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Oral Surgery 2 > Compromised Wound Healing > Flashcards

Compromised Wound Healing Flashcards

1
Q

bone remodeling allows what?

A

for our bones to repair from daily micro-trauma

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2
Q

what are some common reasons of compromised wound healing?

A
  1. medications
  2. radiotherapy (XRT)
  3. infection
  4. systemic disease
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3
Q

disease associated with bone healing problems

A
  1. drug (medication) related osteonecrosis (MRONJ) of the jaws
  2. osteo-radio-necrosis (ORN)
  3. osteomyelitis
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4
Q

drugs associated with MRONJ

A
  1. bisphosphonates
  2. anti-resorptive agents
  3. anti-angiogenic medications
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5
Q

example of anti-resorptive agents

A
  1. denosumab (Prolia, Xgeva)
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6
Q

example of anti-angiogenic medications

A
  1. tyrosine kinase inhibitors
  2. monoclonal antibodies targeting VEGF
  3. Sunitinib
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7
Q

what are bisphosphonates (BP)?

A

synthetic analogs of inorganic pyrophosphate

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8
Q

how does bisphosphonates (BP) work?

A
  1. high affinity for Ca2+
  2. inhibition of osteoclasts
  3. may inhibit capillary neo-angiogenesis
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9
Q

indications for ORAL bisphosphonates (BP)

A
  1. osteoporosis
  2. osteopenia
  3. Paget’s disease
  4. osteogenesis imperfecta
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10
Q

indicatiosn for IV bisphosphonates (BP)

A
  1. bone metastases associated with solid tumors
  2. hypercalcemia of malignancy
  3. multiple myeloma
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11
Q

diagnosis of MRONJ

A
  1. current or previous tx with bisphosphonates (BP)
  2. exposed bone in the maxillofacial region that has persisted for more than EIGHT weeks
  3. no history of radiation therapy to the jaws
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12
Q

commonly prescribed ORAL bisphosphonates (BP)

A
  1. Fosamax (alendronate)

2. Actonel (risedronate)

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13
Q

commonly prescribed IV bisphosphonates (BP)

A
  1. Aredia (pamidronate)
  2. Zometa (zolendronate)
  3. Reclast (zolendronate)
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14
Q

commonly prescribed ORAL AND IV bisphosphonates (BP)

A

Boniva (inandronate)

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15
Q

how does Denosumab (Prolia, Xgeva) work?

A

stops the osteoclasts

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16
Q

how does anti-angiogenic agents work?

A

stop the blood supply in certain areas

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17
Q

what can happen when anti-angiogenic agents stop the formation of new vessels?

A

affects healing of soft tissues and patient can et necrosis

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18
Q

why necrosis in the jaws?

A
  1. increased bone turnover in the jaws

2. thin overlying oral mucosa due to jaw anatomy

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19
Q

remodeling rate of jaw is how many times more than long bones?

A

10x

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20
Q

according to AAOMS position paper, how do you manage a patient about to begin IV therapy?

A
  1. delay therapy, if systemic conditions permit
  2. optimize oral health prior to initiating therapy
  3. allow adequate osseous healing and wait until the surgery sites become mucosalized
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21
Q

how long does it take for surgery sites to become mucosalized?

A

14-21 days

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22
Q

according to AAOMS position paper, how do you manage an asymptomatic patient receiving IV therapy?

A
  1. maintain oral hygiene

2. avoid osseous injury

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23
Q

T/F: according to AAOMS position paper, managing an asymptomatic patient taking oral bisphosphonates (BP) is still lacking sound recommendations

A

true

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24
Q

according to AAOMS position paper, how do you manage an asymptomatic patient taking oral bisphosphonates (BP) for <4 years?

A

proceed with planned tx

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25
Q

according to AAOMS position paper, how do you manage an asymptomatic patient taking oral bisphosphonates (BP) for <4 years and risk factor (steroid/anti-angiogenic meds)?

A

stop BP therapy 2 months prior to tx

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26
Q

according to AAOMS position paper, how do you manage an asymptomatic patient taking oral bisphosphonates (BP) >4 years?

A

drug holiday for 2 months

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27
Q

according to AAOMS position paper, when you should resume tx on asymptomatic patient taking oral bisphosphonates (BP)?

A

when osseous healing has finished in ~14-21 days

28
Q

T/F: while there have been limited studies on drug holidays for tx of MRONJ, currently there have yet to be studies to confirm drug holidays are effective in prevention of MRONJ without increasing the skeletally related risks of low bone mass

A

true

29
Q

drug holidays should be a medical decision based primarily on what?

