1. Any possible cause, shape, size, colour, definition of periphery, consistency, tenderness, attachment to deeper structures, pulsation, associated lymph nodes. It is certain to be warm if in the mouth.

2. A list of possible diagnoses in order of probability, used when multiple diagnoses may explain the signs and symptoms. It is used to guide the choice of special tests, which eventually eliminate diagnoses from the list.

1. Before undergoing a general anaesthetic the patient must take no food for several hours. The timing of food for the insulin-dependent diabetic is critical and omitting food means omitting insulin. It is usual to convert the patient onto soluble insulin and give glucose by intravenous infusion, matching the blood glucose level to the amount of insulin by a ‘sliding scale’. This is easier to monitor on an inpatient basis.

2. General anaesthesia always carries a small risk of mortality. The risk is increased for this patient because she is overweight for her height (BMI = 42). If it is possible to deal with her problem with local anaesthesia (with or without sedation) that risk can be reduced dramatically. If not, she would have to undergo the general anaesthetic as an inpatient.

3. Gauze or other material can be placed over the back of the tongue, suction can be maintained throughout, the volume of irrigant can be kept to that which is required to cool the bur, the patient is not laid absolutely flat.

4. The patient should not drive, operate machinery, cook, look after small children, make important decisions or do anything else that requires careful use of the hands or brain. The advice should be given when the appointment is booked, just before the procedure and after it, to the escort.

5. First thoughts might go to oral or inhalational sedation, but it is worth noting that for some individuals with a ‘needle phobia’, the concern is primarily with needles used inside the mouth rather than in the hand and I.V. sedation may still be appropriate. General anaesthesia should be later in your list.

6. An antiinflammatory drug such as ibuprofen may be your first choice, but paracetamol is also effective, as are combination drugs.

1. The buccal beak has a point (to fit in the furcation) separating two concavities (to fit around the two buccal roots). The palatal beak has a single broader concavity. The handles have curves in two directions. When seen from the side the handles curve from the vertical beaks forward out of the mouth then down again towards the handle end. Both handles curve to the right when seen from the operator’s perspective. Note: many dentists use the upper premolar (root) forceps for upper molars. For these, the beaks each have a single concavity but the handles curve as for the full molar forceps.

2. Straighten the wrist, remove index finger from between handles, move the end of the handle into the palm of the hand and, possibly, place the little finger between the handles (see Fig. 4.12).

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4. Buccally until it just moves, then palatally till it just moves, then a little more each way, eventually wriggling the tooth down through the socket.

5. Limited access due to reduced mouth opening, small or tight oral entrance (e.g. burn scars), large alveolus, large tooth, severe tooth surface loss, extensive caries.

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1. Diagnosis: pain, trismus, increased temperature, red inflamed operculum overlying 8, regional lymphadenopathy. Treatment: extract upper 8 if traumatizing operculum of lower, antibiotics (if systemic involvement), analgesics, improve oral hygiene (e.g. chlorhexidine mouthwashes), irrigate operculum with antiseptic (e.g. chlorhexidine).

2. Recurrent infection (e.g. pericoronitis). Unrestorable caries in third molar or distal aspect of second. Periodontal disease affecting the distal aspect of 7. Cysts or tumours affecting 8. External/internal resorption.

3. Resorption of adjacent teeth, pathological change around the unerupted crown, caries or periodontal disease if this area is not cleaned properly, recurrent pericoronitis.

4. Your surgical skills and technical back-up, a patient who refuses local anaesthesia, at the patient’s request or for a patient who is very anxious, if the operation would take longer than 30 minutes, complication within medical history.

5. Pain, swelling, bruising, trismus, possible para/anaesthesia of lip and tongue (including the possibility of permanent loss of sensation), interference with diet.

6. Diversion of inferior dental canal, darkening of the root where crossed by the canal, interruption of the white line of the canal.

7. The depth of impaction (i.e. the vertical distance from the occlusal surface of the second molar to that of the third molar), angulation, the distance between the second molar and ramus compared to the width of the third molar crown.

8. Sectioning the nerve by extending the distal relieving incision directly backwards, ‘bruising’ the nerve by trapping it between the retractor and bone, stretching the nerve during retraction (if lingual flap is raised), drilling through the lingual plate, suture passing through the nerve.

