explain that we have to complete a full dental examination, and the extent of damage to the teeth has to be known before we can plan the way forward. Advise the mother that every attempt will be made to repair (or restore) the teeth.
At the first visit, if her daughter is quite happy and relaxed about coming in to see you, any soft decay can be removed by gently using a small hand instrument on the affected parts of the teeth. While you are doing this, the mother can be present, encouraging her daughter to open her mouth for the exam and helping to keep her mouth open while you complete any necessary work to the teeth. Explain to the mother that you might not have to use an anaesthetic while you complete the first visit and place the temporary fillings. Clearly advise the mother that in the visit with her daughter you will take your time, treating her daughter both gently and slowly. It is important to advise the actress that in the time since the mother was a child, many things have changed in dentistry. Although we cannot bring back school-milk and we might not be able to repair all the teeth, at least we can start her daughter off on a dental journey to be an adult-patient who is not scared of going to the dentist. If we can do this, then we will stand the best chance of making sure her adult teeth will be the best they can be for the rest of her life. Ask if there are any questions. The mother wants to know what you can do with the teeth that are affected by this ‘nursing bottle caries’ that you mentioned earlier. You need to explain that if her daughter is relaxed and accepts treatment, you can start by removing decay and placing temporary fillings. After a few weeks, these can be looked at again. In those teeth where there is deeper decay, a medicine can be applied to calm down any irritated or inflamed nerves, but to do this may need a local anaesthetic. If her daughter finds this too much, we could try to relax her by using the calming effects of inhaled gasses and air. You can explain that in this procedure, her daughter will be breathing these gases through a nose mask, while she is having treatment. She will not be asleep; she will be awake and relaxed enough to allow the repair work to be completed. These options can be completed in the dental surgery, either by a general dentist or by a specialist. The last option would be to refer her daughter to a hospital for attention by a team of specialists using a general anaesthetic. During this procedure, her daughter would be unconscious while all necessary dental work or at least as much as possible is completed in one visit. Taking this last option, might mean teeth that cannot be repaired or a have doubtful future are extracted, rather than a staged series of appointments in general practice where a more conservative approach is taken at each appointment, with teeth of questionable standing being given a chance to recover, rather than being removed. In discussing a hospital referral, you need to advise the mother of the risks and complications involved in general anaesthesia. This includes the risk of death from such procedures.3 For this reason, a general anaesthetic might only be considered necessary if the previous attempts to manage her daughter’s dental treatment have failed. In consenting for a general anaesthetic, because the mother might not fully comprehend what she is signing, consent to treatment might not be valid, and all attempts must be made to support the mother
in determining the correct treatment she chooses for her daughter. Ask if there are any questions. If there are none, the OSCE can be concluded. Further Notes to This Clinical Case This OSCE is as much about displaying qualities of your being a human being as it is about your being a competent dentist. Questions dealing with caries in children appear in both the MFDS and in the MJDF OSCEs, and the reasons are clear. Do you remember the 5 rules of 5 from the 5th OSCE of Chapter 5? Here are two more figures that are interesting: 1. Nearly 1 in 5 children (17%) between the ages of 1 to 5 have decay.4 2. In some parts of the UK up to 50% of children experience decay before 5 years old.4,5 You can describe the patterns of decay in deciduous teeth in different terms; usually these refer to the patterns of decay seen or their causes. The term ‘early childhood caries’ covers all patterns and all causes of decay. The term ‘nursing bottle caries’ specifically describes a pattern where the decay is limited to the upper deciduous incisors, canines, and, possibly, the upper first molars as well. Occasionally, the lower molars may be affected too, but for the reasons given in this case, the lower incisors will be spared. Where the pattern of decay is more widespread, then the term ‘rampant caries’ is used. However, it is not good practice to label a patient with a condition that has emotive terms and do so without first explaining the condition to them. There is only one thing worse than this, and that is to emotively label the actor’s OSCE-child with a pathological condition. In this case, the question asks you to explain and further manage the patient, not to label and further damage them or make their OSCE-child more dentally phobic than they ever were to begin with. It is important to give some dietary advice and arrange for a specialist referral. Going further than this to mention fluoride supplements is perhaps beyond the scope of the question. The essence of this OSCE is to approach a vulnerable and dentally phobic mother and gain her confidence so she entrusts you to look after her child. If you can do this in the dental clinic and the mother returns as a patient, you can win two patients for life. More important than winning a patient over to accepting dental treatment is the reward in knowing that you have helped a child to overcome a barrier to health care, a barrier unwittingly set in place before she was born, when her mother was a child. References to Clinical Case 39
1. Stephen KW. Systemic fluorides: drops and tablets. Caries Res. 1993;27 Suppl 1:9-15. 2. Massey CC, Shulman JD. Acute ethanol toxicity from ingesting mouthwash in children younger than age 6, 1989-2003. Pediatr Dent. 2006 Sep-Oct;28(5):405-09. 3. Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013 Aug;23(8):741-46. 4. Fayle SA. Chapter 7: Treatment of Dental Caries in the Preschool Child. In Wellbury RR, Duggal MS, Hosey MT. Paediatric Dentistry. 3rd Edition p. 133. Oxford: Oxford University Press 2005. 5. Rayner J, Holt R, Blinkhorn F, Duncan K; British Society of Paediatric Dentistry. British Society of Paediatric Dentistry: a policy document on oral health care in preschool children. Int J Paediatr Dent. 2003 Jul;13(4):279-85. Further Reading 1. Deery C, Toumba KJ. Chapter 6: Diagnosis and Prevention of Dental Caries pp. 107-130. Fayle SA. Chapter 7: Treatment of Dental Caries in the Preschool Child pp. 130-146. In Wellbury RR, Duggal MS, Hosey MT. Paediatric Dentistry. 3rd Edition. Oxford: Oxford University Press 2005. These are two fairly important chapters to read for your exam preparations. 2. Mitchell L, Mitchell DA, McCaul L. Chapter 3: Paediatric Dentistry. In: Oxford Handbook of Clinical Dentistry. 5th Edition pp. 54-117. Oxford: Oxford University Press 2009. A good quick reference chapter with data you can deliver in the clinic. 3. Andlaw RJ, Rock WP. Chapter 3: Dental Health Education. In A Manual of Paedodontics. 3rd Edition pp. 31-42. Edinburgh: Churchill Livingstone 1993. An older text book, it interesting to note the changes in paediatric dentistry across some twenty years! 4. Kay EJ, Tinsley SR. Chapter 4: What Worries Patients about Dentistry? pp. 33-45. Chapter 9: Children Special Cases pp 102-116. In Communication and the Dental Team. London: Stephen Hancocks 2004. Essential reading for developing an empathic approach to patient care in exam questions dealing with cases such as this one. 5. Department of Health. Section 2: Principles of Toothbrushing for Oral Health. In Delivering Better Oral Health: An Evidence-based Toolkit for Prevention. 2nd Edition. London: Department of Health 2009. This text contains useful pictures and diagrams to show to patients. In an examination, you can refer to this text as a source of information.
Clinical Case 40 Background Information The next two OSCEs will deal with simple conservative dentistry; these two questions are based on
patients I have treated in the dental clinic. I have adapted these cases to fit into how you might deal with them in 10 minutes in the OSCES. These are simple cases with no surprises. In the MFDS, you will have 10 OSCES, and in the MJDF, there are 20 OSCEs in the Part 2 exam. In both these exams, there are always questions on conservative dentistry. Just to remind ourselves, the object of these two exams is to test a candidate to a level equivalent to two years postgraduate experience in dental practice and not to the esoteric level of complexity enjoyed by specialists. In every diet of these exams, there will be several simple restorative cases where all you have to do is behave as you do in the clinic while treating a patient. If you attend the revision courses in London at the Royal College of Surgeons England for the MJDF exam, you will gain experience of the procedural scenarios testing your technical skills as a dental surgeon in addition to participating in the conversational questions testing your diagnostic skills as a dental physician. These courses are run by the Royal College of Surgeons appointed lecturers; you should note that the strict exam regulations mean you will not meet any of the examiners in revision courses for the MJDF. In contrast, if you attend the revision courses in Edinburgh or Glasgow run for their Royal College MFDS exams, you will find that these courses concentrate on the diagnostic and dialogue skills you need to develop to pass their exams. Just to remind you, there are no practical tests in Part 2 of the MFDS exam and medical emergencies are currently not being examined in this exam. Lectures are given by the examiners with the opportunity for you to ask questions before they turn the tables on you when you meet again in the exams! Both types of course are worthwhile for you to not only improve your clinical skills, but to develop a feel for the exams too. In this chapter, as I have done throughout the book, answers are provided that demonstrate the content and the skills both MFDS and MJDF examiners seek to gain from a successful candidate. In many of the cases in this book, the level of detail will be sufficient for the SCR component of the MJDF too. Yesterday, I took a day off from writing to attend an all-day seminar in London organised by the Faculty of General Dental Practice. If I could distil several hours of Continuing Professional development into a few words for you then these words would be: ‘In dentistry, things must be simple or they simply must not be.’ Now that I have saved you a whole day of study, you can get on with the next two questions and in these next two questions, as mentioned above, I will keep things simple. Introduction The next patient you have to see is new to the dental practice you work in. He is a middle-aged married man; he works in a bank and has two teenage daughters, who are now bringing their future ex-boyfriends home with them. He feels stressed by all this and tells you that he both grinds and clenches his teeth while at work and at home too. A medical history form was completed today and there are no contraindications to outpatient dental care. You can see from the forms he has completed that he does not smoke at all and only drinks
occasionally. His problem is that he has dental pain, but he isn’t quite sure where the pain is coming from. The actor tells you this pain has been bothering him for four days now. This dental problem does not bother him as much as his children do for taking out increasingly large loans from the ‘Royal Bank of Dad’. The patient has only managed to see you today, as this is the first available appointment you had. In addition to this pain, the actor tells you that a few days ago a piece of tooth had broken. The tooth from which the piece has broken off was restored extensively with a silver filling covering most of the tooth. The filling was of mercury amalgam extending across the mesial, occlusal, distal, and buccal surfaces. The actor tells you the tooth is discoloured, being broken in several places, and has small cracks across the biting surfaces. The missing piece is from the front inside (mesiolingual cusp). The tooth is not mobile at all, and the patient does have a good level of oral hygiene. The cusps of the premolars and molar teeth in the mouth are extensively restored and worn. You are not surprised (or should not be) when the patient tells you he wants to keep the tooth. The patient tells you he has kept the small piece of the tooth that has broken off and asks if a repair can be done today with the broken piece being reattached. The pain he experienced is present when cold water or hot food and drink gets on or near the tooth; this pain does not last long, and there is no pain when biting down on the broken tooth. Questions for Clinical Case 40 1. Introduce yourself and confirm the details that are necessary for you to begin a consultation. What information do you need to know in this case? 2. Define ‘clenching’ and define ‘bruxism’. 3. From the introduction, what do you note has been going on, what has been the effect, and what has been the result of this? 4. Which questions might you ask to gain information and insight into what is going on here? 5. What do you have to develop in your consultation with the actor in order to understand this patient’s problems? 6. How might you explain to the actor/patient what has happened to his tooth? 7. How can you explain to the patient the symptoms reported in terms of what is going on with his tooth? 8. How can you be sure the pain present is coming from the broken tooth? 9. What might happen to the nerves in this tooth? 10. What is the treatment option you might reasonably consider for this tooth? 11. Can you describe the procedure you might carry out on this tooth on the first visit? 12. Why might subsequent visits be necessary and can you describe what you might do in the following visits?
13. What is the rationale behind recall and review before you go to definitive restoration of the tooth? 14. If the tooth remains painful at recall visits what procedures and materials might you use? 15. Which restorative materials you might use for a permanent restoration to this tooth, and what are the advantages and disadvantages of these in this case? 16. How would you explain your choice of restorative materials to the patient? 17. At the first visit, can you give a prognosis? 18. In the first visit what information is important to tell the actor/patient and why? 19. What other dental treatment should be considered at the first visit? 20. Given the causative factors in this case, what other treatments might you consider? Is there a need to involve others in the care of this patient with these options? Answers for Clinical Case 40. 1. After you have introduced yourself to the actor, and you will gain marks for doing so professionally, it is important to confirm with the actor that the medical, dental, and social histories all present no problems for you to look after them as a patient today. Next, go on to ask about the pain or problems the patient might have. From the introduction, you have read that he has dental pain, but he isn’t quite sure where the pain is coming from. You know a tooth has broken, and the cusps of the premolars and molar teeth in the mouth are extensively restored and worn. Again, this is important information in this case. From the information in the introduction, you will need to ask if there are adverse patterns of eating, grinding of teeth, clenching, or bruxism. Points to Note a. Very few patients know the difference between clenching and biting, even less know what bruxism is. b. In an exam question such as this, it is important to use simple terms. 2. Sensible definitions of these terms you can use in the OSCE are as follows: Clenching: There is increased muscular activity but no movement of the lower jaw as the teeth and jaws are held together in an intercuspal position (ICP) by the muscles of mastication. Bruxism: There is increased muscular activity and the teeth are being ground against each other as the muscles contract and relax. The teeth in the jaws move from ICP to a position within an envelope of movement then return to an ICP again. Within bruxism, there is clenching activity; in clenching, there is no bruxism. Both are movement disorders of the masticatory system characterised by teeth grinding and clenching when asleep and while awake. In some studies, nearly one in three people display these conditions.1 3. From the introduction, you can deduce the following information:
The patient tells you that he both grinds and clenches while at work and at home too. Over a period of time, the patient has developed parafunctional habits. These have been caused by the social and family stresses detailed in the introduction and were sufficient to cause increased tooth wear and eventual failure by repetitive cyclical overloading and unloading of an extensively restored and weakened tooth. 4. By using clear terms to ask the patient if they have noticed, or their partner has noticed (i.e. heard) anything such as grinding of the teeth or if they have any pain in the muscles of the cheeks, head, or neck, you can gain more information about the factors initiating the problem seen in this case. Nocturnal bruxism 1. In response to your line of questioning, the actor tells you he does not have any muscle pains in his head or neck, but his noisy night-time tooth grinding has woken his wife and she sleeps in the next room. 2. He adds that this has only just begun to happen recently. 5. You need to develop a rapport with the actor as you would with any patient. From this, you might learn that the recent nocturnal bruxism will have been precipitated by a specific event. In this case in response to your questions, you learn that the following occurred: ‘My youngest daughter asked to borrow some money to go on holiday with her boyfriend, and then she asked if she could borrow my car too. At that point, I bit down hard and my tooth just snapped… I mean it just clean broke…’ ‘With all the money you dentists are going to charge me, it would have been cheaper just to hand her my car keys and my credit card and be done with it.’ Although you do not have to respond directly or immediately to this remark, some paraverbal nodding and non-verbal communication is important in both the MFDS and the MJDF OSCEs at points like this and an empathic: ‘I can see you haven’t been looking forward to this visit’ Is all that is needed before carrying on by using appropriate empathic body language. You need to acknowledge that the character in this OSCE is under considerable stress. 6. You might tell the actor that the tooth has broken not because of one event, but as a result of several events. These events were adverse biting forces over a long period of time that have continually weakened the last standing cusp. You can continue by telling the actor/father/patient in this OSCE: ‘After hearing your daughter’s request, the natural reaction of a father to clench his teeth together was to be expected, and perhaps with hindsight, the last cusp snapping off the tooth could be predicted.’ A filled tooth will always be weaker than an intact healthy natural tooth. The broken tooth was always vulnerable and at risk of this event happening under normal circumstances. The reaction to a stressful demand has resulted in a potential outcome becoming an actual one. 7. In explaining the findings to the patient, you should relate these to the symptoms about which the patient has told you. The symptoms in the introduction are from inflammation of the pulp; explain
this as the inner part of the tooth where the nerves and blood vessels are, explain to the actor; this is pulpitis. The symptoms of poorly localised dental pain that does not last long, quickly fades, and doesn’t wake the patient at night but reappears on exposing the broken tooth to a hot or a cold stimulus (sweet foods are another source of pain not reported in this case) are all indicative of a reversible pulpitis of the tooth. 8. Although the patient cannot localise the pain to a specific tooth (principally because the dental pulp contains no proprioceptive nerve endings), we can be certain that the tooth that has broken is causing the pain. The patient was not in pain before the last remaining cusp on this tooth fractured. 9. The broken tooth only causes pain when exposed to hot and cold stimuli and from this you can advise the actor the nerves in the tooth are alive. If the tooth had no viable nerves, it would be dead and the patient would feel no pain as the last cusp broke off. Nevertheless, there is a risk of the pulp tissue becoming infected and dying if appropriate dental treatment is not carried out fairly promptly. 10. The enamel of the last standing cusp has broken, exposing the dentin underneath; this is not such an extreme dental injury and the actor/patient should be advised of this. The tooth can be restored, and a temporary restoration can be completed in the first visit. Even though the tooth is painful to both hot and cold stimuli, the nerves are not exposed by the break. You can advise the patient as follows: The first thing to do would be to take an X-ray (radiograph) of the tooth. From the results of this, we can find out how much of the tooth is filled and how close the break comes to the nerves. An X-ray will also show if the roots and bones around the teeth are healthy and the level of remaining bone support the tooth has. All of these are important to know when planning the options for restoration. If two radiographs are taken from two different angles, then any fractures in the crown or root can be seen. Two views are needed as a fracture line perpendicular to an X-ray beam will not be seen on the film. 11. In the initial visit, the tooth will be cleaned, and any decay or other broken material will be removed. Then a temporary filling will be attached to the exposed surface of the tooth where the break is. The most appropriate temporary filling material to use would be a Glass Ionomer. You would tell the patient this is a tooth-coloured material which attaches to both the remaining silver filling and to the surface where the tooth is broken. In doing so, the tooth would be sealed off and the risk of bacterial infection that might result in root treatment would be minimised. After this first visit, a recall and review would be necessary for a definitive permanent restoration to be placed. 12. After a period of a week or so the patient will need to re-attend and a clinical review of the tooth would be needed to see if the sensations of pain from hot and cold stimuli have diminished or if they have gone completely. If the symptoms have diminished, then the initial restoration has been appropriate. If the sensations have gone completely, then the initial assessment and dental work was appropriate or the nerve in the tooth may have died. The patient should be advised that future and repeated testing of nerve function is needed. These tests can be those using an electric pulp
tester, ice sticks, ethyl chloride, or heated gutta-percha applied to the crown of the tooth. Explain to the actor in this OSCE, that if the nerve has died, then root treatment will be necessary. But if the nerve is still alive, then regular recall is needed to assess the state of the nerve until it either dies or continues in its current state. 13. The rationale for such recall is that with an extensively filled tooth, the definitive restoration would be one completed using a crown or an onlay covering all, or the majority of the tooth. Given the cost and extensive nature of this work, it is important to know how healthy the roots are underneath a crown or an onlay. It is essential to know if a tooth needs a root treatment and, if indicated, to complete this treatment before, rather than after a crown or onlay is fitted. As root treating a tooth after a crown is placed means either removing the crown or drilling through the crown. Both options are not ideal and can be avoided if we know before permanently restoring the teeth what the chances of root treatment will be. These outcomes should be explained in this OSCE. 14. If the tooth remains painful at recall, then another dressing would be placed to calm the nerves in the tooth. This material may contain a zinc oxide and eugenol dressing, and at recall, if there is any decay left in the tooth, this should be removed. 15. In this case, we need to consider the following factors: a. The tooth is extensively restored. b. The patient has a parafunctional habit of clenching and biting. c. The dentition is worn. Then, the most appropriate restoration would be a cast restoration using precious metal alloys. The specific choice of alloy for the restoration should be on the basis of your understanding of the alloy systems used by the dental technician, its biocompatibility, and the specific site of application intraorally.2 The reasons for being fastidious in such restorative choices are the metals used in the other restorations present in this patient may result in galvanic corrosion, taste disturbances or mucosal lesions developing if the alloy is incompatible with other materials or the patient’s oral mucosa. 3,4 We will return to this particular issue in Clinical Case 43. Of course, a crown can be made from other materials too such as those using resin or polymers, but their limited longevity and high cost mean they are often not viable. Patients often seek an aesthetic as well as a functional solution, and cast restorations using metal-free materials such as lithium disilicate are available. However, their use in this case might be precluded by the patient’s parafunction. If applied in this case, even though modern ceramics are fairly resilient materials, they could be prone to breakage well within the expected service life of the crown.5 16. The choice of materials for a definitive restoration can be explained to the patient in the following clear terms: a. If a metal-free crown is used, although it would initially appear natural and feel comfortable to begin with, in time, the polished biting surface will become rough like the bottom of a cup. The
crown could also break, or worse still, it might cause the excessive wear of the teeth against which it is biting. b. Crowns where porcelain is bonded to metal would not be recommended for this case. This is due to risk of the porcelain breaking off and exposing a metal core that can react with the other restorations present. The metal cores used in these crowns are made from non-precious alloys. c. Porcelain, despite modern advances in ceramic technology, is brittle and it does not easily bond to any form of alloy substructure intended to impart strength to a restoration. d. The use of a precious metal alloy crown is preferred; despite not looking natural, this material more closely matches the physical properties of natural teeth than metal-free crowns. e. Precious alloy crowns are expected to last for many years and are more predictable in function, not being prone to breakage. From the above choices, you can advise the patient that a tooth which is in the back of the mouth and which has been filled repeatedly and has broken yet again, needs to be protected with a strong metal restoration and a precious alloy crown would be the ideal option in their case. 17. The prognosis is difficult to determine at the first visit, especially if there are no test results such as radiographs or vitality testing to back up your thoughts on what will happen next. Point to Note a. In an OSCE if the actor or examiner pushes you to give a prognosis in the absence of test results, you should defer from giving an opinion until you have all the data you need. b. The nerves in the tooth are alive but there is a risk of the nerves becoming infected and dying if appropriate treatment is not carried out. c. This should be explained to the patient as the chance of needing a root treatment is fairly high. In an extensive review of over 47,000 crowns, Burke and Lucarotti (2009) found over ¼ required reintervention with 1/8th of these being root treatment. Other treatments were re-cementation of the crown, replacement with another crown, or extraction in nearly 1/5th of all re-interventions.6 Overall Prognosis a. The MFDS and MJDF revision courses quote figures of 5% to 20% for re-interventions. b. I think no one would criticise you in the OSCE for stating to the actor that from one in twenty up to one in five cases where a tooth has broken, subsequently needed root treatment after crowning. c. These figures are based on those quoted in revision courses and from the evidence accumulated from dental practice. 18. In the first visit, it is important to give information such as the figures noted above for treatment outcomes to your patients in real life as well as the actors in OSCEs. Doing so demonstrates you are a prudent practitioner conscientiously advising a prospective patient. As we have learnt in Clinical Case 38, before you gain consent for treatment, it is one of your duties to inform the patients of the risks and potential outcomes from treatment you might consider providing. If such
figures based on clinical evidence are not given, then the consent you seek for treatment is not informed and, therefore, it will not be valid. In the treatment planning stage, it is important to gain consent and that consent has to be informed. 19. The other options for treatment are to maintain oral hygiene, give diet advice if needed, and then to refer to a specialist for advice on providing an appropriate form of protective night-time bite guard to limit the damage to the other teeth. If the pulpal symptoms from the tooth remain a confounding or confusing issue, then referral to an endodontist would be indicated. 20. You might consider a fitting a bite guard or splint for this patient yourself. In the UK, in general dental practice, many bite guards and removable splints are provided on very questionable clinical grounds. Such appliances are provided both as NHS or private treatment options. Although there may be a need to prescribe such measures, there is limited evidence to support their use in achieving the successful cessation of nocturnal bruxism as noted in this case. In one published case, a night guard was implicated in causing and not curing the symptoms associated with bruxism.7 If their use is to be considered, then the input of a specialist dental practitioner would be needed. In this OSCE, any further treatment options beyond initial assessment, basic temporary restoration, and definitive repair with a cast crown in the absence of confounding symptoms would be within the domain of the specialist, and therefore, referral is clearly indicated. Further Notes to Clinical Case 40 This case deals with a failure of an extensively restored tooth due to functional overload following the repeated stresses of parafunction. The definitive restorative option you provide has to be stronger than the existing amalgam alloy that was retained by mechanical means only. These mechanical means can be those ghastly dentin pins favoured by any dentist who graduated in the last century and any species of oral bacteria as they speed down the pins which are like the hard shoulders of microbiological superhighways to the pulp. Alternative means of mechanical retention are excessive cavity undercutting, undermining any remaining cusps. These are favoured by every species of dental student hacking away the cusps to leave them standing like the four chalk needles off the Isle of Wight. (There are now only three left of these left, as one fell down because of undermining erosion and not dental student activity.) The other example often touted to celebrate excessive undergraduate undercutting is to proclaim a crown preparation or cusps left standing after a cavity preparation to be like the Old Man of Hoy. In defence of undergraduates, this is a questionable comparison as the Old Man of Hoy has been standing for over 400 years and continues to do so. If our work was as durable as this Scottish sandstone sea-stack in the Orkneys, dental patients would have nothing to complain about. Although a cast restoration is preferred as the definitive and permanent solution, another interim measure that works very well is the use of adhesive resin or composite material. Such solutions do work; however, the ability of an acid-etched resin material to adhere to mercury-based amalgam or
dentin surfaces in close proximity to the pulp is limited. Additionally, bacteria are commonly found in the not-so-microscopic gap between a composite filling and dentin and in the interface between the composite and the amalgam. Leakage may occur, and some quite paradoxical pain is common after placing composite fillings. For these reasons, I have not suggested use of this material in this case, but I accept they are used frequently in the dental clinic. If you are going to suggest their use, then do so with an awareness of the potential that resin materials and etchant gels can irritate an inflamed pulp.8 Theoretically, if not actually, if an impermeable seal can be achieved between dentin and an adhesive restoration with a bonding agent, any inflammatory products and dentinal tubule exudate might be trapped, exacerbating the symptoms of pulpitis reversible or otherwise the patient already has. When considering a definitive restoration with a crown, or an onlay, the preparation has to be suitably retentive and the extent of preparation based on radiographic findings. A supragingival or subgingival preparation may be considered to further aid retention. If the latter is planned, then a crown lengthening procedure with encroachment on the gingival margins and viable periodontal tissues is needed. This has to be explained to the patient with the need for them to maintain scrupulous oral hygiene and demonstrate continued absence of periapical pathology, before during and long after your treatment is completed. References to Clinical Case 40 1. Manfredini D, Winocur E, Guarda-Nardini L, Lobbezoo F. Epidemiology of bruxism in adults: a systematic review of the literature. J Orofac Pain. 2013 Spring;27(2):99-110. 2. Givan DA. Precious metals in dentistry. Dent Clin North Am. 2007 Jul;51(3):591-601. 3. Roberts HW, Berzins DW, Moore BK, Charlton DG. Metal-ceramic alloys in dentistry: a review. J Prosthodont. 2009 Feb;18(2):188-94. 4. Koch P, Bahmer FA. Oral lesions and symptoms related to metals used in dental restorations: a clinical, allergological, and histologic study. J Am Acad Dermatol. 1999 Sep;41(3 Pt 1):422-30. 5. Gonzaga CC, Cesar PF, Miranda WG Jr, Yoshimura HN. Slow crack growth and reliability of dental ceramics. Dent Mater. 2011 Apr;27(4):394-406. 6. Burke FJ, Lucarotti PS. Re-intervention on crowns: what comes next? J Dent. 2009 Jan;37(1):2530. 7. Strahlendorf J, Schiffer R, Strahlendorf H. Unilateral or ‘side-locked’ migrainous headache with autonomic symptoms linked to night guard use. Headache. 2008 Nov-Dec;48(10):1537-39. 8. Geurtsen W. Biocompatibility of resin-modified filling materials. Crit Rev Oral Biol Med. 2000;11(3):333-55. Further Reading 1. Mitchell L, Mitchell DA, McCaul L. Chapter 6: Restorative Dentistry. Dental Pain. In Oxford Handbook of Clinical Dentistry. 5th Edition pp. 220-223. Oxford: Oxford University Press 2009.
A good short chapter with the essential data you need to refer to when faced with clinical symptoms. 2. Scottish Dental Clinical Effectiveness Program. Management of Acute Dental Problems. Quick Reference Guide for Health Care Professionals. Dundee: NHS Scotland. [Online] Available from: http://www.sdcep.org.uk/index.aspx?o=3158 [Accessed June 2013]. Up-to-date information source readily available in an easy-to-read format. 3. Yip K, Smales R. Chapter 19: Reviews and Maintenance of Restorations. In A Clinical Guide to Oral Diagnosis and Treatment Planning. pp. 169-177. London: BDJ Books 2012. 4. Davies SJ, Gray RJM. Chapter 3: Good Occlusal Practice in Simple Restorative Dentistry. In A clinical Guide to Occlusion. pp. 23-35. London: BDJ Books 2002. 5. Gray RJM, Davies SJ, Quayle AA. Chapter 6: A Clinical Approach to Treatment. In A Clinical Guide to Temporomandibular Disorders. pp. 31-36. London: BDJ Books 1999. If you are planning any splint treatment on a patient, you should read the above three introductory texts on the subject. This is well-written and well-illustrated material that should help to clarify any problems you might face.
Clinical Case 41 Background Information Here you go with another restorative OSCE with more loss of tooth tissue. In this case, there are different reasons for this. Once again, these scenarios do commonly appear in the exams, reflecting the frequency with which they commonly appear in real life. You will most likely have tackled several cases like this, so I have set out this example as you may find it in the MJDF with answers to the questions the examiners will be looking for. With your clinical experience, most of the information in this case will be familiar. Without too much difficulty, you can easily revise the information needed to pass an MJDF OSCE. While the MJDF approach to answering the question may be different from the MFDS, when, and not if, you are examined on this subject in that exam, you can easily incorporate your knowledge and experience of patient care into your dialogue with the actor during an OSCE in that exam too. Anyway, this case is based on the MJDF exam, together with someone I met outside the Royal College of Surgeons in Edinburgh when I dived in to pay my dues in summer last year. When I surfaced, I found this fellow fixing a ticket on my faithful but raggy old car, badly parked on the cobbles in Hill Square. I can tell you this is the only time I had grounds to appeal anything at RCS Edinburgh. So we got chatting about his job and mine, and well, you know, no one really likes to see a dentist or a traffic warden at work. He told me all about his experiences with dentists, and I told him all about mine with traffic wardens, like the one I was having right now. So I gave him some advice and told him to go round to the Edinburgh Dental Institute for treatment,
(kind of like a verbal referral), and he gave me some good advice on how to get my parking ticket cancelled (and all future ones cancelled too). I hope the advice I gave was as good as that which I received. Therefore, I would like to dedicate this OSCE to this traffic warden as he tickets cars and if you get ticketed outside RCS Edinburgh, Glasgow, or England, or anywhere, then my advice to you is: Be kind (you’ll get off). Introduction A patient comes to see you for a routine dental check-up, and he is happy with the appearance of his teeth. You are not. The patient is a 29-year-old traffic warden, and although he deals with the members of the public on a daily basis, both his clients and he do not have much to smile about or in his case, with. Extra-orally an examination has demonstrated that there are no problems with the TMJs (temperomandibular joints), although the patient seems to adopt a forward posturing of the mandible to bring his teeth together into incision. Almost all the posterior or buccal segment teeth have been extracted from the upper and lower jaws. The few remaining posterior teeth are periodontally sound, but not in functional occlusion with opposing teeth. With no occlusion, the remaining unopposed teeth are now a little over-erupted. Several years ago, PMMA dentures were provided to replace the missing teeth, but these were never worn. The patient tells you that the upper denture kept dropping down, and when he tried to bring his teeth together, the dentures kept ‘banging’ into each other, so now he does not bother any more. He tells you that he has thrown these contraptions away. The loss of posterior teeth, the non-wearing of plastic partial dentures, and the anterior tooth wear have now resulted in a pseudo-Class lll appearance. The patient naturally has a Class l skeletal relationship, but to achieve incision and occlusion, a Class lll posture has been adopted over some time and this now comes quite easily to the patient. Despite this mandibular posturing forward, the patient does not appear to be over closed or to have any loss of lower vertical facial height. Unfortunately the pseudo-Class lll appearance gives the patient a somewhat aggressive facial appearance. On examination, intra-orally there is excessive tooth wear that is greater than that which you would expect for a man of his age. The upper and lower incisors, canines, and premolars are excessively worn down, almost to the gingival margin. The result is these teeth have short crowns, appearing wider than they are tall. There are clearly defined wear facets on the anterior teeth, which interdigitate when in occlusion. There are some deposits of plaque and calculus around the lingual gingival margins of the lower teeth, with cervical decay seen labially in the canines and bucally in the premolars. Despite all this, overall, the oral hygiene is good. For the avoidance of doubt in this OSCE, the following contrived additions to the scenario have been applied: If you could see the dental records, you would see that despite some teeth being nonfunctional and others being excessively worn down, all the teeth are vital.
If vitality testing was to be undertaken, then all the teeth in this OSCE would be vital. Questions to Clinical Case 41 1. How will you begin this OSCE, what questions might you ask, and what symptoms might you need to know about? 2. Other than abuse from members of the public, what else is this traffic warden suffering from? 3. What is your initial working diagnosis? 4. What are the three processes contributing to the condition the patient has? 5. Is there likely to be another process taking place and what might this be, should this be mentioned? 6. What investigations might you start with? 7. Is diet an important factor in this case? How will you investigate this, and what do you expect to find? 8. From this analysis, what might be the next assessment you could consider? 9. After assessing the data you have, what other means of assessing tooth surface loss and remaining tooth can you use? Can you provide specific details on the means to do so and views you would take? 10. Lastly, is there anything else you can rely on to assess tooth surface loss? 11. From the information in the introduction and from the answers to your questions, what are the two most likely causes of tooth surface loss in this patient? What are the signs you might see which will confirm your diagnosis? 12. Before going on to discuss treatment options, what do you need to measure and why? What else do you need to know about the remaining teeth before deciding how to restore them? Please note, as mentioned above, all the teeth are vital and are not endodontically or periodontally involved in this case. 13. The two schools of thought in treating a case such as this are conformative and reorganising. Please explain what is meant by these two terms. 14. If you choose to reorganise the occlusion, what might a specialist or you, working under the guidance of a specialist, utilise to create inter-occlusal space for restorations to be placed? 15. How does such treatment work? 16. Are there other specialists or dental professionals you might include in your care for this patient? 17. How can you utilise more of the remaining tooth structures you wish to restore? What techniques might you use? Would such techniques be within the ‘conformative’ or ‘reorganising’ approach? 18. In the treatment of your patients, not just this case, would you undertake a reorganising approach? If so, why? If not, why not? 19. What are the two choices for the patient in this case, and how can you present these to him? 20. Which treatment option would be indicated in this case, and which treatment option would you
follow? Answers to Clinical Case 41. 1. After completing your professional introductions, it is important to briefly go over the medical and medication histories, if only to confirm they will not be drawn into the management of this case. In your history taking, it is important to take a note of the patient’s social history too. The patient you are dealing with here does not have an easy job and will be under considerable stress, so an understanding and empathic approach is needed if an actor is involved in the case presentation. Despite the stress of work, there are no TMJ problems. You can ask if any other symptoms are present. These are pain in the muscles of mastication, neck pain and headaches. As these symptoms are commonly associated with the dental problem the patient has presented with, you do need to ask about these. In this case, none of these symptoms are present. 2. From the introduction, it is clear that the patient is suffering from excessive tooth wear. Tooth wear is a natural physiological phenomenon occurring throughout life. However, the rate of tooth wear seen here has exceeded the compensatory mechanisms of over-eruption and alveolar remodelling in the maxilla and mandible. So the degree of tooth wear in this case is not physiological. It is pathological. 3. The answer to this question is that we can give an initial working diagnosis that the patient is suffering from tooth surface loss. Principally, this is non-carious tooth surface loss. Additionally, as noted in the introduction, there are some Class V cavities in the teeth and deposits of plaque and calculus; the oral hygiene in this case, like so many others you will see, can benefit from improvement. So you may add that there is gingivitis too. 4. In diagnosing tooth surface loss, three classic underlying processes should be stated to the examiners, and for the sake of completeness, these have to be defined as below: a. Erosion. This form of tooth loss is caused by acid from food or the stomach. The wear facets seen on the teeth are indicative of this process being involved in tooth loss. b. Attrition. Teeth wearing against each other causes this form of tooth loss. In this case, there are no signs of TMJ pain, discomfort, or hypertrophy in the muscles of mastication. These symptoms are often associated with the processes of attrition as bruxism or other parafunctional habits can cause increased wear of both upper and lower teeth as they are ground together. c. Abrasion. A material (other than another tooth) wearing the surfaces of teeth causes this. Such materials can come from the diet. Abrasion can also be caused by excessive wear from the surface of a restoration such as a porcelain crown occluding against enamel. In this case, there is nothing in the introduction to suggest that the traffic warden has an unusual diet or that there are restorations causing abrasion. However, in an OSCE, this cause should be excluded by specific questioning of the actor about his dietary habits, and the dental history should be checked to determine if porcelain crowns are present. In this case, erosion from dietary acids followed by attrition is the most likely cause of the tooth
surface loss. 5. In the introduction, the presence of Class V buccal cavities were also noted, so the process of abfraction is likely to be present too. Abfraction is abrasion and fracture of enamel and dentin. The abrasion—fracture lesion is thought to be caused by cycles of occlusal loading and unloading during occlusion. This induces flexing and fracturing of enamel in the cervical areas of the teeth that are abraded by excessive or incorrect tooth brushing. Dietary acids and caries are often involved in the development of Class V cavities.1-3 This cause of tooth surface loss needs to be mentioned to the actor, and the causative factors must be mentioned to the examiners. Point to note. There is over thirty years research on the subject of abfraction and the aetiology of the Class V cavity. For the MJDF SCRs, a good recall of the conclusions from published research on the subject is important as this clinical phenomenon is fairly common and thus commonly examined on. 6. In a case of tooth surface loss, the first and easiest thing to investigate would be the patient’s dental notes. In any OSCE, always start with the investigation which has the least impact and lowest cost, and this will be a thorough revision of the patient’s dental history. Although the patient is a regular dental attender, the notes reveal no more than the patient is fit and well, takes no medication, and there are no contraindications to outpatient day care. 7. Following a review of the dental history, dietary analysis is extremely useful. In this OSCE, the actor/patient can be asked about his eating habits not only during work but at home too. He tells you that he regularly drinks carbonated sports-type drinks eating chocolate bars as he runs around the streets of Edinburgh ticketing cars, he needs to keep his energy levels constantly high. This is due to the need to run off when the owners of the cars he has just ticketed try to catch him. At night, he runs for the local running club, and he drinks more energy drinks at bedtime. The traffic warden’s diet is as high in sugar as his working life is high on excitement and adrenaline. So acid erosion is likely to be a significant cause of his dental problems. 8. The further investigations you might consider are as follows: Clinical photographs—these are useful to determine the progression of tooth surface loss, especially so if a series of photographs were taken over a long period. The reality in general dental practice in the UK is that patients move from one practice to another, as do dentists. It would be very rare to have a longitudinal series of photographs from which you can compare the rate at which tooth loss has progressed over the years. However, with the advent, advantages and ease of digital photography, you can suggest that intra-oral photography might be used. Clinical photography a. This would be subject to the rigorous data protection measures needed to safeguard the patient’s
identity. b. Consent forms need to be read, understood, and signed if digital photographs were to be taken. 9. Following from photographs, radiographic assessment is the next level of investigation you might consider. Where available, it is best to use existing radiographs and to make comparisons with appropriate views. Aiming devices should be used to enable direct comparisons to be made. If no existing radiographs are available, then the following views might be used: Intra-oral long cone periapical views of the remaining anterior teeth. Such views as necessary to capture as many teeth in one exposure and will reduce the overall radiation dose to the patient. With this case, it would be incorrect to suggest the use of a dental panoramic tomography (DPT) view as there are few posterior teeth in the buccal segments. Radiography guidelines a. In the UK, The Faculty of General Dental Practice Royal College Surgeons (England), do give guidelines for the use of radiographs in their 2004 text Selection Criteria for Dental Radiography (see Further Reading section at the end of this Clinical Case). b. However, there are no specific guidelines dealing with the dental patient with tooth surface loss. The DPT is most useful for imaging the buccal segment dentition. However, the DPT image is also distorted through magnification, and the critical areas we need to look at in this case are not the buccal segments but the anterior labial sextants. In the DPT, this area will have superimposed ghost shadows from the cervical vertebrae, and accurate analysis of this area is almost impossible with a DPT. In this OSCE, you can state that selected intra-oral periapical views are all that are needed. These views will provide sufficient information on the condition of the teeth, the length of roots, the bone support remaining, and signs of any pathology in the dental and related tissues. 10. Finally, to complement the data gathered from the dental history, diet analysis, photographs, and radiographs; study models are very useful. Upper and lower study models mounted in the reproducible retruded contact position (RCP) in a semi-adjustable articulator are useful for the following reasons: a. If we can compare a series of study models taken in sequence, then we can learn about the rate of progression of tooth loss. b. The displacement from RCP to ICP (intercuspal position) can be determined, and this is useful for: c. Treatment planning the restoration of the worn teeth. Both aesthetic and functional increases in length and width of the teeth can be planned. Additionally, planning of removable partial dentures or other solution to replace (if necessary) the missing buccal segment teeth can be achieved by use of study models mounted in articulators. 11. From the results of the investigations and from the data in the introduction, the principal causes of the problems this patient has are acid erosion from a poor diet coupled to some attrition.
