Associate Lecturer, Faculty of Medicine, University of Queensland
Registrar Oral and Maxillofacial Surgery
Queensland, Australia
1
Great Clarendon Street, Oxford, OX2 6DP, United Kingdom
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Series editor preface
The Oxford Assess and Progress series is a groundbreaking development in the extensive area of self-assessment texts available for dental and medical students. The questions were specifically commissioned for the series, written by practising clinicians, extensively peer-reviewed by students and their teachers, and quality-assured to ensure that the material is up-to-date, accurate, and in line with modern testing formats.
The series has a number of unique features and is designed to be as much a formative learning resource as a self-assessment one. The questions are constructed to test the same clinical problem-solving skills that we use as practising clinicians, rather than only to test theoretical knowledge. These skills include:
● gathering and using data required for clinical judgement
● choosing the appropriate examination and investigations
● appl ying knowledge and interpreting findings
● demonstrating diagnostic skills
● ability to evaluate undifferentiated material
● ability to prioritize
● making decisions and demonstrating a structured approach to decision-making.
Each question is bedded in reality and is typically presented as a clinical scenario, the content of which has been chosen to reflect the common and important conditions that most dentists and doctors are likely to encounter both during their training and in exams! The aim of the series is to build the reader’s confidence in recognizing important symptoms and signs and suggesting the most appropriate investigations and management, and, in so doing, to aid the development of a clear approach to patient management which can be transferred to the clinical environment.
The content of the series has deliberately been pinned to the relevant Oxford Handbook but, in addition, has been guided by a blueprint which reflects the themes identified in the General Dental Council’s Preparing for practice—Dental teams learning outcomes for registration, including an evidence-based approach to learning, along with clinical, managerial, and professionalism scenarios.
Particular attention has been paid to giving learning points and constructive feedback on each question, using clear fact- or evidencebased explanations as to why the correct response is right and why the incorrect responses are less appropriate. The question editorials are clearly referenced to the relevant sections of the accompanying Oxford Handbook and/or more widely to medical literature or guidelines. They are designed to guide and motivate the reader, being multi-purpose in nature and covering, e.g. exam technique, approaches to difficult subjects, and links between subjects.
Another unique aspect of the series is the element of competency progression from being a relatively inexperienced student to being a more experienced junior dentist. We have suggested the following four degrees of difficulty to reflect the level of training, so that the reader can monitor their own progress over time:
● g raduate should know ★
● g raduate nice to know ★★
● foundation dentist should know ★★★
● foundation dentist nice to know ★★★★
We advise the reader to attempt the questions in blocks as a way of testing their knowledge in a clinical context. The series can be treated as a dress rehearsal for life as a clinician by using the material to hone clinical acumen and build confidence by encouraging a clear, consistent, and rational approach, proficiency in recognizing and evaluating symptoms and signs, making a rational differential diagnosis, and suggesting appropriate investigations and management.
Adopting such an approach can aid not only success in examinations, which really are designed to confirm learning, but also—more importantly—being a good dentist and doctor. In this way, we can deliver high-quality and safe patient care by recognizing, understanding, and treating common problems, but at the same time remaining alert to the possibility of less likely, but potentially catastrophic, conditions.
David Sales and Kathy Boursicot Series Editors
A note on single best answer questions
Single best answer questions are currently the format of choice being widely used by most undergraduate and postgraduate knowledge tests, and therefore, the questions in this book follow this format.
Single best answer questions have many advantages over other machine-markable formats, such as extended matching questions (EMQs), notably the breadth of sampling or content coverage that they afford.
Briefly, the single best answer or ‘best of five’ question presents a problem, usually a clinical scenario, before presenting the question itself and a list of five options. These consist of one correct answer and four incorrect options, or ‘distractors’, from which the reader has to choose a response.
All of the questions in this book, which are typically based on an evaluation of symptoms, signs, results of investigations, or material interactions, either as single entities or in combination, are designed to test reasoning skills, rather than straightforward recall of facts, and utilize cognitive processes similar to those used in clinical practice.
The peer-reviewed questions are written and edited in accordance with contemporary best assessment practice, and their content has been guided by a blueprint pinned to all areas of the General Dental Council’s document Preparing for practice—Dental teams learning outcomes for registration, which ensures comprehensive coverage.
The answers and their rationales are evidence-based and have been reviewed to ensure that they are absolutely correct. Incorrect options are selected as being plausible, and indeed they may appear correct to the less knowledgeable reader. When answering questions, the reader may wish to use the ‘cover’ test, in which they read the scenario and the question but cover the options.
