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BODC exodontia yr 2 > dry sockets and bisphosphonates > Flashcards

dry sockets and bisphosphonates Flashcards

1
Q

stages of socket healing normally (immediate to 12 months)

A

Immediate reaction
- blood clot forms
- white cells
- vasodilation
1st week
- fibroblasts, capillaries – granulation tissue
- early bone resorption in the borders of socket
- epithelial proliferation over top of socket
2nd week
- significant epithelisation – epithelial continuity achieved
- bone resorption, osteoid formation, maturing granulation tissue
4th week/6th week
- new bone formation
12months
- fully healed

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2
Q

dry socket, and effect and what it is also known as

A

early disruption of the healing
Alveolar osteitis/fibrinolytic alveolitis

Local inflammation of the bone, limited to socket wall
- due to loss of blood clot from socket

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3
Q

symptoms of dry socket

A
  • severe pain
  • resistant to simple analgesics
  • bad taste/smell
  • localised inflammation and tenderness
  • partial or total loss of blood clot
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4
Q

other things similar to dry socket but not dry socket

A

septic socket
osteomyelitis
osteonecrososs

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5
Q

ostenecrosis

A

death of portion of the Jae bone

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6
Q

septic socket

A

infection of the socket

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7
Q

osteomyeleitis

A

infection involving cancellous bone

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8
Q

aetiology of dry socket

A

1- failure of clot to form

2) clot degredation
3) clot loss
4) bacterial colonisation

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9
Q

what can cause failure of the clot to form

A

poor blood supply
smoking
sclerotic bone

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10
Q

clot degredation cause

A

firbinolysis as a result of oestrogen, trump, bacterial pyrogens

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11
Q

clot loss can be duet to

A

excessive mouth washing

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12
Q

why is dry mouth more likely for wisdom

A

lower jaw denser

more likely to have a traumatic removal than other teeth

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13
Q

risk factors for dry socket (patient and technical factorS)

A

patient factors

  • female
  • OCP and menstruation
  • smoker
  • age
  • failure to comply with POI (post operative instructions)
  • poor healing
  • sterioids

technical factors

  • posterior
  • mandible
  • pre existing infection/pericoronitis
  • traumatic extraction
  • experience of surgery
  • inappropriate irrigation
  • LA load (vasoconstrictor)
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14
Q

medications that may dispose to dry socket

A

steroids
cyclosporins
methotrexate
OCP

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15
Q

poor healing of socket risk factors

A
  • smoking
  • steroid therapy
  • immunosuppression/therapy
  • poor controlled diabetes
  • bone pathology
  • poor hygiene
  • previous radiotherapy
  • site of tooth extraction (mandible over maxilla)
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16
Q

how to prevent dry socket

A
  • post op mouthwash
  • avoid smoking
  • BIPP (historical)
  • pre emptive alvogyl (placed into the socket)
  • PRF(no evidence
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17
Q

therapeutic measures to prevent dry socket

A
  • irrigate
  • dress (alvogyl)
  • Analgesia
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18
Q

what does alvogyl contain

A

butamben
iodoform
eugenol

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19
Q

butamben

A

LA

removes pain

20
Q

iodoform

A

antiseptic

remove bactera

21
Q

eugenol

A

analgesic

22
Q

septic socket symptoms

A

Symptoms for dry socket (and evidence of infection)

  • extra oral swelling
  • lymphadenopathy
  • formation of pus
23
Q

management of septic socket

A
  • same as dry socket

- antibiotics can be used, metronidazole (helps deal with infective part, not useful in dry socket)

24
Q

prevention of septic socket

A
  • careful POI
  • antibiotics to compromised patients/history of septic socket
  • consider antibiotics if surgical site is infected at the time of surgery (esp with wisdom)
25
Q

delayed healing

A

Socket almost healed over, but not quite right

26
Q

what can cause delayed healing

A 
Consider other diagnosis
-	eg retained root
-	SCC(squamous cell carcinoma)
Delayed healing treatment
-	curettage (with dressing)
27
Q

osteomylitis and symptoms

A 
infection into cancels part of 
bone
-	pain
-	altered sensation
-	pus, sinus infection
28
Q

acute vs chronic

A

chronic beyond 4 weeks

29
Q

histology and microbiology of osteomyelitis

A

Looks like dead bone
- loss of osteocytes from lacunae (necrotic bone)
- leukocytic infiltration
Histology
- scalloping of bone
- leukocytic infiltrate in marrow spaces
- necrotic bone (lacunae devoid of osteocytes)

