Oral Surgery Flashcards
For extraction of a lower tooth, at what height should the seat be positioned?
Low for lowers
For extraction of an upper tooth, at what height should the seat be positioned?
Up but well retroclined for uppers
When applying forceps to a tooth, where should the beak of the forceps be positioned?
Beak to cheek/furcation
Where should you be standing for a lower RHS extraction and what hand position is used?
stand behind the patient, thumb lingual, index finger buccally
Where should you be standing for a lower LHS extraction and what hand position is used?
stand in front, ballet stance and claw support
Where should you be standing for an upper LHS extraction and what hand position is used?
stand in front, thumb to palate, index buccal
Where should you be standing for an upper RHS extraction and what hand position is used?
stand in front, thumb buccal, index to palate
What movement can be used to extract an upper central incisor?
Rotation, Buccal and back
What movement can be used to extract an upper lateral incisor?
Buccal and back only
What movement can be used to extract an upper canine?
Buccal and back, rotation
What movement can be used to extract an upper first premolar?
buccal and back
What movement can be used to extract an upper second premolar?
rotation, buccal and back
What movement can be used to extract an upper molar?
Buccal and back
What type of forceps are used to extract an upper central and lateral incisor?
Straight forceps
What type of forceps are used to extract an upper canine?
Upper universal or straight forceps
What type of forceps are used to extract upper premolars?
Upper universal forceps
What type of forceps are used to extract upper molars?
R or L upper molar forceps
What movement can be used to extract a lower central incisor?
Buccal and back
What movement can be used to extract a lower lateral incisor?
Buccal and back
What movement can be used to extract a lower canine?
Rotation, buccal and back
What movement can be used to extract a lower first premolar?
Rotation, buccal and back
What movement can be used to extract a lower second premolar?
rotation, buccal and back
What movement can be used to extract a lower first molar?
figure of 8 (or oval), buccal and back
What movement can be used to extract a lower second molar?
figure of 8 (or oval), buccal and back
What type of forceps should be used to extract a lower incisor?
lower narrow forceps
What type of forceps should be used to extract a lower canine?
Lower universal forceps
What type of forceps should be used to extract a lower premolar?
Lower universal forceps
What type of forceps should be used to extract a lower molar?
Lower molar forceps
What does the pink sticker on OS tell you?
referring department
teeth for extraction
FDI system
urgency (red/yellow/green)
radiographs present or not
Medical history
What information must you write on the whiteboard about your patient in OS?
Name
DOB
If they are having an extraction, use 4 quadrants to draw which tooth
brief description of relevant MH
What information must all match before extracting a tooth?
Pink sticker, whiteboard, patient notes and what patient says
Who is the dental surgical safety checklist to be filled out by?
A 2nd person in the room, NOT the operator
What should you ask a patient when you discover they are taking novel oral anticoagulants?
when do they take them?
Have they been advised to miss a dose before extraction? - if not, can we proceed
What should you ask a patient when you discover they are on warfarin?
up to date INR level
is INR level appropriate for extraction?
Is level the correct therapeutic level for the patient?
What should you ask a patient when you discover they are on bisphosphonates?
How long?
Oral or IV?
Use to assess MRONJ risk
What is the proper name for dry socket?
Alveolar osteitis
What is INR level and what is considered a normal INR level
An INR test measures the time for the blood to clot. Healthy people an INR of 1.1 or below is considered normal.
What is an effective therapeutic INR range for people taking warfarin?
2.0-3.0
In what position should the bevel be in when administering LA?
Facing the bone
Describe the points covered in extraction post operative instructions
1) avoid rinsing mouth for 24hrs
2) avoid alcohol today
3) avoid smoking
4) bite on clean cotton for 15mins if bleeds
5) start using hot, salty mouthwash after 24hrs to clean socket and clear debris
6) if asthmatic do not advise ibuprofen as they cannot tolerate it
7) Don’t bite lip
8) avoid strenuous exercise
At what five stages must you be signed off by staff during extraction?
1) before giving LA
2) get staff to watch LA
3) Observe during extraction
4) after notes written and haemostasis achieved
5) patient must not leave until notes signed by staff
What are 6 post operative problems?
Pain - to be expected
swelling
bleeding
bruising
infection
dry socket
What type of forceps can be used on heavily broken-down teeth?
