Diploma of the Faculty of Dental Surgery (MFDS) Oral Surgery, Oral Medicine and Pathology Syllabus

How is dry socket managed?

It is self-limiting; management is symptomatic: irrigate the socket with warm saline/chlorhexidine to remove debris, place a sedative obtundent dressing (e.g. Alvogyl/zinc oxide-eugenol or iodoform-based dressing), provide analgesia, and review. Antibiotics are not usually required.

What is an oro-antral communication (OAC), and how does it differ from an oro-antral fistula (OAF)?

An OAC is an acute, unepithelialised opening between the mouth and the maxillary antrum (often after extraction of upper molars/premolars). An OAF is a chronic, epithelialised tract that has become a persistent established pathway lined by epithelium.

How is an oro-antral communication diagnosed clinically?

Direct vision of the antral lining, bubbling of blood/air at the socket, a positive nose-blowing (Valsalva) test with air or fluid passing into the mouth, a bony defect on probing with a blunt instrument (gentle), and on radiograph a raised/disrupted antral floor. Avoid vigorous probing which may push roots in.

How are small versus large oro-antral communications managed?

Small (<2 mm) often heal spontaneously — encourage clot, antibiotics, antral/nose-blowing precautions. Large or persistent communications require surgical closure, classically with a buccal advancement flap (Rehrmann) or a buccal fat pad/palatal rotation flap, plus antibiotics and decongestants.

Which nerves are most at risk during lower third molar surgery, and what deficits result?

The inferior alveolar nerve (IAN) — altered sensation of the lower lip, chin and teeth; and the lingual nerve — altered sensation/taste of the ipsilateral anterior two-thirds of the tongue and lingual gingiva. Injury may cause anaesthesia, paraesthesia or dysaesthesia.

Define anaesthesia, paraesthesia, dysaesthesia, hypoaesthesia and hyperaesthesia.

Anaesthesia = complete loss of sensation; paraesthesia = abnormal sensation (e.g. tingling), not unpleasant; dysaesthesia = abnormal unpleasant/painful sensation; hypoaesthesia = reduced sensation; hyperaesthesia = increased sensitivity to stimuli.

Classify nerve injuries (Seddon classification) and relate to recovery.

Neurapraxia = conduction block with intact axon, recovers fully (days-weeks); axonotmesis = axonal damage with intact endoneurium, recovers by regeneration over weeks-months; neurotmesis = complete nerve transection, poor spontaneous recovery and may require microsurgical repair.

What should be done if a root or tooth is displaced into the maxillary antrum?

Confirm with radiographs (and the antrum is patent), avoid blind probing, and retrieve the fragment — via the socket if accessible, or via a Caldwell-Luc antrostomy approach if not. Close any oro-antral communication, give antibiotics and antral precautions, and consider referral.

Where can a displaced lower third molar root be pushed, and how is it located/retrieved?

It may be displaced into the lingual (submandibular) space or inferior alveolar canal. Stop, take radiographs (and CBCT) to localise, do not blindly explore, secure the airway, and retrieve via a lingual approach or refer to a specialist; small fragments may sometimes be left and monitored.

Classify odontogenic cysts into developmental and inflammatory types with examples.

Developmental: dentigerous cyst, odontogenic keratocyst (OKC), eruption cyst, lateral periodontal cyst, gingival cyst, calcifying odontogenic cyst. Inflammatory: radicular (periapical/apical) cyst, residual cyst, and inflammatory collateral (paradental) cyst.

What are the characteristic features of an odontogenic keratocyst (OKC)?

Derived from dental lamina remnants; grows along the bone (antero-posteriorly) with little expansion; high recurrence rate; thin parakeratinised stratified squamous epithelial lining with a palisaded basal layer and corrugated surface; daughter cysts; and association with naevoid basal cell carcinoma (Gorlin) syndrome when multiple.

What is the most common odontogenic cyst, and with what is a dentigerous cyst associated?

The radicular (periapical) cyst is the most common odontogenic cyst, arising from a non-vital tooth. A dentigerous cyst is associated with the crown of an unerupted tooth, attached at the amelocemental (cemento-enamel) junction, most commonly the mandibular third molar or maxillary canine.

Name a common odontogenic benign tumour and its key features.

Ameloblastoma — a benign but locally aggressive epithelial odontogenic tumour, commonly in the posterior mandible, presenting as a slow-growing painless swelling with a multilocular 'soap-bubble' or 'honeycomb' radiolucency; it has a high recurrence rate and requires resection with clear margins.

