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Oral Surgery Flashcards

1
Q

A 25 year olf patient presents with an impacted lower wisdom tooth. Name a set of published guidelines for the removal of wisdom teeth.

A

SIGN

NICE

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2
Q

What complications could arise in a patient requiring the extraction of an unerupted premolar if they wear a -/f and the mandibular denture bearing area is very resorbed and the patient has osteoarthritis?

A

Pain, swelling, bleeding, bruising, infection, dry socket (alveolar osteitis), mandibular fracture (atrophic mandible), MRONJ, immunosurpressed and elderly = increased infection risk, nerve damage

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3
Q

When working through a surgical sieve to reach a diagnosis, what does VITAMIN D stand for?

A

Vascular, Infective/Inflammatory, Traumatic, Autoimmune, Metabolic, Idiopathic, Neoplastic, Degenerative

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4
Q

List three reasons for the removal of impacted lower wisdom teeth

A

Pericoronitis

Caries

Systemic symptoms

Pathology

Periodontal disease

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5
Q

What is the incidence of i) temporary and ii) permanent loss of sensation following the removal of wisdom teeth?

A

i) 10% (anywhere from 5-30% accepted)
ii) less than 1%

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6
Q

List four post op complications of removing wisdom teeth

A

Pain

Bruising

Swelling

Limited mouth opening/trismus

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7
Q

Other than pain, bruising and swelling, list 6 signs and symptoms of a body of madible fracture

A

* Bleeding

* Limitation of function

* Mobile teeth

* Lower lip numbness

* Occlusal derangement/step deformity

* Facial asymmetry

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8
Q

What 2 radiographic views would you want to assess a mandibular fracture?

A

OPT and PA mandible

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9
Q

What factors would cause a mandibular fracture to be displaced?

A

Pull of attached muscle (unfavourable)

Angulation of fracture line

Magnitude of force

Opposing occlusion

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10
Q

List 3 management options for a mandibular fracture?

A

Do nothing

ORIF

IMF (inter maxillary fixation)

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11
Q

How does a bite splint for TMD work?

A

Acts as a habit breaker to reduce parafunctional habits.

Reduces load on TMJ

Decreases abnormal activity

Stabilises occlusion

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12
Q

What is artherocentesis and mechanism of action?

A

Sterile saline injected into TM joint space. Breaks fibrous adhesions and flushes away inflammatory exudate

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13
Q

Bleeding wont stop following an extraction. How do you manage this?

A

Take a quick history. Apply pressure. Give LA with vasocontrictor. Suture. Diathermy. If doesnt stop, refer to A&E

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14
Q

What are some local risk factors for delayed onset of bleeding?

A

LA with vasoconstrictor wears off.

Loosening of sutures

Patient traumatises area with tongue, finger, food

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15
Q

Name 2 congenital conditions that cause prolonged bleeding

A

Haemophilia A

Haemophilia B

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16
Q

Name 2 aquired conditions that can cause prolonged bleeding?

A

Warfarin

Aspirin

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17
Q

SIRS (systemic inflammatory response syndrome), 4 criteria with parameters

A

Temperature equal or greater than 38 degrees, or equal or lower than 36 degrees

Heart rate equal or more than 90 BPM

Respiratory rate equal or greater than 20 breaths per minute

WBC count equal or greater than 12,000 mL, or equal to or less than 4,000 mL. 10% immature nutrophils

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18
Q

How many criteria must be met to get a diagnosis of SIRS?

A

2 out of 4

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19
Q

List 4 things to take note of with a facial swelling

A

* Airway compromise

* Fever

* Malaise

* Duration

* Colour

* Size

* Location

*Palpation (firm/mobile)

* Pus

* Heat

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20
Q

Why is written consent gained prior to sedation process?

A

Patient doesnt have capacity to consent during procedure

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21
Q

What drug is commonly used for IV sedation and what preparation would this drug be?

A

Midazolam 5mg/5ml IV

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22
Q

What 3 vital signs would you monitor before, during and after sedation?

A

Oxygen saturation.

