Patient
Management
The largest combined chapter of the OSCE — covering every patient who walks in with a system to manage, a clock that won't slow down, or a tooth knocked out on a soccer pitch. Two of the highest-yield blocks of the exam (Pain 12% + Medical Emergencies 12%) live here.
TMD & Headache Diagnosis
The diagnosis hinges on whether you hear a click, what direction the jaw deviates, and whether the headache is unilateral. Four TMD subtypes, four headache types — distinct enough that two clinical findings usually nail the answer.
Disc displacement: click present?
The four TMD subtypes
| Diagnosis | Pain | Sounds | Opening | Treatment |
|---|---|---|---|---|
| Myofascial Pain | Muscle tender, TMJ not tender, trigger points | None | Limited by pain — assisted opening > active | NSAID, heat, physio, bite plate, soft diet, muscle relaxant |
| DD with reduction | Sometimes — TMJ tender | Reciprocal click (open + close) | Normal · brief deviation | NSAID, heat (or cold if acute), physio, bite plate |
| DD without reduction | Common, especially acute | None (disc stuck anteriorly) | Limited · hard end-feel · deflection to affected side | Same · TMJ surgery if refractory |
| Osteoarthritis | Activity-related, moderate | Crepitus (grinding) | Limited · brief morning stiffness < 30 min | NSAID, cold, physio, bite plate · CBCT shows flattened condyle |
Headaches — four shapes
Migraine Unilateral
Throbbing/pulsating with aura (lights, vision loss), nausea, photophobia. Triggered by hormones, stress, or TMD pain.
Mgmt: NSAID/analgesic. Investigation if red flags or atypical aura.
Tension-type Bilateral
Squeezing, pressure-mild/moderate, like a tight band around the head.
Mgmt: NSAID, heat, physio, psychotherapy. TCAs for chronic prophylaxis.
Sleep-apnea headache Bilateral
Dull pressure-type on waking, resolves within hours.
Mgmt: Sleep study; CPAP for OSA.
Cluster Unilateral
Stabbing, around the eye + temporal region, lasts up to 3 h. Triggered by alcohol, smoking.
Mgmt: 100% O₂, triptans, ± neurology referral.
Dental & In-Office Emergencies
Nine emergencies — and one universal first instinct: position + oxygen. Memorize the one exception: hyperventilation. Cupped hands, no oxygen.
First-3-seconds protocol
The conscious-patient default.
Almost every conscious-patient response in this list opens the same way. Train it as one motion.
- Position. Supine + feet elevated for syncope/most. Upright for hyperventilation, asthma, anaphylaxis.
- Oxygen. Default yes. Skip only for hyperventilation.
- Specific drug. Glucose, salbutamol, epinephrine, nitroglycerin — one per emergency.
- Call 911 if patient unconscious, anaphylaxis, MI, CVA, severe asthma after Salbutamol failure.
The nine emergencies
Syncope
Most common in-office emergency. Pre: cold sweat, nausea. Syncope: dizzy, tachy > 120. Recovery: rapid once supine.
Unconscious Same + head-tilt/chin-lift.
Cardiac Arrest
Unresponsive, no pulse.
Hyperventilation
"Tightness in chest", SOB, dry mouth — can mimic MI.
Anxiety attack
Sudden terror, palpitations, sweating, paresthesia.
Airway Obstruction
Partial: cough/wheeze. Complete: universal choking sign. Phase 1 < 2 min, phase 2 LOC, phase 3 cardiac arrest.
Unconscious Supine + 911 + CPR.
Epinephrine reaction
Sharp BP rise, tremor, dizziness, headache after LA.
Mild allergic reaction
Itching, flushing, nausea, rhinitis. Typically Type IV (delayed) or contact dermatitis.
Anaphylaxis
Skin → eye/oral → GI cramps → bronchoconstriction → cardiovascular collapse.
Unconscious Supine + 911 + epinephrine + O₂.
LA toxicity
Talkative + slurred + metallic taste + tremor → tonic-clonic seizures + CNS depression.
Convulsing 911 + clear instruments + protect.
Unconscious 911 + CPR (maintain airway).
Medical Conditions & Defer Thresholds
When does elective treatment have to wait? Each condition has a numeric threshold or time window the OSCE expects you to know cold.
Always-defer thresholds
Hypertension
Defer elective tx. Hypertensive crisis: O₂ + 911. Always take pre-op BP.
Recent MI
Defer elective. After 30 days: minimize epi, avoid prolonged NSAID, schedule morning, sedation OK.
Recent CVA
Defer elective. If on warfarin: check INR; avoid aspirin/NSAID.
End-stage CKD
Hospital setting only. Avoid NSAIDs and tetracyclines at all stages of severe CKD.
Kidney transplant
Defer elective. Avoid NSAIDs for 6 months post-transplant.
Active TB / COVID
Defer elective. Active COVID emergency tx only at end of day.
