A 3-year-old has asymptomatic cavitated caries affecting the primary maxillary incisors. They are anxious but allow examination following non-pharmacological behaviour management. There are no signs of pulpal involvement.

Alongside acclimatisation and enhanced prevention, what is the most appropriate interim management?

A. Composite resin restorations
B. Extractions under general anaesthetic
C. Extractions with inhalation sedation/local anaesthetic
D. Glass ionomer restorations
E. Silver diamine fluoride

The correct answer is E.

Justification: Silver diamine fluoride is the most appropriate interim option because it is minimally invasive, quick to apply and suitable for arresting cavitated carious lesions in a young child with limited co-operative ability, provided there are no symptoms or signs of pulpal involvement. Glass ionomer restorations may be appropriate once co-operation improves, but in a reluctant 3-year-old they are technique-sensitive and may have limited longevity, particularly in primary anterior teeth. They are therefore less suitable than silver diamine fluoride as the best interim option in this scenario. Composite resin restorations are less appropriate because they require greater co-operation and moisture control. Extraction and referral for general anaesthetic are not indicated for asymptomatic teeth where a less invasive caries-arresting strategy is available.

A 24-year-old patient presents with enlargement of the maxillary anterior gingivae, which bleed during toothbrushing. They are three months post-renal transplant. Their oral hygiene is good and the remaining gingivae appear healthy.

Which medication is the most likely cause?

A. Carbamazepine
B. Ciclosporin
C. Citalopram
D. Clopidogrel
E. Cyclophosphamide

The correct answer is B.

Justification: Ciclosporin is a well-recognised cause of drug-induced gingival enlargement, particularly in transplant recipients. Risk factors include plaque accumulation, younger age and concomitant calcium channel blocker use. The enlargement typically affects the anterior gingivae and may be associated with bleeding. The other listed medications are not commonly associated with gingival overgrowth.

An 18-year-old patient presents with a painless bony swelling of the maxilla, diagnosed as fibrous dysplasia. They have previously been diagnosed with fibrous dysplasia, affecting a rib, and have café-au-lait skin macules.

Which syndrome is most likely to explain this presentation?

A. Brooke-Spiegler syndrome
B. McCune-Albright syndrome
C. Naevoid basal cell carcinoma syndrome
D. Neurofibromatosis type 1
E. Von Hippel-Lindau syndrome

The correct answer is B.

Justification: McCune-Albright syndrome is the single best answer because the patient has polyostotic fibrous dysplasia involving the maxilla and rib, together with café-au-lait macules. This combination is characteristic of fibrous dysplasia/McCune-Albright syndrome. Craniofacial fibrous dysplasia may present as a painless facial swelling or asymmetry, and fibrous dysplasia can involve multiple skeletal sites.

Neurofibromatosis type 1 is an important distractor because it is also associated with café-au-lait macules, but it is not classically associated with polyostotic fibrous dysplasia. Naevoid basal cell carcinoma syndrome is associated with odontogenic keratocysts, basal cell carcinomas and skeletal anomalies rather than this pattern. Brooke-Spiegler syndrome and Von Hippel-Lindau syndrome do not explain the combination of fibrous dysplasia and café-au-lait macules

A 30-year-old patient requires extraction of a painful carious lower first premolar. They report prolonged bleeding after a previous simple extraction, describing blood-stained saliva for several hours that settled with local pressure and required no professional intervention. They take no medication and have no personal or family history suggestive of a bleeding disorder.

What is the most appropriate management plan?

A. Arrange extraction in secondary care
B. Delay extraction and prescribe tranexamic acid mouthwash to be used pre-operatively
C. Proceed with extraction and provide routine post-operative haemostasis advice
D. Refer the patient to a haematologist before arranging extraction
E. Suggest the patient sees their GMP for further investigation

The correct answer is C.

Justification: A previous episode of minor self-limiting post-extraction bleeding, settling with local pressure and requiring no professional intervention, does not by itself indicate a bleeding disorder. In the absence of anticoagulant or antiplatelet medication, relevant medical history, family history, spontaneous bruising, mucosal bleeding or previous surgical bleeding, it is reasonable to proceed with routine extraction using careful local haemostatic measures and clear post-operative instructions.

Pre-operative tranexamic acid is not indicated without a diagnosed bleeding tendency or anticoagulation-related indication. Haematology referral or GMP investigation would be appropriate if the history suggested clinically significant bleeding, such as recurrent spontaneous bleeding, excessive surgical bleeding, prolonged bleeding requiring treatment, or a positive family history.

A patient requires emergency endodontic access of a mandibular first molar that has symptomatic irreversible pulpitis and apical periodontitis.

Which local anaesthetic approach is most likely to provide successful pulpal anaesthesia?

A. Buccal infiltration with 4% articaine
B. Gow-Gates mandibular nerve block with 2% lidocaine
C. Inferior alveolar nerve (IAN) block with 2% lidocaine
D. Inferior alveolar nerve (IAN) block with 2% lidocaine and buccal infiltration with 4% articaine
E. Inferior alveolar nerve (IAN) block with 4% articaine

The correct answer is D.

Justification: Mandibular molars with symptomatic irreversible pulpitis have a higher risk of failed pulpal anaesthesia following a conventional inferior alveolar nerve (IAN) block alone. A 2% lidocaine IAN block supplemented by buccal infiltration with 4% articaine is therefore the most appropriate option listed. The British Endodontic Society Practitioners Guide advises: Consider the use of supplemental techniques such as a buccal infiltration with articaine 4% following an IAN block with lidocaine 2%.