List the most common malignant tumour of the jaws and the most common site of intra-oral squamous cell carcinoma.

Oral squamous cell carcinoma (OSCC) is the most common oral malignancy. Intra-orally the most common sites are the lateral border/ventral surface of the tongue and the floor of mouth. The jaws may also be affected by osteosarcoma and metastatic deposits.

Name the major and minor salivary glands.

Major (paired): parotid, submandibular, and sublingual glands. Minor salivary glands (hundreds) are distributed throughout the oral mucosa, especially the lips, palate, buccal mucosa and floor of mouth.

Differentiate a mucocele from a ranula.

A mucocele is a mucus extravasation/retention cyst of minor salivary glands, commonly on the lower lip, presenting as a bluish fluctuant swelling. A ranula is a mucocele of the sublingual (or submandibular duct) gland in the floor of mouth; a 'plunging' ranula extends through mylohyoid into the neck.

What is sialolithiasis, which gland is most affected, and how does it present?

Sialolithiasis is salivary calculus (stone) formation. It most commonly affects the submandibular gland/Wharton's duct (mucinous secretion, upward duct course). It presents with mealtime pain and swelling of the gland, which may resolve between meals; managed by sialogogues, stone removal or sialendoscopy.

Name the most common benign and most common malignant salivary gland tumours.

Most common benign tumour is the pleomorphic adenoma (most often in the parotid). The most common malignant salivary gland tumour overall is mucoepidermoid carcinoma; adenoid cystic carcinoma is notable for perineural spread.

List the main types of biopsy used in oral pathology.

Incisional biopsy (a representative portion of a larger/suspicious lesion), excisional biopsy (removal of the whole lesion, for small benign lesions), punch biopsy, fine-needle aspiration (FNA) for swellings/lymph nodes, and brush biopsy/cytology as an adjunct.

What principles govern taking an incisional biopsy of a suspected malignancy?

Include a representative area at the edge of the lesion incorporating some adjacent normal tissue, avoid grossly necrotic centres, take an adequate depth, avoid crushing the specimen, orient and place immediately in 10% formalin, and provide a full clinical history and lesion details on the histopathology request form. Suspected malignancy is best biopsied by the treating specialist.

What information must accompany a histopathology request form?

Patient identifiers, relevant medical/social history (e.g. smoking, alcohol), clinical description and site of the lesion (ideally with a diagram), duration, provisional/differential diagnosis, type of biopsy, fixative used, and any previous related pathology.

Describe the clinical appearance and types of oral lichen planus.

A chronic T-cell mediated mucosal condition presenting as bilateral, often symmetrical lesions. Types: reticular (lacy white Wickham's striae, usually asymptomatic), atrophic/erythematous, erosive/ulcerative (painful), plaque-like, papular and bullous. The erosive form is most symptomatic and carries a small malignant transformation risk.

Define leukoplakia and erythroplakia and their malignant potential.

Leukoplakia is a white patch that cannot be rubbed off or attributed to any other definable lesion (a clinical diagnosis of exclusion) with malignant potential. Erythroplakia is a red velvety patch that cannot be attributed to another condition; it has a much higher risk of dysplasia/malignancy than leukoplakia and warrants urgent biopsy.

What is the classification and significance of epithelial dysplasia in oral mucosa?

Dysplasia is graded histologically as mild, moderate or severe (with carcinoma in situ as full-thickness change). Increasing grade correlates with increasing risk of progression to invasive squamous cell carcinoma; it guides the need for excision and surveillance.

Give examples of oral manifestations of systemic disease.

Crohn's disease (cobblestoning, mucosal tags, linear ulcers, lip swelling); coeliac disease (recurrent aphthae, glossitis); pernicious/iron-deficiency anaemia (glossitis, angular cheilitis, aphthae); leukaemia (gingival enlargement, bleeding, ulceration); HIV (candidiasis, hairy leukoplakia, Kaposi sarcoma); and lichenoid reactions in graft-versus-host disease.

List common causes of orofacial pain by category.

Odontogenic (pulpitis, periapical, cracked tooth, dry socket); musculoskeletal (temporomandibular disorders, myofascial pain); neuropathic (trigeminal neuralgia, post-herpetic neuralgia, atypical odontalgia); neurovascular (migraine, cluster headache); and referred (sinusitis, cardiac, salivary, malignancy). Psychogenic factors may contribute.