Cowhorn forceps
At what angle do the beaks of the lower universal forceps sit in relation to the handle and hinge?
90 degrees
What are the beaks like on a lower molar forcep?
two pointed beaks to engage the mesial and distal roots’ furcation
What are lower roots forceps used for and how do they differ from lower universal forceps?
Retained roots
like the universals but narrower beaks to engage narrower part of root
What are the beaks like on a lower universal forcep?
simple beaks to engage all single and multi-rooted teeth
What are the beaks of the upper universal forceps like?
simple beaks
What are the beaks of the upper molar forceps like?
pointed beak on buccal
rounded beak on palatal
Where do cowhorn forceps engage with the tooth?
designed to slide into the furcation between the MB and MD root and the unusually placed beak is designed to engage the palatal root
Do you require a left cowhorn and right cowhorn or does one do both sides?
require LHS and RHS
When doing a palatal infiltration, how far away from the free gingival margin should the needle be inserted?
10mm from the free gingival margin
When carrying out an IANB, what three structures make the ‘triangle’ landmark?
thumbnail, palato-glossal fold and maxillary tuberosity
Where is the barrel of the syringe placed during an IANB?
Over the lower premolars on the opposite side of the mouth parallel to the FOM
Following IANB, if the needle is withdrawn halfway and more LA inserted, what nerve will you anaesthetise?
lingual nerve
What does SBAR stand for?
Situation, background, assessment, recommendation
Where should extracted teeth containing amalgam be placed vs non-amalgam containing teeth?
amalgam - tooth box tub
no amalgam - sharps bucket
What are the five phases involved in bone remodelling?
1)activation
2)osteoclast recruitment and resorption
3)reversal
4)osteoblast recruitment and bone formation
5)termination - quiescence
What is osteogenesis imperfecta?
Genetic bone disorder present at birth. Known as brittle bone disease. A child with OI may have soft bones that fracture easily, bones that are not formed normally, and other problems
What is osteopetrosis?
rare disorder that causes bones to grow abnormally and become overly dense. They are brittle and can fracture (break) easily. Bones may be misshapen and large
What is osteoporosis?
condition that weakens bones, making them fragile and more likely to break.
What is glucocorticoid-induced osteoporosis?
glucocorticoids accelerate resorption while inhibiting formation, their use is associated with early rapid bone loss
What is hyperparathyroidism?
an abnormally high concentration of parathyroid hormone in the blood, resulting in weakening of the bones through loss of calcium
What is Pagets disease?
Disease which disrupts the normal cycle of bone renewal, causing bones to become weakened and possibly deformed
What is fibrous dysplasia?
chronic disorder in which scar-like tissue grows in place of normal bone
How long does the bone remodelling phase take?
6 months
Name four types of drugs which affect bone remodelling
1) Bisphosphonates
2) Denosumab and anti-angiogenic drugs
3) steroids
4) NSAIDs
What are bisphosphonates?
non-metabolised analogues of pyrophosphate capable of localising to bone and inhibiting osteoclastic function
Where/what do bisphosphonates bind avidly to?
exposed bone mineral around resorbing osteoclasts so there are high levels of bisphosphonates in resorption lacunae
Why are bisphosphonates found in high concentrations in bone for such a long time?
They are not metabolised
What is the half life of bisphosphonates?
10 years
Are bisphosphonates anti-angiogenic?
Yes
What are the two classes of bisphosphonates?
Nitrogen containing
Non-nitrogen containing
How do nitrogen containing bisphosphonates work?
resemble pyrophosphate allowing them to be incorporated into phosphate chain of adenosine triphosphate (ATP) making it unusable for energy production in osteoclasts
Name an example of a nitrogen containing bisphosphonate
Clodronate
How do non-nitrogen containing bisphosphonates work?
prevent formation of key isoprenoid lipids in osteoclasts which anchor proteins to cell membrane and without these cell death occurs
Name 4 conditions treated with bisphosphonates
Osteoporosis
Multiple myeloma
Breast cancer
Prostate cancer
In the SDCEP guidelines, what bisphosphonate patients are considered low risk?
not yet started taking them
taking bisphosphonates for prevention or management of osteoporosis
In the SDCEP guidelines, what bisphosphonate patients are considered high risk?
previous diagnosis of MRONJ
taking as management of malignant condition
other non-malignant condition of the bone
under care of specialist for rare condition
concurrent use of systemic corticosteroids or other immunosuppressants
coagulotherapy, chemotherapy, radiotherapy
What treatment are you permitted to carry out in a low risk patient?
if unavoidable, atraumatic extractions - avoid raising flaps and achieve good haemostasis
review at 4 weeks
if not healing at 4-6 refer to maxfax
When should you review a low risk patient following atraumatic extraction?
