CDS Oral Surgery Flashcards
Process of acute apical abscess formation
Irreversible pulpitis - loss of tooth vitality - apical periodontitis - acute apical abscess
Infection from maxillary molar spreads buccally above the insertion of the buccinator
Spreads into buccal space causing buccal swelling
Maxillary molar infection breaks through buccally below the insertion of the buccinator
Drains into the mouth creating a draining sinus on the attached mucosa
Quite painless usually but a bad taste and possibly a bubble present
Why is infection from a maxillary molar more likely to spread buccally than palatally?
Infection follows the path of least resistance, bone is less dense buccaly
Which tooth in the upper arch is most likely to have infection spread palatally?
Lateral incisor - root is quite palatally placed
What happens if infection from maxillary tooth spreads upwards?
Into maxillary sinus - can cause sinusitis, rare
Infection from lower tooth spreads lingually and perforates the bone above the insertion of mylohyoid
Spreads into the sublingual space, creating a sublingual abscess
Infection from lower tooth spreads lingually and perforates the bone below the insertion of mylohyoid
Spreads into the submandibular space
Does sublingual or submandibular infection cause more problems?
Submandibular
Infection from lower tooth spreads buccally and perforates the bone above the insertion of buccinator
Draining sinus into the mouth
Infection from lower tooth spreads buccally and perforates the bone below the insertion of buccinator
Buccal space infection and swelling
Which direction is infection in the posterior lower teeth likely to spread?
Lingually - bone is thinner than buccally
Which direction is infection in the lower anterior teeth likely to spread?
Labially
What determines whether infection spreads into sublingual or submandibular space from the lower teeth?
Which tooth is affected in relation to the mylohyoid line
Premolars more likely to end up in the sublingual space
7 or 8 infections most likely into the submandibular space
Masticatory spaces
Pterygomandibular space
Infratemporal space
Deep temporal space
Superficial temporal space
Masseteric space
Infection can easily spread between lots of these spaces as all of them communicate with each other
Result of infection spreading to masticatory spaces on the muscles
Severe trismus - the muscles go into spasm
Pterygomandibular space
Bound by the mandible, medial and lateral pterygoid muscles
Infratemporal space
Infratemporal fossa region
Deep temporal space
Deep to temporalis
Superficial temporal space
Superficial to temporalis
Masseteric space
Between the masseter and the ramus of the mandible
Path of infection spreading to masticatory spaces
Sublingual/submandibular spreads backwards into the jaw
Where can infection spread to from masticatory spaces?
Lateral pharyngeal space
then
Retropharyngeal space
then
Prevertebral space
Clinical appearance of infection in the lateral pharyngeal space
Oral cavity has an area being pushed in around the lateral pharyngeal space, a bulge in the pharynx
Where can infection in the retropharyngeal space spread to?
Upwards - base of the skull
Downwards - superior mediastinum
Where can infection in the prevertebral space spread to?
Upwards - base of the skull
Downwards - inferior mediastinum
What can infection spread to the mediastinum cause?
Cardiac tamponade
What can infection spreading to the base of the skull lead to?
Abscess on the brain
Infection in the cavernous sinus
Infection can spread into the cavernous sinus, resulting in a cavernous sinus thrombosis - rare
Path of upper vs lower tooth infection to cavernous sinus
Upper - infraorbital space - valveless veins in this region - cavernous sinus
Lower - Lateral pharyngeal space - infratemporal space - pterygoid plexus which communicates with the brain - valveless veins - cavernous sinus
Infection from upperr anterior spread
Lip
Nasiolabial
Lower eyelid
Infection from upper lateral incisor spread
Palate
Face
Upper premolars and molars infection spread
Cheek
Infra-temporal region
Maxillary antrum (v rare)
Palate
Chronic draining abscess
Infection drains into mout
Blister forms, bursts, bad taste, disappears then comes back
Clinical sign of infraorbital infection
Loss of nasiolabial fold
Lower anterior teeth infection spread
Mental and submental space
Tend to stick there but could spread into the sublingual or submandibular space
Lower premolars and molars infection spread
Buccal space
Submasseteric space
Sublingual space
Submandibular space
Lateral pharyngeal space
Clinical sign of submandibular space infection
Can’t feel the border of the mandible
Surgical management of large abscesses
Sometimes under local, otherwise it requires hospital admission and GA
Establishment of drainage - get rid of pus
Incise the skin if necessary - if possible do this intra-orally, may need to be extra-orally
Remove source of infection - extirpate pulp or extract - ideally immediately but v difficult to anaesthetise pt when they have severe infection
Antibiotic therapy for large abscesses
Depends on lots of factors
Not offered if you can remove the cause and obtain proper drainage and no need in pts that are not systemically unwell
Consider
Toxicity
Desirability
Medical history
SIRS
Systemic inflammatory response syndrome
Raised temp
Raised HR
Raised resp rate
Raised white cell count
What does SIRS indicate?
Antibiotic therapy and urgent hospital referral
Anatomical consideration when incising submandibular abscess
Consider the marginal mandibular branch of the facial nerve, which runs down the border of the mandible and ends at the corner of the mouth.
Always go at least 2 fingers with below the inferior border of the mandible. If the branch is damaged it can stop patients smiling on that side of the face.
How to drain abscess once incised
Finger into the hole or Hilton technique
Hilton technique
To drain an abscess - use scissors or instrument with two ends, insert instrument in closed position and open in the incision, stretching the tissues.
Once you have surgically drained an abscess how is it managed?
Drain is sutured in for a few days and covered with a dressing
Dressing is repeatedly replaced until it is clean
Ludwig’s angina
Bilateral cellulitis of the sublingual and submandibular spaces
Ludwig’s angina features
Raised tongue
Difficulty breathing
Difficulty swallowing
Drooling
Diffuse redness and swelling bilaterally in submandibular region
SIRS
Why does Ludwig’s angina require urgent treatment?
Can compromise the airway
Is gram positive or gram negative purple?
Gram positive
Cocci vs bacili
Cocci - round
Bacili - rod shape
Streptococcus structure
chains
Capnophilic bacteria meaning
Need carbon dioxide to survive and grow
What type of microorganism does metronidazole work on?
Only strict anaerobes
Types of acquired resistance
Mutation
Acquisition of new DNA - transformation, transduction or conjugation
DNA transformation
Uptake of short fragments of naked DNA by naturally transformable bacteria
DNA transduction
Transfer of DNA from one bacterium into another via bacteriophages
DNA conjugation
Transfer of DNA material via sexual pilus, required cell to cell contact
Altered target site antibiotic resistance
The path of entry for the antibiotic into the bacteria cell has changed shape and the antibiotic can no longer get in the attack the inside of the bacteria
Pulp hyperaemia
Increased blood supply to the pulp
Pulp can recover from minor trauma at this stage, going back to normal or an acute pulpitis could develop
Sharp pain lasting for seconds when stimulated, resolving after stimulus
Caries approaching pulp but tooth can still be restored without treating pulp
Reversible pulpitis
Acute pulpitis
Sudden onset inflammation of the pulp
Constant severe pain
Reacts to thermal stimuli
Referral of pain/ poorly localised pain
Little response to analgesics
Becoming irreversible
This can become a chronic pulpitis which will flare up every now and then (goes between acute and chronic)
Chronic pulpitis spread out of the pulp chamber becomes
Acute apical periodontitis
Acute apical periodontitis can develop into ___ when actual infection is present (not just inflammation)
Acute apical abscess
Abscess
A collection of dead neutrophils and other cells
Chronic apical infection
Can go back and forth with acute apical abscess, when the abscess subsides but there is ongoing low grade infection around the apex
Apical cyst
Can form from long term chronic apical infection
Painless but can increase in size over time or become infected - painful
Open pulpitis symptoms
Can be less severe as the exposed pulp releases pressure
Acute pulpitis diagnosis
History
Visual exam
Negative TTP usually as PDL is not yet inflamed
Pulp testing is ambiguous
Radiographs won’t show much except from a big cavity
Diagnostic LA - numb the pt next to suspected tooth and see if the pain goes away
Removal of restorations if necessary
What can happen once there is an acute pulpitis?
It can to and fro with chronic pulpitis or develop into an acute apical periodontitis
Acute apical periodontitis diagnosis
Easy diagnosis
TTP
Tooth is non vital (unless traumatic)
Radiographs - loss of lamina dura, radiolucent shadow (may indicate an old lesion eg. flare up of apical granuloma), delay in changes of apex of tooth, widening of apical periodontal space and possible resorption of the root
Cause of traumatic periodontitis
Parafunction - clenching or grinding
Diagnosis of traumatic periodontitis
Clinical exam of the occlusion - functional positioning, posturing
TTP
Normal vitality
Radiographs - may show generalised widening or periodontal space
Treatment for traumatic periodontitis
Occlusal adjustment
Therapy for parafunction
Causes of acute apical abscess
Acute apical periodontitis can develop into this
Pericoronitis - inflammation around a crown, usually PE
Periodontal abscess - pulp is fine, abscess develops directly in the periodontium
Sialadenitits - infection of the glands, usually one of the major salivary glands, resulting in swelling and redness, dryness and pus
Acute apical abscess organisms
Polymicrobial
Anaerobes play an important part
Strep anginosus, prevotella intermedia both common
Antibiotics effective against strep anginosus examples
Penicillin
Erythromycin
When does antimicrobial resistance occur?
When microorganisms such as bacteria viruses fungi and parasites change in ways that render the medications used to cure the infections they cause ineffective
How do antibiotics fight infection?
Inhibit bacterial cell wall synthesis, damage cell membranes, disrupt bacterial metabolism and restrict the ability to multiply
Broad spectrum antibiotics
Target several classes including good bacteria, making them unsuitable for self limiting conditions
Where can antibiotic resistant bacteria occur?
