Membership of the Joint Dental Faculties (MJDF) Oral Surgery and Dental Emergencies Syllabus

What is the SDCEP advice on timing extractions for a patient taking a once-daily DOAC such as rivaroxaban?

Consider treating early in the day and either miss/delay the morning dose on the day of the procedure (per SDCEP guidance), using local haemostatic measures, then resume the dose later that day; do not routinely interrupt twice-daily DOACs but consider delaying the morning dose.

Define dry socket (alveolar osteitis) and give its typical time of onset.

A localised inflammation of the alveolar bone due to breakdown/loss of the blood clot exposing bare bone, presenting with severe throbbing pain typically 3–4 days after extraction, often with halitosis and an empty/grey socket but no pus.

List the main risk factors for dry socket.

Mandibular molar extractions, smoking, oral contraceptive pill, female sex, surgical/traumatic extraction, excessive socket irrigation, poor oral hygiene, previous dry socket, and a history of irradiation.

How is dry socket managed?

Reassure, give local anaesthesia, gently irrigate the socket with warm saline/chlorhexidine to remove debris, and dress with an obtundent/antiseptic dressing (e.g. Alvogyl), advise analgesia and warm salt-water rinses, and review; antibiotics are not routinely indicated.

Define oro-antral communication (OAC) versus oro-antral fistula (OAF).

An OAC is an acute, often transient unepithelialised opening between the oral cavity and the maxillary antrum created during extraction; an OAF is a chronic, epithelialised tract that persists when an OAC fails to heal.

Which tooth extraction most commonly causes an oro-antral communication, and how is a small OAC (<2 mm) managed?

Upper first molar (and other maxillary molars/premolars) most commonly. A small communication (<2 mm) with a healthy antrum is usually managed conservatively — encourage clot formation, suture, give antibiotics, nasal decongestants and antral (sinus precaution) instructions.

How is a larger oro-antral communication (>3–4 mm) surgically closed?

With a buccal advancement flap (Rehrmann), a buccal fat pad flap, or a palatal rotation/transposition flap to achieve tension-free, layered closure; sinus care antibiotics and decongestants are given.

What is the Sandler/Valsalva test in the context of OAC?

The nose-blowing (Valsalva) test: the patient gently blows out through the nose with nostrils pinched while the socket is observed for air or fluid bubbling, confirming a communication with the antrum; it should be used cautiously as it can enlarge a small OAC.

Compare the clinical presentation of inferior alveolar nerve injury versus lingual nerve injury.

IAN injury causes altered sensation of the ipsilateral lower lip, chin, and labial gingivae/teeth; lingual nerve injury causes altered sensation (and taste, via chorda tympani) of the anterior two-thirds of the tongue and lingual gingivae on that side.

Define the terms anaesthesia, paraesthesia, dysaesthesia and hypoaesthesia used to describe nerve injury.

Anaesthesia = complete numbness/loss of sensation; paraesthesia = abnormal but non-painful sensation (tingling); dysaesthesia = abnormal unpleasant/painful sensation; hypoaesthesia = reduced sensation; hyperaesthesia = increased sensitivity.

What is the Seddon classification of nerve injury?

Neurapraxia (conduction block, no axon damage, full recovery), axonotmesis (axon disruption with intact endoneurium, recovery possible via regeneration), and neurotmesis (complete nerve transection, poor/no spontaneous recovery).

What proportion of inferior alveolar nerve injuries from third molar surgery are temporary, and by when should referral for persistent injury occur?

The majority are temporary, resolving within ~8 weeks; permanent injury occurs in roughly <1% of cases. Persistent or worsening sensory deficits, or any suspected nerve transection, should be referred promptly (ideally within a few weeks) for specialist assessment.

Define MRONJ and state the diagnostic criteria.

Medication-Related Osteonecrosis of the Jaw: exposed bone, or bone that can be probed through a fistula, in the maxillofacial region that has persisted for more than 8 weeks, in a patient currently or previously treated with anti-resorptive (bisphosphonate/denosumab) or anti-angiogenic drugs, and with no history of radiotherapy to the jaws or obvious metastatic disease.

Name the main drug classes associated with MRONJ.

Anti-resorptives — bisphosphonates (e.g. alendronate, zoledronate) and denosumab (RANKL inhibitor) — and anti-angiogenic agents (e.g. bevacizumab, sunitinib).

According to SDCEP, which patients are at higher risk of MRONJ?

Patients taking anti-resorptives/anti-angiogenics for cancer (oncology indications, higher doses), those on bisphosphonates for more than 5 years, anyone on these drugs plus systemic glucocorticoids, and patients with previous MRONJ.

What is the key preventive dental advice before a patient starts anti-resorptive therapy?

Optimise oral health and complete any necessary extractions/dento-alveolar surgery before starting the drug, allowing healing; thereafter maintain good oral hygiene and regular dental care to avoid the need for future extractions.

