Oral Surgery Flashcards

Question

List the safety feature of the quantiflex machine used in inhalation sedation.

Answer 1

* Pin index system = prevents the wrong cylinder being attached * Diameter index system = prevents cross connection of piping * Minimum oxygen delivery = 30% * Oxygen fail safe = operates when oxygen pressure < 40 psi * Air entrainment valve * Oxygen flush button * Oxygen monitor * Reservoir bag * Colour coding = ensure the tanks aren’t attached to the wrong tubes. * Scavenging system = ensure nirous oxide not breathed into the atmosphere * Oxygen & nitrous oxide pressure dials * Pressure reducing valves * One way expiratory valve * Quick fit connection for positive pressure oxygen delivery

Answer 2

Uncooperative/ pre-coperative patient severely anxious or phobic complex/long procedures (multiple extractions,) MH contraindicating other sedation options - Inhalation e.g. Tonsillar/adenoidal enlargement/mouth breathers, Severe COPD, Fear of mask/ Claustrophobia, Patients with limited ability to understand what is required of them during the procedure (i.e. small children under 7 or those with learning difficulties) - IV-

Answer 3

1. Induction 2. Excitement 3. Surgical anaesthesia 4. Overdose

Answer 4

Patient details - name, DOB, address, contact details guardian details - name, relation, address, contact MH - allergies, meds, conditions DH and justification for GA TX plan radiographs supporting the justification GMP and GDP - name, contact details, address (referrer?)

Answer 5

A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render unintended loss of consciousness unlikely. The level of sedation must be such that the patient remains conscious, retains protective reflexes, and is able to understand and respond to verbal commands. Lara definition- Where drug produces a state of depression in the central nervous system to enable treatment but the patient can remain conscious/ retain protective reflexes and understand & respond to verbal commands during treatment.

Answer 6

Gamma Aminobutyric acid - inhibitory neurotransmitter

Answer 7

An inhibitory CNS neurotransmitter which prolongs time for receptor repolarisation of the cerebral cortex and motor circuits to slow the brain down.

Answer 8

90-150 mins

Answer 9

Medical - Severe or uncontrolled systemic disease = unfit for sedation - Severe mental or physical disability = are unable to communicate and understand what is involved - Severe psychiatric problems = are unable to communicate and understand what is involved - Narcolepsy = if px fall asleep and cannot communicate with dentist that fails as part of the conscious sedation criteria - Hypothyroidism - myasthenia gravis (muscle wasting disorder) = don’t want to relax already weakened muscles as it can affect breathing further -hepatic insufficiency (inability to metabolise the drug) -Pregnancy & lactation- drug will pass to the baby Social - Unwilling: become more uncooperative - Uncooperative: become more uncooperative - Unaccompanied: have to be observed closely after treatment whilst drug is metabolised (different for inhalation) - Children: IV cannot be used on those under 12 - Very old: IV cannot be used on these px Dental - Procedure too difficult and cannot be done with LA alone = long procedure, sedation wears off and px becomes uncooperative - Procedure too long (same as above) - Spreading infection = Airway threatening or Limits LA - Procedure too traumatic (see first)

Answer 10

MH: ASA class, medications, allergies DH: Level of anxiety and cause/Cooperation level and willingness/ treatment needs SH: Drug abuse, dependance, tolerance/alcohol/ employed (can't return for 24h)/carer or dependants Vital Signs: HR BP: taken at initial assessment and then every 5 mins during sedation (ensure BP cuff and oxygen saturation clip is on different arms) Oxygen saturation: taken at initial assessment and then every 5 mins during sedation BMI=weight (kg)/height (m2)

Answer 11

American Society of Anaesthologists- used to classify medical status. 1. A normal healthy patient (no medical conditions) 2. A patient with mild systemic disease (well controlled diabetes/ hypotension/smoker) 3. A patient with severe systemic disease (poorly controlled hypotension/ diabetes etc/ Alcohol dependence/ BMI >40) 4. A patient with severe systemic disease that is a constant threat to life (MI in last 3 months/ sepsis/ESRD) 5. A moribund patient who is not expected to survive without the operation (anerusym/intracranial bleed) 6. A declared brain-dead patient whose organs are being removed for donor purposes IV sedation only compatible with ASA I or ASA II IV sedation of the other ASA classified patients are treated with an anaesthetist led sedation in a hospital environment