In anyone who uses antibiotics, and can live in that person for up to a year
Altered target site
Mechanism of antibiotic resistance
The way that the antibiotic gets into the bacteria cell has changed shape and the antibiotic can no longer get in to attack the inside of the bacteria
Enzymatic inactivation
Mechanism of antibiotic resistance
Bacteria produces enzymes which destroy antibiotics or prevent binding to target sites and having effect on the bacteria
What is the usual antibiotic resistance mechanism of prevotella and fusobacterium?
Beta-lactamase enzymes
Carbapenems
New class of beta lactam antiobiotics developed to counteract ESBLs
Almost generate a forcefield around the beta lactam molecule
(BUT bacteria have developed a carbapenemase enzyme)
ESBLs
Extended spectrum beta lactamases
Enzyme produced by bacteria which reduce the choice of antibiotics that can work
CPE
Carbapenemase producing eneterobacterales - almost untreatable
Enterobacterales
Group of gram negative bacili found in common infections such as E.coli
Last therapeutic option to treat complex infections caused by multi drug resistant bacteria
Carbapenems
Decreased uptake mechanism
Mechanism of antibiotic resistance
Thick gelatinous capsule around bacterial cell wall - very difficult to get antibiotics to penetrate the mucopolysaccharide
What is the key to treating any dental infection?
Remove the source - extraction or extirpation of the pulp
Methods of resistance
Mutation
Inactivation
Efflux - antimicrobials pumped out of cell
Two routes of infection from oral cavity to periapical region
Through crown - carious cavity or trauma -> pulp -> apical foramen
Via periodontal ligament
Endogenous infection
Infectious agent is derived from our own flora
Examples of microbial agents involved in acute dental infection
Strep anginosus (gram +ve cocci)
Prevotella intermedia (gram -ve bacili)
What clinical specimen is best for investigation of microbials in acute periapical infection?
Aspirated pus (has not been contaminated with saliva flora)
Examples of microbial agents involved often in periodontal abscess
Anaerobic streptococci
Prevotella intermedia
Treatment for localised infection
Establish and document a diagnosis
Remove the source of infection
Examples of microbial agents involved in pericoronitis
Predominantly mixed oral anaerobes - e.g. P intermedia, S.anginosis
Treatment for pericoronitis
Local measures such as operculectomy, systemic tx only if systemic symptoms, metronidazole if appropriate
Microbial cause of dry socket and tx
Localised alveolar osteitis
Mixed oral flora
Does NOT require antibiotics, local tx such as curettage of socket, rinse, alvogyl
Predisposing factors for osteomyelitis of the jaws
Bisphosphonate therapy
Impaired vascularity of bone (radiotherapy, Pagets disease)
Foreign bodies (implants)
Compound fractures
Impaired host defences (diabetes)
Treatment of osteomyelitis of the mandible
LA, curettage, IV antibiotics
Microbiology involved in osteomyelitis of the mandible
Anaerobic gram -ve bacilli
Anaerobic streptococci
S anginosus, S aureus
Management of salivary gland infection
Drain the pus
Flucloxacillin and metronidazole
Microbiology of salivary gland infection
S aureus and mixed anaerobes
What needs documented when treating an infection?
Diagnosis
Antibiotic choice, dose, route and duration
Review date
Document deviation from guidance
Ludwig’s angina
Bilateral infection of the submandibular space
Most commonly caused by anaerobic gram negative bacilli
Strep anginosus and anaerobic streptococci, could be staph aureus
Most common microbial associated with hospitalisation from dental infection
S milerii and mixed anaerobes
Sepsis
Life threatening organ dysfunction caused by disregulated host response to infection
SIRS + suspected/confirmed infection
SIRS
Systemic inflammatory response syndrome
Temp <36 or 38+
Heart rate >90/min
Resp rate >20/min
WCC <4000/μL or >12000/μL
Sepsis six
Give high flow oxygen
Take blood cultures
Give IV antibiotics
Give a fluid challenge
Measure lactate
Measure urine output
S I R for choice of antibiotics
Susceptible at standard dose
Susceptible at increased dose
Resistant even with increased dose
What is a breakpoint of an antibiotic?
A chosen concentration (mg/L) of an antibiotic which defines whether a species of bacteria is susceptible or resistant to the antibiotic
Resistance
A high likelihood of therapeutic failure even when there is increased exposure
Stewardship
An organisational or healthcare system wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness
A coherent set of actions which promote using antimicrobials responsibly
2 key ways of tackling AMR
Reducing the need for and unintentional exposure to antimicrobials
Optimising the use of antimicrobials
Responsibilities of stewardship
Vaccination
Infection prevention and control
Public health interventions - e.g sanitation, oral health
Antimicrobial prescribers
WHO global action plan on antimicrobial resistance 5 strategic objectives
Improve awareness and understanding
Strengthen the knowledge through surveillance and research
Reduce the incidence of infection
Optimise the use of antimicrobial medicines
Ensure sustainable investment
Recommended first line when antibiotics required for acute dento-alveolar infection
Phenoxymethylpenicillin
What is penicillin V most effective against?
Oral streptococci
Anaerobes
Selected gram negative cocci
Amoxicillin compared to Pen V
Possesses the same spectrum plus more active against gram negative cocci and members of the family enterobacteriaceae
Strep anginosus is invariably sensitive to _____
Amoxicillin and Pen V
what is the problem with using amoxicillin over Pen V?
Broader spectrum of activity so it has a greater impact on selection of resistance in the host micro flora
Recommended dose of first line antibiotics for acute dentoalveolar infection
Phenyoxymethylpenicillin
500mg 6 hourly 5 days
Important to review after 24-48 hours
Examples of unacceptable reasons for dental antibiotic prescribing
Workload pressures
Unsure of diagnosis
Treatment had to be delayed
Three examples of oral health conditions that antibiotics DO NOT WORK FOR
Acute pulpitis
Gingivitis
Sinusitis
Alternative causes of acute apical abscess (not usual route of acute pulpitis to apical periodontitis)
Periodontal abscess - pulp is fine, abscess develops directly in the periodontium
Pericoronitis - inflammation around a crown, usually partially erupted
Sialadenitis - infection of the glands, usually one of the major salivary glands, resulting in swelling and redness, dryness and pus
Cervico-facial actinomycosis
Very chronic pus producing infection which can develop after an extraction
5 cardinal signs of inflammation
Heat
Swelling
Pain
Redness
Loss of function
Symptoms of early stage abscess before the infection has broken through bone and into soft tissues
Almost identical to acute apical periodontitis
Severe unremitting pain
Acute tenderness in function
Acute tenderness to percussion
No swelling, redness or heat until the abscess spreads out from within the jaw bone
Symptoms of acute apical abscess that has perforate through bone
Pain often remits initially due to release in pressure (unless in the palate)
Swelling, redness and heat (in soft tissues) become increasingly apparent
As swelling increases pain returns
There is initial reduction in tenderness to percussion of the tooth as pus escapes into the soft tissues
Factors determining the site of spread of dental infection
Position of the tooth in the arch
Root length
Muscle attachments
Potential spaces in proximity to lesion that dental infection could spread into
Submental space
Sublingual space
Submandibular space
Buccal space
Infraorbital space
Lateral pharyngeal space
Palate
Need for antibiotics in case of dental infection is determined by
Severity
Absence of adequate drainage
Patients medical condition
Local factors
Local factors denoting need for antibiotics
Toxicity (if pt is systemically unwell)
Airway compromisation
Dysphagia
Trismus
Lymphadenitis
Location - floor of mouth
Systemic factors denoting need for antibiotics in case of dental infection
Immunocompromised pt - acquired causes (HIV), drug induces (steroids/cytostatics), blood disorders (leukaemias), poorly controlled diabetes, extremes of age
Reversible pulpitis
A level of inflammation in which returning to a normal state is possible if noxious stimuli removed
The pulp is inflamed due to caries or a restoration etc, if the cause is removed, the pulp will recover to normal health
Usually mild to moderate tooth pain, no pain without stimulus, subsides in <5secs, no mobility, no pain on percussion
Irreversible pulpitis
Higher level of inflammation where the dental pulp has been damaged beyond the point of recovery
Sharp throbbing sever pain upon stimulation and pain may be spontaneous or occur without stimulation, pain persists after stimulus is removed, >5secs
TX - RCT or extraction
Periapical granuloma
Chronic apical periodontitis
Mass of chronically inflamed granulation tissue at apex of tooth (plasma cells, lymphocytes and few histocytes with fibroblasts and capillaries)
NOT a true granuloma because not granulomatous inflammation (it has epithelioid histiocytes mixed with lymphocytes and giant cells)
Etiology of an apical radicular cyst
Caries/trauma/periodontal disease
Death of dental pulp
Apical bone inflammation
Dental granuloma
Stimulation of epithelial rests of Malassez (remnants of embryological origin)
Epithelial proliferation
Periapical cyst formation
% of minor salivary gland tumours that are malignant
40-50%
Coughing blood suggests
Lung cancer
Could be pharynx or larynx
When to make an urgent referral for suspected oral cancer?
Persistent unexplained head and neck lumps >3 weeks
Unexplained ulceration or swelling/induration of the oral mucosa persisting >3 weeks
All unexplained red or mixed red and white patches of the oral mucosa persisting for > 3weeks
Persistent (not intermittent) hoarseness lasting for >3 weeks
Persistent pain in the throat or pain on swallowing lasting for >3weeks
Ludwig’s angina
Pus either side of the mylohyoid line
Mylohyoid line
Bony ridge on the internal surface of the mandible, running posteriosuperiorly.