9. For: infection present (e.g. systemic involvement) or risk of infection significant (e.g. prolonged surgery), prevention of infective endocarditis in ‘at-risk’ patients, compromised host defence (i.e. significant medical history). Against: may encourage lax surgery, potential risk of allergy, unnecessary in the vast number of cases—good local hygiene is more important.

10. Dry socket: irrigate with warm saline or chlorhexidine; place a sedative dressing. Infected wound: if systemic involvement or regional lymphadenopathy, prescribe antibiotics. Trismus: usually resolves after a couple of weeks. Inferior dental or lingual nerve injury: review. Damage usually improves (up to 10% may have dysaesthesia at one week; this has reduced to < 1% by 1 year). Prolonged loss of fungiform papillae associated with poor prognosis. If no significant sensibility at 4–6 weeks, consider nerve repair.

11. Ensure you discuss with the patient the risks and benefits of the operation, and that these are recorded in the patient’s notes. Ideally, your dental nurse should act as a witness. Provide the patient with an information leaflet. Consider obtaining written consent in which the likely risks are outlined.

12. Distal relieving incision should be up the external oblique ridge, in a distobuccal direction, remaining on bone at all times. A common error by those inexperienced is to extend the incision distal to the 2nd molar in the direction of the midline of the molar teeth. This risks running off the bone, into the lingual nerve and causing troublesome bleeding. The anterior relieving incision for a triangular flap should include the papilla distal to the lower 2nd molar and then curve down gently in an anterior direction. This allows the flap to rest on bone after removal of bone and tooth, ensuring adequate blood supply to the flap with minimal disruption to the gingiva of the lower 2nd molar. Beware of extending the incision too far into the sulcus as this risks cutting an arteriolar branch of the facial artery. The incision should be through the periosteum to the bone and thus in the correct tissue plane such that on raising the flap bone rather than bleeding periosteum is visible.

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2. It generally gives good access allowing the margin to be replaced on bone and is easy to reposition. However, sometimes, particularly on very convex surfaces, access may be better with a three-sided flap. The risk of recession at the gingival margin seems to be greater than for a semilunar flap.

3. The wound may be packed to control haemorrage, specifically to keep the operative field as dry as possible. Packing also prevents filling material being spilled into the bone. Ribbon gauze, an alginate swab or bone wax may all be used.

4. Ongoing or developing pain, tenderness, swelling or discharge. Do not expect any radiographic change and so do not take a radiograph at this stage.

5. A radiograph should be taken shortly after the procedure (on the same day or within 2 weeks) as a baseline against which to measure future change and to confirm that the procedure appears to have been completed satisfactorily. There is no value in taking another radiograph until 6 months, the earliest time at which complete bone repair might be found. If that has not occurred, further radiographs at 6-month intervals for up to 2 years may help to clarify the outcome. Complete bone repair is the most reliable sign of success, but progressive reduction in the size of an apical radiolucency over 12 months may be consistent with elimination of infection. Remember that in large bone cavities some healing with scar tissue occurs; this does not show as bone on the radiograph.

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5. Should be a representative sample of the mass; must include some normal tissue; should be deep enough to include a substantial zone of connective tissue; should be wide enough to permit a number of complete sections to be made after processing; should be amenable to closure.

6. Plain radiographs, aspiration, angiography. Do not take an incisional biopsy!

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3. Slow growth over years; periodic associated infection; smooth, rounded surface, either bony hard or clearly fluctuant; normal function in adjacent tissues.

4. Displacement of teeth; mobility of teeth; pathological fracture (but this is more commonly associated with tumours and osteomyelitis); non-vital tooth (but remember that most non-vital teeth do not have associated cysts).

5. Treatment involves making a window in the cyst and keeping that open while the cyst shrinks away from the teeth and nerve. Initially the wound will be packed open, then a bung will be made to seal the opening. Treatment may take up to 2 years and there will be a number of visits in that time. It may be necessary to operate later to remove the residual tissue.

1. Tobacco use (smoking or chewing) and alcohol consumption.

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4. Regular 6-month monitoring for life; early attention to all new caries or periodontal disease; continuing use of fluoride mouthwash indefinitely; urgent referral of patient if any suspicion of recurrence or new cancer; absolute avoidance of dental extractions or surgery in patients who have received radiotherapy.