Answer 12

Blood pressure, Oxygen saturation and heart rate

Answer 13

Perio-endo lesion - with root damage - without root damage Periodontal abscess Symptomatic periapical periodontitis

Answer 14

assume PA already taken TTP (lateral= perio abscess or vertical) Sensitivity testing: EPT/ECT 6ppc

Answer 15

Non- vital = RCT (or extraction) Vital = dilate/incise to drain, initially subgingival scale shy of base of pocket, advise analgesia and CHX, review and thorough PMPR once acute symptoms subside

Answer 16

Bridge - resin retained or conventional - fixed fixed or centilever Implant RPD

Answer 17

Confirm radiographically = PA +/- OPT if root is not quite in sinus you can try and retrieve it. or if small = consider leaving but advise risk of infection If root is in the sinus: Create BAF Open access to sinus using electric handpeice (So you don't force air into the tissues- which would cause infection) A- suction the root out B- Irrigate using saline. C-Ribbon gauze- tuck it up into the antrum & try pull the root out when you remove the gauze. Close like you would an OAC. **Prescribe antibiotics.**Do we?

Answer 18

Stop and evaluate Explain what has happened to patient Ensure pre-op radiograph is present Discuss tx options w patient and get consent 1. leave and monitor = if tooth has no PA/hasnt been mobilised 2. try to remove with instruments e.g. coupland, cryers, root forceps 3. Progress to surgical 4. refer 1. Look in the socket to see what has been left behind. 2. If we can't see anything radiograph **Treatment options: ** Continue extraction- use Cryer's elevator/ Upper root forceps / Lower root forceps. Leave the roots- retained roots Factors allowing successful healing- If the tooth is still vital/Fractured root hasn't been mobilised/Complete wound closing. But there are risks- future infection.

Answer 19

**Causes**: Single standing teeth (fragile surrounding bone) Bone loss & unerupted teeth cause alveolar weakness. Extracting in the wrong order (should extract back to front) Inadequate alveolar support. Pathological germination. **How to diagnose: ** Key indicator: Tear on the palate Noise Movement noted both visually or with supporting fingers More than one tooth movement **Treatment** is dependent on bone size & success of extraction: If extraction is successful & -Small bit of bone- disect out the bone and close the wound. (disect to prevent gum ripping) -Large bit of bone- Put the bone back (reduce)and stabilise with *splints* (rigid- achieved by splinting fractured area to stable bone/lots of stable teeth e..g 5/6/7/8) *orthodontic wire welded with composite/ arch wire* If extraction is unsuccessful: 1.Stabilise maxilla 2.If tooth is interfeering with occlusion (can be due to inflamed PDL & oedema) reduce the crown (it will be extracted anyway) 3.Antibiotics and keep mouth clean with an antiseptic mouthwash. 4.Leave extraction for 8 weeks and ensure patient is keeping splint clean- if extraction was due to pain- we need to deal with the pain i.e. remove pulp and dress. Otherwise wait until the bone is fixed. Give post op instructions. Dissect out with the tooth (if its small enough) using a scalpel. Do not just try to pull the tooth out as the gum will rip. Reduce using fingers or forceps (putting it back in the correct position)

Answer 20

Inflammation around the crown of a partially erupted tooth - Food & debris gets trapped under the operculum resulting in inflammation or infection 3rd Molars

Answer 21

* Pain – variable - starts mild and progresses, described as throbbing. * Swelling – Intra or extraoral at angle of the mandible * Bad taste * Pus discharge * Occlusal trauma to operculum from opposing cusps = Ulceration of operculum * Evidence of cheek biting * Foetor oris * Limited mouth opening – where extraoral swelling from angle moves to the submandibular area and can then move into submasseteric area * Dysphagia – when infection reaches parapharyngeal space/tonsils * Pyrexia (fever) * Malaise * Regional lymphadenopathy

Answer 22

Rood and Shehab paper 1990. **1. interruption of the white lines/lamina dura of the canal** **2. darkening of the root where crossed by the canal** ** 3. diversion/deflection of the inferior dental canal ** 4. deflection of root; 5. narrowing of inferior dental canal; 6. Narrowing of the root; 7. Dark and bifid root; (split or divide over the canal) Lara- same answer in order that makes more sense to me (everyone else ignore xx) **Roots**: * Darkening of the root where crossed by the canal (high risk) * Deflection of the root. * Narrowing of the root where they meet the canal. * Dark and bifid root. **Canal** * Interuption of white lines/lamina dura of canal (high risk) * Diversion/ deflection of inferior dental canal (high risk) * Narrowing of inferior alveolar canal