The site of origin for the mylohyoid muscle
Most important issue associated with Ludwig’s angina
Airway problems due to the swelling causing the tongue to rise up
Upper central infection tends to cause swelling where?
Lip
Upper laterals, canines and first premolar infections are likely to cause swelling where?
Eye
Upper 2nd premolar and molar infections are likely to spread and swell where?
Sinus, cheek, temple
Where is a lower incisor infection likely to cause infection?
Mental/submental
Where are infections of lower canines and premolars likely to cause swelling?
Submandibular
Where are lower molar infections likely to cause swelling?
Pharynx/cheek
What determines the spread of infection of a dental infection?
The root length of the tooth and its position in the arch in relation to the mylohyoid line
Triangle of danger
Named so because of the connection from the facial veins into the cavernous sinus
Infection which enters the veins in this area can cause cerebral abscess
Cavernous sinus
A vascular space under the pituitary gland, with nerves and blood vessels running through it
Types of elevators
Warwick James - right left and straight
Cryer’s - right and left
Coupland’s - size 1, 2, 3
Name and what they are used for
Left to right
Upper root forceps - retained roots
Upper straight forceps - upper anteriors
Upper universals - canines and premolars
Upper molar forceps (left and right)
Upper third molar bayonet forceps
Describe upper molar forceps and why are they shaped this way?
One rounded and one pointed beak
The pointed beak is designed to engage the furcation on the buccal side
Name and what they are used for
Left to right
Lower root forceps - retained roots
Lower universal forceps - lower incisors, canines and premolars
Lower molar forceps
Cowhorn forceps - lower molars, often broken down ones that are not easily gripped
Patient positioning for extractions
Upper tooth - supine 45-90 degrees
Lower tooth - more upright 0-45 degrees
At a comfortable height for the operator
Where should the operator be positioned for an extraction of a lower right tooth?
Behind the right shoulder
Where should the operator be positioned for extraction of an upper right tooth?
To the front of the patient on their RHS
Where should the operator be positioned for extraction of an upper left tooth?
To the front of the patient on their RHS
Where should the operator be positioned for extraction of an lower left tooth?
To the front of the patient on their RHS
Describe extraction technique with forceps
Make sure soft tissues are clear of the forceps
Position forceps as far down the tooth as possible without traumatising the gingivae
Place the thumb and forefinger of the non dominant hand on the alveolar bone to support it
Apply apical pressure and carry out extraction movements - on multi rooted teeth such as molars this is buccal expansion and figure of 8, on single rooted teeth (and sometimes premolars) use rotation
Procedure following extraction
Check apices are intact
Check socket is clear
If RR or bony sequestrum that is easily removed, remove it
Place dampened gauze and get patient to bite, applying pressure
Check for haemostasis after 5-10 minutes
Give post-op instructions
What are luxators and elevators for?
Used to aid extraction of retained roots and teeth
Used to aid mobility before using forceps
Luxator
Used to tear and sever the periodontal ligament, creating mobility
How do elevators work?
By creating space by using
- Wedge
- Lever
or
- wheel and axle
motions
How to tell the difference between a luxator and a coupland’s elevator?
Luxators have a rounded edge
Name and what are they used for
Warwick James (left, straight, right)
Used as elevators to create space
Particularly handy when extracting third molars
Left and right
Used as elevators to create space
Particularly useful when used in the furcation area of a molar tooth
How to hold elevators?
Bottom of the handle in the palm
Curve middle, ring and pinkie fingers around the handle
Put index finger on the shank for support and control
How to use a luxator?
Position the same as when using forceps
- Support alveolar bone with non dominant hand
- Luxate in the buccal sulcus from mesial to distal
Lack of stability can cause soft tissue trauma
How to use a Coupland’s?
Lever or wedge motion
Correct positioning when extracting a tooth allows you to..
Keep your arms close to your body
Provides stability and support
Allows you to keep your wrists straight enough to deliver adequate force with your arm and shoulder, and not with your fingers/hand, the force can thus be controlled in the face of sudden loss of resistance from a root or fracture of the bone
Types of suture technique
Simple interrupted
Horizontal mattress
Vertical mattress
Figure of 8
Continuous
What type of suture is this?
Vertical mattress
What type of suture is this?
Vertical mattress
What type of suture is this?
Horizontal mattress
Approximately how far from the wound edge should sutures be placed?
2-5mm
Describe a vertical mattress suture
A shallower, more superficial suture closer to the wound edge, within a deeper, further from the wound edge suture
Why use resorbable sutures?
In areas where the suture requires to be buried, or is difficult to remove
Used for most intra-oral wounds
Why use non resorbable sutures?
Sutures retain tensile strength and remain in the tissue until removed
Often used in areas where high tensile strength is required for a longer period of time
Such as OAC, skin closure, or to hold dressings when exposing canines
Example of resorbable mono filament suture
Monocryl
Example of resorbable polyfilament suture
Vicryl, Velosorb, Polysorb
Example of non resorbable monofilament suture
Nylon
Prolene
Example of non resorbable poly filament suture
Silk
What is the difference between monofilament and polyfilament?
Monofilament - sutures are made from a single strand. These are less likely to facilitate an infection because it is more difficult for bacteria to colonise on a single strand
Polyfilament - Sutures are made from several smaller strands twisted together and can be easier to handle. They are often contraindicated in contaminated wounds due to wicking
What is wicking/the wick effect?
Studies have shown multifilament sutures can absorb fluids and bacteria thus enabling infection to penetrate the body along the suture tract
Advantage of polyfilament sutures
Can be easier to handle
Disadvantage of polyfilament sutures
Wicking/ the wick effect
Advantage of monofilament sutures
Less likely to facilitate an infection because it is more difficult for bacteria to colonise a single strand
Consideration of LA in pregnant women
Citanest contains felypressin which may induce labour
Which type of elevator’s are you more likely to use wheel and axle motion with?
Cryer’s
Required INR for warfarin patients for extraction and which guidelines?
SDCEP
1-4
How do new oral anti-coagulants work?
by inhibiting the action of factor 10a on the coagulation cascade
Bones associated with the TMJ
Temporal
Sphenoid
Zygomatic
Maxilla
Mandible
Describe the structure of the mandible
2 superior processes - condyloid and coronoid
The mandibular notch is between the two
Inferior to this is the neck, the ramus and then the angle
Moving anteriorly there is the body of the mandible, beginning just lateral to the mental foramina, where the mental nerve exits to provide sensory innervation to the chin and some of the mandibular teeth. In the midline of the body is the mandibular symphysis.
Describe the internal aspect of the mandible
The mandibular foramen, where the inferior alveolar nerve enters into the mandibular canal and the submandibular fossa, which the submandibular gland is pressed against are on the internal aspect
A - Coronoid process
B - Angle
C - Ramus
D - Neck
E - Condyloid process
F - Mandibular notch
Body of the mandible (left)
Mental foramen
Where is the mental nerve derived from?
It is a branch of the inferior alveolar nerve which is a branch of the mandibular nerve which is the third division of the trigeminal nerve
What does the mental nerve innervate?
It provides sensory innervation to the chin and lip, anterior buccal mucosa and some mandibular teeth
Where does the mental nerve exit the skull through?
Mental foramen
Through what does the inferior alveolar nerve enter the mandibular canal?
Through the mandibular foramen
Where does the condyloid process articulate with to give the TMJ?
Mandibular fossa of the temporal bone
What is anterior movement of the TMJ limited by?
Articular eminence
Where is the articular eminence located?
On the zygomatic arch, just anterior to TMJ
A - zygomatic arch
B - articular tubercle/eminence
C - mandibular fossa
D - Styloid process
E - Mastoid process
F - External auditory meatus
What type of joint is the TMJ?
Synovial
What is the TMJ?
A synovial joint at the articulation between the condyloid process of the mandible and the mandibular fossa of the temporal bone, found in the a region known as infratemporal fossa
What is the region of the skull that TMJ is found in?
Infratemporal fossa
What splits the TMJ into an upper and a lower compartment?
Articular disc
A - articular disc
B - articular tubercle/eminence
C - Articular capsule
D - Ramus of mandible
E - Mandibular condyle
F - Inferior joint cavity
G - Superior joint cavity
H - Mandibular fossa
what is the difference between the upper and lower compartments of the TMJ?
Gliding movements such as protrusion and retraction or side to side are permitted in the upper
Rotational movements such as elevation and depression are permitted in the lower
What must happen before depression of the mandible will be allowed?
The condylar process must move anteriorly within the upper compartment of the TMJ
What will happen if the condylar process moves anteriorly beyond the articular eminence and how is this fixed?
MoM will spasm and TMJ will become dislocated
Put downward pressure on the lower molars and guide the head of the mandible back into the mandibular fossa
What is the lateral temporomandibular ligament and its role?
Attaches to zygomatic arch and posterior portion of the neck of the mandible
Limits posterior movement of the mandible
What limits posterior movement of the mandible?
Lateral temporomandibular ligament
1 - joint capsul
2 - lateral temporomandibular ligement
3 - sphenomandibular ligament
4 - styloid process
5 - stylomandibular ligament
What are the medial ligaments to the TMJ?
Sphenomandibular ligament
Stylomanidbular ligament
What is the function of the sphenomandibular and stylomandibular ligaments?
Limiting lateral movement of the TMJ
Where does the sphenomandibular ligament run from/to?
From the ramus to the sphenoid bone
Where does the stylomandibular ligament run from/to?
From the ramus to the styloid process
Muscles of mastication
Temporalis
Masseter
Lateral pterygoid
Medial pterygoid
Which bone are the pterygoid plates part of?
Sphenoid
Where are the pterygoid muscles located in relation to the mandible?
