Oral Surgery Flashcards
What analgesics are available for dentists to use according to the dental practitioners formulary?
Aspirin Ibuprofen Diclofenac Paracetamol Dihydrocodeine Carbamazepine
What type of drug is aspirin?
NSAID
What dose of aspirin is usually administered for odontogenic pain?
2 tablets (300mg), 4x daily, preferably after food
What are contra-indications of aspirin use?
Children/adolescents under 16; breast feeding
Previous or active peptic ulceration
Haemophiliacs
Hypersensitivity to aspirin or another NSAID
What are adverse affects of aspirin?
GIT problems
Hypersensitivity - Acute bronchospasm/asthma type attack
Overdose - tinnitus, metabolic acidosis
Aspirin burns - mucosal
What type of drug is ibuprofen?
NSAID
More commonly used than aspirin
What dose of ibuprofen is used for odontogenic pain?
1 tablet (400mg), 4x daily, preferably after food
What dose of aspirin is given after a ischaemic event?
Single dose ASAP (300mg)
Maintenance 75mg daily
What groups of patients should be cautious of when prescribing ibuprofen? (8 groups)
Previous or active peptic ulceration Elderly Pregnant and breast-feeding Renal, hepatic or cardiac impairment History of hypersensitivity to aspirin or other NSAIDs Asthmatics Patients taking other NSAIDs Patients on long term systemic steroids
What are the common side effects of ibuprofen?
- GIT discomfort, occasionally bleeding and ulceration
- Hypersensitivity reactions e.g. rashes, angioedema and bronchospasm
- Others; headache, dizziness, nervousness, depression, drowsiness, insomnia etc
Aspirin and Ibuprofen are what type of drug and what is their mechanism of action broadly?
They are NSAIDs
They inhibit COX-1 and consequently the prostaglandins associated with that system
When should selective COX-2 inhibitors be used?
COX-2 selectives should only be used to manage dental pain in patients at high risk of gastric or duodenal ulceration
How does paracetemol work?
Indirectly inhibiting COX - especially in brain
Thalamus is the main site of action
Which groups of people do you have to take caution with when prescribing paracetamol?
Hepatic impairment
Renal impairment
Alcohol dependence
What dose of paracetemol do you prescribe for odontogenic pain?
Adults - 1-2 tablets (0.5-1g) every 4-6hrs
Max dose - 4g daily
Children - depends on weight/age - check BNF
When a pt overdoses on paracetamol what will they experience?
- anorexia, nausea, vomiting - usually settles within 24h
- persistence of this usually involves abdominal pain, right subcostal pain and tenderness usually indicates development of hepatic necrosis
- liver damage is maximal 3-4 days after ingestion and may lead to jaundice, renal failure, haemorrhage, hypoglycaemia, encephalopathy, cerebral oedema and death
What opioid analgesic is available to dentists and how does it work briefly?
Dihydrocodeine
Act in the spinal cord - especially dorsal horn pathways associated with paleospinothalamic pathways
BNF states opioid analgesics are relatively ineffective in dental pain
What are the problems associated w opioid analgesics?
Dependence - physiological and physical
Tolerance
Effects on smooth muscles - constipation, urinary and bile retention
What are side effects of opioids?
Most common - nausea, vomiting and drowsiness
Larger doses produce respiratory depression and hypotension
What are contra-indications of opioids?
Acute respiratory depression
Acute alcoholism
Raised intracranial pressure/head injury
Which groups should you be cautious about when prescribing opioids?
Hypotensive Asthmatics Pregnant/breast-feeding Renal/hepatic disease Elderly/children
NEVER prescribe in raised intracranial pressure/suspected head injury
What dose of dihydrocodeine should you administer for odontogenic pain?
30mg every 4-6h
What drug is used for trigeminal neuralgia?
Carbamazepine
What is trigeminal neuralgia?
What are the clinical features?
Stabbing, burning and often severe pain due to irritated or damaged nerve
Severe spasms of pain - "electric shock" usually unilateral older-age group Trigger spot identified Females more than males Periods of remission Recurrences often greater severity
What dose of carbamazepine do you administer?
Starting dose - 100mg 1-2x daily
Usual dose - 200mg 3-4x daily
Max dose - 1.6g daily
What are the contra-indications of carbamazepine?