5. Surgery: destruction of complicated structures, need for reconstruction, lengthy operation and hospital stay.

1. Where a discrepancy in the height, width or regularity of the denture-bearing area, or discrepancy in arch sizes renders conventional prosthodontics unsatisfactory.

2. Reposition displaced alveolar bone, trim sharp bone edges, minimize bone loss during surgical removal of teeth, alveoplasty (particularly if there is a considerable bony undercut).

3. Endosseous implants (literally within the bone) are usually covered by mucosa for a period of months awaiting osseointegration and subsequent uncovering and loading. Subperiosteal implants consist of a metal frame inserted as an onlay directly on to the surface of cortical bone with abutments protruding through the mucosa. The frame is fabricated from impressions of the exposed surface of the jaw. Wound dehiscence and infection are common problems. Transosseous implants extend all the way through the bone and may be indicated for a severely atrophic mandible in which endosseous implants are contraindicated.

4. Biocompatibility of the implant material, design of the implant, surface characteristics, physical health of the patient, anatomical conditions, patient’s cooperation, oral hygiene status and smoking habits; operator experience; loading of the implants after osseointegration.

5. Use only sharp drill bits; run the drill slowly, with little pressure, applied intermittently and with thorough cooling using saline; increase the drill size progressively; insert the implant slowly.

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6. (a, b) Repair of the lip at 4–6 months; repair of the palate by the first birthday; alveolar bone grafting as needed aged 8–9; orthognathic surgery aged 16–18 as needed.

1. Assess the airway, bleeding problems and the level of consciousness. Manage bleeding with pressure (such as with gauze or by bringing fracture ends together with a ligature around the adjacent teeth). Clean and suture soft tissue injuries. Seek any further injuries, take radiographs and refer if appropriate.

2. Abrasions, lacerations, haemorrhage, haematoma, swelling may all overlie sites of fracture. Reluctance to use muscles that move the jaw (guarding), deviation on jaw movement, bone deformity, displacement of the eye or abnormality of eye movement may be signs of fractures.

3. Fixation is the process in which the bone ends on either side of a fracture are prevented from moving relative to each other, after they have been repositioned (reduced). Often fixation is achieved with ‘mini-plates’.

4. Assess. If the injury needs to be treated under general anaesthesia, refer to hospital. If not, give local anaesthetic, examine, thoroughly clean, remove necrotic tissue only, close in layers: vermilion, then muscle, mucosa and skin.

5. Enquire about sleep disturbance, jumpiness and flashbacks. If you suspect PTSD, refer the patient to her family practitioner or, with the patient’s consent, consult a clinical psychologist or a voluntary organization such as Victim Support or Women’s Aid.

1. Recent contact with mumps; swelling anatomically in the parotid(s); pain worsens on eating and drinking; lack of suppuration; reduced salivary flow usually bilateral.

2. Such a symptomless lump is most likely to be a stone. Plain radiographs (OPT and lower occlusal) should demonstrate it. If no stone is demonstrated, consider a neoplasm (benign or malignant) and arrange a CT or MRI.

3. Organic: Sjögren’s syndrome, benign lymphoepithelial lesion; radiation damage; sarcoidosis; HIV infection.

Functional: depression; dehydration; drugs (such as antidepressants).

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4. Signs and symptoms of acute sinusitis: history of recent URTI (or extraction with OAC formation, recent introduction of foreign body into antrum or other trauma to antrum); headache and pain over affected antrum and in premolars and molars of affected side, tenderness in buccal sulcus over anterior antral wall. The pain is typically throbbing, dull and heavy in character and worse when head is inclined forwards, but is not affected by temperature or sweet stimuli. Purulent nasal discharge and/or postnasal drip may be present. A radiograph will show mucosal thickening and, perhaps, a fluid level due to a collection of pus, but radiography is not usually necessary. Chronic sinusitis usually follows acute sinusitis, may persist or recur over a prolonged period of time, but is largely asymptomatic between acute attacks.

5. Signs and symptoms of a malignant antral tumour depend on the direction of tumour spread. They include pain in maxilla; nasal obstruction; nasal discharge; swelling and/or ulceration in buccal sulcus, palate or extraorally over the maxilla; redness of skin over the maxilla; mobility of teeth adjacent to the antrum; herniation of tumour through an extraction socket; excessive postextraction bleeding; epistaxis; paraesthesia in the distribution of the infraorbital nerve; diplopia; raised pupillary level; proptosis; trismus. Action: Refer immediately to ENT or oral and maxillofacial surgeon. Stress that an urgent appointment is required.