If you could examine the patient, this can be confirmed from the way the teeth meet. The upper and lower incisors now wear into each other’s incisal edges. Through continual wear and parafunction, these incisal edges have developed into worn occlusal surfaces with characteristic enamel splintering and detachment from the underlying dentin as a result of shearing forces. A closer examination of the teeth might reveal that the loss of tooth substance is not limited to the palatal surface only, so acid erosion from the stomach can be ruled out. Other than the abfraction lesions in the lower canines and premolars, the non-occluding parts of the teeth do not show excessive loss of enamel, and this is indicative of a tooth loss pattern caused by attrition and erosion. The absence of smooth wear facets means abrasion is not implicated to a significant degree in the loss of tooth surface here. 12. Before going on to discuss treatment options, we need to look at the vertical dimension the patient displays both at rest and when occluded. With the mandible posturing forward to enable the remaining teeth to meet and incise, the loss of posterior teeth means incision and occlusion are now the same—that is while the patient is biting, it may be possible, that he is functionally overloading the anterior teeth. The forces directed on to these teeth may further contribute or accelerate the tooth loss. With this process, there will be further loss of vertical height in the patient and loss of inter-occlusal space that may affect the treatment options available. The other important point we need to consider when planning treatment for this case is: How much of each remaining tooth can be usefully restored? In tooth wear cases, if we wish to rebuild the teeth to an original size, with compensatory overeruption, the remaining root structures might not support such extensive coronal restorations. With proportionately short remaining roots, a root length to crown height discrepancy will occur with unfavourable mechanical vectors causing failure in an unreasonably short time. 13. There are two schools of thought regarding treatment options we can follow in this case: a. The Conformative Approach Any conservation work is reparative only. This approach will preserve the existing occlusal pattern and maintain the occlusal vertical dimension in the current intercuspal position. This is a convenient approach for both the dentist and the patient. The advantages are the repair work is easy to complete. If the appropriate materials are used, the patient needs minimal adaptation to this approach. Since the occlusal dimension is to be preserved, there is a risk that the preparation of excessively worn teeth may breach pulp tissue covered by a thin remaining layer of dentin now exposed through enamel wear. The conformative approach is limited to single crowns, simple bridgework, and the possible use of removable prostheses to replace the missing posterior teeth. However, in most cases, with a conformative approach, the preservation of what is present rather
than the replacement of what is absent is practised. b. The Reorganising Approach The conservation work is both restorative and reparative. There will be an increase in the vertical dimension and the intercuspal position will change too. The mandibular teeth will be repositioned in a more retruded position relative to the maxillary teeth, enabling the creation of more vertical height. This retruded position becomes the new intercuspal position. Often a diagnostic wax-up and the use of study casts mounted in semi-adjustable articulators and perhaps computer-generated rapid prototyping of models will be used to assist in treatment planning. The reorganising approach means a significant increase in vertical dimensions of the teeth which are worn down. This increase can be achieved through use of indirect laboratory-produced restorations, such as crown and bridgework, coupled to replacement of missing posterior teeth with removable or fixed prostheses. Precision attachments retaining cobalt chrome dentures or implantsupported bridgework can be used. 14. The Dahl appliance can be utilised in this case to reorganise the occlusal relationship, creating sufficient inter-occlusal space in which definitive restoration work can be placed.4,5 15. The Dahl-Krogstad-Karlsen technique (to give the full name, but now referred to as the Dahl technique), first described in 1975,5 is the clinical use of an anterior bite plane fixed into place for 3 to 6 months to disclude remaining buccal segment teeth or any functional posterior teeth. When sufficient space is created, a posterior bite plane can be used, while the space created anteriorly is maintained with crown and bridgework and the new occlusal relationship is consolidated in the buccal segments. The use of Dahl appliances reduces the need to undertake extensive crown lengthening to make retentive preparations for indirect restorations such as crown and bridgework. The technique as described by Dahl is a differential eruption: intrusion technique using appliances cemented on to the incisal and occlusal surfaces of teeth. These techniques have proven to be useful in the reorganising approach to dental treatment.4 Point to Note 1. In both the MFDS and MJDF exams, a good working knowledge of how the Dahl appliance exerts its influence on the dentition and articulation is needed. 16. The inclusion of the input from a periodontal specialist and a hygienist in the overall treatment plan is needed. The specialist input ensures that the patient’s oral hygiene and gum health are maintained, especially if we consider the patient’s dietary habits necessitated by his need to maintain energy levels as he runs around ticketing cars. If we also consider the restorative options we might use in this case, before embarking on any complex treatment plan, then establishing, maintaining, and demonstrating good oral hygiene are essential. 17. Surgical crown lengthening might be considered so that the restored teeth are both functional and aesthetically pleasing for the patient. As mentioned in the previous answer, good oral hygiene and periodontal health are essential before considering any advanced restorative care for this patient.
Surgical crown lengthening only increases clinical height of the crowns by reducing the relative length of the roots. If, following restoration there is no increase in the patient’s occluso-vertical dimension (OVD), this is still a conformative approach. If surgical crown lengthening with additional restoration increases the clinical crown height and increases the patient’s vertical dimension, then this becomes Reorganising approach. 18. The reorganising approach is the domain of the specialist prosthodontist or a general dental practitioner with extensive experience of the subject, working under the guidance of a prosthodontist or within a hospital department. Of course, there are general dental practitioners with no postgraduate education in this field engaged in this type of dental work, and they can be split into two groups: Those who have already had clinical negligence claims against them, and those who are yet to have clinical negligence claims against them. 19. With respect to this case, the choices are to repair in general dental practice or to restore in specialist practice. The patient has no pain or discomfort. He only turned up for a routine check-up. It is important to document your findings and to do so comprehensively with clinical photographs, radiographs, and study models. The patient should be informed of the pathological processes occurring, the options he has for treatment, and the implications if he chooses not to have treatment. These choices have to be given in balanced and equal terms. There should be no bias in delivering your views. 20. The traffic warden is not bothered by the appearance of his teeth. Therefore, in this case, accepting the reduced vertical dimension and conservatively repairing the teeth is a start. On review and recall, a set of dentures either PMMA or cobalt chrome supported by the existing teeth and mucosa may reintroduce function to the posterior segments and prevent further eruption of the unopposed teeth. Given the history of poor compliance or limited success with wearing dentures, a simple solution such as the Every denture in PMMA retained with Adams Cribs on the remaining posterior teeth may be attempted. If successful, then after some time, progression to cobalt chrome dentures may be attempted with a stepwise approach to moving from simple repair of the anterior teeth to their restoration. In time, more complex options can be built into the conformative approach you plan for this patient. Further Notes to Clinical Case 41 When I met the character on whom this OSCE is based, I asked what he wanted to do regarding his dental treatment. He said to me: ‘Och, Ah cannae be bother’ aboo’t gettin’ mah gnashers seen tae as ah’ll ainly get ‘em punched oot by a punter.’
This may be translated into language applicable to your examination as follows: ‘The options for dental treatment you have provided for me today might not be applicable, given my social circumstances. As I remain at risk of frequent assault (and battery) from members of the public, with a risk of my suffering extensive dental trauma to any extensive and thus expensive restorative work you and your fine colleagues may plan for me.’ If faced with this response, you can always suggest a mouth guard, boxing lessons, or both. A more appropriate response in the safety-conscious litigious world we now live in is to accept his somewhat fatalistic if not realistic view and opt for the conformative reparative solution. Removal of decay from the buccal segment Class V lesions, placing Glass Ionomer in these cavities, and restoring the incisal areas with composite with rotary disc polishing of incisal fractures should prevent further propagation of fracturing in the enamel. In a case such as this, do not attempt to radically change too much too quickly. In time, the patient might just be steered round to accepting further treatment that may include restoration rather than just repair. References to Clinical Case 41 1. Grippo JO. Abfractions: a new classification of hard tissue lesions of teeth. J Esthet Dent. 1991 Jan-Feb;3(1):14-9. 2. Antonelli JR, Hottel TL, Garcia-Godoy F. Abfraction lesions—where do they come from? A review of the literature. J Tenn Dent Assoc. 2013 Spring-Summer;93(1):14-9. 3. Grippo JO, Simring M, Coleman TA. Abfraction, abrasion, biocorrosion, and the enigma of noncarious cervical lesions: a 20-year perspective. J Esthet Restor Dent. 2012 Feb; 24(1):10-23. 4. Poyser NJ, Porter RW, Briggs PF, Chana HS, Kelleher MG. The Dahl concept: past, present and future. Br Dent J. 2005 Jun 11;198(11):669-76. 5. Dahl BL, Krogstad O, Karlsen K. An alternative treatment in cases with advanced localised attrition. J Oral Rehabil. 1975 Jul;2(3):209-14. (The original paper on this ‘modern’ concept which is now nearly 40 years old) Further Reading to Clinical Case 41 1. Mitchell L, Mitchell DA, McCaul L. Chapter 6: Restorative Dentistry. Attrition Abrasion and Erosion In Oxford Handbook of Clinical Dentistry. 5th Edition pp. 268-269. Oxford: Oxford University Press 2009. A concise chapter on the subject matter covered in this case, this is quite good with all the basic information you need for ready reference while in the dental clinic. 2. Scottish Dental Clinical Effectiveness Program. Management of Acute Dental Problems. Quick Reference Guide for Health Care Professionals. Dundee: NHS Scotland. [Online] Available from: http://www.sdcep.org.uk/index.aspx?o=3158 [Accessed August 2013].
A readily available source of clinical information. 3. Kaidonis J. Chapter 9: Non-Carious Tooth Surface Loss and Assessment of Risk. In Yip K, Smales R. A Clinical Guide to Oral Diagnosis and Treatment Planning. pp. 72-81. London: BDJ Books 2012. 4. Davies SJ, Gray RJM, Qualtrough AJE. Chapter 9: Management of Tooth Surface Loss. In Davies SJ, Gray RJM. In A Clinical Guide to Occlusion. pp. 81-91. London: BDJ Books 2002. Well-illustrated and easy-to-read textbook. 5. Evans RD. Chapter 10: Orthodontic Options pp. 55-58. Ward VJ. Chapter 11: Surgical Crown Lengthening pp. 59-62. In Ibbetson R, Eder A. Tooth Surface Loss. London: BDJ Books 2000. In addition to the chapters noted, this textbook is essential reading on the subject of tooth surface loss.
Woody’s Work 42 Background to This Case Around about this time, at the start of summer last year, Dr M N Wood, specialist in Dental Surgery, Special Needs Dentistry, and examiner in his specialties gave me a couple of tickets to see the Boss play at ‘London Calling: Live in Hyde Park’. Tickets for this gig were so sought after, you would give your eye teeth for them, and Mike had just handed me a pair of front row tickets… Result! I agreed to trade clinical learning under Woody’s watchful eye in his Specialist Sedation Clinic in Luton for these two tickets. On reflection, that was a bit unfair on Woody as the experience and learning under his tutelage and guidance would be worth way more than two tickets to see Bruce Springsteen; it was like ‘heads I win tails you lose, Mike’ . . . Double Result!! Of course, Woody being both modest and a hardcore Springsteen fan, disagreed and thought Springsteen Live was worth way more than his ability to teach. So the deal was done. Woody mumbled at me (Mike always mumbles) to take my tickets and his greetings from Luton’s Bury Park and go listen to Springsteen’s greetings from Asbury Park. Woody was to the left of the stage, and I ended up down the right-hand side with about 50,000 others behind us. By eleven, the Boss and McCartney were on stage, and then someone had the bright idea of stopping the gig when the best was still to come… Dealing with the Anxious Child When placed in new and unusual surroundings, children of all ages become quite apprehensive. Working in dental clinics with children and their transmitted parental memories of unpleasant dental experiences is never going to be easy for the patient, their parents, or for you, the practitioner. Management of children can range from the verbal behavioural modification techniques to the pharmacological sedation techniques using inhalation or intravenous sedation. These techniques are useful in complex dental surgical cases where referral to a hospital clinic for a general anaesthetic is not deemed appropriate.
The fear of dentists in children usually arises from a fear of needles, so using a local anaesthetic is going to be difficult and initiating IV sedation is going to be almost impossible. The use of ‘inhalation nitrous oxide’ sedation in a very nervous child where a surgical procedure is needed is not going to be easy, but it does provide a way for making some progress in treatment delivery.1 In the hands of a specialist, several techniques currently being developed and trialled are now proving to be very useful in dealing with the anxious dentally phobic patient who needs to have a surgical procedure. Introduction to the Case A local general dental practitioner has referred a fit and healthy but dentally phobic 12-year-old patient for a ‘general anaesthetic’ to complete a surgical procedure as part of an orthodontic treatment plan. The child specifically has a fear of needles. In response to this, an alternative option to general anaesthesia was suggested to the parent, and consent forms were delivered, completed, and returned. The parent has now attended the sedation clinic to discuss the options with yourself. The orthodontic referral by the general dental practitioner was to seek the best treatment for two maxillary permanent canines ectopically displaced in the palate. The position of the canines was confirmed both clinically (the crowns of these teeth could be palpated under the palatal mucosa) and radiographically too. A dental panoramic (DPT) film with two periapical views taken demonstrated the canines to be palatal in relation to the incisors and premolars in the upper dental arch. The deciduous canines were retained and not mobile despite a dental panoramic radiograph showing their roots to be partially resorbed by the follicle of the advancing permanent canines. The skeletal pattern is Class l, and the permanent incisors are in a Class l relationship. The lateral incisors are quite small and peg-like. In common with the small appearance of these teeth and the palatal displacement of the canines, there is a degree of mild spacing in the upper arch. The upper first premolars are present, but as stated, the permanent canines are ectopic, being palatally displaced. Question on Woody’s Work In this case, explain to the actor portraying the parent of the child the nature of the dental condition their child has. After this, with respect to the latest guidelines, go on to discuss the various restorative, surgical, and orthodontic options for treatment of their child. The child is dentally phobic and was referred for a general anaesthetic as a dental outpatient, but in the options for treatment, another option other than general anaesthetic was mentioned. What is this likely to be? Point to Note This OSCE is presented as an MFDS type of question with a theme: Provide an Explanation, and a topic: Unerupted Canines.
Answer for Woody’s Work. In common with the other OSCEs, a polite professional introduction is needed. By now, you will have more than adequate clinical experience of politely and professionally introducing yourself to patients and their parents; doing so in an OSCE is no different. Do not forget that you are awarded marks for your professionalism as well as your communication skills in both MFDS and MJDF exams. In the MFDS OSCE, there will be clinical photographs and copies of radiographs that you can use to discuss the case with an actor who will play the part of the parent. This material will be present in the handout sheets you are given at the start of the exam. The contents of the referral letter and information present in any radiographs should be discussed with the actor. Explanations Any parent will be concerned that perhaps their child is missing something. In this case, the adult teeth are apparently missing. An explanation advising the parent that the adult teeth are not missing and they are present, but in the palate, is needed. This explanation can be achieved by presenting radiographs to the actor or parent and explaining where the canines are in relation to the other teeth in the child’s mouth. Radiography and Explanations 1. In most cases of referral for impacted or ectopic canines, the referring GDP will also send a dental panoramic radiograph (DPT or OPG). 2. This DPT can be used along with periapical views to demonstrate that the teeth are present and are of a normal size and shape but are in the palate and not yet in the mouth. 3. A combination of the DPT with PA radiographs can allow a parallax interpretation of the radiographs to localise the upper canines. 4. In a specialist dental clinic, the use of cone beam computerised tomography can precisely locate ectopic canines and other anatomical structures which might be missed with other radiographic techniques.2,3, 5. However, you need to be aware of the increased radiation dose with this imaging technique.4 The prevalence of the condition of maxillary impaction of canines should be given to the actor/parent. This is 2% (you can say: 1 child in 50 has this problem).5 You can explain that this tooth can become jammed or impacted on the way into the mouth. In your explanations, you can add, by way of comparison, that wisdom teeth are the most commonly impacted teeth. When canines are stuck on their way into the mouth, they are most commonly stuck in the palatal side of the upper jaws and less commonly on the outer side towards the lip of the upper jaw. Figures from canine studies The figures you can quote to the actor/parent are as follows:
1. In the general population, 1-2% of the population have stuck canines.5,6 2. These occur twice as frequently in the palatal side of the upper arch than on the buccal side7 3. Nearly 1 in 10 children with jammed canines have them on both sides of the mouth. 4. Lower canines seldom have this problem. 5. One clinical sign which leads us to expect the canines are stuck are small upper teeth.8 You need to advise the actor in this OSCE that from the age of 10 onwards, the path of eruption of the upper canines needs to be checked, and this can be done by finger pressure, checking the crowns of the canines as they descend down through the arch. If everything is proceeding normally, the canines can be felt as bulges in the gums under the lips. By the age of 12 in girls and 13 in boys, the maxillary canines should be erupting.9 Point to Note The expected eruption times of upper permanent canines are those from Hurme in 1949 and are still applied today; these are: 12.3 years in girls, and 13.1 years in boys. I have included these figures from an interest point given the age of the study and that these figures still being applied today.9 In this case, no bulges were felt. Therefore, the referring dentist took some X-rays, and we can now see the canines are displaced into the palate. If you could examine the patient and see the radiographs, you would see that the upper lateral incisors are quite small. So in the OSCE, you can point out this clinical finding to the actor and examiner. Continuing, you can explain that the size of roots of the upper second incisor teeth is important in the eruption processes. They are thought in some way to act as guides for the canines to follow as they pass into the mouth. Together with small crowns, the roots of these teeth are also quite small (this can be confirmed on the X-rays); because of this, you might suggest the canines have now become somewhat lost on their way down into the mouth, having no adequate guidance. As the OSCE continues, you should ask if there are any questions. If your explanations are clear, concise, and free from obscure terminology, you might continue by explaining the treatment options to the actor for their ‘OSCE-child’. Ectopic canines guidelines In this case with the absence of theoretical ‘naturally occurring guidelines’ (for the maxillary canines to follow), we might usefully refer to the practical 2010 FDS RCS (England) Clinical Standards Committee Guidelines for the Management of Palatally Ectopic Maxillary Canines.10,11 These guidelines are the possible treatment options graded on clinical evidence evaluated by the Scottish Intercollegiate Guidance Network (SIGN).12 Such evidence is evaluated as follows: Grade
Description
A
A body of literature including a Randomised Controlled Trial (RCT)
B
No RCT but well-conducted clinical studies.
C
Expert committee evidence and reports. Clinical experience from respected authority
The FDS RCS England guidelines and SIGN Grades with the best available evidence for each option applicable to this case are as follows: 1. Leave and observe. SIGN Grade: C 2. Extract deciduous canines. SIGN Grade: A 3. Surgical exposure and extraction of permanent canines. SIGN Grade: C 4. Transplantation of the permanent canines SIGN Grade: B 5. Surgical exposure and alignment of permanent canines. SIGN Grade: C 1. Leave and Observe The choices of treatment start with the simplest option of doing nothing—leaving the canines in place. However, these teeth will need to be monitored regularly as two problems may arise. Firstly, cysts may form. The surrounding teeth and their roots can be displaced or absorbed by such cysts. Secondly, the adult teeth may continue to erupt into the mouth, pushing other teeth out of the way or absorbing the roots of the teeth in their way. The final position these teeth end up in may not be ideal. If the option of doing nothing is chosen, there might be further restorative problems that would need to be addressed in the future. Doing nothing now means doing a lot later on The deciduous canines may need to be built-up to resemble adult teeth. This first option is not ideal as tooth-coloured restorative materials will discolour after a relatively short time. In addition, the roots of these teeth are already being resorbed by the advancing adult canines. So these primary teeth may not have a long time in function before they are naturally lost. It might also be an option if (or more correctly, when) the deciduous canines are lost, bridges can be used to replace them. 2. Deciduous Canine Extraction Removing the deciduous canines is an option thought to accelerate the descent of the permanent canines. However, in a literature review and meta-analysis, some doubt has been expressed about the validity of this.13 Therefore, even though the SIGN grading is the highest possible to support this option, the latest RCT evidence would seem to contradict this. If the deciduous teeth are extracted and the canines do not erupt, the spaces will need to be restored with bridgework. You need to explain in an OSCE to the actor that the bridges you refer to are porcelain teeth bonded to metal frames or wings, which are then glued to the backs of the teeth either side of the missing ones. You might also add that it is better to use one wing rather than two with the porcelain tooth being attached by one side only to this wing (cantilever bridge design). If considering fitting bridges, we would assume the canines would be left in the palate and no further eruption or
cyst formation would occur. However, continued eruption may occur, and this would be monitored. Pause to ask if there are any questions. In an SCR or OSCE, the examiner or actor may press you on the point of why you would prefer a cantilever design rather than a double-wing single pontic design. If asked, you can explain the rationale behind this is that if one wing debonds and the other does not, there is a significant risk of decay to the tooth underlying the debonded wing. From clinical evidence, debond of one wing but not the other is commonly seen, so the bridge stays in situ. From this observation, it is now thought more appropriate to use cantilevered resin-retained bridges, where it is favourable to have debond rather than decay. There are many complexities in bridge design and many mechanical and biological factors to comprehend when prescribing such a restorative option.14 After checking your answer is understood, continue with the next option. 3. Permanent Canine Extraction The third option would be to remove the permanent canines surgically, leaving the milk teeth (deciduous canines) in position. This procedure would mean the extractions are completed under intravenous sedation and local anaesthetic in a specialist outpatient dental practice or referral to a hospital for a general anaesthetic. With such a procedure, there is always a risk that adjacent teeth and vital structures might be damaged during the procedure. The erupting canines are already resorbing the roots of the deciduous teeth, so the chances of their remaining in the mouth for as long as adult teeth, is already limited. Once more we may consider fitting bridges to replace the deciduous canines when they are lost. Again, pause and ask if there are any questions; if there are none continue with the fourth option. 4. Canine Transplantation The canines can be moved (or transplanted) into the correct position, but this can only be done if there is adequate space. In this case, there is upper arch spacing and the deciduous canines are narrower than the adult teeth. This option might result in the permanent canines needing root treatment as their nerves might not survive a rapid move. This is because the blood supply to these teeth will become detached and the pulp will not revascularise. You can explain this in the OSCE as the blood supply to the pulp being cut off and the chances of re-attachment are very low. Even if the blood supply is not cut off, it may become strangled if the teeth are surgically rotated into their new positions. Other complications are, following this transplantation, the teeth may become stuck to the bone in the position they are moved into (this is fusion or ankylosis), and with further growth of the jaws into adulthood, such transplanted canines will look quite out of place. For these reasons, you can suggest transplantation is not a realistic option in this case. Despite these complications, the SIGN Grade of A suggests this option is supported by a wealth of evidence.
The contradiction in terms of it’s SIGN Grade C is the last option but is perhaps the most appropriate one to follow in this case: 5. Exposure and Alignment The last option is to use a surgical procedure with a sedation technique to expose or uncover the canines; this can take around 30 minutes to complete. After suggesting this in the OSCE then: Pause and ask the actor if there are any questions. If there are none, the next thing to do will be to explain this option in more detail to the actor. The post-operative signs should also be explained as must the risk of any complications. The procedural details The surgical technique to be used will involve cutting the gum and removing any residual bone covering the canine in the palate until a sufficient amount of the adult canine teeth are exposed to enable brackets and gold chains to be glued to their enamel. The amount of gum to be cut is about a square centimetre, and the amount of bone to be removed is around half of this. Finally, only a few square millimetres of tooth need to be uncovered to enable an orthodontic bracket and chain to be glued in place. Despite the relatively small size of the access needed, the procedure will result in pain, bleeding, swelling, and bruising, along with difficulty in eating for several days afterwards. There is a need to maintain scrupulous oral hygiene, and this will mean regular tooth brushing and mouth washing. If orthodontic treatment is being considered, then this level of oral hygiene will need to be maintained for the duration of treatment. At the same time, if it has already been agreed (in accordance with the guidelines) and it is in the treatment plan with the orthodontist and parents, the deciduous canines may need to be removed. After this procedure, as stated, there will be pain and swelling for several days. If stitches were used, these will dissolve, so there is no need to come back to have them removed, but post-operative review will be needed to ensure the bracket and chain are still fixed in place and there is no infection of the surgical site. It should be mentioned that there is a small risk that the permanent canines may not improve their position, but this is a rare complication. More commonly, but thankfully, an infrequent occurrence is the risk of the bracket and chain becoming detached from the tooth. The chain glued on to the canines is also attached to a fixed upper orthodontic appliance; this chain then slowly pulls the teeth into the correct position in the dental arch over a period of several months. The orthodontic appliance consists of a series of brackets fixed to the upper teeth with an arch wire and ties to provide anchorage for the chain pulling the canine into the mouth as the other teeth are repositioned into alignment. After explaining this procedure to the actor, once again you need to ask if there are any questions, and the actor may ask as so many parents do: ‘Will my child be put to sleep for this operation?’ The answer you can give is:
‘No, your child will not be asleep. During sedation, your child will be awake but relaxed.’ In this OSCE, the child was referred for a general anaesthetic, but an alternative option referred to in the questions for this case was suggested to the parent, who was keen to learn more about this. As the child in this OSCE is dentally phobic, you can advise that an advanced sedation technique will be used by a specialist in Special Needs Dentistry. Local anaesthesia will be needed, and this will be delivered through the usual syringe and cartridge methods, but only after adequate sedation has been achieved for the patient in this case. Patients don’t really care how much you know… Advising the parent that the dentist who will conduct the procedure has extensive experience, training, and postgraduate qualifications in the techniques they will be using is one small way to reassure a nervous parent and patient. Sometimes in real life, the patients may well ask about the experience and qualifications of the operator who will be conducting the procedure. . . . As long as they know how much you really care. For sure qualifications and knowledge are important. However these have to be backed up by experience and application of your professional understanding and undertakings in the clinical environment. Patients and parents really need to see that you care and once again an empathic supportive chairside manner is of utmost importance, especially with dentally phobic parents and patients undergoing minor oral surgical procedures such as the one detailed in this OSCE A warm approach with humanity and empathy makes all the difference for a parent especially if their child has a fear of the dentist too. Intranasal Sedation A caring, empathic, positive approach is essential in a case like this. It would be appropriate to advise the parent/actor that at all times a team of nurses trained to work with and support the dental specialist will be looking after their child. Advise the mother that this team will monitor and record both the heart rate and oxygen levels of their child until the procedure is completed. After the surgery has finished, the monitoring will continue and their child will be supervised during recovery in the clinic until it is safe for them to go home. In the OSCE, you need to mention that following any sedation procedure, a patient needs to be looked after for several hours up to 24 hours, until recovery is complete. The actor asks as their child is scared of needles, how will the specialist give the medication? The answer to this question is to state that there are advanced sedation techniques that specialists have developed to achieve this result. You can ask if the parent would like to know more about these. You can advise of the following technique: The sedative will be given not intravenously nor orally, but intranasally in a spray form. Following
this, gas and air (nitrous oxide) will be used to maintain sedation during the procedure. The evidence we have are the results of this technique are very good with a 96% success rate. Nearly all the parents found the procedure to be acceptable. Half of the children had no problems accepting the intranasal sedation. The other half were troubled by a burning sensation and irritation, which lasted for a few minutes only.15 For this reason, intranasal sedation might not be regarded as suitable for all dentally phobic patients, but it is a useful technique which, if used by dentists experienced in the technique and assisted by trained staff, can be a viable alternative to general anaesthesia for dental patients, and it is one we might like to use in this case.16 You can state the following to the actor in this OSCE: 1. In your child’s case, we may consider using this technique as a safe alternative to a hospital admission for a general anaesthetic. 2. The option to attend for sedation was provided because we have a duty as dental professionals to ensure that referral for general anaesthetic is avoided whenever reasonably possible. At this point, you can ask the parent if there are any questions on what has been explained. If there are none, the process of informing and gaining consent can begin. From the point of gaining consent to completion of the procedure, this consent, once gained, has to be maintained. In this case, the parent will assent for treatment and their child patient, through parental support, consents for the procedure. Why we undertake sedation 1. As long as safer techniques are available as viable alternatives to dental general anaesthesia, we owe our colleagues in hospital and our patients a duty to ensure these techniques are used to reduce the burden on hospital services. 2. More importantly, we need to reduce, if not remove, the risk to patients from undergoing any procedure where the risks of morbidity and mortality can be avoided by using alternative procedures. Further Note about Woody Mike Woods was both a gentleman and a giant, a dentist in the vanguard of specialists in Special Needs Dentistry and Oral Surgery in the UK. When not dancing to Springsteen, sitting on a standing committee, climbing mountains for charities, and a trustee of SAAD, Woody was writing papers that considerably advanced our knowledge of his specialty. As an expert in his chosen field, Woody examined for the Royal Colleges, achieving Fellowship of the Royal College of Surgeons in Edinburgh. He also had a razor-sharp sense of humour. I would like to share one example of Woody’s wit with you. Chairing one clinical meeting, while noting down the apologies from those who were absent, Woody looked up and upon spotting a fellow specialist, a Dental Public Health consultant, he quietly turned to me and asked if I could note her apology for being present.
Woody’s FDS arrived from Edinburgh the day we gathered in Maulden to celebrate his life. I would like to note my apology for Woody’s absence from our profession. This case is based on just a small part of his work, written in his memory, dedicated to his family at home, his family and friends in clinic. Until we meet again, Sala Kahle, Woody Michael Norman Wood B Ch. D. Hons (Stellenbosch) MSc. (Sedation and Special Care Dentistry) MFGDP (England) MFD RCS (Ireland) M SND RCS (Edinburgh) PDD. DUI (Lille) FDS RCS (Edinburgh) 2 August 1963-21 May 2013 References about Woody’s Work 1. Williams V, Riley A, Rayner R, Richardson K. Inhaled nitrous oxide during painful procedures: a satisfaction survey. Paediatr Nurs. 2006 Oct;18(8):31-3.
2. American Academy of Oral and Maxillofacial Radiology. Clinical recommendations regarding use of cone beam computed tomography in orthodontic treatment. Position statement by the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013 Aug;116(2):238-57. 3. Maverna R, Gracco A. Different diagnostic tools for the localization of impacted maxillary canines: clinical considerations. Prog Orthod. 2007;8(1):28-44. 4. Whaites E. Chapter 19: Alternative and Specialized Imaging Modalities. In Essentials of Dental Radiography and Radiology. 4th Edition pp. 232-235. Edinburgh: Churchill Livingstone 2007. 5. Gorlin RJ, Cohen MM, Levin LS. Syndromes of the Head and Neck. 3rd Edition. Oxford: Oxford University Press 1990. 6. Mitchell L. Chapter 14: Canines. In An introduction to Orthodontics. 2nd Edition pp. 139-147. Oxford: Oxford Uninversity Press 2001. 7. Ericson S, Kurol J. Radiographic examination of ectopically erupting maxillary canines. Am J Orthod Dentofacial Orthop. 1987 Jun;91(6):483-92. 8. Brin I, Becker A, Shalhav M. Position of the maxillary permanent canine in relation to anomalous or missing lateral incisors: a population study. Eur J Orthod. 1986 Feb;8(1):12-6. 9. Hurme VO. Ranges of normalcy in the eruption of permanent teeth. J Dent Child. 1949;16(2):11-5. 10. Husain J, Burden D, McSherry P. National clinical guidelines for management of the palatally ectopic maxillary canine. Br Dent J. 2012 Aug;213(4):171-76. 11. Clinical Standards Committee, Royal College of Surgeons of England Dental Faculty. Management of the Palatally Ectopic Maxillary Canine. London Royal College of Surgeons of England 2010. [Online] Available from: http://www.rcseng.ac.uk/fds/publications-clinicalguidelines/clinical _guidelines/documents/ManPalEctMaxCan2010.pdf [Accessed August 2013]. 12. Scottish Intercollegiate Guidance Network 2013. [Online] http://www.sign.ac.uk/methodology/index [Accessed August 2013].
Available
from:
13. O’Neill J. Limited evidence for interceptive extraction of deciduous teeth to prevent permanent canine impaction. Evid Based Dent. 2013 Mar;14(1):23-4. 14. Hill EE. Decision-making for treatment planning a cantilevered fixed partial denture. Compend Contin Educ Dent. 2009 Nov-Dec;30(9):580-85. Some of Woody’s Work. 15. Wood M. The safety and efficacy of intranasal midazolam sedation combined with inhalation sedation with nitrous oxide and oxygen in paediatric dental patients as an alternative to general anaesthesia. SAAD Dig. 2010 Jan;26:12-22. 16. Wood M. The safety and efficacy of using a concentrated intranasal midazolam formulation for paediatric dental sedation. SAAD Dig. 2011 Jan;27:16-23.
Clinical Case 43 Background Information This next case is based on a patient I saw a few weeks ago in the clinic. In the MJDF exam, a few OSCEs seem to be giveaway questions. Examples of these can be writing out a prescription. You will be provided with the British National Formulary with the current and correct drug regimens to refer to. Writing out a referral letter for a patient is another giveaway OSCE. Again all the details in the dental notes and medical history are provided for you to use. These questions are like those modern openbook exam questions that were not used in the undergraduate dental curriculum. Such types of questions I had not heard of before, only very recently. I remember back at dental school, you had to learn everything. The morning of exams, your neck would be straining, trying to support your head with the weight of facts crammed into it. Back in those days, if you could fit a fact into your brain, then you learnt it. This approach to passing exams reminded me of a pilot I worked with a few years back. We were taking an aircraft out of Ceduna to Oak Valley S.A. with the Royal Flying Doctor Service. Some stuff we had to take was self-loading cargo (also known as passengers) and the other stuff was medical equipment we had to load ourselves. Between flights, I was trying to work out the weight and balance calculations. ‘Aww don’t wurry about that nonsense, mate. If you can fit it in and we can shut the door, she’s good to go.’ The handling pilot reassured me of that with his veteran aviator’s aura of… confidence. I was waiting for him to kick a tyre or another part of the aeroplane as part of his time-tested preflight ritual. Instead, he walked off and took his customary pre-flight pee towards the terminal building, not as an act of defiance to authority or anything; the terminal was downwind from where we were parked. None of this weight and balance nonsense applied. So too, in my dental student days, you didn’t have to weigh up the facts or balance the evidence for learning something, or worse doing something to someone on the clinic. If I could fit a fact into my head, I was positively encouraged to do so, before going off to commit some form of dentistry that had been practised unquestioningly by generations of students trained to kick a tyre and not rock the boat. I do not know how we managed to get off the ground; rolling down the runway from a standing start at the numbers, we ground our way over the piano keys, crossed the ILS markers, and were barely 50 feet over the opposite threshold before we established a positive rate of climb. By the time we transited the Woomera ranges, we were holding at 25,000 feet, burning off surplus Jet A1 to be within our landing weight on a visual approach for Oak Valley. Today in exams and the practice of dentistry, weight and balance does apply. Do not go into the OSCEs with a head crammed full of useless, irrelevant, and dangerous outdated information; you will
not pass. Sometimes I think of examiners like being ATCOs (air traffic controllers); they will not let you cross a threshold or give you a zone clearance unless it is safe to proceed and you can read back your clearance. For patient safety, OSCEs are just the same. Anyway, this OSCE has nothing to do with flying and the patient is not a pilot. Nevertheless, if you plan your flight, then your approach will be correct. If you do not plan your revision, then your whole approach to the actor will be wrong. In the MFDS, I overheard one examiner loudly exclaim about a candidate: ‘His whole approach was wrong.’ When flying, if your approach is wrong, you have the opportunity to go around or, in our case, burn off or dump fuel. In the MFDS and MJDF, you also have the opportunity to go around; it’s called a fail and you get to resit the whole exam. Go-arounds, dumping fuel, and resits are expensive, time-consuming affairs. It is better to prepare well and pass first time than needlessly go around. Introduction A 56-year-old fit and well male attends for the first time with you. The medical history is clear; he neither smokes nor drinks and takes no medication. He is a regular dental attender and has had crown and bridgework placed by previous dentists. The last restoration was placed three years ago. This was a silver-coloured non-precious alloy crown on the lower left number six (tooth number 36) and this was placed next to a precious alloy gold crown on the lower left seven (tooth number 37) that had been in place for many years. Two years before attending with you, the patient noticed a white patch on the left side of his tongue adjacent to metal crowns. His previous dentist dismissed this white patch as: ‘Nothing to worry about’. The patient was not convinced that this was nothing to worry about and attended with a general medical practitioner (GMP), who then phoned the dentist and after some discussion gave the patient some steroid tablets. These were hydrocortisone sodium succinate tablets at 2.5 mgs. These were taken four times daily for one week. These were dissolved in the mouth next to the tongue lesion. This medication was tried for one week with no resolution of the symptoms; the patient re-attended with the GMP, who wrote up the notes and discharged the patient with no further interventions planned. The GMP stated to the patient: ‘Everything is normal.’ One year passed with the patient continuing to be troubled by the appearance of the painless white patch. The patient has some concerns that not all might be well.
Today the patient has attended with yourself, and the white patch is still present. The details of this lesion are described below: White patch 10 mm × 5 mm on the left lateral margin of the tongue—it is not on the dorsal surface, but it does extend from the lateral margin to the lingual surface. The lesion does appear to be corrugated in places. The borders are clearly defined, not indurated, and there are no speckling or red patches present. A thorough extra-oral exam reveals no TMJ problems and critically in this case: no lymphadenopathy. Intra-orally, there do appear to be white lace-like patterns of reticular lichen planus on the left and right buccal mucosa. There are no sharp or rough edges on the tooth surfaces likely to have caused traumatic ulceration to the tongue. If you could feel this white patch, it would feel rough, harder than the surrounding mucosa of the tongue, and it cannot be rubbed off. Questions to Clinical Case 43. 1. How will you manage the patient’s concerns as you begin this consultation? 2. How will you begin to find out what the cause of the white patch is? Which questions and systems might you ask and use in your search for an answer? 3. After going through the questions and systems, which are the three most likely causes are you left with for this patient’s white patch? 4. Can you list the options for investigation? 5. After going through your list of options for investigation, which is the most appropriate one and why? 6. Can you describe a procedure you might consider necessary and will you carry this out? 7. What term might describe this lesion? Can you provide a list of the likely causes of the white patch in this case? 8. From the results you have received, what is the cause of this white patch? 9. What are some of the predisposing factors causative of this lesion? What is the most likely cause? 10. Can you give some of the options you might consider to resolve this problem? Answers to Clinical Case 43. 1. From the introduction, you know this patient has an unusual clinical presentation and he is worried about it. The repeated visits to his previous dentist and doctor have not answered the patient’s questions, and he is left with both doubts and fears. These are the reasons he is coming to see you. The two previous consultations noted in the introduction were dentist—and doctor-dominated affairs with little opportunity for patient input. The throwaway comments from the GDP and GMP of: ‘Nothing to worry about’ and ‘Everything is normal’ are indicative of this. These comments are neither empathic, nor do they manage the concerns of the patient.
