The task
Assume that today's date is 22 October 2026. You examined Mrs Wisniewski and took a panoramic radiograph today.
You are Dr Hui Xie, a general dental practitioner in private practice. Using the information in the case notes, write a letter to Dr Prakash Kamath, an oral and maxillofacial surgeon, referring Mrs Wisniewski for assessment and surgical removal of her impacted lower left third molar. Address the letter to Dr Prakash Kamath, Oral and Maxillofacial Surgeon, Oral and Maxillofacial Surgery Clinic, 45 Park Road. In your answer: expand the relevant notes into complete sentences; do not use note form; use letter format. The body of the letter should be approximately 180–200 words.
Length: the body of the letter should be about 180–200 words. You have 45 minutes in the test: 5 minutes to read, 40 to write. Letter type: Referral letter.
Case notes
Patient details
- Name: Mrs Njeri Wisniewski
- DOB: 14/03/1962 (64 yrs)
- Address: 12 Elm Avenue
- Pt of practice since 2011; 6/12 recall
Social background
- Lives with husband (retired), who can drive her to and from appts
- Retired librarian; grows orchids
- Non-smoker; alcohol 1–2 glasses wine/wk
- Daughter's wedding in Dec; worried about 'looking swollen in the photos'
- Husband told staff she 'makes a fuss about everything'
- Complained receptionist was rude when appt rescheduled last month
Medical history
- Atrial fibrillation (dx 2019) on warfarin, managed by GP; target INR 2.0–3.0
- Current warfarin dose 5 mg daily (adjusted by GP 25/09/26)
- Hypertension: perindopril 5 mg daily
- Hypothyroidism: levothyroxine 100 mcg daily
- Allergy: penicillin (urticarial rash 1998)
- Hysterectomy 2009
Dental history
- Extraction 46 in 2015 (before warfarin), uneventful healing
- Pericoronitis around 38 x3 episodes in last 8/12 (Feb, Jun, Sep 26)
- Sep episode (19/09): pain, swelling, trismus → irrigation + metronidazole 5/7 (penicillin allergy)
- INR ↑ to 3.6 following metronidazole course (interaction) → GP adjusted warfarin dose
- Recent INRs (GP): 2.4 (11/08/26), 3.6 (24/09/26), 2.6 (08/10/26), 2.5 (20/10/26)
- Dental anxiety; requests IV sedation if possible
- Oral hygiene good; brushes BD, flosses daily
Examination 22/10/26
- 38 partially erupted, mesioangular; operculum mildly inflamed, no pus; no trismus; no lymphadenopathy
- Lower lip and chin sensation normal bilaterally
- 48 fully erupted, functional, asymptomatic
- Pt asked for 'a clean' at same visit → scale and polish done
Radiograph
- OPG 22/10/26: 38 mesioangular impaction; roots overlap inferior alveolar canal, with darkening of roots and interruption of canal white line
- Suggests close relationship to IAN; CBCT may be required (specialist to decide)
- OPG image to be sent electronically with referral
Plan
- Risks discussed incl. bleeding and altered sensation lip/chin; pt wishes to proceed
- Advised not to stop or change warfarin unless instructed by surgeon/GP
- Refer OMFS: assessment and surgical removal 38 ± CBCT; periop anticoagulation management to be planned with GP
- Interim: chlorhexidine 0.2% mouthwash, warm saline rinses; urgent dental review if spreading swelling or fever; attend ED immediately if difficulty swallowing; call ambulance if difficulty breathing
- Routine recall 6/12
Who is reading, and what do they need?
Dr Kamath is a specialist surgeon who has not met the patient. He needs the surgical indication, the anticoagulation and INR picture, the allergy, the OPG findings and what the patient has been told. He does not need routine dental or social detail, so keep the letter focused on assessment and perioperative planning.