Answer 23

Usually transient and self limiting, however; +/- local anaesthetic (IDB) – depends on pain/patient; - Incision of localised pericoronal abscess if required - Irrigation with warm saline (or chlorhexidine - controversial due to anaphylaxis) (10-20ml syringe with blunt needle – under the operculum). Post-op; - Patient instructed on frequent warm saline or chlorhexidine mouthwashes at home - Advice regarding analgesia - Instruct patient to keep fluid levels up and keep eating (soft/liquid diet if necessary) If px has a large extra-oral swelling, systemically unwell, trismus, dysphagia or breathing difficulties – refer to maxillofacial unit or A&E AB Use: Generally do not prescribe antibiotics unless more severe localised pericoronitis, px systemically unwell (fever etc), extra-oral swelling, severe trismus, px immunocompromised e.g. diabetic or if there is persistent infection after local measures. Long term: (if recurrent) - 8’s extracted once the acute pericoronitis has been resolved - Extraction of upper third molar if traumatising the operculum

Answer 24

Nerve damage - Numbness (anaesthesia) or tingling (paraesthesia) of lower lip, chin, side of tongue (sensory damage NOT motor) Demonstrate the areas that will be affected Temporary numbness from IDB (lower lip and chin) may take weeks/months to improve 10-20% will experience temporary effects Permanent numbness from IDB; Average <1% will experience this Advise that risk can be greater than average if tooth/root is in close proximity to the IDC Other nerve damages: Lingual Nerve (one side of tongue, taste) Temporary – Literature quotes 0.25 – 23% Permanent – Literature quotes 0.14 – 2% - Altered taste (rare) (Chorda Tympani - arises from Facial nerve, taste buds from anterior two thirds of tongue, carries fibres via Lingual nerve) - Dysaesthesia (rare) – painful, uncomfortable, unpleasant sensation of lower lip, chin, tongue; sometimes neuralgia type pain. - Hypoaesthesia (reduced sensation) or heightened sensation (increased sensation). Nerves mostly recover within 9 months however can recover up to 18-24 months but after this time there would not be much hope for any further recovery

Answer 25

CBCT (or CT if not available)

Answer 26

Coronectomy

Answer 27

Liver disease = reduced clotting factors anticoagulant meds (warfarin or apixaban) antiplatelets (clopidogrel) inherited bleeding disorder - haemophilia A, B or von willebrand disease (INR should be LESS THAN 4) Post Op haemostasis: - firm and even pressure with damp gauze for 20 mins ++ - La & vasoconstrictor - oxidised regenerated cellulose (surgicel) pack and sutures - fibrin foam - gelatine sponge

Answer 28

Pre-op Via: - Size and location of tooth (last standing upper moalrs) - large, bulbous, splayed roots. - Radiographic position of roots in relation to antrum during pre-op assessment (roots wrapped around floor) Post extraction: - Bone at trifurcation of roots/type of roots - Bubbling of blood at the socket post extraction - Direct vision with Good light and suction - change in suction sound (can sometimes create an echo) - valsalva manoeuvre (careful and gently as can create an OAC if bone fractured but lining not torn) - **RADIOGRAPHICALLY** -** A breach in the sinus lining- you can see the extraction socket overlapping the maxillary sinus.** -Run a periodontal probe along the socket- you may feel the probe drop at one point- does it drop through? (take care not to create an OAC- some recommend not using this technique) - milk the socket to see where the blood is coming from??

Answer 29

- Hx of upper extraction/non-healing socket - Problems with fluid consumption = fluids from nose - Problems with speech or singing (nasal quality) - Problems playing brass/wind instruments - Problems smoking cigarettes or using a straw - Bad taste/odour/halitosis/pus discharge/salty taste (post-nasal drip) - Pain/sinusitis type symptoms

Answer 30

1. Remove the sinus tract (before the flap made) 2. Raise the flap; - Buccal Advancement Flap (need to release the periosetum) -can fail in a larger communication -f it fails: - Buccal Fat Pad with Buccal Advancement Flap = reinforced/thicker flap using fatty globular tissue (More bruising/swelling ) 3.Washout the antrum – not always done (OAF associated with sinusitis) 4. close the flap (tension free ) provide nasal drops: ephedrine 0.5% 10ml (1-2 drops 4x per days for a max of 7 days) proovide pen V 250mg 2 tablets 4x per day for 5 days