Jollying the Patient Along a. The post BDS Dental Foundation curriculum does not encourage the paternalistic ‘Doctor knows best and don’t worry, dear’ approach to managing concerns. b. Therefore, such responses as those given to this patient have no place in the MJDF and MFDS OSCEs. c. These blocking tactics, offering advice and reassurance before actually finding out what the patient’s problem is, or ‘jollying the patient along’ will only serve to encourage a patient not to disclose problems.1 d. Non-disclosure may mean there is a delay in seeking another opinion. e. When faced with such responses, patients may think they are burdening a health care professional with a problem that is irrelevant. f. Or the patient does not want to appear pathetic or ungrateful to the doctor or dentist when they do not attend to their concerns, so they jog-on. Moving the consultation to a patient-centred encounter is important. This consultation has to be both patient-centred and to have an explicit agenda. In this case, the agenda is to manage the concerns of a patient within a focused consultation with an empathic dialogue centred on the concerns, expectations, and ideas the patient may have about a white patch they have on their tongue. The actor will convincingly portray a worried patient. After you have introduced yourself, the best way to begin to answer the first question is with an opening statement such as: ‘I can see from your notes (the introduction) that you have been to see both a dentist and a doctor and now you are coming to see me. This can’t be easy for you, and I can see you are troubled by all of this.’ The tone you use to deliver this statement should be both enquiring and receptive so the patient can begin their dialogue with you. The patient is worried by the clinical presentation described in the introduction. He is concerned that something is going on, and he is bothered that no investigations have been undertaken. He has only been given some steroid tablets, and these have done nothing, that is the white patch is still present. You can acknowledge the patient’s concerns and confirm what you know from the introduction with the patient—that he is keeping well and does not attend the doctor for any medical condition and is not taking any medication. Key Skills + Core Chores a. In this consultation, you need to elicit the patient’s problems and concerns. b. One way to do this is to acquire and maintain eye contact at an early stage of this OSCE as you would in any clinical exam.2 c. By doing so, you are demonstrating interest in the problem the patient has come to see you about. d. Use active listening to clarify what the patient is concerned about. You can achieve this by
responding to cues about problems and responding appropriately to any distress shown by the actor in the OSCE.2,3 e. If the actor in this case has important statements, do not interrupt them. Allow the actor to complete these, and in doing so, you will be receiving the information you need to progress to the next stage of the OSCE.4 2. From this empathic positive beginning, you can begin to look at the likely causes of a white patch, while still managing the concerns of the patient. You might confidently continue by reminding the patient he has good health and he neither smokes nor takes any medication. Therefore, these two common causes of white patches in the mouth can be excluded from the probable causes in his case. Continuing, you can mention to the patient that oral lesions are very common. In a recent 6-year survey where over 30,000 people were examined, nearly 28% had oral lesions of note, with just over 2.5% of these being white patches.5 You can advise the patient that the most likely cause can be established by going through a systematic series of questions together with the patient as you point out your observations from what you already know. Surgical Sieves By asking the patient relevant questions, you can build on the knowledge you already have. From your undergraduate days, you will be familiar with surgical sieves, and these can be applied to this OSCE to find out the cause of this white patch. The most common sieve dentists use is: A VITAMIN C Acquired, Vascular, Infective, Traumatic, Auto-immune, Metabolic, Inflammatory, Neoplastic, and Congenital. ‘Sorting’ the facts of this case through this sieve as follows: The clinical presentation is that of a corrugated white patch. This has appeared two years ago, so somehow this has been Acquired. There is no red speckling in or around the border of the lesion, so a Vascular cause, although possible, is unlikely. As the lesion has been present for some time with no systemic signs, it is persistent, so we can eliminate Infective causes. (The prospect of HIV-associated oral hairy cell leukoplakia did cross a colleague’s mind when discussing the case.) We can put these to one side for just now. There are no rough edges on adjacent teeth and the lesion is chronic, so we can eliminate the Traumatic causes such as biting either intentionally or accidentally. The lesion does not look like a burn or a bite mark. With reference to smoking and medication, the medical history shows no evidence of these. The patient is fit and well. So we can eliminate Auto-immune and Metabolic causes. There is an Inflammatory or reactive process in the mucosa. There is no induration or lymphadenopathy, so Neoplastic causes can be set aside. As the lesion has
appeared a few years ago, it is not from childhood and the patient is in his mid-50s so Congenital causes can be eliminated. This leaves us with the Acquired or Inflammatory causes. After going through one sieve, your finely filtered facts can be passed through another sieve. Again continue to involve the patient in this. A Patient-Centred Consultation a. By going through these options with the patient, you are actively involving them in the consultation, something the previous dentist and doctor omitted to do. b. The best way to manage the concerns of this patient is by making them the centre of the consultation. c. The patient’s concerns can be managed in other indirect ways too. d. By participating with you in a logical process of eliminating the more sinister causes of white patches, you can help to reduce the patient’s fears. With patients who are anxious about receiving bad news, the risk of catastrophising or that their aberrant thoughts or worst fears will be confirmed, will be reduced by metaphorically asking them to ‘hold the surgical sieve for you’. This can be achieved by both patient and dentist going through the facts of the case together with you, while you both separate the improbable from the possible. Other filters I have found to be useful in the clinic are: The ‘i 5’ filter for cases such as the 5% to 15% of the population who have oral lesions patches. 6 The causes can be: Infection, Inflammation, Injury, Iatrogenic, and Idiopathic. Lastly, if you are really stuck and you like to take your problems home, then the final sieve you can use before you call it a day is: MIDNIGHT: Metabolic, Inflammatory, Degenerative, Neoplastic, Iatrogenic, Genetic, H for all the possible viral causes (HBV, HCV, HPV, and HIV), and Traumatic. Again, the participation of the patient in these proceedings shows you are making them the centre of the consultation. 3. In this case, shaking the facts through three sieves above gives us the three most likely causes as: Inflammatory Acquired Iatrogenic We can now present these three reasons to the patient and begin to narrow down the likely causes of their white patch. Having eliminated the improbable, we are left with the possible. Again, by making the consultation patient-centred, empathic, and logical, we can begin to manage their concerns. From your revision and clinical experience, you will know that taking a good history goes a long way
towards an accurate diagnosis. In this case, the taking of a good history is also important in managing the concerns of the patient so they continue to participate in this consultation and the proposed treatment plan. 4. The first investigations of an oral white patch are to take an up-to-date medical and dental history and to write up the patient notes as the surgical sieves are completed. From the introduction, the investigations of clinical examination and palpation reveal a 10 mm × 5 mm hard rough white patch on the tongue that is now thought to be acquired, iatrogenic, or inflammatory in nature. Most commonly, a biopsy would be indicated for such a lesion. When this is suggested, the patient may state that if the lesion is common and not a sinister one, then taking a biopsy seems to be excessive. You can reply that there are other methods of sampling tissues, but these have not proven to have a sufficiently adequate predictive value in accurately determining the cause of a white patch. You might briefly mention the following techniques to the patient: a. Taking a brush to sample some cells from the white patch. b. Staining the white patch with a blue dye to determine if there are any cancerous areas, but this test has been unpredictable with many false positives in benign lesions and false negatives in malignant lesions, and the dye itself is toxic. c. Light illumination with filtered light sources and dyes to identify cancer cells; again this has proven to be unreliable. It is important to state to the patient these tests were developed specifically to look for, or screen for oral cancers in populations and not in patients. Many proved to be unreliable. In this case, even though the patient most likely does not have cancer, screening tests cannot be considered as an alternative to a surgical biopsy. 5. From the list of possible investigations you might carry out, a biopsy is the most appropriate option, and you can now suggest this to the patient. A biopsy enables us to demonstrate with a greater degree of accuracy and clarity than the other tests two important outcomes and these are: a. The absence of an oral cancer in your case. b. The exact nature of the reaction in the white patch, and this will help us to identify what it is and what is causing it. c. For these reasons, the risk to benefit ratio for surgical biopsy is favourable. Ask the patient if there are any further questions. In reply, the patient asks if you can perform the biopsy. Your response should be that generally all white lesions in the mouth can be biopsied. In this case if you thought the lesion was caused by friction or trauma, or that the lesion was a typical lichen planus with keratosis, then biopsy would not be needed. Conversely, if you thought the lesion to be malignant or cancerous, involved blood vessels, or was
part of a condition requiring hospital care, then referral for biopsy would be needed. Since the white patch is not likely to be any of these conditions and it is easily accessible and not in an area where further soft tissue damage might occur, then biopsy in general practice is indicated. 6. The procedure for a biopsy is to take a sample of the lesion together with some healthy tissue too. An incisional biopsy would be indicated, and this can be completed by a general dental practitioner, using local anaesthetic. The sample size would by 10 mm × 4 mm and up to 3 mm in depth to include basal membrane, and some muscle tissue could be included. This sample would be placed in a plastic specimen pot with an orienting suture. An accompanying referral letter would be sent to a consultant histopathologist with relevant clinical details. The options should be given to the patient and their decision whether or not to have a biopsy and where this procedure will be performed, that is either in general practice, or in hospital should be respected. In this case, the patient chose to go to a major teaching hospital for a biopsy. An incisional biopsy was performed, and the results were sent to both patient and practitioner within 2 weeks. 7. The white patch was referred for biopsy as a leukoplakia. This term specifically means a white patch that cannot be ascribed to any other lesion or condition. After passing through several sieves, the most likely causes are as follows: 1. Sublingual keratosis. These are corrugated white patches on the floor of the mouth with a high degree of malignant transformation. Often they are bilateral. In this case, this lesion is unilateral and only just extends to the ventral tongue surface. Therefore it is unlikely to be a sublingual keratosis. 2. Frictional keratosis from a restoration is possible but unlikely as the crown margins are smooth; nevertheless, there may be a connection between the crowns and this lesion. 3. Chronic candidal lesion. The site of the white patch is unusual for this lesion, and therefore, a biopsy together with resolution following antifungal treatment are indicative of this type of lesion. 4. Squamous cell or other carcinoma. The patient does not smoke, and there is no ulceration and no induration; despite this reason not passing through the sieve, we should not discount this as a cause just yet. 5. Lichen planus or lichenoid reaction. Although there are mucosal lesions which look like lichen planus, there are no cutaneous lesions in this case. Therefore, this is unlikely to be lichen planus as the white patch is unilateral; it is more likely to be a lichenoid reaction. 8. The biopsy result stated the sample was consistent with a lichenoid reaction. There was no cellular dysplasia and the classic sawtooth rete ridges and a dense infiltrate of lymphocytes could be seen around a thickened basal membrane. The muscle tissue and vasculature beneath the mucosa was unaffected. The histological picture was consistent with the clinical presentation. 9. The predisposing factors to lichen planus and lichenoid reaction in this case are the dental restorative materials used. Specifically, these were the dissimilar metals used in the crowns in
teeth 36 and 37 (lower left first and second molars). Although other causes such as viral involvement are causative of lichenoid reactions, specifically hepatitis C, this could be ruled out as could an HIV-associated oral hairy cell leukoplakia as the patient was not seropositive for these. 10. With lichen planus and lichenoid reactions, topical steroids might be used to treat chronic mucosal lesions with immunological involvement. Previously, the use of a mouthwash containing steroids proved ineffective, so too perhaps might be use of steroids that can be injected into the lesion itself. The cause of this lichenoid reaction is most likely to be from dissimilar metals in the two adjacent crowns 36, 37 reacting, and the products of galvanic corrosion and gold salts then producing the localised lichenoid reaction in the oral mucosa. The answer following confirmation of the biopsy result and discussion with the patient, might be to remove both crowns, replacing them with either two crowns containing gold alloys that will not react with other metal restorations the patient already has or 2 non-metal crowns. In addition to not reacting with existing restorations, the restorative materials you plan to use should not initiate any further mucosal reaction. Following this, a period of review would be necessary to observe the patient’s mucosa, ensuring there is no reappearance of the lichenoid reaction. Further Notes to Cinical Case 43. When the patient appeared in the dental clinic, there were several opinions on what the likely cause of the white patch could be. Very much like a weight and balance check mentioned in the introduction, these opinions were thrown in with no regard to their potential weight or subsequent impact they might have on the balance of care for the patient. These opinions ranged from the improbable oral squamous cell carcinoma to HIV-associated oral hairy cell leukoplakia. Both were unlikely as the patient had no risk factors for these conditions. He was not smoker and was not in a high-risk group for HIV-associated illnesses. Today in the dental clinic, when considering these conditions and, in fact, all medical conditions with dental presentations, it is useful to think of our patients of being ‘at risk’. There is ‘high risk’ and there is ‘low risk’ but there is no longer ‘no risk’. Even though oral cancer and HIV-associated lesions are unlikely causes of the white patch in this case, they should not be completely ruled out due to the life-altering consequences of failing to diagnose these conditions. If we do correctly identify such causes, we have to be particularly careful in the way we deliver the news, especially if the patient may not be aware they have a condition with life-changing or life-limiting consequences. The journey is more important than the destination. It is interesting to note that the opinion of the previous dentist was ultimately confirmed but only after the entire history was taken, together with the use of a surgical sieve, and the result of a biopsy being delivered. Truly, there was as stated by that dentist:
‘Nothing to worry about.’ But in this case, it wasn’t the destination; it was the journey, specifically the patient journey that was not ideal. Despite the assumptions of the previous dentist and doctor, the oral mucosa was not normal, and so in one respect, the doctor was wrong. The patient knew this and sought further explanations. In this case, the one thing the pilot, the dentist, and the doctor all had in common was their assumptions to work were based on previous experiences. Even though their assumptions were correct, their approach was not, and where aviation and dentistry are concerned, you are only as good as your last landing or your last filling. The key to managing this question in the MFDS is to manage the patient’s concerns by appropriate use of empathic verbal and non-verbal communication. By keeping the patient central to everything you do with a defined agenda, in which you can exercise your communication skills to gather information, interact with the patient, and manage the clinical issues, you can easily pass this type of OSCE in the MFDS. In the MJDF, you will need to demonstrate these skills and know about the condition of lichenoid reaction, its histopathology, and the causes and potential cures if you are to successfully discuss this with the examiners in an OSCE or an SCR. In the dental clinic, you would need to select the information you need to work with and not throw everything into the case and try to close the door on it. You need to make a decision on whether to do the biopsy yourself—and this is based on relevant information—and refer your sample for analysis or refer the patient to a hospital. In this case, after some deliberation, the patient chose the latter option and was relieved to be given the good news and his fears of malignancy could be laid to rest. He will re-attend in the dental clinic to have conservative replacement of the crowns with review of the lesion that should resolve in time. References to Clinical Case 43 1. Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ. 2002 Sep 28;325(7366):697-700. 2. Goldberg DP, Jenkins L, Miller T, Farrier EB. The ability of trainee general practitioners to identify psychological distress among their patients. Psychology. 1993;23:185-93. 3. Maguire P, Faulkner A, Booth K, Elliott C, Hillier V. Helping cancer patients to disclose their concerns. Eur J Cancer. 1996;32a:78-81. 4. Beckman AB, Frankel RM. The effect of physician behaviour on the collection of data. Ann Intern Med. 1984;101:692-96. 5. Shulman JD, Beach MM, Rivera-Hidalgo F. The prevalence of oral mucosal lesions in U.S. adults: data from the Third National Health and Nutrition Examination Survey, 1988-1994. J Am Dent Assoc. 2004 Sep;135(9):1279-86. 6. Yip K, Smales SR. Chapter 11: Dental Developmental and Oral Soft Tissue Conditions. In A Clinical Guide to Oral Diagnosis and Treatment Planning. pp. 88-97. London: BDJ Books 2012.
Further Reading to Clinical Case 43 1. Scully C. Chapter 4: Signs and Symptoms pp. 74-96. Chapter 11: Mucosal, Oral and Cutaneous Disorders pp. 281-295. In Medical Problems in Dentistry. 6th Edition. Edinburgh: Churchill Livingstone 2010. Essential background reading. 2. Mitchell L, Mitchell DA, McCaul L. Chapter 8: Oral Surgery, Biopsy. In Oxford Handbook of Clinical Dentistry. 5th Edition p. 373. Oxford: Oxford University Press 2009. A good reference source for use on the clinic on biopsy techniques, more of a reminder for reassurance than anything else. 3. Cawson RA, Odell EW. Section 2: Soft-Tissue Disease, Part 15: Benign Chronic White Mucosal Lesions. In Essentials of Oral Pathology and Oral Medicine. 6th Edition pp. 208-215. Edinburgh: Churchill Livingstone 1997. A good book now nearly 20 years old, but the basic histopathology hasn’t changed at all; the colour pictures and descriptions are very good. 4. Yip K, Smales SR. Chapter 11: Dental Developmental and Oral Soft Tissue Conditions. In A Clinical Guide to Oral Diagnosis and Treatment Planning. pp. 88-97. London: BDJ Books 2012. Another good reference source, well written and illustrated, available from the BDA library. 5. Lingen MW, Kalmar JR, Harrison T, Speight PM. Critical evaluation of diagnostic aids for the detection of oral cancer. Oral Oncol. 2008;44:10-22. An article that reinforces the essential role of surgical biopsy above other techniques for oral cancer detection
Clinical Case 44 Background Information Orthodontics is a postgraduate specialty. However, the general dental practitioner will have to deal with patients undergoing orthodontic treatment for problems in their facial growth or dental development. Prior to receiving an orthodontic assessment or treatment, patients are examined by dentists in general practice, and based on this, a referral to an orthodontist is made. For the MFDS and MJDF examinations, you will not be expected to demonstrate the knowledge of an orthodontic specialist. However, you should have a working knowledge of orthodontics to know when to refer a patient for treatment and when you can get involved, providing treatment to intercept a potential problem to stop it from developing into a clinical one. Such treatment should assist the oral health and development of a patient’s dentition, and it should either completely avoid the need to send a patient for orthodontic treatment or reduce the level and length of time that orthodontic treatment will take.
Although orthodontics is a specialty, it cannot stand alone without the support and input from other specialists, dentists, and professions complementary to dentistry. In the MFDS and MJDF, it is expected that you can demonstrate a good working knowledge of the core skills of orthodontics. In addition to this, you need to be aware of the relationship between orthodontic treatment and dentofacial growth. Furthermore, the influence that orthodontic treatment can have on the behavioural and social development of a child is of fundamental importance. As a candidate for the MFDS and MJDF exams, you will be expected to show an understanding of such a relationship. In the MFDS and MJDF exams, you should be competent to carry out an orthodontic assessment and understand (i.e. memorise and have accurate recall of) the Index of Orthodontic Treatment Needs (IOTN). You should know when to refer and how to refer, when to treat and how to treat, and be able to manage problems in those patients undergoing orthodontic treatment, such as breakages in appliances. Accurate interpretation of radiographs is vital, and you need to be able to document what you see and communicate these and other findings to specialist colleagues, the parents, and patients in appropriate and clearly understood terms. In addition to the above competencies, you need to have a good knowledge of the development of your patient’s dentition from the deciduous teeth, through the mixed phase, to the eruption of the adult teeth. You should know when and how interceptive procedures can complement corrective procedures. The use of space maintainers and functional devices should be familiar to you, as should the ability to insert, remove, and repair these items. Active removable appliances, although less popular now, still have an important part to play in orthodontic treatment, and you should know when these can be used to tilt single teeth or, in certain cases, correct a crossbite. As always, communication is important. By now, you will have developed the ability to explain in lay terms to parents, patients, and other practitioners the options for dental treatment you propose. The same communication skills need to be applied for the patient undergoing orthodontic treatment so they are aware of what their treatment can or cannot achieve. Your ability to communicate effectively should be continually refined together with your increasing applied clinical knowledge based on the basic dental sciences you have learnt as an undergraduate. As your experience in the clinic grows and your revision progresses, you will develop a feel for how orthodontic treatment fits into the overall care plan for your patients and the ways in which other procedures such as orthognathic surgery are options for such care. In this regard, you should be familiar with the principles of surgical and non-surgical treatment for oro-facial developmental abnormalities and be able to describe such procedures in answering questions in the OSCEs and SCRs. Very much like a child’s dentition, orthodontics and dentistry have not yet stopped developing. Therefore, you should be aware of the recent developments and contemporary treatments and the indications for their use together with their advantages and disadvantages. In reviewing the MFDS OSCEs from 2011 to 2012, in 80 exam questions, there were 12 OSCEs dealing with some aspect of growth and development, orthodontic treatment, or orthognathic surgery. In the MJDF OSCEs, every exam will have a question in this subject area. In this OSCE, I have followed the MJDF model and provided a scenario based on a clinical case
with a series of structured questions to be answered. Introduction A healthy and physically active, bright 12-year-old girl attends with her mother for a routine exam, or at least that is what the appointment said this would be. She has previously seen a colleague who has made some detailed notes on her dental condition. These notes state: a. Patient has a Class ll skeletal pattern, retr uded mandible.upper jaw,. b. The upper lips do not cover the incisors, there is a gummy smile and the patient when observed in the clinic appears to mouth breath.(lips are incompetent) c. There is crowding of the lower incisors with an approximate 8 mm overjet and reduced overbite.(The crowding is moderate 2 to 4 mm space needed each side) d. The upper arch is spaced. The cENTRAL INCISORS protrude, THE lateral incisors are very small being narrow and shorter than the other teeth. Some teeth are missing, incisors not well aligned. Smile appears awfukl ‘gappy’. d. The oral hygiene is poor. Plaque in all sextants covering up to one third of the teeth labially. In the lower labial sextant, there is calculus labually lingually. In all sextants there is a mild generalized gingivitis. e. Absence of the lower right second premolar and upper left first premolar. (In line with the FGDP Selection CRITERIa for Dental Radiography in the developing dentition), following views taken: A Panoramic radiograph and 2 Bitewings f. From these exposures there is an un-erupted lower right second premolar. Possibly impeded in eruption due to crowding and a miss ing upper left first premolar. The crypts with developing crowns of the third molars cannot be seen. Bone levels in all areas of the mouth were good with no sign of periodontal or bony pathology. No deciduous teeth remain. g. Decay in the first and second molar teeth. 2 left and right Bitewing radiographs clearly show occlusal decay in all of the first molars into dentine and decay in the upper second molars limited to enamel only. From the outset, the patient advises you that if this visit has anything to do with braces or putting wires in her mouth, she is not having any of it. In an act of defiance (or it could just be her defending the boundaries she feels comfortable with) her arms are crossed, and she refuses to sit in or anywhere near the dental chair. Using an empathic and understanding manner of communication, you learn from the patient that her best friend recently had a brace fitted and she got ‘dumped’ just because of that. Going on, the patient tells you: ‘Soon after getting braces, my friend got really bad spots on her face, put on weight, and that is clearly her dentist’s fault too because he fitted her up with a dirty used brace to save money, and
he doesn’t wash his hands either between patients.’ After a short pause for breath she continues… ‘As for the silver grills he glued in my best friend’s mouth, food gets stuck in and wires stick out.’ She finishes by telling you quite clearly: ‘After that, if you think you are going anywhere near my trap with your wires and your pliers, you are dreaming, you can take your dentists’ gear and shove them somewhere else, for all the good they are going to do me.’ With that, she went back to texting her friends on her mobile phone. Mercifully, in the MFDS and MJDF exams, you do not have to deal with children in a state of hormonal flux while the winds of puberty sweep over them. For that privilege, you have already signed up to work in dentistry. Once again, the device used in the OSCE is to utilise an actor as the parent and to answer the questions they or an examiner will ask. Questions to Clinical Case 44. 1. What grading can be given to the relationship of the incisors in this case? 2. What system of orthodontic classification is used in the UK to determine severity of malocclusion and eligibility for NHS orthodontic care? 3. Can you use this system, and if so, can you decide what, if any, orthodontic treatment is needed? 4. Can you describe the two components of this system? 6. With the data you have from the introduction and using the system you have described, how would you grade this patient? 7. How would you approach the orthodontic assessment of a patient such as this? 8. Which aspect of the occlusion is likely to present the greatest potential problem to the patient? 9. Which aspect of the occlusion is likely to present the greatest problem to yourself or your colleagues? 10. After considering your answer to the previous question, what condition might the patient have and can you give some figures from studies for the prevalence of missing teeth? 11. If you were to begin treatment, from the data given in the introduction, how would you begin? 12. If you can convince the patient to have orthodontic treatment, what techniques might this involve to begin with and how do these work? 13. How might you present the case for Orthodontic treatment to this patient, what must they be aware of before consenting to treatment? 14. If no orthodontic treatment was chosen, what must you do? 15. If the patient does choose orthodontic treatment, what is involved?
Answers to Clinical Case 44. These answers are brief and to the point as you will need to adhere to the time limits of the MJDF OSCE or SCR if you wish to answer all the questions. 1. The incisors are in a Class 2 relationship. You can be sure of this from the information which states there is an overjet of approximately 8 mm. What is not known from the introduction is the degree of proclination of the upper incisors. It is likely the upper incisors are in a Class 2 division i relationship; however, without the use of study models, clinical photographs, or a lateral cephalometric view, we cannot be certain of this. 2. In the UK, the Index of Orthodontic Treatment Needs (IOTN) system is used. With this system, an objective measure of the need and eligibility of children under 18 years to access NHS orthodontic treatment can be determined. The IOTN is an objective and reliable way to select those children who will benefit most from treatment. 3. It has been noted that the accurate use of IOTN requires specialist training. Therefore, the final assessment of dental health needs for orthodontic treatment should take place with a specialist orthodontist. However, using the IOTN in an initial consultation provides for a thorough check for other dento-facial abnormalities too. Problems requiring surgery or the need for a combined input of dental specialties can be identified by using this system. In using the IOTN, those patients who do not have a need for treatment or have a minor need will be confident that an objective opinion on their dental development was provided, and this can be qualified by referral to a specialist for an expert opinion. 5. The IOTN has two parts as follows: 1. Dental Health Component. This (DHC) has 5 grades. These are Grade 5: Great treatment needed, Grade 4: Treatment needed, Grade 3: Borderline treatment needed, Grade 2: Little treatment needed, and Grade 1: No treatment needed. Each of these grades has specific examples of malocclusions. If a patient has any of these, then the patient is graded according to the worst score. 2. Aesthetic Component. This consists of a series of 10 colour photographs selected by a panel of lay persons into grades of ‘dental attractiveness’. This is used where the appearance of a patient’s teeth overrule any absolute values obtained in the DHC score. The assessing clinician grades the patient according to how close to one of the 10 photographs the patient’s teeth appear. Where there is a ‘borderline treatment need’ (IOTN 3), the aesthetic component can be used to determine if NHS treatment is permissible. 6. In this case, the overjet measurement was noted to be approximate, and this was 8 mm. If the overjet measurement was accurate then the IOTN DHC would be Grade 4 (a): treatment is needed. In this case, the absence of an adult tooth is graded as: Less extensive hypodontia which may require pre-restorative orthodontics. This is Grade 4 (h). However, the impeded non-eruption of the lower premolar due to crowding means the IOTN DHC Grade 5 (i) is applied as there is a ‘great need for orthodontic treatment’.
7. In one word, the answer is: Carefully. Much of the data for an assessment is already in the notes and in the radiographs already reported on. Study models would be ideal, but at this stage of an orthodontic examination, it is not essential to have them. It is important to engage the mother in any assessment involving her child. If a patient is adamant they do not want to have treatment and are doing everything they can to prevent an assessment from taking place, there is little to be gained from trying to complete an actual clinical exam (especially if sufficient data can be learnt from other sources). Minor Matters. 1. Trying to complete a clinical exam and doing so forcibly may constitute an assault and battery against a child. 2. Assuming the child is competent, although they do not yet legally have the status of an adult, their minor views have to be respected in this consultation. If a child refuses treatment, their views can be overruled by parents, legal guardians, and, if necessary, a court order. 1 In England and Wales (of note if you are sitting the MJDF), there are no statutes in law governing the rights of those under 16 to consent to medical or dental treatment. There is, however, the case, the law, and the concept of Gillick or Fraser competence to assess understanding, maturity, and intelligence of a minor to consent to treatment.2 3. Such competence will vary from child to child and from procedure to procedure. So it would seem to be the case that the welfare of the child, rather than the rights of the child, are to be respected. If the child is making the correct decision regarding their treatment, their wishes have to be respected.3 4. What is less clear is our position in law, if a Fraser competent child is refusing treatment. In such cases such as this, the Clinical Standards Committee RCS FDS (England) Guidelines state as follows: The courts (but not parents) can overrule both consent and refusal of consent to medical treatment if it is deemed to be in the child’s ‘best interests’.4 5. In Scotland (of note if you are sitting the MFDS), there is a statutory framework in relation to giving consent for children under the age of 16—The Age of Legal Capacity (Scotland) Act 19915 This states that at age 16, in law, one is competent to make their own decisions about medical and dental care, that is they are adults. Up to this age, they may have capacity to make their own decisions with regard to giving, or withholding, consent to medical or dental care, but this depends on: a. The nature or complexity of the treatment proposed. b. Their level of understanding of the risks, benefits, and implications of the treatment and any available alternatives. c. The implications of not having treatment. In effect, the extent to which a child can give or withhold consent will be directly proportional to their age and level of understanding and
inversely proportional to the potential significance of the treatment. 6. In essence, although there is a different law and legal system in Scotland, Fraser and Gillick apply. If a child is considered to have capacity to consent on their own behalf in relation to an intervention, then the parents will no longer have any right to give consent in this area. It is, however, considered good practice to involve the parents in the decision—making process as far as possible, although the child may have the final say. 8. The greatest potential problem facing the patient is from the increased overjet at approximately 8 mm, meaning this patient is at increased risk from dental trauma to the upper incisors. This is an established fact based on clinical evidence. The 1983 UK Child Dental Health Survey revealed that children with overjets in excess of 9 mm were twice as likely to suffer dental trauma as those children with smaller overjets.6 Although the peak incidence was 10 years old and boys more than girls were affected in this case, the lip incompetence and significant overjet means there is an ongoing risk from such trauma. The risk factors for trauma are increased overjet, protruding teeth, and insufficient lip closure. All of these significantly predispose this OSCE-child to dental injury. This should be mentioned to the actor/parent during your consultation. 9. Undoubtedly, from the information in the introduction, the greatest problem is that resulting in the 5 (i) IOTN grading: The impeded eruption of the lower right second premolar (tooth number 45). Lower premolars normally erupt after the canines; in this case, there is simply no room in the arch to accommodate this tooth. The missing upper left first premolar (tooth number 24) also causes some problems as there is spacing in the upper arch where this tooth should be, but this problem can potentially be resolved with a restorative solution in the future. The proximity of the root of tooth 45 to the neurovasculature of the mental foramen only adds to the complexity of deciding how to deal with this problem, as does the potential risk in the future of cystic change around this tooth. By the very nature of these problems, you might consider referring to a specialist team of orthodontists and oral surgeons to discuss a multidisciplinary solution. 10. The patient is missing five teeth, and tooth 45 has failed to erupt due to crowding. This is known as hypodontia. If six teeth were missing in total, by definition, the patient would have oligodontia. In calculating the numbers of missing teeth, the third molars are not included in defining oligodontia. a . Hypodontia has been reported in the literature to affect females more than males.7 One recent study in 2013 reported this difference at 25%.8 b. The most common missing teeth are the third molars in a range of 25% to 35% of the general population missing one or more of these teeth, with some racial differences noted in the studies.911 This data comes from several recent studies looking at populations in USA, Europe, and the Middle East. c. Next come the lower second premolars (as seen in this case) with some 3% of the population missing one of these.12 Some dental sources state the lateral incisors are more commonly absent, but these teeth are only slightly more commonly present with 2% of the population missing an
upper lateral incisor.13 d. Overall, some 5% of the population have missing adult teeth.14 Only 1% have missing primary teeth. If there are missing primary teeth, then there is a strong possibility of missing adult teeth too.12 e. In one large study, between 5% and 10% of orthodontic patients have missing teeth.15 11. The first and perhaps most important thing to do in this case is to provide oral hygiene instruction (OHI), monitor, and if necessary, improve the diet. The plaque and calculus has to be removed, and the presence of generalised marginal gingivitis has to be treated. Rigorous practically enforceable OHI with a hygienist and tooth brush instructions (TBI) need to be implemented as soon as possible. Following this, the decay in the permanent first and second molars needs to be treated. The second molars need restoration in the enamel only, and minimal preparation resin restorations will be sufficient. If these restorations can be completed without the need to use a local anaesthetic, then the confidence this girl will have in your abilities to undertake dentistry will grow as will her faith that the treatment you provide is really in her best interests. After this, restoration of the first molars can proceed. Point to Note One fact to be wary of is that radiographic presentation of demineralisation is often (if not always) less than the actual clinical extent of a lesion in the tooth. Again, use of a minimally traumatic cavity preparation technique, such as atraumatic use of hand instruments in a stepwise sequence to remove decayed dentin in measured amounts is needed. Temporary filling with Glass Polyalkenoate with review after two to three months and removal of any decay left in the base of the cavity is needed. This technique can minimise the risk of compromising the pulp at the first visit by excessive removal of dentin in one visit. Points to Note a. This approach is less painful than a full assault on a child’s tooth with a high-speed hand piece spraying water everywhere but mostly up a child’s nose or down their throat. b. Topical fluoride application can be applied at this first visit too. 12. The patient does have a Skeletal Class ll pattern, and she is in the middle of the rapid (pubertal) phase of skeletal growth. It is important to enhance the naturally occurring growth in the lower jaw and possibly restrain any unwanted growth in the upper jaw. Functional appliances such as the ubiquitous Clark’s Twin Block (CTB) removable appliance, or variations on this theme, can readily achieve this and are ideally suited for use in this case. An orthodontic specialist will decide on the best appliance to use in this case. There are several classifications of functional appliances, but they all work in a similar manner. In a case such as this,
the following processes are likely to occur: 1. Some of the effects of a functional appliance will be skeletal, enhancing mandibular growth and restraining maxillary growth. The glenoid fossa may be translated anteriorly by the effect of dynamic muscular action, and there could be several millimetres of basal bone growth in the mandible. The maxillary growth can be further inhibited by use of the CTB appliance and external headgear too. 2. Most of the effect of a functional appliance can be dental. Upper incisors can be tipped posteriorly whereas the lower incisors can be tipped anteriorly. Such effects are determined by the placement of labial bows or active components attached to a functional appliance. Similarly, there can be tipping or tilting movement of buccal segment teeth such as an inhibitory movement of the (decayed) maxillary molars. Further intrusive or extrusive movement of various teeth can be achieved, thus increasing the lower facial height. 3. If CTBs or other appliances are to work, the patient needs to be in an active growth phase. There is still much confusion and controversy surrounding the mode and site of action of functional appliances. However the following processes are likely to occur: a. Dento alveolar distalisation of upper teeth and some mesialisation of the lower arch. b. Restriction of maxillary skeletal growth during the pubertal growth phase. c. Accelaration of mandibular growth, although this may be a transient effect only. d. Anterior repositioning and remodelling of the glenoid fossa.16-18 4. Although the patient is within the correct age range to benefit from such an appliance, having an orthodontic appliance in her head might be the last thing on her mind right now. 5. Cooperation and a keen patient are the keys to success with these appliances. Orthodontic treatment might be more troublesome than having a boyfriend as her best friend has recently found out. For optimum results, a CTB needs to be worn full-time (including eating and sleeping with it) for the next three to six months of her turbulent teenage life. 13. Although the orthodontic specialist would be the arbiter whether treatment would/could proceed or not, as a referring dentist, you have to be able to explain to your patient what orthodontic treatment involves. By the time the patient comes to reconsider the merits of having a nice smile for life and the oral health and social benefits this may bring, you will already have completed the basic conservation work to the molars and improved both her gingival health and periodontal condition considerably. By then, your patient will be more receptive to your ideas. Presenting an option for orthodontic treatment involves weighing up the benefits and balancing the risks. This information should be presented in a language the patient can identify with and the mother can clearly understand, as she will be the one to approve or disprove the ideas you and your colleagues have in store for her daughter. In the real world, there is a patient information leaflet you can hand out, asking both mother and daughter to read and for them to return to you in a week for a further consultation involving more questions and answers. The British Orthodontic Society has produced Patient Information leaflets
which are available online. In an OSCE, the information you need to give should advise the patient and parent what wearing a functional, then a fixed appliance involves. Among other things, there is a need to maintain excellent oral hygiene, to regularly re-attend with the orthodontist, and to undertake treatment that can last up to a year and a half with monthly recalls. Initially, after fitting an appliance, there will be pain for a few days, but this period of discomfort soon passes; however, for the duration of treatment, there will be restrictions on what can be eaten. If or when the appliances are damaged or if the brackets debond from the teeth, then more return visits are needed to rectify such problems, and the rate at which treatment progresses may slow down. Most importantly, the need to maintain strict oral hygiene is vital to ensure no decay or ‘scarring of the enamel of teeth’ occurs from demineralisation or decay during treatment, as this can be difficult to rectify after treatment is completed. After the active phase of treatment is over, there is a need to wear a retainer for some time afterwards or to have a retainer bonded to the teeth to prevent them from moving back to the position they were in before treatment began. It is important that the patient and parent ask as many questions as needed before signing the consent form to agree to undergo orthodontic treatment. 14. A patient may decide not to go ahead with the treatment. As a dentist, you have to respect such decisions, no matter how perverse they appear at the time. This decision should be clearly documented in the patent record cards, together with the reasons why this option was chosen. The full extent of any advice you have given to the patient should also be recorded in the notes. Often patients will re-attend several years later and either demand that treatment is started, or claim the risks of not treating a malocclusion were not fully explained to them at the time. It is important to document all discussions and outcomes from any meetings and to retain the notes for the correct period of time. Dental Record Retention Dental records need to be retained for 11 years from date of consultation or to the age of 25 years whichever is the longer. In this case the notes will be kept until the patient is 25 years old. 15. In this case, if the patient undertakes orthodontic treatment, the initial phase after OHI, TBI and, conservation work is to undergo treatment with a functional appliance during the rapid pubertal growth phase. A decision has to be made on what to do with tooth 45. Whether 45 is extracted or included in the dentition (with perhaps another tooth being sacrificed in its place) is an informed choice the parents will make. Any decision will follow specialist orthodontic and surgical advice. Upper and lower fixed appliance treatment will be needed and this phase can last up to 18 months. After this, the teeth need to be retained in their new positions. This could be for up to one year with removable retainers worn in the upper arch, initially day and night, then night-time only. To prevent late lower incisor crowding, a retainer could be fixed to the lingual surfaces of the lower teeth. This would remain in place for several years.
Recall and review on a regular basis with a dentist and orthodontist would be needed. In the MJDF SCR, you will have completed the question by answering all of the above. In an OSCE for MJDF or MFDS, at the end of the consultation, you can ask the parent if there are any further questions, and if there are none, you can finish. Further Notes to This Clinical Case. In both MJDF and MFDS exams, as mentioned previously, a successful candidate will not be expected to demonstrate the knowledge of a specialist orthodontist who might be involved in the care of a case such as this. Nevertheless, a successful candidate should show a sound understanding of basic treatment principles. A candidate for the MJDF and MFDS should be able to: 1. Recognise and diagnose a malocclusion. 2. Identify the most urgent problems that need to be corrected in an orthodontic case. 3. Be able to use the IOTN DHC and aesthetic components and recognise the need to refer to a specialist. 4. Understand the extent and limitations of the role of a GDP in the orthodontic treatment process. In the MFDS, a dialogue between the candidate and an actor portraying the mother will take place and in 10 or so minutes, the following areas should be covered: 1. Taking a history with assessment of records, radiographs, and study models as necessary to form a problem list with possible solutions. 2. Review the general aims of orthodontic treatment with the actor and assess whether a demonstrable benefit to the patient is possible. The aims of orthodontic treatment are a. To improve the dental health. b. To establish a functioning dentition. c. To have an aesthetically acceptable and pleasing result for the patient and parents. d. To have a stable dentition at the end of treatment. 3. Discuss the treatment options with the actor and include the advantages and disadvantages of either choosing to undergo treatment or choosing not to have orthodontic treatment, gaining consent as necessary and answering any questions the actor may have. References to Clinical Case 44 1. Shield JP, Baum JD. Children’s consent to treatment. Br Med J. 1994;308:1182-83. 2. Gillick v. West Norfolk and Wisbech AHA (1986) AC112 and 113. 3. Wheeler R. Gillick or Fraser? A plea for consistency over competence in children. Br Med J. 2006;332:807. 4. Clinical Standards Committee: Nunn J, Foster M, Master M, Greening S. Consent and the Use of
Physical Intervention in the Care of Children. pp. 5-6. London: Faculty of Dental Surgery Royal College of Surgeons of England 2008. [Online] Available from: http://www.rcseng.ac.uk/fds/publications-clinicalguidelines/clinical_guidelines/documents/paed_dent_intervention.pdf [Accessed August 2013]. 5.
Age of Legal Capacity (Scotland) Act 1991 (c.50). [Online] Available from: http://www.opsi.gov.uk/ACTS/acts1991/Ukpga_19910050_en_2.htm#mdiv1 [Accessed August 2013].