Heart rate

Respiratory rate

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23
Q

What drug is used to reverse the effect of midazalam?

A

Flumazenil

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24
Q

Give 3 pieces of advice you would give to a patient following sedation?

A

No driving.

Avoid the internet

Dont sign any legal documents

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25
Q

What are the indications for inhalation sedation?

A

Conditions aggrevated by stress; epilepsy, hypertension, asthma, ischemic heart disease.

Social; anxiety, gagging

Dental; unpleasant or traumatic procedures

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26
Q

What are the advantages of inhalation sedation vs midazolam?

A

Quicker onset. Quicker recovery. Recovery time independent of dose. No needles. No amnesia. Nitrous oxide not metabolised so very safe. No chaperone required for adults. Less side effects

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27
Q

What are the contraindications of inhalation sedation?

A

Unable to nose breathe; mouth breather/poor cooperation, cold, tonsilitis.

First trimester of pregnancy

Severe COPD

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28
Q

List the safety features of the quantiflex machine.

A

* Oxygen flush buttong.

* Reservoir bag.

* Scavenger system.

* Coloured cylinders (black o2, blue NO)

* Pin index so the gases cant be mixed

* Minimum O2 set at 30%

* NO stops if O2 stops

O2 fail safe at 40 psi

* O2 monitor

* One way expiratory valve

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29
Q

When might a referral for GA be made?

A

When a patient is uncooperative.

When a patient is anxious/phobic

Complex or long procedures

Multiple extractions

Benefits must outweigh risks

Procedure/dentist requires complete stillness

MH contraindicates sedation

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30
Q

What are the 4 stages of anaesthesia?

A
  1. Induction
  2. Excitement

3 Surgical anaesthesia

4 Overdose

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31
Q

What needs to be included in a referral for GA?

A

Patient name, DOB, address and contact details.

Medica history

GMP details

Justification for GA

Radiographs

Treatment plan

GDP name and contact details

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32
Q

What is the definition of conscius sedation?

A

Use of drugs to depress the CNS to allow treatment.

The patient must be able to maintain verbal contact, remain conscious, retain protective reflexes and is able to understand and respond to verbal commands

Margin of safety is wide enough so that unintended loss of consciousness is unlikely

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33
Q

What is GABA?

A

Gamma-aminobutiyric acid

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34
Q

What is the function of GABA?

A

Inhibitory neurotransmitter in the CNS

35
Q

What is the half life of midazolam?

A

90-150 minutes

36
Q

What are the contraindications for IV sedation

A

Severe systemic disease.

Severe special needs.

Severe psychiatric problems

COPD

Pregnancy/breastfeeding

Taking erythromycin.

Uncooperative pt

No chaperone

Under 12 yo or elderly

37
Q

Give 6 things you assess a patient for before IV sedation

A

ASA class

Heart rate

Blood pressure

Weight

MH any drugs?

Cooperation level

38
Q

What is the ASA classification?

A
  1. Fit and well
  2. Mild systemic disease
  3. Severe systemic disease
  4. Severe systemic disease with threat to life
  5. Moribund

6 Braindead

39
Q

What do you monitor in a sedated patietn?

A

Hb level -> O2 saturation. Heart rate

40
Q

Pt attends practice c/o pain on biting. o/e 9mm suppurating pocket with vertical body defect radiographically tooth 15.

Give 3 differential diagnosis

A

Symptomatic periapical periodontitis

Periodontal abscess

Periapical abscess

41
Q

Pt attends practice c/o pain on biting. o/e 9mm suppurating pocket with vertical body defect radiographically tooth 15.

What special investigations would you carry out to help determine diagnosis?

A

Sensibility testing. EPT. TTP

42
Q

Pt attends practice c/o pain on biting. o/e 9mm suppurating pocket with vertical body defect radiographically tooth 15.

Explain one suitable initial treatment you would carry out

A

Draining of pus

Removing the source of infection; RCT or extraction

43
Q

What two local factors would you check for suitability for an implant?

A

Alveolar bone levels.

Space available, need 7mm between two crowns

44
Q

What two general factors woul dyou check for suitability for an implant?

