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4D Curriculum Revision > Guideline: THIRD MOLAR REMOVAL > Flashcards

Guideline: THIRD MOLAR REMOVAL Flashcards

1
Q

What are two clinical guidelines on third molar surgery?

A
  1. NICE 2000
  2. The Royal College of Surgeons of England, 2022 (mandibular third molars)
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2
Q

The failed eruption of mandibular third molars (M3Ms) may be either due to ectopic development or impaction. What is the difference?

A

Ectopic development = abnormal position of developing tooth)

Impaction = eruption path is blocked by heart or soft tissue, or disease

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3
Q

When M3M is partially erupted (visible) or soft tissue impacted (non-visible), what issue arises?

A

communication with the oral cavity may develop, which allows bacterial ingress and infection to occur

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4
Q

What is the concern about NICE 2000 guideline?

A

It discourages prophylactic removal of M3Ms, however such approach it can result in delaying inevitable surgery with damage to the adjacent second molar.

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5
Q

What is the main reason for third molar disease and the subsequent removal of the tooth?

A

INFECTION like pericoronitis, caries, periapical disease, local bone infections

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6
Q

What types of intervention are there for M3Ms?

A
  • referral
  • clinical review
  • extraction of M3M
  • extraction of maxillary third molar
  • coronectomy

less common: operculectomy, surgical exposure, pre-surgical orthodontics, surgical re- implantation/autotransplantation

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7
Q

When to third molars usually erupt?

A

19-20 years old

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8
Q

In order to erupt into the mouth, M3Ma must develop or migrate into a favourable upright position which commonly continues up to age…?

A

25

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9
Q

Unerupted M3Ms may change position favourably or unfavourably until when?

A

middle of third decade (or later)

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10
Q

When does crown calcification starts for third molars? when is it complete? When are roots complete?

A

crown calcification starts 7- 9 years for maxillary third molars, 8-10 for mandibular. crowns completed by 12-16 years. roots completed by 18-25 years.

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11
Q

What is the most significant variable associated with third molar impaction?

A

inadequate hard tissue space (not enough space between distal of second molar and ascending ramus of the mandible)

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12
Q

What does impaction predisposes a tooth to?

A

pathological changes such as periocoronitis, caries, resorption, periodontal problems

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13
Q

RECURRENT PERICORONITIS is an indication for surgery. What are predisposing factors to pericoronitis?

A
  • partial eruption (usually at 20-25 yo)
  • insufficient space
  • vertical or distoangular impaction
  • opposing tooth causing mechanical trauma
  • upper respiratory tract infections, stress, fatigue
  • poor OH
  • white race
  • a full dentition
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14
Q

What is the microbiology of pericoronitis?

A

Predominantly anaerobic.
Streptococci, Actinomyces, Propionibacterium, a beta-lactamase producing Prevotella, Bacteroides, Fusobacterium, Staphylococci. Treponema denticola too.

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15
Q

What aspects of pericoronitis indicate removal of causative molar?

A
  • acute spreading of infection
  • repeated infection impacting quality of life
  • or infection requiring antibiotics
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16
Q

When should antibiotics be prescribed for infection of M3M?

A

ONLY when
- cannot remove surgically
- cannot drain the infection under LA
- evidence of systemic spread (urgent referral for hospitalisation)

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17
Q

What is the mx of periapical infection od M3M?

A

can’t do root canal tx due to limited access. so XLA.

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18
Q

Spreading chronic local infection or inflammation includes:

A
  • osteomyelitis
  • osteoradionecrosis or osteonecrosis
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19
Q

What are main causes indicating removal of M3M in older patients like 52-74 years?

A

Caries and periodontal disease

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20
Q

How to manage caries of third molars?

A

if unrestorable - surgical removal
if restorable - that is preferred tx

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21
Q

In what patients there is association between retained M3Ms and distal caries on M2M?

A

patients with horizontal or mesioangular partially erupted M3Ms + have been in the mouth long enough to cause caries

*also presence of soft tissue over impacted third molar increases risk of second molar caries

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22
Q

What is the association between periodontal disease and impacted third molars?

A

Increasing evidence that presence of partially erupted M3M may increase the risk of perio disease around other molar teeth in adolescent patients.
Remember about smokers where perio progresses more rapidly.

23
Q

Other reasons for removal of third molars include:

A
  • cysts and tumours
  • internal/external resorption
  • fracture of mandible or tooth/teeth
  • orthognathic surgery
  • age of patient and related disease indications
24
Q

What are risks of M3M surgery?

A

pain, bleeding, swelling, bruising, infection. inferior alveolar and lingual nerve injury.

25
Q

What social factors might push toward prophylactic approach to remove the third molars?

A

limited access to routine medical care, occupation - astronauts, troops etc.

26
Q

The incidence of postoperative morbidity following third molar removal is higher in patients aged…?

A

> 25 years old

27
Q

clinical assessment - what do you check extraorally?

A
  1. TMJ to exclude TMD (preauricular pain similat to pericoronitis)
  2. consideration of limited mouth opening
  3. lymph nodes enlargement (systemic spread)
  4. facial asymmetry
  5. exclusion of any pre-existing trigeminal neuropathy
28
Q

clinical examination - what do you check intraorally?