6. Mitchell L. Chapter 1: The Rationale for Orthodontic Treatment. Section 1.3.1: Dental Health. Trauma to Anterior Teeth. In An Introduction to Orthodontics. 2nd Edition p. 2. Oxford: Oxford University Press 2001. 7. Crawford PJM, Aldred MJ. Chapter 13: Anomalies of Tooth Formation and Eruption. In Wellbury RR, Duggal MS, Hosey MT. Paediatric Dentistry. 3rd Edition pp. 297-298. Oxford: Oxford University Press 2005. 8. Képes D, Gábris K. [Prevalence of hypodontia at the department of pedodontics and orthodontics of Semmelweis University]. Dental Survey (Fogorvosi Szemle) 2013 Mar; 106 (1):23-6. 9. Harris EF, Clark LL. Hypodontia: an epidemiologic study of American black and white people. Am J Orthod Dentofacial Orthop. 2008 Dec;134(6):761-67. 10. Rozkovcová E, Marková M, Lánik J, Zvárová J. Agenesis of third molars in young Czech population. Prague Med Rep. 2004;105(1):35-52. 11. Aslan BI, Akarslan ZZ. Teeth number anomalies in permanent dentition among non-syndromic dental patients. Coll Antropol. 2013 Mar;37(1):115-20. 12. Mitchell L, Mitchell DA, McCaul L. Chapter 3: Paediatric Dentistry. Abnormalities of Tooth Number. In Oxford Handbook of Clinical Dentistry. 5th Edition pp. 64-65. Oxford: Oxford University Press 2009. 13. Brook AH. Dental anomalies of number, form and size: their prevalence in British schoolchildren. J Int Assoc Dent Child. 1974 Dec;5(2):37-53. 14. Scully C. Chapter 4: Signs and Symptoms. In Scully C. Medical Problems in Dentistry. 6th Edition p. 84. Edinburgh: Churchill Livingstone 2010. 15. Topkara A, Sari Z. Prevalence and distribution of hypodontia in a Turkish orthodontic patient population: results from a large academic cohort. Eur J Paediatr Dent. 2011 Jun;12(2):123-27. 16. Clark WJ. The twin block technique: a functional orthopedic appliance system. Am J Orthod Dentofacial Orthop. 1988 Jan;93(1):1-18. 17. Barton S, Cook PA. Predicting functional appliance treatment outcome in Class II malocclusions —a review. Am J Orthod Dentofacial Orthop. 1997 Sep;112(3):282-86. 18. Carter NE. Chapter 18: Functional Appliances. Section 18.2: Mode of Action. In Mitchell L. An Untroduction to Orthodontics. 2nd Edition pp. 188-198. Oxford: Oxford University Press 2001. Further Reading to Clinical Case 44
1. Mitchell L. Chapter 5: Orthodontic Assessment. In An Introduction to Orthodontics. 2nd Edition pp. 43-45. Oxford: Oxford University Press 2001. 2. Houston WJB. Chapter 17: Functional Appliances. In Stephens CD, Tulley WJA. A Textbook of Orthodontics. 2nd Edition pp. 323-345. Oxford: Wright 1992. 3. Kay EJ, Tinsley SR. Chapter 5: Motivation Yours, the Patient’s and the Practice’s. In Communication and the Dental Team. pp. 46-59. London: Stephen Hancocks 2004. 4. Gibilaro A, Harrison MG. Chapter 33: First Permanent Molars. In Odell EW. Clinical Problem Solving in Dentistry. 3rd Edition pp. 155-159. Edinburgh: Churchill Livingstone 2010. 5. Mossey PA, Stirrups DR. Part 2: Discipline Specific Skills. Section 2.3: Orthodontics. In Holsgrove G, Stirrups DR, Davenport ES. Essential Skills for Dentists. pp. 297-311. Oxford: Oxford University Press 2006.
Clinical Case 45 Background Information The last OSCE in this chapter is based on a patient whom I have been looking after for some years now. This case began a long time before the Royal College of Surgeons of England conceived the MJDF. The experience I gained from this case, with advice from senior colleagues, was (I hope) usefully invested in enabling subsequent patients to benefit from a higher standard of dental care. Additionally, this case did provide the incentive for me to begin my journey towards gaining postgraduate qualifications. This might seem a little odd; surely, the aim of studying for and gaining postgraduate qualifications is for the benefit of patients. It is not for patients to attend with the intention of (thought) provoking the dentist into further study. This case was back to front in that respect. Consequently, this patient became a benchmark in my revision courses and preparation for exam questions as an example of what we need to do. I hope that in your clinical work and revision, you too will have cases just like this one, where (without giving too much away) a diagnosis does not bring the patient to their knees but it brings you to your feet: You get up and get on with what you need to do to progress with your learning. OK, without any more messing about, long introductions and flannel, here is the last case in this chapter. Introduction The patient is a pleasant 58-year-old woman who smokes and drinks. She is fit and well, working as an accountant for a dental equipment manufacturer. Therefore, she has been a regular dental attender for most of her life. Before coming to see you, a colleague has limited the extent of his treatment on this patient to completing some basic fillings and crown work, completely ignoring both the periodontal condition and the symptoms the patient has been complaining of for some time now. The patient’s main complaint is pain and discomfort from the right side of the mouth and this has been
ongoing for some time. The patient tells you that in the previous two years, your colleague has ignored this symptom, instead choosing to concentrate on undertaking basic dental work such as placing amalgam restorations and crowns in the first and second molars on the right side. These crowns are porcelain bonded to non-precious alloys. An extra-oral examination of the patient reveals no problems with the left and right TMJs. However, on the right side, the submandibular lymph nodes are a little swollen. If you could palpate these, you would feel them to be noticeably firmer than the nodes on the left side. For some weeks, the patient has been complaining of: ‘An irritating gnawing pain from the right side of the mouth’. In response to this symptom, the patient has been biting on the cheek on the right side. Unsurprisingly, now there are signs of mucosal trauma of the right cheek and food packing between the crowns of the right maxillary first and second molars. Both of these teeth are tender to percussion. A periapical radiograph reveals widening of the periapical membrane around the apices of the roots of the crowned first maxillary molar. A root treatment was started on this tooth with pulpal extirpations of all three canals being completed in the first visit. From the condition of the contents of the canals, it was confirmed this tooth was not vital, and further visits were planned to complete the root treatment. The bitten and chewed mucosa appears red and ulcerated with some white patches. A reasonable assumption is that the clinical appearance is most likely to be in response to the cheek biting, or there may be a lichenoid reaction of the patient’s mucosa to the restorations placed by your colleague (similar to OSCE 43). Further treatment planned in addition to the root canal work was for referral to a hygienist to treat the generalised gingivitis. After two weeks, there was no easing of the pain from the right side. The patient continued to bite on the irritated cheek mucosa. This was becoming more of an annoyance, rather than anything else. In response to a request from the patient, a decision was taken to excise the irritated, traumatised, and inflamed mucosal tissue from the cheek. After discussing various options with the patient, consent was given to remove a sample of the cheek mucosa. When the sample was removed, the patient decided that if removing the irritated, traumatised, and inflamed cheek sample solved the problem, that is all she wanted to know and completing the root treatment would conclude her dental treatment. At the completion of the biopsy, the mucosa was sutured and the sample promptly delivered to the local hospital’s histopathology department for analysis. The patient was discharged with the following advice: ‘From this sample, we will, hopefully, find out the answer to what is causing the pain.’ Clinical Case 45 Part 1: Questions 1. From the information in the introduction what are the most likely causes of the irritation and
inflammation in the cheek? 2. The patient has pain on the right side, where is the pain most likely to be coming from? 3. Can you broadly describe the sensory nerve supply to the affected area? 4. If faced with a problem as described in this case, can you perform a biopsy in general dental practice? 5. Which type of biopsy would you perform and why? Clinical Case 45 Part 1: Answers 1. One piece of advice commonly given in the MFDS revision courses is that common things happen commonly, and the aphorism of the late Dr Theodore Woodward, professor at the University of Maryland Medical School, is, therefore, commonly quoted in these revision courses: ‘When you hear hoof beats, think of horses, not zebras’.1 Woodward’s original admonition to medical trainees in the late 1940s was ‘Don’t look for zebras on Greene Street.’ (The University of Maryland Hospital is located on Greene Street in Baltimore.) How this developed into the precise wording of the aphorism is still unknown. Nevertheless, it seems proper to credit Dr Woodward with inventing it.2 In dentistry, just as in medicine, the same applies. In this case, the common problems you can think of causing the clinical presentation as described above might form your differential diagnosis. As in OSCE 43, the use of a surgical sieve is useful. However, in this case, rather than straining ourselves (no pun intended) by using any one of the sieves previously mentioned, we might solve this case not by using a specific surgical sieve, but by considering the most likely causes from the most common to the least common as we filter facts to form our differential diagnoses. Two Heads Are Better Than One As before, we need to engage the patient to ‘hold the sieve’ while we filter the evidence either for or against the likely causes of their pain. By making this investigation a patient-centred affair, we will be using two heads to solve one problem. In the clinic, patients will come with suggestions and information from the Internet. As mentioned earlier, some 85% of patients will have access to the Internet.3 Important information leading to a definitive diagnosis might be gained from such sources. It is important that where necessary, you are able to meaningfully discuss and where necessary, incorporate such data into your diagnostic approach. In the answers to this case, patient-centred Internet references have been cited. a. Normal mucosa. The white patches seen may comprise excessive keratin deposits, and the red patches being minor salivary glands or Fordyce spots. This explanation is unlikely, and the mucosa is not normal, although most patients’ mouths do have white patches in them and these are, in the main, harmless common clinical signs. While this reason may account for the clinical signs, it does
not account for the clinical symptoms described. b. Trauma. The sources of trauma can be mechanical or thermal, from cheek biting, hot food burning the mucosa, or commonly the patient placing an aspirin against the mucosa to ease any pain felt. Although the former reasons are most likely, the latter is unlikely and there is no mention of this being done in the introduction. On balance, this is the most likely cause of the clinical presentation seen in this case. c. Infection. With the damage to the mucosa, infection with an opportunistic pathogen commonly found in the oral mucosa may follow. One likely source of infection is from a candidal species. In this case, given the duration of the complaint, a chronic hyperplastic candidosis may be responsible for the clinical presentation seen. The white patches may, indeed, be caused by a fungal infection. However, the most common sites of such infections are the tongue dorsum and the posterior commissures of the buccal mucosa and not the cheek mucosa as in this case. Despite the unusual site of the lesion, we cannot completely exclude this as a cause. If candidal infection is a cause, it does not explain the symptoms experienced by the patient. Oral candidal infections are characteristically painless. d. Lichen planus. This may explain the clinical presentation. Lichen planus is a common condition, with 2% of the population being affected.4 It is 1.5 × more common in females and is frequently seen in smokers too. Lichen planus is principally a cutaneous condition with half of the cases having additional oral lesions.5 In this case, there were no cutaneous lesions. Furthermore, this lesion is not bilateral as lichen planus commonly is. Nor does the lesion fit the common presentation of the most common reticular pattern of lichen planus. Perhaps the lesion in this case is one of the five other forms of lichen planus: These are plaque-like, papular, bullous, atrophic or most likely in this case, erosive lichen planus. If we believe this lesion to be erosive lichen planus, then the pre-malignant potential of this lesion has to be considered, although this remains a controversial suggestion. e. Lupus erythematosus. In the absence of the characteristic malar ‘butterfly’ rash, this lesion may be a form of lupus. Indeed, there may be the possibility that this lesion could be either systemic lupus erythematosus (SLE) or Discoid Lupus Erythematosus. (DLE) Certainly, the presentation with ulceration and white patches is highly suggestive of this connective tissue disease. However, we would expect this to be bilateral. Oral presentations are rarely an early feature of SLE and are only seen in 10% to 20% of all cases.6 Although there is pain associated with SLE, this is from arthralgia and associated systemic conditions, rather than the oral lesion itself (as in this case). SLE and DLE are relatively rare but cannot be absolutely excluded in this case. f. Pemphigus vulgaris. This is truly uncommon; however the site of the lesion and the patient do match the criteria for this condition. Females aged 40 to 60 are commonly affected and a painful ulcerated oral lesion on the buccal mucosa which breaks down following mechanical trauma would seem to fit the diagnostic criteria.7 However, there are no cutaneous lesions, and in this case, there is only one localised lesion. So on this basis, we might reserve judgement for this being the cause of the condition. g. Mucous membrane pemphigoid. Although this is uncommon, the clinical presentation does fit the
criteria for the condition, given the age and gender of the patient. There is a painful chronic ulcerated non-healing lesion, and there are no cutaneous lesions. The only problem in this case is the location of the lesion does not fit the characteristic pattern for mucous membrane pemphigoid. With this condition, the palate and gingivae are more commonly affected. 8 With the patient in this case, the lesion is on the buccal mucosa. Pemphigus and Pemphigoid In both pemphigus and pemphigoid, females are more commonly affected. The conditionmostly presents in the age range 40 to 60 years. The mouth is the most common site, before spread to the skin in pemphigus (which can prove to be fatal) but not in pemphigoid, whereother mucosal tissues may be involved and the cutaneous tissues are seldom affected (the condition is indolent but not fatal) In pemphigus, the condition is intra-epithelial whereas in pemphigoid, the condition is sub-epithelial. Diagnoses and differentiation in these conditions is achieved by immunofluorescence against IgG in pemphigus and anti-c3 basement membrane in pemphigoid, where a characteristic line of antibody binding against the basement membrane gives a clear diagnosis.9 Despite the clinical picture including the presentation of pain closely matching these two uncommon conditions, it is unlikely in this case that the patient has these, due to the location of the lesion not fitting the characteristic disease pattern. h. Unknown or smoking-related conditions. The patient is a smoker, so there could be a number of mucosal conditions she might have. These are the tobacco-related leukoplakias and variations on this of erythroleukoplakia, the verrucous, speckled, or nodular leukoplakias. Although in the UK, these conditions may be termed pre-malignant and are quite rare, in erythroleukoplakia, the risk of malignant transformation is, nevertheless, quite high.10 In contrast, white patches are very commonly seen, but overall, they have a low level of malignant transformation. It is important to note that erosive lichen planus and SLE both have the potential to become malignant, although, as stated previously, this remains a controversial issue.11 g. Neoplastic conditions. Despite a high degree of suspicion being trained into us as dental undergraduates, oral carcinoma is still reportedly relatively rare. It accounts for 2% of all malignant tumours in the UK. If there is an oral neoplasia, this is most likely to be an oral squamous cell carcinoma, 90% of all oral neoplasias being of this type.12,13 Most of the remaining oral neoplasias are adenocarcinomas of the minor salivary glands or undifferentiated metastatic secondary tumours. Zebras, Fascinomas and Zebromas a. One characteristic of most but not all oral neoplasias is they do not initially present as painful lesions unless neural tissue is involved. b. So with all of the information above, it is unlikely that an oral neoplasia is present if we follow the aphorism of Woodward as advised in the MFDS revision courses. c. Neoplasia, in this case, is likely to be a ‘zebra’, and an adenocarcinoma might be a very rare breed of ‘zebra’. In medical terms to go directly to such a diagnosis would be a ‘fascinoma’ (a
fascinating pathology). d. The rarest result would therefore be a Zebroma. 2. The pain on the right side is most likely to be coming from the teeth and not from the mucosal tissues. In this case, the lesion does not show any of the features associated with malignancy, and despite the ulceration, there is no induration. There does appear to be pain from the lesion. That in itself is unusual. The submandibular lymph nodes are raised on the side of the lesion. There are two non-precious alloy crowns and strong evidence to suggest traumatic biting is the cause of the ulceration of the cheek mucosa. Periapical pathology from the non-vital maxillary molar may explain the pain the patient has experienced and certainly the submandibular lymph nodes do drain these teeth, so a non-vital infected first molar would explain the lymph node swelling. So the clinical picture would seem to suggest that a non-vital upper right first molar may be the source of the pain. Despite the patient being a smoker, from all the evidence, the lesion is most likely to be a result of biting trauma and dental pain. However, what is not consistent with pain of dental origin is the description of a gnawing pain of long duration. It is known that pulpal pain can be diffuse and non-specific, whereas periodontal pain can be specific and localised. The pain described here does not fit this pattern. It might be possible that nerves in the damaged cheek mucosa are responsible for some of the pain sensations, together with pain from the upper first molar. 3. The nerves involved in transmitting the pain sensations in this case are the afferent fibres of the trigeminal nerve. This is the fifth cranial nerve. Specifically: Divisions Two and Three (or CNV ii, and CNV iii). Also known as the maxillary and mandibular divisions, these are responsible for pain transmission in this case. Whereas the CNV ii is purely a sensory nerve, the CNV iii has both motor and sensory functions too, although in the answer in this case we will focus more on the sensory branches. In the MFDS OSCE, you will not be asked about the anatomical pathways of this nerve; however, in the MJDF OSCE or indeed in the SCR (Structured Clinical Reasoning) questions of MJDF Part 2, you could be asked such a question. Points to Note 1. In the MJDF OSCEs and SCR, it is useful to be more than familiar with the locations where this nerve conducts its business. 2. If you have forgotten about the trigeminal nerve, then please consider revising your regional anatomy. 3. Your whole working life is in many ways a long painful relationship with the trigeminal nerves of your patients 4. I have included a brief account of this nerve’s involvement as it relates to our case: The fifth cranial nerve chews your food and feels your face. (Prof. Steven Goldberg)14 In the beginning (or at the end, as we are dealing with the sensory functions in this case) there is the
sensory cortex of the parietal lobe. From here, the CN V fibres descend and cross the midline of the brain into a long somatic sensory nucleus extending from the pons through the medulla down to the posterior horn of the spinal cord. Following Goldberg’s example, I have tried to describe the CN V sensory nucleus and pathway in a way that is easy for you to remember: a. At the upper pontine level: proprioception is processed. b. The middle medullary mass: mainly minute momentary messages from the mouth are measured. c. Sinking spinally: sore sensations are sorted. From top to bottom, there is a stacking of the nerves from fine to coarse in terms of their sensory abilities in the CN V sensory nucleus. From the sensory nucleus, the CN V fibres pass to the busy trigeminal ganglion, where the bodies of the sensory nerves live. This ‘gang-lion’ sits in Meckel’s cave in the dura mater, covering the trigeminal impression near the apex of the petrous part of the temporal bone. This gang-lion is crescent shaped, with its convexity directed forward. Medially, it is very close to the internal carotid artery and the posterior part of the cavernous sinus. The greater superficial petrosal nerve lies underneath the ganglion. The ganglion receives on its medial side: Filaments from the carotid plexus of the sympathetic chain. It gives off minute branches to the tentorium cerebelli and to the dura mater in the middle fossa of the cranium. From the busy gang-lion’s convex border, forward and laterally in the temporal bone, there is Standing Room Only for three branches to exit through the: Superior Orbital Fissure. CN V i returns here. Foramen Rotundum CN V ii returns here. Foramen Ovale. CN V iii leaves here. CN V i The ophthalmic branch leaves the skull through the Superior orbital fissure to go about its sensory business on the scalp, forehead, eyelid, cornea, and tip of the nose. (We can leave this branch alone now as it plays no further part in our case, other than if you are confused and you can feel yourself scratching your head.) CN V ii The maxillary branch departs the ganglion passing through the cavernous sinus, leaving the skull through the foramen Rotundum. Here in the pterygopalatine fossa, a ganglion dangles by two branches from the maxillary nerve. It receives parasympathetic fibres from the facial nerve’s greater petrosal branch crying fibres to the lacrimal glands and out through the inferior orbital nerve. A sympathetic supply from the superior cervical plexus rushes through the deep petrosal nerve on its way through the ganglion without stopping. This sympathetic nerve supplies the blood vessels and mucous glands of the head and neck territory covered by CN V ii. Meanwhile, in the sensory maxillary trunk, nerves are sent out to the nasal, palatine, and superior alveolar territories. With relevance to this case: The CN V ii receives sensory information from upper lips, upper teeth,
gums, and palate. CN V iii The mandibular branch is the largest branch to depart the ganglion leaving the skull through the foramen Ovale, to enter the infratemporal fossa. A motor root runs in front of and medial to a sensory root. The sensory branches are buccal nerve, auriculoremporal nerve, lingual nerve, and inferior alveolar nerve. Sensation from the lower lip, the lower teeth and gums, the chin, and the jaw (except the angle of the jaw, which is supplied by spinal nerves C2-C3), parts of the external ear, and parts of the meninges are all covered by nerves of the mandibular branch. Of importance to this case: The mandibular nerve carries touch/position and pain/temperature sensation from the mouth. It does not carry taste sensation; the CN Vll chorda tympani is responsible for that. One of its branches, the lingual nerve, carries multiple types of nerve fibre that do not originate in the mandibular nerve. The three branches of the CN V provide sensory innervations to precisely demarcated dermatomes with little, if any, overlap in their territories across the face and scalp, in contrast to other areas of the body, where there is considerable overlap in dermatome coverage. The information above should be combined with a good working knowledge of the regional anatomy of the head and neck. It is important to know about the motor as well as the sensory branches of the trigeminal nerve and the intimate relationship of these to the facial nerve. With relevance to this case: The sensory branches of the CN V ii and CN V iii are implicated in the symptoms our patient has been complaining of. Nervous revision 1. If you plan to sit the MFDS, then you can calmly avoid the above answer. 2. If you intend to study for both the MFDS and the MJDF, then learn the above in context with the relationship of the trigeminal and facial nerves to clinical cases you have treated, studied, or will be examined on. 4. The answer to: ‘Can you perform a biopsy?’ is really, ‘Would you perform a biopsy?’ Apart from answering a question with a question, in the MJDF, you may be asked to perform a practical test on a biopsy pad. Certainly, the MJDF revision courses provide many opportunities to practise these skills. In the MFDS, you can relax; your healing hands play no part in the examination. In the MFDS, as in real life, you need to decide if a biopsy should be undertaken, and if so, why. As a rule, all unusual lesions in the mouth should be biopsied. Many lesions in the mouth are perfectly harmless. Those caused by trauma, frictional keratosis, or lichen planus, or lichenoid reactions do not need to be biopsied. However, whether to biopsy or not is a decision left to an experienced specialist; your decision is to refer for biopsy, if you are not going to perform the biopsy yourself. Your reasons to biopsy are to exclude the possibility of neoplasia or to determine if dysplasia is present, and to identify if there is an infective cause such as the presence of candidal hyphae, or to
identify any other specific cause for the presence of the lesion. There is no reason why biopsy should not be performed by a dentist working in general practice or in hospital; your decision to do the biopsy or refer will be governed by your experience and ability to liaise with hospital specialists. Despite the above reasons, there are certain lesions you would do well to refer. Among these are the haemangiomas or sarcomas. Apart from bleeding excessively, why would you biopsy lesions that are so characteristic and pathognomic in their appearance? One example we do not see so much of is the oral Kaposi sarcoma—once seen, rarely biopsied, and never forgotten. Inaccessible lesions, those in the palate, and those closely involved with complex neurovascular structures in glands where there are risks associated with biopsy should be referred. There are other reasons to refer too: a. When care for the patient will be better served in a hospital, where the testing, the diagnosis, and the aftercare can be more integrated. b. In these cases, then the first link in the chain of care starts with the use of a pen to refer and not a scalpel to biopsy. c. Lastly, those who will give the diagnosis, with all that this may entail, should undertake the biopsy when a lesion clearly shows clinical signs of malignancy. In this case, there are clear indications that the lesion is a traumatic ulceration; the swollen lymph nodes are caused by the upper first molar, and the pain experienced is caused by the traumatic ulceration and the pulpal pathology. The lesion is not in a high-risk site and there is ulceration, but there is no induration and the redness is most likely from trauma. So on balance, a biopsy in general practice would seem to be sensible. 5. In this case, an incisional sample 6 mm × 6 mm was taken under local anaesthetic and placed in ethyl alcohol (diluted in water to 30%) and sent for routine histological analysis. The choice of incisional biopsy was to include normal tissue and a section of the lesion too, with minimal further disruption to the oral tissues or inconvenience to the patient. An excisional biopsy would have been excessively large and would have caused further disturbance to an area already traumatised. The incisional biopsy preserves some of the lesion in the surrounding healthy tissue. Should complete removal be needed, a surgical specialist can determine the orientation of remaining affected tissue and normal mucosa. Normally, formol-saline solution is used to preserve the sample; however, in this case there was no formol-saline so an isotonic solution of food grade ethyl alcohol was used to preserve and sterilise the tissue sample. Further Notes to Clinical Case 45 Part 1 Biopsy might seem excessive as most lesions with white patches in the mouth are benign, and some 5% of the population over the age of 50 have white lesions of some type.15 There are less invasive tests, but all have to be undertaken with specialised equipment or referral to specialist centres. Much of the early promise of these tests such as: in vivo staining with toluidine blue dye, autofluorescence, and illumination with light of specific wavelengths failed to reach any meaningful conclusions in
clinical trials.15 It has to be stated that these alternative techniques were specifically developed to look for oral cancers. Despite their having limited value as diagnostic tests, they may still be useful as screening tools. Until further clinical trials are conducted, such as a randomised clinical trial with the strongest evidence to prove or refute the use of alternative tests, the biopsy remains the safest procedure to conduct in clinic. Patients often (but not always) do not find biopsy traumatic, suture removal and healing are uncomplicated, and it is a procedure any dental surgeon can undertake, and where indicated, it should be done immediately. References to Clinical Case 45 Part 1 1. Theodore E. Woodward; in collaboration with the Medical Alumni Association of the University of Maryland and the Historical Society of Carroll County. Make Room for Sentiment: A Physician’s Story. Baltimore: The Association 1998. 2. Sotos J, Zebra Cards. [Online] Available from: http://www.zebracards.com/a-home.html [Accessed August 2013]. 3. Meyer UA. How Genomics will change personalised medicine. Presentation at Swiss Clinical Trials Organisation Conference, Zurich 2012. 4. Usatine RP, Tinitigan M. Diagnosis and treatment of lichen planus. Am Fam Physician. 2011 Jul 1;84(1):53-60. 5. Mitchell L, Mitchell DA, McCaul L. Chapter 9: Oral Medicine. Oral Manifestations of Skin Disease. In Oxford Handbook of Clinical Dentistry. 5th Edition p. 430. Oxford: Oxford University Press 2009. 6. Scully C. Chapter 18: Auto Immune Disease. The Connective Tissue Diseases. In Medical Problems in Dentistry. 6th Edition pp. 427-428. Edinburgh: Churchill Livingstone 2010. 7. Fatahzadeh M. Timely recognition of pemphigus vulgaris by dental professionals. Quintessence Int. 2013 Jul;44(7):521-30. 8. Soames JV, Southam JC. Chapter 12: Oral Ulceration and Vesiculobullous Diseases; Vesiculobullous Diseases. In Soames and Southam Oral Pathology. 2nd Edition pp. 212-213. Oxford: Oxford Medical Publications 1993. 9. Scully C, Felix DH. Chapter 2: Mouth Ulcers of More Serious Connotation. In Scully C, Felix DH. Oral Medicine Update for the Dental Practitioner. pp. 9-10. London: BDJ Books 2006. 10. Scully C, Felix DH. Chapter 5: Oral White Patches. In Scully C, Felix DH. Oral Medicine Update for the Dental Practitioner. pp. 25-26. London: BDJ Books 2006. 11. Fang M, Zhang W, Chen Y, He Z . Malignant transformation of oral lichen planus: a retrospective study of 23 cases. Quintessence Int. 2009 Mar;40(3):235-42. 12. NHS Choices Mouth Cancer. [Online] Available from: http://www.nhs.uk/conditions/Cancer-of-
the-mouth/Pages/Introduction.aspx [Accessed August 2013]. 13. Mitchell L, Mitchell DA, McCaul L. Chapter 9: Oral Medicine. Oral Cancer. In Oxford Handbook of Clinical Dentistry. 5th Edition p. 416. Oxford: Oxford University Press 2009. 14. Goldberg S. Chapter 4: Brain Stem. In Clinical Neuroanatomy Made Ridiculously Simple. 2nd Edition pp. 28-37. Miami, FL: MedMaster Publishing 2000. 15. Twitchen MJ, Odell EW. Case 45. A White Patch on the Tongue. In Odell EW. Clinical Problem Solving in Dentistry. 3rd Edition pp. 211-212. Edinburgh: Churchill Livingstone 2010. Clinical Case 45 Part 2 Brown Envelope—Pink Paper Within two weeks (actually it was closer to one week), a brown envelope arrived with a pink slip inside. It looked like a routine result, the patient’s name together with the consultant’s name on top and the results below. The Histopathology Clinical details: Mobile lump removed submucosal tissue. Routine. Specimen: Right cheek mucosa. Macroscopy: Specimen received in alcohol. Microscopy: Sections show salivary tissue associated with a nodular lesion composed of cords and cribriform islands of infiltrating basaloid cells. The appearance is classically that of adenoid cystic carcinoma of salivary gland. These are slow-growing malignant tumours that may metastasise to the lungs, and radical surgical excision is the treatment of choice. For this reason, surgical referral is advised. The abnormality extends to the limits of resection. The case has been reviewed and discussed. Conclusion: SALIVARY GLAND ADENOID CYSTIC CARCINOMA SURGICAL REFERRAL ADVISED
Questions Clinical Case 45. Part 2 1. What condition does the patient have? 2. With what frequency is this condition seen and what might be the cause? 3. What do you need to do now? 4. How do you explain the test results to the patient? 5. What happens next? Answers Clinical Case 45. Part 2 1. The patient has an adenoid cystic carcinoma or ACC. This is a salivary gland neoplasm of the minor salivary glands. The diagnosis was evident by the characteristic histological pattern of small round groups of darkly staining cells surrounded by larger areas of clear spaces. This has been termed a Swiss-cheese appearance. The ACC grows slowly but tends to infiltrate along nerve channels. When the mandible and maxilla become involved, then spread is more extensive than radiographs might show. Metastatic spread is a late feature of the ACC. At that stage, the prognosis
is very poor with spread to the lungs and multiple pulmonary metastases being common. 2. As previously stated, the most common form of oral cancer is the oral squamous cell carcinoma (90%) with the remainder being rarer forms of oral neoplasias.1,2 Although tumours of the salivary glands are the next most common after the oral squamous cell carcinomas, the minor salivary gland tumours are very rare, with the ACC comprising 10% to 15% of all minor salivary gland tumours and 3% of parotid tumours.3 The Cancer Research Campaign UK web site (http://www.cancerresearchuk.org) provides very accessible figures on the epidemiology of all cancers, not only in the UK but Europe and worldwide too. In 2009, oral cancer was the 15th most common cancer in the UK with 6,236 new cases reported with males being nearly twice as likely to have this condition (19:10 ratio of male to female new cancer being reported).4 In Europe, the incidence of salivary gland tumours is 1.3 per 100,000.5 This figure is from a 2012 pan-European study with 94 collaborating authors and is in broad agreement with those from Cawson and Odell 1998.6 In the UK, in a 10-year retrospective prevalence study of two defined hospital populations, the incidence of salivary gland neoplasms was again found to be in agreement with this figure of 0.8 to 1.4 per 100,000.7 Simple Questions but No Easy Answers Classically, ACC is a histologically defined cancer. The tumour can be a primary or a secondary, occurring in glandular tissue throughout the body, not just the head and neck and not just the minor salivary glands. The difficulty in UK and Europe, in addition to the differences in language and terminology, is that there are several registration criteria for cancers across different studies. This further complicates and confounds the attempts of practitioners to give patients matter-of-fact answers to the simple questions often asked when giving a patient a diagnosis: a. How many people have my condition? b. What caused this? c. How long have I got to live? a. If we combine the data from the most recent sources of all the cancers diagnosed in the UK, with the established patterns documented in the literature, tumours in the minor salivary glands are rarer than those in the major glands. As stated above, only 15% to 20% of all oral cancers occur in the minor glands, with the ACC being in the range of 10% to 15% of these. If we combine the figures from Cancer Research, UK, with the patterns documented in the texts, then at most only 10 to 20 or so ACCs of the minor salivary glands will be diagnosed every year in the UK. b. Poor diet and nutrition, smoking and drinking, or a combination of these, are the major risk factors for oral cancer, with UV exposure in sun beds and sunlight being the main causes of lip cancer. In this case, this cause can be confidently excluded. However, the other cofactors that frequently occur together are linked socially.
Damage to the DNA in the cells of the oral mucosa may arise from infection with viruses, EpsteinBarr (EBV), herpes simplex (HSV), the human papilloma (HPV) viruses all being implicated. Type 16 HPV has been suggested as an initiating factor in predisposing a patient to lesion development. Patients who are immunosuppressed (e.g. transplant patients and patients being medicated for autoimmune conditions) or immunocompromised patients (those with HIV or AIDS) may then be at greater risk of developing oral cancers (such as the Kaposi sarcoma mentioned previously.) As episomal viral DNA becomes integrated into a mucosal cell’s DNA, cells replicate in the absence of effective tumour suppressor gene activity, and so disruption in the cell cycle leads to disorder in the structure and function of tissues as neoplasia progresses unabated from the molecular to the cellular, becoming the lesion we see clinically. Oncogenesis and neoplasia and the specific reason why one patient will develop a cancer and another patient with the same risk factors will not are complex questions. The excellent article by Rautava and Syrjanen (2012) reviews the advances in this field since they first proposed the implication of viral involvement in oral cancer nearly 30 years ago.8 The simple answer is we do not yet know why a patient will develop an ACC; despite this, clear risk factors and treatment strategies have been established to lessen the impact this cancer has on the patient. c. In contrast to the 19:10 male to female ratio for all oral cancers in the UK, with ACC there are no notable gender differences; however, women affected have a better prognosis. 9 Nevertheless, the mean 10-year survival is still less than 60%. 3. Having received the test results, a coordinated approach to patient care is immediately established. This is one of those areas of clinical activity where processes are established without the patient actually being aware and thus consenting to these measures being set up for them. The first thing you have to do is to contact the histopathologist and confirm receipt of the diagnosis. An appointment to discuss the biopsy with the consultant histopathologist comes next. The patient’s general medical practitioner is contacted, and a coordinated referral to the Maxillofacial Surgical Department of the hospital where the surgical team have the most experience of dealing with this form of cancer is arranged. Following notification of the all the primary care workers, an appointment to begin the surgical care pathway for the patient is arranged; the patient is contacted to let them know an appointment has been made to come to discuss their test results. In this case, a telephone call to the patient, letting them know the test results were back and that the cause of the pain had been identified was made. The patient was invited to attend for an appointment where a liaison consultant psychiatrist and consultant maxillofacial surgeon would be present too. 4. Explaining the results of the biopsy to the patient has to be undertaken in a methodical structured manner. Breaking Bad News
a. Breaking bad news is an area comprehensively covered in the MFDS revision courses. b. However, those inexperienced in breaking bad news cannot teach you how to do it. c. This is an essential part of clinical practice that you need to see and hear for yourself, so you can begin to develop the necessary communication skills to deal with these situations in the clinic. Although revision courses can prepare you for an exam, they are no substitute for experience. Before the consultation begins with the patient, a preliminary discussion with those responsible for secondary care is made. The person who took the decision to undertake a biopsy has the duty to tell the patient of the results. Whether you are experienced or not, in my experience, the best way to break any bad news is to use the SPIKES protocol.10 We have already discussed this technique, introducing it to you in Ethical Example 27, dealing with a lost biopsy sample. To remind you the SPIKES protocol is: An acronym for: Setting Perception Invitation Knowledge Empathy Strategy. (In the MFDS and MJDF OSCEs, the theme will be to provide an explanation and the topic will be to explain the bad news from a test result to the actor or the patient.) In this Clinical Case, the biopsy sample has thankfully not been lost, but we hae to deliver the bad news: The consultation begins in the OSCE and in real life with your and your colleagues’ professional introductions. In this case, the patient and her partner know you already, so your senior colleagues will introduce themselves. After this, you can begin to break the bad news. a. The privacy of a consultation room in a hospital with your senior colleagues, nursing staff, and the patient’s partner in attendance is an appropriate Setting to break bad news. You might continue with the following statement: ‘As you know, you have had discomfort and pain for some time. You have asked me to find out what is the problem. I have found out what the problem is, and this is something we were not looking for, but we have found out for you.’ Both patient and her partner are keen to find out and indicate that they would both like to know. Before going any further, ask the patient if they have any idea what might be the problem. b. The patient shakes her head and says she has no idea. Her Perception is there is a problem, but she is not aware of the nature of the problem. You need to ask the patient’s permission to give her the test results. The patient agrees and you can give a small indication of the news you have to bring. ‘We have found out what the problem is, and this is not something we were looking for. It is something both rare and serious.’ c. Pause and again ask the patient for permission to continue; the patient then Invites you to continue. ‘You have cancer, and we are certain this is what was causing the pain you have been experiencing for some time.’
d. Pause and continue, provide the patient with the Knowledge of their biopsy result. ‘The cancer you have is quite rare, but we are fairly confident that we can treat your cancer, and that is why I have asked you here today to discuss treatment with my senior colleagues.’ e. Pause and look at your patient to see what you have told the patient has been taken in. Make sure the patient is OK with what you are telling them and again pause as necessary. If everything is OK, then continue. If not, acknowledge their distress and explore their concerns and feelings. Empathy is so important when breaking bad news, and I have found the following to be valuable in such situations: ‘I can see this is not easy for you, and it hasn’t been easy for me to tell you. However, I want you to know that we are confident in our abilities to treat you.’ ‘I wish I had better news for you and I am sorry things have worked out this way, but we will stay in touch throughout your treatment and healing.’ ‘My job to a certain degree has finished for just now, and my colleagues will make sure you are taken care of in this hospital. They know what to do to treat the cancer you have.’ The handing over to your colleagues and an explanation of what will happen next is the beginning of the Strategy phase of breaking bad news: ‘When my colleagues have completed their work, we will meet up again and carry on from today.’ ‘Do you have any questions for me?’ It is important to respond to any concerns and to help the patient to prioritise them. Today you only give information to the patient they need so they can absorb and process the news they have cancer. In an OSCE, that deals with breaking bad news. Do not give a detailed pathological explanation of the cancer to the actor or in real life to a patient; this is not needed. f. Your Strategy is to offer advice and reassurance to the patient, but not false hope. Agree on an action plan and follow up. The safety net is to check it is OK to end this stage of the consultation with yourself and allow your senior colleagues to take over. Again, ask if there are any questions. If there are none, you can leave your contact details for the patient. 5. As I remember, the patient asked me to wait for her and her partner. She finished the consultation with the specialists and surgeons, and we went outside. Sitting on a bench in a garden behind the hospital, she lit and smoked a cigarette. ‘These things have done this, haven’t they? Now might be a good time to stop.’ It is entirely up to the patient to decide if they want to proceed with surgery. So what happens next is their decision. In this case, the patient underwent surgery, and the ACC was completely excised. A soft tissue flap comprising buccinator muscle, connective tissue, and mucosa was raised, rotated, and sutured to reconstruct and cover the defect. There was minimal if any cosmetic impact extra-orally, and if you were to examine the patient following this surgery, you would be aware that the buccal vestibule was shortened in height and you could feel the tightness in mucosa where the buccinator’s
anterior border was sutured into the underlying connective tissue of the cheek. The surgery removed the primary tumour, and there was no detectable spread to the lymph nodes. The mucosa surrounding the tumour was repeatedly tested and found to be normal. Once initial treatment and surgery is completed, your role will be to provide preventive advice ensuring good oral health and to maintain your watch checking the oral mucosa for signs of cancer. The patient has to be reviewed regularly for many years; the greatest recurrence is within 3 years. Initially, the patient is seen monthly, then every few months for one year. This review period then stretches out to every six months. By the time the 5-year point is reached, the recall is yearly.4 Further Notes to Clinical Case 45 Part 2 Seven years down the line following surgery, the patient is well and has quit smoking. She married her partner a few weeks ago. The ‘get out of jail’ card in this case is Sutton’s law: You go for the first diagnostic test likely to be the most useful. Biopsy of the lesion led us to oral cancer. Willie Sutton robbed banks for a living. During a lengthy career, he may figuratively have made a killing, but Sutton never actually killed anyone. When asked why he robbed banks, Sutton did not reply: ‘Because that is where the money is.’ Nevertheless, today Willie Sutton, bank robber, is wrongly credited with this, but rightly, he does have a clinical law bearing his name.11 Sutton’s Law teaches us to test patients in the sequence that is most likely to result in a quick diagnosis and to prompt treatment minimising unnecessary costs. Sutton’s law states that when undertaking diagnosis, one should first consider the obvious. It suggests one should first conduct those tests which could confirm (or rule out) the most likely causes. The cheek mucosa was biopsied, because that is where the pain is and that is where the answer was. Sutton’s law and Woodward’s Zebra’s on Greene Street are examples of Occam’s razor or diagnostic parsimony.12 Both are useful in finding out the condition a patient is most likely to have. We do need to look for the fewest possible causes that fit the symptoms. Diagnostic parsimony is taught in the revision courses, and it is beneficial. However, credence should be given to Hickam’s counterargument, which states ‘Patients can have as many diseases as they damn well please.’ John Hickam MD was chair of Medicine at Indiana University.13 It is more likely that a patient has several common diseases, rather than a single rare condition with which we can explain their symptoms. Independently of statistics and chance, some patients do, in fact, have multiple diseases or, in this case, an obscure disease that nullifies the approach of explaining a collection of symptoms with one common disease.
