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Oral Surgery > 3rd molars and general extractions > Flashcards

3rd molars and general extractions Flashcards

1
Q

What is healing by primary intention

A

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,

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2
Q

Nerves at risk from the XLA of a 3rd molar

A

Lingual n
Mylohyoid n
IA n
Long Buccal n

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3
Q

Strong ind for XLA of 8’s

A
  • 1/more episodes of inf/pericoronitis
  • caries and unrestorable
  • periodontal disease in association with position
  • dentigerous cyst formation
  • External resorption
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4
Q

Ind for XLA of 3rd molar

A
  • 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
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5
Q

Not advisable for XLA of third molar

A
  • 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
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6
Q

History for 3rd molar XLA

A 
Patient's details
Presenting complaint/HPC
MH
DH
SH
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7
Q

Important aspects of clinical assessment of 3rd molar

A 
Eruption status
Caries
Periodontal status
Infection present
Rg - orientation and proximity to IDN
Occlusal relationship
TM function
Lymphadenopathy
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8
Q

Important aspects of Rg assessment

A 
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
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9
Q

Rg signs of increase risk of IDN damage

A
  • Narrowing of IA canal
  • Diversion of IA canal
  • Interuption of canal tramlines
  • Darkening of root when crossing canal
  • Deflection of root
  • Juxta apical area
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10
Q

Types of angulation/orientation

A 
Horizontal
Vertical
Transverse
Mesial
Distal

-Against curve of Spee

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11
Q

Types of Depth

A

Superficial
Moderate
Deep

  • to 7 crown
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12
Q

What is pericoronitis

-how can it occur

A

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
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13
Q

Signs/symps of pericoronitis

A
  • pain - biting/constant
  • swelling
  • pus disharge
  • erythema
  • Occlusal trauma
  • ulceration of operculum
  • bad taste/halitosis
  • trismus
  • dysphagia
  • pyrexia/malaise
  • regional lymphadenopathy
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14
Q

Spread of infection in 3rd molars

A

Buccal
Submandibular/sublingual
Submasseteric
Paratonsillar

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15
Q

Treatment of pericoronitis

A
  • 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
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16
Q

Consent aspects for 3rd molar XLA

-Warnings

A

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
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17
Q

Surgical principles

A 
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
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18
Q

Why retract tissue

A

Better access and vision

- Howarth’s periosteal elevator/rake retractor

19
Q

How to remove bone

A

Straight electrical handpiece
Coolant and aspiration
Rosehead/fissure bur - tungsten carbide
Deep narrow gutter

20
Q

Principles of elevator use

  • mechanics
A

Mechanical advantage
careful application of force to loosen tooth prior to foreceps
removal of retained roots/apices

  • Wheel and axel
  • Wedge
  • Lever
21
Q

Post op advice

A
  • 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
22
Q

What is a coronectomy and what is it used for

A

Alternative to whole tooth XLA if increased chance of IAN damage

23
Q

Risks of coronectomy

A

-if root mobilised this may also be removed
-leaving roots behind can eventually lead to an infection
-

24
Q

Coronectomy procedure

A
  • 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

25
Q

Upper third molar XLA - Procedure

A

Elevation only/Elevation and foreceps

MUST support tuberosity

26
Q

Perioperative complications - 3rd molars

A
  • Difficult access
  • # of adjacent tooth/restoration
  • # of mandible
  • loss of tooth
  • Haemostasis failure
  • soft tissue injuries

Upper

  • Tuberosity #
  • OAC
  • Root in antrum
27
Q

Post op complications - 3rd molars

A 
Pain
Bleeding
Bruising
Swelling
Trismus
Altered taste
Para/dysaesthesia
Dry socket
Infection
Osteomyelitis
MRONJ
28
Q

Aspirin
-Type of drug
-Use

A

NSAID
Dental and TMJ pain
Cardiac

29
Q

Aspirin
=properties (4)

A

Analgesic - peripheral

Antipyretic - prevents temperature rise (IL-1 reduced)

Metabolic->BMR, PLTs, Prothrombin and blood sugar

Anti-inflammatory - < prostaglandins means less redness and swelling

30
Q

Physiology of pain

A

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

31
Q

Aspirin
Mechanism

A

-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

32
Q

Aspirin
-Adverse effects

A
  1. GIT problems
  2. Hypersensitivity
  3. Overdose – tinnitus, metabolic acidosis
  4. Aspirin Burns - Mucosa
33
Q

How can Aspirin cause GIT issues
-who should AVOID aspirin

A

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

34
Q

Aspirin overdose symps

A

Hyperventilation
- Tinnitus, deafness
- Vasodilatation & sweating
- Metabolic acidosis (can be life threatening)
- Coma (Uncommon)

35
Q

Name the 13 groups of patients that should AVOID taking Aspirin

A
  1. Peptic Ulceration
  2. Epigastric pain
  3. Bleeding abnormalities
  4. Anticoagulants
  5. Pregnancy/breast-feeding
  6. Patients on steroids
  7. Renal/Hepatic
    impairment
  8. Children & Adolescents
    under 16 years
  9. Asthma
  10. Hypersensitivity to other
    NSAIDs
  11. Taking other NSAIDs
  12. Elderly
  13. G6PD-deficiency
36
Q

Aspirin:
Why avoid in children?

A

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

37
Q

MAX dose of ibuprofen for an adult

A

2.4g

38
Q

Caution when prescribing ibuprofen in these pt groups (8)

A
  1. Previous or active peptic ulceration
  2. The Elderly
  3. Pregnancy & lactation
  4. Renal, cardiac or hepatic impairment
  5. History of hypersensitivity to Aspirin & other NSAIDs
  6. Asthma
  7. Patient taking other NSAIDs
  8. Patients on long term systemic steroids
39
Q

Side effects of ibuprofen

A

GIT discomfort, occasionally bleeding & ulceration

  1. Hypersensitivity reactions e.g. rashes, angioedema &
    bronchospasm
  2. 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)
40
Q

Name some drugs that can interact with ibuprofen

A

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

41
Q

What do NSAIDs do to Cyclo-oxygenase

A

NSAIDs inhibit cyclo-oxygenases and so
reduce prostaglandins (which sensitise the
tissues to other inflammatory mediators
resulting in pain).

42
Q

What do NSAIDs do to Cyclo-oxygenase

A

NSAIDs inhibit cyclo-oxygenases and so
reduce prostaglandins (which sensitise the
tissues to other inflammatory mediators
resulting in pain).

43
Q

Functions of COX-1 (cyclo-oxygenase 1)

A

predominantly responsible for
catalysing the reaction that produces
prostaglandins associated with:
-Platelet aggregation
-Protection of the gastric mucosa

Oral Surgery (4 decks)

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