3rd molars and general extractions Flashcards
What is healing by primary intention
Defect is small and surrounding tissue is slack enough to allow advancement of flap for closure.
Best outcome as adjacent area is similar quality of tissue without need for separate donor site. Heals faster,
Nerves at risk from the XLA of a 3rd molar
Lingual n
Mylohyoid n
IA n
Long Buccal n
Strong ind for XLA of 8’s
- 1/more episodes of inf/pericoronitis
- caries and unrestorable
- periodontal disease in association with position
- dentigerous cyst formation
- External resorption
Ind for XLA of 3rd molar
- 1/more episodes of inf/pericoronitis
- Predisposing risk factors - submariner
- MH where retention poses serious implications
- GA administration for 1 3rd molar removal (to avoid repeat GAs)
- Fracture of mandible
- unerupted inatrophic mandible
- Atypical pain but avoid confusion with TMD
- closed to implant area, partially erutped
Not advisable for XLA of third molar
- 3rd molar seems to be erupting into a favourable position and become part of dentition
- MH means risk of procedure greater than benefit
- ## risk of surgical complication greater than benefit
History for 3rd molar XLA
Patient's details Presenting complaint/HPC MH DH SH
Important aspects of clinical assessment of 3rd molar
Eruption status Caries Periodontal status Infection present Rg - orientation and proximity to IDN Occlusal relationship TM function Lymphadenopathy
Important aspects of Rg assessment
Orientation of tooth - impaction angulation Proximity to IDN/ max sinus Crown size and condition Root no. and morphology Periodontal status Follicular width Pathology - dentigerous cyst
Rg signs of increase risk of IDN damage
- Narrowing of IA canal
- Diversion of IA canal
- Interuption of canal tramlines
- Darkening of root when crossing canal
- Deflection of root
- Juxta apical area
Types of angulation/orientation
Horizontal Vertical Transverse Mesial Distal
-Against curve of Spee
Types of Depth
Superficial
Moderate
Deep
- to 7 crown
What is pericoronitis
-how can it occur
inflammation of the soft tissue adjacent to the crown of a tooth
- communication between oral cavity and tooth
- Food/bacteria trapped under operculum and is difficult to clean
Signs/symps of pericoronitis
- pain - biting/constant
- swelling
- pus disharge
- erythema
- Occlusal trauma
- ulceration of operculum
- bad taste/halitosis
- trismus
- dysphagia
- pyrexia/malaise
- regional lymphadenopathy
Spread of infection in 3rd molars
Buccal
Submandibular/sublingual
Submasseteric
Paratonsillar
Treatment of pericoronitis
- Incision and drainage
- Irrigate with warm saline
- XLA of opposing 3rd molar (operculum trauma)
- advise/prescribe analgesia
- Talbot’s iodine
- Only prescribe AB’s if systemic involvement
Consent aspects for 3rd molar XLA
-Warnings
VERBAL AND WRITTEN - GA/IV/LA
- Explain procedure (what to expect in lay terms)
- damage to adjacent tooth/restoration
- jaw fracture
- pain/swelling/bruising/bleeding
- Trismus
- Dry socket
- Dysaesthesia
- Infection
Nerve
- IDN - Temp: 2.7-36% - Perm: <1%
- Lingual - Temp: 0.25-3.6% Perm: 0.14-2%
- Altered taste
Surgical principles
Wide based incision Scalpel one continuous stroke No sharp angles Flap reflection to bone Adequate sized flap Minimise damage to dental papillae No crushing Keep tissue moist Don't close wounds under tension Aim for healing by primary intention
Why retract tissue
Better access and vision
- Howarth’s periosteal elevator/rake retractor
How to remove bone
Straight electrical handpiece
Coolant and aspiration
Rosehead/fissure bur - tungsten carbide
Deep narrow gutter
Principles of elevator use
- mechanics
Mechanical advantage
careful application of force to loosen tooth prior to foreceps
removal of retained roots/apices
- Wheel and axel
- Wedge
- Lever
Post op advice
- Expect pain - analgesia
- swelling/bruising - cold pack
- Rinse out mouth with salt water from day after XLA
- Keep area as clean as poss
- eat softer/cooler foods as not to damage area/encourage bleeding
- not stick anything in socket
- Not smoke for at least 48hr
- Avoid alcohol for 24hr
- Haemostasis advice - damp gauze
- LA - bite gum/cheek
- sutures
What is a coronectomy and what is it used for
Alternative to whole tooth XLA if increased chance of IAN damage
Risks of coronectomy
-if root mobilised this may also be removed