Misdiagnosis leads to the loss of a person’s health and potentially their life too. We have to test and pursue all reasonable theories, even if one explanation appears so biased or so unlikely that in suggesting it, there is a risk of collegiate ridicule. The diagnostic parsimony of Woodward and the counterbalance it finds in Hickam are both essential in dental diagnosis. Any set of symptoms could be indicative of a range of possible diseases and their combinations. At no point in treating a patient should you either accept an answer because a diagnosis appears most relevant, or should you reject a diagnosis because the answer seems too remote to be true. A Ticket to the Zoo That brown envelope sent first class with the pink slip was your ticket to the zoo to have a look at the zebras. I would like to end this chapter with an anecdote that underlines the thought that in coming to an accurate diagnosis, you have to be aware of and sensitive to clinical conditions, character, culture, and sometimes the not-so-obvious. On a hot summer day, three friends, an imam, a bishop, and a rabbi decided to take a walk one afternoon in London’s Regent’s Park Zoo and having seen the zebras, the imam turned to his two friends exclaiming: ‘I am thirsty and tired. I must have water.’ The bishop replied: ‘I am also thirsty, and I am tired. I must have wine.’ The rabbi responded to his friends: ‘I too am thirsty, and I am also tired. I must have diabetes.’ Anon References to Clinical Case 45 Part 2 1. Soames JV, Southam JC. Chapter 10: Oral Epithelial Tumours Melanocytic Naevi and Malignant Neoplasm. In Soames and Southam Oral Pathology. 2nd Edition pp. 154-155. Oxford: Oxford Medical Publications 1993. 2. Cawson RA, Odell EW. Chapter 17: Oral Cancer. In Essentials of Oral Pathology and Oral Medicine. 6th Edition pp. 228-238. Edinburgh: Churchill Livingstone 1998. 3. Soames JV, Southam JC. Chapter 14: Diseases of Salivary Glands, Salivary Gland Tumours. In Soames and Southam Oral Pathology. 2nd Edition pp. 250-251. Oxford: Oxford Medical Publications 1993. 4. Cancer Research Campaign UK. Oral Cancer Incidence Statistics. [Online] Available from: http://www.cancerresearchuk.org/cancer-info/cancerstats/types/oral/incidence/uk-oral-cancerincidence-statistics#By [Accessed August 2013].
5. Van Dijk BA, Gatta G, Capocaccia R, et al. Rare cancers of the head and neck area in Europe. Eur J Cancer. 2012 Apr;48(6):783-96. 6. Cawson RA, Odell EW. Chapter 18: Soft Tissue Disease. Neoplastic and Non-neoplastic Diseases of Salivary Glands. In Essentials of Oral Pathology and Oral Medicine. 6th Edition pp. 247-251. Edinburgh: Churchill Livingstone 1998. 7. Bradley PJ, McGurk M. Incidence of salivary gland neoplasms in a defined UK population. Br J Oral Maxillofac Surg. 2013 Jul;51(5):399-403. 8. Rautava J, Syrjänen S. Biology of human papillomavirus infections in head and neck carcinogenesis. Head Neck Pathol. 2012 Jul;6 Suppl 1: S3-15. 9. Ellington CL, Goodman M, Kono SA, et al. Adenoid cystic carcinoma of the head and neck: incidence and survival trends based on 1973-2007 Surveillance, Epidemiology, and End Results data. Cancer. 2012 Sep 15;118(18):4444-51. 10. Baile WF, Buckman B, Lenzia R, Glober G, Beale EA, Kudelka AP. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-11. 11. Rytand DA. Sutton’s or Dock’s law? N Engl J Med. 1980 Apr 24;302(17):972. 12. Wardrop D. Ockham’s Razor: sharpen or resheathe? J R Soc Med. 2008 Feb;101(2):50-1. 13. Indiana University School of Medicine. History of the Department of Medicine. 2009. [Online] Available from: www.medicine.iupui.edu/DoM/about/history/ [Accessed August 2013]. Further Reading to Clinical Case 45 Parts 1 and 2 1. Scully C. Chapter 22: Malignant Disease. In Medical Problems in Dentistry. 6th Edition pp. 517538. Edinburgh: Churchill Livingstone 2010. A core textbook with essential reading for the MFDS and MJDF exams. In some areas, you might need to back up the text with further reading. Although there are no citations in the text, there are references at the end of each chapter. 2. Sciubba JJ. 2001 Oral Cancer. The importance of early diagnosis and treatment. Am J Clin Dermatol. 2001;2:239-51. Well-written article on the need to examine each patient correctly and thoroughly. 3. Downer MC, Moles RR, Plamer S, Speight PM. A systemic review of measures of effectiveness in screening for oral cancer and precancer. Oral Oncol. 2006;42:551-60. Some of the contemporary developments in diagnosis and screening and their validity are looked at in this article which underpins the importance of biopsy. 4. Scottish Intercollegiate Guidance Network (SIGN) Diagnosis and Management of Head and Neck Cancer. A National Clinical Guideline. NHS Scotland 2006 October. [Online] Available from: http://www.sign.ac.uk/pdf/sign90.pdf [Accessed July 2013]. If you plan on sitting the MFDS, then reading this guideline will give you an indication of what is
expected from you in the exam. 5. Fordice J. Adenoid cystic carcinoma of the head and neck—predictors of morbidity and mortality. Arch Otolaryngol Head Neck Surg. 1999;125(2):149-52. A good article on the lesion the patient in this OSCE presented with. 6. Goldberg S. Chapter 4: Brain Stem. In Clinical Neuroanatomy Made Ridiculously Simple. 26th Printing pp. 28-44. Miami, FL: MedMaster Publishing 2000. A good text with mnemonics to aid in learning some complex nerve pathways. 7. McMinn RMH, Hutchings RT, Logan BML. The Mouth Palate and Pharynx. In A Colour Atlas of Head and Neck Anatomy. pp. 136-147. London: Wolfe Medical Publications 1990. Well-illustrated basic anatomy textbook; if you have this book and a set of anatomical models you will have no problems in the clinic. 8. Murphy TR. Section 3: Head and Neck. In Practical Human Anatomy Series. Laboratory Handbook and Pictorial Guide. London: Lloyd Luke Medical Books 1982. 9. Baile WF, Buckman B, Lenzia R, Glober G, Beale EA, Kudelka AP. SPIKES: a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-11. Referred to in the text and well worth reading when building your skills for the times you will have to give your patients bad news.
6 Procedural Problems Introduction The Story So Far… In the first five chapters, we have covered an introduction to the exams you will be sitting, the practical aspects of dealing with medical emergencies, some common medical conditions and drug interactions, various ethical aspects of dental practice, and, in the previous chapter, a range of the regular and perhaps one not-so-regular dental problem to end that chapter. Chapters 2 to 5 were representative of the cases and clinical problems that any foundation grade dentist might reasonably be expected to competently deal with in the clinic and in the MFDS and MJDF exams. These scenarios were presented as OSCEs with additional questions and answers to maintain your interest, giving an indication of what is required for the Structured Clinical Reasoning (SCR) Exam in Part 2 of the MJDF. With the exception of the medical emergencies OSCEs, which are strict liability exercises, you either complete the tasks in accordance with the recommendations or you fail the question; the subjects for the remaining questions were based on real patients. Their stories were adapted to those themes and topics frequently seen in both the MFDS and MJDF clinical exams. Despite the presentation of these questions as OSCEs, there should be sufficient depth and detail contained in these chapters to benefit your revision for the SCR questions in the MJDF too. In this final chapter, I would like to take a closer look at some aspects of dentistry providing an essential service for the patient and some activities providing a service for the practitioner too. You should be aware of these, not just because you might be examined on them, but more importantly, they are now essential subjects surrounding and supporting the core concepts of clinical dentistry you were taught while at dental school. Among the paraclinical activities are the health promotion and prevention measures that can be performed by any member of the dental team. Specifically, diet advice, lifestyle guidance, disease prevention, and harm reduction programmes—all of these are now important in everyday clinical practice for the benefit of your patients. In parallel with these measures, guidance from professional advisers, collegiate monitoring, and support strategies have all become common procedures useful in providing essential services benefitting you as a dental practitioner. Perhaps, there was always a need for such measures to begin with, but this area of dentistry in the UK (at least) had been chronically overlooked. In recent years, there has been an acute rise in intrusive over-regulation from administrative authorities appointed to control dentistry in the UK. This threatening onslaught has effectively encroached on established and accepted professional activities that had never been questioned from within or from outside the dental profession. Notable examples of these were no need to document the provenance of laboratory work, no need to qualify CPD
activities, and no need to work with trained accountable or registered members of the dental team; in fact, up to a few years ago, there was no requirement for a dental team. Today, there is no doubt that such external monitoring and regulation is needed to maintain standards in any profession and not just dentistry. If there are concerns raised and practices are questioned, then just as the dentistry we practise has to be justified and based on evidence, so too must the external monitoring of our profession be subjected to analysis, justification, and criticism where necessary. Any concerns raised and the measures taken to control risk have to be open to scrutiny. Firstly, such enquiry and analysis has to be open to the dental profession collectively and the dental professional individually to comment on. Secondly, it has to be open to the public who pay for both the scrutiny and the dentistry to comment on and not limited to those who appoint the regulators in the name of patient protection. Just while we are on this subject, it’s not just the dentists who have come under the intense spotlight and attention of regulators and administrators. With the advent of mandatory registration of professions complementary to dentistry, there have been opening of additional lists in the GDC register to include dental nurses, therapists, hygienists, orthodontic therapists, dental technicians, clinical dental technicians, and specialists. All of the above registrants are now fair game for external administration and regulation too. In 2009, the GDC published Scope of Practice, a guidebook detailing the specific functions and limitations of the activities of the previously noted registrants. However, with the advent of mandatory registration of professions complementary to dentistry and the additional lists in the GDC register, rather than becoming a unified and stronger profession, UK dentistry—as far as our patients can make out—seems to have become fragmented into esoteric subspecialties. Our patients, in many cases, do not know whom they need to see for what and to whom they need to complain when things do not go according to (treatment) plan.1 The opening of a direct access policy so patients can see a hygienist without the need to be referred by a dentist is an interesting development. Certainly, many hygienists have expanded their roles beyond what is noted in the 2009 Scope of Practice to undertake procedures beyond what many dentists would feel comfortable doing. These procedures such as the cosmetic or aesthetic clinical work using dermal fillers, botulinum toxin or other non-dental techniques, although performed in the dental clinic, are firstly, outside the mouth and secondly, outside my experience. As they are outside the remit of the MFDS/MJDF syllabus, they are outside the scope of this book. Nevertheless, our dental patients will attend and will need to know about such non-dental procedures. For those of you who wish to incorporate these things into your clinical practice, there are many courses and texts available to guide you in this relatively new area of clinical work. Whichever side of the fence you choose to sit on, either for or against appointed regulators (rather than elected regulators) of the dental profession, the scope of the regulator’s activity and the means at their disposal does provide a good amount of material that you might be examined on. This material is predominantly in the MJDF OSCE and SCR syllabus. To date, I have not seen any questions on this topic in the MFDS examination. As the MFDS OSCE syllabus adapts, as it surely must, to this newly developing and increasingly expanding aspect of
dentistry, in the future, there may well be OSCEs in the MFDS in this area too. On balance and in comparison, I have found the MJDF to be a more progressive exam with questions on audit, clinical governance, peer review, competence, and performance being included in the OSCEs and SCRs for that exam. However, I have not yet seen any questions dealing with the extraoral cosmetic or aesthetic procedures mentioned above. So with the above in mind, much of what goes on in today’s dental world isn’t actually dentistry, and these activities were not foreseen when those of you with a few years of clinical experience behind you were at dental school (that is anyone like me who graduated last century). For sure, the new graduate now sitting the MFDS and MJDF will have entered the profession with these new measures already in place. We can’t go back to the way things were, and while there may be over-regulation, today things have noticeably improved for the patient, if not for the practitioner. It behoves all candidates for the MJDF and, in time, perhaps the MFDS to be aware of the structure of how dentistry is regulated in the UK and how the regulators affect you. While you might never be examined on this subject in the MFDS or MJDF, one day you may be cross-examined on it by the GDC. It is important to be aware of the ways regulators and managers operate and realise too that measures are put in place not only to protect the patient but to uphold the standing the dental profession has with its patients and with the public too. The many measures that have been put in place to protect the patient have been placed not so much as a benefit or an expectation; it is more likely that they have been placed because there is a fundamental need perceived by the regulators today that patients need to be protected. If you look at some of the disciplinary cases at the GDC, it is easy to see why there is a real concern from the regulators who seek to safeguard the patient. The former chair of the GDC Professor Kevin O’Brien made this point clearly: Most of the feedback I’ve seen on the new ‘Standards’ has been positive so far, but I have picked up on some comments that suggest they’re not necessary as dental professionals already know to act professionally. In my opinion, this ideal world does not exist, and it is clear that standards are required.2 The paradox in not being aware of the extent of regulatory measures might not put your patient at risk, but it could place your professional registration at risk. On another level, it might not increase your chances of passing an exam if you were to be examined in this area and you had not revised the latest developments in this area of UK dentistry. In your exam revision, the subjects of the OSCES in this chapter are those you need to show an awareness of, even though they might not necessarily relate directly to clinical dentistry. Nevertheless, they have become important in all areas of health care and not just dentistry. Setting aside the multiple overseers and regulators for a moment and focusing on what is important right now: Your patients and your examiners will expect you to be conversant in these areas of dentistry, if you are to effectively treat your patients, pass your exams, and progress in your career with a knowledge of what is expected of you as a dentist working in the UK. Important Developments
In 2013, three important developments occurred that will have a direct effect on how dentistry is regulated and practised in the UK for the foreseeable future. In the introduction to Chapter 4, these developments were mentioned in the context of an ethical framework. From a practical point either as a GDC registrant in the UK, or as an exam candidate outside the UK, you need to be aware of these developments and what they mean for you, either working in the UK or preparing for your Membership of a Dental Faculty in one of the UK’s Royal Colleges of Surgeons. The first development was the replacement of the 2005 Standards Guidance with the 2013 Standards for the Dental Team. All UK GDC registrants were sent a copy of this document in August 2013. This document is available online from: gdcuk.org.3 The dental procedures you undertake together with the professional behaviours you display in the clinic, in the MFDS or MJDF examinations, and in all areas of your professional and personal life will be governed by the 9 principles, 27 patient expectations, 42 standards, and 172 points of guidance contained in the 2013 Standards for the Dental Team. Interestingly, the Scope of Practice document, setting out who can do what in the dental team (referred to above and in Chapter 4) remains unchanged in the advent of the 2013 Standards for the Dental Team Document. Revising for your exams is a good time to reflect on the contents of this publication and what the document as a whole means for you. The second development in October 2013 was the establishment of a body of 12 members selected and appointed to lead the new General Dental Council. The process leading to this started nearly 10 years previously with the Shipman enquiry, 4 leading to a UK Government White Paper5 and a change in the constitution of the GDC.6 The role of this appointed body is to provide strategic leadership for the GDC in the UK. The GDC will still control entry to the dental registers, assure the quality of dental education, set standards of practice for dental professionals, and investigate complaints from the public about lapses of standards in registrants.7 The third development in 2013 was the GDC’s preliminary response to the publication of the Francis Report. In summary, Mr. Robert Francis Q.C. stated that in order to bring teeth to the task of changing behaviour (in the NHS), five things will be needed.8 These are as follows: 1. A structure of clearly understood fundamental standards and measures of compliance, accepted and embraced by the public and health care professionals, with rigorous and clear means of enforcement. 2. Openness, transparency, and candour throughout the (NHS health care) system. 3. Improved support for compassionate caring and committed nursing. 4. Strong and patient centred health care leadership. 5. Accurate, useful, and relevant information. In response to this, the GDC approved a dynamic and ongoing action plan with the following strands of activity:9
1. Standards of care and putting the patient first. 2. Openness, transparency, and candour. 3. Ensuring that the regulation and oversight of education and training protects patients. 4. Proactive regulation. 5. Data and information sharing and joint working between regulators. 6. Hearing the patient’s voice. Presently, the UK-devolved administrations have not formally responded to the Francis Report, and the GDC is considering the findings from recently published Berwick Report on patient safety. 10 So there is no formal timeline for the GDC to implement any changes found to be necessary. Nevertheless, the GDC’s direction of travel and the recommendations from the 12-member appointed council will determine which areas will receive priority attention in their action plan.11 Any recommendations made will be taken forward within the framework of the Draft Care and Support Bill12 and the Law Commission Bill that will set out the future of professional activity regulation in the UK, although this is not expected to be set before Parliament before May 2014 at the earliest.11 One area the GDC is quite keen to move ahead with is the implementation of an Indicative Sanctions Guidance. There is an intention of setting out clearly that instances of dishonesty or lack of candour in relation to poor dental treatment, or the obstruction of someone else being honest, or providing misleading information to a regulator would be treated as matters of extreme seriousness by a GDC Investigating Committee.13 In the preparation for this chapter and writing the introduction, I have had the opportunity to discuss the changes occurring in dentistry with colleagues, solicitors, and directing staff in the GDC. I have mentioned in my discussions the purpose and content of this book; I have shared my thoughts and some of the content too. The last chapter finished with an anecdote, and I will begin this chapter with another from Immanuel Olsvanger (1888-1961) but adapted to where we are in this sea of change. ‘When I told that anecdote ending the last chapter to a psychiatrist, she laughed three times. Once when I told her, a second time when I explained it, and a third time when she understood. I then told the same anecdote to a dento-legal adviser; he only laughed twice—once when I told him and a second time when I explained it. As he never understood it, he only laughed twice. I then repeated this anecdote to an NHS manager. She laughed once when I told her. She didn’t give me permission to explain, and so she would never understand. Then came the barrister at the GDC; he didn’t even laugh once. After I told him, he then told me: ‘I’ve heard it before and anyway, I can tell it better than you.’ On to the procedures and the problems. References Introduction Chapter 6 1. Rowland D. Whitaker T. Theme 4: Proactive Regulation Section 38. In Francis Report Action Plan. p. 14. [Online] Available from: http://www.gdcuk.org
/Aboutus/Thecouncil/Meetings%202013/Item%206%20Francis %20Action%20Plan.pdf [Accessed August 2013].
2. O’Brien K. View from the Chair. In GDC News and Publications. July 2013. [Online] Available f r o m : http://www.gdcuk.org /Newsandpublications/viewfromthechair/Documents/View%20from%20the%20Chair%20July%202 [Accessed August 2013].
3. Standards for the Dental Team. General Dental Council. London. Approved 20 June 2013. [Online] Available from: http://www.gdcuk.org/Dentalprofessionals/Standards/Documents/Standards_for_the_Dental_Team__web_PDF.pdf [Accessed July 2013]. 4. The Shipman Inquiry. Safeguarding Patients: Lessons from the Past-proposals for the Future. London: The Stationary Office 2004. 5. HM Government Trust. Assurance and Safety: The Regulation of Health Professionals in the 21st Century. London: The Stationary Office 2007. 6. HM Government. General Dental Council (Constitution of Committees) Rules 2009. London: The Stationary Office 2009. 7. Moyes W. New Body to Lead General Dental Council. London: General Dental Council. 6th August 2013 Announcement. [Online] Available from: http://www.gdcuk.org/Newsandpublications/Pressreleases/Pages/New-body-to-lead-the-General-DentalCouncil.aspx [Accessed August 2013]. 8. The Mid Staffordshire NHS Foundation Trust Public Inquiry. Chairman’s Statement. [Online] Available from: http://www.midstaffspublicinquiry.com/sites/default/files/report/Chairman0001s_statement.pdf [Accessed July 2013]. 9. Rowland D, Whitaker T. Francis Report Action Plan. London: General Dental Council 2013. [Online] Available from: http://www.gdcuk.org /Aboutus/Thecouncil/Meetings%202013/Item%206%20Francis%20Action%20Plan.pdf [Accessed August 2013].
10. NHS Commissioning Board National Advisory Group on the Safety of Patients in England. A Promise to Learn a Commitment to Act. Improving the Safety of Patients in England. [Online] Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Rep [Accessed August2013]. 11. Whittaker T. Director of Policy and Communications General Dental Council. Personal Communication. 15th August 2013. 12. UK Department of Health. Draft Care and Support Bill, Care and Support Bill. [Online] Available from: http://media.dh.gov.uk/network/365/files/2012/07/CARE-AND-SUPPORT-BILLFINAL.pdf [Accessed August 2013].
13. Rowland D, Whitaker T. Theme 2: Openness Transparency and Candour Section 21. In Francis Report Action Plan. pp. 10-11. [Online] Available from: http://www.gdcuk.org /Aboutus/Thecouncil/Meetings%202013/Item%206%20Francis%20Action%20Plan.pdf [Accessed August 2013].
Procedural Problem 46 Background Information Having either bored you senseless or scared you witless with the introduction to this chapter, perhaps getting down to another area of dentistry that wasn’t taught while I was at dental school but really has become an important part of daily dental practice in the UK might be a good way to begin the OSCEs of this chapter. Smoking Cessation Globally, the tobacco industry is huge, and in response to this, the smoking cessation industry has become big business too. Tobacco is one of the most widely used addictive substances in the world, and it can be grown almost anywhere. In the UK, tobacco taxation is heavy; this raises revenue for the Government and is a good way to attempt to stop people from smoking. Tobacco is both addictive and carcinogenic, the tobacco industry being aware of these effects for decades.1 Until recently, cigarette manufacturers have won more than half of all cases brought against them and overturned several rulings in US courts.2 In 1998, the UK Government published a comprehensive tobacco policy covering advertising, marketing, taxation, smoking cessation, anti-tobacco campaigns, and passive smoking. This document was the UK Government White Paper: Smoking Kills. It was extensive, covering both work and public places, international aspects of the tobacco trade, and protection of children, and it established a range of targets to reduce smoking.3 From 2002, the Tobacco Advertising and Promotion Act (TAPA) UK started a process leading to the restrictions on tobacco product placement, which should lead to a total ban by 2015.4 In 2004, the UK joined the WHO Framework Convention on Tobacco Control with restriction on where smoking is permitted, and the manner of tobacco product advertising. Tobacco control legislation in the UK continued in 2006 with the Health Act mandating penalties that could be enforced by 2007 for violations of the Smoke-Free Premises and Enforcements Regulations.5 The UK is not alone in legislating against tobacco smoking. In 2009, Barack Obama signed into law the Family Smoking Prevention and Tobacco Control Act, a sweeping anti-smoking ruling designed to prevent children and teenagers in the US from becoming addicted to cigarettes.6 In the UK, the NHS has launched many smoking-cessation initiatives with the support of companies in the pharmaceutical industry to assist patients with their decision to quit smoking. Smoking-cessation programmes can be delivered by any member of the dental team often with training in this area, although such training is neither essential nor mandatory. Introduction to Procedural Problem 46.
A regular patient of yours comes in to see you. She is in her late 40s and wasn’t due in for another three months. This visit was prompted by her very best friend from schooldays, recently having been diagnosed with oral cancer. Your patient is a frequent dental attender. Her dental treatment has been straightforward with simple restorative dentistry and frequent visits to the hygienist. The CPITN is recorded as being 2s in all of the sextants. The dental notes indicate there are noticeable plaque and calculus deposits in the lingual area of the lower incisors and the buccal area around the upper molars. Oral hygiene instruction was given, but the patient has difficulty in following hygiene instructions and maintaining oral cleanliness. She does smoke up to 10 cigarettes a day and more when her job as a school secretary in a local secondary school gives her stress (as she tells you). She has smoked since she was a teenager. Her husband works in a garage; your patient informs you: ‘He both smokes like a chimney and drinks like a fish.’ Your patient adds that her husband has no wish to give up either of these cherished activities. Your patient tells you her husband has told her she doesn’t have the will power to quit, and if she did, the next thing she would do is leave him. In the meantime, he takes a perverse delight in mocking her repeated failures not only in trying to stop smoking but her plans to lose weight and run a small business typing manuscripts for a local publisher. As she has been married for more than twenty years, her children have left home, and now she feels very set in her ways and changing the habits of a lifetime and changing her lifestyle are going to be difficult for her. Your patient now wants to give up smoking for good. Her doctor is too busy to see her, so in the school holidays she has had a free moment and she would like to know how she can quit smoking. She has tried before several times. Each time, her attempts to quit have resulted in failure, but now with the news of her friend’s condition and further mocking from her husband, she has decided to try one more time. Questions for this Procedural Problem. 1. How might you approach this case? 2. What should you be aware of from the above introduction? 3. In addition to smoking, are there other behaviours you should be aware of? 4. What is the main strategy or intervention that you might begin to approach the subject of smoking cessation? 5. In which other ways can a patient be assisted in their attempt to quit smoking? Can you list the strategies commonly used? 6. How can your knowledge of psychology and pharmacology be combined in finding the best method to assist the patient in smoking cessation? 7. What is the likelihood the patient will succeed? 8. In the process of quitting smoking, what other effects might you see?
9. What impact might quitting smoking have for this patient? 10. Is there anything else you should be aware of when giving smoking-cessation advice? Answers to this Procedural Problem. 1. Begin with your professional introductions to the case. In this OSCE, you don’t need to take a full medical history but you would do in real life. You do need to be aware of any medical problems a patient may have and medication they are taking. In the OSCE, briefly, three questions are all you need to ask: if there are any medical problems, or any recent visits to the doctor, or medications they are taking. The fact that the patient’s own GMP was too busy to see her may be taken as either, the GMP really is too busy to see her or the patient is medically fit and well. In this case, more important than the medical and dental histories, is the social history; there may be some elements of the social history that are less than ideal. A dominant husband who ridicules his wife’s attempts to stop smoking can be counterproductive to your intention to initiate a smokingcessation program, and this must be dealt with sensitively. In the OSCE, you can suggest that a joint consultation with the husband in attendance might be a way to present some of the advantages of stopping smoking and reducing alcohol intake. In the OSCE, you don’t need to go into the fine details at this stage, other than reaffirm what the patient or actor already knows, and that is to state there are more advantages to stopping smoking than there are disadvantages. If you can bring the husband into the consultation and establish why he is so set against his wife’s desire to stop smoking and perhaps bring him round to supporting his wife’s efforts, rather than viewing them as a source of entertainment, then the chances of her succeeding will increase too. 2. It is clear that the patient doesn’t have much support from her husband. Following the news of her friend’s cancer diagnosis, she wants to give up smoking. From the introduction, there is clearly an issue between the patient and her husband. In the OSCE and in real life, you need to be aware of domestic stresses. Unless these involve reported violence or clear documented abuse, do not allow this information to cloud either the issue of smoking-cessation advice or your professional focus on dealing with this case. Although the husband has mocked his wife, this is, in fact, another motivational factor that has prompted the patient into coming to see you. From the introduction, you can see the patient has very real fears. One of the overt fears is that of cancer, and the patient will need information, support, and advice in a form she can understand to address this. Another fear, somewhat hidden, is that of weight gain. For a woman in her forties approaching menopause and thinking of quitting smoking, weight gain is a real issue. Again information to deal with this noted side effect of smoking cessation needs to be given. Lastly, there is a fear of further failure, and this should be addressed too. An empathic supportive attitude with an ability to filter out the extraneous details of the introduction is needed to get this patient on the right track so you can begin to give smoking cessation advice. 3. Other behaviours associated with smoking in our patients are alcohol and drug use and abuse of either recreational or prescription drugs. It is important to have a documented medical and drug history and if necessary, to liaise with the patient’s GMP to find out if there are any prescription
medications being taken by the patient. Due to possible drug interactions with medications that may be prescribed in the course of a smoking-cessation programme, in addition to the medical history, an up-to-date drug history would be taken from the patient. Addictive Behaviours and Fears a. One notable aspect of the MFDS or MJDF revision courses on smoking cessation and the actual OSCE question itself, is that the actor portraying the smoker who wants to quit lives in a world where they only smoke but do not drink, that is, only one addictive behaviour will be presented and examined on at a time. b. If you can suspend your disbelief, then go along with this, while remembering to ask about other behaviours. c. Even if they are not in the script, the examiners will note your grounding in reality just for asking the question on medications and alcohol use in the patient. d. The strategy in this case is to address the patient’s or actor’s fears by advising of the advantages of smoking cessation. Advice on risk reduction from diseases associated with smoking can be given in a way that further supports the patient’s decision to quit. In this OSCE you might usefully state: ‘Although the risk from cancer may take up to 10 years to equal to that of a non-smoker, on the way to this milestone, the first benefits are noticeable in a few hours of your last cigarette as your body begins to heal. In the days and weeks after quitting, the risk of heart and lung disease drops dramatically, and in a few months breathlessness goes away as lung function improves and your heart and chest become healthier.’ 4. There is no shortage of information available on smoking cessation in the literature. This information can be found in NHS publications available both online and in the clinic too. However, it is important not to overload the patient with data and to keep things simple at this stage. The most useful and widely accepted strategy to begin with is the 5A Intervention. 7 This programme was developed by the US Public Health Service and is now almost universally endorsed as a useful measure to promote, if not actually achieve, smoking cessation.8,9 This intervention was briefly mentioned in Ethical Example 27 and is now discussed in greater detail: Ask—in this case you didn’t need to ask the patient if they wanted to quit, but you can tell the actress/patient that you do ask all your dental patients if they wish to quit. You can respond positively with encouragement in this case to the patient’s wishes to quit, telling her she is not alone and in fact she is in a majority group. Advise—you can tell the patient that you strongly urge all patients who use tobacco to stop doing so. This reaffirms the patient’s decision is the correct one. The latest evidence would suggest there are studies indicating there are now more patients who have quit smoking than there are smokers. Assess—determining the patient’s willingness to attempt to quit is subjective. Despite repeated failures, this patient is having another go. Even if this can’t be quantified in a meaningful way, her
repeated trying is to be commended. Many smokers have repeated attempts at quitting before eventually succeeding. Assist—aid the patient in their attempt to quit smoking by providing counselling, support, and medication where necessary. Arrange—ensure follow-up contact. It is really important not to lose the patient in the days and weeks after the initial consultation, and you do need to maintain close contact with them. In the OSCE and in the clinic one really essential quote to use is: ‘We will stay in touch to help you get through this programme.’ 5. The other strategies are as follows: a. Cold Turkey. The patient can be advised that an abrupt withdrawal—just quitting smoking from one day to the next—is successful in a significant proportion of long-term quitters. There are several studies ongoing from the 1980s that support this method of quitting as still being a viable option.9,10 b. Other unassisted methods such as gradual cutting down on numbers of cigarettes smoked per day might not be as dramatic as ‘cold turkey’ but could be just as effective.11 c. Assisted methods. These range from counselling, the keeping of a smoking diary, noting the times and situations when and where tobacco is smoked, and identifying and then eliminating these situations. Other forms of analysis of smoking-promoting behaviours can be presented for comment and discussion in group or individual sessions for advice and support. With these activities, a health care worker can monitor the progress of your patient with CO (carbon monoxide) monitoring devices to monitor CO levels as your patient hopefully continues to quit. The results from a recent dental school study in Switzerland have demonstrated the usefulness of CO monitoring in smoking cessation.12 d. Community programmes such as smoke-free zones and times in the workplace are useful as are blanket bans on smoking. Although the school where this patient works will be a smoke-free area, her home is not, and for this reason, the husband needs to become involved in the patient’s attempts to quit. e. Acupuncture, hypnosis, and aromatherapy have all been suggested as being useful, and certainly these can be mentioned in the OSCE and in real life too, if only for the sake of completeness, although earlier guidelines and a Cochrane review of these methods are inconclusive as to their efficacy in smoking cessation.13,14 f. Pharmacological methods can be used to assist a patient. The three main drugs are: a. Nicotine replacement therapy (NRT): patches, tablets, lozenges, gums, and inhalers. b. Prescription medications such as antidepressants, specifically, Bupropion. c. Nicotine partial receptor agonists such as Varenicline. g. Combinations of the above forms of smoking-cessation strategies; of one measure with another into multimodal strategies have been tried. The available results suggest that the greater the
numbers of channels used to expose a smoker to quitting, the greater the chances of success.15 Recently, the use of electronic media such as mobile phone prompts reminding the recipient to keep on quitting together with community group incentives and WHO initiatives such as World No Smoking Day (31 May) are all proving to be worthwhile. Does the Patient Need Help? a. In this case, the patient attended more or less already having decided she wants to quit. b. Whether she is seeking an affirmation, encouragement, or assistance needs to be known before you launch into all the ways you can help her. c. Many smokers have succeeded in quitting with no help whatsoever, and before we launch into helping someone to quit, it is important to make an assessment to determine if they actually need our help to begin with. 6. The method of action of smoking strategies run from sheer will power in cold turkey and the cutdown methods through peer pressure and social conscience with the community programmes to the more complex modes of action of the pharmacological agents mentioned above. Tobacco contains the chemical nicotine. The addiction to smoking begins when nicotine from inhaled smoke acts on nicotinic acetylcholine receptors in the CNS, releasing neurotransmitters such as dopamine, glutamate, and gamma-aminobutyric acid (GABA). Cessation of smoking leads to symptoms of nicotine withdrawal such as anxiety and irritability. Smoking-cessation strategies generally try to address the nicotine addiction and the nicotine withdrawal symptoms. If we can relate these to the patient in this OSCE, then clearly she has a high external locus of control. From the introduction, you might think the patient also has low self esteem. Certainly, she is influenced by events around her and is subject to and possibly subdued by the behavioural influences of her husband. Therefore, suggesting to the patient that she just stops smoking and endures the symptoms of an abrupt withdrawal might not work in her case, and the resulting failed attempt to stop smoking would reinforce any negative self-image she has. Assisted smoking cessation may be useful, and we can start this process by suggesting participation in community activity and group events. Many of these are coordinated by the NHS, and details can be provided by you. These are available online from NHS Choices.16 This can be mentioned in the OSCE. You can also mention that you will seek and compile a list of appropriate programmes that you can go through with the patient. The most frequently mentioned is nicotine replacement therapy (NRT). These medications are available in the UK without prescription. NRT does what is says, but recent studies have demonstrated that while it may be good at replacing nicotine, it is not so good at replacing tobacco in the long term. Initially, the effectiveness tapers down to just under one-third of NRT users abstaining from tobacco-smoking at 52 weeks after starting an NRT programme.17 The other methods we can suggest involve combining NRT with counselling to increase the effectiveness of the withdrawal strategy. A recent Cochrane review has established that behavioural
support with NRT can increase the effectiveness of a smoking-cessation strategy.18 The Importance of a Medication History Other pharmacological agents are useful too. However, these require referral to a GMP, and you will see from the following list why. When considering smoking cessation in a dental patient, it is important to take a medical history that includes medication and drugs the patient might already be taking. a. Antidepressants: Bupropion is useful in smoking cessation but is contraindicated in epilepsy, seizure disorders, and anorexia/bulimia. If sedatives such as benzodiazepines or antidepressant drugs such as MAO inhibitors are being used, or the patient is in the acute phase of alcohol recovery, this drug-assisted method cannot be used to aid smoking cessation. However, a recent randomised controlled trial (RCT) demonstrated that although there is no statistical difference between Bupropion, NRT, and combination treatments, in those patients with depressive illness, Bupropion is more effective.19 b. Varenicline tartrate is another prescription drug that decreases the urge to smoke and reduces withdrawal symptoms too. Extensive studies have proven the worth of this medication in smoking cessation. However, Varenicline use carries the increased risk of stroke, myocardial infarct, and suicidal ideation. Despite this, a recent survey has demonstrated significantly better results than NRT up to 6 months; beyond this time, no significant differences between Varenicline and NRT were observed.20 The Treatment Ladder Although Bupropion and Varenicline are discussed in the MFDS revision courses as being useful in smoking cessation, given the risks and side effects (noted above), their use should be the sole preserve of the GMP who is up to date with the latest drug reviews and has the time to actually see the patient interested in smoking cessation. In common with most drugs, these medications cannot be remotely prescribed. Smoking-cessation strategies are like a treatment ladder, with the simplest methods being no intervention or no assistance right up to the complex drug-assisted methods. With full knowledge of a patient’s medical and social history and how smoking-cessation strategies work, we can determine what will be the most effective strategy for this patient and all others who wish to stop smoking. 7. There is every chance the patient in this OSCE will eventually succeed with her attempt to quit smoking. The most important thing to tell a patient/actor is that previous failed attempts are actually indicative of a repeated desire to quit. The repeated failure is a good indication that success will eventually happen if further attempts at quitting are made. The combination of behavioural support and medication can greatly increase the chances of success. In this case, the husband has expressed his opinions and desire to carry on smoking. It has been proven that the success rates of those who have to live with smokers is lower than those who do not.21 In this case, supportive input from your colleagues and group therapy can offset the negative influence
of the patient’s husband. While the patient continues her efforts with smoking cessation at home while she will not be actively smoking, she will be passively smoking, so many of the physiological and psychological risk factors remain for her to resume smoking again and suffer its effects. 8. When giving smoking-cessation advice, the side effect most pertinent to this case is weight gain. A recent meta-analysis revealed this can be 4-5 kg in the 12 months after quitting, with most of this occurring in the first 3 months. However, this meta-analysis revealed that there was a considerable variation in weight change with both weight gain and loss being seen.22 Another study determined that weight gain was due to decreased lipolysis and increased appetite.23 However, this explanation does not explain weight loss in quitters. When the addictive effects of nicotine are removed, there is a complex series of actions and interactions occurring in the spectrum of withdrawal signs and symptoms. In addition to weight change, the actress/patient in this OSCE should be warned that in the first few weeks the following symptoms can be experienced: a. Altered moods. This spans from anger, anxiety, and depression all due to down-regulation of neurotransmitters previously stimulated by nicotine. b. Difficulty in concentrating with reduced attention span and as a result: c. Impatience. d. Insomnia. These are all well-noted withdrawal symptoms. The signs associated with tobacco cessation and nicotine withdrawal are increased mouth ulcers, coughing, and decreased salivary flow rates but not to a degree that dry mouth is noted. 9. The impact from smoking cessation is the long-term benefit that comes with better health. Initially, the symptoms and signs of nicotine withdrawal, as noted above, may be thought by the patient to be anything but signs of improving health. However, these are transient and relatively short term when compared to increased lifespan, especially the decreasing risk of cancers to the head, neck, and aero-digestive tract associated with tobacco use. Many of tobacco’s detrimental health effects can be reduced or largely removed through smoking cessation. The health benefits in time from stopping smoking include the following: 1 hour: Patient’s blood pressure and heart rate decrease. 1 day: Expired gas CO levels become normal. 1 week: Sense of smell and taste start to recover. 3 months: Circulation and lung function show improvement. 6 months: Coughing and shortness of breath become less noticeable. 9 months to 1 year: Risk of coronary heart disease reduces to half that of a smoker. 5 years: Risk of stroke falls to the same as a non-smoker, with the risks of many cancers of mouth, throat, oesophagus, bladder, cervix all decreasing significantly.
