Oral Surgery Flashcards
What are the symptoms of pulp hyperaemia?
Pain lasting for seconds, stimulated by sweet or cold foods, resolves after stimulus removed
What causes pulp hyperaemia?
Caries close to the pulp but not in the pulp, can be treated without treating pulp. Also known as reversible pulpitis
What are the clinical features of acute pulpitis?
constant severe pain that lingers when stimulus removed, response to thermal stimuli, no response to TTP, analgesics don’t help
If untreated, what is the pathway following acute pulpitis?
Becomes chronic - can flare up every now and again
Becomes acute apical periodontitis
What are clinical features of acute apical periodontitis?
TTP, radiolucency at apex, unclear lamina dura, can tell you exactly where pain is coming from, tooth non-vital
How can you differentiate between acute apical periodontitis and traumatic occlusion?
traumatic occlusion - the tooth will be vital, there will be widening of PDL on radiograph, need to examine occlusion
how does acute apical periodontitis develop in the pathway
to an acute apical abscess
what are the clinical features of an acute apical abscess?
before it erodes through bone and soft tissue - similar to acute apical periodontitis - TTP, tender in function, severe pain
After it erodes through - release of pain, as no longer a build up, initial reduction in TTP as pus escapes through soft tissue, swelling, redness heat
how would you treat an acute apical abscess
incision and drainage - either intra orally or extra orally depending on swelling
removal of source of infection - extraction of tooth, pulp extirpation
how do you assess the need for antibioitics?
local factors - is the swelling compromising the airway, dysphagia, trismus, toxicity
patient factors - immunocompromised patients (HIV, drug induced - steroids, blood disorders - leukemia), elderly, diabetes
systemic involvement - malaise and fever
spreading infection - cellulitis, lymph node involvement, swelling
describe periapical granuloma (chronic apical periodontitis)
mass of chronically inflammed granulation tissue at apex of tooth - plasma cells, lymphocytes, fibroblasts, capillaries
why is the mylohyoid line important in spreading dental infection
this is the line where mylohyoid muscle attaches to the mandible. Infection above this line will spread in to the sublingual space, whereas infection below this will spread into submandibular space
what causes a cavernous sinus thrombosis
infection in facial vein (can come from dental infection in maxillary teeth), this vein drains into cavernous sinus, which has venous connections into the brain - can develop an infection in the brain
can come from infection into canine space
name the pathways of spreading infection for upper anterior teeth
lip, nasolabial region - spreads buccally but below muscle attachment so spreads into mouth, lower eyelid - infraorbital more common in canine as root is longer. lateral incisor can drain into palate as root is palatal
canine space - up to eye
name the areas where upper premolars and molars infection can spread to
cheek - above buccinator attachment
infratemporal region - can communicate with other areas in cheek so spreads to infra orbital
palate - uncommon
maxillary antrum
how can infection from mandibular teeth spread
anterior teeth - mental and submental
posterior teeth - buccal, sublingual, submandibular initially then spreads backwards to lateral pharangeal space and can push on airways
how do you manage spreading infection
drainage - intraoral or extra oral incision
removal of source - extraction or extirpate pulp
antibiotics - depends on patient and area of abscess
what 3 things can you check in a dental chair for systemic involvement of infection
increased heart rate, increased temperature and increased respiratory rate
what is ludwig’s angina
bilateral cellulitis of the sublingual and submandibular spaces
what are the features of ludwigs anginga
extra orally - swelling and redness in submandibular region on both sides
intra orally - swelling in sublingual, difficulty breathing and swallowing, drooling
what soft tissue surgeries can be carried out to aid denture retention?