-leaving roots behind can eventually lead to an infection
-
Coronectomy procedure
- Flap design
- Transsect tooth 3-4mm below enamel of crown
- Elevate crown with an elevator carefully
- irrigate socket and replace flap
Follow up 1-2weeks
Upper third molar XLA - Procedure
Elevation only/Elevation and foreceps
MUST support tuberosity
Perioperative complications - 3rd molars
- Difficult access
- # of adjacent tooth/restoration
- # of mandible
- loss of tooth
- Haemostasis failure
- soft tissue injuries
Upper
- Tuberosity #
- OAC
- Root in antrum
Post op complications - 3rd molars
Pain Bleeding Bruising Swelling Trismus Altered taste Para/dysaesthesia Dry socket Infection Osteomyelitis MRONJ
Aspirin
-Type of drug
-Use
NSAID
Dental and TMJ pain
Cardiac
Aspirin
=properties (4)
Analgesic - peripheral
Antipyretic - prevents temperature rise (IL-1 reduced)
Metabolic->BMR, PLTs, Prothrombin and blood sugar
Anti-inflammatory - < prostaglandins means less redness and swelling
Physiology of pain
Trauma and infection lead to the breakdown of
membrane phospholipids producing arachidonic
acid
-Arachidonic acid can be broken down to form
prostaglandins
- Prostaglandins sensitise the tissues to other inflam products = PAIN
Aspirin
Mechanism
-Aspirin reduces production of prostaglandins
-It inhibits cyclo-oxygenases (COX-1 & 2)
-It is more effective at inhibiting COX-1
-COX-1 inhibition reduces platelet aggregation
and predisposes to damage of the gastric
mucosa
Aspirin
-Adverse effects
- GIT problems
- Hypersensitivity
- Overdose – tinnitus, metabolic acidosis
- Aspirin Burns - Mucosa
How can Aspirin cause GIT issues
-who should AVOID aspirin
Mostly on mucosal lining of stomach
-Prostaglandins (PGE
2 & PGI2)
-inhibit gastric acid secretion
-Increase blood flow through the gastric mucosa
-Help production of mucin by cells in stomach lining
(cytoprotective action
-STOMACH ULCER and GORD
ASTHMATICs
Aspirin overdose symps
Hyperventilation
- Tinnitus, deafness
- Vasodilatation & sweating
- Metabolic acidosis (can be life threatening)
- Coma (Uncommon)
Name the 13 groups of patients that should AVOID taking Aspirin
- Peptic Ulceration
- Epigastric pain
- Bleeding abnormalities
- Anticoagulants
- Pregnancy/breast-feeding
- Patients on steroids
- Renal/Hepatic
impairment - Children & Adolescents
under 16 years - Asthma
- Hypersensitivity to other
NSAIDs - Taking other NSAIDs
- Elderly
- G6PD-deficiency
Aspirin:
Why avoid in children?
Reye’s Syndrome:
- Very serious, up to 50% mortality
- Contraindicated if under 16 years
- Avoid during fever or viral infection in adolescents
- Contraindicated in breast-feeding
MAX dose of ibuprofen for an adult
2.4g
Caution when prescribing ibuprofen in these pt groups (8)
- Previous or active peptic ulceration
- The Elderly
- Pregnancy & lactation
- Renal, cardiac or hepatic impairment
- History of hypersensitivity to Aspirin & other NSAIDs
- Asthma
- Patient taking other NSAIDs
- Patients on long term systemic steroids
Side effects of ibuprofen
GIT discomfort, occasionally bleeding & ulceration
- Hypersensitivity reactions e.g. rashes, angioedema &
bronchospasm - Others: headache, dizziness, nervousness, depression,
drowsiness, insomnia, vertigo, hearing
disturbance/tinnitus, photosensitivity, haematuria, blood disorders, fluid retention, renal impairment, hepatic damage, pancreatitis, eye changes,
Stevens-Johnson
syndrome & others (see BNF)
Name some drugs that can interact with ibuprofen
ACE Inhibitors
* Other Analgesics
* Antibacterials
* Anticoagulants
* Antidepressants
* Antidiabetics
* Corticosteroids
* Cytotoxics
* Diuretics
* Beta-blockers
* Calcium-channel blockers
* Cardiac glycosides
* Ciclosporin
* Clonidine
* Clopidogrel (an antiplatelet
drug)
* Lithium
* Tacrolimus
* Vasodilator Antihypertensives
What do NSAIDs do to Cyclo-oxygenase
NSAIDs inhibit cyclo-oxygenases and so
reduce prostaglandins (which sensitise the
tissues to other inflammatory mediators
resulting in pain).
What do NSAIDs do to Cyclo-oxygenase
NSAIDs inhibit cyclo-oxygenases and so
reduce prostaglandins (which sensitise the
tissues to other inflammatory mediators
resulting in pain).
Functions of COX-1 (cyclo-oxygenase 1)
predominantly responsible for
catalysing the reaction that produces
prostaglandins associated with:
-Platelet aggregation
-Protection of the gastric mucosa