30
Q

polymicrobial infection of osteomyelitis

A
  • bacteriodes
  • porphyromonas
  • prevotella
  • staphylococcci
31
Q

osteoradionecrosis and what it leads to

A

exposed to radiograpy

- causes endarteritis obliterans and damage to bone cells (arteries furinng up in bone, worse blood supply)

32
Q

threshold between high and low risk for osteoradionecrosis

A

65 grays

33
Q

management of osteonecrosis

A
  • prevention better than cure
  • remove teeth of doubtful prognosis prior to radiotherapy
  • good oral health and prevention with F-
  • need antibiotics and careful surgery
  • hyperbaric oxygen, antibiotics if infected, debridement
34
Q

MRONJ

A

Medication related necrosis of jaws

Previously known as BRONJ, bisphosphonates cause this

35
Q

bisphosphonates

A
  • Risedronate
  • Alendronate
  • Etidronate
  • Pamidronate ***
  • Zoledronate ***
  • **intravenous, therefore given for more severe illnesses
36
Q

what do bisphosphonates do

A

reduce bone turnover through effects on oestoclasts

37
Q

benefits of bisphosphonates in different diseases

A

1) osteoporosis
- deposition less than resorption
2) pagets
- excessive resorption +- deposition
3) metastasis
- invasion involves bone resorption
- therefore stop the cancer

38
Q

structure of bisphosphonates

A
  • 2 phosphonate groups (PO3) groups
  • linked by central carbon
  • 2x side chains (R groups)
    Phosphonate groups bind to calcium on bone
  • R group then exposed
39
Q

nitrogenous vs non nitrogenous R group

A

Nitrogenous
- prevent formation of proteins needed to maintain osteoclast cytoskeleton (loss of ruffle border)
- disruption rather than killing
Non nitrogenous
- compete with ATP leading to osteoclast apoptosis
- usually too toxic, kill of osteoclasts

40
Q

criteria for MRONJ

A

exposed bone for more than 8 weeks
no history of RT
patient is linked drugs wise to it

41
Q

stages of MRONJ

A 
0
- non specific, pain radiograph changes no exposed bone
1
exposed/necortic bone.no symptoms or infectin
2
exposed necrotic bone
infection+- pus
3 
as above extends beyond alveous
etraorla features
fracture
42
Q

why does MRONJ occur

A

1) anti angiogenesis
- compromised blood supply
2) direct toxicity to cells within bone
- bone necrotic
3) toxicity to overlying soft tissues
- inability to heal over exposed bone

43
Q

prevention for MRONG

A

1) stop bisphosphonate?
- risk of BRONJ persists for 12m
- no merit for oral patients
- some merit in a 3m drug holiday for IV
- coming off medication may be outweighed
2) piecemeal extractions
- reduce mucoperiosteal stripping
3) CTX (C terminal cross linking telopeptide)
- marker of burn turnover? Classifies BRONJ risk
- not predictive of BRONJ

44
Q

patients with high IV dose of bisphosphonates

A

High risk of MRONJ
- use antibiotic prophylaxis
- may not prevent but lower the staging of MRONJ
recommending
- antibiotics 2 day before, 14 days after

45
Q

management of MRONJ

A 
Management is supportive
-	analgesia
-	chlorhex M/W
-	antibiotics if frank pus/pain
-	limited debridement
Close review
-	consider withdrawal of bisphosphonate
46
Q

different diagnosis of dry socket and how to rule out

A

septic socket - full exam, presence of pus, systemic signs of infection, lymphadenopathy
retained root - radiograph
MROJ- associated medications, review healing untill 8 weeks

BODC exodontia yr 2 (25 decks)

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