excision - removal of frenulum (lingual, buccal, labial) removal of denture induced hyperplasia, removal of flabby ridges, reduction of retromolar pad and maxillary tuberosity
what is denture induced hyperplasia
denture flanges are over extended, or given an immediate and told to come back for a new one and dont - digs in and causes ulceration and keratosis
what is a knife edge ridge and why does it interfere with denture
when the alveolar ridge is sharp (normally mandibular anterior) but covered by gingiva, when patient wears denture it digs into this sharp ridge and is uncomfortable, can be smoothed in surgery
how can flabby ridges affect denture fit
they bend and move when pressed against - remove soft tissue and cover bone
what hard tissues can be removed to improve denture fit
mandibular tori, palatine tori, retained roots, unerupted teeth, ridge defect
why are retained roots/teeth a problem for denture fit
the alveolar bone resorbs due to lack of teeth and the teeth/roots can come to the top, painful for the denture to sit on and risk of infection
what are common causes of temporomandibular joint dysfunction
inflammation of muscles of mastication or TMJ due to parafunctional habits - clench teeth, grinding. Joint dysfunction or myofascial pain
what is the pathophysiology of TMD
when closed, PT puts pressure on disc - clenching - this causes disc to slip forward. When patient goes to open their mouth there is an obstruction (disc) so condyle cannot move. The patient manipulates jaw slightly (move to one side) to get disc back in place. Can then open jaw as condyle can move forward. This can cause pain in joint and ear. Can have popping sound as disc goes back into place. This is anterior displacement with reduction.
How is TMD treated
counselling - reassurance, education, stop habits - bite raised appliance. soft diet, dont open too wide, support jaw on opening. Can advise NSAIDs and muscle relaxants
what are less common causes of TMD
ankylosis, hyperplasia, degenerative disease, infection, chronic recurrent dislocation, neoplasia
what does impacted mean
eruption is blocked
what is a result of impaction
caries, pericoronitits, cyst formation
what nerves are at risk during M3M surgery
lingual nerve, inferior alveolar nerve, nerve to mylohyoid, long buccal nerve
what is the location of the lingual nerve
lies on the superior attachment of the mylohyoid muscle - close relationship to lingual plate in mandibular and retromolar area
what were the previous guidelines for extraction of M3M and why were they updated
previously - do not extract unless clinical evidence of disease. High risks of surgery so would have to justify removal. This has changed as it was thought to be postponing the inevitable - if left in situ, infection would develop and would make the surgery more complicated and risks would be greater.
what are therapeutic indications for extraction of 3rd molars
infection - pericoronitis, caries
cyst formation
tumours
external resorption of 7 or 8
what are other indications for extraction (not therapeutic)
within surgical field
medical reasons - to be dentally fit, beginning radiotherapy treatment, heart surgery, immunosupressed
high risk of disease developing
acessibility - not in the country submariners eg
getting a GA - wouldnt want risk of needing another GA soon
what is pericoronitis
inflammation around the crown of the tooth. Tooth is normally partially erupted, inflammation of gum on eruption - formation of operculum - flap of gum preventing eruption. Food trapping at operculum - inflammation and infection, caused by anaerobic microbes
what are signs and symptoms of pericoronitis
pain, swelling intra oral and extra oral, occlusal trauma to operculum, cheek biting, limited mouth opening, lymphadenopathy, fever, malaise, suppurating pus, bad taste in mouth
how is pericoronitis treated
if pericoronal abscess - incise and drain
use blunt needle to irrigate gently at operculum - with saline or chlorhexidine - remove food and bacteria. If trauma to operculum from maxillary 3rd molar - may remove this. Should only prescribe antibiotics if systemic involvement - fever, malaise, lymphadenopathy. Advice on analgesia
what should be included in your history taking for assess 3rd molars?
