THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH

MEMBERSHIP IN ORAL AND MAXILLOFACIAL SURGERY

CASE HISTORY TEMPLATE

DATE OF EXAMINATION: [month, year of examination]

CANDIDATE NUMBER: [N]

CASE NUMBER: [N]

PATIENT’S INITIALS: [AS]

COLOUR CODE:

GREEN

CASE SUMMARY

A sixty year old man attended the Outpatients Dept with a 3 month history of pain and swelling
of the left mandibular alveolus, with a bad taste and trismus.
Medically he suffered from Type 2 Diabetes, Hypertension, Hyperlipidaemia and smoked 20
cigarettes per day. He took Atenolol, Metformin, Simvastatin, Aspirin and was mildly obese.
Extraoral examination was unremarkable.
Intraorally he had a discharging sinus in the lower left posterior alveolus, with evidence of
smokers keratosis and moderate chronic periodontitis.
The tooth was removed under GA with no lasting complications although the inferior alveolar
bundle was clearly observed at Surgery

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February 2011
SECTION 1 ASSESSMENT
PATIENT DETAILS

Initials: AS

Sex: M

Date of birth: 20/01/49

Age at start of treatment: 60 yrs

PATIENT’S COMPLAINTS
Recurrent pain and swelling of left mandibular alveolus, bad taste
and difficulty in mouth-opening over the previous 3 months.

RELEVANT MEDICAL HISTORY

Smoker 20 cigarettes/day, NIDDM, Hypertension, Hyperlipidaemia

CLINICAL EXAMINATION: EXTRA-ORAL

NAD, inter-incisal opening 35mm, no cervical lymphadenopathy

CLINICAL EXAMINATION: INTRA-ORAL

Soft tissues & mucosa Sinus left mandibular alveolar crest, Smokers keratosis,
generalised erythema

Teeth Several missing teeth, dental amalgam and composite

restorations, tobacco staining, no prostheses

Periodontal tissues Supragingival calculus, moderate periodontal pocketing

3-5 mm in depth

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February 2011
IMAGING
1) & 2) Radiographs of carious lower left third molar with apical pathology in close proximity to the
inferior alveolar nerve

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February 2011
 3) Peri-operative photograph showing inferior alveolar bundle at base of third molar socket

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February 2011
INVESTIGATIONS

Radiology: Orthopantomogram, Periapical, Chest X-Ray

Haematology: Full Blood Count, Urea & Electrolytes, Fasting Blood Glucose
Anaesthetic Preassessment Clinic
Oral & Maxillofacial Preassessment & Consent clinic

DIAGNOSTIC SUMMARY

1) Impacted carious lower left third molar (wisdom) tooth

2) Apical pathology and localised osteitis

3) Close proximity to inferior alveolar bundle

4) Discharging sinus on to mandibular alveolus

5) Relevant Medical History:-Smoker, NIDDM, Hypertension, Hyperlipidaemia

6) Relevant Drug History:- B-Blocker (atenolol), Metformin, Statin, Aspirin

7) Assessment of fitness for General Anaesthetic

8) Taking Informed Consent & explanation of possible complications

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February 2011
TREATMENT PLAN

1) Full explanation to patient. Presence of an unerupted, carious and intermittently infected

lower left third molar tooth.

2) Removal of lower left wisdom tooth (3rd molar) under General Anaesthetic.

3) Risks of GA and Surgery explained to the patient. This included an Anaesthetic

preassessment. The Anaesthetist felt that as he had Type 2 Diabetes on oral
hypoglycaemic medication, there was no need for perioperative insulin, although regular
glucose monitoring would be required. No oral hypoglycaemic to be taken on the day of
Surgery.

4) Informed consent obtained including GA risks, Surgical and postoperative complications.

5) Advice given to omit aspirin on day of Surgery.

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February 2011
2. TREATMENT

1) The patient was admitted for day case general anaesthesia. (A bed being available for
overnight stay if required.)

2) The treatment plan was reiterated to the patient. The proximity to the inferior alveolar
nerve was reinforced and warnings given of damage to that structure, the lingual nerve
and possible mandibular fracture. Pain, haemorrhage, swelling, trismus and need for
sutures were also mentioned. The patient was asked to confirm he had starved and
omitted relevant drugs; consent was confirmed.

3) Endotracheal anaesthesia was performed, 1.2g intravenous Co-amoxiclav and 8mg

Dexamethasone were given. A standard third molar incision made. A mucoperiosteal flap
was raised and a retractor placed. Lingual retraction was performed but no retraction of
the lingual gingiva.

4) Bone removal was performed with a round bur.

5) The tooth was elevated with a Coupland elevator. The inferior alveolar bundle was
observed at the base of the socket but no adverse bleeding encountered.

6) The flap was sutured with 3/0 vicryl rapide suture and a pressure pack applied.

3. POST TREATMENT

Immediate post-operative recovery was uneventful. The temperature, blood pressure and
pulse were normal. The patient ate & drank without undue nausea and appropriate dietary
advice was offered for the postoperative period. The blood glucose remained below 7.0
mmol/l and no undue haemorrhage encountered. He returned to his normal medication the
following day.

At review appointment, two weeks later healing was satisfactory, there was no paraesthesia
and the patient was discharged.

Smoking cessation advice was offered but declined by the patient.

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February 2011
4. CRITICAL APPRAISAL

This case may appear straightforward but had many potential complications:

1) The patient’s medical history. The patient requested General Anaesthesia (GA) which
involved a preassessment and informed consent. Smoking is a relative contraindication to
GA, as is diabetes, but if adequate planning is given a safe anaesthetic can be
administered. Possibly a sliding-scale insulin/glucose/potassium infusion may be
considered for precise control of blood glucose. Mini-aspirin usually only minimally affects
the bleeding time although for more major surgery, it should be omitted for a longer
period.

2) Social History: the patient was married and could be overseen by an adult hence day stay
anaesthesia was reasonable.

3) The root of the tooth was close to the inferior alveolar canal radiographically. The canal
was narrowed with loss of the tramline although not greatly deviated from its course. This
prompted a full explanation of possible anaesthesia/paraesthesia especially to the mental
nerve. Due warnings of damage to the lingual nerve and possible jaw fracture were also
covered. A lingual mucoperiosteal flap was not raised to prevent potential lingual nerve
damage.

4) As the tooth was carious and infected, it fitted into the NICE (SIGN) guidelines for removal
of third molar teeth. The presence of infection precluded observation or coronectomy. In
view of the acute infection, an intravenous antibiotic was administered. Steroids were
given to counteract swelling and minimise postoperative nausea. Although they can have
a diabetogenic effect, this is unlikely at a single dose.

5) GA vs LA +/- sedation: as hospital general anaesthetic facilities, staff and recovery were
available, it was decided it was appropriate to give general anaesthesia. This also
complied with the patient’s request. This type of case could present a risk in high street
practice and should be referred accordingly.

6) A review 2 weeks later revealed no obvious complication and the patient was discharged
at that stage but opportunity given for further review if requested.

7) This case shows how a comprehensive history, examination and investigations can
foresee complications. The patient was properly assessed, advised and consented. In
such a way potential problems can be anticipated and largely avoided.

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February 2011