Lecture 7

Question 1

tooth is out.. what happens now?

cascade of reparative processes initiated immediately what are they (4)

each stage has to happen and be completed before next stage

Answer 1

Hemostasis - happens immediately- 2days- platelets -get a nice fibrin clot to form a matter of minutes - sig

Then acute inflammation phase - body cleans - 30min-5days (granulocytes)

Proliferation - new shit - monocyte/macrophage - 1hr-2week

Remodeling - entire life -

Question 2

the platelets during hemostasis stage of healing cause _ (major cause of postop pain)

Answer 2

inflammation (IL,PGs) (which is next phase)

24-72hr -

warmth redness - about 24hr post is expected

Question 3

_ phase

creates and stablizies the blood clot

signals for cells to clean up the wound

Answer 3

inflammation - signals for cells to clean up the wound

hemostasis - creates and stablizes the blood clot

Question 4

_ phase

collagen and capillaries form on fibrin from clot
creates provisional matrix upon which bone will form

fibroblasts are moving in to lay down new tissues

Answer 4

proliferation

Question 5

_phase 3/4 week time frame

migration from coronal soft tissue across bed of granulation tissue
stops when it meets the contralateral advancing edge

Answer 5

epithelialization

gum tissue to fold over 3/4 weeks

secondary healing

not primary - suture gum to gum

Question 6

_ phase

provisional collagen matrix with woven bone - and then eventually mature bone

Answer 6

remodeling

Goes on forever - will never see this but
Can see it if we take serial ceph or radioimages

Radiograph lags behind actually what is happeneing in the body by 3 months

Question 7

remodeling phase

2-4 weeks
6-8 weeks
12-24 week

Answer 7

2-4 weeks; granulation tissue and provisional matrix mostly , 10.5% woven bone - 0 lamellar bone/marrow

6-8 weeks; a lot of provisonal matrix and woven bone, little to no granulation tissue, no lammellar bone

12-24 weeks; little lamellar bone decent amount of woven and a lot of provisional matrix

Question 8

normal healing time:
week 1
week 3
4-6 months

Answer 8

week 1 - mild-moderate discomfort (angiogenious 1-3 days)

week 3 - socket “healed over”
new bone formation 3-4 weeks

weeks 4-6 bone growth

bone reorganization 6weeks - 4 months

radiographic 4-6 months the lamina dura resrob

Question 9

number one thing to set up patient for poor wound healing

Answer 9

poor oral hygiene

immature Tissue has to compete for O2 because of bacteria competition

large inflammatory response - gingiva puffy and angry

delayed healing

Question 10

why does smoking cause poor wound healing

Answer 10

causes peripheral vasoconstriction - decreases tissue perfusion

1cig - 1hr of vasoconstriction

1pack per day= all day vasoconstricted

Question 11

Above this amount of radioation - sets up for wound healing problems

Answer 11

> 5000centiGy to jaws

radiation-induced fibrosis - Everything in the path becomes fibriotic - scar - still hard tissue but it is scar like

turnover rate of surviving bone is slowed and can be ineffective in self-repair (ostero-radio-Necrosis of bone that has been radiated more than 5000cGy - and then have something traumatic (like tooth extraction) exposes bone and fucks shit up - sometimes never heal )

Question 12

_ drugs on wound healing

given IV,IM - Nitrogen-containing bisphosphonates (Zometa,Pamidronate)

RANKL inhibitors = denosumab (Prolia, Xgeva) - more common rn

Tx of bony metastais of solid tumors and osteolytic lesions of metastatic cancers

potent osteroclastic inhibiton

Answer 12

anti=resoprtive drugs

Block the action of osteroclasts
Tumor has less ability to invade and metastasized

Question 13

what is localized alveolar osteitis

Answer 13

dry socket

not an infection!

local inflammation of bone

cause - loss,lysis, or breakdown of the blood clot prior to its maturation into granulation tissue

Question 14

3-5 days post-op (thru acute inflammation pahse of healing)

increase in quantity and or change in quality of pain
malodor, foul taste
-ineffective pain medication

Answer 14

localized alveolar osteitis

Question 15

factors that can increase risk of osteitis (dry socket)

~arch?
~meds?

Answer 15

mandibular tooth - lower blood supply because more cortical/compact bone

smoking - vasoconstriction

oral contraceptives - estrogen related

Pericornitis - if active at time could increase risk

increased age of patient

surgical time - more exposure to air(O2)

traumatic extraction - soft tissue damage too

inadequate irrigation - surgical buzzing thru bone getting too hot = dry socket at least

Question 16

how can you decrease risk of localized alveolar osteitis

Answer 16

0.12% CHX gluconate rinse couple days before

sound surgical technique(copious irrigation with normal saline)

no evidence for antibiotics pre/post op of dry socket

osteitis is inflammation of bone - not an infection

Question 17

TX of localized alveolar osteitis

Answer 17

irrigate and place palliative dressing

iodoform gauze with eugenol on it (dry socket paste)

resolution 3-5 days, up to2 weeks in some patients

if not by then something else is going on - osteomyelitis?(smoking, diabetes, chronic sterioid use)

Question 18

bone infection

medical and surgical issue
can lead to significant morbidity

Answer 18

osteomyelitis

Need to be treatred by OMFS - this is not Dry Socket but presents as if it was but just doesn’t clear up
So if post surgery we have what we think dry socket is and doesn’t heal for like 4-5 days