4 weeks
What are the 3 criteria for MRONJ?
1) current or previous treatment with bisphosphonates, antiangiogenics or RANKL inhibitors
2) exposed bone in maxfax region or bone that can be probed that has persisted more than 8 weeks
3) no history of radiation therapy to jaws
What are the signs and symptoms of MRONJ?
Areas of exposed necrotic bone
internal or external discharging fistulas
pain or painless
loose or mobile teeth
bony sequestrae
paraesthesia
mandibular preference 60-70%
What is denosumab?
human monoclonal antibody that inhibits osteoclastic function
How quickly is osteoclastic function inhibited once denosumab has been administered and when does function return?
inhibited within 6 hours of SC injection and returns 6 months later
How does denosumab work?
Inhibits receptor activator of nuclear factor kappa B ligand (RANKL) which is a protein which acts as the primary signal for bone removal
Which drugs affect absorption of calcium from the stomach?
anti-seizure drugs eg. carbamazepine, phenytoin and long term proton pump inhibitors
What drugs can increase renal excretion of calcium?
Diurectics
What drugs can decrease androgen and oestrogen levels?
Drugs used in treatment of breast and prostate cancer
Why do steroids delay healing?
due to their anti-inflammatory action and their inhibition of fibroblastic proliferation, collagen synthesis and epithelialisation
How do NSAIDs interfere with the production of certain types of prostaglandins?
They interfere with the activity of COX enzymes to inhibit production of prostaglandins
How can ethnic background impact the difficulty of extraction?
Different bone densities
afro caribbean/asian patients = dense bone
How can a lone standing molar be difficult to extract?
Thickening of PDL and surrounding alveolar bone due to heavy occlusal loading
What is impaction?
when the tooth is prevented from achieving a functional occlusal position
What are the four most commonly impacted teeth?
Mandibular third molars
Maxillary canines
Maxillary incisors
Second premolars
What is an operculum?
piece of gum lying over biting surface of a tooth
How can crowding impact extraction?
prevents access for the beaks of the forceps
Which teeth are most greatly impacted by crowding?
The teeth that erupt later
What is the main difficulty when extracting maxillary third molars?
access - diffuicult as mouth opening brings coronoid process into space lateral to maxillary third molar. can also be buccally inclined
What is pneumatisation of the maxillary antrum?
When the antrum erodes into the space where adjacent teeth may have been
How can abrasion impact extraction?
crown is predisposed to fracture so beaks of forceps must be firmly on root of tooth or else fracture can occur
Why can endodontically treated teeth be an issue upon extraction?
they are brittle and likely to fracture easily
At what stage is surgery indicated rather than extraction with forceps?
If a root is fractured below the level of the alveolus
What reasons would unerupted impacted teeth be removed?
orthodontic reasons
restorative/aesthetic reasons
pathology eg. cysts
What are submerged teeth?
one that is depressed below the occlusal plane. Often when there is no permanent successor, dental ankylosis is thought to be a major cause, requires surgery.
What is dental ankylosis?
tooth fuses to the surrounding bone and slowly begins to sink or submerge into the nearby gum tissue
What are some radiographic features of difficulty upon extraction?
Bulbous roots
dilacerated/divergent/convergent roots
fused roots
multi-rooted teeth
hypercementosis
ankylosis
lone standing molars
deeply impacted third molars
How are teeth with bulbous roots removed?
surgery
What are convergent roots?
roots which curve together
What are divergent roots?
more in different directions
What is a dilacerated tooth?
abnormal bend in the root or crown of a tooth
Which teeth commonly have very divergent roots and why?
deciduous molars as successor sits between them
Curvature of roots can indicate a close relationship to what in the mandible?
Inferior dental canal
What is hypercementosis?
excessive deposition of cementum on the tooth roots
What is cemeto-osseous dysplasia?
replacement of normal bone by fibrous tissue and subsequently followed by its calcification with osseous and cementum-like material
What are osteolytic lesions?
areas of damaged bone that most often occur in people with certain cancers, such as multiple myeloma and breast cancer - cause destruction of bone
What is osteomyelitis?
inflammation of bone or bone marrow, usually due to infection.
