AUSTRALASIAN COLLEGE FOR EMERGENCY MEDICINE

54th FELLOWSHIP EXAMINATION

16th October 2014

Written Exam: 2 SAQs and 5 MCQs

Clinical Exam2 OSCEs

Duration: 30 minutes, 3 teams

SAQ 1Case Stem: This is Logan. He is from Logan.He drives a Holden. On weekends he also sells…

SAQ 1Case Stem: This is Logan. He is from Logan.He drives a Holden. On weekends he also sells… vitamins and supplements.

SAQ 1

Sat night watching TV on couch4 guys bashed him up for no reason

SAQ 1. Describe the dental injuries in this photo. (2 minutes)

Dental Trauma

3 take home points

1. Two groups of dental trauma: Fractures & Luxations

2. Dental Box with 2 types of cement: Calcium & GIC- “Fractures = Calcium to put a Cap”- “Luxations = GIC to close the Gap”

3. Avulsions: <1hr, Saliva/Milk, Splint

Dental Trauma2 groups of dental trauma: 1. Hard Dental tissue injury = FRACTURES

Clinical significance: Class 2 and 3 need emergency capping to reduce risk of pulp infection

What Ellis class is the fracture of tooth 11?What Ellis class is the fracture of tooth 21?

Dental TraumaTwo groups of dental trauma: 2. Periodontal tissue injury = LUXATIONS

4 types of luxation- SUBLUX = loose but no displacement- LATERAL = Sideways displacement- INTRUSIVE = into socket- EXTRUSIVE = partially out of socket

Avulsion = tooth completely out of socket

SAQ 1. Describe Logan’s dental injuries.

Vocab:Luxation – lateral, extrusive, intrusiveAvulsion

Complex dental injury involving teeth 22 and 23 and surrounding gingiva, lip and adjacent alveolar bone. Complete avulsion of tooth 23 with exposed peri-odontal ligament cells and possible Ellis 4 root fracture. Anterior displacement of tooth 22 with intrusive luxation.

SAQ 2a. Describe and interpret Logan’s OPG. (1 minute)

SAQ 2a. Describe and interpret Logan’s OPG.

REPORT:Oblique fracture is seen extending through the left maxilla.Movement artefact obscuring the apices of the upper jaw teeth. Previous dental work noted. No mandibular fracture is identified. The temporomandibular joints are normally opposed. No air-fluid level within the right maxillary antra.

Different Case Stem = but same location of pain.37yr aboriginal woman, No trauma, left toothache 4 days, left upper gingival swelling, and fevers.

SAQ 2b. Describe and interpret this OPG (1 minute)

REPORT:Multiple missing teeth. Multiple dental fillings. Multiple dental caries. Lucency surrounding root of tooth 23 concerning for dental abscess.

Dental Trauma

MCQ 1

In avulsion dental injuries, how soon should the tooth be re-inserted to maximize the viability of the peri-odontal ligament cells?

1hr, 2hrs, 3hrs, 4hrs

Dental Trauma

MCQ 1

In avulsion dental injuries, how soon should the tooth be re-inserted to maximize the viability of the peri-odontal ligament cells?

1hr, 2hrs, 3hrs, 4hrs

Answer: Aim to reinsert tooth with intact viable peri-odontal cells within 1 hr. Timing – 85-97% tooth survival if reimplanted within 5 mins, <1% survival if >60mins coz periodontoid ligament cells dead and apex socket closes over. If place tooth in isotonic solution = increase viability time to 4-6 hrs.

Dental Trauma

MCQ 2

All of the following are an appropriate transportation medium for an avulsed tooth, EXCEPT

Salivamilkcontact lens solution chocolate yoghurt

Dental Trauma

MCQ 2

All of the following are an appropriate transportation medium for an avulsed tooth, EXCEPT

Saliva, milk, contact lens solution, chocolate yoghurt

Answer: Maintain periodontal cells via saliva, milk (isotonic, mg and ca), sterile saline, contact lens solution. NOT soy, choc milk, juice. Prolongs viability of cells to 4-6hrs.

Dental Trauma

MCQ 3

When handling an avulsed tooth you should always:

Scrub the root clean, hold only the crown, boil the tooth for sterilization, Lick your fingers first

Dental Trauma

MCQ 3

When handling an avulsed tooth you should always:

Scrub the root clean, hold only the crown, boil the tooth for sterilization, Lick your fingers first

Answer: do not scrub root, only handle crown, thus avoid disruption of periodontal ligament cells

Dental Trauma

MCQ 4

An infra-orbital nerve block in dental trauma results in local anaesthesia to which teeth:

Front 2 incisors 11 and 21, Maxillary Incisors / Canine / Molars, Mandibular teeth 31 to 35, Maxillary teeth 21 to 25

Dental Trauma

MCQ 4

An infra-orbital nerve block in dental trauma results in local anaesthesia to which teeth:

Front 2 incisors 11 and 21, Maxillary Incisors / Canine / Molars, Mandibular teeth 31 to 35, Maxillary teeth 21 to 25

Answer: infra-orbital nerve block (maxillary teeth 1-5), individual maxillary teeth local block, inferior-alveolar block (all mandibular teeth)

Dental Trauma

MCQ 5

To splint an avulsed tooth to an adjacent tooth, all of the following methods are acceptable EXCEPT:

Blutac and tinfoil, Using Glass Ionomer Cement, Using Calcium hydroxide cement, Mouth guard

Dental TraumaMCQ 5To splint an avulsed tooth to an adjacent tooth, all of the following methods are acceptable EXCEPT:Blutac and tinfoil, Glass Ionomer Cement, Calcium hydroxide, Mouth guard

2 types of cement in Dental Box• Calcium Hydroxide = FRACTURES• Glass Ionomer Cement = LUXATIONS

Remember:

“Calcium = CAP” “GIC = GAP”

Calcium hydroxide for “capping” a tooth with an Ellis 2 or 3 dental fracture.

GIC to splint an avulsed tooth that has left a “gap”

Dental TraumaMCQ 5To splint an avulsed tooth to an adjacent tooth, all of the following methods are acceptable EXCEPT:Blutac and tinfoil, Glass Ionomer Cement, Calcium hydroxide, Mouth guard

2 types of cement in Dental Box• Calcium Hydroxide = FRACTURES

– Fractures only = Ellis 2 or 3 only with pulp exposed– Calcium Hydroxide for pulp capping only– 4 benefits: antibacterial, localized buffer to

neutralize acid, binds strongly to dentin, alters the physical matrix of dentin to decrease demineralisation

Remember:

“Calcium = CAP” “GIC = GAP”

Calcium hydroxide for “capping” a tooth with an Ellis 2 or 3 dental fracture.

GIC to splint an avulsed tooth that has left a “gap”

Dental TraumaMCQ 5To splint an avulsed tooth to an adjacent tooth, all of the following methods are acceptable EXCEPT:Blutac and tinfoil, Glass Ionomer Cement, Calcium hydroxide, Mouth guard

2 types of cement in Dental Box• Glass Ionomer Cement = LUXATIONS

– Splinting of Luxations & Avulsions, NOT fracture pulp capping

– polymer of silicon, fluoride and aluminum. – 3 benefits: tooth coloured, binds to strongly to

enamel, releases fluoride. – Cons: lower compressible strength thus mainly for

outside of tooth fillings or splinting, not mastication surface of tooth, thus not for capping

Remember:

“Calcium = CAP” “GIC = GAP”

Calcium hydroxide for “capping” a tooth with an Ellis 2 or 3 dental fracture.

GIC to splint an avulsed tooth that has left a “gap”

Dental TraumaOSCE 1

CLINICAL SCENARIO STEM:You are an emergency physician working in a rural district hospital.

A 34yr old man called Logan has been assaulted in his home and presents with a dental avulsion of his left tooth.

You have a dental trauma box and no other assistance.

INSTRUCTIONS:You are required to use the contents of the dental box to reinsert and splint his tooth into anatomical position.You have 4 minutes.

Dental TraumaOSCE 2

CLINICAL SCENARIO STEM:You are an emergency physician working in a rural district hospital.

A 34yr old man called Logan has been assaulted in his home and presents with a dental fracture of his left tooth with exposed pulp.

You have a dental trauma box and no other assistance.

INSTRUCTIONS:You are required to use the contents of the dental box to apply a dental cap to prevent a pulp infection.You have 4 minutes.

References and Resources:

- Dental Trauma Box. Dr Tony Skapetis. Clinical Senior Lecturer in the Faculty of Dentistry at Sydney University, BDS, MEd, PhD, Dentistry/Medical Education

- Emergency Dental, Handbook for Medical practitioners. 2010. Dr Tony Skapetis.

- Classification of Dental Trauma & Management of dental avulsions: Powerpoint slides by Tony Skapetis

- Paul Lawless @ Annerley Meats for the teeth

Dental Trauma

3 take home points

1. Two groups of dental trauma: _____ & _____

2. Dental Box with 2 types of cement: ____ & ____- “Fractures = ______ to put a Cap”- “Luxations = GIC to close the ______”

3. Avulsions: ____, milk/saliva, _____

Dental Trauma

3 take home points

1. Two groups of dental trauma: Fractures & Luxations

2. Dental Box with 2 types of cement: Calcium & GIC- “Fractures = Calcium to put a Cap”- “Luxations = GIC to close the Gap”

3. Avulsions: <1hr, Saliva/Milk, Splint

Dental Trauma

THE END

BEFORE AFTER

AUSTRALASIAN COLLEGE FOR EMERGENCY MEDICINE

54th FELLOWSHIP EXAMINATION

16th October 2014

END OF THE EXAM.EVERYONE PASSED !