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Exodontia > Dry sockets and bisphosphonates > Flashcards

Dry sockets and bisphosphonates Flashcards

1
Q

Normal healing of sockets: immediate reaction

A

Blood clot, white cells, vasodilation

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2
Q

Normal healing of sockets: 1st week

A

Fibroblasts, capillaries – granulation tissue, early bone resorption, epithelial proliferation

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3
Q

Normal healing of sockets: 2nd week

A

Significant epithelialisation, bone resorption, osteoid formation, maturing granulation tissue

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4
Q

Normal healing of sockets: 3rd week

A

Rounding of alveolar crest, resorption of socket wall, new bone, organised clot, epithelial coverage

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5
Q

Normal healing of sockets: 4th week to 6th to 12th month

A

New bone formation

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6
Q

Poor healing can be caused by

A 
Smoking
Steroid therapy
Immunosuppression/Immunosuppressive therapy
Poorly controlled diabetes
Bone pathology
Poor hygiene
Previous radiotherapy
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7
Q

Dry socket - localised osteitis

A 
Severe pain
Resistant to simple analgesics
Foul taste and smell
Localised inflammation and tenderness
Partial or total loss of blood clot
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8
Q

Dry socket- localised osteitis aetiology

A

Not fully understood

Probably a mixture of local trauma, fibrinolysis and bacterial infection

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9
Q

Dry socket - localised osteitis prevalence

A 
3% of patients after extraction
F>M (oral contraceptive pill)
Posterior>anterior
Mandible>maxilla
LA>GA
Smokers>non-smokers
Pre-existing pericoronitis (8s)
Failure to comply with P.O.I
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10
Q

Dry sockets - management

A 
Prevention
-prophylactic therapy?
Irrigate
Dress
*Antibiotics not usually indicated; metronidazole is drug of choice
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11
Q

Alvogyl

A

Butamben 25.7g
Iodoform 15.8g
Eugenol 13.7g
Olive oil, spearmint oil, sodium lauryl sulphate, calcium carbonate, pehghawar djambi, purified water

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12
Q

Dry sockets - prevention

A

Not always possible
Give clear POI
Consider using Alvogyl prophylactically in pts with previous history of dry sockets

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13
Q

Infected socket

A 
Like dry socket + evidence of infection
-swelling
-lymphadenopathy
-formation of pus
Manage as dry socket +/- antibiotics
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14
Q

Infected sockets - prevention

A

Not always possible
Careful POI
Antibiotics to compromised patients
Consider antibiotics if surgical site is infected at time of surgery (especially wisdom tooth surgery)

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15
Q

Delayed healing e.g. granulation tissue in socket

A

X-ray?
Curettage
+/- dressing
Consider other diagnoses if poor response to treatment – squamous cell carcinoma

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16
Q

Osteomyelitis

A

Infection in cancellous part of bone
Rare following dental extraction
More likely in mandible
Acute or chronic
-pain, altered sensation, pus, sinus formation, bone rarefaction on x-ray, fracture
Manage with antibiotics and debridement – ref to oral and maxillofacial surgery

17
Q

Osteoradionecrosis - previous radiotherapy

A

Endarteritis obliterans and damage to bone cells
Mandible > maxilla
Delayed healing and risk of osteoradionecrosis
Over 60 Gray
Reduced incidence of the last few decades
Various levels of damage
Can lead to fracture

18
Q

Previous radiotherapy

A

Prevention is better than cure
Remove teeth of doubtful prognosis prior to radiotherapy
Good oral health and prevention with F-
Need antibiotics and careful surgery
Management depends on severity
Hyperbaric oxygen, antibiotics if infected, debridement

19
Q

MRONJ - medication related osteonecrosis of the jaws

A

Bisphophonates BRONJ
Other drugs
-Monoclonal antibodies e.g. Denosumab
-tyrosine Kinase inhibitors e.g. Sunitinib

20
Q

Bisphosphonate related osteonecrosis of the jaws

A

Area of exposed or necrotic bone in maxillofacial region that does not heal within 8 weeks after identification by health care provider, in px who was receiving/ had been exposed to bisphosphonate, & had not had radiation therapy to craniofacial region

21
Q

Bisphosphonate therapy used for

A 
Used commonly to prevent and treat:
-osteoporosis
-cortico-steroid induced osteoporosis
Also used to treat
-Paget’s disease
-hypercalcaemia of malignancy
-bone metastases
Adsorbed onto HA crystals in bone
Interfere with bone turnover
Act on osteoclasts and anti-angiogenic
22
Q

Bisphosphonates

A 
Can be given as daily or weekly doses orally
Intra-venously   -  (metastatic disease)
-Risedronate sodium
-Alendronic acid
-Disodium Etidronate
-Disodium Pamidronate
-Zoledronic acid
23
Q

MRONJ relevance to dentistry

A

Can occur spontaneously but also following:

  • dental extraction
  • implant placement
  • other minor surgical procedure
  • dental infection
  • trauma - e.g. from denture
24
Q

Risk of developing MRONJ

A

0.004- 0.1% for oral drugs
Aprox. 1% with IV drugs for cancer patients
> with duration
Most patients should be managed in GDP

25
Q

Prevention of MRONJ

A

Pre-treatment dental assessment
Make dentally fit and maintain good oral health
Minimal surgical intervention
Review post extraction to assess healing
Consent
Referral for specialist care if MRONJ develops or where patients on I.V therapy

26
Q

Management of MRONJ

A

In specialist centres
Difficult
Not an infective process but super-added infection likely to occur
Radiographically similar to osteo-radionecrosis
Antiseptics, antibiotics, surgery not usually indicated, but may become necessary

27
Q

MRONJ staging

A

At risk - no treatment required, px education

Stage 0 - Stage 3

28
Q

Stage 0 MRONJ

A

Non-specific, pain, radiographic changes, no exposed bone

-pain medication, treat other dental problems, monitor

29
Q

Stage 1 MRONJ

A

Exposed/ necrotic bone, no symptoms or infection

-antibacterial mouthwash, px education, review need for BP monitor

30
Q

Stage 2 MRONJ

A

Exposed necrotic bone, pain, infection +/- pus

  • antibacterial mouthwash
  • antibiotics
  • pain control
  • debridement of necrotic bone
31
Q

Stage 3 MRONJ

A

Exposed necrotic bone, pain, infection +/- pus, extends beyond alveolus, extra-oral features, OAC, fracture

  • antibacterial mouthwash
  • antibiotics
  • pain control
  • debridement of necrotic bone
  • surgical debridement and resection

Exodontia (21 decks)

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