What should you never use to section roots before extraction and why?
a high speed handpiece - causes surgical emphysema and introduces air into tissue and can lead to cellulitis
Name six forms of odontogenic infection
1) Periodontitis
2) caries
3) periapical periodontitis
4) pericoronitis
5) osteomyelitis
6) maxillary sinusitis
What is the sequelae of infection dependent on?
1) virulence of organism
2) host resistance
3) local anatomy
4) treatment of infection
Why are antibiotics not helpful for targeting infections of the non-vital tooth?
non-vital teeth do not have a vascular supply, therefore the antibiotics cannot reach the site where the vast majority of the bacteria are
What will antibiotics do for a non-vital tooth?
kill bacteria in PDL and surrounding tissues so may relieve symptoms but will not kill the source of infection
What is cellulitis?
diffuse inflammation of the soft tissues which is not circumscribed or confined to one area but tends to spread through tissue spaces along fascial planes
How does vasodilation assist spread of cellulitis?
opens up tissue spaces/fascial planes, aiding potential spread of infection
What is Ludwig’s angina?
rare but serious bacterial skin infection that affects mouth, neck and jaw. Considered type of cellulitis which spreads quickly to infect soft tissues under tongue
Where are the cavernous sinuses?
located under the brain behind each eye socket
Which major blood vessel passes through the cavernous sinuses taking blood away from the brain?
Jugular vein
What is a cavernous sinus thrombosis?
a blood clot in the cavernous sinuses. Forms when there is infection in the face or skull which spreads to the sinus to prevent further spread, however, the clot also restricts blood flow from brain possibly damaging brain, eyes and nerves.
What is sepsis?
life-threatening organ dysfunction caused by a dysregulated host response to infection
What are some signs of sepsis?
slurred speech
extreme shivering
passed no urine in a day
severe breathlessness
illness so bad feel as if they are dying
skin mottled/discoloured/ashen
rash does not blanch with pressure
cyanosis of lips/tongue/skin
What is cyanosis?
Blue skin or lips (cyanosis) happens when there’s not enough oxygen in your blood, or you have poor blood circulation
What body temperature can be indicative of sepsis?
above 38 or below 36 degrees
What heart rate can be indicative of sepsis?
above 90 bpm, high risk over 130bpm
What respiratory rate can be indicative of sepsis?
more than 20 breaths/min, high risk over 25
What white cell count can be indicative of sepsis?
more than 12 or less than 4
What systolic blood pressure can be indicative of sepsis?
less than 100mmHg, high risk less than 90mmHg
What is the spread of odontogenic infection dependent on?
positioning of apex in relation to buccal, palatal or lingual shelf and also in relation to the muscle attachment
What is mediastinitis?
inflammation of the chest area between the lungs (mediastinum).
In the mandible, spread of infection into which area can cause asphyxia?
laryngeal inlet
From the spread of odontogenic infection to the laryngeal inlet, where can the infection continue to and what can it cause?
potential spread to pre-tracheal fascia or pre-vertebral fascia or the retropharyngeal space which lead to the chest/mediastinum, causing mediastinitis which can be fatal
Which tissue spaces are involved in Ludwig’s angina?
bilateral involvement of submandibular, submental, sublingual and parapharyngeal and retropharyngeal spaces such that glottal oedema forms
What is glottal oedema and what can it lead to?
abnormal accumulation of fluid in tissues involving the supraglottic and subglottic region where laryngeal mucosa is loose. Can lead to asphyxiation
What is asphyxiation?
the state or process of being deprived of oxygen, which can result in unconsciousness or death; suffocation
How does cavernous sinus thrombosis manifest? (symptoms)
difficulty moving the eyes, build up of pressure behind the eye, proptosis of eye, eyeball pushed forward
Cavernous sinus thrombosis has a potentially fatal outcome in how many patients?
2/3
How is sepsis managed?
Blood cultures taken ideally before ABX
serum lactate level taken - over 2 in sepsis
give oxygen
give empirical IV ABX
give IV fluids
monitor urine output
What are the four main principles of management of odontogenic infection?
1) eliminate cause of infection ASAP
2) Provide a path of least resistance
3) Symptomatic management
4) Review
After a sepsis diagnosis and management, how soon after should a patient be reviewed?