10 years: Risk of dying from lung cancer is half that of a smoker, and the risks of larynx and pancreas cancers decrease too.24,25 15 years: Risk of coronary heart disease drops to the level of a non-smoker with lowered risk for developing COPD (chronic obstructive pulmonary disease).24,25 Points to Note a. The age at the point of quitting smoking is important with regard to the benefits gained. The notable studies of Doll and Peto should be read. Their studies are available online.25,26 b. Stopping smoking at age 50, halves the hazards of the habit. Stopping at 60, 50, 40, or 30 gives the quitter: 3, 6, 9, or 10 more years of life. c. Smokers die 10 years earlier than quitters. d. In this case, a patient stopping in her late 40s can still benefit from added years with improved health. e. Perhaps the most notable and easily quantifiable benefit is the monetary saving that can be gained by not buying cigarettes, and there are many online calculators tracking the current cost of tobacco with daily use giving the cost savings, which are quite staggering. 10. When giving smoking-cessation advice, the patient’s motivation should be recognised and positively encouraged. The patient’s fears of cancer really need to be discussed, and information needs to be provided. Fear comes from the unknown, and bringing this matter out from the darkness of the patient’s mind and into the light of the dental clinic is so important. Information needs to be provided not only about the risks of cancer and smoking but lifestyle too. This information needs to be provided in a way the patient can understand and act on. While it may be tempting to provide facts, figures, and forecasts, what is more useful for the patient are broad terms and general trends to help them realise where they are now, between state of health and risk of disease. It is also important to reinforce the idea that even if this attempt might not succeed, another failure is an indication that the patient is still on the right path to success and quitting. Referral to the patient’s GMP and smoking-cessation programmes are needed, and the patient should be informed of your readiness to assist. Lastly, it is important to ensure that the patient is not lost to follow-up, and further appointments need to be booked. As stated above, these can always include her husband. At every stage of your discussions with the patient or the actor in the OSCE, do ask if there are any questions. Further Notes to Procedural Problem 46. Questions with a structure and defined answers are seen in the MJDF OSCEs, whereas the MFDS is a more free-flowing discussion between the actor and candidate. Therefore you will not have a rigidly
defined series of questions from the examiner to answer. So do remember to keep things simple and to ask if the data you give to the actor in the MFDS is understood before moving on with the next area to be discussed. Although a lot of references have been provided here and the answers in this OSCE are more detailed than needed for the MFDS, this level of detail will be useful in the MJDF SCR questions. In that exam, the patterns and trends of disease related to smoking do need to be known. The two subjects omitted so far, but examined at MJDF are pack years and QALYs: 1. Pack years: This is a way to measure a person’s smoking over a long period. It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. In this case, the patient has smoked ½ pack (ten cigarettes) per day for some 20 years. This is 10 pack year smoking history. One pack year is the equivalent of 365.24 packs of cigarettes or of 7,305 cigarettes. Number of pack years = (number of cigarettes smoked per day × number of years smoked)/20 (1 pack has 20 cigarettes). Quantification of pack years smoked is important in clinical care where degree of tobacco exposure is correlated to risk of disease. I have found that pack year calculations are not very helpful as patients seem to underestimate how many cigarettes they smoke and for how long they have smoked. Also, when going through the calculations, patients have told me they often feel they are being lectured to. I have included this as you may be asked to run a quick pack year calculation in the MJDF OSCE. 2. QALY. This is: Quality Adjusted Life Year and is a cost-effectiveness analysis. In this OSCE, the QALY is the cost to gain 1 year of disease-free life if the patient stops smoking. The two difficulties we face with QALYs are: First: how do we define what a disease-free year is? Second: there are certain states of disease-free life that are not desirable. If given a choice, the patient might prefer to die rather than endure the morbid results of surgery following (for example) exenteration or maxillectomy following treatment for oral cancer. Against this are the morbidities resulting from smoking such as atherosclerosis resulting in lower limb amputation, and despite these outcomes, patients (in my experience) just carry on smoking! You can relax, as you will not be asked to mention anything on QALYs in the MFDS OSCE. If you were to do so, then you might lose marks for using technical terms both actor and examiner either will not appreciate or they fail to understand why you are introducing these terms into your discussion with a patient. However, in the MJDF you might be asked to run through a QALY calculation—if not in the OSCE, then possibly in the SCR questions.
Here is an example below as it might relate to this case: 1. An intervention involves a dentist giving a 10-minute interview to improve the use of NRT (available without prescription). 2. This intervention causes 50% of smokers to use NRT when only 25% would have done so without the dentist’s interview (a combined smoking cessation modality). 3. A foundation grade dentist costs the clinic £120/hour (including nurse time) so 10 minutes is 1/6 of this or £20. 4. NRT costs £150, and this results in 2 QALYs gained as a result of smoking cessation. 5. Costs: As every participant receives the intervention, the average dentist cost per participant is £20 (100% * £20). As 25% of participants now use NRT when they would not have done so previously, the average NRT cost per participant is £150 (25% * £600). Thus, the overall average cost of the intervention per participant is £170 (£20 + £150). 6. Benefit: As 25% of participants now use NRT when they would not have done so previously, the average benefit per participant is 0.5 QALYs (25% * 2 QALYs). 7. Cost per QALY gained: Combining the estimates of the cost and benefit of the interventions, we can say that the cost per QALY gained of this dentist-based intervention is £340 (£170/0.5 QALYs). To gain another year of disease-free life for the patient will cost the UK NHS £340. Just to finish this OSCE, in the real world of increasing disease costs and decreasing health benefits, by the time you read this book, the above figures may not be representative of what it actually costs for smoking cessation in the UK. Research based in Stirling, Scotland, revealed that the QALYs can run into several thousand pounds and the 1-year quit rates are very poor, despite this, smoking cessation remains a cost-effective exercise.27 The First Words Last Keeping one eye on the past, 2016 will see the 400th anniversary of King James’s (VIth of Scotland and Ist of England) anti-smoking paper of 1616, following from his earlier work of 1604; A Counterblaste to Tobacco. A copy of this work can be viewed in the Royal College of Physicians’ library in Edinburgh, and it is quite remarkable for its prescient views on the dangers of smoking. Written in early modern English, this 12-page tract covers many of tobacco’s dangers and even mentions the problem of passive smoking.28 It is famous for the concluding paragraph in which King James writes that smoking is: “A cuftome lothfome to the eye, hatefull to the Nofe, harmefull to the braine, daungerous to the Lungs, and in the blacke ftinking fume thereof, neereft refembling the horrible Stygian fmoke of the pit that is bottomeleffe”
References to Procedural Problem 46 1.
Daynard
RA, Bates C, Francey N. Tobacco litigation worldwide. BMJ. 2000 Jan
8;320(7227):111-13. 2. Douglas CE, Davis RM, Beasley JK. Epidemiology of the third wave of tobacco litigation in the United States, 1994-2005. Tob Control. 2006;15(Suppl 4): iv 9-iv16. 3. Smoking kills. A White Paper on Tobacco. London Department of Health (DOH) 1998 ISBN 0101417721. [Online] Available from: http://www.archive.official-documents.co.uk/document/cm41/4177/contents.htm [Accessed August 2013]. 4. Tobacco Advertising and Promotions Act 2002 Chapter 36. London: HM Stationary Office 2002. [Online] Available from: http://www.legislation.gov.uk/ukpga/2002/36/pdfs/ukpga_20020036_en.pdf [Accessed August 2013]. 5. Health Act 2006 Chapter 28. London: HM Stationary Office 2006. [Online] Available from: http://www.legislation.gov.uk/ukpga/2006/28/pdfs/ukpga_20060028_en.pdf [Accessed August 2013]. 6. Family Smoking Prevention and Tobacco Control Act. US Food and Drug Administration Center for Tobacco Products. 2009-2010 Inaugural Year in Review. [Online] Available from: http://www.fda.gov/downloads/TobaccoProducts/NewsEvents/UCM216374.pdf [Accessed July 2013]. 7. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000. 8. Larzelere MM, Williams DE. Promoting smoking cessation. Am Fam Physician. 2012 Mar 15;85(6):591-98. 9. Puschel K, Thompson B, Coronado G, Huang Y, Gonzalez L, Rivera S. Effectiveness of a brief intervention based on the ‘5A’ model for smoking cessation at the primary care level in Santiago, Chile. Health Promot Int. 2008 Sep;23(3):240-50. 10. Fiore MC, Novotny TE, Pierce JP, et al. Methods used to quit smoking in the United States. Do cessation programs help? JAMA. 1990 May 23-30;263(20):2760-65. 11. Lee CW, Kahende J. Factors associated with successful smoking cessation in the United States, 2000. Am J Public Health. 2007 Aug;97(8):1503-09. 12. Brügger OE, Frei M, Sendi P, Reichart PA, Ramseier CA, Bornstein MM. Assessment of smoking behaviour in a dental setting: a 1-year follow-up study using self-reported questionnaire data and exhaled carbon monoxide levels. Clin Oral Investig. 2013 Jul 20. 13. Baker TB, et al. (2008). Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. [Online] Available from: http://www.ahrq.gov/professionals/cliniciansproviders/guidelines-recommendations/tobacco/clinicians/treating_tobacco_use08.pdf [Accessed August 2013].
14. White AR, Rampes H, Liu JP, Stead LF, Campbell J. Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev. 2011 Jan 19;(1). CD000009 15. Reus VI, Smith BJ. Multimodal techniques for smoking cessation: a review of their efficacy and utilisation and clinical practice guidelines. Int J Clin Pract. 2008 Nov;62(11):1753-68. 16. NHS Choices Stop Smoking. [Online] Available from: http://www.nhs.uk/livewell/smoking/pages/stopsmokingnewhome.aspx [Accessed August 2013]. 17. Kralikova E, Kmetova A, Stepankova L, Zvolska K, Davis R, West R. Fifty-two-week continuous abstinence rates of smokers being treated with varenicline versus nicotine replacement therapy. Addiction. 2013 Aug; 108 (8): 1497-502. 18. Hartmann-Boyce J, Stead LF, Cahill K, Lancaster T. Efficacy of interventions to combat tobacco addiction: Cochrane update of 2012 reviews. Addiction. 2013 Oct;108(10):1711-21 19. Stapleton J, West R, Hajek P. Randomized trial of NRT, bupropion, and NRT plus bupropion for smoking cessation: effectiveness in clinical practice. Addiction. 2013 Jul 17. 20. Kotz D, Brown J, West R. Effectiveness of varenicline versus nicotine replacement therapy for smoking cessation with minimal professional support: evidence from an English population study. Psychopharmacology (Berl). 2013 Jul 20. 21. Mills AL, Messer K, Gilpin EA, Pierce JP. The effect of smoke-free homes on adult smoking behaviour: a review. Nicotine Tob Res. 2009 Oct;11(10):1131-41. 22. Aubin HJ, Farley A, Lycett D, Lahmek P, Aveyard P. Weight gain in smokers after quitting cigarettes: meta-analysis. BMJ. 2012 Jul 10;345. [Online] Available from: http://www.bmj.com/content/345/bmj.e4439 [Accessed August 2013]. 23. Vanni H, Kazeros A, Wang R , et al. Cigarette smoking induces over expression of a fat-depleting gene AZGP1 in the human. Chest. 2009 May;135(5):1197-208. 24. American Cancer Society. When Smokers Quit: What Are the Benefits Over Time? [Online] Available from: http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-quitting smoking-benefits [Accessed August 2013]. 25. Peto R, Darby S, Deo H, Silcocks P, Whitley E, Doll R. Smoking, smoking cessation, and lung cancer in the UK since 1950: combination of national statistics with two case-control studies. BMJ. 2000 Aug 5;321(7257):323-29. 26. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004 Jun 26;328(7455):1519. [Online] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC437139/ [Accessed August 2013]. 27. Bauld L, Boyd KA, Briggs AH, et al. One-year outcomes and a cost-effectiveness analysis for smokers accessing group-based and pharmacy-led cessation services. Nicotine Tob Res. 2011 Feb;13(2):135-45. 28. Milne I. A counterblaste to tobacco: King James anti-smoking tract of 1616. J R Coll Physicians
Edinb. 2011;41:89. Further Reading to Procedural Problem 46 1. Scully C. Chapter 34: Substance Dependence Nicotine and Tobacco. In Medical Problems in Dentistry. 6th Edition pp. 695-698. Edinburgh: Churchill Livingstone 2010. A good basic introduction to the subject. 2. Benowitz NL, Benowitz NL. Nicotine addiction. New Engl J Med. 2010;362(24):2295-303. 3. Carson KV, Verbiest ME, Crone MR, et al. Training health professionals in smoking cessation. Cochrane Database Syst Rev. 2012;16:5. An up-to-date review on the subject revealing that 13 out of 17 included studies show no effect on abstinence from interventions, that NRT is not effective on its own, and that training health care workers to give advice is more effective than untrained professionals doing the job. 4. Papadakis S, McDonald P, Mullen KA, Reid R, Skulsky K, Pipe A. Strategies to increase the delivery of smoking cessation treatments in primary care settings: a systematic review and metaanalysis. Prev Med. 2010;51(3-4):199-213. 5. Hildebrand JR, Sastry S. ‘Stop smoking!’ do we say it enough? J Oncol Pract. 2013 Sep 1;9(5):230-2 An interesting paper looking into a problem that health care workers doubt the efficacy of smoking-cessation measures and therefore might no longer dedicate sufficient time and effort to providing it for their patients.
Procedural Problem 47 Background Information This next OSCE is right out of the MJDF exam. In the MFDS, you don’t get an opportunity to complete an OSCE dealing with a colleague’s shortcomings. With the advent of mandatory continuing professional development (CPD), both the quality and quantity of courses you complete has to be logged and presented to the GDC in 5-year cycles. By sitting down and studying for the MFDS and MJDF exams and by attending the revision courses, you should amass a sufficient amount of CPD time to be well ahead of your mandatory-verifiable and optional-verifiable or non-verifiable requirements for the next 5 years. By reading this book from cover to cover, I have estimated that you can accumulate more than 150 or so hours of non-verifiable CPD, an average of 3 hours per OSCE. If you choose to write a book, and I hope that many of you do, then the average time to write out an OSCE is about 2 to 3 days, taking about 5 to 8 hours per day. This is between 1,000 and 1,500 hours for the OSCEs and some more on top of that for the editing, proof reading, indexing, and referencing. This CPD only becomes verifiable with sales of the book and feedback from the reader. Given the costs of attending CPD courses, some running into hundreds of pounds for a day, it is actually cheaper
to write a book than attend some of these courses. Well, of course it is, but as a vice dean of one of the Royal Colleges asked me: ‘Don’t you have anything better to do with your time, I mean, can’t you go and find a hobby?’ Well, hobbies cost time and money; even the safest (a professor at dental school collected stamps from Gibraltar) can cost a huge amount of money and time… Unless you are a professor, then collect CPD, not stamps. You have to be careful where you collect your CPD too; if you choose not to do anything at all or attend highly specific but not specified courses, then the GDC could view this as your practice of dentistry being less than ideal. One of the Professional Conduct Committees from the GDC might then be interested in you spending some time with them in London, while an overpaid barrister gives you a good listening to as you go through your CPD collection. With that outcome in mind, it seems a lot easier to face the situation and do some courses, fill in your logbook, and submit your CPD when asked to do so. Introduction You are working in a general dental practice, studying for the MJDF and MFDS, amassing a huge amount of CPD. Both this effort and your clinical work are well documented. In stark contrast, you see that your senior colleague and his nurse have not been completing or updating the patients’ medical histories on a regular basis. You also have had some difficulties with the trainee nurses who do not want to take notes or record any soft tissue examinations from the patients. Generally, in the clinic, note-taking is very poor. There are elements of the patient notes being split between a newly installed computer system and the good old-fashioned record cards. You decide to take up these matters with the practice owner who tells you to: ‘Keep your snout in your own trough.’ This is as far as you get with the practice owner. You decide to find out what the specific requirements are. You then decide to have a word with your study advisers. Questions for Procedural Problem 47. 1. What are the requirements regarding medical histories? 2. What are the requirements regarding the recording of soft tissue examinations? 3. How might you record the intra-oral soft tissues? 4. Should you do as the practice owner tells you and was his response appropriate? 5. Who is responsible for the taking of dental notes?
6. Can you mitigate your position in law with regard to the GDC’s position on your responsibility to take notes? 7. How can this matter be documented and standards improved upon? What process would you use to do so? 8. Can you define what clinical governance is? 9. In addressing the problems of this case, can you describe in detail the issues you would monitor and improve upon? 10. In the UK, in addition to the GDC, is there another body present to ensure clinical standards are met and maintained? Answers to Procedural Problem 47. 1. Unless you have just landed on this question from an elsewhere and an ‘elsewhen’ or have not read through the previous 46 cases, then the answer should be clear. Dental note-taking should be accurate, contemporaneous and must include an updated medical history at every visit. Just because a dental patient looks fit and well and has sprinted up a set of stairs to get into your waiting room, eager to read those raggy old magazines in the waiting room, it doesn’t necessarily mean they are fit and well. The requirements to take notes can be found in the 2013 GDC publication, Standards for the Dental Team.1 Principle 1 states: ‘Put patients’ interests first. There is a patient expectation that all aspects of their health and well-being will be considered.’ The Standard 1.4 (p. 11) states: ‘Take a holistic and preventative approach to patient care which is appropriate to the individual patient.’ Although Guidance 1.4.1 (p. 13) defines a holistic approach as one that takes account of patient’s overall health and Standard 1.4.2 (p. 13) mentions providing treatment in the patient’s best interests and ‘following clinical guidelines’. It is interesting to note that no specific mention is made in Principle 1 (pp. 8-17) of actually taking a medical history. Surely this is the most important aspect of putting a patient’s interests first, one that must be considered before anything else? In the 2013 Standards, we have to look further for this. In Principle 4, ‘Maintaining and protecting patient’s information’, there is a patient expectation that ‘records are up to date, complete, clear, accurate, and legible’ (p. 36), and the Standard 4.1 (p. 37) states: You must ‘make and keep contemporaneous, complete, and accurate patient records.’ The Guidance 4.1.1 (p. 38), tells us: ‘You must make and keep complete and accurate patient records, including an up-to-date medical history, each time that you treat patients.’ Notwithstanding this guidance, there may be a valid reason why clinical notes are neither clear, nor contemporaneous or complete. 2. In the 2013 Standards, there are no specific requirements to record the examination of the soft tissues. This is interesting as there have been several GDC conduct cases where allegations have been made that the defendant registrant either did not conduct a soft tissue exam or record the findings of that exam. The results of these cases can be retrieved from the General Dental Council web site: www.gdc-uk.org
Recording of soft tissues should be completed, if not at every visit, then at least as part of the examination of new patients and recall examination for regular and returning patients. Soft tissue examination can be quite a subjective exercise, unlike the recording of the dentition and restorations present, the periodontal condition with CPITN and BPE, or the orthodontic presentation with IOTN. Nevertheless, soft tissue examination should be completed and recorded in a systematic and consistent manner. 3. One way to record the examination of the intra-oral soft tissues is to note each area of the mouth in turn: floor, palate, sulci: buccal and labial, left and right, upper and lower, tongue upper and lower surfaces. The fauces: anterior and posterior and the retromolar areas too. Each of these areas of the mouth should be examined, and the findings should be recorded individually. Any unusual presentation should be noted which might take the form of changes in: a. Colour: Inflammatory changes, dark/pale appearance, white patches, or other discolouration. b. Surface: Profile or texture, e.g. swelling, ulceration, induration, loss of normal roughness, or smoothness. c. Shape: The anatomical features, e.g. loss of papillae, asymmetry should be noted. By taking care and attention with the soft tissue examination, a consecutive picture of change can be established in subsequent visits that might lead to an earlier, more effective diagnosis, than if no notes were taken. If you refer to OSCE 45, you will remember the patient had attended her previous GDP for two years with pain and discomfort. With respect to soft tissue examinations, the buccal sulci was never examined in that time, during which the adenoid cystic carcinoma was quietly developing. If you also recall Medical Matter 25, (the patient whose husband had recently died of throat cancer) thought it odd that I wished to examine her throat and neck. So soft tissue examination must be completed and the findings do need to be recorded in the dental notes, either on paper or in a computer system, with ease of access for both formats. 4. In answer to this question, it might be useful to quote advice from a dento-legal adviser: ‘If you want to keep your job, keep your mouth shut, but I would look for another job.’2 Or from an NHS Primary Care Trust dental adviser: ‘Keep your head down and keep your mouth shut, and things will get better.’3 Lastly, this little gem from a Dental Public Health consultant: ‘Let sleeping dogs lie.’4 All of this advice on what to do is in some disparity to the recommendations of the Francis Report and the 2013 GDC Standards publications.1 The 2013 Standards Guidelines raise specific issues about the practice owner’s comment, his attitude, and the above noted responses from three senior colleagues: In Principle 1 (pp. 8-17), there is a patient expectation that all members of the dental team will be honest and act with integrity. The standards supporting this are:
Standard 1.7: Put patients’ interests before your own or those of any colleague, business, or organisation. (p. 11) Standard 1. 9: Find out about laws and regulations that affect your work and follow them. (p. 11) In Principle 6 (pp. 52-61), there is a patient expectation that members of the dental team will work effectively together. The standards supporting this are: Standard 6.1: (p. 55): Work effectively with your colleagues and contribute to good teamwork. Standard 6.6: (p. 55): Demonstrate effective management and leadership skills if you manage a team. In Principle 8 (pp. 68-77), it says there is a patient expectation that the dental team will act promptly to protect their safety if there are concerns about the health, performance, or behaviour of a dental professional or the environment where treatment is provided. The standard supporting this is: Standard 8.2: (p. 71): Act promptly if patients or colleagues are at risk and take measures to protect them. Standard 8.3: (p. 71): Make sure if you employ, manage, or lead a team that you encourage and support a culture where staff can raise concerns openly and without fear of reprisal. In Section 9 (pp. 78-84), there is a patient expectation that all members of the dental team will maintain appropriate personal and professional behaviour. The standard supporting this is: Standard 9.2: (p. 81: You must protect patients and colleagues from risks posed by your health, conduct or performance. Somewhere between the GDC’s actual detachment from the clinical environment and reality lies the decision you need to make and the answer to this question. In my experience, follow the GDC guidelines to the letter. Just don’t expect them to pay your solicitor’s fees in the ensuing employment tribunal when you prove your case on the appropriateness of your soon-to-be future ex-employer’s conduct and choice of words as you vindicate your opposition to his contempt for his profession or his fellow dental professionals. On balance, the 2013 GDC Standards, now mentioned by many practice-owning dentists to be more patient-centred than the 2005 Standards might actually give the working dentist some clearly defined employment parameters and real protection in law when faced with workplace difficulties. In this respect, the words of O’Brien in 20135 that: ‘in dentistry the ideal world does not exist and it is clear that standards are required’, ring clear and true. 5. The responsibility for note-taking lies with the dentist. That is the short answer. If you are a teenage trainee dental nurse studying for your NVQ, well done, shift the blame, carry on texting in the clinic, mobile phone in one hand, suction in the other, and let the dentist take the hit. Well yes, the dentist is responsible but not entirely so. Now that dental team working is encouraged and GDC registration for all members of the dental team is mandatory, the responsibility is shared. OK, the greater part of responsibility might still lie with the dentist as the senior registered member of the dental team, but some responsibility will lie with other team
members too. 6. However, in law it is not how a contract is written out, with an apparent professional inequality between dentist and dental nurse but rather, how the terms are actually exercised. It is the answer to the question of: ‘What is really going on in the clinic?’ which will determine the nature and substance of any contracted activity of employment. The responsibility for note-taking does not automatically and wholly rest with the dentist. Rather than the responsibility for note-taking being determined by the contracted participant’s respective professional positions in work, or their status at the GDC, the situation as it is played out in the dental clinic plays a significant part in law in determining who is responsible, in this case for the poor note-taking. If we revert to the 2009 GDC publication: Scope of Practice, which lays down the terms of dentistry and the nature and substance of those who work in a dental clinic, the section on dental nurses states their duties and includes the following: ‘Recording dental charting carried out by other appropriate registrants.’ 6 (This goes some way to prove that a dental nurse is involved and responsible.) It gets better with the following clause: ‘Dental nurses keep full and accurate patient records.’6 So it is the dental nurse who is the keeper of the dental notes. A legal definition of keeper is: A custodian, a manager, or a superintendent, one who has the care, the custody, or the management of anything or any place. Nowhere in the GDC publication Scope of Practice does it state that the dental nurse is subordinate to the dentist in any activity, nor does it state that the dentist is the sole note taker or note keeper. A Socratic and Not a Didactic View To be fair to the GDC, they do get around this by stating that the dentist can perform the above mentioned duties, that is anything a dental nurse does, a dentist can also do, but it doesn’t say by how much, or by how much better or by how much less and so on. As the dental nurse is an employee, then ultimately it is your soon-to-be future ex-boss who has responsibility for the situation you are concerned about. The above is a Socratic rather than a didactic argument for academic purposes only and perhaps use in an MJDF SCR, certainly not in your defence at the GDC. You will only infuriate the legal assessor in a hearing if you use this as a line of defence to fall back on. (You can still explore the meanings used in the GDC publications with your study group) 7. If faced with a problem such as the one described in this OSCE, completing an audit is one way to begin to rectify a problem. a. Specifically, clinical auditing is a quality improvement exercise. It is a process to improve patient care and outcomes through a systematic review of existing procedures against defined criteria and then implementation of the improvements that are needed. b. Crucially in clinical audit, performance is reviewed to ensure that what should be done is being
done. If not, it provides the means to enable necessary improvements to be made. c. Clinical audit is a key component of your working within the NHS. d. Auditing in the dental clinic was also a requirement of the MJDF (old syllabus). It is still conducted by those of you who are foundation grade dentists based in a hospital or community clinic. e. Clinical audit is an important element of clinical governance contributing to the care of dental patients. In order to maintain the correct standard of dental care, audit has been a requirement for dentists under the NHS Terms of Service since 2001. 8. Clinical governance is the term used to describe the accountable and transparent framework we need to work in. Existing standards can be protected and an environment is created whereby the level of care we give to our patients can be safeguarded and then improved upon. Audit provides a mechanism to document this process of improvement, both in terms of quality and quantity of improvement gained. 9. In addressing the matters arising from this case, the audit might be conducted as follows: Firstly, by identifying an area to be audited. Secondly, by selecting a topic in this area. Thirdly, by including the criteria to be audited and setting a standard to be achieved. The following is an example of this process: Audit Topic 1. To determine whether an accurate, comprehensive, and up-to-date medical history is being currently recorded for each dental patient by comparing dental notes to an agreed standard. 2. To identify areas of weakness in the taking of medical histories. 3. To implement changes to improve the standard of medical histories. The audit standard is set somewhat arbitrarily: 90% of all patients’ records should satisfy all the following 5 criteria: 1. A medical history must be in the dental notes. 2. A medical history must be signed and dated by the patient/parent/guardian. 3. The medical history must be updated by the last recall appointment. 4. Every question on the medical history form must have a Yes/No answer completed, including patient contact details and GMP details. 5. All medication names and dose must be recorded. Audit Methods A pilot audit of 50 records will be selected at random; there will be no specific inclusion or exclusion criteria. Audit element
Yes No
Medical History in Dental Notes. Medical history signed and dated. Medical history form updated on last visit. All questions completed in medical history. All medication, drugs, and doses completed.
You can run the first audit cycle and analyse the results, presenting them in a simple histogram. A second audit cycle is run and, if necessary, the standard is modified to: 95% of all patients’ records should satisfy the aforementioned criteria. Or the audit elements can be changed if there is 100% compliance in one element. There is no point in repeatedly examining this element. If we consistently find medical histories present in all of the dental notes, but there is an assortment of medical history types, we may wish to standardise this element to specify: medical history to be of an approved type. (e.g. an NHS, BDA (British Dental Association) CODE (Confederation of Dental Employers) or other type taking into account the latest clinical guidelines on matters such as antimicrobial prophylaxis for endocarditis or procedures permitted when the patient is medicated with Bisphosphonates) Audit element
Yes No
Approved Medical History in Dental Notes. Medical history signed and dated. Medical history form updated on last visit. All questions completed in medical history. All medication, drugs, and doses completed.
Now you can run a second cycle with say 100 dental notes, again taken at random. It might be the case you don’t reach your standard in the pilot cycle or the second cycle. However, any changes, (hopefully improvements) towards the standard are noted. Audit cycles can be repeated as many times as needed. The best bit is you can get the dental nurse (remember she is the keeper of the notes) to take an active part in ownership of her responsibilities, i.e. by her participation in an audit. Points to Note a. In the MJDF, you won’t be asked to undertake an audit, but you might be asked to comment on one. b. In an OSCE, based on performance issues, you need to comprehensively understand how to construct, run and interpret the results of an audit. c. You will need to explain to the examiner not only what you are doing, but why you are doing it
and who will benefit from your efforts. 10. In addition to the GDC, there are other organisations taking an active interest in maintaining a registrant’s professional standards. Principle 8: ‘Raise concerns if patients are at risk’, in the 2013 Standards for Professionals publication, lists some of these organisations: The Care Quality Commission, The Health Care Inspector Wales, and the Regulation and Quality Improvement Authority and Health Care Improvement Scotland. One organisation not mentioned in the 2013 standards is NCAS. (NCAS is not the National Centre for Atmospheric Science, although there have been some opinions expressed about hot air when dealing with NCAS staff.) NCAS is the Clinical Advisory Service of the National Health Service. This organisation has moved from the National Institute of Clinical Excellence into the NHS Litigation Authority. NCAS has been used by NHS managers who are co-inspired to improve patient care by helping to resolve concerns about the professional practice of doctors, dentists, and pharmacists in the UK and overseas. Apparently, NCAS provides expert advice and support, clinical assessment, and training, to the NHS and other health care partners when concerns are raised. Certainly in an SCR or the OSCE, mention should be made of the existence of this organisation. Further Notes to This Procedural Problem. In the MJDF, if you have an OSCE dealing with professional performance, then reading the GDC guidance books can provide a good source of revision and better than that, discussion too. It is most likely that by now you will have completed an audit or other peer review activity, so you can rely on that experience to carry you through this type of OSCE. As for following the GDC guidance, well, you can make up your own mind on that one; it could well be a choice of your job or your registration. Personally and professionally, I would tend to stay very close to the regulations and remain on the right side of the law, be this statute, civil or criminal, and if you find yourself straying to the other side, there should be some very sound reasons for you doing so. Rather than dealing with NCAS and the GDC in any excessive detail, a more efficient use of your time and energies before your exams is to fulfil your CPD requirements and complete your audits. Make sure everything in the pages of your dental notes is in ‘apple pie order’ (from the French nappe plie or neatly folded). Even if your dental nurse colleague is less than helpful in your efforts to do clinical dentistry, as far as note-taking is concerned, I think you might make a good argument for bringing them to task. After all, they are GDC registrants too. References to Procedural Problem 47
1. Standards for the Dental Team. General Dental Council London Approved 20 June 2013. [Online] Available from: http://www.gdcuk.org/Dentalprofessionals/Standards/Documents/Standards_for_the_Dental_Team__web_PDF.pdf [Accessed July 2013].
2. Senior Dento-Legal Adviser in a leading UK-based indemnity provider who wished to remain anonymous. 2011. 3. NHS PCT Adviser to a South East England Primary Care Trust who wished to remain anonymous. 2011. 4. Consultant in Dental Public Health who gave this advice in 2011 at a Local Dental Committee Meeting in Bedfordshire, who wished to remain anonymous.
5. O’Brien K. View from the Chair. GDC News and Publications July 2013. [Online] Available f r o m : http://www.gdcuk.org/ Newsandpublications/viewfromthechair/Documents/View%20from%20the%20Chair%20July%2020 [Accessed August 2013]. 6.
Scope of Practice. General Dental Council 2009. [Online] Available from: http://www.gdcuk.org/Newsandpublications/Publications/Publications/ScopeofpracticeApril2009[1 [Accessed July 2013].
Further Reading to Procedural Problem 47 1. General Dental Council Standards Guidance. Standards for Dental Professionals. May 2005. 2. General Dental Council Standards Guidance. Principles of Complaints Handling. May 2006. 3. General Dental Council Standards Guidance Principles of Raising Concerns May. 2006. All of the above online and available from: http://www.gdcuk.org/Dentalprofessionals/Standards/Documents/Standards_for_the_Dental_Team__web_PDF.pdf [Accessed June/July/August 2013]. 4. Jones T, Cawthorn S. What is clinical audit? Evidence-based medicine. Hayward Med Commun. 2002. Vol 4. No 1 [Online] Available from: http://www.nottingham.ac.uk/nmp/sonet/rlos/placs/critical_reflection/pdf/whatisclinaudit.pdf [Accessed October 2013] 5. Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998. Jul 4;317 (7150): 61-5 6. Howard P, Hall J. Guide to the Courswork Module of the MFGDP (UK) Examination. London: Faculty of General Dental Practitioners (UK), The Royal College of Surgeons of England 2002. This text written by a clinical director and a chief examiner tells you everything you need to know about audit, governance, and implementing monitoring and improvement protocols in your practice of dentistry.
Procedural Problem 48 Background Information Although the vice dean of the Dental Faculty RCS Edinburgh told me to get a hobby, bashing the UK Government policies regulating health care workers isn’t one of them. Even though some health
regulators and administrators are quite capable of marching out of step with the rest of Europe, it isn’t within the scope of this book to either force them into step or trip them up. Anyway, enough of them for just a minute and on to this OSCE. The decision to test patients for a dental disease or a medical condition with dental implications is borne out of the knowledge of what having a disease may entail for the patient. The benefit gained from learning a patient has a treatable condition has to be balanced against the cost of testing and the cost for treatment if the disease is present. We then have to set this against the risk to the patient if the disease is present and is neither diagnosed nor treated. What is good for the patient is good for the practitioner. In the UK, mandatory testing to demonstrate immunisation against hepatitis B is a requirement of registration with the GDC. This is both sensible and well founded, protecting both the patient and the practitioner with little cost or risk from a disease with complications such as morbidity and mortality from hepatocellular carcinoma.1 In 2004 or thereabouts, the GDC then decided to make it a condition of registration that new dental graduates and dentists re-registering with them had to demonstrate lack of infection from HIV too. I know this, as I returned to the UK at that time, having to provide a UK-certified microbiology report to the GDC stating this. The GDC then retreated from this quite untenable position and offered refunds to the dental students who had to undergo HIV testing. As I wasn’t a dental student, I wasn’t eligible for a refund of the quite ridiculous cost to test me for something I did not have, and if I had, then it wouldn’t stop me from unrestricted dental practice in most of the rest of Europe. How could the GDC get the point of hepatitis immunisation so right and a few years later get the point of HIV testing so wrong? In this OSCE, the application of an established 400-year-old philosophical argument may help us to decide why we need to test for the presence of a viral infection in our patients. Hopefully, after reading this OSCE and applying the same philosophical argument to the points raised in the introduction, we might begin to unravel why dentists need to assure the GDC that infection with HIV is absent. As stated above, the purpose of this book and this OSCE is not to be critical of authority or its policies; rather, it is the purpose to stimulate thought and encourage discussion. Whichever exam you are sitting, MFDS or MJDF, please do not learn this OSCE but rather read this, and if reading this OSCE changes the way you think about the treatment of your patients, then you will have learnt something. If it doesn’t, then let me know why not, so I can learn something too. Introduction A female patient, who has just turned 16, comes to see you for her routine dental examination. She has been in social care and is now in foster care. She has had a turbulent childhood as a consequence of interventions from social workers; she has moved from area to area and from school to school. Now she is more settled, still at school, and continuing with her studies. She hopes to go to college, and at this appointment, she has asked you about dental nursing as a possible career. Having just completed another cycle of your oral soft tissue and medical history audit, you are quite keen to examine all of your patient’s oral soft tissues and review all of their medical histories too.
You notice a small growth on the dorso-lateral margin of the tongue. There is some slight swelling of the lymph nodes. With the patient’s consent, you take a clinical photograph, place this in the dental practice computer records, and send the photograph to the local hospital histopathology department. Without a biopsy sample, it is difficult to make a diagnosis; however, you are relieved when the histopathologist tells you the lesion is most likely to be a benign exophytic papilloma, an OSP (Oral Squamous Cell Papilloma). The information you receive is that this lesion is caused by the human papilloma virus. Most frequently types 6 and 11, or less frequently HPV type 16 can cause oral lesions.2,3 The treatment of choice is complete excision at the base of the growth. The histopathologist advises this can be completed by you and the tissue sample can be sent into the hospital for routine histology. You decide to perform an excisional biopsy with local anaesthetic: The tissue is placed in 10% formol saline and sent to the local hospital. Routine staining with haematoxylin and eosin and examination under light microscopy gives a picture of several finger-like projections of epithelium with a normal maturation pattern and the presence of hyperparakeratosis. Koilocytosis as a result of perinuclear cytoplasmic vacuolisation of cells in the spinous layer is seen. The classic perinuclear pale or clear halos and the occasional presence of basal cell layer hyperplasia completes the picture to confirm the lesion is a benign exophytic squamous cell papilloma.4 In accordance with your audit from the previous procedural problem at the recall visit as well as giving the results of the biopsy, you also go through the patient’s medical history form, finding out the patient is not taking any medication but does admit to smoking and drinking. The patient has no other details noted and is not taking the OCP (oral contraceptive pill). The only other relevant fact is that the patient is currently not registered with a general medical practitioner. Again with the patient’s consent you have an idea she might benefit from referral to a doctor. Question: Why Refer to a Doctor? What possible reasons might you have for referring this patient to a doctor? The Answer Rather than go through the whole song and dance routine of the OSCEs, by now, you will be so familiar with the script and focused on the exams, you will be introducing yourself to actors in your sleep and after collecting your shopping, you will be asking the checkout staff at the supermarket if they have any questions… OK, let’s just get into this OSCE. If you have a notion that a test or an intervention may benefit your patient, then you would go for it, wouldn’t you? If you believe that your patient may be at risk from a disease and there was a way to prevent the patient from suffering from the effects of the disease, then you would do everything possible to give your patient the best chance of good health. If you thought a patient was at risk from a disease that potentially could be life altering, limiting, or
ending and such an outcome can be prevented, then you would do everything to avoid an adverse outcome. From the introduction to this case, you can gather up the important and relevant facts, just as you would from the actor in an OSCE, or your patient in the clinic. In this case, the patient has had a chaotic beginning to her life, moving from school to school. The lesion on the tongue is benign, and the results from the hospital tell you this. The information passed to you from the histopathologist is that the HPV types causative of this lesion are HPV 6, 11, and rarely, HPV 16. The first two types are not implicated in neoplastic change, but the latter type is implicated in both cervical and oral cancer, although its role is not that clearly defined at this time.5,6 The decision to refer the patient to a doctor is based on Pascal’s Wager. 7 This is an argument in philosophy dating from the seventeenth century. It proposes that humans bet with their life and their lifestyle choices that God either exists or God does not exist. If a person lives as though God exists and he does, then there is infinite gain, that is they end up in heaven, which is generally considered a good result. If God does not actually exist, such a person will only have a finite loss due to abstinence when alive. Life ends, and that is it. If a person doesn’t believe in God and that he exists, the person may gain something during life, but that person doesn’t end up in heaven and they spend infinity in hell, which is generally considered not a good result. If God doesn’t exist, then they have gained only during life, when compared to the believer, but life ends, and that is it. The philosopher Alan Hayak neatly summarised Pascal’s Wager in table form:8,9 God actually exists Person believes in God
God does not actually exist
Person has infinite gain Person has finite loss
Person disbelieves in God Person has infinite loss Person has finite gain
Then Hayak waged war on Pascal’s Wager, tearing it apart and reassembling it. Never mind heaven and hell, what on earth has this to do with the MJDF and the MFDS? This time last year I was invited to attend a medical conference in Zurich, and Pascal popped up in a lecture by Felix Frueh.10
Russell Teagarden was the first to propose the use of Pascal’s Wager in medical applications in pharmacopoeia in 2009.11 Felix Frueh then adapted this concept to pharmacogenetic screening patients for disease markers, even though the disease may not be clinically present. If there is a benefit from a test and you choose not to test a patient who is at risk, then there is a potential for harm
and loss for that patient. Pascal, Patients, and Papillomas
In this case, if we suspect the OSCE portrays a patient who may be at risk from a disease with lifealtering, life-limiting or life-ending consequences, that is oral and cervical cancer from HPV 16 exposure, applying Pascal’s Wager can help in our decision making when choosing to refer for testing. In this case, the knowledge that there is cancer risk from HPV16, coupled to other risk factors, such as potentially no HPV vaccination, dictates that referral to a doctor is needed. In this OSCE, the information in the introduction tells you the patient is 16 years old and has passed through several schools while in care. She smokes, is not taking the OCP, and is not on a GMP list. We can take the information and interpret it as follows: This patient may have fallen through the vaccination program for HPV, and she may or may not be sexually active. The fact that she doesn’t take the OCP may mean she is not sexually active and not at risk from acquiring HPV. Or that she is sexually active and uses other methods of contraception that reduce but do not entirely eliminate the risk of contracting HPV. The fact that an OSP is present means the patient has already been exposed to HPV. We are faced with the problem of deciding if this exposure to HPV contained one of the high-risk types, e.g. HPV 16, that with other sub-types is responsible for some 70% of cervical cancers.6 Do we accept that the patient has been exposed and ignore the possible consequences for the patient in the future? Or do we refer and engage in a harm reduction approach with a doctor? From the section on medical ethics, the answer lies in the Hippocratic oath; Primum Non Nocere. If doing nothing (an act in itself) might result in harm, then we are ethically forced into doing something to do no harm Referring this patient to a doctor has many benefits, little risk, but some cost to the health service. If the patient is not seropositive for HPV 16, then she can enter the ‘catch up’ vaccination cohort. Studies suggest that significantly more adolescent girls enter a catch up vaccination programme when prompted to do so than those who are not prompted, although there are many socio-economic factors providing barriers to vaccination uptake.12,13 For sure, the patient will be behind her age group, but a vaccination programme will potentially protect her for up to eight years from the risks of developing cervical cancer. If the patient has been exposed to HPV 16 or other high-risk sub-types, then
vaccination is no longer an effective option. However, a doctor may take the decision to vaccinate and some protection may be afforded against other high-risk sub-types, HPV 6, 11, or HPV 18, that the patient may not yet have been exposed to, although these are not implicated in OSP or oral cancers. Currently in the UK, in the absence of any increase in the provision of NHS care, the patient will have to wait another 9 years to the age of 25 before routine cervical examination and Pap testing (Papanicolaou histological examination of cervical cells) is conducted. If by then there have been HPV-induced cellular changes, these can be identified and treated with colposcopy, HPV triage, and assessment test of cure. Further Notes to This Procedural Problem. Hopefully, you can see the application of Pascal’s Wager in this example. I have used Pascal’s Wager in the clinic and in MFDS OSCEs too. When discussing treatment with an actor in an OSCE, you can communicate an option within the structure of Pascal’s Wager as follows: ‘We can choose to test and to treat the condition if you have it.’ ‘What do you think?’ ‘If we do test and you don’t have the condition, then you will be relieved to know that your worries, although well founded, can now be put to the back of your mind.’ ‘However, if we don’t test and you do have the condition, then it will be more difficult to deal with the consequences later on.’ ‘What do you think of this option?’ ‘If we don’t test and you don’t have a condition, then things will pretty much carry on as now, although we will be left not really knowing what the specific cause of the problem has been, and I would feel this to be inappropriate, given the nature of our concerns just now.’ ‘What do think of my thoughts on how we might take your care forward?’ There is an MFDS OSCE dealing with the follow-up dental care after radiotherapy. However, the actor portrayed a patient who was about to enter the regimen for radiotherapy and he wanted to know if the treatment was going to work and why was he having the treatment done. If faced with such a question as I have been in real life, for goodness’ sake don’t say: ‘Well, you have consented to it, haven’t you?’ Application of Pascal’s Wager can give an empathic supportive answer without giving false hope. It is preferable to say: ‘If the specialists looking after you felt that there was an improved chance of your living and having a better quality of life by having the treatment, then they would not have given you this option as a choice. On that basis, I would fully support your decision to go ahead with this treatment.’