Kathy Boursicot and David Sales Series Editors
Author preface
Dental school can be a challenging and emotional time. The breadth of experiences gained both professionally and socially cannot be rivalled, and in hindsight, most come to look upon their time at university as a thoroughly enjoyable experience. Needless to say, preparing for the multitude of examinations and assessments throughout the programme is never a favourite pastime, but a necessary evil nonetheless. Whether it is the prospect of finals or postgraduate examinations on the horizon, we remember the constant pressure to read and revise only too well. Our own experiences frequently involved discussing a range of possible questions which lacked informative answers. This led us to the Oxford Assess and Progress Series and to the production of this book.
The Oxford Handbook of Clinical Dentistry (OHCD) was never far from reach during dental school, and within this book, we have attempted to provide a series of single best answer questions that link the OHCD with real-life practical scenarios to test reasoning and application of knowledge. Where possible, recommended reading and references to seminal papers have been provided to encourage further reading and to support evidence-based practice. Within the book, we have selected Keywords, where relevant, to help highlight specific clues or words that can assist with recall in those high-pressure situations. All questions have been written and peer-reviewed by clinicians working within each specialty, and we have endeavoured to provide in-depth justification for correct and incorrect answers. Undoubtedly, some topics will remain contentious, but, where necessary, we have explained our reasoning and hope that this highlights the ‘grey’ areas in many dental scenarios. Chapters are formatted by specialty, and we have attempted to maintain a clear focus on clinically oriented scenarios that will be beneficial for finals and beyond. A selection of questions on ‘Law and ethics’ have been written and combined into the clinical specialty for which they are relevant.
As previously mentioned, we started this book with the hope of providing an informative and supportive revision tool that encourages further reading and evidence-based practice. Looking back, we all remember dental school with fond memories, and we hope that you find this book useful and wish you the very best for your finals and future careers beyond.
Nicholas Longridge, Peter Clarke, Raheel Aftab, and Tariq Ali
Acknowledgements
The authors would like to thank all of the contributors for their hard work in producing the content for this book. Special thanks must go to the authors of the Oxford Handbook of Clinical Dentistry David and Laura Mitchell, for allowing us to use their excellent book as a guiding framework and revision source. We would like to thank all reviewers students and specialists for their detailed feedback and discussion points, which we hope to have reflected in the final book. We are also indebted to Geraldine Jeffers and Rachel Goldsworthy at Oxford University Press for their support, guidance, and patience throughout the entire project. Nick would like to thank his wife, Sarah, and his parents for their endless support. Peter would like to thank his wife, Tess, for her patience and understanding throughout the process. Tariq would like to thank his family, friends, and colleagues for their constant support throughout his career. Raheel would also like to thank his family. All four authors would like to dedicate the book to their good friend Andy Jones, who was taken from this world too soon and sadly passed away in 207.
Publisher’s acknowledgement
Thank you to the 27 dental lecturers and clinicians who participated in our anonymous peer-review process and kindly gave their time to this project.
Thank you to Dr Karolin Hijazi, Clinical Lecturer in Oral Medicine, University of Aberdeen Dental School, who reviewed the oral medicine chapter.
Thank you to Professor Balvinder Khambay, School of Dentistry, University of Birmingham, and Mr P J Turner, Consultant Orthodontist, Birmingham School of Dentistry, who reviewed the orthodontic chapter. Thank you to David and Laura Mitchell who gave their kind permission for the reuse of a table and figure from the Oxford Handbook of Clinical Dentistry.
Contributors
Abbreviations
How
About the authors
Nicholas Longridge is an Academic Clinical Fellow/Specialty Trainee in Endodontics at Liverpool University Dental Hospital. Alongside his specialist training, Nicholas is completing a 3-year Doctorate in Dental Sciences (DDSc) in Endodontics. His current research interests are in regenerative endodontics and pulp biology. Prior to commencing his specialist training, Nicholas worked as a dental core trainee in a variety of hospital settings across different specialties. He is a member of the Royal College of Surgeons of Edinburgh and has a Bachelor of Science degree in Anatomy and Human Biology.
Peter Clarke is a Specialty Registrar in Restorative Dentistry at the University Dental Hospital of Manchester. Having completed his undergraduate training, he proceeded to undertake a number of core training jobs, covering a variety of disciplines. Having been involved at various levels in undergraduate teaching and examining throughout his career, he now plays an active role in coordinating the regional teaching programme for dental core trainees.