presenting complaing, HPC (SOCRATES + how many episodes) history of swelling - how long, has it gotten bigger - MH any relevant medications or diseases that would interfere with treatment, SH - if they have a job, are a carer - might be affected for a couple fo days after surgery - DH - have they had dental treatment before, dentally anxious
what should be included in the clinical history when assessing 3rd molars
extra oral: TMD - can have pre-auricular pain, might think it is M3M
MOM, lymph nodes, asymmetry, mouth opening
intra oral: soft tissues, current dentition - carious etc., status of M2M, eruption status of M3M - pus, caries, operculum, occlusion to maxillary, working space distal to ramus of mandible - periodontal status
when should you take a radiograph of M3M
only if surgical intervention is happening - do not expose dose if just monitoring, it is not necessary. OPT is preferred but PA can also be done
what should be recorded on radiographic report of OPT for 3rd molar
presence or absence of disease
anatomy of 3M - crown shape, root shape, no. of roots, caries
orientation of impaction
depth of impaction
working space - 3M to ramus of mandible
follicular status
periodontal status
relationship of 3M to maxillary sinus or inferior alveolar nerve canal
what radiographic signs are most commonly associated with an increase risk of damage to inferior alveolar nerve during 3M surgery
diversion of the inferior dental canal - as canal passes 3M it bends to take outline of root - normally inferior
darkening of the root where crossed by the canal - dark band across root
interruption of the white lines of the canal - white line disappears
when might further imaging be required prior to 3M surgery
if conventional imaging has shown a potential close relationship between 3M roots and IAN canal - CBCT can be used
If concerned of caries - PA could be used
what are potential orientations of impaction of 3M
mesial, distal, vertical, horizontal, transverse, aberrant
how do you confirm angulation of impaction of a M3M
draw a horizontal line along curve of spee, then draw line vertical from roots of 3M - the angulation of where these lines meet will tell you the angulation of tooth. Can also compare to vertical line of 7
what would be the definition of a superficially impacted M3M
crown of 8 is related to crown of 7
what would be the definition of a moderately impacted M3M
crown of 8 is related to crown and roots of 7
what would be the definition of a deeply impacted M3M
crown of 8 is only related to roots of 7
what are common treatment options for M3M
referral - to oral surgery department in dental hosp, MFDS unit, specialist
clinical review - monitor
extraction of maxillary 3M
coronectomy
when might no treatment be required for M3M
if no disease or low risk of disease associated
what should be included during the consent process
procedure - what is involved in a way that the patient understands, if there is a need to drill bone or section tooth or raise a flap and place a stitch
complications - risks involved
what post operative complications are common in M3M surgery
pain, bleeding, bruising, swelling, infection, limited mouth opening, dry socket
numbess/altered sensation to chin/lip/tongue - damage to IAN - may be permanent or temporary
altered taste - damage to lingual nerve, chorda tympani runs in this
how long after surgery can nerves recover
18-24 months, after this, recovery is rare
what should be included in a referral for M3M surgery
Situation - PT presents with pain associated with impacted 48
Background - HPC, how many episodes, were antibiotics prescribed
Assessment - moderate mesially impacted, caries, OHI difficult, food packing - include MH and SH
Recommendation - PT is keen for surgical removal and i think this is indicated in this case
what are the functions of the maxillary sinus
vocal resonance, warming inspired air, lightening the skull
how is a OAC diagnosed
lining at the trifuraction of molar, radiographic view of roots in sinus, investigate with blunt probe, good lighting can see dark hole, blood bubbling when breathing, air gushing through into mouth, good suction causing echoing in sinus
how is an OAC treated
if small - less than 2mm - encourage bleeding and clot formation then close over with silk sutures. post op instructions - avoid blowing nose, smoking, drinking through straw, singing and review. if larger - close with buccal advancement flap - 3 sided flap, remove buccal bone, release from periosteum, then ensure no tension when pulling over defect and suture. same post op and antibiotics
what are the differences in OAC and OAF
OAC is acute, just happened right after extraction. OAF is established, epithelial lining between two areas. chronic. OAF is treated differently - incision circular around defect up to sinus, to remove epithelium then close with buccal advancement flap