The pterygoid muscles are located medial to the mandible
Describe medial pterygoid structure
Has two heads
Deep head - attached to medial aspect of the lateral pterygoid plate
Superficial - attached to the maxilla and the palatine bones
Both heads run posterior inferiorly to reach a point at which they fuse and will then insert onto the ramus of the mandible
1 Lateral pterygoid
2 Medial pterygoid
Describe lateral pterygoid structure
Superior head attaches to the roof of the infratemporal fossa and the lateral portion of the lateral pterygoid plate
Inferior head attaches to lateral portion of lateral pterygoid plate
Moving posteriorly both heads will fuse and attach to the condylar process of the mandible
What happens when lateral pterygoid muscles act bilaterally?
They protrude the jaw
Which action of the lateral pterygoids is paramount to the opening of the mouth?
Acting bilaterally to protrude the jaw
What does unilateral contraction of the lateral pterygoids do?
Swings the jaw to the contralateral side
What does bilateral action of the medial pterygoid muscles do?
Closes the jaw and assists in protrusion
What does unilateral contraction of medial pterygoid muscles do?
Swings the jaw to the contralateral side
Where does temporalis arise from and attach to?
From the temporal fossa, attaching to the coronoid process of the mandible
Describe the difference between the anterior and posterior fibres of temporalis
The anterior fibres run vertically and will assist in closing the jaw
The posterior fibres run horizontally and will retract the mandible
Where is masseter located?
On the lateral side of the mandible
Structure of masseter
Superficial head - attached to zygomatic bone
Deep head - attached to zygomatic arch
Inferiorly both heads attach to the ramus and angle of the mandible
Action of masseter
Elevates the mandible to close the mouth
Innervation of muscles of mastication
All innervated by the mandibular division of the trigeminal nerve
When is the TMJ most stable?
When the jaw is closed with teeth in occlusion
What is the most common kind of TMJ displacement?
Anterior dislocation - the condyloid process moves anterior to the articular eminence and the MoM spasm, preventing retraction of the mandible
What opposes anterior dislocation of the TMJ?
Articular eminence, lateral temporomandibular ligament, and the contraction of medial pterygoid, masseter and temporalis
Origin of the masseter
2 origins
Zygomatic buttress of the zygomatic bone and medial aspect of zygomatic process of the temporal bone
Insertion of the masseter
Lateral surface of the angle of the mandible
Origin of temporalis
Temporal fossa
Insertion of temporalis
Coronoid process
Origin of medial pterygoid
Medial surface of the lateral pterygoid plate
Insertion of the medial pterygoid
Medial side of the angle of the mandible
Lateral pterygoid origin
2 origins
Lateral surface of lateral pterygoid plate and the base of skull/top of infratemporal fossa
Insertion of the lateral pterygoid
Pterygoid fovea at the condyle
Blood supply to the TMJ
Deep auricular artery (branch of the 1st part of the maxillary artery)
Nerve supply to the TMJ and why is this relevant to symptoms?
Auriculotemporal, masseteric, posterior deep temporal nerve
Auriculotemporal nerve also supplies parts of EAM and some with TMD get pain in the ear
Suprahyoid muscles
Digastric
Mylohyoid
Geniohyoid
Stylohyoid
Infrahyoid muscles
Thyrohyoid
Sternohyoid
Sternothyroid
Omohyoid
A Digastric (anterior belly)
B Geniohyoid
C Mylohyoid
D Stylohyoid
E Digastric (posterior belly)
A Thyrohyoid
B Sternothyroid
C Omohyoid (superior belly)
D Sternohyoid
E Omohyoid (inferior belly)
Which part of the articular disc can not feel pain and why?
The anterior band of the articular disc
Does not have sensory innervation
What does the articular disc do during jaw movements?
Slides back and forth with the condyle
Causes of TMD
Myofascial pain (muscles)
Disc displacement (anterior with or without reduction)
Degenerative such as osteoarthritis or rheumatoid arthritis
Chronic recurrent dislocation
Ankylosis (very rare)
Hyperplasia (one condyle grows more)
Neoplasia (tumours)
Infection (incredibly rare)
What could be a localised degenerative cause of TMD?
Osteoarthritis
What could be a systemic degenerative cause of TMD?
Rheumatoid arthritis
What does it mean if anterior disc displacement is ‘with reduction’?
With reduction - disc eventually slips back into place
Without reduction - stuck in front of the condyle permanently
Appearance of condylar hyperplasia
Facial asymmetry
Chin points away from the side of the condyle that is growing more
Possible neoplastic causes of TMJ (rare)
Osteochondroma - overgrowth of bone and cartilage
Osteoma - benign bony tumour
Osteosarcoma - malignant bone tumour
How to relocate a dislocated TMJ?
Hold jaw with thumbs inside the mouth on the buccal surfaces of lower molars and push down and backwards slowly
Sometimes muscle relaxants such as benzodiazepines are necessary
Possible pathogenesis to myofascial pain TMJ
Inflammation in the MoM or TMJ secondary to parafunctional habits
Trauma - either directly to the joint or indirectly such as sustained opening
Stress
Psychogenic
Occlusal abnormalities (no evidence)
Social history considerations for a TMD patient
Occupation, stress, home life, sleeping pattern, recent bereavement, relationships, habits, hobbies
E/O exam of TMD patient
MoM
Joint - clicks/ crepitus
Jaw movements
Facial asymmetry
Intra-oral exam for TMD patient
Interincisal mouth opening - could use Willis bite gauge
Signs of parafunction - tongue scalloping, biting cheeks, linea alba, occlusal NCTSL
When are you more likely to do special investigations for TMD?
Suspicion of pathology
Common clinical features of TMD
Females > males
Age 18-30
Intermittent pain of several months or years
Muscle/joint/ear pain, particularly on waking
Trismus/locking
Clicking/popping
Headaches
Potential differential diagnoses for TMD
Dental pain
Sinusitis
Ear pathology
Salivary gland pathology
Referred neck pain
Headache
Atypical facial pain
Trigeminal neuralgia
Angina
Condylar fracture
Temporal arteritis
What is temporal arteritis?
Inflammation of the temporal artery which can result in blindness
Presents as very severe pain in the temporal region
Treatment for TMJ dysfunction
Patient education
Counselling
Jaw exercises
Medication
(Electromyographic recording)
What medication can be used to treat TMD?
NSAIDs
Muscle relaxants
Tricyclic antidepressants
Botox
Steroids
What does TMD counselling include?
Soft diet
Masticate bilaterally
No wide opening
No chewing gum
Don’t incise food
Cut food into small pieces
Stop parafunctional habits
Support mouth on opening such as yawning
Physical therapy for TMD
Physiotherapy
Massage/heat
Acupuncture
Relaxation
Ultrasound therapy
TENS
Hypnotherapy
Examples of irreversible treatment for TMD
Occlusal adjustment
TMJ surgery
How might patients with TMJ disc displacement present?
Painful clicking TMJ
The click is due to a lack of coordinated movement between the condyle and the articular disc
Jaw tightness/locking
The mandible may deviate initially to the affect side
What can happen if TMJ disc displacement is left untreated?
Osteoarthritis
Treatment for TMJ disc displacement
Counselling, limited mouth opening, bite raising appliance (occasionally surgery)
What is this?
Jaw screw
For trismus
Placed between incisors then on twisting, opens the mouth
Treatment for trismus
Physio therapy
Therabite jaw rehabilitation system
Jaw screw
Guidelines for TMJ dysfunction
NICE
When would you refer a TMD patient to oral med or OMFS?
History of trauma or fracture to TMJ complex
Markedly limited mouth opening suggesting disc displacement without reduction
Pain or reduced function in people with rheumatic joint disease
Worsening symptoms lasting >3 months despite primary care tx
Other chronic pain comorbidities
Recurrent dislocation
Severe pain and dysfunction not responding to conservative management
What should you consider before assessing a trauma case?
ATLS - Advanced Trauma Life Support, treat the greatest threat to life first
ABCD - Airway, breathing, circulation, disability
What is the Glasgow Coma Scale?
Used to assess head injuries
Eye opening, verbal response and motor response are all considered and given points in order to give a GCS score
Glasgow Coma Scale scores
Mild 13-15
Moderate 9-12
Severe 3-8
Glasgow Coma Scale Eye opening scores
Spontaneous - 4
To sounds - 3
To pressure - 2
None - 1
Glasgow Coma Scale verbal response scores
Orientated - 5
Confused - 4
Words - 3
Sounds - 2
None - 1
Glasgow Coma Scale motor response scores
Obey commands - 5
Localising - 5
Normal flexion - 4
Abnormal flexion - 3
Extension - 2
None - 1
Indicators of mandible fracture
Sublingual haematoma
2 point mobility vertically
Abnormal sensation contralateral to the side of injury
Pain contralateral to the side of injury
Numbness that can’t be explained by direct injury to the nerve
What is needed to diagnose a mandible fracture?
2 regular Xrays or a CT scan
(there is no role for half OPGs)
How to manage a mandible fracture
Fast the patient
Analgesia - can swallow tablets with small amount of water
Antibiotics for open fractures - amoxicillin and metronidazole or equivalent
Liquid diet
Immediate discussion with OMFS team
What region would be considered a midface fracture?
Eyebrows to maxillary teeth, including zygoma
Important signs of broken bone in the midface
Epistaxis (nose bleed) without a blow to the nose
V2 numbness without a direct blow to the nerve
Subconjunctival bleed
Midface mobility
Malocclusion
Surgical emphysema around eye
Swelling after nose blowing
Diplopia
Change of appearance
Clear liquid CSF running out of nose
Diplopia
Double vision
What causes a subconjunctival bleed?
Seen in some midface fractures
Conjunctiva has been torn by the fracture, and blood turns the white of the eye deep red (not the whole eye)
Epistaxis
Nose bleed
How to check for midface mobility?