Answer 31

Bone dimensions: Mesial/ distal :1.5mm away from adjacent teeth. Bucco-palatally :2mm Apico-coronally- 2mm from ACJ 2mm away from adajcent structures (IAN/ Maxillary sinus) We want 7mm of space in the edentulous area . CBCT Allows more accurate assessment of; - Root positions - Bone width - Bone volume

Answer 32

* Bridge - adhesive or Conventional * fixed fixed (post) or cantilever (ant) * RPD * Accept the space * close with orthodontics

Answer 33

Fracture of the maxillary tuberosity OAC Root in the antrum

Answer 34

* Buccal Advancement Flap (can fail in a larger communication) * Buccal Fat Pad with Buccal Advancement Flap = reinforced/thicker flap. Used if a buccal advanacement flap fails.

Answer 35

Bridge - adhesive or Conventional fixed fixed (post) or cantilever (ant) RPD orthodontics + restorative

Answer 36

Midline shift and spacing -Space is too wide for a 1 pontic bridge but too narrow for a 2 pontic bridge. - psychological impact of no teeth - self conscious/lack of confidence - teasing/bullying by peers

Answer 37

Problems with biting/incising food (mastication) problems with speech (fricatives and whistling) Missing canine (canine guidance) Lower teeth- risk of overeruption.

Answer 38

History: MH - medications, allergies, health issues e.g. Diabetes/ osteoporosis/ bisphosphonates, bleeding disorders etc (can affect Implant surgery) DH - motivation, compliance (regular attender), caries risk, fear&anxiety. SH - smoking/ ability to afford treatment. Active disease: - caries - gingivitis/peridontal disease (BPE & 6PPC) IOTN? (if ortho referral)

Answer 39

Root morphology Alveolar bone width and height Surrounding anatomy (maxillary sinus, IDN) Alignment/spacing/crowding of the dentition OH disease status - caries & periodontal

Answer 40

Impacted wisdom teeth that are free from disease (healthy) should not be operated on. (Emer -) SIGN - unless justified, risk>benefit, no evidence of associated pathology, risk of surgical complications NICE - Unless Pathology shouldn't be removed

Answer 41

What are the therapeutic indications for extraction? * **infection**: from caries, pericoronitis, periodontal disease or local bone infection (most common) * Any **history** of pericoronitis, one or more cases of infection or untreatable pulpal/PA disease = extraction considered * **8’s needing restored**= poor access and poor moisture control * **Horizontal/Mesioangular impaction** = more prone to bone loss distal to 7 (late removal > 30y/o = no improvement of perio disease on lower 7. * - **Cysts** = most commonly present between 20-50y/o Most common = dentigenous cyst - arises from reduced enamel epithelium separation from the crown.Most common = in mandible (10x) * - **prior to cancer treatment**: indicates remove of 8 if the px is receiving radiotherapy as it prevents removal at a later date and reduces risk of osteoradionecrosis * - **External resorption **of 7 or 8 – occurs commonly between 21-30y/o Other indications: - Surgical indications ie within the surgical field (orthognathic, fractured mandible, in resection of diseased tissue surgeries) - If tooth has a high risk of disease e.g. in horizontal/mesioangular impaction - Medical indications eg. awaiting cardiac surgery (must be dentally fit), immunosuppressed, starting bisphosphonates or to prevent osteonecrosis - Accessibility to the dentist e.g. submariners, aid workers etc - Patient age: complications and recovery time increase with age - Autotransplantation: tooth relocated to another site i.e. 1st molar site (low success and not widely used) - General Anesthetic: radical tx to prevent a further GA