1. Any four of: location to masticatory muscles or preauricular region, duration of onset and persistence of the pain, association with jaw movement rather than chewing, often bilateral, relation to time of day, lack of a ‘dental’ cause, tenderness of muscles.

2. Any two of: specific location of pain to preauricular area, tenderness of TMJ itself, limitation of lateral excursive movement.

3. Disc displacement without reduction usually results in restriction of mouth opening that is of sudden onset; if eased it also releases suddenly; there is no significant variation in opening with time; there is a history of clicking; it is not possible to extend opening with finger pressure; on imaging the disc with MRI or arthrography the disc is seen to remain forwards of the condyle throughout the range of movement.

4. Surgery should be considered if the patient is suffering from the disorder, if conservative treatments have been unsuccessful, if it is unlikely that symptoms will subside spontaneously in a reasonable time.

5. They are common clinical features of degenerative joint disease, but on their own they do not exclude the rarer systemic inflammatory arthropathies.

6. Advice should include the benign nature of the condition, local heat, resting the jaw muscles as much as possible, avoiding daytime clenching, the use of regular analgesics (NSAIDs if tolerable).

Treatment is likely to include an appliance, such as a soft bite guard, but physiotherapy should be considered and antidepressants can be used.

7. Features include prolonged pain (months to years), limited (or no) response to treatment, few features typical of dental pains (e.g. thermal stimuli), allodynia or hyperalgesia, history of repeated dry socket and poor healing after extraction, tendency of the pain to migrate, decreasing confidence of the patient in dental (and medical) advice.

8. Trigeminal neuralgia should exhibit sudden onset of short periods of intense pain with pain-free periods (or much reduced pain), a trigger zone, precise location within a division of the trigeminal nerve, responsiveness to carbamazepine, patient not woken by pain.

9. General dental treatment planning for those with atypical facial pain should include irreversible treatments only when they are justified for demonstrable dental disease. Patients should be counselled in advance that that line will be taken, but that justified treatment will be offered as normal.

1. Disc displacement with reduction. If the patient is not concerned she should merely be reassured. Conservative treatments may be tried, but surgery is hard to justify in the absence of symptoms.

2. Myofascial pain dysfunction. There is no place for surgery in this condition.

3. Disc displacement without reduction. Surgery may be considered, although it is not essential. Note that as many as 50% of patients may become symptom-free within 2 years, and many of the remainder will see an improvement in symptoms, without surgical treatment. Closed manipulation with or without arthrocentesis may work well, or an open procedure might be considered. In either event, many surgeons would investigate further to confirm (or otherwise) the diagnosis.

4. MRI or arthrography to determine disc position and mobility.

5. Often an imaginary line is drawn from the point of the tragus to the outer canthus of the eye. A point is marked 10 mm forwards along that line and 2 mm below it. With the mouth open, the line of approach to the joint from there is upwards, forwards and inwards.

6. Auriculotemporal and both zygomatic and temporal branches of the facial nerve.

7. The mouth will be held closed for about a minute after the dislocation. Patient should be careful to restrict mouth opening for at least 24 hours and great care taken in activities such as yawning, laughing and biting not to open the mouth more than absolutely essential.

1. He would be grade 3 because of multiple diseases and a complex drug regimen which would affect management. He is still not out of the period where further infarcts are likely. The vein grafts to his coronary system will not have healed and his myocardium will still not yet be well perfused. There is little capacity for his heart to respond to a demand for extra work. In addition the warfarin does increase the likelihood of bleeding following extraction. If the grafting is successful, his exercise tolerance will improve and provided he has no other risk factors for venous thrombosis, he will be taken off warfarin (although he is likely to remain on aspirin). If everything goes well he will be much better able to tolerate stressful surgery in 6 months time.

2. Firstly ask what type of epilepsy the patient suffers, the frequency of seizures, whether hospital admission has ever been required for persistent seizures, whether there are any precipitating factors such as stress and whether they get any warning or ‘aura’. Ensure that you and your team are aware of how to manage epileptic fits and that oxygen and suction are always available. Make sure the patient knows they are to take their normal medication prior to the visit. There is no requirement to change your choice of local anesthetic drugs, but sedation can reduce the likelihood of fitting in less well-controlled individuals.