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BDS 3: Oral Surgery > L2 Rarer Complications in Oral Surgery > Flashcards

L2 Rarer Complications in Oral Surgery Flashcards

1
Q

What is an OAC?

A

An oroantral communication, a connection between the maxillary sinus and the mouth.

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2
Q

Which teeth are at the highest risk of an OAC?

A

The maxillary posterior teeth

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3
Q

How can you determine the OAC risk radiographically?

A

A high risk tooth will have a low maxillary antrum floor

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4
Q

How will an OAC appear clinically?

A

Post extraction, gentle suction and good light, will see large dark hole.
Suction will become high pitched.
Pinch nose and blow gently, bubbles will fill the hole. Not recommended!! Can create an OAC in pts with a thin membrane still remaining.- DONT DO THIS

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5
Q

What is an OAF?

A

An oroantral fistula

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6
Q

How is an OAF different to an OAC?

A

An OAC occurs immediately post extraction, an OAF forms 72 hours later as an epithelial lining forms on the inside of the connection.
OAF is more difficult to manage, it is a permanent opening.

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7
Q

Why is the nose blowing test for an OAC not always recommended?

A

It can create an OAC in patients who still have a thin membrane remaining.

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8
Q

How can an OAC be managed non-surgically?

A

For very small defects, smaller than 5mm, the OAC can heal spontaneously if not infected.

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9
Q

How is an OAC managed surgically?

A

Buccal advancement flap:
- 3 sided flap created and closed over defect
- This shortens the sulcus, and can make denture making afterwards more challenging

For an OAF: dissect the OAF and then close defect

Review after 2-3 weeks

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10
Q

What are the post-operative instructions following an OAC buccal advancement flap?

A
  • No nose blowing for 6 weeks
  • Analgesic and OHI advice
  • Antibiotics: usually 500mg amoxicillin
  • Xylometazoline 1% nasal drops, 2-3 drops, 2-3 times a day for a week (helps to clear congestion)
  • Steam inhalation
  • Review after 2-3 weeks
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11
Q

How will a patient with an OAC or OAF present if it’s not noticed at the time of surgery?

A
  • Fluid moving up into the nose when drinking
  • Bad taste in mouth
  • Generalised pain in cheek on side affected
  • Blocked nose on affected side
  • Open socket
  • Patient sounding congested when speaking
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12
Q

What fracture can occur when extracting maxillary posterior teeth?

A

Maxillary tuberosity fracture

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13
Q

What teeth are more likely to result in a tuberosity fracture when being extracted?

A
  • Upper wisdom teeth
  • Lone standing molars
  • Teeth which are palatally positioned
  • Bublous and multi-rooted teeth
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14
Q

What are the signs of a tuberosity fracture?

A
  • Large crack on attempted elevation
  • Classic tear of soft palate
  • Teeth loose but unable to deliver easily
  • Excessive bleeding
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15
Q

If a tuberosity fracture has occured, what should you do to prevent it from becoming more severe?

A
  • Assess size of fracture
  • Carefully disect loose bone away from soft tissue to prevent excessive tearing/trauma to soft tissue
  • Risk of creating OAC
  • Do NOT just pull the tooth!
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16
Q

How should a small tuberosity fracture without a sinus perforation (OAC) be managed?

A

Dissect the tooth (split and carefully extract) and bone from the soft tissue and suture

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17
Q

How should a small tuberosity fracture with a sinus perforation (less than 3-4mm) be managed?

A

Dissect the segment and close the socket, usually easy as there’s lots of soft tissue available

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18
Q

How should a tuberosity fracture of a very large segment involving multiple teeth be managed?

A
  • Consider stabilisation by splinting to adjacent teeth
  • Allow segment to heal for 6-8 weeks
  • Patient returns for extraction in a more controlled manner (surgical sectioning), consider referral to OS/OMFS for this
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19
Q

Which extraction is most high risk of inferior dental nerve injury?