Answer 42

Therapeutic Indications: - Infection: from caries, pericoronitis, periodontal disease or local bone infection (most common) - Any history of pericoronitis, one or more cases of infection or untreatable pulpal/PA disease = extraction considered Restoring 8’s = poor access and poor moisture control Horizontal/Mesioangular impaction = more prone to bone loss distal to 7 (late removal > 30y/o = no improvement of perio disease on lower 7. - Cysts = most commonly present between 20-50y/o Most common = dentigenous cyst - arises from reduced enamel epithelium separation from the crown Most common = in mandible (10x) - Tumours: indicates remove of 8 if the px is receiving radiotherapy as it prevents removal at a later date and reduces risk of osteoradionecrosis - External resorption of 7 or 8 – occurs commonly between 21-30y/o Other indications: - Surgical indications ie within the surgical field (orthognathic, fractured mandible, in resection of diseased tissue surgeries) - If tooth has a high risk of disease e.g. in horizontal/mesioangular impaction - Medical indications eg. awaiting cardiac surgery (must be dentally fit), immunosuppressed, starting bisphosphonates or to prevent osteonecrosis - Accessibility to the dentist e.g. submariners, aid workers etc - Patient age: complications and recovery time increase with age - Autotransplantation: tooth relocated to another site i.e. 1st molar site (low success and not widely used) - General Anesthetic: radical tx to prevent a further GA

Answer 43

1. Presence or absence of disease (in 3M or elsewhere) 2. Anatomy of 3M (crown size, shape, condition, root formation – apical hooks or large curves) Assess crown to root ratio 3. Depth of impaction 4. Orientation of impaction (vertical, horizontal, transverse, M or D) 5. Working distance (distal of lower 7 to ramus of mandible) 6. Follicular width (appears as radiolucency on an x-ray) : can become a cyst follicules > 2.5-3mm 7. Periodontal status 8. The relationship or proximity of upper third molars to the maxillary antrum and of lower third molars to the inferior dental canal 9. Any other pathology/abnoramlity

Answer 44

Temporary numbness may take weeks/months to improve; 10-20% will experience temporary effects Permanent numbness; Average <1% will experience this Nerves mostly recover within 9 months however can recover up to 18-24 months but after this time there would not be much hope for any further recovery

Answer 45

Buccal mucoperiosteal flap: 2 sided or 3 sided (various suturing pattern) +/- raising a lingual flap

Answer 46

Post Op haemostasis: - firm and even pressure with damp gauze for 20 mins ++ - La & vasoconstrictor - oxidised regenerated cellulose (surgicel) pack and sutures - fibrin foam - gelatine sponge

Answer 47

Soft tissues – La & vasoconstrictor or oxidised regenerated cellulose (surgicel) pack and sutures Bone – bone wax, pack (WHVP) Vessels (veins, arteries, arterioles) – diathermy and ligatures (bigger vessels)

Answer 48

Liver disease = reduced clotting factors anticoagulant meds (e.g. warfarin apixaban) antiplatelets (e.g. clopidogrel aspirin) inherited bleeding disorder - haemophilia A, B or von willebrand disease (INR should be LESS THAN 4)

Answer 49

Thumb in the coronoid notch of the ramus of the mandible fingers on the posterior border of the mandible barrel of LA over the opposite premolars and visualise the pterygomandibular raphe - union of the superior pharyngeal constrictor muscle and the buccinator muscle * hold thumb horizontal in the notch and have the needle at the superior border of you finger nail, in the middle of the triangle 1cm above the last standing molar * advance needle until you contact bone (1cm of needle still visible), retract slightly, aspirate and deposit * if too much needle showing retract slightly and move back * if needle doesn't contact bone retract slightly and move further forward

Answer 50

Akinosi Block technique: Used for patients with severe trismus (they are unable to open their mouth) 1. Pull cheek away 2. Needle moves in parallel to the floor just above the gingival margin of the upper molars. 3. Keep inserting the needle until the barrel end is in line with the 7 and 8s. 4. Inject Gow Gate technique: (requires px to open wide) Injection site - anterior to the neck of the condyle in proximity to the mandibular branch of the trigeminal nerve after its exit from the foramen ovale.

Answer 51

Apologise and explain what has happened to the patient and why it had happened. Give them reassurance that it is a temporary Provide eye protection (eye patch) until blink reflex returns to normal Advise length of paralysis can vary but will improve over a period of days/week Review the patient

Answer 52

Ensure flap has adequate circulation/perfusion and is of adequate size - so that the flap doesn't become necrotic Use scalpel in one continuous stroke No sharp angles created in the soft tissue Minimise trauma to the papillae Do not crush the raised flap/soft tissues Keep the tissues moist Ensure the margins of the flap where the sutures will be placed are on sound bone Wounds must not be closed under tension - high risk that the wound will breakdown Aim for healing by primary intention as it minimises scarring. Occurs when edges of the wound are close together/held together by sutures/glue Secondary is when the dermal edges are not in close proximity and the wound heals from the bottom upwards = scarring.