AV conduction abnormalities
History of bone marrow depression
Poryphyria (group of liver disorders in which substances called porphyrins build up in the body, negatively affecting the skin or nervous system)
What are the indications for extractions?
Unrestorable teeth Symptomatic partially erupted teeth Traumatic position Orthodontic indications Interference with construction of dentures
What would categorise a tooth as unrestorable and ready for extraction?
Gross caries Advanced periodontal disease Tooth/root fracture Severe tooth surface loss Pulpal necrosis Apical infection
How can you tell the difference between a straight upper anterior forcep and an upper universal forcep?
Slightly curved handle in the upper universal forceps
What forcep is used for extraction of upper canine and premolar teeth?
Upper universal forcep
Distinguished from the upper anterior forcep as it has a slightly curved handle viewed from the side
What forcep is used for extraction of upper left molar teeth?
Upper left molar forceps
Look for the projection, which engages the bifurcation between the mesiobuccal and distobuccal roots
Remember “beak to cheek”
What forcep is used for extraction of upper right molar teeth?
Upper right molar forceps
Look for the projection, which engages the bifurcation between the mesiobuccal and distobuccal roots
Remember “beak to cheek”
What forcep is used for extraction of upper retained roots?
Upper Root forceps
Curvature held towards the fingers
Slender, long beaks that help engage broken down roots in the upper jaw
When compared to the upper straight and upper universal they have a curved handle
What is the composition of the upper molar forcep tips?
Upper molars have 2 roots bucally and 1 palatally - need to have forceps that engages two different things on either side
Smooth curved end - palatal root
Triangular end - buccal - point is designed to go into the furcation of the two roots - pointy bit engages there - beak to cheek
How do you differentiate upper and lower forceps?
90-degree bend
What are the three lower extraction forceps?
Lower Universal
Lower Molar
Cowhorn
How do you identify lower universal forceps?
Tips are concave on both sides - used on lower anteriors and premolars - concave side is used to engage the root surface
How do you identify lower molar forceps?
Two pointy beaks - designed to engage to buccal and lingual furcation on the lower 6s
How do you identify cowhorn forceps?
Very pointy and quite sharp - narrow end
Designed to be used on two rooted lower molars - wont work if the molars have a single root therefore need to use the radiograph to confirm this
Can crush the crown if not placed properly into the furcation
Apart from Upper and Lower forceps what are the other type of FORCEPS?
Bayonet forceps
Z-shaped - bayonet pattern
Used for difficult to access wisdom teeth
Root patterns varies a lot so cannot have forceps w pointy beaks to engage furcation as you don’t know where theyre going to be
Tips are same as upper universals
Root Forceps
Very fine tip - for removing little roots - do not use on wisdom teeth
For lower right molar extraction where would the operator stand? (RH)
Stand behind the patient and slightly to their right
LH is opposite
For an upper right molar extraction where would the operator stand? (RH)
In front of the patient and to their right
LH is opposite
For an upper left molar extraction where would the operator stand? (RH)
In front of the patient and to their right
LH is opposite
For a lower left molar extraction where would the operator stand? (RH)
In front of the patient and to their right
LH is opposite
What position would you have the patient in for an extraction?
Upright
For upper molars you can lay the patient a bit more flat
What are the different types of elevators?
Couplands
Cryers
Warwick James
What are couplands elevators used for?
Come in different sizes - 1-3
1 being narrowest, 3 widest
Designed to tear the PDL and widen PDL space - and even elevate tooth
What are cryers elevators used for?
Used to get rid of retained roots
Concave surface is pointing towards the ceiling - pointy bits towards each other
How can you identify Warwick James elevators?
Come in sets of 3
Points are less sharp - theyre curved
Straight one is like a fine couplands
Used for wisdom teeth - smaller therefore fit into narrower areas
Concave surface pointing the ceiling and pointy bits facing each other
When do you use a luxator?
Use it to sever the PDL
Should be used before elevator as they’re much sharper at the tip compared to couplands
Bc theyre so sharp they will go deeper into the PDL space and can immobilise a tooth much more
What is a periotome?
Known as the ultimate luxator
Tip is like a periodontal probe - mini blade at the end of the handle
Work the blade down the PDL space and cut it round the tooth
This makes extraction easier and can take out the tooth atraumatically without losing any bone - important if planning to do implant after
Takes v long to cut PDL with this however
What are the 3 mechanical priniciples for tooth elevation?
