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basic oral and dental care > dry sockets and bisphosphonates > Flashcards

dry sockets and bisphosphonates Flashcards

1
Q

What happens in the first week of socket healing?

A 
Blood clot form
WBCs
Vasodilation
Fibroblasts and capillaries infuse
Early bone resorption
Epithelia proliferates on top of socket
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2
Q

What happens in the second week of socket healing?

A

Epithelial continuity will be achieved
Bone resorption
Osteoid formation
Maturing granulation tissue

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3
Q

What happens from the 4th week to the 6-12th month in socket healing?

A

New bone formation

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4
Q

What is a dry socket?

A

Aka alveolar osteitis, fibrinolytic alveolitis
Early disruption of healing process due to blood clot being lost
Local inflam of bone limited to socket wall

Symptoms- severe pain, resistant to simple analgesics, foul taste and smell, localised inflam and tenderness, partial/total loss of blood clot

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5
Q

What isn’t a dry socket?

A

Septic socket- infection of socket
Osteomyelitis- infection inv. cancellous bone (marrow)
Osteonecrosis- death of portion of jaw bone

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6
Q

Why might a dry socket form? (Aetiology)

A

Failure of clot to form- poor blood supply, smoking, sclerotic bone

Clot degradation- fibrinolytic due to oestrogen, trauma, bacterial pyrogens

Clot loss- excessive mouth wash

Bacterial colonisation- further breakdown of clot

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7
Q

What is the incidence of dry socket?

A

Depends on tooth
Average- 0.5-5%
Lower wisdom tooth- 25% (lower jaw denser than upper jaw, more traumatic extraction)

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8
Q

What are patient risk factors for dry socket?

A 
Female
Oestrogen and menstruation
Smoker
Failure to comply w POI
Age (older- poor blood supply)
Poor healing
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9
Q

What are technical risk factors for dry socket?

A 
Posterior
Mandible
Pre existing infection/pericoronitis
Traumatic extraction
Surgeon experience
Inappropriate irrigation
LA load (vasoconstrictor)
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10
Q

Why might poor healing occur?

A 
Smoking
Steroid therapy
Immunosuppression/therapy
Poorly controlled diabetes
Bone pathology
Poor hygiene
Previous radiotherapy
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11
Q

How are dry sockets managed?

A

Preventative-
~post op mouthwash
~avoid smoking
~pre-emptive Alvogyl

Therapeutic-
~irrigate
~dress (Alvogyl)
~analgesia 
~smoking cessation
~gentle mouth bathing
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12
Q

What is Alvogyl?

A

Butamben (LA)
Iodoform (antiseptic)
Euganol (analgesic)

Derived from fern fibres (trichomes) taken from rhizomes

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13
Q

What is a septic socket?

A

Dry socket + infection

Symptoms- swelling, lymphadenopathy, pus formation

Manage as dry socket +/antibiotics (metronidazole)

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14
Q

How can septic socket be prevented?

A

POI
Antibiotics prophylactically for compromised patients or history of septic socket
Antibiotics if surgical site is infected at time of surgery

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15
Q

How might you consider delayed healing affecting a socket?

A

Granulation tissue in socket
Most consider other diagnoses- retained root/bony sequestrum/OSCC
Treatment- curettage +/ dressing

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16
Q

What is osteomyelitis?

A

Infection into cancellous part of bone
Rare following extraction

Symptoms- pain, altered sensation, pus, sinus formation

Manage- antibiotics and debridement

Acute vs Chronic (4+ weeks)

17
Q

What does osteomyelitis look like histologically?

A

Necrotic bone- loss of osteocytes from lacunae
Leukocytic infiltration in marrow spaces
Scalloping of bone

18
Q

What is the microbiology of osteomyelitis?

A 
Polymicrobial
~bacteriodes 
~porphyromonas
~prevotella
~staphylococci (esp if pathological fracture due to link w oral cavity)
19
Q

What is osteoradionecrosis?

A

Patient exposed to radiotherapy
Endarteritis obliterans (arteries flaring up in bone)- bone cells damaged and has poor blood supply
Mandible more predisposed as denser and has poor blood supply anyways
Exposure of 65 Grays is threshold

20
Q

How can osteoradionecrosis be managed?

A

Prevention better than cure
Remove doubtful teeth before radiotherapy
Good oral health + fluoride
Antibiotics and careful surgery
Depends on severity
Hyperbaric O2, debridement
Cut back bone to bleeding state- shows blood supply

21
Q

What is MRONJ?