Raheel Aftab is a general dental practitioner working within a multidisciplinary dental team in Kent. Following his undergraduate training, Raheel passed the Membership of Joint Dental Faculties from the Royal Colleague of Surgeons England examinations and soon after completed a Postgraduate Certificate in Primary Dental Care from the University of Kent. He is currently undergoing further training at King’s College London in fixed and removable prosthodontics. Alongside his clinical duties, Raheel is an Educational Supervisor for Health Education London and Kent, Surrey, and Sussex. Raheel takes a particular interest in digital dentistry, incorporating digital workflow and CAD/CAM as part of routine dental care for his patients.
Tariq Ali is a dual-qualified Oral and Maxillofacial Surgery Registrar currently working in Queensland, Australia. He undertook both his undergraduate degrees in the United Kingdom, having first completed Medicine at the University of Birmingham and later completing Dentistry at the University of Liverpool. He has worked in a broad range of surgical specialties and emergency medicine, having completed his memberships in Dentistry, Surgery, and Emergency Medicine. Tariq has also completed his Diploma in Head and Neck Surgery at the Royal College of Surgeons England, a prerequisite to otorhinolaryngology training. He now plays an active role in clinical teaching for medical and dental students at the University of Queenland.
Series editors
Katharine Boursicot
BSc MBBS MRCOG
MAHPE NTF SFHEA FRSM is a consultant in health professions education, with special expertise in assessment. Previously, she was Head of Assessment at St George’s, University of London, Barts and the London School of Medicine and Dentistry, and Associate Dean for Assessment at Cambridge University School of Clinical Medicine. She is consultant on assessment to several UK medical schools, medical Royal Colleges, and international institutions, as well as an assessment advisor to the General Medical Council.
David Sales trained as a general practitioner and has been involved in medical assessment for 30 years. Previously he was the convenor of the MRCGP knowledge test, chair of the Professional and Linguistics Assessment Board (PLAB) Part panel, and consultant to the General Medical Council Fitness to Practise knowledge tests across all medical and surgical specialties. He has run item writing workshops for a number of undergraduate medical schools, medical royal colleges including the Diploma of Membership of the Faculty of Dental Surgery (MFDS) and internationally in Europe, South East Asia, South Asia, and South Africa.
Contributors
Nadia M Ahmed
Specialist Orthodontist
Kettering General Hospital Northamptonshire, UK
Gurpreet Singh Jutley
Rheumatologist
University Hospital Birmingham West Midlands, UK
Thomas Albert Park
Clinical Dental Officer
Pennine Care NHS Foundation Trust
Greater Manchester, UK
Normal and average values
Haematology: reference intervals
Measurement Reference
White cell count (WCC)
Red cell count
4.0–.0 × 09/L
M: 4.5–6.5 × 02/L; F: 3.9–5.6 × 02/L
Haemoglobin M: 3.5–8.0 g/dL; F: .5–6.0 g/dL
Packed red cell volume (PCV) or haematocrit M: 0.4–0.54 I/L; F: 0.37–0.47 I/L
Mean cell volume (MCV)
76–96 fL
Mean cell haemoglobin (MCH) 27–32 pg
Mean cell haemoglobin concentration (MCHC) 30–36 g/dL
Neutrophil count
Lymphocyte count
Eosinophil count
Basophil count
Monocyte count
2.0–7.5 × 09/L; 40–75% WCC
.3–3.5 × 09/L; 20–45% WCC
0.04–0.44 × 09/L; –6% WCC
0.0–0. × 09/L; 0–% WCC
0.2–0.8 × 09/L; 2–0% WCC
Platelet count 50–400 × 09/L
Reticulocyte count 25–00 × 09/L; 0.8–2.0%
Erythrocyte sedimentation rate <20 mm/hour (but depends on age; see OHCM 0th edn, p. 372)
Activated partial thromboplastin time (VIII, IX, XI, XII) 35–45 seconds
Prothrombin time 0–4 seconds
International normalized ratio (INR)
2.0–3.0
2.5–3.5
3.0–4.5
Clinical state (see OHCM 0th edn, p. 35)
Treatment of deep vein thrombosis (DVT), pulmonary emboli (treat for 3–6 months)
Embolism prophylaxis in atrial fibrillation (see OHCM, p. 335)
Recurrent DVT and pulmonary embolism; arterial disease, including myocardial infarction; arterial grafts; cardiac prosthetic valves (if caged ball, aim for 4–4.9) and grafts
Biochemistry
Alanine aminotransferase (ALT) 5–35 IU/L
Albumin
Alkaline phosphatase (ALP)
Amylase
35–50 g/L
30–50 IU/L
0–80 U/dL
Aspartate aminotransferase (AST) 5–35 IU/L
Bilirubin
Calcium (total)
Chloride
Cortisol
C-reactive protein (CRP)
Creatine kinase
Creatinine
3–7 μmol/L
2.2–2.65 mmol/L
95–05 mmol/L
450–750 nmol/L (a.m.)