A

Extraction of mandibular third molars

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20
Q

What are the mechanical causes of an ID nerve injury?

A
  • LA needle damaging the nerve
  • Compression of the nerve
  • Complete nerve transection (polo nerve)
  • Haematoma
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21
Q

What are the chemical causes of an ID nerve injury?

A
  • LA
  • Extrusion of root canal materials through tooth apex onto nerve
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22
Q

What are the thermal causes of an ID nerve injury?

A
  • Nerve heating up if not using a saline cooled bur
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23
Q

How can you identify a high risk tooth of ID nerve injury?

A

Based on the pre-operative radiograph.
Look for:
- Darkening of the root
- Narrowing of the root
- Deflected roots
- Dark and bifid tooth apex
- Interruption of white line of canal
- Diversion of canal
- Narrowing of canal

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24
Q

What are the 5 descriptions of a nerve injury?

A
  • Anaesthesia: total loss of sensation
  • Parasthesia: abnormal sensation which isn’t unpleasant
  • Dysesthesia: abnormal unpleasant sensation
  • Ageusia: loss of taste
  • Dysgeusia: altered taste
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25
Q

How should you manage a nerve injury?

A
  • Get a clear description of the sensation, e.g. electric shock
  • Check the sharp point discrimination using light touch with cotton wool, 2-point discrimination, sharp discrimination, blunt discrimination, check left vs right
  • Document clearly
26
Q

How should you manage a nerve injury long term?

A
  • Compare discrimination and touch at following visits
  • Refer all cases of nerve injury to secondary care
  • Complete nerve sectioning will not recover, would require referral to a specialist centre for possible surgical repair
27
Q

What percentage of lingual nerve injuries related to third molar surgery recover within the first 3 months?

A

Up to 94% of cases

28
Q

Can the lingual nerve be assessed radiographically prior to extraction?

A

No, it cannot be seen on X-rays but you can estimate the position.

29
Q

What type of injury can occur to the lingual nerve?

A
  • Most injuries are due to retraction of the nerve causing it to be stretched out, this affects sensation and is usually temporary (will recover)
  • If the nerve is transected, it will need referring for an MRI, it is a more serious injury

Lingual nerve injury affects taste.

30
Q

What does MRONJ stand for?

A

Medication Related Osteonecrosis of the Jaw
(Used to be called BRONJ, b for bisphosphonates but now we now more drugs cause it)

31
Q

What drugs can cause MRONJ?

A
  • Antiresorptive drugs (slow down bone resorption)
  • Antiangiogenic drugs (block BV growth, used to treat cancers)
32
Q

Define MRONJ.

A

Exposed bone or bone that can be probed through a fistula in the maxillofacial region that has persisted for more than 8 weeks in patients with a history of treatment with these drugs, and where there has been no history of radiation therapy to the jaw or no obvious metastatic disease in the jaws.

33
Q

What is the incidence of MRONJ?

A
  • 1% for cancer patients being treated with anti-resorptive or anti-angiogenic drugs
  • 0.01-0.1% for osteoporosis patients taking anti-resorptive drugs
34
Q

Does MRONJ always occur after a dental procedure?

A

No, it usually occurs following a dental procedure but can occur spontaneously.

35
Q

How do antiresorptives and antiangiogenics cause MRONJ?

A
  • Inhibit osteoclast formation and migration
  • Reduces bone turnover to reduce risk of fracture e.g. in osteoporotic patients
  • Lack of normal bone turnover = poor healing post extraction
  • Current hypotheses for the causes of necrosis include suppression of bone turnover, inhibition of angiogenesis, toxic effects on soft tissue, inflammation or infection
36
Q

When should you review patients post extraction who are at risk of MRONJ?

A

Review 8 weeks after extraction.

37
Q

How is MRONJ managed?

A
  • If it occurs in general practice, refer to OS/OMFS
  • Conservative management: OH and salt water rinses, irrigation syringes
  • If it becomes secondarily infected abx are indicated
  • May need to remove loose pieces of bone with tweezers, or gently gring away to allow for soft tissue coverage
38
Q

Name some bisphosphonates.