Describe the classic features and first-line drug treatment of trigeminal neuralgia.

Severe, brief, paroxysmal, electric-shock-like unilateral pain in a trigeminal division (often V2/V3), triggered by light touch, washing, eating or wind, with refractory periods between attacks. First-line treatment is carbamazepine; microvascular decompression is a surgical option for refractory cases.

Define xerostomia and list common causes of dry mouth/salivary dysfunction.

Xerostomia is the subjective sensation of dry mouth. Causes: medications (anticholinergics, antidepressants, antihistamines, diuretics), Sjögren's syndrome, head and neck radiotherapy, dehydration, diabetes, anxiety, and mouth-breathing. Consequences include caries, candidiasis, dysphagia and altered taste.

What is Sjögren's syndrome and how is it characterised?

A chronic autoimmune exocrinopathy causing lymphocytic destruction of salivary and lacrimal glands, producing dry mouth (xerostomia) and dry eyes (keratoconjunctivitis sicca). Primary occurs alone; secondary occurs with another connective tissue disease (e.g. rheumatoid arthritis). It carries an increased risk of MALT lymphoma; anti-Ro/SS-A and anti-La/SS-B antibodies are markers.

Describe burning mouth syndrome (BMS) and its management.

BMS is a chronic burning sensation of the oral mucosa (often the tongue) with clinically normal mucosa and no identifiable local or systemic cause. It is more common in peri/post-menopausal women. Management involves excluding causes (candida, deficiencies, diabetes, dry mouth, parafunction), reassurance, cognitive behavioural therapy, and low-dose neuromodulators (e.g. clonazepam, gabapentin or tricyclics).

What are the major risk factors for oral squamous cell carcinoma?

Tobacco (smoked and smokeless/chewed), areca/betel nut and paan, heavy alcohol (synergistic with tobacco), HPV (especially type 16, more for oropharyngeal SCC), sunlight (lip cancer), increasing age, immunosuppression, chronic trauma, and pre-existing potentially malignant disorders. Diets low in fruit/vegetables also contribute.

List the oral potentially malignant disorders (OPMDs).

Leukoplakia, erythroplakia, erythroleukoplakia (speckled), oral submucous fibrosis, oral lichen planus (erosive), actinic cheilitis, oral lupus erythematosus, and dyskeratosis congenita. These carry an increased risk of transformation to squamous cell carcinoma and need monitoring.

What clinical features of an oral lesion should raise suspicion of malignancy and prompt urgent referral?

A non-healing ulcer persisting more than 3 weeks, an indurated/rolled margin, a fixed or hard lesion, exophytic or speckled red-white patch, bleeding, tooth mobility without cause, persistent neck lymphadenopathy, dysphagia, numbness, or referred otalgia. Any unexplained red or red-white patch should be referred.

What is the '2-week wait' urgent cancer referral pathway and when is it used?

It is the UK NHS urgent suspected-cancer referral that ensures the patient is seen by a specialist within two weeks. For oral cancer it is used for any unexplained ulceration/red or red-white patch persisting more than 3 weeks, persistent unexplained neck lump, or other suspicious features, referred to oral/maxillofacial or head-and-neck services.

Outline the TNM staging system as applied to oral cancer.

T = primary tumour size/local extent (T1 ≤2 cm, T2 >2-4 cm, T3 >4 cm, T4 invading adjacent structures, with depth of invasion now incorporated), N = regional lymph node involvement (N0-N3 by number, size, laterality and extranodal extension), and M = distant metastasis (M0/M1). These combine into overall stage I-IV.

What is the role of the multidisciplinary team (MDT) in head and neck cancer management?

The MDT (surgeons, oncologists, radiologists, pathologists, restorative dentists, clinical nurse specialists, dietitians, speech and language therapists, etc.) reviews diagnosis, imaging and histology to plan and coordinate treatment (surgery, radiotherapy, chemotherapy), rehabilitation and supportive/palliative care, ensuring patient-centred decisions.

How can dental practitioners contribute to prevention and early detection of oral cancer?

Provide tobacco and alcohol cessation/brief intervention advice, perform thorough soft-tissue (mucosal) examinations at every routine recall, recognise and urgently refer suspicious lesions, document and review white/red patches, promote HPV awareness and a healthy diet, and educate patients on self-examination and risk factors.