Hold forehead still and pull palate backwards and forwards
What is meant by surgical emphysema?
Air in the soft tissues
Seen around the eye in some midface fractures
What is required to assess a midface fracture?
2 Xrays
Le fort fractures
The face breaks in three particular patterns in the midface
All fractures extend into the pterygoid columns, if the pterygoids aren’t broken then you don’t have a Le Fort fracture
How to tell which type of Le Fort fracture?
Hold head and pull on teeth
If teeth move - Le Fort I
If nose moves - Le Fort II
If eyes move - Le Fort III
Management of zygoma fracture
No indication for routine antibiotics
Call OMFS - vast majority will be followed up in 7-10 days
No nose blowing
Soft diet for their comfort
Give warning re retrobulbar bleed, as this can lead to blindness (rare)
Retrobulbar bleed
Rare, sight-threatening emergency, that results in accumulation of blood in the retrobulbar space
Orbit fracture
Breaking of just the eye socket, deep segments rather than the rim - would be zygoma fracture
Management of orbit fracture
Ensure visual acuity and diplopia documented
Discuss with OMFS
Don’t bother CTing
No need for routine antibiotics
No nose blowing
Give warning re retrobulbar bleed
Indicators of an orbit fracture
Eyebrow sign - gas leaks and rises to just below eyebrow
Eye may be sunken or dropped down
When would you give warning about retrobulbar bleed?
Zygoma fracture
Orbit fracture
Management of maxilla fracture (le fort type)
Fast the patient
Antibiotics
Discussion with OMFS
Liquid diet
No nose blowing
Most will need assessed on the day
Pathognomic features of zygoma fracture
Unilateral epistaxis when the noe has not been injured
Eyebrow sign
Paraesthesia when trauma was distant to extraosseous infraorbital nerve
Buttress tenderness
Nasal Orbital Ethmoidal fracture pathognomic features
Retropositioned nose
Buttress not tender
Epistaxis
Often numb
Steps at IOR, pyriform, glabella
Hyperteloric (eyes drift apart)
Naso-maxillary fracture pathognomic features
Tender IOR/pyriform
Buttress intact
Often numb
Unilateral epistaxis without blow to the nose
Same as zygoma EXCEPT buttress
Where is the parasymphasis of the mandible?
Anterior to mental foramen
Most common imaging for midface fractures?
OPG and PA mandible
(two angulations of PA mandible for zygoma or orbit)
What does SIRS stand for?
Systemic inflammatory response syndrome
SIRS Systemic Inflammatory Response Syndrome criteria
Fever 38C +
Hypothermia <36C
Tachycardia - high pulse >90bpm
Tachypnoea - high breathing rate >20 breaths/min
Change in blood count (WBC count >1200)
Partial pressure CO2 <32mmHg
Hot potato syndrome
Infection causes raised floor of mouth, patient talks like they have hot potato in their mouth
Where must you never incise an intraoral abscess in GDP?
Floor of mouth
Should you suture the wound from draining an abscess?
No - allows more drainage
What are rongeurs?
Bone nibblers
Used to remove small fragments of bone
What excisional soft tissue surgery might be used for before provision of dentures?
Frenoplasty
Papillary hyperplasia
Flabby ridges
Denture induced hyperplasia
Maxillary tuberosity reduction
Retromolar pad reduction
Why might a labial frenoplasty be required?
Oral hygiene issues
What risk must be considered during a buccal frenoplasty?
Risk of damaging the mental nerve
When might a lingual frenoplasty be necessary?
Tongue tie
When might a buccal frenoplasty be necessary?
High buccal frenum in a denture patient
This would break the seal and displace the lower denture every time the patient moves
What should be done if denture associated papillary hyperplasia does not resolve with removal of the denture?
Excisional surgery
Vestibuloplasty
Surgery to deepen the sulcus in order to achieve better denture retention by having more space for extending the flange
When might hard tissue excisional surgery be considered before provision of dentures?
Removal of retained teeth/roots/pathology
Ridge defect correction (alveoplasty)
Mandibular tori
Maxillary tori
Maxillary tuberosity
Exostoses
Undercuts
Genial tubercle reduction
Mylohyoid ridge reduction
Why might retained roots or “buried” teeth become a problem in denture provision?
If the ridge resorbs these may end up palpable or visible and interfere with the fitting surface
What can be seen here and what is the most likely cause?
Well defined, unilocular, corticated radiolucency
Residual cyst - apical radicular cyst in relation to one of the teeth in the region, tooth has been removed but the cyst has remained
How would you manage this?
Biopsy to determine what it is
CBCT to see relation to the IAN
Then decide on final tx plan
What surgical technique would be used for this and why?
Alveoplasty to prevent interference with denture retention
What is the likely cause of this?
Retained lower anteriors for much longer than the posteriors
What is this and how would you manage it/why?
Knife edge ridge
This is sharp and can be uncomfortable when wearing a denture or traumatic to soft tissues
Smooth this ridge to make it more comfortable but do not take too much away as this could negatively affect denture retention
Management of a maxillary torus in denture patients
Surgically remove the bony projection OR design denture around it e.g. horseshoe shape
Why might a large maxillary tuberosity occur?
Large bony tuberosity OR lots of excess fibrous tissue surrounding normal bone
Which two structures on the mandible can become prominent and might require removal/reduction with very sever bone resorption?
Genial tubercle
Mylohyoid ridge
Examples of hard tissue augmentation procedures that might be done for denture patients
Autografts
Allografts
Xenografts
Synthetic grafts
Autografts
Bone taken from elsewhere in the body for a graft
eg hip bone being used to augment the maxillary ridge
Allografts
Bone taken from human cadavers for bone grafts
Commonly used for alveolar bone for implants
Xenografts
Bone from animals, usually cows, can be horses
Used to provide framework for bone regeneration
Pros/cons of synthetic bone grafts
No risk of disease transmission
No cultural/religious/ethical issues
Can be very effective but some can have a lower rate of being accepted by the body
Customisable to be exact shape/size/porosity that you want
When would inferior alveolar nerve relocation be done? And describe the procedure
In severe cases of bone resorption the mental foramen can end up at the surface
In some cases the entire IAN can be just covered by soft tissue rather than by bone
Denture fitted to these tissues will press on the nerve causing numbness and pain
To reposition you would open up to expose the nerve, drill a channel deeper down in the body of the mandible and reposition the nerve further down
Why might implants be provided for complete denture patients?
For implant retained overdentures
23 year old pt attends reporting pain from LL for 18 months, pt says pain is from wisdom tooth and asks for it to be removed. What do you want to know?
SOCRATES
HPC - past episodes of pericoronitis/antibiotics/swelling history
Systemic MH, meds, allergies
PDH, anxiety, previous extractions, any problems
SH - smoking, drinking, occupation, caring responsibilities
How will you carry out a comprehensive assessment of someone reporting signs of pericoronitis?
Extra oral
TMJs
Lymphnodes
Asymmetry
MoM
Mouth opening
Intra oral
Soft tissues
Dentition
Caries
Perio
OH
Working distance
L8 erupted?
Condition of adjacent 7
Presence of other 8s
Assessment findings
LL8 partially erupted- approx 1/2 occlusal surface is visible
LL8 appears vertically impacted on clinical examination
Operculum appears infllamed
Patient reports recurrent episodes of pain from LL quadrant and on examination you find this. What is your next step?
OPT
Report
OPT diagnostically acceptable
Vertical/slighty distoangular LL8 superficial impaction
LL8 crown healthy - no signs of caries
LL8 crown wider than roots
LL8 has at least 2 roots
LL8 apices appear close to ID canal but no signs of intimate relationship
LL7 appears sound
Adequate bone levels
Pericoronitis recurring LL8
What are the treatment options
Clinical review - monitor at regular examination, only require radiographs if change in signs or symptoms
Surgical removal of LL8
(No indication for further imaging or coronectomy in this case as no intimate relationship with ID canal, no indication for XLA UL8 as doesn’t look to be occluding against operculum)
What information do you need to give to ensure pt is making informed decision about surgical removal of LL8?
Discuss option of LA/Conscious sedation/GA (and referral if required)
Regarding procedure:
Pain, Swelling, Bleeding, Infection, Jaw stiffness, Dry socket
Temporary (2-20%) or Permanent (<1%) damage to nerve, possibility of numbness, tingling or painful sensation
Areas affected could include side of chin, lip, tongue, gums or cheek
Small risk of loss of taste
Surgical approach: cut in gum, bone removal which will feel like vibration/water, pressure, stitches (dissolving)
Usual age of eruption for third molars
18-24 years
When can crown calcification of 8s start to be seen radiographically?
7-9 for uppers
8-10 for lowers
(completed by about 18)
What age is root calcification of 8s complete?
18-25
How common is it that and adult has 1 or more third molars present?
1 in 4
Agenesis
Failure of an organ to develop
Is third molar agenesis more common in mandible or maxilla?
Maxilla
Is third molar agenesis more common in men or women?
Women
What age would you expect to see third molars radiographically, after which they almost never develop?
14
What is a common reason for older patients to have issues with third molars?
Third molars causing problems with dentures
Impacted
Tooth eruption is blocked
Failure to erupt into either a full or partial functional position, or at all
What is the most common reason for third molars failing to erupt?
Impaction
What are M3Ms usually impacted against?
Adjacent tooth, alveolar bone, surrounding mucosal soft tissue or a combination of these factors
Eruption of impacted third molars
Impacted third molars can be unerupted, partially erupted or fully erupted
Fully erupted
Whole occlusal surface through the mucosa and exposed to the oral cavity
Incidence of impacted lower 3rd molars
36-59%
Consequences of third molar impaction
Caries (in 8 or 7)
Pericoronitis
Cyst formation (often results from the failure of the follicle to separate)
What does it mean if a tooth appears unerupted clinically, but radiographically there is caries?