48-72hrs later
What does the presence of a sinus indicate?
The presence of chronic, long standing infection
Where are sinuses often found intra-orally?
at the junction between attached gingivae and reflective mucosa
How are sinuses formed in the mouth and where do they come from and go to?
pus is allowed to tract through alveolus and erupt through overlying mucosa creating a communication between apex of tooth and oral cavity for pus to discharge.
What is a sinus tract lined with?
granulation tissue
What is a fistula?
epithelial lined tract connecting two body cavities
When does a sinus become a fistula?
When the granulation tissue of a sinus (non-epithelialised), becomes epithelialised
What is an orocutaneous fistula?
when puss tracts extra-orally through the skin
What is the treatment of an orocutaneous fistula?
extirpation of pulp or extraction of tooth as well as excising fistula. As it is epithelialised it will not spontaneously close on removal of infection source
How does a buccal space infection occur?
erosion of bone caused by build up of pus above muscle attachment to buccinator
Which teeth are most commonly associated with a buccal space infection?
Maxillary molars
Clinically, how will a buccal space infection present?
a swelling of cheek below the zygomatic arch
Why is a peri-orbital swelling particularly concerning?
proximity and potential spread to the cavernous sinus
How does an infection of the canine space present clinically?
infra-orbital swelling
obliteration of naso-labial fold
How does the canine space become infected given the muscle between it and the oral cavity?
canine root long enough to pass muscles of facial expression
What tooth is normally associated with infection of the infratemporal space?
usually upper 8
How does infection of the infratemporal space present clinically?
severe trismus
bulging of temporalis
cavernous sinus thrombosis
Which major vessel passes through the cavernous sinus?
internal carotid artery
Which cranial nerves pass through the cavernous sinus?
abducent nerve
oculomotor nerve
trochlear nerve
trigeminal div I and II
Which teeth are usually linked to infection of the submandibular or sublingual space?
usually lower molars
What determines whether a tooth infects the SM space instead of the SL space?
long roots - SM space (under mylohyoid attachment)
short roots - SL space
How does an infection of the submandibular space present?
firm swelling in the SM region
trismus
How does an infection of the sublingual space present?
little extra-orally
intra-oral swelling of FOM
Which teeth are usually responsible for infection of the submental space?
usually lower incisors
How does infection of the submental space present clinically?
firm swelling under chin
discomfort on swallowing
What are the three cervical fascial spaces?
1) Retropharyngeal space
2) prevertebral space
3) lateral pharyngeal space
What is the prevertebral space in relation to the diaphragm?
the inferior border of the diaphragm
Why do infected areas often have a poor blood supply?
as a collection of pus grows it compresses the adjacent tissues as well as their blood vessels
Due to the poor blood supply to abscesses, what is the appropriate treatment for an abscess?
Drainage and removal of cause
What does drainage through a tooth involve?
opening an access cavity to provide a path of least resistance then placing a temp filling following drainage
When there is pus present in soft tissues, can you just carry out RCT or extraction alone?
No
When excising an abscess, where should it be done and what steps follow?
find most gravitationally dependent point of access
incise through mucosa and periosteum using No. 11 blade
avoid vital structures
blunt dissection to remove locules of pus
What results in more scarring - extra-oral excision or pus tract?
Pus tract
What instrument is used for blunt dissection and how is it used?
Spencer-wells artery forcep or Mackindoe scissors
Open and close instrument to crush locules and break fibrous strands supporting them to release and drain the pus
What is routinely done with discharging pus?
undertake culture and sensitivity using microbiology swab or syringe. (syringe exposes to air which can kill anaerobic bacteria)
Which analgesics can be prescribed following drainage and excision and what are their functions?
Paracetamol - lowers temperature
ibuprofen - anti-inflammatory
co-codamol - pain relief
dihydrocodeine - not as effective for dental pain
When would an antibiotic be indicated when there is an abscess?
systemic involvement
significant cellulitis
compromised host defences
involvement of fascial planes
What is the antibiotic of choice for abscesses and why?
most abscesses are anaerobic - metronidazole drug of choice
In severe infections, which two antibiotics can be combined?
Metronidazole and Penicillin V
When should an abscess patient be referred? 8 reasons
rapidly progressing infection
difficulty swallowing
temp over 39
compromised host defences
difficulty breathing
involvement of fascial spaces
severe trismus
infection not responding to treatment
Which three sites of drainage can be anaesthetised using LA?