The use of Pascal’s Wager in this OSCE almost forces us into making a decision on behalf of our patient. The issue of a common and benign OSP in the tongue is an indication of exposure to and infection with HPV. This presentation on its own should not raise any further comment; however, if we look at all of the information provided in the introduction and we adopt a holistic approach to patient care as advocated by the 2013 GDC Standards for the Dental Team, then the medical and social issues are clear. With such clarity, as health care professionals, morally and ethically we are now obliged to do something. In this case, a routine visit to the dentist has enabled a young patient to access care for possible vaccination and definite risk reduction for a condition that Cancer Research UK has stated is the second-most common cancer in women under the age of 35.14 In the UK, every year 3,400 women are diagnosed with cervical cancer.14 According to data from the NHS, it is estimated that some 400 lives could be saved annually in the UK by vaccinating girls before they are infected with HPV. 15 As for screening on its own, with an increased activity following a celebrity diagnosis of cervical cancer, an additional 6,350 cervical abnormalities were detected in the UK; of these, 370 were suspected neoplasia.16 QED Pascal. References to Procedural Problem 48 1. Laszlo J, Sivarajasingam V, Ogden GR. A virus, the vice chancellors and principles of vaccination. Br Dent J. 1996 Feb 24;180(4):124-26. 2. Syrjänen S. Current concepts on human papillomavirus infections in children. APMIS. 2010 Jun;118(6-7):494-509. 3. Eversole LR. Papillary lesions of the oral cavity: relationship to human papillomaviruses. J Calif Dent Assoc. 2000 Dec;28(12):922-27. 4. Cawson RA, Odell EW. Chapter 19: Soft Tissue Disease. Benign Epithelial Tumours and Tumour Like Lesions. Squamous Cell Papilloma. In Essentials of Oral Pathology and Oral Medicine. 6th Edition pp. 260-261. Edinburgh: Churchill Livingstone 1998. 5. Kansy K, Thiele O, Freier K. The role of human papillomavirus in oral squamous cell carcinoma: myth and reality. Oral Maxillofac Surg. 2012 Dec 16. 6. Grulich AE, Jin F, Conway EL, Stein AN, Hocking J. Cancers attributable to human papillomavirus infection. Sex Health. 2010 Sep;7(3):244-52.
7. Jordan J. ed. Gambling on God. Lanham, MD: Rowman & Littlefield, 1994. Section on Pascal’s Wager. [Online] Available from: http://www.calvin.edu/academic/philosophy/virtual_library/articles/clark_kelly_j/gambling_on_god [Accessed June 2013]/. 8. Hajek A. Objecting vaguely to Pascal’s Wager. Philos Stud. 2000;98(1):1-16. 9. Hajek A. Waging war on Pascal’s Wager. Philos Rev. 2003;112(1):27-56.
10. Frueh FW. Personalised Medicine for the (European) Citizen—Towards More Precise Medicine for the Diagnosis, Treatment and Prevention of Disease. SCTO Zurich June 2012. 11. Teagarden JR. Warfarin and pharmacogenomic testing: what would Pascal do? Pharmacotherapy 2009;29(3):245-47. 12. Hohwü L, Bro F. [Contact from general practitioners to unvaccinated girls can increase HPV vaccination consent]. Ugeskr Laeger. 2012 Apr 2;174(14):942-45. 13. Bowyer HL, Forster AS, Marlow LA, Waller J . Predicting human papilloma virus vaccination behaviour among adolescent girls in England: results from a prospective survey. J Fam Plann Reprod Health Care. 2013 Jul 31. 14. Cancer Research UK. Cervical Cancer Risks and Causes. How Common Cervical Cancer Is. [Online] Available from: http://www.cancerresearchuk.org/cancer-help/type/cervicalcancer/about/cervical-cancer-risks-and-causes [Accessed July 2013]. 15. NHS Choices Web Site. Human Papilloma Virus (HPV) Cervical Cancer Vaccine. [Online] Available from: http://www.nhs.uk/conditions/vaccinations/pages/hpv-human-papillomavirusvaccine.aspx [Accessed August 2013]. 16. Lancucki L, Sasieni P, Patnick J, Day TJ, Vessey MP. The impact of Jade Goody’s diagnosis and death on the NHS Cervical Screening Programme. J Med Screen. 2012 Jun;19(2):89-93. Further Reading 1. Lycan WG, Schlesinger GN. You Bet Your Life: Pascal’s Wager Defended. In Geivett RD, Sweetman B. Contemporary Perspectives on Religious Epistemology. Oxford: Oxford University Press 1992. 2
. Cancer Research UK HPV and Cancer. [Online] Available http://www.cancerresearchuk.org/cancer-info/healthyliving/hpv/ [Accessed August 2013].
from:
3. Ciarrocca K, Jackson LL, De Rossi SS. Human papillomavirus: the fundamentals of HPV for oral health care providers. J Calif Dent Assoc. 2013 May;41(5):349-55. 4. Rautava J, Syrjänen S. Human papillomavirus infections in the oral mucosa. J Am Dent Assoc. 2011 Aug;142(8):905-14. 5. Closmann JJ. The human papilloma virus, the vaccines, and oral and oropharyngeal squamous cell carcinoma: what every dentist should know. Gen Dent. 2007 May-Jun;55(3):252-54; quiz 255, 264. Five easy-to-read sources of information to back up your learning in this area.
Procedural Problem 49 Background Information Today in the UK, in England and Wales, the NHS regulations governing primary dental care are quite different from those in Scotland. In 2008, Mr Justice Collins sitting in the high court in the case of Crouch v. South Birmingham PCT commented on the NHS contractual regulations:
‘It’s like going through a marsh, trying to leap from tussock to tussock…’1 Adding to this observation, the high court judge then stated the contract between a dentist and the NHS was of: ‘inordinate length’, further adding: ‘I do pity these poor dentists who have to struggle with this kind of rubbish.’1 In addition to a kind of rubbish contract and our professional obligations determined by the GDC, there are the additional matters of the regulations handed out from the Department of Health to contend with too. The most notable of these guidance publications are the Health Technical Memoranda or the HTM documents. Those of you who are recent graduates, foundation grade trainees, or dentists based in general dental practice in the UK in England and Wales will all be familiar with the HTM series, especially HTM 01 05, which has been available since 2009. While this book is being written, the HTM 01 05 is being updated in 2013 with a few changes in the procedures you have to follow. In Scotland, the Scottish Health Technical Memoranda (SHTM) 2010 and 2030 from Health Protection Scotland provide guidance on the local disinfection units (LDUs) that are now essential installations in all primary care dental practices. If you are sitting the MFDS, you can relax as you will not need to jump from tussock to tussock through the HTM 01 05 or the SHTM 2010/30 as this area is not examined in the MFDS OSCE syllabus. If you are sitting the MJDF, then you should get your HTM 01 05-approved protective boots on and jump in to the marsh of decontamination regulations in primary care dental practice. I have read through both the 2009 and the 2013 versions of HTM 01 05, and while there are some changes, most things have stayed the same. You still get the advice on keeping water away from electrical devices in Section 6.692 (a really great contribution from Captain Obvious in the Department of Health) The ‘model’ dental nurse on page 34 is the same, and despite wearing an intimidating amount of ‘personal protective equipment’, she still hasn’t managed to tie her hair back. Just for a moment imagine yourself to be the dental patient faced with such a nurse in her glorious evil finery beckoning you to be seated… (no thanks). If you have any more observations other than the inappropriately coloured red floor, the overloaded wall socket sprouting a trail of electrical wires in the photograph on page 4, and sharp safe bins precariously perched on the window sill, do share them either with the Department of Health, or others in your MJDF or MFDS study group. Continuing on a serious note: If you consider, for a moment that demonstrating immunisation from hepatitis B and declaring absence of infection from specific transmissible illnesses (e.g. HIV), are the foundations on which we can build a protective arch of cross-infection control, it surely follows that our adherence to what is written in HTM 01 05 is the keystone in maintaining the integrity of that arch.
Cross-infection control is a fundamentally important topic, and the GDC have specified that this is another core area of your CPD. Even though the MFDS syllabus seemingly sidesteps this area, in some of the OSCEs, actors will allude to issues of cross-infection control and demand answers. So you do have to know this area very well. In every sitting of the MJDF OSCEs, there are always two or more questions on cross-infection control, for example: Needlestick injuries, sharps disposal, and clinical waste disposal all being frequently examined. In this OSCE, I have taken some of the differences between the 2009 edition of HTM 01 05 and the 2013 edition as a source of material from which to ask questions. Rather than provide an introduction or background to this OSCE, as I have done in the previous OSCEs, I’ll just get straight into the questions themselves. Where the answers can be found in the HTM 01-05 2013 version, the references, with section and page numbers are given after each answer). Questions 1. Can you provide definitions for the following terms: ‘decontamination’, ‘disinfection’, and ‘sterilisation’? 2. What is a washer-disinfector? What are the differences between this and an autoclave? 3. In broad terms, what do the most recent regulations on use of sharps advise us? 4. Can you reuse endodontic instruments? 5. After sterilisation in an autoclave, how long can unwrapped instruments be stored for? 6. How long can wrapped instruments be stored for? 7. In a designated cleaning area, how many sinks are needed? 8. Regarding clinical clothing, what is the recommended temperature to wash these at and what is noticeable by its absence from HTM 0105 regarding clinical wear? 9. How can you deal with spillages of blood and other body fluids in the clinical environment? 10. To recap (no pun) needle stick injuries, can you describe the purpose of the 2013 regulations? Answers These are important terms you might need to define in an MJDF OSCE or SCR: a. Decontamination is an overall process whereby reusable instruments are rendered safe for handling and reuse. This process is essential to minimise, if not eliminate, the risk of crossinfection between successive dental patients and between patients and staff. Decontamination is a process of defined stages. These include cleaning, disinfection, inspection, then sterilisation. b. Disinfection takes place after instrument cleaning; this reduces the number of viable microorganisms present, making instruments safer to handle. This can involve the use of a spray,
wiping, or washing surfaces or equipment that can’t be placed in an ultrasonic bath, such as your hands or the dental chair. Disinfection will inactivate viable micro-organisms, but it will not eliminate or remove bacterial spores. The aim of disinfection is to reduce micro-organism numbers and activity to an attenuated non-harmful level. As a further note, chemical solutions are not ideal for disinfecting instruments unless specified by the manufacturer, and therefore, thermal disinfection is necessary, requiring a washer-disinfector. c. Sterilisation is the process intended to deactivate and remove all living organisms from any object. These can be instruments, tissues, surfaces, or clinical areas. Unlike disinfection, sterilisation completely kills all micro-organisms. Instruments that are reusable in the dental clinic need to be sterilised before being used on the next patient. The most common way to achieve this in the dental surgery is by use of a non-vacuum autoclave (N type) or a modern vacuum autoclave (B type). The time temperature cycles to achieve sterilisation are as follows: Non-Vacuum Autoclaves Non-Vacuum Steam autoclave
Temperature (°C) Pressure (PSI) Time (minutes) 121
15
15
Unwrapped items 132
30
3
Vacuum Autoclaves Vacuum
Temperature (°C) Pressure (PSI) Time (minutes)
Lightly wrapped items 132
30
8
Heavily wrapped items 132
30
10
Points to Note a. In the HTM 0105 version 1 (2009) and version 2 (2013), these figures are not given. b. It is expected that sterilisation cycles will be validated by means of a printout at the end of every cycle and a record kept of this data, proving sterilisation standards were achieved. c. Yet the specific data on what temperature and pressure sterilisation is achieved is not given in HTM 01-05, only that the cycle is validated. I think it is important to know these figures. d. The above information comes from the Autoclave Temperature and Time Pressure Chart published in the Journal of the American Dental Association.3 2. Washer-disinfectors do not sterilise, whereas autoclaves do. The former use water with chemical detergents added to clean, whereas the latter use water and pressure to achieve sterilisation. Washer-disinfectors do things by fives, and it is important to know the stages.
i. Flushing with water at less than 45 degrees centigrade prevents proteins being fixed to surfaces. ii. Washing with water and detergent mix to remove remaining contamination. iii. Rinsing to remove excessive detergent and contaminated liquid. iv. Thermal disinfection at 80 degrees centigrade for 2 minutes or 90 degrees centigrade for 1 minute. v. Drying to remove any residual moisture. (Section 3: Cleaning Instruments. 3.14 p. 17 HTM 01-05 2013) Following this stage in the disinfection cycle, the instruments are placed in an autoclave to be sterilised. 3. The most recent regulations dealing with sharp instruments in the dental clinic mandate that we move from risk assessment to risk reduction. These are the Health and Safety Executive (Sharp Instruments in Healthcare) Regulations that came into force on 11 May 2013. Northern Ireland will introduce equivalent regulations on the same date. With such risk reduction, we have to decide whether or not to re-sheath needles. We also have to provide procedures and training so that all members of the dental team will now be required to: a. Effectively use and dispose of sharps b. Use ‘safer sharps’ where reasonably practicable and reduce, if not remove, the practice of recapping of needles c. Place sharps bins close to the point of use d. Investigate and take action in response to work-related sharps injuries.4 4. The answer depends on which country in the UK dentistry is being practised. In England and Wales, following an announcement from the chief dental officer in 2010, endodontic instruments can be sterilised, stored, and reused on the same patient.5 However, in Scotland, the answer is no; endodontic instruments remain strictly single-use for all patients. Both the Scottish chief medical and dental officers have stated that from 2007 all single-use dental materials including matrix bands and endodontic instruments must remain single-use.6 In England and Wales, if reusing endodontic instruments, these have to be processed separately from other instruments to remove the risk of cross-contamination and cross-infection. Even though there has been a relaxing in the approach to endodontic instruments being reused on the same patient, the manufacturers still market and label these as strictly single-use only. Therefore, if they are recycled, there is a risk of fatigue fracture occurring during reuse. There is an additional risk of a single-use instrument being recycled and then being used on another patient. If we look at the risk versus the benefit in reusing single-use endodontic instruments, given the cost saving versus the real risk of intra-canal instrument fracture and a theoretical risk of prion transmission, on balance, one might be inclined to maintain the status quo and use root canal instruments once only.
5. Unwrapped instruments can be stored in a clinical area for up to 24 hours and in a non-clinical area for up to one week. Instruments should be dry and protected from contamination and kept in mini-racks placed in cupboards or in covered drawers. Instruments should not be stored on open work surfaces, particularly so in clinical areas. (Section 2: Esssential Quality Requirements, 2.4 part K p 11 HTM 01-05 2013) 6. Instruments that have been wrapped before sterilising in a vacuum autoclave or after sterilising in a non-vacuum autoclave can now be stored for up to one year. (Part 4: Sterilisation. Section: Packaging and Related Decontamination Strategy, 4.22 to 4.29. pp. 2528 HTM 01-05 2013) Please note these are two of the important changes from 2009 in the 2013 edition of HTM 01 05. 7. At one time, in a UK dental practice, you needed to have more sinks than a U-boat captain. Or for those of you not old enough, you needed more sinks than the stock market. Now that many Polish plumbers have left the UK, the HTM 01 05 requirement for sinks in dental practices seems to have sunk. (There wasn’t a problem with Poland sending fighter pilots during the Battle of Britain; it is just their plumbers and builders the English objected to afterwards.) You can now have one sink for manual cleaning, so long as you have a separate bowl to put in the sink for rinsing instruments. This rinsing bowl must not be used for cleaning. However, two sinks is still the best. Or three sinks if you include the separate one for hand cleaning. 8 . In the previous HTM 01-05 guidelines, clinical clothes had to be washed at a minimum of 60 degrees centigrade. However, there was no practical way of monitoring this or the number of times clothes were worn. In addition, the guidelines from the 2009 HTM 01-05 placed no realistically enforceable restriction on the time limit or location where clinical clothing could be worn. However, in 2013, in Part 6: General Hygiene Principles, Section: Clothing, Uniforms, and Laundry, it is stated that clothing used for decontamination and clinical work should not be worn outside the practice and a similar approach is recommended for clinical clothing too. (Section 6: General Hygeine, Principles 6.31 to 6.35. pp. 34-35 HTM 01-05 2013) Why We Need the Guidelines In recent times, dental practice owners have been keen to promote their corporate image on clinical clothes. I know one practice owner who wrote to a well-known toothpaste manufacturer trying to sell advertising space on his dental nurse’s top, next to his dental practice logo. Great idea, until every lunchtime when this nurse, accompanied by her gang of teenagers from college, would swarm down to the corner shop with the dental practice logo framed between cigarette in one hand, and a can of lager in the other. Not a great place to advertise oral health products. The practical answer is that clinical uniforms must not be worn outside the clinic area and should be washed at the hottest temperature suitable for the fabric.
9. Blood spillages should be disinfected with a solution containing sodium hypochlorite that is made up either fresh for the purpose of decontamination using hypochlorite-generating tablets or at least weekly in clean containers. These containers are considered single-use due to the risk of microbial colonisation of containers. (This seems a little odd, if a new solution is made up daily, then it should be able to remove any microbial colonisation.) For blood spillages, the use of hypochlorite at a concentration of 1000 ppm available chlorine is recommended. Contact times should not be less than 5 minutes. A higher available chlorine concentration of 10,000 ppm is useful, particularly for blood contamination. The use of alcohol for the same decontamination process is not ideal as ethyl or methyl alcohol can fix proteins to surfaces, presenting a potential biohazard. (Section 6: General Hygeine Principles 6.74 p. 39 HTM 01-05 2013) 10. In the MJDF, the sharp injury can be an entire OSCE in itself. This subject has been covered in Ethical Example 28. In that question, the focus of the answers was not so much on the regulations but more on the procedures and follow-up to an injury. In this question, the answer is focused more on the 2013 legislation covering incidents such as needle stick injuries in the dental surgery and what administrative duties need to be undertaken to both prevent and to deal with this occurrence. Sharps! Points to Note a. As a result of the 2013 change in UK legislation, it is likely this subject will continue to be an examination question in the MJDF for the foreseeable future. As in the past, it is unlikely that this subject will be examined in the MFDS. b. Although you don’t need to know the new legislation in great detail, you do need to be aware of its existence and be able to inform the examiners in an OSCE or an SCR that the regulations changed in 2013 from a risk assessment and reduction approach to one of risk control and, where possible, risk elimination. c. The new regulations are the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.7 d. This is a statutory instrument that came into force on the 11 May 2013. e. This statutory instrument is the implementation of the European Directive Framework Agreement that came into effect on 10 May 2010, (2010/32/EU) preventing sharps injuries in hospitals and the health care sector. Anyone who has a sharps injury must document this, and there is now a legal requirement to train staff to do so. This is in addition to the standing Regulation of Dangerous Diseases and Occurrences Regulations. (RIDDOR) In the event of injury where there is exposure to a blood-borne virus or other significant infection, a documented investigation needs to be completed. This may involve establishing the serus status of the
patient. If this information is already known from the patient notes (another good reason to have upto-date medical histories), then it should be handled confidentially to assist in deciding if the injured person should receive prophylactic anti-viral treatment. The follow-up to a sharps injury means the employer must ensure that when notified of any incident involving the risk of transmissible infection, there is immediate access to medical advice, post-exposure prophylaxis, and counselling as necessary. Safety Legislation in Dentistry All safety regulations in UK dentistry still comes under the 1974 Health and Safety at Work Act, which places a duty of care on the employer to safeguard the health, safety, and welfare of all employees. Under this act are several regulations determining the appropriate training, information instructions and equipment necessary to conduct procedures safely where the risk can be controlled. The law in respect of sharps injuries consists of several regulations from 1974 up to the 2013 implementation of the European Directive.8 The current framework is designed to bring together the multiple laws and regulations to afford more coordinated protection to the employee with regard to the risk presented by sharps injuries in the workplace.9 Up to the implementation of the European Directive in 2013, the emphasis in the UK has been to modify the behaviour of clinical workers to reduce the risk. Now the emphasis is on prevention of exposure in the first place. Rather than first trying to change the behaviour of the clinical worker to deal with the hazard, a hierarchy of control applied to sharps injury risk places the elimination of the hazard as the priority task. From the most effective to the least effective, the order of priorities are eliminating the need to give unnecessary injections, use of safer devices, staff training, using precautions, and finally, using protective equipment.8 In addition to the hierarchy of control, risk assessment is an essential requirement of the 2013 European Directive. As with most things in dentistry, risk assessment has five stages, and with respect to sharp injuries these are as follows:10 i. Identifying the hazard, e.g. familiarisation with the regulations and the workplace. ii. Decide who might be harmed and in which ways, e.g. which staff members are at risk. iii. Evaluate risks and decide on precautions, e.g. current practice compared to best practice. iv. Record findings and implement them, e.g. action plan and key performance indicators. v. Review assessment and update as necessary, e.g. reactive report or proactive audit. One of the most important aspects of the 2013 Directive is the need to instil a no-blame culture in the health care workplace. It is widely accepted that needle stick and sharps injuries are under-reported, but the reasons for this are unclear. 8 In fact, it has been documented that under-reporting can be as high as tenfold.11 It is vital that all injuries are reported and investigated to reduce the risk to the person injured and the potential risk to other patients from transmission of infection. The cost to conduct such reporting and investigation is a fraction of those sums paid in compensation when
breaches of the regulations have resulted in harm.8 Non-compliance with Health and Safety Law carries sanctions punishable under criminal law. With the 2013 GDC response to the Francis Report and Indicative Sanctions Guidance, a failure to report a sharps injury in the workplace could lead to professional sanctions in a conduct hearing in the GDC, and it is conceivable that conditions might be placed and/or there may be suspension of a registrant’s ability to practice until a full risk assessment is concluded. Further Notes to This Procedural Problem. Although this OSCE is firmly in the domain of the MJDF, in the MFDS, there are OSCEs that indirectly deal with issues covered in the SHTM 2010/2030 and the HTM 01-05. One such question in the MFDS is the matter of dealing with broken endodontic instruments and the risk of infection. It is important that you are able to clearly and confidently reassure the actor playing the patient that there is no risk due to the Scottish regulations absolutely forbidding reuse of endodontic instruments. In the MJDF, it is important to know the details of HTM 01-05 with the same degree of clarity that you might be able to recall the categories of the IOTN or the CPITN. From my experience of the MJDF exam, I would suggest that you have a good working knowledge from the clinically relevant parts of HTM 01 05 2013. When you are at work, look around to gain an understanding for the regulations governing crossinfection control as it applies to your daily work. As for the engineering, technical specifications, and industry standards, I do not think it is necessary or expected in the MJDF that you learn this area to any detail, other than know where to look to find the data you need as it applies to the equipment you use. Auditing infection control is another area that has changed from 2009 to 2013. Dental practice staff should audit their decontamination processes every six months using an approved audit tool as found in HTM 01-05. These can be downloaded from the DOH web site.12 Lastly, if you are not already operating at Best Practice level, you should have in place a detailed plan on how the provision of decontamination services will move you and your colleagues towards such a standard from the current Essential Quality Requirements level. Although in 2013, just as in 2009, there is still no time limit in which to do so. OK, now on to the last OSCE and something different, but before doing so, here are your references for this important core area of dental practice in the UK. References to Procedural Problem 49 1. Bajaj A. Orthodontist wins high court battle over contract. Br Dent J. 2008 March; (204): 287. [Online] Available from: http://www.nature.com/bdj/journal/v204/n6/full/bdj.2008.209.html [Accessed October 2013] 2. Department of Health. Section 6: General Hygiene Principles. In Decontamination Health
Technical Memorandum 01-05: Decontamination in Primary Care Dental Practices. 2nd Edition p. 39. London: DOH 2013. 3. Autoclave times and pressure chart. J Am Dent Assoc. 1991;122. 4. Health and Safety Executive. Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. [Online] Avalable from: http://www.hse.gov.uk/pubns/hsis7.htm [Accessed August 2013]. 5. Dental Protection Ask DPL: Cockcroft B. Chief Dental Officer Update. Commentary on Reuse of Endodontic Instruments. March 2010. [Online] Available from: http://www.dentalprotection.org/uk/AskDPL/bda_advice_sheet_a12 [Accessed August 2013]. 6. Chief Medical Officer Chief Dental Officer. Important Advice for Dentists on Re-Use of Endodontic Instruments and Variant Creutzfeldt-Jakob Disease (vCJD). Edinburgh Scottish Executive Health Department. 19 April 2007. CMO (2007) 5. [Online] Available from: http://www.sehd.scot.nhs.uk/cmo/CMO(2007)05.pdf [Accessed August 2013]. 7. The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. [Online] Available from: http://www.legislation.gov.uk/uksi/2013/645/contents/made [Accessed August 2013]. 8. Gallagher R, Sunley K. Section 2: The Law and Sharps Injuries. In Sharps Safety RCN Guidance to Support Implementation of the EU Directive 2010/32 EU on the Prevention of Sharps Injuries in the Health Care Sector. pp. 6-9. London: Royal College of Nursing 2011. 9. Council Directive 2010/32/EU (2010) Implementing the Framework Agreement on Prevention from Sharps Injuries in the Hospital and Health Care Sector, Concluded by HOSPEEM and EPSU, Official Journal of European Union. [Online] Available from: http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2010:134:0066:0072:EN:PDF [Accesed August 2013]. 10. Health and Safety Executive. Five Steps to Risk Assessment. [Online] Available from: http://www.hse.gov.uk/risk/fivesteps.htm [Accessed August 2013]. 11. Elder A, Paterson C. Sharps injuries in UK health care: a review of injury rates, viral transmission and potential efficacy of safety devices. Occup Med (Lond). 2006 Dec;56(8):566-74. 12. Infection Prevention Society and Department of Health. Local Self-assessment Audit for Assessing Implementation of HTM 01-05: Decontamination in Primary Care Dental Practices and Related Infection Prevention and Control Issues. [Online] Available from: https://www.gov.uk/government/publications/local-self-assessment-audit-for-assessingimplementation-of-htm-01-05-decontamination-in-primary-care-dental-practices-and-relatedinfection-prevention-and-control-issues [Accessed July 2013]. Further Reading to Procedural Problem 49 1. Fryers v. Belfast Health and Social Care (2009) High Court of Justice Northern Ireland. [Online] Available from: www.courtsni.gov.uk A case of a hospital worker traumatised in the aftermath of a sharps injury. 2. Grime, P. Generic Business Case for Investment in Safer Systems of Work. London: SNN 2006.
[Online] Available from: www.saferneedles.org.uk/?page=71&id=5 [Accessed August 2013]. 3. Cormack H, Cross S, Whittington C. Health and Safety Executive: Identifying and Evaluating the Social and Psychological Impact of Workplace Accidents and Ill Health Incidents on Employees. Research Report 464, Sudbury: HSE Books 2006. [Online] Available from: http://www.hse.gov.uk/research/rrpdf/rr464.pdf [Accesed August 2013]. 4. International Labour Organization/World Health Organization. Joint ILO/WHO Guidelines on Health Services and HIV/AIDS. Geneva: International Labour Office 2005. [Online] Available from: http://www.ilo.org/public/english/region/eurpro/moscow/areas/aids/ilo_who_guidelines.pdf [Accessed August 2013]. A detailed report specifically dealing with HIV. 5. Sharps Safety RCN Guidance to Support Implementation of the EU Directive 2010/32 EU on the Prevention of Sharps Injuries in the Health Care Sector. London: Royal College of Nursing 2011. [Online] Available from: http://www.rcn.org.uk/__data/assets/pdf_file/0008/418490/004135.pdf [Accessed August 2013]. A good, well-referenced, and easy-to-read text on sharps injuries from a nursing perspective.
Procedural Problem 50 Background Information Even if you find learning all about administration and regulation a bit tedious, one thing you might be interested in is the recent dramatic rise in numbers of public hearings at the GDC. About this time last year, a short while before I had a notion about writing this book, the GDC were advertising for registrants to sit on one of their appointment panels; being bored and having nothing planned for a few weeks, I decided to send off an application. I mean, who wouldn’t? The GDC were paying travel and full expenses to come to London for an interview. I figured that aside from all that, I had the qualifications and experience and as you have gathered by now, I have a few opinions that need to be shared. Anyway get this, it was a Thursday afternoon and a GDC communications officer told me if I hadn’t heard by Friday, then I was one of the ‘lucky few’ who would be shortlisted for interview. Friday passed, then Saturday, you don’t get post on Sunday and still nothing came from the GDC by Monday. Great, I thought by Tuesday, the GDC must have either made a terrible mistake and I was up for an interview (couldn’t wait to share my opinions), or the post was late and I had been binned and I had to keep my opinions to myself, bottling them up for a few more years. By Wednesday I was getting bored again, so I phoned up the GDC, to be told my application as a lay applicant had been rejected. ‘OK,’ I replied, helpfully telling them, ‘I am not a lay applicant. I am a registrant. Can you put my application back in through the section marked Registrants and see what happens?’ The short reply was ‘In that case, you really cannot be a lay applicant as you are a registrant, and your application is now rejected on that basis.’
‘Excuse me,’ I continued, ‘but I am certain I did apply as a registrant.’ I was insistent the GDC check their information. ‘OK, in that case we will check’ came the response. ‘No, you are still rejected: lay, registrant, or otherwise, and anyway, it is too late to reapply now. Our mistake, we apologise, and you are rejected. Someone here must have made a mistake, and you are not going to get an interview. Bye.’ Anyway, for my next great idea, I decided to look at the number of hearings the GDC were having and sat in the BDA library, trawling through 15 years of conduct cases, and this is what I found: There was a gender bias; being male, you were more likely to end up in front of a Fitness to Practise Panel. The nearer to London you were, the more likely you were going to have a hearing. But if you practised further away, you mostly ended up at the GDC for something pretty serious like a missed diagnosis with the patient suffering the consequences. Closer to London, the lure of easy money, crime, and decadent sociopathic behaviours bringing dentistry into disrepute brought registrants into the GDC for a little chat. Dental nurses were increasingly getting hauled up for all kinds of naughtiness (not quite on the same scale as dentists), but crime and conviction was a still good way to spend some time with a Conduct Committee if you were a registrant. The only registrants who did not seem to appear in front of the GDC were corporate-body-owning dentists, and Dental Public Health consultants. Both groups were conspicuous by their total absence at hearings in the past fifteen or so years. Possibly because the conduct of these two types of dentists affect whole populations and not individual patients, the GDC might not be able to tackle some of the nonsense that they could possibly be getting up to. I was quite intrigued by all this and asked the GDC for further information; I wrote to them and waited for a few weeks, then received a CD with nothing more than what I had already uncovered down at the BDA library. Looking through the CD as part of my CPD, it was clear the GDC had not done any research on the profile of hearings, or if they had, I wasn’t getting my hands on it. So having looked at the villains of dentistry, I decided to turn my attention to the heroes and heroines. No surprises for guessing that the GDC didn’t keep records of them either and had not done any research on their registrants who had made significant contributions to dentistry in the UK. Back on the phone to the GDC, this time I asked them about some famous dentists. Reading from the register, I began… ‘Davies, Beryl Murray Davies? You know the dentist who worked in the Special Operations Executive in the war, the dentist who Leo Marks wrote about in his book Between Silk and Cyanide?’ ‘Never heard of her’ came the reply.
‘Mclean, John Walford Mclean? He developed dental ceramics and Glass Ionomer fillings?’ ‘No, never heard of him either.’ ‘OK… How about Holliday?’ ‘Billie or Doc?’ came the response. (Doc Holliday actually was a dentist.) So someone at the GDC does have a sense of humour. Back to the BDA library to write this book. Procedural Problem 50 Part 1 Introduction You are working as a foundation grade dentist in an NHS practice, and its coming up to the end of the contract period and the practice as a whole has not met its performance targets. This is the second year this has happened. One month before the end of the contract period, an NHS administrator visits the practice and encourages you and your colleagues to do more Band 3 treatments as a way of reaching your targets. You point out you have a ‘child-only’ NHS contract. At this, the administrator suggests that you just go ahead and do crowns on children’s teeth. ‘Surely, you can fit crowns on children’s teeth?’ the administrator enquires. Not feeling comfortable with this idea and wishing to practise in a more preventive manner, you think that perhaps launching an oral health campaign and sending out preventive information may be one way to bring more patients into the practice for dental check-ups. Then you can claim Band 1 and Band 2 treatments, when the patients attend. The administrator acknowledges this suggestion, and with your colleagues, you discuss ways of altering your dental practising profile to achieve your UDA targets, but you want to do so in an ethical manner. Two of your colleagues decide to go ahead with this oral health campaign and claim for the NHS Band 1 treatments on the basis that the regulations,(tussocks and all), somehow allow such claims to be made. While your colleagues are doing this, the NHS administrators do not object to the practice doing this as the books will all be balanced out nicely at the end of the financial year. There is some talk of swings and roundabouts, losing in some areas but gaining in others. The contract year ends, and the practice as a whole met its target. There is no clawback of funds from the NHS, and another year rolls around with no financial penalties. A few months later, a letter arrives. This letter is from the NHS Litigation Authority, and it details an analysis of the dental practice’s profile completed by the NHS Business Services Authority. Some unusual patterns of claims have been highlighted, and this letter invites comments from the dentists concerned.
Your colleagues think nothing of this letter; after all, they have fulfilled their contractual obligations. A standard reply is sent in response to this letter. A few months later, a second series of letters arrive from the GDC asking for further information. After a year, your colleagues have a date for the Professional Conduct Committee at the GDC to attend as respondents in the case against them. Questions Part 1 1. Faced with pressure to complete targets in dentistry, what must you do? 2. Who is responsible for the work completed? 3. Can a non-clinical administrator from the NHS order you to practise dentistry in a way you do not feel comfortable with? 4. How can sending out oral health promotion leaflets possibly equate to conducting a clinical exam? Is this justifiable dentistry? 5. If faced with a GDC enquiry into your conduct in this matter, what must you do? Answers Part 1 1. Pressure at work as a dentist is normal, and this is something you have to recognize. However, it is the degree and direction of the pressure you face that determines whether you should accept it or not. At present in the UK, there is no shortage of newly qualified dentists, but there is a shortage of foundation training positions, and this situation looks unlikely to change for some time. In such times as these, one commonly used tactic by PCTs and employers is to reinforce a notion that if a dentist or an employee is not willing to carry out what is essentially an order, then the employee can be quickly replaced. As a dentist, in addition to the duty of care you have for your patients, governed by professional standards, you do have a duty of care for yourself. If the pressure is transient and bearable, then accept the situation and carry on working. If the pressure is such that it influences your ability to function and places patients at risk, perhaps through working longer hours or increasing the intensity or frequency of patients you see, then not only will your patients be placed at risk but you will suffer too. Such pressure must be firmly resisted. It is the job of the managers who operate at various levels in the dental profession, either in primary care single practices, group practices, corporate bodies, or in the recently vanished PCTs to make sure you do your job. It is not their job to compromise your professional standing in order to reach their targets set by nonclinical administrators further up their chain of authority. It is preferable to lose a job than lose your position in your profession. The situation in this OSCE is not of your making, and if there is no sensible solution you can reach through discussion with your colleagues or dialogue with the managers (NHS managers are often incapable of discussion), then alternative strategies including your using the door marked Exit should
be considered. It should be remembered that among all the people operating in dentistry in the UK, the managers are unique in not being registered with the GDC and have no specific scope of practice allocated to them. It is quite incredible that still in 2013, with the new Standards for the Dental Team, the GDC allow managers to have the most authority with the least professional accountability. In the final weighing and balancing, do you really want to follow directions from someone who is not registered with the GDC and not subject to the same professional standards as you? 2. The responsibility for work completed is with the dentist who treats the patient or, in this case, the performer. However, this is only on a clinical level. From an administrative level, the responsibility will rest with the contract holder or the provider, and this will often be the practice owner or principal. However, if the performer is able to transmit claims directly to the NHS (e.g. with their own contract number), then more of the responsibility lies with them than if all claims for work completed are passed from performer to provider and then to the NHS for payment. In this OSCE, it is not clear what the specific arrangement is. Notwithstanding this, in any employment relationship, either self-employment or employment, the greater responsibility lies with the senior party, and in this case, it is the practice owner. A lesser but still significant responsibility remains with the dentist employed in the practice who does the work. 3. The short answer is that non-clinical administrators can do whatever they want, as long as it fits into their own framework. In this case, a non-clinical administrator can issue whatever order they want in an attempt to reach their targets. However, asking and doing are two different things. If carrying out a request is not in your clinical abilities or it breaches specific professional standards, then the answer to the administrator is that you cannot accede to their demands. In this case, it is mentioned that you do not feel comfortable with the order, and there could be several reasons for you feeling this way. Perhaps it is the way the order was given, or it could be that carrying out an order compromises your ability to look after your patients. An alternative is that you value the freedoms that being a member of a profession brings and you feel uncomfortable with an order being given by a non-registered administrator as it encroaches on your professional freedoms. 4. Unless there are specific written directions from an NHS administrator or from an NHS dental practice advisor instructing you to either alter the working conditions or the contractual relationship with your area team (AT) (formerly the PCT), then the answer to this question is that oral health promotion and disease prevention programmes are different from oral examinations. Without clear written instructions stating that you can claim for dental treatment by undertaking a disease prevention programme, it would be very unwise to embark on a course of action that may be difficult for you to rationalise or justify. The problem arising from such a course of action, especially if NHS funds are being claimed, is that the public have paid for one thing but are now receiving something else that was not asked for.
The difficulty we now have is the purchaser of NHS dental care, the AT, now believes that money has been paid for something that has not been delivered by the dentist. Let’s be clear about this; in this case, dental examinations on children were claimed but no examinations actually took place. If the matter cannot be resolved locally and it is referred to the GDC, a charge of dishonesty may be made, and this would be difficult to defend without clear directions from an administrator or higher authority explaining that an oral health promotion was asked for, paid for, and then delivered. 5. In this case, a GDC enquiry did take place, and the dentist who initiated the oral health promotion programme but claimed for oral examinations instead was erased from the GDC register for dishonesty. The dishonesty in this case was presented as being repeated dishonesty, in that each claim for an examination, where in fact none took place, was a separate dishonest event in itself and in total; although the sums involved were relatively small, a GDC conduct committee took the view that the deliberate and repeated dishonesty passed the Ghosh test.1 Points to Note 1. The Ghosh test of dishonesty is a double test of objectivity and subjectivity. If we apply the test to this case: Would a common man regard the conduct as dishonest, and if so, would the defendant with this knowledge regard his conduct as dishonest? Only if the answer to both questions is yes, then dishonesty is proven. 2. One problem with the application of this test is the confusion that may arise between the objective and subjective elements in the minds of a jury or a disciplinary committee.2 3. The long-standing authority of Ghosh has attracted considerable criticism, and its application from criminal law dealing with theft to civil law dealing with administrative procedure is as complex as it is confusing.3 4. The critics of Ghosh have so far not found an alternative to this test, and in the meantime, it still stands and will continue to be used by Professional Conduct Committees to decide on the state of mind of registrants accused of dishonesty. Notwithstanding the complexities of the psychological and sociological application of Ghosh, it is difficult to see how there could have been any other outcome in this case, other than a sanction reflecting the committee’s views. When faced with a GDC enquiry today, there is more than enough time from the first letter arriving from the GDC to the start of a public hearing to put measures into place to remedy any shortcomings that have been identified. During such a period (currently this can be more than one year), reflection of the failings and significant events leading to a GDC hearing can be analysed and remedied as necessary. If there are clear breaches of the GDC standards, then showing insight into one’s failings can go a long way towards explaining one’s current position in law before a committee, and this should make a proportionate sanction more likely.