This suggests that there is a communication between this tooth and the oral cavity, since the bacteria is able to reach it and cause caries
Probe carefully distal to 7 to try to find this communication
4 nerves at risk during 3rd molar surgery
Inferior alveolar nerve
Lingual nerve
Nerve to mylohyoid
Long buccal nerve
Which two nerves are most likely to be damaged during third molar surgery?
Inferior alveolar nerve
Lingual nerve
Inferior alveolar nerve
Peripheral sensory nerve formed from the mandibular division of the trigeminal nerve.
Supplies all the mandibular teeth (on its side) and mucosa and skin of the lower lip and chin on that side
Inferior alveolar nerve and third molar relationship
Position in relation to the mandibular third molar varies greatly
Usually need radiograph before third molar surgery to see this
Risk to the nerve should be considered
Lingual nerve
Branch of the mandibular division of the trigeminal nerve supplying anterior two thirds of the dorsal and ventral mucosa of the tongue
Also gives off a branch which supplies lingual gingivae and FoM
Lingual nerve position
Lingual nerve varies in position
Close relationship to the lingual plate in the mandibular and retromolar area
At or above level of the lingual plate in 15-18%
Between 0.3-5mm medial to mandible
Must be very careful to avoid during third molar surgery
Guidelines for 3rd molar surgery
NICE and SIGN basically dictate that because of the related risks, you must be able to justify third molar surgery with pathology - caries, significant infection, perio, cyst
RCS FDS - more recent acknowledges that you might be delaying inevitable surgery which could make it more difficult in future, and recommended changing from a solely therapeutic approach to a mixed range of interventions
Therapeutic indications for third molar surgery
Infection - caries, pericoronitis, perio, local bone infection, most common
Cysts
Tumours
External resorption of 7 or 8
If there is any history of pericoronitis..
Removal of any symptomatic third molar should always be considered
1st and 2nd most common reasons for removal of third molars
1st caries
2nd pericoronitis
Why is restoring a caries lower 8 usually not done?
Access and moisture control make it very difficult
8s are not really necessary
What type of third molar impaction is more prone to causing bone loss distal to the lower 7
Horizontal and mesio angular impaction
What is the best way to reduce bone loss distal to a 7, if there is a horizontally or mesio angular impacted 8?
Early extraction of the third molar
Late removal, especially after age 30 has not been shown to improve periodontal status of the adjacent 7
Most common age range for cyst formation
20s-50s
When do cysts normally first become symptomatic?
When they become very large and/or infected
Most common type of cyst to be found associated with third molars
Indigenous cyst
Indigenous cyst
Arises from the reduced enamel epithelium separation from the crown
Are cysts associated with third molars more common in mandible or maxilla?
Mandible
Why is prophylactic removal or coronectomy of a disease free lower 8 to prevent cyst formation not routine?
This would prevent development of a cyst but the number of cysts that you’re going to prevent by doing this would be fairly small so it is not usually an indication
Tumours as indication to removal third molars
If the tumour is close to the lower 8 it might be extracted as part of a cancer, in part of the dissection as may other teeth
If the pt has tumour anywhere in the body and will be having radiotherapy, it might be indication to remove lower 8 because of the future ORN risk
Why might resorption be indication for third molar removal?
External resorption is the destruction of tissue, the cause of inflammation is often unclear but left untreated it is usually progressive
External resorption of the third molar or of the second molar caused by the third molar should always make us consider third molar removal
Most common age for external resorption of lower 7 by lower 8
21-30
(relatively rare)
Non therapeutic indications for extractions of third molars
Surgical indications
High risk of disease
Medical indications
Accessibility
Patient age
Auto transplantation
General anaesthetic
Examples of possible surgical indications for third molar removal
Tooth is within surgical field - orthognathic, fractured mandible, in resection of diseased tissue
What are high risk of disease indications for third molar removal?
Mesio angular or horizontally impacted lower 8
High risk of caries for 8 or 7 and of periodontal bone loss
Medical indications for removal of third molars
needing signed off dentally fit e.g. Awaiting cardiac surgery
Immunosuppressed (or about to become)
Before going on bisphosphonates
Before starting radiotherapy or chemotherapy
When might you be more likely to consider removal of 8s in a perfectly healthy patient?
If they have limited access to the dentist e.g. submariners
Why is patient age an indicator in 3rd molar removal?
Complications and recovery time increase with age, so it might make sense to taje the tooth out while the patient is young
Where would an 8 usually be moved to in autotransplantation?
Lower 6 position
Why might you be more inclined to take out a third molar in someone alongside other dental treatment?
If they were going for GA
Pericoronitis
Inflammation around the crown of a partially erupted tooth
Tooth is normally partially erupted
What causes pericoronitis?
Food and debris gets trapped under the operculum of a partially erupted tooth, resulting in inflammation or infection
Describe pericoronitis infection
Usually transient and self-limiting
Most common age for pericoronitis
20-40
General health factor in pericoronitis
Upper respiratory tract infection can become pericoronitis
What type of microbes are likely to be involved in pericoronitis?
Anaerobes
Examples of bacteria found in pericoronitis infections
Streptococci
Actinomyces
Prioponibacterium
Beta-lactamase producing prevotella
Bacteroides
Fusobacterium
Staphylococci
Pericoronitis signs and symptoms
Pain
Swelling
Bad taste/halitosis
Pus
Occlusal trauma to operculum
Ulceration of operculum
Evidence of cheek biting
Limited mouth opening
Dysphagia
Pyrexia
Malaise
Regional lymphadenopathy
What might be seen in severe pericoronitis?
Extra oral swelling
Most commonly starting at the angle of the mandible
Can spread anywhere, commonly submandibular areas
If pericoronitis infection spreads distobuccally under the masseter, what is this called? and give a characteristic sign
Submasseteric abscess
Pt can not open mouth
What symptom might arise from spread of pericoronitis infection into the parapharyngeal space?
Dysphagia
This might present with drooling
Pericoronitis treatment
IF pt is acutely symptomatic you might
- Incise pericoronal abscess
- Irrigate under operculum with chlorhexidine or saline using blunt syringe (10-20ml)
- Extract upper third molar if traumatising operculum
- Instruct pt on warm salt water or chlorhexidine MW
- Antibiotics if systemically unwell, extra-oral swelling, immunocompromised
- If large extra oral swelling, significantly unwell, trismus, dysphagia - refer to OMFS or A&E
(generally do not remove the third molar during an acute episode of pericoronitis)
Why is operculectomy now not done very often?
Within weeks or months the operculum grows back to where it was so not much is gained
Method of pericoronitis management that is no longer in favour
Operculectomy
Predisposing factors for pericoronitis
Partial eruption and vertical or distoangular impaction
Opposing maxillary 2nd or 3rd molar causing mechanical trauma
URTI
Stress/fatigue
Poor OH
Insufficient space between ascending ramus and distal aspect of M2M
White race
Full dentition
Most current guidelines on third molar management
RCS FDS
When is it appropriate to take out a third molar with no associated pathology?
If the risk and likelihood of it causing problems at some point in the future is too high
History during assessment of patient presenting with third molar
General appearance - asymmetry, difficulty speaking, look unwell
C/O and HPC
Medical history
Dental history
Social history
3 components of assessment of pt presenting with third molar
History
Clinical examination
Radiographic assessment (if indicated)
HPC for pericoronitis
How long, how many episodes, how often, severity, requirement for antibiotics
SOCRATES
Underlying systemic diseases that might interfere with normal healing
Diabetes
Chronic renal disease
Liver disease
Bleeding disorder
Immunosuppressed
Radio or chemotherapy
Medications relevant during third molar treatment planning
Contraceptive - increased risk of dry socket
Steroid therapy - increased risk of wound infection and delayed healing
Bisphosphonates - MRONJ
Anticoagulants and antiplatelets
What would you ask if a patient has previous extractions, and you are planning third molar management?
How did they find it?
Any sedation/GA
Surgical
Any delay in healing
Any issues post op
Extra-oral exam of patient presenting with third molars
TMJ
Mouth opening
Lymphadenopathy
Facial asymmetry
MoM
Why is it important to examine TMJ when a patient presents with third molars?
TMD can give pre-auricular pain very similar to pericoronitis
Good to know if there’s a click before surgery so that pt does not think surgery caused this
Intra-oral examination of patient presenting with third molar
Soft tissues
Dentition
M2M
Working space
Eruption status of M3Ms
Condition of dentition
Occlusion
Oral hygiene
Caries
Perio
When would you do radiographic assessment of a patient presenting with third molars?
Only if surgical intervention is being considered
What radiograph(s) would you take to assess third molars?
OPT
What can be determined from an OPT to assess third molars?
Presence or absence of disease
Anatomy of 3M (crown size, shape, condition, root formation, crown:root)
Depth of impaction
Orientation of impaction
Working distance
Follicular width
Periodontal status
Relationship or proximity of U8s to maxillary sinus, and L8s to IAN canal
Any other associated pathology
Superficial impaction
When the crown of the 8 is sitting at the same height as the crown of the adjacent seven
Deep impaction
When the crown of the 8 is at the same level as the roots of the adjacent 7
Moderate impaction
When the crown of the 8 is level with crown and root of the adjacent 7
Dental follicle
Tissue that surrounds the crown of a developing tooth
As the tooth pushes into oral cavity you normally lose this but if a tooth is unerupted this would appear as radiolucency
What does dental follicle becoming bigger than expected indicate?
Suggests pathology such as a cyst
Concern at anything over 2.5-3mm
Why is it important to discuss the relationship of the M3M with the inferior dental CANAL (not the nerve) when discussing radiographs?
