MOCK OSCE Question 1 [[L34 Neuropathic Orofacial Pain including Burning MouthSyndrome#post-traumatic-trigeminal-neuropathic-pain|Post-Traumatic Trigeminal Neuropathic Pain]] Sophie is a 22-year-old female university student who presents to your dental practice reporting persistent pain and altered sensation involving her lower left lip and chin. The symptoms began following surgical extraction of tooth 37 six months ago. She describes the pain as a constant dull ache with occasional sharp, electric-shock-like sensations. She reports that her lower lip feels “numb but painful at the same time” and states that the discomfort is affecting her ability to concentrate on her studies and is interfering with eating and socialising.
- List 3 possible causes of post-traumatic trigeminal neuropathic pain (PTTNP). (3 marks)
- Describe 3 clinical features that would support a diagnosis of PTTNP in this patient. (3 marks)
- Outline 3 key components of your initial clinical assessment of this patient. (3 marks)
- List 3 special investigations that may assist in the evaluation of this patient. (3 marks)
- List 3 pharmacological agents that may be used in the management of neuropathic pain in this patient. (3 marks)
- List 3 non-pharmacological strategies that may assist this patient in managing her condition. (3 marks)
- Identify 3 factors that may influence the prognosis and likelihood of nerve recovery in this patient. (3 marks)
First try answers
- 3 possible causes of PTTNP
- Lingual nerve damage during extraction - and resulting sensitization
- IAN nerve damage during extraction - and resulting sensitization
- Central sensitatization?
- Pain follows branches of trigeminal nerve (i.e. q tip running along )?
- Pain remains for 3 months post trauma?
- ?
- History
- palpation of muscles to rule out myalgia
- swabbing p/ts face with q tips to trace path of trigem
- Following the IASP/ DCD-TMD criteria questionnaire?
- Carbamazepine
- Pregabalin
- Gabapentin
- Gamma knife
- Acupuncture
- Risk factor reduction (stress or emotional state)
- Extent of paresthesia
- Severity of parasthesia
- ? Contents
Marking key Causes of nerve injury during extraction (any 3):
- direct surgical trauma to the inferior alveolar nerve or lingual nerve during extraction
- compression or traction of the nerve by instruments, elevators, or retractors;
- thermal injury from surgical drilling without irrigation
- stretching injury during forceful elevation or sectioning of the tooth
- Post-operative hematoma causing secondary nerve compression
- chemical injury from local anesthetic agents injected intra-neurally
- anatomical proximity of the tooth roots to the inferior alveolar canal (predisposing risk factor )
Clinical features supporting PTTNP (any 3)
- Persistent pain lasting beyond the expected healing period (typically defined as more than 3 months post-procedure );
- pain with a neuropathic character:burning,aching, shooting, or electric-shock-like sensations;
- Sensory disturbance within the ian distribution; hypoaesthesia (reduced sensation), paraesthesia (abnormal sensation such as tingling or “pins and needles”), or dysasethesia (unpleasant or painful abnormal sensation):
- Allodynia (pain evoked by a normally non-painful stimulus) or hyperalgesia (exaggerated pain response to a painful stimulus)
- Absence of identifiable local dental pathology (e.g. infection, retained root fragment to account for the pain)
- Pain confined to the anatomical distribution of the affected nerve (lower lip, chin , mandibular teeth, adjacent gingiva).