Answer 53

1. Achieve anaesthesia – ensures pain relief and haemostasis * Local Anaesthesia * IV Sedation & LA * General Anaesthetic 2. Access - 2/3 sided buccal mucoperiosteal flap +/- raising a lingual flap 3. Bone removal as necessary Electrical straight handpiece with saline cooled bur and a Round or fissure stainless steel & tungsten carbide burs buccal aspect of the tooth around the margin and onto the distal aspect of the impaction 4. Tooth/root division as necessary and remove 5. Ensure apices intact 6. Inspect and debridement the socket - Bone file or handpiece to remove sharp bony edges - Mitchell’s trimmer or Victoria curette to remove soft tissue debris - Flush Sterile saline into socket and under flap = irrigation - Aspirate under flap to remove debris = suction 7. Suture 8. Achieve haemostasis biting down on a damp guaze (10/15 mins 9. Post-operative instructions (verbal and written)

Answer 54

To irrigate sockets after extraction

Answer 55

Jaw fracture (rare) Loss of tooth Soft tissue damage Damage to nerves Damage to vessels Haemorrhage Dislocation of TMJ Damage to adjacent teeth/restorations Broken instruments fracture of tooth/roots

Answer 56

Neurapraxia: Contunity of epieneural sheath and axons maintained (bruised) Axonotmesis: Continuity of axons disrupted but no damage to the epineural sheath Neurotmesis: Complete loss of nerve continuity/(nerve transected)

Answer 57

- Reposition tissues - Cover bone - Compress blood vessels - Prevent wound breakdown - Achieve haemostasis

Answer 58

Non Absorbable i.e. Mersilk, Prolene, Ethylon When used? supported and retained for long periods of time i.e. closure of OAF and exposed canines. Absorbable i.e. Velosorb fast Last for 1/2 weeks Broken down via hydrolysis When used? When it is not possible to remove sutures When edges only have to be held together temporarily Monofilaments: (1 strand of material) i.e. Proline and ethylon These are also Non-Absorbable Used in areas more prone to scarring polyfilaments: (several strands of material) i.e. Velosorb fast (A) and Mersilk (NA)

Answer 59

Fracture of the tooth/root Fracture of the alveolar plate Fracture of the maxillary tuberosity Jaw fracture Oro-antral communication Loss of tooth Soft tissue damage Damage to nerves/vessels Haemorrhage Dislocation of TMJ Damage to adjacent teeth Broken instruments Wrong tooth

Answer 60

Assess INR 24 hours before (if poorly controlled) or 48 (72?) hours before if better controlled. = Should be less than 4. * Stage treatment * Limit treatment area * Treat early in the day and early in the week Avoid lingual infiltration and IDB - if have to do IDB use vasoconstrictors and aspiration technique Ensure an atraumatic technique Use additional haemostatic aids such as extra la+vasoconstrictor, surgical pack (oxidised regenerated cellulose) and sutures. ensure haemostatsis before px leaves surgery and provide thorough post op instructions including what to do if the bleeding starts and cannot be controlled + emergency contact details book for a review appt.

Answer 61

Bisphosphonates are widely used to treat and prevent bone-related conditions. They act by inhibiting osteoclast activity and bone resorption= poor healing of the bone socket used for: osteoporosis (in postmenopausal women) Paget’s disease of bone anticancer treatment regimens, particularly for metastatic bone cancer and multiple myeloma

Answer 62

HX: Those on bisphosphonates, anti-angiogenic or RANKL inhibitors. Exam: Exposed bone/lack of healing of bone that can be probed via an intra-oral or extra-oral fistula and has been present for 8 weeks.