However, it must be stressed that GDC sanctions are not primarily punitive measures, such as those sentences delivered in criminal cases. After all, the GDC operate to a civil standard that is a balance of probabilities in their favour to prove the case and not the criminal standard that is to prove facts beyond reasonable doubt. Although mitigation might result in a more appropriate sanction, it does not result in a lesser sanction. The prime role of the GDC is to protect the dental patient, maintain professional standards, and uphold the confidence the public have in the dental profession, and not to isolate and punish the dentist. Further Note to Procedural Problem 50 Part 1. A finding of dishonesty is always difficult to reconcile with someone remaining on the GDC register or as a member of any body of professionals. Dishonesty is considered to be a serious and deeply ingrained condition with little prospect of remedy. A case of repeated dishonesty will always be viewed as a serious departure from the acceptable standards that any professional should uphold. Despite the proven facts of this case resulting in erasure, the dentist chose to exercise a right of appeal to the High Court in London. While some might view this as a tactic showing a total lack of insight, this period does allow a further year of work as a dentist. It is during this period of reflection that an honest analysis into the conduct leading to the GDC hearing might be made. It is hoped that reversion to the GDC or the PSA (Professional Standards Authority) for proportionate and appropriate sanctions will be the outcome of this final stage of this dentist’s disciplinary journey. References to Part 1 1. England and Wales Court of Appeal (Criminal Division) Decisions the Lord Chief Justice of England (Lord Lane) Mr Justice Lloyd and Mr Justice Eastham Regina v. Deb Baran Ghosh. [Online] Available from: http://www.bailii.org/ew/cases/EWCA/Crim/1982/2.html [Accessed August 2013]. 2. Campbell K. Test of dishonesty in R. v. Ghosh. Camb Law J. 1984;43(2):349-62. 3. Halpin A. Chapter 4: Some Problems with the Definition of Theft. Section: The Test for Dishonesty. In Definition in the Criminal Law. pp. 151-164. Oxford: Haart Publishing 2004. Procedural Problem 50 Part 2 Introduction Amidst all the chaos and stress of an NHS Litigation Authority and GDC enquiry of your colleagues, you go ahead and treat a friend of your family to some veneers. This patient has very small lateral incisors, and you know that whatever you do will be an improvement on the appearance of the existing dentition. You treat her as a private patient and so avoid any involvement with the Primary Care Trust. As the patient is known to you socially and is a family friend, you do not bother with taking a medical history or writing any dental notes. After all,
this is a friend and it’s just between you and her with no involvement of the NHS in your private affairs. You go ahead, doing some crown lengthening with electro-surgery using LA to reduce the discomfort as you remove some inflamed gingival tissue around the small lateral incisors. There is no recording of the current periodontal condition in the notes. The patient is a family friend. You believe all of this medical history taking and periodontal condition monitoring isn’t necessary or even relevant in this case. Anyway, in other cases, you would normally take records, wouldn’t you? You rationalise this decision by thinking that if there are any problems, you can resolve them outside the clinical environment when you meet socially. Just to bear out this laissez-faire approach, you continue to meet socially, and two weeks later, you fit the veneers. The practice manager sends the patient an invoice for payment; as she is a private patient, the sums involved are considerable. A month later, a letter arrives from your patient, but the envelope doesn’t contain the payment. In this letter, the patient alleges: After the electrical cutting and chopping up of my gums, there was still is considerable pain and discomfort. and I
tried to reach you but I have been unable to contact you. I think the teeth not only look too big, they collide with the bite on the lower teeth bashing into them. All of this is most not up to scratch. As you read the letter you are beginning to get a sore head. To add to your growing headache, the letter continues…
The shade of teeth is wrong too and you know you work in a practice where a dentists have been struck off and have been under investigation for cheating the NHS out of money?! How could you treat me like this?! I have always been an NHS patient, you have always looked after me up to now, but
you this
time YOU have let me down… badly. A few months later, another letters arrives, this time from the GDC asking for further information. After a year, you too have a date for the Professional Conduct Committee at the GDC to attend as respondent in the case against you. Questions Part 2 1. Are there any circumstances when taking a medical history is neither relevant, nor appropriate or indeed not necessary before treatment? Can you complete treatment without writing notes of documenting what you have done? 2. a. How common are smaller teeth and absent teeth? b. What are the possible treatment options? 3 a. Are there any disadvantages in the treatment options you have described?
b. Can you describe in broad terms the materials you might choose? 4. a. Discuss the concept of consent. Is consent always necessary? b. Are there cases where a laissez-faire approach to dentistry works? 5. When faced with a GDC enquiry into your conduct in this matter, what must you do? Answers Part 2 1. In most cases, before commencing treatment, a medical history must always be taken first. In my experience, there have been a few occasions when a medical history might conceivably not be taken before treating a patient, and I might provide the following examples: a. When attending a road traffic accident and other acts of emergency care or acts in the nature of a good Samaritan. b. When treating a child who was brought into the surgery with lacerations to the head after falling on to a glass table in the waiting room. c. hen treating my old mother. However, in all these cases, a detailed set of notes was written up and submitted as follows: a. To the Police Road Traffic Officer, as the road traffic accident was fatal. b. To the Hospital Accident and Emergency Department as the child was referred for further treatment. c. To my old mother’s doctor. Points to Note a. There are only two people you can treat without first taking a medical history. First, your mother and second, anyone you attend to in an emergency. b. In these cases, you should make time to complete notes as soon as possible afterwards. c. For anyone and everyone else, a medical history must be completed before treatment starts; there are no exceptions to this rule. 2 a. Maxillary incisors are naturally smaller than central incisors and canines. In studies, the size difference between the maxillary 2s and 3s is reported to be 1 to 1.5 mm.1,2 Anything more than this might lie outside the parameters of normalcy. But how small is ‘small’ in a tooth that is naturally smaller anyway? Well, the answer lies in the eyes of the owner and not in the eyes of the beholder, i.e. the patient and not the dentist. One study stated that overall, small teeth occur in approximately 5% of the population.3 (from the previous OSCEs, you could have guessed that numbers were coming). This study looked at all teeth and is now well over 50 years old. A recent meta-analysis of 30 papers and 36 studies in 2013 specifically investigating the maxillary lateral incisor revealed a prevalence of nearly 1 in 50 (1.8%) patients having small lateral incisors.
If one lateral incisor is small, then just over half (55%) of these cases were associated with a missing contra-lateral tooth. Women were more predisposed to this condition, and racial differences were noted too.4 To be clear: the condition in this case is one of dental hypoplasia, which refers to a tooth or part of the tooth structure which is smaller than normal but not missing. The figures for missing teeth are interesting too. One in fifty or 2% of the UK population have missing lateral incisors.5 Overall, hypodontia in the secondary dentition affects from 3.5% to 6.5% of the population (so the average is again 5%). If we look at missing teeth overall, a meta-analysis published in 2005 revealed a prevalence of 5.3% (by combining all the studies in this paper).6 This figure agrees remarkably well with the 1974 paper of Brook, even though that paper was confined to British schoolchildren, it still investigated their adult dentition.5 In the 2005 meta-analysis, it was noted that more women in Europe and Australia have smaller teeth than those in North America.6 It is important to consider hypodontia. As noted (4), it is associated with smaller-than-average-toothsize in the remaining dentition. With peg lateral incisors and the remaining teeth being microdontic or hypodontic, there is a redundancy of space in the dental arch. It is this aesthetic asymmetry or disharmony that often causes the patient to seek dental treatment.7,8 As mentioned in the study cited above (4), if more women are affected and if all other factors are equal (which in many cases they are not), then potentially more women will seek a solution for this problem. Points to Note a. In the OSCE exams, if you give a figure of 5% for hypodontia prevalence and 2% for hypoplastic upper lateral incisors, I think these are acceptable figures. b. In the examinations, if pressed further, you can provide the references and specific figures from the latest meta-analyses cited here. c. It is important when looking at the studies not to be confused by the dental terms used. d. Small teeth or microdontia is also termed dental hypoplasia. e. Hypodontia refers to a tooth that is missing, and a tooth that has not developed is dental agenesis. 2 b. The treatment options and procedures that should be explained to an actor or a patient are as follows: a. Do nothing, leave alone, and accept the appearance. b. If treatment is considered, then a diagnostic wax-up on study casts is the way to present the options to the patient and these can be as follows: c. Composite build-up on the front (labial) face of the tooth matching the central incisor and canine proportions. This procedure does not need local anaesthetic or the need to remove enamel. However, acid etching and cleaning of the tooth with an abrasive material may be needed to remove stains or decay if present. This treatment option should be considered an interim option
only as composite material does not last as long as the next option. d. Porcelain veneers can be bonded on to the tooth, but this procedure will require removal of some enamel and this will most likely have to be completed under local anaesthetic. The tooth may be sensitive after this. Some of the gum tissue around the tooth may need to be removed; this will cause further pain and discomfort for a few days until the healing process is complete. Porcelain veneers do last longer than composite material and have a more natural translucent appearance. e. While veneers require some preparation to the teeth, the next option to crown the upper lateral incisors will need more drilling (preparation) to the front surface and all around the tooth to remove up to 1.5 mm of enamel and possibly some dentine too. Crowns (or caps as the actors in the MFDS OSCEs will refer to them) can be made from a variety of materials. This can be porcelain, or porcelain fused to gold or non-precious metal alloys. Current trends a. Another option favoured by celebrities who want to be famous and patients who want to be celebrities is to have gold teeth. b. This option should be mentioned while the current fashion trends prevail. You might also mention that there are modern materials and techniques enabling crowns, and in some cases veneers, to be made in the dental clinic in only a few minutes. One technique is CADCAM (computer-aided design, computer-aided manufacture). If this option is available and chosen, there is no need to use a laboratory with the associated delay. f. If the small lateral incisors are retained deciduous teeth, then their loss (exfoliation) is to be expected and accepted at some point. If this is the case, but it is not clear from the introduction whether it is, then other options should be considered. These are, in order of technique from least invasive to most invasive: Partial upper denture, resinretained bridges, conventional bridges and finally, implants. These options are often considered when, and not before, an upper deciduous incisor is missing.9 Points to Note a. In the MFDS, often specific clinical details are not given, and it should be stressed that your detailed questioning of the actor is needed to elicit such information. b. In this case, you need to determine whether the small upper laterals are, in fact, retained primary teeth or small secondary teeth. c. In real life, if faced with a patient with small upper lateral incisors, radiographs, study models, clinical notes, and as complete a dental history as possible are all needed to determine the most appropriate restorative treatment to carry out. One final option that must always be given to the patient is referral to a specialist to conduct some or all of the options listed above. One option I have left to the end is that of orthodontic treatment within a specialist orthodontic-
restorative clinic. In cases such as this one, this option must always be given to the patient. Points to Note a. Often teeth that appear smaller do so because of a discrepancy in tooth size to arch size. b. Simply building up the small lateral incisors while correcting one problem does not address wider issues affecting the whole mouth. c. Referral to a specialist for advice can give a valuable alternative viewpoint on further treatment strategies. d. With any treatment plan there will be options. These have both advantages and disadvantages (or benefits and risks). e. These must be made clear to the patient in the process of obtaining consent. 3 a. The disadvantages of the options provided in the previous answer are as follows: a. Doing nothing, while the easiest and cheapest option, this may result in the small upper lateral incisors continuing to be a source of concern or upset to the patient. If these teeth are the primary teeth, are decayed, or have small roots, then the continual degradation of these teeth may lead to their eventual loss and the patient should be informed that doing nothing will result in this. b. Placing composite veneers, can only be an interim or short-term measure. However, composite materials do last. A 2010 study revealed 5-year survival of 79.2%. 10 After some time, replacement or repair becomes necessary. Staining, fracturing, and debonding are common problems. What is currently unknown are the indicators for replacement or repair of composite restorations. A recent Cochrane review investigating composite fillings was unable to answer this question. It must be pointed out that this 2010 review was limited to posterior teeth only.11 If composites are placed as a cosmetic solution, then the costs have to be explained to the patient, as this option might not be justifiably offered under an NHS contract. c. Porcelain veneers are more expensive than composite restorations. While lasting longer, porcelain veneers do require tooth preparation, and this means cutting into the enamel and in some cases, cutting into the gum above the tooth too. Points to Note a. A gingivectomy is useful to remove hypertrophic supra-alveolar tissue and gives the appearance of a longer crown. b. However, such periodontal surgery can be painful as it produces a raw wound and exposes the root surfaces to the oral environment causing pain and sensitivity that can last for several days or weeks after the procedure. c. Although these are temporary symptoms, the patient must be made aware of these during the consultation when options are explained. There is a delay of some two weeks from tooth preparation to fitting of laboratory veneers, and therefore, temporary veneers are needed. Although more durable than enamel, porcelain veneers
do have a finite life. They are prone to fracture in the same way natural enamel is. Nevertheless, there are extensive studies attesting to the longevity of this restorative option. A 2010 review of some 50 articles reported less than 5% failure at 5 years and less than 10% failure at 10 years.12 Rather than structural or mechanical failure, one of the main reasons for patients with veneers to reattend is a biological failure. The gum (gingivae) around all teeth recedes, and with veneers, gum recession will show where the veneer ends and the natural tooth begins. When this can be seen, the veneer often cannot be repaired and replacement is the only option with further cost to the patient. In the consultation and consenting stage of the treatment plan, these factors have to be explained to the actor in the OSCE or the patient in the clinic. d. Crowns are the most extensive and expensive restorative option. They require complete allaround preparation of the tooth. The disadvantage of this is if the tooth is naturally small, then further reduction will result in a tooth that is either very weak or the pulp tissue can become exposed and compromised by the preparation. Again, sensitivity or pulpal inflammation and necrosis are complications that must be explained to the patient during the preoperative discussion phase. The teeth against which crowns and veneers incise or occlude can become worn by the ceramic and it may be advisable to place metal backings on the incisal or occlusal surfaces. If contemplating this, do be sure to tell the patient your reasons for prescribing this and what their final appearance in the mouth will be like. 3 b. Several materials can be used to make crowns. Porcelain fused to metal crowns are strong and reliable in function with minimal chance of porcelain debond or fracturing. However, they are radio-opaque, and therefore, secondary decay extending to dentin leading to inflammatory processes in the pulp tissue will not be seen in X-ray views. Metal-free ceramic crowns are available. In broad terms, ceramic materials have a wide range of radio lucencies depending on their alumina content, with zirconia ceramics being more radio-opaque.13 There are a great number of ceramics available, and you have to be aware of their clinical properties too. Again in broad terms, ceramics are good at resisting compressive forces, but they do fail in tension. Points to Note a. If we go a little beyond the level of information needed for discussion in the MFDS OSCEs, the following is, nevertheless useful when thinking about the most appropriate material to use when discussing treatment options with your colleagues and in CPD courses. b. If you are sitting the MJDF, a good working knowledge of restorative materials and processes is essential for the OSCEs and the SCR questions you will face in that exam. c. In the SCR exam questions, it is important to be able to discuss the advantages and disadvantages of restorative materials you will be using. Manufacturing methods One way to classify restorative materials is by the methods used to create them.
a. Powder and liquid applied to a metal or non-metal core to build up a crown form: this is purely a manual technique and currently the most common way to make all indirect restorations (crowns and inlays). This is an established and accepted technique being relatively cost-efficient for all involved—the technician, the dentist, and the patient. b. Ceramic pressed or machined into a block for milling in a CAD CAM process: there is no manual work involved in this process. This is a relatively new technique and eliminates the need for a technician, but is still relatively expensive. However, the cost to purchase the CAD CAM unit (both hardware and software) means that several hundred restorations must be completed in a relatively short time (perhaps one to two years) before the unit becomes obsolete or breaks down. To achieve this break-even point, the cost to the dentist and patient is disproportionately higher than if a manual technique to produce indirect restorations is used. The only real advantage is that a restoration can be placed in hours, rather than weeks. c. Machined cores made from glass-free sintered alumina or glass-infiltrated blocks on to which a powder liquid cover is manually applied: this is a hybrid machine-manual process. The accuracy of machining produces a core that accurately fits a scanned model, and it is then completed with the artistic skills of a ceramicist. This option is considerably more expensive than established methods of producing restorations. The cost to purchase expensive milling and scanning machinery is borne by the laboratory, so in theory and in practice, the unit cost to the dentist and patient is lower. d. One exciting development is the potential for the dentist to scan and transmit an electronic impression. The technician can begin to work on the restoration almost immediately. When this development will be fully implemented into practice, the need to take impressions, disinfect them, and post to a laboratory disappears and so turnaround times, costs and infection risks will be eliminated too. Chemical composition If we look a little deeper into materials, from a structural or chemical point of view, there are four different types of dental ceramics available. a. Silica glass-based systems are brittle glass-like materials with a translucent appearance. This material has very narrowly defined clinical applications due to poor strength and intrinsic low colour value. The colour of the underlying prepared tooth can determine how the final restoration appears. However, with resin cements, this problem and that of the material’s inherent weakness can be overcome to some degree.14 b. Silica with fillers—crystalline leucite and modern lithium disilicates—are relatively strong and can be further divided by the amount of filler present. There are two sub-types, the first having less than 50% filler; these are the feldspathic porcelains. The second type have more than 50% filler; these types can be machined or milled, having silica filler with lithium oxide added. A recent prospective study revealed a survival rate comparable to the traditional ceramic-metal restoration with no restriction on the materials used to cement the crowns in place.15
c. Crystal-based glass-particle-filled castable systems have been available for over 30 years. They were introduced in the 1980s as an alternative to conventional porcelain-fused-to-metal restorations and have been successful in clinical applications. These materials display physical properties similar to enamel in terms of hardness, abrasion resistance, and translucency and are ideal for anterior restorations.16 d. Polycrystalline solids of alumina and zirconia are strong modern materials. Essentially, they are solid monophase glass produced by sintering crystals together without an intervening matrix, thus eliminating any porosities or air inclusions. The materials can be an aluminous silicate or zirconia oxide framework mass-produced and supplied in units or blocks. These are machined into shape with CAD CAM milling equipment, producing crowns and bridges for placement in the same clinical session as tooth preparation. These materials demonstrate excellent 5- and 10year survivability when used in anterior resin-retained bridge applications.17,18 4. Consent is always necessary. You cannot get away from this. I could just leave it there, and this would be the shortest answer in this book. However, at the MFDS and MJDF examination level, you need give some more detail. The consent to treat needs to be valid. Not only does it have to withstand the legal challenge if things do not go according to plan, it has to be in the patient’s best interest too. While we are discussing consent, it really is important to stress that consent is not something the patient agrees to just at the beginning of a procedure; it is something that needs to be valid right up to the end of the procedure too. If a treatment plan consists of multiple procedures, then consent should be verified for each of these stages too. In essence, consent has to be a process running in parallel with the treatment you deliver and not a signature sitting quietly at the start of a treatment plan, relegated to the bottom of a piece of paper the patient did sign, but neither read nor understood. There is a great quote from the Scottish poet Andrew Laing (1844-1912) about statistics. I think it applies equally well to consent: ‘You don’t want to rely on consent as a drunken man uses a lamp post: for support rather than illumination.’ When, and not if, your dental records are examined, if it is clear that consent was valid and obtained and maintained throughout your treatment, this will cast your approach to patient care in a favourable light. Consent Concepts a. Consent is both a legal and a clinical requirement. b. Consent does not have to be in any form; it can be oral or written. c. Consent can be implied or expressed: i When a practitioner’s proposal is met with a patient’s compliant actions, this is an indication of implied consent. ii In contrast to this, when the specific nature of a procedure is written, detailed, and signed by both patient and practitioner before treatment starts, but only after the patient fully understands what it is they are signing, this is expressed consent.
If this document is altered, further amendments have to be signed by both parties for the consent to be valid. d. The concept of consent is a positive action. e. If specific consent has not been obtained, there is perhaps only one defence in law that might be used and that is ‘medical necessity in an emergency’. In this case, and in most dental exam questions, such a defence is both unlikely and improbable, given the nature of dentistry in general practice. f. The legal position on who needs to prove consent in civil proceedings is still unclear. 19 It has even been suggested that consent is a defence the medical professional will raise to what will otherwise be a tort, and so the medical professional has to prove there was consent.20 g. In the 2013 Standards for the Dental Team, the GDC now give some fairly clear guidance on obtaining consent. Remarkably though, the principle remains: obtain valid consent21 and not: obtain and maintain consent. In discussion with the secretary to the Standards Review Working Group, the issue of the precise wording of the principle was thought to be one of semantics and not one of strictly defined legal terms.22 In this OSCE, the patient consented to have a cosmetic dental procedure to enhance the appearance of two small or short lateral incisors. The patient implicitly consented for an overall treatment but did not expressly consent to have a gingivectomy by use of electrosurgery. Implied consent was believed to have been obtained as the patient was not forcibly restrained while undergoing the procedure that was not expressly consented for. Consent Components In consenting for any dental procedure, the following have to be present:19 a. The patient or their representative in law has to be competent to consent or assent for treatment to proceed. b. The patient or their representative has to be sufficiently informed. c. The patient or their representatives are not subjected to undue influence or coercion. d. At any time, the patient or their representative must be free to withdraw their consent. e. If dental treatment is to have the satisfactory outcome acceptable to the patient and expected by the practitioner, then both obtaining and holding consent are needed. Points to Note a. In answer 4 b., it was stated that ‘consent does not have to be in any form, it can be oral or written’. There is no legal distinction between the two, although if sedation, general anaesthetic, or major surgery is contemplated, the patient must sign a written consent form. (Standard 3.1.6)21 b. Although dental surgery is not major surgery, in the interests of good practice and especially in the current litigious economic times we work in, obtaining written consent is now expected. c. Nevertheless, Herring (Section 4.4: The Form of Consent, p. 163) states:19 ‘Although in the case
of major surgery it is common to ask a patient to sign a consent form, this is not, strictly speaking, necessary. There is a case where the precise nature of consent has been described as “pure window dressing”’ (Taylor v. Shropshire Health Authority).23 d. If we again think about consent being used to illuminate your approach to patient care, if you were to cite Taylor as your defence when you do not have signed forms, this would be about as useful as strapping a bag of carrots to your head to help you see better in the dark as you stumble about from one court case to another, trying to illuminate your defence. e. Better and simpler, even if it is not strictly necessary, is to obtain written proof of your valid consenting process. Then, as Herring points out, you have the benefit of a signed form specifying what the patient has been told and what they have consented to.19 In 2001, the UK Department of Health issued an authoritative statement on just how important obtaining consent is. Patients have a fundamental legal and ethical right to determine what happens to their own bodies. Valid consent to treatment is, therefore, absolutely central in all forms of healthcare, from providing personal care to undertaking major surgery. Seeking consent is also a matter of common courtesy between health professionals and patients.24 What counts as consent for the purpose of law does not necessarily reflect how consent would be understood by philosophers and others.19 Indeed, it has been commented that informed consent is based on a legal fiction, because it does not presuppose autonomous authorisation from the patient.25 Setting aside philosophy for a moment and getting back to the dental clinic and the exams; in order for consent to be effective, it is not sufficient just to show the patient said, ‘yes’. As Herring states, there actually has to be an agreement to receive treatment.19 In 2008, the General Medical Council issued quite clear guidance to its registrants on the importance of consent. This guidance was significant in that it emphasised the need for medical practitioners to ensure that patients understood, by whatever means necessary, the need for treatment. 26 The guidance also accepted the need in exceptional circumstances to withhold information on significant risks that if disclosed might cause a patient serious harm. However, in this respect, the serious harm does not descend to a patient becoming angry, upset, or refusing treatment. In the 2013 Standards for the Dental Team, the GDC have incorporated much of what the GMC had published in 2008. I think it is useful to consider not only the GDC’s Principle 3: Obtaining valid consent, but the GMC guidelines too when obtaining then maintaining consent from a patient. By taking both of these into consideration, not only will we gain consent but also we will reduce the chances of unintentionally trespassing against the autonomy of our patients. Consent 10 Commandments These are based on the GMC 2008 guidelines.26 In seeking permission or consent to dentally treat a patient you need to 1. Give a diagnosis and a prognosis.
2. Detail all uncertainties you have and the need for further investigation when necessary. 3. Give all the options from not treating through treatment you or specialists to whom you will refer might provide. 4. Explain the purpose of the treatment you are proposing and what this involves. 5. In clear terms, give the advantages and disadvantages of the options provided. 6. Identify all those involved in the treatment including specialists and what they will do. 7. Clearly explain the right of the patient to refuse treatment or to stop treatment at any time. 8. Explain the costs involved and whether these will be funded privately or publicly. 9. Explain any conflict of interest and thus any barriers to providing treatment. 10. Explain whether any treatment you wish to provide is experimental, part of a research programme, or if students are involved. It is not sufficient to provide a list of the above items as they apply to a patient; you need to go further than this and ensure that the patient understands the items as they apply to their treatment. Our answer to whether consent is necessary started with a straightforward ‘Yes’, and now we have a legal opinion stating written consent is window dressing, and a philosophical argument stating informed consent is based on a legal fiction! In the MFDS and MJDF, it is best to keep things simple and state that the law of consent is not so clear-cut, but notwithstanding this, a patient’s autonomy must be respected at all times and that the yes offered from the patient does not constitute consent; there needs to be more than this. In the following example we shall deal with the problem we face when the patient says yes, but they really mean no. It is one thing to consent a patient for the loss of a tooth if a patient has been given all the options and after consideration of all the options (in clear precise terms) they opt for extraction. It is another matter if a patient is offered choices, but the information is given in a biased way. For example by stating: ‘We can simply and easily take your tooth out… or… ‘You can subject yourself to a complex multi-appointment endodontic-specialist-surgical procedure, either anterograde or retrograde, apically sealing and incarcerating residual bacteria then periapical radiography to confirm surgical outcome, the absence of periapical pathosis possibly involving referral to a hospital clinic to see an endodontic specialist!?’ In response to this technical tirade of biased jargon, the bewildered patient offers a weak and frightened: ‘No.’ You then extract the tooth, believing you have obtained consent. This is not consent, no matter how gentle your extraction will be or how implicit their ‘No’ was; this is battery and a trespass against the patient. The battery aspect has criminal overtones, and trespassing is a tort against the patient’s autonomy. In this example, there may also be a degree of negligence as there has been a departure
from accepted professional practice. With both yes and no answers, the standards and principles of obtaining valid consent have been clearly breached. Punitive sanctions can be levied in actions against a battery but not negligence as the level of damages awarded in those actions are proportional to the loss suffered. Another aspect to contend with in battery and negligence is involvement of the GDC. An investigation and public hearing on the proven facts might well determine that a registrant’s conduct is impaired. If it is, then sanctions are made, as stated in Part 1 of this question, not to punish the dentist, but to uphold the confidence the public have by protecting the reputation of the dental profession. 4 b. During the eighteenth-century Scottish Enlightenment, the philosopher and economist Adam Smith viewed laissez-faire as a moral programme of a free market. Natural law could be exercised by those seeking freedom from external influences. It was believed that external regulation limited one’s ability to grow, and so the full potential of a person or indeed a profession might not be realised. Although we no longer encourage paternalistic relationships (dentist knows best; patient puts up, if not, shuts up) we now have mutual relationships (shared responsibility) or consumerist relationships (where the patient orders the dentist to carry out treatment) or even default relationships (where no one takes responsibility).27,28 A true laissez-faire relationship in dentistry could work where the following principles are present: a. There is no outside interference from a regulatory body. b. A firm acceptance by the dentist that the patient has rights and freedoms that cannot be trespassed. c. At all times, the dentist and patient will operate in a harmonious relationship. So if the above are followed, in answer to the question: Yes, we can have laissez-faire in dentistry. Its application to dentistry does not mean either voiding a patient’s rights or avoiding consent. In this case, everything worked well, up to the point the patient felt their rights had been trespassed. The failure to consent, the failure to address the peri and post-operative concerns, and finally, the demand for payment, all breached the accords of laissez-faire. The system collapsed and predictably, external regulators became involved. Although laissez-faire is well established, if you want to apply it to dentistry, then you have to be avant-garde to do so. It is an economic concept, and so far, it has been restricted to culture, politics, and art, but not yet practised in dentistry (at least in the UK). In a recent publication, this method of patient care has been explored as a possible way of motivating patients’ behaviour towards better health.29 In the absence of any evidence suggesting the dental profession’s acceptance of laissez-faire, going down this route as an individual practitioner is a high-risk strategy, not in the best interests of your patient or yourself. In the early twentieth century, John Maynard Keynes was highly critical of laissez-faire, arguing that a free market was an inappropriate mechanism to govern any aspect of human life.30 As health care is an essential aspect of human life, we can deduce from Keynes that it must be regulated. In this case,
what started as an easy-going private approach to dentistry ended up as a very formal public conduct hearing at the GDC. 5. When faced with a GDC enquiry, there is ample time to consider the allegations and the remedies available. In the first instance, the patient’s costs should be refunded and the serious and significant breaches of professional practice need to be addressed by attending post-graduate courses to enable specific and appropriate continuing professional development. In this case, these shortcomings were failing to obtain consent and failing to record contemporaneous dental notes, especially the updating of the patient’s medical history. A substantive public hearing that seeks to demonstrate the dental profession in the UK will not accept these significant shortcomings in clinical practice as being acceptable. However, an ability to demonstrate insight, remorse, and remedy goes a long way towards indicating that there is no current impairment of a registrant’s fitness to practice. In the case on which Part 2 of this OSCE was based, in all the circumstances, despite expressing disapproval, the GDC committee members considered the dentist’s fitness to practice was not currently impaired. References to Part 2 1. Van Beek GC. Dental Morphology: An Illustrated Guide. Oxford: Wright Butterworth Heinemann 1993. 2. Tuverson DL. Orthodontic treatment using canines in place of missing maxillary incisors. Am J Orthod. 1970;58:109-27. 3. Bolton WA. Disharmony in tooth size and its relation to the analysis and treatment of malocclusion. Angle Ortodontist. 1958;28:113-30. 4. Hua F, He H, Ngan P, Bouzid W. Prevalence of peg-shaped maxillary permanent lateral incisors: a meta-analysis. Am J Orthod Dentofacial Orthop. 2013 Jul;144(1):97-109. 5. Brook AH. Dental anomalies of number form and size: their prevalence in British schoolchildren. J Int Assoc Dent Child. 1974;5:37-53. 6. Flores-Mir C. More women in Europe and Australia have dental agenesis than their counterparts in North America. Evid Based Dent. 2005;6(1):22-3. 7. Bukhary SMN, Gill DS, Tredwin CJ, Moles DR. The influence of varying maxillary lateral incisor dimension on perceived smile aesthetics. Br Dent J. 2007;203:687-93. 8. Lewis BR, Gahan MJ, Hodge TM, Moore D. The orthodontic-restorative interface: 2. Compensating for variations in tooth number and shape. Dent Update. 2010 Apr;37(3):138-52. 9. Savarrio L, McIntyre GT. To open or to close space-that is the missing lateral incisor question. Dent Update. 2005 Jan-Feb;32(1):16-25. 10. Wolff D, Kraus T, Schach C , et al. Recontouring teeth and closing diastemas with direct composite buildups: a clinical evaluation of survival and quality parameters. J Dent. 2010 Dec;38(12):1001-09. 11. Sharif MO, Catleugh M, Merry A, et al. Replacement versus repair of defective restorations in
adults: resin composite. Cochrane Database Syst Rev. 2010 Feb 17;(2):CD005971. 12. Land MF, Hopp CD. Survival rates of all-ceramic systems differ by clinical indication and fabrication method. J Evid Based Dent Pract. 2010 Mar;10(1):37-8. 13. Okuda Y, Noda M, Kono H, Miyamoto M, Sato H, Ban S. Radio-opacity of core materials for allceramic restorations. Dent Mater J. 2010 Jan;29(1):35-40. 14. Mizrahi B. All-ceramic silica/glass-based crowns-clinical protocols. Br Dent J. 2011 Sep 23;211(6):257-62. 15. Kern M, Sasse M, Wolfart S. Ten-year outcome of three-unit fixed dental prostheses made from monolithic lithium disilicate ceramic. J Am Dent Assoc. 2012 Mar;143(3):234-40. 16. Lang SA, Starr CB. Castable glass ceramics for veneer restorations. J Prosthet Dent. 1992 May;67(5):590-94. 17. Sasse M, Kern M. CAD/CAM single retainer zirconia-ceramic resin-bonded fixed dental prostheses: clinical outcome after 5 years. Int J Comput Dent. 2013;16(2):109-18. 18. Kern M, Sasse M. Ten-year survival of anterior all-ceramic resin-bonded fixed dental prostheses. J Adhes Dent. 2011 Oct;13(5):407-10. 19. Herring J. Chapter 4: Consent to Treatment. In Medical Law and Ethics. 4th Edition pp. 154-155. Oxford: Oxford University Press 2012. 20. Kennedy I, Grubb A. Kennedy and Grub Medical Law. 3rd Edition. London: Butterworths 2000. 21. General Dental Council. Principle 3: Obtain Valid Consent in Standards for the Dental Team 2013 pp. 26-33. London: GDC 2013. 22. Collard J. Secretary to the Standards Review Working Group. Personal Communication. 20 August 2013. 23. Lewis C, Buchan A. Chapter 11: Wrongful Birth. In Lewis and Buchan. Clinical Negligence: A Practical Guide (Value of Claim). pp. 280-286. London: Bloomsbury Professional 2012. Taylor v. Shropshire Health Authority (1998) Lloyd’s Rep. Med. 395. 24. Department of Health. Section 1: Introduction p. 9. In Good Practice in Consent Implementation Guide: Consent to Examination or Treatment. [Online archive] Available from: http://webarchive.nationalarchives.gov.uk /20130107105354/http://www.dh. gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4019061.pdf [Accessed August 2013]. 25. Epstein M. Why effective consent presupposes autonomous authorisation: a counterorthodox argument. J Med Ethics. 2006 Jun;32(6):342-45. 26. GMC. Consent Guidance: Patients and Doctors Making Decisions Together. [Online] Available from: http://www.gmcuk.org/static/documents/content/GMC_Consent_0513_Revised.pdf [Accessed July 2013].
27. Morgan M. Chapter 4: The Doctor-Patient Relationship. In Scambler G. Sociology as Applied to Medicine. 6th Edition pp. 50-63. Philadelphia: Saunders Elsevier 2008. [Online] Available from: http://faculty.ksu.edu.sa/nadalyousefi/communication_skills/The_Doctor%E2%80%93Patient.pdf [Accessed July 2013]. 28. Charles C, Whelan T, Gafni A. What do we mean by partnership in making decisions about treatment? BMJ. 1999 Sep 18;319(7212):780-82. 29. Huynh HP, Sweeny K. Clinician styles of care: transforming patient care at the intersection of leadership and medicine. J Health Psychol. 2013 Jul 17. 30. Barnett V. Chapter 9: The Fool’s Gold Standard and Laissez Faire. In John Maynard Keynes. pp. 127-147. Oxford: Routledge 2013. Further Reading 1. Fekonja A. Hypodontia in orthodontically treated children. Eur J Orthod. 2005;27(5):457-60. 2. Gahan MJ, Lewis BR, Moore D, Hodge TM. The orthodontic-restorative interface: 1. Patient assessment. Dent Update. 2010 Mar;37(2):74-6, 78-80. 3. Lewis BR, Gahan MJ, Hodge TM, Moore D. The orthodontic-restorative interface: 2. Compensating for variations in tooth number and shape. Dent Update. 2010 Apr;37(3):138-40. 4. Shah P. Optimizing esthetics and function through interdisciplinary dentistry. Gen Dent. 2008 May;56(3):268-72. 5. Craigie J. Competence practical rationality and what a patient values. Bioethics. 2011;25:326. That concludes this case, this chapter and the book. Almost…
The End… (of the Beginning) In the introduction to this case, I mentioned my search for exceptional members of our profession but instead, ended up writing a book, finishing up at the GDC with two conduct cases to reflect on. A lot can happen in a year. Rather than ending this book with a tale of two dentists at the GDC, the following account from the history of our profession is a more appropriate way to begin your career. Nearly 80 years after she qualified, the story of Miss Beryl Murray Davies is remarkable. Her values are as necessary today, as her skills and courage were needed 80 years ago. The search uncovering her life took me from the BDA library and GDC register in Wimpole Street to the National Archives in Kew, the Imperial War Museum in Lambeth, and from there to a quiet corner of a disused airfield in Bedfordshire. Beryl Murray Davies, of Scottish descent, was quite short in stature with a firm temperament. She qualified LDS RCS England in 1933 and registered with the GDC Number 23668 on 1 January 1934. After moving around in the early stages of her career, by 1943, she was working in 77 Harley Street for a South African dentist. Upon hearing that she had been approached by the Special Operations
Executive (SOE), her practice principal who had previously turned down the opportunity to work for the SOE himself, expressed considerable displeasure at Beryl’s enthusiasm for the task. Later on Beryl would professionally outgrow her principal. Towering over her, he threatened her with being blackballed and run out of the dental profession if she even considered leaving him or setting up on her own. Beryl’s god-daughter, Michelle Berriedale Johnson, revealed that Beryl told her principal where to go, packed her bags, and after working for the SOE, established a successful practice in London’s West End with many prominent patients. To this day, from 1943 to the end of World War II almost all of Beryl’s work with the SOE remains shrouded in secrecy. We know she was responsible for the dental care of several SOE agents. This work involved using restorative techniques and materials found in Europe, rather than England. More intriguing than this was the dental work to place potassium cyanide pellets inside prosthetic teeth, which an SOE agent might use to commit suicide rather than be tortured and reveal secrets. Despite searching for over one year, the trail for Beryl Murray Davies and the SOE runs cold at Tempsford Airfield, Bedfordshire. When you visit, you will see a wheat field with a memorial at the Gibraltar Barn for the SOE agents who volunteered to be flown from there into occupied Europe. As we know today, many never returned. In contrast to the obscurity of Beryl’s work, the 1948 War Crimes Deposition of Dr Martin Karl Hellinger is chilling in its clarity. Hellinger qualified as a dentist in 1927 from Leipzig, joining the SS in 1939. From spring 1943 to April 1945 as a hauptsturmfuhrer of the Waffen SS, Hellinger willingly participated in the systematic mistreatment and brutality against prisoners in the Ravensbruck Concentration Camp. Among those tortured and murdered there were four SOE agents: Denise Bloch, Lilian Rolfe, Cecily MacKenzie-Lefort, and Violette Szabo G.C. From what we now know, it is most likely that these SOE agents were previously Beryl Murray Davies’s dental patients. Hellinger admitted to the war crime of taking gold teeth from prisoners murdered in Ravensbruck. He received a 15-year prison sentence and was released early on 14 May 1955. Between the obstinate good of Beryl Murray Davies and obedient evil of Martin Karl Hellinger is a clear line where the words of Eliezer Yudkowsky live: ‘Many stand their ground and face the darkness when it comes for them. Fewer come for the darkness and force it to face them.’ At the age of 102, on 2 January 2012, Beryl Murray Davies went to her rest, her work with the SOE unrecognised by our profession. Bequeathing a legacy to the Faculty of Dental Surgery Royal College of Surgeons of England, Beryl’s last wishes were that she might in some way assist young dentists in advancing their careers. The choices facing dentists today will never again be as extreme as those faced by Beryl Murray Davies and her generation. Despite the burden of increasing regulation, we still have considerable freedoms, and with our profession and freedom, we can make choices for ourselves and for our patients.
I hope the cases and examples of clinical care throughout this book help you to decide how to make the very best choices for your profession and the patients you will look after. Good luck with both.
Essential reading for Beryl Murray Davies. 1. Marks L. Between Silk and Cyanide: A Codemaker’s War, 1941-1945. pp. 507-508. London and New York: Harper Collins 1998. 2. Helm S. A Life in Secrets: Vera Atkins and the Lost Agents of the SOE. London: Little, Brown 2005. 3. American Academy of the History of Dentistry. Jnl. Hist. Dent. 2005; 53-54:11-2.