A

If there are any medical contraindications such as bisphosphonates. Patients smoking status

45
Q

As per SIGN guidelines, when are impacted 3rd molars not advisable to be removed?

A

8’s predicted to erupt healthily.

MH precludes extraction.

Deeply impacted with no pathology.

High risk of surgical complications

Risk of madibular fracture

46
Q

As per SIGN guidelines, when is it advisable to remove and impacted 3rd molar?

A

Pt is experiencing significant infection associated with unerupted 8.

In patients with predisposing risk factors where occupation/lifestyle make accessing dental care difficult.

Patients whose medical history carries more risk from retention than possible complications of removal ie radiotherapy, cardiac surgery.

In patients who have agreed to a tooth transplant procedure, orthognathic surgery or other relevant local surgical procedure.

When patient is having GA for removal of 8, consideration should be given to removing the others

47
Q

What are some stong indications for the extraction of a lower 8?

A

Previous episodes of infection such as pericoronitis, cellulitis, abscess formation, or untreatable pulpal/periapical pathology

Caries in the 8 with little chance of useful restoration

Caries present in adjacent 7 that cannot be restored without removal of 8

Perio disease due to position of 8

Dentigerous cyst formation or other pathology

External resorption of 8 or 7, where it appears to be caused by the 8

48
Q

what are the principles of a flap design?

A

Wide based incision with own blood supply

Cut in a continuous stroke

Reflect flap down to bone

Avoid interdental papilla

Keep moist

No sharp angles

Margins on sound bone

Do not crush tissues

Do not close under tension

Aim for healing by primary intention

49
Q

What are some other indications for the extraction of a lower 8?

A

Autogenous transplantation into a 6 socket

Cases of fracture in the mandible in the 8 region, or for a tooth involved in tumour resection

UE 8 in atrophic mandile

Prophylactic removal of PE 8, where specific medical conditions are present

Acute exacerbation of symptoms such as operculitis while patient is on waiting list, extraction of upper 8 to relieve symptoms

PE or UE 8 close to alveolar ridge when patient is having denture constructed or is close to a planned implant

50
Q

What is assessed on a radiograph before removing an 8?

A

Type and orientation of impaction and access to the tooth - working distance

Crown size and condition (caries, size, shape)

Root number and morphology, presence of any apical hooks

Alveolar bone level, including depth and the point of elevation and density

Follicular width

Perio status along with that of the adjacent tooth

Relationship or proximity of upper 8s to maxillary sinus, lower 8s to IAC

51
Q

Briefly describe the surgical removal of a lower 8

A

LA (+/- Inhalation/IV sedation/GA)

Gain access - flaps/bone removal as necessary

Tooth division as necessary

Tooth removal

Debridement

Suture

Achieve haemostasis

Post op instructions and medication

52
Q

What is the use of iodine in extractions?

A

Found in alvogyl, used in the management of dry sockets

53
Q

Name 3 types of nerve damage

A

Neurapraxia

Axonotmesis

Neurotmesis

54
Q

What are 5 presenting symptoms of an OAC?

A

Bubbling from tooth socket when patient breathes

Bone at trifurcation of roots

Direct vision

Blunt probe

Nose holding test

Nasal voice

55
Q

Describe the surgical closure of an OAC

A

Buccal advancement flap

If smaller than 2mm, encourage bleeding of the socket and close with suture

ABs

Post op instructions

Use of steam inhalation, avoid anything that forms pressure; sneeze/cough etiquitte

56
Q

Give 4 signs indicating tooth proxiity to IAC

A

Defleciton of IAC

Darkening of root crossing canal

Deflection of root

Narrowing of IAC

57
Q

Pt has swelling around UE lower 8, facial swelling and is feeling unwell. 6 things from history and investigation to note before looking at region in mouth

A

Pain history

Temperature

Breathing rate

Heart rate

How long has swelling been present

How quickly has it increased in size?

58
Q

Pt has swelling around UE 8, facial swelling and feels unwell, what is your initial management?