What to include
Selection is the skill the Content and Conciseness criteria reward. These notes earn their place:
| Case note | Why it belongs |
|---|---|
| Pericoronitis around 38 three times in 8 months (Feb, Jun, Sep 26) | This is the indication for surgical removal, and the dates show the recurrence the surgeon is asked to act on. |
| Sep episode: pain, swelling, trismus; irrigation and metronidazole 5/7 because of penicillin allergy | It shows the latest episode's severity and why metronidazole was used, and records the allergy that affects the surgeon's later antibiotic choice. |
| INR rose to 3.6 after metronidazole; GP adjusted warfarin dose | The drug interaction is directly relevant to any further antibiotic use around surgery and to perioperative planning. |
| AF on warfarin, target INR 2.0–3.0, 5 mg daily; INRs 2.4, 3.6, 2.6, 2.5 | The surgeon needs the indication, target range and dated results, including the most recent on 20/10/26, to plan bleeding management. Other regular medications can be named briefly. |
| OPG: roots overlap the canal, root darkening, interrupted white line; suggests close IAN relationship | These findings justify specialist assessment and possible CBCT. They must be reported as suggestive, not as proof of nerve involvement. |
| 38 partially erupted, mesioangular, mildly inflamed operculum; lip and chin sensation normal | Current clinical status and a documented baseline sensation help the surgeon compare findings before and after any surgery. |
| Risks discussed including bleeding and altered lip/chin sensation; wishes to proceed; told not to alter warfarin | Shows consent discussion has started and that the patient has been told not to change warfarin unless instructed. Also states that perioperative anticoagulation is to be planned with the GP. |
| Dental anxiety; requests IV sedation; husband can drive her to and from appointments | The sedation request affects the surgeon's planning, and the husband's availability to drive her is a practical safety point if sedation is used. |
What to leave out or compress
| Case note | Why it goes |
|---|---|
| Daughter's wedding in Dec; worried about looking swollen in photos | Looks relevant to timing, but the notes give no request about scheduling or urgency, so it is personal concern and not a clinical reason for referral. |
| Husband said she 'makes a fuss about everything' | It is a third-party opinion with no bearing on the surgical decision, and including it could undermine the patient. |
| Complaint that the receptionist was rude over rescheduling | This is an administrative matter within the practice and has no clinical value for the surgeon. |
| Retired librarian, grows orchids, alcohol 1–2 glasses wine/wk, hysterectomy 2009 | None of this changes the surgical or anticoagulation planning. Alcohol is minimal and the others are background detail. |
| Scale and polish done at the same visit after she asked for 'a clean' | Routine care unrelated to the referral reason; including it would take words from the surgical and anticoagulation information. |
| Interim chlorhexidine, saline rinses, and escalation advice; routine recall 6/12 | The surgeon does not need this to assess the tooth. If any of it is mentioned, state all three escalation instructions from the notes, not a selection. |
A paragraph plan for this case
Open with the referral purpose and the patient's identifiers, then give the pericoronitis history and the antibiotic and INR event in one paragraph. Follow with warfarin status and INR results, then examination and OPG findings with the sedation request and what the patient has been told. Close with the specific requests and the shared plan with the GP.
Where candidates slip on this task
- Do not write that the nerve is involved or at close risk as fact. The OPG only suggests a close relationship to the IAN, and the CBCT decision belongs to the specialist.
- State the metronidazole and INR 3.6 sequence clearly with the dates given, and report the INRs as recorded without calling them a trend. The latest result is 2.5 on 20/10/26.
- Check the dates and the count of episodes: three episodes in 8 months, with the September one on 19/09. Be clear that the warfarin dose was adjusted by the GP, not the dentist.
No model letter is published here. Write for the named reader from the case notes in the timed editor, then get it marked.
Write it in the timed editor and get marked on the 6 criteria
More Dentistry letter tasks
- Orthodontic assessment for increased overjet referral letter
- Persistent white patch on the tongue referral letter
- Update to the regular dentist: periodontal abscess drained in a patient with poorly controlled type 2 diabetes update letter
Your profession's guide: OET Dentistry. Layout and structure: OET letter format.
Questions about this task
Should I mention the penicillin allergy even though no antibiotic is being requested?
Yes. The allergy explains why metronidazole was used and why the INR rose, and it matters if the surgeon considers antibiotics around surgery. Give it briefly with its reaction and year.
How much of the INR history should be included?
Give the target range, the current dose and the dated results, linking the 3.6 to the metronidazole course. The surgeon needs these for planning with the GP, so do not leave out the most recent result.
Sources
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