Key components of the initial clincial assessment (any 3)
- Detailed pain history: onset and timeline in relation to the procedure, pain character and quality, severity using a numerical rating scale (NRS 0-10), distribution, and aggravating/relieving factors;
- comprehensive intraoral examination: assessment of the extraction socket for sings of infection, dry socket, or healing complications, and examination of adjacent teeth and soft tissues
- Cranial nerve sensory examination: bedside assessment of hte inferior alveolar and lingaul nerve distributions using light touch, pin-prick and two-point discrimination
- Medical and medicaiton history including current use of analgesics or other medications
- Psychosocial assessment: impact on daily activities, sleep quality, study, social function and emotional wellbeing
- assessment of any prior investigations or treatments performed since the proceder
**Special investigations **:
- Panoramic radiograph (OPG): to assess the healing extraction socket, exclude retained fragments or bony pathology, and review the relationship of the inferior alveolar canal to the former tooth position;
- CBCT imaging: where greater anatomical detail of the inferior alveolar canal and surrounding structures is required
- Cranial nerve examination; quantitative or qualitative sensory testing (QST): structured psychophysical testing to objectively characterize the sensory deficit and identify allodynia or hyperalgesia;
- Standardizes sensory mapping: documentation of the area of sensory disturbance using a dermatomal map with photographic record
Pharmacological Management
- Tricyclic antidepressants : e.g. amitriptyline or nortriptyline - first-line agents for peripheral neuropathic pain, acting via noradrenergic and serotonergic pathways;
- Gabapentinoids e.g. gabapentin or pregabalin - act on voltage-gated calcium channels to reduce central sensitization and abnormal neuronal firing
- Anticonvulsants: e.g. carbamazepine or oxcarbazepine - sodium channel blockers with established efficacy in trigeminal neuropathic conditions
- Serotonin-noradrenaline reuptake inhibitors (SNRIs) e.g. duloxetine or venlafaxine - an alternative first-line option with evidence in neuropathic pain conditions
- Topical agents (e.g topical lidocaine (5% patch or gel) or topical capsaicin) - useful adjuncts with a localized mechanism of action and minimal systemic side effects
Non - Pharmacological Management
- Patient education and reassurance: explaining the nature of neuropathic pain, the expected clinical course, and the rationale for treatment
- Cognitive-behavioural therapy (CBT): to address maladaptive pain beliefs, catastrophising and fear-avoidance behaviours
- Pain neuroscience education: structured educaiton to improve understanding of central sensitisaiton and neural plasticity
- Physiotherapy or orofacial physiotherapy: manual techniques and sensory re-education to promote neural recovery and functional rehabilitation
- Transcutaneous electrical nerve stimulation (TENS): neuromodulatory technique providing symptomatic pain relief:
- Mindfulness-based stress reduction (MBSR): evidence-based approach to improving pain coping and psychological well being:
Prognostic factors influencing nerve recovery (any 3):
- Time elapsed since injury: earlier intervention and spontaneous recovery are more likely wihtin the first 3-6 months; delayed recovery beyond 12 months is associated with poorer outcomes
- Severity of the nerve injury: neuropraxia (conduction block without axonal disruption) carries the best prognosis for full recovery; axonotmesis and neurotmesis carry progressively worse prognoses
- Age of the patient: younger patients generally dmeonstrate superior nerve regeneration capcity compared with older individuals
- Development of central sensitisation: establishment of central sensitsaiton is associated with a more refractory clinical course and guarded prognosis
- Psychological factors: high levels of pain catastrophising, anxiety, or depression are associated with worse outcomes and greater disability
- Anatomical factors: documented close proximity of the tooth roots to the inferior alveolar canal on pre-operative imaging, suggesing a higher-risk extraction, may indicate more significant initial nerve injury
Total: 21 marks
Mock OSCE Question 2
L33 Temporomandibular disorders; Extracapsular disorders
Karen is a 35-year-old female who presents to your dental practice reporting a clicking sound in her right jaw joint that has been present for approximately 12 months. She describes intermittent right-sided jaw pain, particularly during chewing and when opening widely. She also reports occasional brief episodes in which her jaw momentarily “locks” on opening, but states that she is always able to free it herself with a small jaw movement. There is no significant restriction of mouth opening and she has no prior history of trauma to the jaw. On examination, maximum unassisted mouth opening is 42 mm with a reproducible click on the right side during both opening and closing. There is mild tenderness on palpation of the right masseter and right lateral pole of the condyle.
