Extractions

Question 1

What are three things that must be identified in MH to have safe exodontia

Answer 1

Excessive bleeding- haematological conditions, anticoagulation, alcohol
Delayed/non healing-poorly controlled diabetes, immunocompromised, biphosphonates; smoking-dry socket
Collapse- have they eaten, how they managed previous LA, recreational drugs, hypoglycemia, anxiety, vasovagal, Addisonian crisis
Allergy-latex , drugs

Question 2

Reasons tooth is deemed unrestorable

Answer 2

Irreversible pulpitis
Periapical periodontitis
Dental abscess
Vertical fracture
Unrestorable caries
Advanced periodontitis

Question 3

Immediate complications during the XLA

Answer 3

Failure of LA
Failure to move tooth
Fracture to tooth/root
Fracture of alveolus
OAC
Displacement of root/tooth into tissues
Thermal/chemical injury
Damage to surrounding tissues/teeth
Haemorrhage
TMJ injury
Fracture of the mandible
Damage to trigeminal nerve

Risk assessment prior XLA/during treatment planning!! Need to be mentioned during treatment planning

Question 4

Delayed complications of XLA

Answer 4

Pain, swelling, trismus, bleeding, infection, dry socket, oroantral fistula, nerve, nerve damage

Question 5

Factors making XLA difficult

Answer 5

Tooth and pt factors
Local, regional and systemic factors
Clinical and radiographic factors

Question 6

Problems with XLA

Answer 6

Acute infection-LA efficacyz pt motivation

Previous treatment -failed XLA, RCTz heavily restored

Longstanding infection -perio bone loss

Question 7

What to ask about previous XLA?

Answer 7

Did you have stitches?
How long were you in the chair?
Did it hurt during the XLA?
Previous dry socket

Question 8

E/O regarding the XLA

Answer 8

Swelling- LA efficacy and painful to support mandible if swollen

Question 9

Attrition and XLA

Answer 9

You can expect dense reactive bone

Question 10

Two reasons for failure to move tooth

Answer 10

Inadequate experience
Poor surgical technique

Question 11

Reasons for fractured maxillary tuberosities

Answer 11

Lone standing upper molar- bone is stronger
Hypercementosis
Bulbous roots
Splayed roots
Excessive force
Ankylosis

Question 12

What radiographic view to ask for maxillary sinus/ OAC

Answer 12

Occipito mental view

Question 13

Ludwig’s angina

Answer 13

Bilateral sublingual submandibular and submental space infection
Leads to raised and swollen tongue
Pyrexia ,dysphagia, dyspnoea,
Potentially life threatening
Treated by drainage and IV antibiotics

Question 14

When to refer to hospital regarding infection

Answer 14

Rapid spreading, bilateral swelling
Difficulty swallowing water
Eye closing due to swelling
Severely immunocompromised

Question 15

Types of post op bleeding sockets

Answer 15

Reactionary-up to 24 h post-op or injury. Due to loss of vasoconstriction effect in LA (clot is dislodged from not following post op instructions)

Secondary- 7-10 days post-op or injury such as infection

Question 16

Management of bleeding socket

Answer 16

Clean the area
Pack correctly
Check history (predisposing pathology, previous XLA)
Examine (signs of underlying cause)
Investigate ( haemoglobin, clotting screen platelets, bleeding time…)
If bleeding persists ( la, suture, haemostatic agents etc?
Hospital admissions
Transfuse
Specific systemic treatment following the investigation

Question 17

Risk for dry socket

Answer 17

Smoking more than 20/day
Increased bone density (pagets, osteoporosis)
Previous history of dry socket
oral contraceptives
Complex surgical procedure

Question 18

Surgical sieve

Answer 18

V-vascular (hemangioma, haematoma)
I- infective/inflammation (abscess, periodontal disease, acute necrotising ulcerative gingivitis etc)
T-trauma, fractured mandible, sharp injury
A- autoimmune (MS, pemphigus, lupus..)
M- metabolic (diabetes)
I- iatrogenic (radiation necrosis, Endo treatment, implant treatment…)
N-neoplastic (cancer/malignancy, benign, cyst, salivary gland lesion)

C- congenital (migraine, epilepsy)
D- degenerative (perio disease, neck arthritis)
E- endocrine/environmental (diabetes, hypoglycemia)
F-functional

Question 19

Antibiotics for pericoronitis

Answer 19

3 day course of metronidazole
400mg, one tablet three times daily

Question 20

Other causes of OAC

Answer 20

XLA of upper molars, premolars
Tumours
Bone infections
Operation to maxillary sinus
Trauma
Dentigerous cysts
Apical infections

Question 21

Factors making wisdom teeth XLA easier

Answer 21

Mesio angular impaction
Fused conical roots
Elastic bone (seen in younger pt)
Wide PDL
Separated from 2nd molar and IDN
Large follicle

Question 22

Management of bleeding socket

Answer 22

1. Squeezing socket
2. Pressure by gauze
3. Soaking with adrenaline
4. Stitches and LA
5. Surgicel (oxidised cellulose)/ surgispon(absorbable gellatin sponge)
6. Bone wax
7. Diathermy
8. Tranexamic acid

Question 23

Anticoagulants/antiplatelets

Answer 23

DOACs( direct oral anticoagulants)- apixaban, rivaroxaban-if low bleeding risk-treat without interruption; if higher bleeding risk-miss or delay morning dose
Treat early in the day, limit initial treatment area and assess bleeding before continuing, consider staging, suturing and packing

Vitamin K antagonists (anticoagulation)-warfarin - check INR (less than 4, in last 72h)
Consider limiting treatment area, staging, pack and suture.

Antiplatelets therapy
1. Aspirin alone- treat without interruption (limit treatment area, stage excessive procedures, use local haemostatic measures)
2. Clopidogrel alone or with aspirin- treat without interrupting medication- except prolonged bleeding, limit treatment area, staging, packing and suturing

Low risk- simple extraction, incision and drainage of intra oral swellings, RSD, 6-point chart, restoration with subgingival margins

Higher risk- complex extractions or more than 3 teeth, flap raising procedures, biopsies…

Question 24

LA

Answer 24

Esters-procaine; unstable, rapidly resorbable, resorb in plasma-release PABA causing hypersensitivity

Amides-lidocaine,prilocaine, mepivacaine, bupivacaine, articaine
Slowly metabolised by liver, low hypersensitivity

Mode of action of LA- blocking of terminal nerve endings
Depends of LA, technique and pt

Mechanisam-blockage of sodium channel-failure to achieve action potential-blockage

Unionised (lipid soluble) form enters the sodium channels and becomes ionized (water soluble) form causes the sodium channel blockage

Max safe dose of adrenaline 0.25 mg
In 2.2 ml (1:80 000) cartilage there is 0.0275 mg
Max dose in 70kg man-7 cartridges

Felypressin -contracts smooth muscle, not in pregnancy