80–280 nmol/L (midnight)
<0 mg/L
M: 25–95 IU/L
F: 25–70 IU/L
70–<50 μmol/L
Normal value
Ferritin 2–200 μg/L
Folate 2. μg/L
Gamma glutamyl transpeptidase (GGT)
Lactate dehydrogenase (LDH)
Magnesium
Osmolality
Potassium
M: –5 IU/L
F: 7–33 IU/L
70–250 IU/L
0.75–.05 mmol/L
278–305 mOsmol/kg
3.5–5 mmol/L
Biochemistry
Protein (total)
N ORMAL AND AVERAGE VALUES
60–80 g/L
Sodium 35–45 mmol/L
Thyroid-stimulating hormone (TSH)
Thyroxine (T4)
Thyroxine (free)
Urate
Urea
Vitamin B2
Arterial blood gases
0.5–5.7 mU/L
70–40 nmol/L
9–22 pmol/L
M: 20–480 mmol/L F: 50–39 mmol/L
2.5–6.7 mmol/L
0.3–0.68 mmol/L
pH 7.35–7.45
Arterial oxygen partial pressure (PaO2)
Arterial carbon dioxide partial pressure (PaCO2)
>0.6 kPa
4.7–6.0 kPa
Base excess ± 2 mmol/L
Urine
Cortisol (free)
Osmolality
<280 nmol/24 hours
350–000 mOsmol/kg
Potassium 4–20 mmol/24 hours
Protein <50 mg/24 hours
Sodium 00–250 mmol/24 hours
The index of orthodontic treatment need*
Grade (none)
Extremely minor malocclusions, including displacements of < mm.
Grade 2 (little)
2a Increased overjet 3.6–6 mm with competent lips.
2b Reverse overjet 0.– mm.
2c Anterior or posterior crossbite with up to mm discrepancy between retruded contact position and intercuspal position.
2d Displacement of teeth .–2 mm.
2e Anterior or posterior openbite .–2 mm.
2f Increased overbite 3.5 mm or more, without gingival contact.
2g Pre-normal or post-normal occlusions with no other anomalies. Includes up to half a unit discrepancy.
Grade 3 (moderate)
3a Increased overjet 3.6–6 mm with incompetent lips.
3b Reverse overjet .–3.5 mm.
3c Anterior or posterior crossbites with .–2 mm discrepancy.
3d Displacement of teeth 2.–4 mm.
3e Lateral or anterior openbite 2.–4 mm.
3f Increased and complete overbite without gingival trauma.
Grade 4 (great)
4a Increased overjet 6.–9 mm.
4b Reversed overjet >3.5 mm with no masticatory or speech difficulties.
4c Anterior or posterior crossbites with >2 mm discrepancy between retruded contact position and intercuspal position.
4f Increased and complete overbite with gingival or palatal trauma.
4h Less extensi ve hypodontia requiring pre-restorative orthodontic space closure to obviate the need for a prosthesis.
4l Posterior lingual crossbite with no functional occlusal contact in one or both buccal segments.
4m Reverse overjet .–3.5 mm with recorded masticatory and speech difficulties.
4t Partially erupted teeth, tipped and impacted against adjacent teeth.
4× Supplemental teeth.
Grade 5 (very great)
5a Increased overjet >9 mm.
5h Extensi ve hypodontia with restorative implications (more than one tooth missing in any quadrant) requiring pre-restorative orthodontics.
5i Impeded eruption of teeth (with the exception of third molars) due to crowding, displacement, the presence of supernumerary teeth, retained deciduous teeth, and any pathological cause.
5m Reverse overjet >3.5 mm with reported masticatory and speech difficulties.
5p Defects of cleft lip and palate.
5s Submerged deciduous teeth.
Cephalometric values
Table Cephalometric values: anal ysis of lateral skull tracings*
SNA = 8° (± 3)
SNB = 79° (± 3)
ANB = 3° (± 2)
-Max = 09° (± 6)
-Mand = 93° (± 6) or 20 minus MMPA
MMPA = 27° (± 4)
Facial proportion = 55% (± 2)
Inter-incisal angle = 33° (± 0)
* Reproduced from Mitchell D, Mitchell L, Oxford Handbook Clinical Dentistry, 6th Edition, Table 4., page 30, (204). By permission of Oxford University Press.