A

Medication related osteonecrosis of the jaws

Due to bisphosphonates and other drugs (monoclonal antibodies eg. Denosumab OR tyrosine kinase inhibitors eg. Sunitinib)

Exposed bone >8 weeks
No history of radiotherapy
Patient on drug linked to MRONJ

22
Q

What are bisphosphonates?

A

Risedronate
Alendronate
Etidronate
-given daily or weekly orally

Pamidronate
Zoledronatd
-intravenously for more severe things like metastatic cancer

Bisphosphonates given to reduce bone turnover through effects on osteoclasts
Beneficial for-
~osteoporosis (deposition

23
Q

How do bisphosphonates work?

A

2 PO3 groups
Linked by central carbon
2 side chains (R groups)

Phosphonate groups bind to Ca on surface of bone which exposes R group

Types of R groups-
1. Nitrogenous- prevents formation of proteins needed to maintain osteoclast cytoskeleton (reduces folding in ruffle border)

  1. Non- nitrogenous- compete w ATP leading to osteoclast apoptosis
24
Q

What are the main clinical scenarios for bisphosphonates?

A

Metastatic breast cancer
~high dose, intravenous
~10% risk of MRONJ over 3 years

Osteoporosis
~low dose
~1/100000 a year
~1/1000 following extraction

25
Q

What are the treatment strategies of MRONJ?

A

At risk- no treatment indicated, pt. education
Stage 0- pain meds, treat other dental problems, monitor
Stage 1- antibacterial mouthwash, education, review needed for BP, monitor
Stage 2- antibacterial mouthwash, antibiotics, pain control, debridement of necrotic bone
Stage 3- above + surgical debridement and resection

26
Q

What are the stages of MRONJ?

A

Stage 0- non specific, pain, radiographic changes, no exposed bone
Stage 1- exposed/necrotic bone, no symptoms or infection
Stage 2- exposed necrotic bone, pain, infection +/ pus
Stage 3- above + extends beyond alveolus, EO features, fracture,

27
Q

Why does MRONJ occur?

A

Anti-angiogenesis- compromised blood supply
Toxicity to overlying soft tissues- inability to heal over exposed bone
Direct toxicity to cells within bone- necrosis

28
Q

How can MRONJ be prevented?

A

Avoid extractions w patients on those meds

For oral bisphosphonates- chlorhexidine mouthwash 1 week pre and post op, no benefits to antibiotics

Stop bisphosphonate?- however drug holiday needs to be 3 months

Piecemeal extractions- reduce mucoperiosteal stripping

CTX not used

29
Q

What is someone has high dose IV bisphosphonates?

A

High risk

Antibiotic prophylaxis- low evidence
However lower stage of MRONJ
~American dental association (2 days before and 14 days after)
~BDJ- penicillin V 500mg QDS, 1 hr preop, 5 days post op

30
Q

How can MRONJ be managed?

A

Surgery response is poor

Analgesia, chlorhexidine mouthwash, antibiotics if pus, limited debdridement, monitor

Consider withdrawal of bisphosphonates

31
Q

How can MRONJ be prevented?

A 
Pre treatment dental assessment 
Ensure good oral health
Minimal surgical intervention 
Review post extraction to assess healing
Consent
Refer to specialist care if MRONJ develops or high risk patient
32
Q

What medications might predispose to dry socket?

A 
Steroids
Immunosuppressants such as cyclosporins or methotrexate
Oestrogen sources
Bisphosphonates
Vasoconstrictor in LA
33
Q

What factors (not meds) predispose to dry socket?

A 
Smoking
Medical history, eg Paget’s disease, osteopetrosis
Site of tooth extraction
History of traumatic extraction
Inexperienced surgeon
Excessive mouth rinsing
Non compliance to POI
34
Q

What treatments can be given for dry socket?

A

Irrigate w chlorhexidine
Dress w Alvogyl
Provide analgesics
Repeat POI inc. no smoking

35
Q

What are differential diagnoses to dry socket and how would you rule them out?

A

Septic socket- full exam, presence of pus, systemic signs of infection, lymphadenopathy
Retained root- radiograph
MRONJ- med history, review healing until 8 weeks
ORNJ- history of radiotherapy

basic oral and dental care (49 decks)

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