Nerves can not be seen radiographically, you are looking at the canal
Signs of close proximity of M3Ms to the inferior dental canal
Interruption of the white lines/lamina dura of the canal
Darkening of the root where crossed by the canal
Diversion/deflection of the inferior dental canal
Deflection of root
Narrowing of canal
Narrowing of root
Dark and bifid root apex
Juxta apical area
Three radiographic signs associated with significantly increased risk of nerve injury during third molar surgery
Interruption of the white lines of the canal
Diversion of the canal
Darkening of the root where crossed by the canal
Juxta apical area
A well circumscribed radiolucent region lateral to the root of the third molar, usually not right at the apex
Usually well defined, can appear corticated
Lamina dura of the root still intact and appearance not pathological
What do guidelines suggest about further imaging after OPT for third molars
Where conventional imaging has shown a close relationship between the third molar and the inferior dental canal, CBCT may be of benefit
What information can CBCT give you on the relationship between M3M and inferior alveolar nerve canal?
Is there bone between the ID canal and apices of the tooth
Is the tooth actually compressing the canal
Why is CBCT better than CT for third molar assessment?
Limited FoV of CBCT is advantageous in terms of image reconstruction and the radiation dose to the patient
% of different angulations of third molars
Vertical 30-38%
Mesial around 40%
Distal around 6-15%
Horizontal 3-15%
Transverse or aberrant less common
Most difficult third molar angulation to remove
Distal
Most common third molar angulation
Mesial
What is angulation of third molars measured against?
Curve of Spee
Curve of Spee
Curve as you follow the natural cusps of the dentition
Angulation of M3Ms
LR8 is mesially impacted
LL8 is horizontally impacted
Why is it important to measure angulation of lower third molar impactions against the curve of spee?
It is easy to confuse a distal angulation with a vertical angulation
Distal is much more difficult to extract
Why are distally impacted M3Ms so difficult to extract
it is very unlikely you will get it out intact without distal bone removal, and the roots of distally impacted 8s are often very close to roots of the 7 so it can be difficult to get and application point and you need to be very careful not to damage the 7
Angulation of L8s
LR8 is horizontally impacted
LL8 is distally impacted
Angulation of L8s
LR8 is vertically impacted
LL8 is distally impacted
Angulation of LR8
LR8 is transversely impacted
Position of LL8
Aberrant position
Why is it good to assess depth of impaction radiographically?
Gives an indication of the amount of bone removal required
Depth of impactions of L8s
LR8 is moderate
LL8 is superficial
Depth of impaction
Superficial
Depth of impaction
Moderate impaction
What must be considered if 7 next to an impacted 8 has a large or overhanging restoration?
Risk of restoration fracture during extraction of the 8 - pt must be warned of this if they have
- Large restoration
- Crown
- Overhangs
If this happens the tooth would need to be temporised and dealt with later
Common treatment options for impacted M3Ms
Referral
Clinical review
Removal
Extraction of the maxillary 3rd molar
Coronectomy
Clinical review of M3M
Review signs and symptoms associated, can be done at regular review
No indication for radiographic assessment unless clinically there are signs/symptoms
Coronectomy of M3M
Removing the crown and leaving the roots in situ
Only usually considered if close relationship between M3M and IAN canal
Less common treatment options for M3Ms
Operculectomy
Surgical exposure
Pre-surgical orthodontics
Autotransplantation
Important aspects of decision making in M3M treatment planning
Decision should be made jointly between patient and clinician
Patient involvement - communicate findings, risk status, tx options including risks and benefits
Good notekeeping
Current status of patient and M3M
Risk of complication
Patient access to treatment
How to manage asymptomatic 3rd molars with disease present or high risk of disease development
Clinician should use their expertise to assess the risk eg of caries, perio, etc then consider surgical intervention
This might be affected by risk of complications eg proximity to IAN canal in which case the decision might be active surveillance
Active surveillance of M3M
Monitoring the tooth with radiographs at regular intervals
Sometimes done for asymptomatic M3Ms either with disease present or high risk of disease developing
What can you consult for M3M treatment planning?
Summary of the management of patients with Mandibular Third Molars from the RCS FDS guidelines
Management of asymptomatic M3M with no disease present/low risk of disease
Clinical review is likely to be the most appropriate management
Pt medical history may change this e.g. if tooth is in surgical field
Management of symptomatic M3M with high risk of or disease present
Consider cause of the symptoms - caries, perio etc
Then consider tx options
Management of symptomatic M3Ms with no disease present and low risk of disease
Consider other causes of symptoms - consider TMJ, salivary gland disease
It would not be indicated to remove a deeply impacted M3M if it is disease free
Which patients may only be able to tolerate 3rd molar removal under GA?
Extremely anxious
Contraindications to sedation
Other factors complicating the surgery e.g. extensive resection being done at the same time
When would you explain risk of jaw fracture to a patient having extraction of M3M?
Edentulous/atrophic mandible
Aberrant lower 8 close to lower border
Large cystic lesion associated with the tooth
How would you explain the procedure of M3M surgical extraction to a patient?
Minor surgical procedure
Cut flap
Possible drilling
Stitches - 2-3 weeks to dissolve
If tooth is likely to need sectioned explain this
Risks to explain to pt having M3M removal
If 2nd molars have large restorations explain risk of restoration fracture
Pain
Swelling
Bruising
Jaw stiffness/limited mouth opening
Bleeding
Infection
Dry socket
Numbness or tingling
Why is the jaw sometimes stiff with limited opening after M3M extraction?
Mouth has been open for a long time with pressure on the lower jaw
Factors making dry socket more common
Extraction of 8s
Females
Mandible
Smokers
If pt has had dry socket before
Contraceptive pill
Nerve anaesthesia feeling
Numbness
Nerve paraesthesia feeling
Tingling
% of patients who experience temporary IAN damage after M3M extraction
10-20%
% of patients who experience permanent IAN damage after M3M extraction
<1%
% of patients who experience temporary lingual nerve damage after M3M extraction
0/25-23%
% of patients who experience permanent lingual nerve damage after M3M extraction
0.14-2%
What is the time frame for nerve recovery?
Most will happen within 9 months but nerves have been shown to have recovery up to 18-24months after surgery
After this any recovery very unlikely
Chorda tympani
Carries taste sensation from anterior two third of the tongue
Carries fibres via lingual nerve
Arises from facial nerve
Most common sensation from nerve damage during M3M surgery
Numbness - anaesthesia
Tingling - paraesthesia
Rarer sensations from nerve damage during M3M surgery
Painful uncomfortable sensation - dysaesthesia
Reduced sensation - hypoaesthesia
Increased sensation - hyperaesthesia
When would you not opt for CBCT having seen close relationship of M3M and IAN canal on OPT?
IF the results will not change the txp
- Patient wants full surgical removal regardless of the risk
- Grossly carious lower 8 not suitable for coronectomy
What must be included in a M3M referral letter
SBAR
Situation
Background (HPC)
Assessment
Recommendation
When is a surgical removal required?
When tooth cannot be removed with forceps alone
Basic principles of surgical extraction
Risk assessment
Aseptic technique
Minimal trauma to hard and soft tissues
Surgical removal process
Anaesthesia
Access
Bone removal as necessary
Tooth division as necessary
Debridement - ensure all apices are accounted for
Suture
Achieve haemostasis
Post op instructions
Access for surgical removal
Access to the tooth is gained by raising a buccal mucoperiosteal flap
(+/- raising a lingual flap)
Maximum access with minimal trauma
Larger flaps heal just as quickly as smaller
Use scalpel in one continuous stroke
Minimise trauma to papillae
Reflection of soft tissues for surgical extraction
Commence reflection at base of relieving incision
Undermine/free the papillae before proceeding with reflection distally to avoid tears (Warwick James)
Reflect with periosteal elevator firmly on bone
in order to avoid dissection occurring superior to periosteum and reduce soft tissue bruising/trauma
Instruments used to reflect surgical flap
Mitchel’s trimmer
Howarth’s periosteal elevator
Ash periosteal elevator
Instruments used to retract surgical flap
Howarth’s periosteal elevator
Rake retractor
Minnesota retractor
Why is it important to retract the flap during surgical extractions
Access to the operative field
Protect the soft tissues
Name left to right
Howarth’s periosteal elevator
Rake retractor
Minnesota retractor
What is important for atraumatic retraction of soft tissues during surgical extractions?
Rest firmly on bone
Awareness of adjacent structures e.g. mental nerve
Why are air driven handpieces not used during surgical extractions?
May cause surgical emphysema
Bone removal process for surgical extraction
Electrical straight handpiece with SS or Tungsten carbide saline cooled bur (to avoid bone necrosis)
Round bur used to cut buccal gutter and on to distal aspect of impaction, starting distally and coming mesial (reduces risk to lingual nerve and other soft tissues behind M3M)
Buccal gutter as narrow and deep as poss
Bone removed to allow application of elevators
What is done after bone removal during surgical extraction?
Operator must assess the possibility of removing the tooth in one piece with elevators and forceps
If this is not possible and adequate bone has been removed the tooth should then be sectioned with drillOPerator
Most commonly sections between crown and roots, then sometimes further separation of the roots from each other
Operator may prefer to section vertically
A 68 year old female with history of a fractured neck of femur has been given 2 drugs to prevent her getting another fracture. Give two drug types and examples that this could be
Anti-resorptives - bisphosphonates - zoledronic acid
Vitamin supplements - Vit D
What significant oral condition may arise from taking some anti-resorptive drugs?