Buccal/labial sulcus
palate - parallel to vessels
SL space - buccal and parallel to sublingual fold
Which six sites of drainage should general anaesthetic be used with?
1) submasseteric
2) pterygomandibular
3) infratemporal
4) parapharyngeal
5) submental
6) submandibular
How does Ludwig’s angina present?
rapid, board-like swelling of FOM, elevation of tongue, dysphagia, dysarthia, trismus
glottal oedema - suffocation
mediastinitus
What is dysphagia?
difficulty swallowing
What is dysarthia?
difficulty speaking
What is the priority when managing a patient with Ludwig’s angina?
stabilising airway
What are the symptoms of CNS LA toxicity at a low dose?
excitatory at low doses - agitation, confusion, dizziness, dysphoria, auditory changes, tinnitus, perioral numbness, metallic taste, and dysarthria
What are the symptoms of CNS LA toxicity at higher doses?
depressant - Perioral tingling, drowsiness, unconsciousness, respiratory arrest
Name the two phases of CNS LA toxicity
excitation and depression
Which system is most resistant to LA toxicity - CNS or CVS?
CVS more resistant
Explain the biphasic presentation of CVS LA toxicity
Early cardio-excitatory effects such as tachycardia and increasing blood pressure are followed quickly by hypotension that is unresponsive to resuscitation leading to cardiovascular collapse and death
Is LA cardiac arrest responsive to resuscitation?
No
What can we do to avoid LA toxicity?
slow injection
aspirate
limit dose
What is the treatment for LA toxicity?
STOP
BLS
call for help
monitor patient
Treatment is lipid emulsion therapy
When assessing the degree of difficulty of extraction, which of the following clinical features is not considered a feature that increases the degree difficulty?
a. crowding
b. a lone standing maxillary molar in occlusion
c. a partially erupted impacted third molar
d. erosion/abrasion cavities
e. furcation involvement
E
When assessing the degree of difficulty of extraction, which of the following radiographic features is not considered a feature that increases the degree difficulty?
a. bulbous roots
b. divergent roots on a multi-rooted tooth
c. hypercementosis
d. root resorption
e. a dilacerated root
D
Which teeth can be extracted using upper straight forceps?
a. only maxillary incisors
b. maxillary incisors and canines
c. all single rooted maxillary teeth
d. from the second maxillary premolar forward
e. all maxillary teeth
B
Which mandibular teeth can be extracted using a rotatory rather than a buccal and back movement?
a. lower first premolar
b. lower first and second premolars
c. lower incisors
d. lower canines
e. lower first molars
B
Which one of the following drugs does not affect bone remodelling?
a. alendronate
b. prednisolone
d. demosumab
d. diclofenac
e. amoxicillin
E
Which of the following statements is not true of bisphosphonates?
a. they are non-metabolised analogues of pyrophosphate that are capable of localizing to bone and inhibiting osteoclastic function
b. bind avidly to exposed bone mineral around osteoblasts
c. are not metabolised therefore these high concentrations are maintained within bone for long periods of time
d. are anti-angiogenic
e. there are 2 classes nitrogen and non-nitrogen containing
B
Which of the following is classified as a high-risk patient for developing MRONJ according to SDCEP guidelines?
a. a patient with a previous diagnosis of MRONJ
b. a patient taking subcutaneous bisphosphates once per year
c. a patient taking demosumab injections
d. a patient who has been taking oral bisphosphonates for 2 years
e. a patient who takes oral bisphosphonates and used a steroid based cream as required for eczema
A
Which of the following is an indicator of sepsis?
a. a respiratory rate of 12 breaths per minutes
b. a systolic BP of 120 mmHg
c. a temperature of > 38oC or < 36oC
d. white blood cell count (WBC) 4.0 - 11.0 x 10*9/L
e. a heart rate of 72 bpm
C
How would you manage an odontogenic infection with abscess formation as demonstrated by a large swelling in the buccal sulcus with from a lower first molar?
a. prescribe amoxicillin
b. prescribe amoxicillin and metronidazole
c. extraction the lower first molar
d. extripate the pulp for the lower first molar and put in a sedative dressing and incise and drain the buccal swelling
e. incise and drain the buccal swelling
D