By organ system — drug + dental considerations
| System / Disease | Avoid | Dental considerations |
|---|---|---|
| Hypertension | Prolonged NSAIDs · Erythromycin/Clarithromycin if β-blocker | Minimize epi · morning appt · sedation OK · pre-op BP |
| Ischemic / CHD | NSAIDs if on antiplatelet · Erythromycin/Clari if Ca-blocker · Nitroglycerin if Viagra/Cialis | Same as HTN |
| Congestive heart failure | NSAIDs · Erythromycin/Clari/Acetaminophen if on Digoxin | Same as HTN |
| Cardiac arrhythmia | NSAIDs if on antiplatelet · Macrolides (QT) | Minimize epi |
| Asthma | NSAIDs if persistent · Erythromycin/Clari if on theophylline | Morning appt · sedation OK |
| COPD | N₂O · Opioids · Erythromycin/Clari if on theophylline | Morning appt · sedation OK |
| Diabetes | Aspirin/NSAID if on sulfonylurea | Morning appt · glucometer: < 3.9 give glucose, < 11 defer |
| Adrenal insufficiency | — | Morning · sedation OK · supplemental corticosteroids · pre-op BP |
| Peptic ulcer / Crohn's / GERD | NSAIDs / Aspirin | GERD: treat at 45° angle |
| Hepatitis | Coordinate with physician | Symptomatic: defer · end-stage: hospital |
| Cirrhosis | Opioids · Amide LA | Medical consult |
| Epilepsy | — | Avoid orthostatic HPT · pre-op BP · sedation if poorly controlled |
| CKD GFR 15-30 | NSAIDs · tetracyclines | Medical consult |
Tooth Trauma — Adult & Primary
Six injury patterns, each with its own splint window. Primary teeth are different — and one rule is absolute: never reimplant a primary avulsion.
Splint times — adult permanent teeth
Subluxation
- Flexible splint if mobility
Extrusion
- + 4 wk if alveolar #
Avulsion
- If reimplant < 60 min
Lateral Lux
- Reposition first
Intrusion
- Surgical reposition if > 3 mm
Root #
- Apical/middle 1/3
- *4 mo if cervical 1/3
Adult tooth trauma — full table
| Injury | Pulp / Mobility | Radiograph | Treatment |
|---|---|---|---|
| Concussion | Pulp+ · normal mobility · non-displaced | None | Observe 1 yr. Necrosis: RCT (mature) or apexification/regen (immature). |
| Subluxation | Pulp− likely · ↑ mobility · non-displaced · sulcus bleed | None | Observe. Flexible splint 2 wk if mobile. |
| Lateral luxation | Pulp− likely · immobile · displaced · alveolar # | ↑ PDL | Reposition + flexible splint 4 wk. Endo within 2-3 wk if mature. |
| Intrusion | Pulp− likely · immobile · infra-occluded | Absent PDL · CEJ apical | Immature: re-erupt 8 wk. Mature: surgical reposition + flexible splint 4 wk. Endo within 2-3 wk if mature. |
| Extrusion | Pulp− likely · ↑ mobility · displaced incisally | ↑ PDL apically | Reposition + flexible splint 2 wk (+4 if alveolar #). |
| Avulsion | Tooth out of mouth | — | Reimplant < 60 min · flexible splint 2 wk · antibiotic (amox; clinda/doxy if PCN allergy) · CHX 0.12% bid × 2 wk · endo within 2-3 wk (mature). Open apex: same minus RCT, regen if necrotic. |
Primary tooth trauma
| Injury | Treatment |
|---|---|
| Concussion / Subluxation | Observe + CHX rinse. |
| Extrusion | If non-interfering with occlusion → spontaneous repositioning. If > 3 mm or excessively mobile → extract. |
| Lateral luxation | Mild: spontaneous. Severe: reposition + flexible splint 4 wk. |
| Intrusion | Observe — allow spontaneous repositioning. Always radiograph to check successor. |
| Avulsion | Do NOT reimplant. Radiograph to confirm no fragments. CHX rinse. |
Tooth Fractures
Crown · Crown-Root · Root · Alveolar. Treatment escalates with depth and pulp involvement.
Fracture zones & treatment escalation
Adult fractures — quick reference
| Type | Treatment |
|---|---|
| Enamel craze / infraction | Observe; restore if severe |
| Enamel only | Bond fragment if available; or recontour + composite |
| Enamel-Dentin (no pulp) | Bond fragment or composite (small < 0.5 mm) covering exposed dentin |
| Enamel-Dentin + pulp | Direct cap or partial pulpotomy (depending on size). Bond fragment or restore. |
| Crown-root no pulp | Emergency: stabilize to neighbours. Definitive: comprehensive tx. |
| Crown-root + pulp | Emergency: stabilize. Definitive: immature → partial pulpotomy + restore. Mature → RCT + restore. Non-restorable → extract. |
| Root fracture | Reposition coronal. Apical/middle 1/3 → flexible splint 4 wk. Cervical 1/3 → splint up to 4 mo. Future necrosis → endo of coronal segment only. |
| Alveolar fracture | Reposition + flexible splint 4 wk. Endo if necrosis. |