Wheel and Axle (rotation)
Lever
Wedge
When can you use Wheel and Axle method and how does it work?
With elevators but not a luxator
Place elevator mesially, into the gap on the buccal side
The tip is engaging the CDJ and push it in as deep as you can
Thereafter rotate it, and as it twists, it elevates the tooth
What is the lever technique?
This generates much more force than the wheel and axle technique and can be dangerous if not done properly - could potentially fracture the mandible
What is the wedge technique?
This can also be done with a luxator as well as an elevator
Push into the PDL space and the tooth comes up
Need a v sharp instrument for this to happen
How would you use the elevators to remove a molar tooth?
Usually start with mesial application - using a couplands, cryers or warwick james
Insert the couplands with the concave surface facing the mesial surface of the tooth being elevated and then do a rotational action
Swap to buccal side - can keep using a couplands or switch to cryers which uses tip to engage the furcation - twist it and this allows the tooth to move up lingually
What are the stages of oral surgery?
Consent Surgical pause/safety checklist Anaesthesia Access Bone removal as necessary Tooth division as necessary Debridement/wound management Suture Achieve haemostasis Post-operative instructions Post-operative medication Follow-up
What does “consent” mean in terms of oral surgery?
GDC states must obtain consent and written consent where pt requires GA - Clause 3 and 3.1.6
Surgical/non-surgical procedures also require written consent
Most important thing is having discussion w the patient and making sure they understand the procedure otherwise signature means nothing
What does “surgical safety checklist” mean in referral to the oral surgery procedure?
Check whether we have got the right patient
Operating on the correct side and that we have got everything prepared at the beginning of the procedure
What principles apply to surgical access for oral surgery?
Wide based incision-circulation/perfusion
Use scalpel in one firm continuous stroke
No sharp angles
Adequately sized flap
Flap retraction should be down to bone and done cleanly
Minimise trauma to dental papillae
No crushing
Keep tissues moist
Ensure that flap margins and sutures will lie sound on bone
Make sure wounds are not closed under tension
Aim for healing by primary intention to minimise scarring
What flaps would be raised to remove a wisdom tooth?
3-sided tooth or envelope flap
How is a 3-sided flap raised?
Distal leading incision
Crevicular incision around the tooth and mesial leading incision
Make sure the distal leading incision is not too lingual - risks injuring the lingual nerve - keep it more buccal following the external oblique ridge of the mandible
How is an envelope flap raised?
Envelope flap is the same as a 3-sided flap except there is no mesial leading incision
So a distal leading incision and the crevicular incision is extended through the 7 and sometimes 6 too
What instruments would you use for soft tissue retraction?
Howarth’s periosteal elevator or rake retractor
Allows access to operative field
Also allows protection of soft tissues
Why are air driven handpieces not used for bone removal and tooth division?
They may lead to surgical emphysema
Electrical straight handpiece with saline or sterile water - cooled bur is used instead
How does bone removal help wisdom tooth extraction?
Buccal gutter created around the 8 which allows elevation of the tooth
What is the sequential action once bone has been removed in a wisdom tooth extraction?
Once bone has been removed, you will have to divide the tooth into individual roots or take the crown of the tooth
What needs to occur after use of elevators?
Careful debridement after the use of elevators to remove any bone fragments that have been created
What are the three stages of debridement?
Physical - bone file/handpiece to remove any sharp bony edges
Mitchell’s trimmer or Victoria curette to remove soft tissue debris
Irrigation - sterile saline into socket and under flap
Suction - aspirate under flap to remove debris
Check socket for retained apices etc
What are the aims of suturing?
Reposition tissues Cover bone Prevent wound breakdown Achieve haemostasis Encourage healing by primary intention
When would you use non-absorbable sutures?
If extended retention periods are required
Must be removed post-op
e.g. closure of OAF or exposure of canine tooth
When would you use absorbable sutures?
Holds tissue edges together temporarily
If removal of suture not possible/desirable
Lasts for a week or two
What is the cross-section of a suture needle?
- Triangular
Tip of triangle on inside - cutting
Tip of triangle on outside - reverse cutting - Round (taper)
Where do you hold the suture needle?