A
  • Zoledronate
  • Alendronate (alendronic acid)
  • Pamidronate
  • Ibandronate
  • Clodronate
  • Etidronate
39
Q

Name some antiangiogenic drugs.

A
  • Bevacizumab
  • Sunitinib
  • Sorafenib
  • Pazopanib
    -Axitinib
40
Q

Name other drugs that can cause MRONJ.

A
  • RANKL inhibitors: denosumab
  • m-TOR inhibitors: everolimus, temsirolimus
41
Q

What risk assessment should be carried out before treating patients taking drugs making them high risk for MRONJ?

A
  • Take a thorough medical history, particularly if they have a history of osteoporosis or breast/bone/metastatic cancer
  • Try to avoid extractions where possible
  • If extraction is necessary explain risks and gain informed consent
42
Q

Which concurrent drug makes a pt higher risk for MRONJ?

A

Taking anti-resosptive/anti-angiogenic alongside a systemic corticosteroid- makes them high risk of MRONJ.

43
Q

How long after taking MORNJ risk drugs is the pt still considered high risk?

A

For 5 years following them discontinuing medication use.

44
Q

What does this image show?

A

A patient with MRONJ which is very severe and complex, has created an extra-oral fistula in the mental region.

45
Q

Which guidance is recommended to follow when considering MRONJ?

A
46
Q

What is ORN?

A

Osteoradionecrosis
Defined as exposed irradiated bone that fails to heal over a period of 3 months without any evidence of persisting or recurrent tumour.
Large area of non-healing bone.
Very difficult to manage/treat.

47
Q

What is endarteritis obliterans?

A

Hypocellular, hypovascular and hypoxic environment leading to avascular necrotic bone

48
Q

When does osteoradionecrosis of the jaw occur?

A

Usually following extraction in a patient who has previously undergone radiotherapy.

49
Q

What should a patient have before commencing head and neck radiotherapy?

A

A dental screen prior to radiotherapy.
Poor prognosis teeth should be removed prior to radiotherapy.

50
Q

What radiation dose creates a higher risk of ORN?

A

60Gy or greater radiation dose

51
Q

Does ORN risk decrease over time following radiotherapy?

A

NO.
(Unlike MRONJ which decreases after 5 years).

52
Q

Should you extract a tooth in a pt at risk for MRONJ in primary care?

A

No, refer to secondary care.

53
Q

What is the treatment for ORN?

A
  • Conservative management: removal of loose pieces of bone
  • Antibiotics
  • Hyperbaric oxygen chambers in some areas on the country
  • Pentoxifylline (400mg BD) and Tocopherol 1000 IU
  • Severe cases: surgical resection and reconstruction
54
Q

What is the Notani ORN Classification system?

A
55
Q

What is osteomyelitis?

A

A rare infection and inflammatory process which begins in the bone marrow and spreads to the periosteum.
Can occur post dental extraction or occur spontaneously.
Can spread to skin.

56
Q

How does osteomyelitis present?

A
  • In patients post extraction: deep seated boring pain
  • Spontaneously: swelling, loosening of teeth, altered sensation
57
Q

How is osteomyelitis managed?

A
  • Long course antibiotics
  • May need to be admitted to hospital for IV abx
58
Q

Is osteomyelitis common?

A

No, will rarely see but should bear in mind.

59
Q

What type of patients will have osteomyelitis?

A
  • Immunocompromised
  • Poor OHI
  • Smokers
  • Diabetics
60
Q

When should you have a high suspicion for osteomyelitis?

A

Multiple treatments for “dry socket”.

61
Q

Will you see radiographic changes in early osteomyelitis?

A

No.

62
Q

What can be helpful in the treatment of osteomyelitis?

A
  • Sending pus samples to the lab to target abx treatment
  • Send bone samples to target treatment choice

BDS 3: Oral Surgery (3 decks)

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