how is a fractured maxillary tuberosity diagnosed and what is the aetiology
extraction of a lone standing molar, extraction in the wrong order, unknown unerupted molar and poor alveolar support is the aetiology, diagnosed by seeing or feeling movement of the aveolar bone, bone on the tooth extracted, hearing a crack
how is a fractured tuberosity treated
if tooth is extracted, dissect and close over, if stopped before extraction - splint tooth on adjacent teeth, take it out of occlusion and extirpate pulp, then extract surgically in 4-6 weeks. antibiotics or antispetics may be required
what are the signs and symptoms of sinusitits
congested - feeling heavy, headache, facial pain, ear pain, dental pain (sensitivity of all upper teeth), pain when moving head (downwards then upwards), pressure, nasal voice, fever
how can sinusitis be treated
primarily treat symptoms - decongestant - 0.5% ephedrine nasal drops - one in each nostril 3 times a day as required for maximum 7 days
if ongoing, antibtioics may be required - look this up as to which ones to use - SIGN GUIDELINES
what are the sepsis signs
HR - increased above 91, higher than 130 very worried
BP - systolic below 90-80
O2 - below 95%
RR - above 22
temperature - above 38 or below 36
confused mental state
not passed urine in over 12-18 hours
what is the sepsis 6
3 in. - IV antibiotics - metronidazole and phenoxymethylpenicillin until culture tells us specific ones
IV fluids and oxygen
3 out - blood for cultures, lactace levels and urine output
what is MRONJ
medication related osteonecrosis of the jaw. Patients on specific medication which reduces bone turnover and blood supply to bones - for prostate or breast cancer, osteoporosis. delayed healing after extraction due to reduced action of osteoblasts and reduced blood supply to bone
what medications can cause MRONJ
bisphosphonates - alendronic acid, zolendronic acid
RANKL inhibitors - densosumab
anti-angiogenic
what must be fulfilled for a diagnosis of MRONJ
must be on one of the medications
never had radiotherapy to h&n
delayed healing 8 weeks after extraction
what constitutes no risk of MRONJ
never been on medication or stopped denosumab more than 9 months ago
what constitutes low risk of MRONJ
on denosumab in the last 9 months
bisphosphonate medication for less than 5 years and no systemic glucocorticoid taken
what constitutes higher risk of mronj
on bisphosphonates for more than 5 years
or on it for less than 5 years but also taken glucocorticoid
how are patients with low risk of MRONJ treated
advise of risk, give ohi, diet advice, alcohol advice, smoking cessation
if extraction required - treat as normal and gain valid consent by advising them of risk
review 8 weeks after xla and refer is MRONJ present
how are patients with high risk of MRONJ treated
advise of risk, make xla last resort, exhaust all other measures first - retained roots, decoronation
review 8 weeks post xla for MRONJ and refer if there
what are the classifications of MRONJ
0 - previous MRONJ but no evidence of exposure
1 - evidence of exposure but no symptoms or infection
2 - exposure with symptoms and infection
3 - as 2 but with extra-oral fistula/extending past alveolar bone/ oral-antral communication
what general advice should be followed for all patients on anti-coagulant medication
should be carried out earlier in the day and week
pre and post instructions should be given
local measures should be carried out to prevent bleeding - pressure, pack, suture
initial treatment should be limited and bleeding assessed before progress
complex and invasive treatment should be staged
emergency contact details should be given
patient should not leave until haemostasis has been achieved
what constitutes a high risk bleeding procedure for patients on NOACs and how is this managed
any procedure raising a flap
biopsy
gingival contouring
if take two doses a day - miss morning dose but take evening as normal
if take one morning dose - delay morning dose until 4 hours after haemostasis has been achieved
what constitutes a low risk bleeding procedure for patients on NOACs and how is this managed
simple extractions of 1-3 teeth, provided they are not adjacent to one another
RSD, subgingival restoration, 6PPC
no changes to their medication dosage
how are patients on warfarin managed
should have INR checked 24 hours before procedure (can be up to 72 but only if well controlled)
if above 4 - delay treatment or if urgent, refer
if below 4 - continue as normal but carry out general advice
what medications can anti-coagulant interact with
NSAID - increased risk of bleeding
carbmazepine - increased risk of thrombosis
fluconazole and miconazole - warfarin - increased bleeding risk