- What causes unilateral jaw clicking. (3 marks)
- Based solely on the information provided above, what are the possible diagnoses for this patient? (3 marks)
- Describe the key components of your clinical examination of this patient’s temporomandibular joints and masticatory muscles. (3 marks)
- List 3 investigations that may assist in the diagnosis and management of this patient. (3 marks)
- Outline the conservative management options available for this patient’s condition. (3 marks)
- Identify 3 findings or factors that would indicate a need for specialist referral. (3 marks)
- List 3 factors that may influence this patient’s prognosis. (3 marks)
First try answers
- 1
- High filling
- unilateral condylar resorption
- unilateral trauma
- unilateral myalgia?
- 2
- Disk displacement with reduction with locking
- Myalgia
- ?
- 3
- Palpation of TMJ during opening and excursive/protrusive movements
- Pressing on masticatory muscles to determine trigger points -?
- 4
- MRI
- Ultrasound
- 5
- Jaw stretching excercises (opening to max 20 times , 5 times a day)?
- NSAIDs
- Accupuncture
- 6
- Pain
- Constant locking
- Deflection
- 7
- Frequency of locking
- Severity of symptoms
- If symptoms are progressing or reducing
Marking Key
Causes of unilateral:
- Microtrauma (i.e. overactive muscles)
- Macrotrauma (pucnh)
- Motor vehicle incidents ( i.e. acceleration deceleration)
Possible Diagnoses for the patient
- Arthralgia (e.g. capsulitis)
- Myalgia
- Disc displacement with reduction and intermittent locking
- “Right TMJ disc displacement with reduction;right TMJ disc displacement with reduction with intermittent locking; right TMJ arthralgia. Accept any clinically consistent combination of these diagnoses based on the history and examination of findings provided.”
**Key Components of clinical examination of the patient’s temporomandibular joints and masticatory muscles **
- visual inspection for facial asymmetry and mandibular deviation on opening; measurement of maximum unassisted and assisted mouth opening (in mm), lateral excursion and protrusion ; palpation of the TMJs (lateral pole and posterior attachement) and masticatory muscles (masseter , temporalis, medial and lateral pterygoid ) for tenderness; palpation or auscultation for joint sounds with characterisation of timing (opening click, closing click or crepitus)
**Key investigations
- OPG as a baseline assessment of bony joint architecture; MRI of the TMJs to assess disc position, morphology, and the presence of joint effusion; CBCT where bony pathology, condylar resorption, or articular surface changes are suspected; serological investigations (e.g. ESR, CRP, rheumatoid factor, ANA) if systemic arthritis is a differential diagnosis
Conservative Patient Management Options
- Patient education and reassurance;
- Dietary modification
- soft diet
- avoidance of hard foods and wide opening
- Parafunctional habit awareness and reversal (e.g. clenching, jaw bracing)
- stabilisation splint therapy
- directed jaw excercies and physiotherapy
- NSAIDs for pain management
Need for specialist referral
- Failure to respond to an adequate trial of conservative manangement
- Progressive restirction of mouth opneing or worsening of symptoms
- evidence of structural joint destruction or condylar resorption on imaging
- suspected systemic arthritis requiring rehumatological assessment;
- diagnostic uncertainty;
- significant psychosocial impact or comorbid chornic pain conditions requiring multidisciplinary input
**Factors Influencing Patients Prognosis
- Severity and chronicity of the disorder at presentation
- Presence of psychosocial comorbidities including anxiety, depression, and pain catastrophizing; degree of structural change evident on imaging; patient adherence to self-management strategies; coexistence of other chronic overlapping pain conditions
Total: 21 marks
Mock OSCE Question 3
David is a 54-year-old male referred to your clinic by his general medical practitioner. He reports loud snoring, excessive daytime sleepiness — including falling asleep at his desk during the working day — and unrefreshing sleep. His partner has observed episodes in which he stops breathing during the night. He has a BMI of 32 and a known history of hypertension managed with antihypertensive medication. On examination you note a Class II skeletal pattern with a retrognathic mandible, a high Mallampati score, and clinical evidence of bruxism. His referring practitioner suspects obstructive sleep apnoea (OSA) and has asked you to assess and manage him.