A

LA

Irrigate under operculum

Incise and drain

Can extract upper 8 if irritating operculum

Extract lower 8

59
Q

What two nerves are at risk of damage when ext lower 8s and what tissues do the supply

A

Lingual nerve - tongue

IAN - chin and lip

60
Q

What might a patient c/o if they have a sialolith?

A

Fluctuant swelling at meal times

Pain

Dry mouth

Bad taste

Thick saliva

61
Q

What gland/duct is most commonly affected by sialolith and why?

A

Submandibular gland

Duct has a tortuous and uphill path

62
Q

If you suspect a sialolith, what investigations can be done?

A

Palpation of gland and duct

Lower occlusal radiograph

Sialography

63
Q

How can a sialolith be managed?

A

Surgical removal - LA, secure gland and stone, make an incision and remove, suture, POIG

Sialoendoscopic removal by basket retrieval

Shockwave lithotripsy

64
Q

What are the risk factors for an OAC?

A

Roots in antrum

Maxillary molars

Cyst

Hypercementosis

Large maxillary antrum

Ankylosis

Divergent roots

65
Q

What is the juxta apical area?

A

A well circumscribed radiolucent area lateral to the root rather than the apex

66
Q

What is warfarin and how does it work?

A

An anticoagulant

A vitamin K agonist

Inhibits clotting factors 2, 7, 9, 10

67
Q

A patient is taking warfarin, do you manage the extraction differently?

A

Check INR no more than 48 hours before ext, ideally less than 24 esp if uncontrolled

INR must be below 4. Check local guidelines

Atraumatic technique

Suture socket

Can use oral tranexamic acid

Ensure HA

Emphasise post op instructions; verbal and written

Review

68
Q

Pt has swelling around unerupted lower 8, facial swelling and feeling slightly unwell. What 6 things from history and investigation should be noted before looking at the mouth?

A

Pain history

Temperature

Breathing rate

Heart rate

How long swelling has been present/how quickly it has increased in size

69
Q

You are planning to extract a tooth from a patient on bisphosphonates. What are they and what conditions are they used for?

A

Reduce bony turnover by inhibiting osteoclast recruitment, function and formation. Used for osteoperosis, Pagets disease, osteogenesis imperfecta, malignant metastasis

70
Q

How is MRONJ diagnosed?

A

Must be on bisphosphonates or similar ie anti angeogenesis drugs, RANKL inhibitors

No history of head and neck radiotherapy

Exposed bone for more than 8 weeks

71
Q

Following a recent extraction, a patient attends with a dry socket. What is this?

A

Alveolar osteitis.

Not an infection

Exposed and inflammed lamina dura usually due to loss of clot following extraction

72
Q

When should an extraction site have healed?

A

Within 2 to 3 weeks

73
Q

Name four types of sutures and give examples

A

Monofilament resorbable - monocryl

Polyfilament resorbable - Vicryl

Monofilament non resorbable - Prolene

Polyfilament non resorbable - Mersilk

74
Q

What is osteomyelitis?

A

Bilateral infection of bone. Results in inlammation causing necrosis

75
Q

What are the risk factors for osteomyelitis?

A

Immunocompromised patients

Mandible more than maxilla

Mandibular fracture

76
Q

What is haemophillia A?

A

Clotting factor VIII deficiency

77
Q

What is haemophillia B?

A

Clotting factor IX deficiency

78
Q

What is Von Willebrand disease?

A

Affects Factor VIII

79
Q

How is haem A/B and Von Willebrands managed>

A

Factor replacement

Desmopressin

Tranexamic acid

80
Q

What are the steps that should be followed when carrying out oral surgery

A

Gain consent

Surgical pause/safety checklist

Anaesthesia

Access

Bone removal as necessary

Tooth division as necessary

Debridement/wound management

Suture

Achieve haemostasis

Post op instructions

Post op medication

Follow up

81
Q

Identify this flap design

A

3 sided flap design

82
Q

Identify this flap design

A

Envelope

83
Q

What are the aims of suturing?

A

Reposition the tissues

Cover bone

Prevent wound breakdown

Achieve hamostasis

Encourage healing by primary intention

Final Flashcards (13 decks)

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