A
  1. soft tissues
  2. hard tissues
  3. condition and prognosis of second molar
  4. eruption status of third molar and eruption potential
  5. hypodontia
  6. occlusion
  7. oral hygiene
29
Q

what radiograph do you take after clinical examination?

A

panoramic radiography when surgical intervention is being considered

30
Q

When Cone beam computed tomography (CBCT) is used?

A

Current evidence suggests that CBCT has no effect on outcome. As the radiation dose and financial costs are higher than conventional imaging, CBCT should not be used routinely.
Where there is close relationship IAN-M3M, CBCT may be useful in cases where findings will alter treatment decisions.

31
Q

What is the long term outcome for asymptomatic third molars that are disease free?

A

Difficult to predict. Clinician’s expertise to weigh up probability and severity of risks.

32
Q

What needs to be communicated to the patient for valid and informed consent?

A

findings of the assessment, the risks status, tx options and their risks and benefits, inc. material risks. check understanding.

33
Q

What medical factors may compromise healing after the M3M surgery?

A

diabetes mellitus, chronic renal disease, hepatic disease, haematological disorders, malnutrition (inc EDs), immunosuppression, chemo/radiotherapy, local bone disease
mind medications: contraceptives, steroid therapy, previous history of steroids, bisphosphonates.

34
Q

MRONJ risk assessment - what are low risk patients? (SDCEP 2017)

A

patients being treated for osteoporosis or other non-malignant bone disease with:
- oral bisphosphonates
- quaterly/yearly IV bisphosphonates
- denosumab

for LESS than 5 years.
NOT tx with systemic glucocorticosteroids.

35
Q

MRONJ risk assessment - what are high risk patients? (SDCEP 2017)

A

Patients being treated for osteoporosis or other non-malignant bone disease with oral/IV bisphosphonates for MORE than 5 years.

Bisphosphonates or denosumab any length of time but concurrent systemic glucocorticosteroids.

patients tx with anti-resorptive and/or anti-angiogenic drugs as part of CANCER mx

Previous diagnosis of MRONJ.

36
Q

MRONJ risk patients. In how many weeks after extractions should the socket heal? What do you do if it doesn’t?

A

8 weeks to heal.
If the extraction socket is not healed in 8 weeks and you suspect MRONJ - refer to oral surgery/special care specialist

37
Q

What is the guideline for patients on anticoagulant/antiplatelet drugs?

A

SDCEP Mx of dental patients taking anticoagulants or antiplatelet drugs 2022

38
Q

Give examples of Direct Oral Anticoagulant (DOAC) drugs

A

Apixaban, rivaroxaban, edoxaban, dabigatran

39
Q

Higher bleeding risk dental procedures and patients on DOAC - what do you do?

A

Advise patient to miss or delay morning dose before tx

40
Q

What type of drug is warfarin?

A

Vitamin K Antagonist

41
Q

Below what IRN it is okay to treat the patient?

A

IRN below 4

*ideally checked no more than 24h before procedure or 72 if stable
*consider limiting initial tx areas
*if above 4 - refer if urgent

42
Q

Give examples of antiplatelet drugs

A

Aspirin
Clopidogrel

43
Q

Give examples of dental procedures of low risk of postoperative bleeding complications

A

simple extractions
incision of extraoral swelling
detailed 6 point chart
RSD
restorations with subgingival margin

44
Q

Give examples of dental procedures of high risk of postoperative bleeding complications

A

complex extractions, adjacent extractions
flap raising procedures
biopsies

45
Q

What radiographic signs are associated with significantly increased risk of IAN injury during M3M surgery?

A
  • diversion of the inferior dental canal
  • darkening of the root where crossed by the canal
  • interruption of the canal lamina dura
46
Q

What medicament is effective in preventing dry socket (alveolar osteitis)?

A

chlorhexidine

47
Q

what are adverse effects of chlorhexidine use?

A

staining, altered sensation, burning sensation, hypersensitivity, mucosal lesions

48
Q

What is the optimal postop pain mx for dental extractions in adults?

A

ibuprofen 400mg + paracetamol 1000mg

49
Q

What is the role of steroid medication in M3M surgery?

A

Steroid medication provided parenterally during surgery reduces trismus, pain and inflammation. Where an opportunity is available, there is evidence to justify parental steroids given peri-operatively.

50
Q

What can be used if patient is haemostatically compromised?

A

absorbable haemostatic gelatin sponge, collagen fleece (Surgicel)

TXA mouthwash (warfarin patients)

51
Q

Consider operculectomy of a partially erupted M3M?

A

mmmmmm limited evidence

52
Q

what can you say to a patient if they ask about crowding related to mandibular third molars?

A
  • cause of dental crowding is multifactorial and complex
  • third molars may play bigger role in some patients, but not enough research to tell accurately who is at risk
  • no matter what the cause, it is difficult to predict or prevent dental crowding

*AAOMS paper in royal college of surgeons guideline

53
Q
A

4D Curriculum Revision (2 decks)

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