- List 3 risk factors for OSA that are present in this patient. (3 marks)
- Explain the pathophysiology of OSA and describe how it relates to oral manifestations. (3 marks)
- Describe the role of the dentist in screening and diagnosing OSA. (3 marks)
- Outline 2 oral appliances commonly used in OSA management and explain their mechanisms of action. (3 marks)
- Describe 2 complications of untreated OSA relevant to dental and systemic health. (3 marks)
- List 3 non-pharmacological lifestyle modifications that may reduce the severity of OSA. (3 marks)
- What challenges may arise in the long-term management of OSA with oral appliance therapy? (3 marks)
Total: 21 marks
First try answers
- 1
- Class II skeletal pattern with retrognathic mandible
- Hypertension
- Obesity
- 2
- cant keep airway open , dry mouth?
- 3
- administer screening questionnaires (STOP BANG)
- administer MAS
- Referral to specialist
- 4
- tongue suck
- mandible advancement
- 5
- depression
- high risk for myocardial infarction
- 6
- Weight loss
- Stress management
- sleep hygiene / sleeping on sid e
- 7
- development of malocclusion
- higher risk for candidosis ?
Marking Key
Risk Factors OSA
- Male Gender
- BMI over 32
- Hypertension
- Retrognathia (craniofacial risk factor for upperairway narrowing)
- High Mallamptai score (indicating upper airway crowing )
Pathophysiology of OSA and describe how it relates to oral manifestations
- OSA results from repetitive collapse of the upper airway during sleep due to loss of pharyngeal muscle tone
- collapse leads to intermittent hypoxia and hypercapnia
- arousal responses cause sleep fragmentation and sympathetic nervous system activation
- increased respiratory effort and jaw bracing during airway obstruction may contribute to masticatory muscle hyperactivity and sleep bruxism
- chronic mouth breathing secondary to upper airway obstruction can cause xerostomia and increased risk of dental caries
**Role of the Dentist in screening and Diagnosing OSA **
- Identify risk factors through comprehensive history-taking and oral examination
- Use validated screening tools (e.g. STOP-BANG questionnaire, Epworth Sleepiness Scale)
- Recognize oral and craniofacial signs associated with OSA (e.g. retrognathia, macroglossia, scalloped tongue, high arched palate, enlarged tonsils, bruxism )
- Refer to a sleep physician for definitive diagnosis via polysomnography (in-laboratory) or home sleep testing
Outline 2 oral appliances commonly used in OSA management and explain their mechanisms of action
- tongue retaining devises (TRDs)
- Hold the tongue in an anterior position via a negative pressure bulb, preventing posterior displacement of the tongue and pharyngeal obstruction
- Mandibular advancement appliances (MAAs/ MADs):
- protrude the mandible anteriorly to enlarge the upper airway, increase pharyngeal muscle tone and reduce upper airway collapsibility during sleep
Describe 2 complications of untreated OSA relevant to dental and systemic health
- Dental/orofacial:
- sleep bruxism
- Temporomandibular disorders
- Xerostomia
- Increased caries risk
- periodontal disease exacerbation
- Systemic:
- hypertension
- increased risk of cardiovascular disease and stroke
- type 2 diabetes
- neurocognitive impairment
- excessive daytime sleepiness impairing occupational and driving safety **Non- Pharmacological Modifications to OSA **
- weight reduction
- Positional therapy (avoidance of supine sleeping )
- reduction or elimination of alcohol and sedatives beofre sleep
- smoking cessation
- regular physical exercise
Challenges for long-term management of OSA with oral appliance therapy
- patient non-compliance iwth nightly appliance use
- orofacial discomfort, tooth soreness or TMJ pain
- Appliance induced occlusal changes and anterior open bite over time
- need for ongoing titration, monitoring and review of treatment efficacy
- appliance wear, fracture or deteriortation requiring replacement