A

medical decision based primarily upon the risk for skeletally related events (e.g. fractures)

30
Q

clinical stage 1 of MRONJ

A
  1. exposed/necrotic bone
  2. asymptomatic
  3. no infection
31
Q

tx of clinical stage 1 of MRONJ

A

oral antimicrobial rinses (e.g. Peridex)

32
Q

clinical stage 2 of MRONJ

A
  1. exposed/necrotic bone
  2. pain
  3. infection
33
Q

tx of clinical stage 2 of MRONJ

A
  1. oral antimicrobial rinses

2. antibiotic therapy

34
Q

clinical stage 3 of MRONJ

A
  1. exposed/necrotic bone
  2. pain
  3. infection
  4. one or more of the following…
    a. fracture
    b. extra-oral fistula
    c. oro-nasal communication d. osteolysis
35
Q

tx of clinical stage 3 of MRONJ

A
  1. surgical debridement of resection

2. antibiotic therapy

36
Q

how to manage patient who is about to start IV bisphosphonates (BP)?

A

get healthy before

37
Q

how to manage patient who is receiving IV bisphosphonates (BP)?

A

avoid osseous surgery if possible

38
Q

how to manage patient who is taking oral bisphosphonates (BP)?

A

informed consent/medical consult if considering drug holiday

39
Q

how to manage patient who has established MRONJ?

A

consult and refer

40
Q

T/F: you should take thorough medical hx before performing extraction

A

true

41
Q

osteo-radio-necrosis (ORN)

A

a condition in which irradiated bone becomes exposed through a wound in the overlying skin and/pr mucosa and persist without healing for 3 to 6 months

42
Q

3 H’s theory of pathogenesis

A
  1. hypoxia
  2. hypovascularity
  3. hypocellularity
43
Q

stage 1 osteo-radio-necrosis (ORN)

A

superficial involvement, only cortical bone exposed

44
Q

tx for stage 1 osteo-radio-necrosis (ORN)

A

chlorhexidine mouthwash

45
Q

stage 2 osteo-radio-necrosis (ORN)

A

localized involvement with involvement of cortical and medullary bone

46
Q

tx for stage 2 osteo-radio-necrosis (ORN)

A
  1. local debridement with or without HBO (hyperbaric oxygen)

2. chlorhexidine mouthwash

47
Q

stage 3 osteo-radio-necrosis (ORN)

A

diffuse involvement including inferior border

48
Q

tx for stage 3 osteo-radio-necrosis (ORN)

A

surgical resection and reconstruction

49
Q

stage 3 osteo-radio-necrosis (ORN) is usually associated with what?

A

pathologic fracture and possible osteo-cutaneous fistula

50
Q

what does hyperbaric oxygen (HBO) therapy stimulate?

A
  1. collagen synthesis
  2. angiogenesis
  3. epithelialization
51
Q

osteomyelitis

A

inflammatory process of the bone marrow that involves cancellous and cortical bone with a tendency of progression

52
Q

pathogenesis of osteomyelitis

A
  1. bacterial infection
  2. inflammation/edema of bone marrow
  3. compression of blood vessels in the bone marrow
  4. ischemia
  5. necrosis (osteomyelitis)
53
Q

T/F: osteomyelitis occurs more often in the maxilla than the mandible

A

false, mandible > maxilla

54
Q

why does osteomyelitis occur more often in the mandible vs the maxilla?

A

maxilla has a lot of blood supply compared to mandible

55
Q

predisposing factors of osteomyelitis

A
  1. immune-compromised patients
  2. diabetes mellitus
  3. alcoholism (malnutrition)
  4. myeloproliferative disease: leukemia, sickle cell
  5. chemotherapy
  6. fractures and odontogenic infections in immune-compromised patients
  7. osteopetrosis (Albers-Schonberg disease)
56
Q

radiographic findings of osteomyelitis

A
  1. “moth-eaten” appearance

2. radio-opacities which are due to sequestras

57
Q

sequestra

A

islands of necrotic non-resorbed bone

58
Q

signs and symptoms of osteomyelitis

A
  1. pain
  2. swelling
  3. fever, malaise, trismus
  4. parasthesia/anesthesia
  5. tenderness of involved area
  6. exposed bone
  7. osteo-cutaneous fistula with purulent discharge
59
Q

medical management of patients with osteomyelitis

A
  1. abx (long term)

2. hospitalization may be required for IV abx

60
Q

what is the abx of choice to tx patients with osteomyelitis

A

clindamycin

61
Q

how long are patients with mild cases of osteomyelitis

hospitalized for in order to get IV abx?

A

4 weeks

62
Q

how long are patients with severe cases of osteomyelitis

hospitalized for in order to get IV abx?

A

up to 6 weeks

63
Q

surgical management of patients with osteomyelitis

A

debridement/marginal resection/segmental resection (depend on involvement to remove dead bone)

64
Q

how can you tell if bone is healthy?

A

if it’s bleeding

65
Q

how long does dry socket last for?

A

not longer than 1 week

Oral Surgery 2 (13 decks)

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