Medication related osteo necrosis of the jaw
Four ways in which MRONJ can be prevented
Patient education
OHI
Consider high fluoride toothpaste
Make pt dentally fit before starting antiresorptives
Remove risk factors where poss eg sharp denture flange
Smoking cessation advice
Non-invasive alternative treatment such as RCT
Management options for MRONJ
Monitoring
Specific OHI for exposed bone
Antiseptic MW
Occasionally antibiotics
Minimal surgical debridement in select cases
Primary closure where possible
Remove traumatic causes
Consult GMP to check if drug modification or replacement is appropriate
Symptomatic relief
Topical analgesics
Radiographs to establish differential diagnosis
Referral to secondary care
Top to bottom
Frontal sinus
Sphenoid sinus
Ethmoidal air cells
Maxillary sinus
Which of the sinuses are most well formed at birth?
Maxillary and ethmoid
Formation occurs withing 3-4th foetal month
Functions of paranasal sinuses
Resonance to the voice
Reserve chambers for warming inspired air
Reduce the weight of the skull
Which of the sinuses is usually the largest?
Maxillary
Maxillary sinus description
Pyramid shaped cavity within the body of each maxilla
Volume approx 15ml in average adult
37mmH 27mmW 35mmAP on average
Ostium of the maxillary sinus
Located medially near the roof of the maxillary sinus
Drains into middle meatus
Approx 4mm diameter
Lined with mucosa
Can become narrowed or blocked during episodes of inflammation or disease
What is generally found on the posterior wall of the maxillary sinus cavity?
The alveolar canals that transport the posterior superior alveolar vessels and nerves to the maxillary posterior teeth
Roots of maxillary molars and sometimes premolars may project into ____
The floor of the maxillary sinus
The roots may perforate the bone so that only the mucosal lining of the sinus covers them
Epithelium of the sinuses
Pseudostratified ciliated columnar epithelium
What is the role of the cilia in the maxillary sinus
- Mobilised trapped particulate matter and foreign material within the sinus
- Move this material towards the ostia for elimination into the nasal cavity
Possible issues with maxillary sinus
OAC - acute
OAF - chronic
Root (or entire tooth) pushed into the sinus
Sinusitis
Benign lesion
Malignant lesions
How is an OAC usually created?
On extraction of upper molar with roots projecting onto the floor of the maxillary sinus, a communication between the sinus and the mouth is created by either breaking the bone, or tearing the lining of the sinus
Why is an OAC a problem?
Bacteria from the mouth can now enter into the sinus, which can result in sinusitis and make other functions problematic
How do you diagnose an OAC?
Size of tooth
Radiographic position of roots in relation to sinus
Bone at trifurcation of roots
Bubbling of blood
Nose holding test
Direct vission
Good light and suction - echo
Blunt probe
Which two ways that you would investigate whether an OAC has been created could potentially create an OAC if not careful?
Nose holding test
Probing
OAF
Oro-antral communication that persists as an opening, and a sinus tract forms and become epithelialized
Oro antral fistula
When might a pre-op assessment suggest likelihood of and OAC?
Roots of the tooth for XLA appear to by within the sinus or projecting onto lining of the sinus
Very thin bone in the area
What is this?
OAC
What is this?
OAF
What is shown here?
OAF radiographic appearance
Management of OAC
Tell the patient
If small or sinus lining intact - encourage clot, suture margins, possible antibiotic, post op instructions minimising pressure formation within sinuses and the mouth - avoid straws, balloons, singing, smoking, blowing nose
If large or lining torn - close with buccal advancement flap, can refer urgently to OS for this
OACs <2mm prognosis
Usually heal with normal blood clot formation and routine mucosal healing
What type of flap is usually used to close an OAC?
Buccal advancement flap
Buccal advancement flap
Three sided flap with a crestal incision and two relieving incisions
Flare base to ensure that there is bloody supply to all of the flap
Procedure of closing OAC with buccal advancement flap
Lift the flap of mucosa, sometimes need to chip away some buccal bone. This flap will not stretch easily across so you need to incise the periosteum of the flap (fresh blade) on the underside. This will make the flap loose enough to stretch it over the OAC.
Be very careful when incising the periosteum not to cut the flap off.
One initial suture. Usually resorbable sutures, but sometimes these dissolve too quickly. Then follow with more sutures for complete primary closure.
Patients with an OAF may complain of
- Problems with fluid consumption, fluids from nose
- Nasal quality to speech and singing
- Problems playing brass/wind instruments
- Problems smoking or using a straw
- Bad taste/odour/halitosis/pus discharge
- Pain/sinusitis type symptoms
OAF management
The same as the OAC closure except first you must excise the epithelialized sinus tract, then perform buccal advancement flap.
Sometimes an antral washout is also required - if chronic sinusitis and sinus is full of infection, this is flushed out and aspirated.
This can cause reduction in sulcus depth.
Potential flap designs for OAC/ OAF closure
- Buccal advancement flap
- Buccal fat pad with buccal advancement flap - if bigger OAF or OAC, two layer closure, very effective
- Palatal flap - incredibly painful, leaves exposed bone on the palate
- Bone graft/collagen membrane
- Rotated tongue flap (historical)
Aetiology of fractured maxillary tuberosity
- Single standing molar
- Unknown unerupted molar or wisdom tooth
- Pathological gemination/concrescence
- Extracting in wrong order (you should start posterior and move forward)
- Inadequate alveolar support
Diagnosis of fractured maxillary tuberosity
- Noise
- Movement noted both visually or with supporting fingers
- More than one tooth movement
- Tear in soft tissue of palate
Management of maxillary tuberosity fracture
if noticed early enough
Reduce and stabilise
* Orthodontic buccal arch wire with composite
* Arch bar
* Splints (lab made)
If bone removed - dissect out and primary closure of wound
If maxillary tuberosity fracture is treated by splinting tooth must remember:
- Remove or treat pulp
- Ensure it is out of occlusion
- Consider antibiotics and antiseptics
- Post-op instructions
- Remove the tooth surgically 4-8 weeks later
Management of a root or tooth in the maxillary sinus
Confirm radiographically by OPT, occlusal or periapical (+/-CBCT)
CBCT should be done on the day of retrieval as it can move around
Decision on retrieval
If in doubt or retrieval difficult - refer
How to manage?
You can leave this piece of root because if it has not torn the lining, it will not cause sinusitis or other problems and it will not move from there
Removal of root in the maxillary sinus process
Open fenestration with care
Suction - efficient and narrow bore
Small curettes
Irrigation or ribbon gauze
Close as for OAC
Careful not to tear lining
If this doesn’t work - Caldwell-Luc approach (buccal window cut in bone)
If unretrievable - refer to ENT for endoscopic retrieval
What must you remember when examining patients with maxillary discomfort?
- Close relationship of the sinuses and the posterior maxillary teeth
- The aetiology of paranasal sinus inflammation and infection
- Patients with sinusitis often present to the dentist first
Aetiology of Sinusitis
Mostly precipitated by the effects of a viral infection (debate over antibiotics)
Inflammation and oedema
Obstruction of ostia
Trapping of debris within sinus cavity
Mucociliary clearance patterns may be altered by allergens, inflammation, anatomic abnormalities
Normal function further disrupted by cellular damage to mucosal lining, affecting ciliary function
Build up in sinus and bacterial overgrowth
2 effects of sinus not being able to evacuate its contents efficiently
Build up of pressure
Stagnation in sinuses - opportune situation for bacterial overgrowth of normal flora
Signs and symptoms of sinusitis
- Facial pain
- Pressure
- Congestion
- Nasal obstruction
- Paranasal drainage
- Hyposmia
- Fever
- Headache
- (dental pain)
- Halitosis
- Fatigue
- Cough
- Ear pain
- Anaesthesia/paraesthesia over cheek
Dental causes that must be ruled out with similar symptoms to sinusitis
- PA abscess
- Periodontal infection
- Deep caries
- Recent extraction socket
- TMD
- Neuralgia or atypical facial pain/chronic midfacial pain
Specific indicators of sinusitis, that indicate the symptoms do not have a dental cause
Discomfort on palpation infraorbitally
A diffuse pain the maxillary teeth
Equal sensitivity from percussion of multiple teeth in the same region
Pain that worsens with head or facial movement (jump up and down, bend and stand up)
Treatment aims for patients with sinusitis
Treat presenting symptoms
Reduce tissue oedema
Reverse obstruction of the ostia
Sinusitis treatments
Decongestants to reduce mucosal oedema - ephedrine nasal drops 0.5% one drop up each nostril up to three times daily when required (max 7 days as will cause atrophy of sinus and nose lining)
Humidified air also helpful (steam/menthol inhalations)
Why can’t you use decongestants long term?
Will cause atrophy of the lining of the sinus and the nose
Antibiotics for sinusitis
Only to be used if symptomatic treatment not effective/symptoms worse
AND
Signs and symptoms point to bacterial sinusitis
Amoxicillin 500mg 3x daily 7 days
Doxycycline 100mg 1x daily 7 days (200mg loading dose)
SDCEP guidance
Fungal infections of sinuses
Very rarely non-resolving sinusitis may be due to a fungal infection
This can cause expansion of the bony walls by increased mucous secretion and fungal growth (this can happen with other types of infection too)
What types of trauma can cause sinusitis by violating the integrity of the bony cavity and sinus membrane?
Sinus wall fractures
Orbital floor fractures
RCT
Extractions
Implants/sinus lifts
Deep perio treatment
Nasal packing
Nasogastric tubes
Mechanical (nasal) intubation
What is a sinus lift?
Procedure used to reduce volume of the sinus to increase amount of bone available usually for implants
Benign sinus lesions
Polyps, papillomas, antral pseudocysts, mucoceles, mucous retention cysts, odontogenic cysts/tumours expanding into the sinus
Malignant lesions of the maxillary sinus
Primary tumours
Local spread from adjacent sites
How much alveolar bone support should you have for a post?
At least half of post length into the root in bone