Grab the suture needle with the suture holder 1/3rd from the swaged end
Swaged end is where the needle is connected to the suture material
How is haemostasis achieved peri-operatively?
LA w Vasoconstrictor
Artery forceps
Diathermy
Bone Wax
How is haemostasis achieved post-operatively?
Pressure LA infiltration Diathermy WHVP Surgicel Sutures
What are the post-operative instructions for oral surgery? (4 points)
o Do not rinse out for several hours (better not to rinse till next day, then avoid vigorous mouth rinsing – wash clot away)
o Avoid trauma - do not explore socket with tongue or fingers/hard food
o Avoid hot food that day
o Avoid excessive physical exercise and excess alcohol – increase blood pressure
How do you control bleeding?
Biting on damp gauze/tissue
Pressure for at least 30 min (longer if bleeding continues)
Points of contact if bleeding continues
What post-operative medication is usually administered?
Don’t routinely give antibiotics - partly because we dont need. to and partly due to antibiotic resistance
Most commonly be given some sort of analgesia post-operative - ibuprofen or paracetamol
What 4 nerves can be damaged during removal of third molars?
Lingual
Inferior alveolar
Mylohyoid
Buccal
What is the blue safetyplus needle?
Blue is the short needle, yellow longer
25mm
30 gauge
What parts do you need to assemble a local anaesthetic syringe?
Plunger
Rubber bung
Safety plus needle
LA cartridge
What is the yellow safetyplus needle?
Yellow is the longer needle, blue shorter
35mm
27 Gauge
How do you assemble the LA syringe?
Grab the plunger and the rubber bung
The rubber bung has 2 sides, place the wider side first onto the end of the plunger
Then select the local anaesthetic cartridge and place it into the safetyplus needle holder with gold side entering first
Lift the black handle on the plunger to the top and insert it into the safety plus syringe and connect them together
Pull down the safety plus top with a single click
What are the two types of LA?
Esters and Amides
Leaning towards more amide usage now
What types of vasconstrictor are used in LA and why do we need them?
LA can either contain no vasoconstrictor, adrenaline or felypressin (octapressin)
Cause blood vessels to constrict, advantageous as it allows the LA to stay in the injected area for a longer amount of time
Also can be used to control bleeding and help haemostasis
What preservatives are found within local anaesthetic?
Bisulphate
Propylparaben - this is what tends to cause the problem w allergies so true allergy is to this
They’re there to prolong the shelf life
How do you ensure that you have not placed the LA needle into a blood vessel?
Aspirate
Pull syringe back slightly when inserted
If in blood vessel then you will see blood drawn back
What is the advantage of adrenaline containing LA?
Prolongs the effects of the LA
What group of people should you avoid when using LA containing felypressin (octapressin)?
Pregnant women
Have been cases of women going into labour
What is an infiltration?
Local anaesthetic solution is deposited around terminal branches of nerves
Used to anaesthetise soft tissues
Used to produce pulpal anaesthesia where the alveolar bone is thin
- Maxilla
- Lower anteriors
What is the alternative to using the infiltration technique for LA?
Block technique
Anaesthetic is deposited around the nerve trunk
Abolishes sensation distal to site - so all the terminal fibres
Used to produce soft tissue anaesthesia
Used where bone is too thick to allow infiltration
- Mandible
Can also use it where we are working on multiple teeth or a large area
How would you anaesthetise the pulp of an upper tooth?
Buccal infiltration
How would you anaesthetise the buccal gingivae of the maxilla?
Buccal infiltration
How would you anaesthetise the palatal gingivae of the maxilla?
Palatal injection
How would you anaesthetise the dental pulp of lower molars?
Inferior alveolar nerve block
How would you anaesthetise the dental pulp of lower second premolar?
Inferior alveolar nerve block
How would you anaesthetise the dental pulp of lower premolars and canine?
Mental (incisive) nerve block
How would you anaesthetise the dental pulp of lower canine and incisors?
Buccal/labial infiltration
How would you anaesthetise the buccal gingivae in lower molars and second premolar?
(Long) Buccal infiltration
How would you anaesthetise the buccal gingivae in lower first premolar and canine?
Infiltration or long buccal or mental nerve block
How would you anaesthetise the buccal gingivae in lower incisors and canines?
Buccal/labial infiltration