List the anatomical routes/spaces by which mandibular molar infection can spread.

Determined by the position of root apices relative to muscle attachments (mylohyoid): infection can spread to the sublingual, submandibular, submental, buccal, masticator (masseteric/pterygomandibular/temporal), lateral pharyngeal, and retropharyngeal spaces.

What is Ludwig's angina and why is it a life-threatening emergency?

A rapidly spreading bilateral cellulitis of the submandibular, sublingual and submental spaces, usually of odontogenic origin, causing a raised tongue, woody floor of mouth, drooling and airway compromise — it is an emergency because of the risk of airway obstruction; requires urgent referral, airway management, IV antibiotics and drainage.

Describe the management of an acute (localised) dental abscess.

Establish drainage and remove the cause — incise and drain any fluctuant swelling, drain via the tooth (extirpate pulp or extract), provide analgesia; antibiotics are only indicated if there is spreading infection, systemic involvement, or the patient is immunocompromised, not for a localised abscess that can be drained.

What is the first-line antibiotic for a spreading dental infection in a non-penicillin-allergic adult per UK guidance, with dose?

Amoxicillin 500 mg three times daily for 5 days (or phenoxymethylpenicillin 500 mg–1 g four times daily); metronidazole 400 mg three times daily may be added/used for anaerobic involvement; clindamycin or clarithromycin are alternatives in penicillin allergy.

State the core principles of antimicrobial stewardship in dentistry.

Antibiotics are an adjunct, not a substitute, for operative treatment; prescribe only when there is evidence of spreading infection or systemic involvement; use the narrowest effective spectrum, correct dose and shortest course; review and avoid repeat prescribing; this reduces resistance and adverse effects.

What are the systemic 'red flag' signs that a dental infection requires urgent hospital referral?

Difficulty breathing or swallowing, trismus limiting mouth opening, raised floor of mouth/tongue, rapidly spreading swelling, eye signs (cavernous sinus involvement), pyrexia and signs of sepsis (tachycardia, hypotension), dehydration, and systemic malaise — these indicate severe or spreading infection.

Which dental hard-tissue injury classification distinguishes enamel, dentine and pulp involvement?

Ellis classification (and the WHO/Andreasen classification): enamel-only fracture, enamel–dentine fracture (uncomplicated), and enamel–dentine–pulp fracture (complicated crown fracture); these guide treatment from smoothing/composite to pulp therapy.

Differentiate an uncomplicated from a complicated crown fracture and the treatment of each.

Uncomplicated = enamel ± dentine with no pulp exposure, treated by sealing exposed dentine and composite restoration; complicated = pulp is exposed, treated by direct pulp cap or partial (Cvek) pulpotomy in immature teeth, or pulpotomy/root canal treatment in mature teeth depending on exposure size and time.

What are the immediate first-aid instructions for an avulsed permanent tooth at the scene?

Find the tooth, hold it by the crown (not the root), if dirty rinse briefly in cold milk or saliva, reimplant it immediately into the socket and bite on gauze; if reimplantation is not possible, store it in cold milk, saliva (buccal sulcus) or a tissue-culture/HBSS medium — never in water — and seek urgent dental care.

Why is extra-oral dry time critical in avulsion, and what is the threshold?

PDL cells die rapidly when dry; an extra-oral dry time greater than 60 minutes means the PDL is considered non-viable, changing the prognosis and protocol (the tooth is reimplanted to maintain alveolar bone but ankylosis/replacement resorption is expected).

How does management of an avulsed open-apex (immature) tooth differ from a closed-apex tooth after replantation?

In a closed (mature) apex, pulp necrosis is inevitable so root canal treatment is started within ~7–10 days (before splint removal); in an open (immature) apex there is potential for revascularisation, so the pulp is monitored and endodontics only performed if necrosis develops.

What splint type and duration are recommended for an avulsed and replanted permanent tooth?

A passive, flexible (physiological) splint for approximately 2 weeks; if there is an associated alveolar/marginal bone fracture, splinting is extended to about 4 weeks.

Compare splinting duration for subluxation, extrusion/lateral luxation, and root fracture injuries.

Subluxation: flexible splint up to ~2 weeks (often none needed); extrusion and lateral luxation: flexible splint ~2 weeks (4 weeks for lateral luxation with bone fracture); mid-root fracture: flexible splint ~4 weeks; cervical-third root fracture: up to ~4 months of rigid/flexible splinting.

What clinical and radiographic signs suggest a fractured mandible, and what is the classic sign of a condylar fracture?

Pain, swelling, trismus, deranged occlusion, step deformity, mobility across the fracture, sublingual haematoma (Coleman's sign), and paraesthesia of the lip; bilateral condylar fractures classically produce an anterior open bite and deviation of the mandible toward the fractured side on opening.