Answer 63

Low risk: Px NOT currently being treated with systemic glucocorticosteroids and - oral BP's < 5 years - IV BP's < 5 years - denosumab High risk: - Use in cancer treatment - Used alongside corticosteroids - Used for > 5 years - Had MRONJ before - oral or IV BP's > 5 years - BP's or denosumab WITH systemic glucocorticosteroids - anti-resorptive or anti-angiogenic drugs - previous MRONJ

Answer 64

Assess risk and discuss risks with the patient and obtain valid consent Low risk: Perform straightforward extractions and procedures that may impact on bone in primary care. (no AB's necessary) higher risk: Explore all possible alternatives to extraction where teeth could potentially be retained e.g. retaining roots in absence of infection. If extraction remains the most appropriate treatment, proceed as for low risk patients For both: provide POI and advise the patient to contact the practice if they have any concerns, such as unexpected pain, tingling, numbness, altered sensation or swelling in the extraction area. Review healing. If the extraction socket is not healed at 8 weeks and you suspect that the patient has MRONJ, refer to an oral surgery/special care dentistry specialist as per local protocols.

Answer 65

A localised osteitis - inflammation of the lamina dura Its delayed healing NOT associated with infection What causes this? The normal clot partially/fully disappears or doesn’t form at all Symptoms: Intense, dull aching, throbbing pain that keeps the patient up at night. Pain can radiate to the ear Bad smell Bad taste

Answer 66

initial healing = 1-2 weeks soft tissue healing = 3-4 weeks

Answer 67

Predisposing factors: Molars - posterior teeth are more prone Mandibular teeth: blood supply is worse, only from 1 main artery. Smoking/ex-smokers as it reduces the blood supply: warn them Females OCPs LA with vasoconstrictor: lots of Excessive trauma during extraction Excessive mouth rinsing post extraction Previous dry socket: variable

Answer 68

Check that there’s no tooth fragments/bony sequestra remaining in the socket - Take a radiograph to confirm Reassurance that this is common Advise analgesics and hot salty mouthwashes LA block Irrigate socket with warm saline (with regular appointments) Debride the socket to encourage new clots (controversial) Antiseptic pack e.g. alvogyl: packed into the socket and it disintegrates itself. No sutures. or BIP paste/gauze packed into the socket, needs to be replaced as they don’t dissolve. Suture over the top. Don’t prescribe antibiotics as its not an infection

Answer 69

Patients who have received radiotherapy of the head and neck, the mandible is the most commonly affected (because it has one main artery) What occurs In these patients? At a site of radiation injury the bone becomes non-vital, the blood supply reduces (from endarteritis obliterans), bone turn over slows down and Self repair is ineffective.

Answer 70

Patients who have received radiotherapy of the head and neck the mandible as it is the most commonly affected because it has one main artery if radiation dose to the primary tumour = exceeded 60Gy * The dose fraction was large with a high number of fractions * Those with local trauma as the result of a tooth extraction (especially mandibular extractions as it is perfused less), uncontrolled periodontal disease or an ill-fitting prosthesis. * The person is immunodeficient * The person is malnourished

Answer 71

ensure px dentally fit before tx. - ensure XLA done 10 days before starting Scaling and reinforcing good OHI Careful and atraumatic technique achieve primary closure after invasive treatment Hyperbaric oxygen before and after the extraction: increases tissue oxygen and increases vascular ingrowth to hypoxic areas. Refer and take advice | SDCEP- NO LONGER ANTIBIOTIC or CHX

Answer 72

Refer the patient: Small exposure- Patient will be monitored/ OHI/ antibiotics/ antibacterial mouthwash. Large exposure- may need surgery for surgical debridement. debridement ------- Irrigate and remove necrotic debris Remove loose sequestra/necrotic sequestra (bone) Large wounds: resect the exposed bone and close the soft tissues Hyperbaric oxygen therapy: increases tissue oxygen and increases vascular ingrowth to hypoxic areas. use vitamin E and pentoxyfylline

Answer 73

Upper Forceps Straight- 13 to 23 Universal (curved handle)- canine and premolars Molars x2- there is a left and right instrument, the rule is beak to cheek Upper root - look identical to upper universal with thinner beaks used on roots 3rd molar bayonets - straighter handle, bend in the tip, thicken beak than the root forceps (8's) straight vs universal - both identical however the universal instrument has a curved handle universal vs root - both identical however the root instrument has a much smaller tip Lower Forceps All have a 90 degree bend on the tip Universal- 35 to 45 Molar- two beaks to engage the space between the mesial and distal roots and can be used for both left and right side Cowhorn (sharper and narrower pincers) used on either side can be used in: molars with lack of crown, with divergent roots, in young patients Root - identical to universal with a smaller tip

Answer 74

Use: to loosen and widen the PDL (**space**) Types: Coupland’s - square/sharp edge The higher the number the bigger Cryer’s (sets of 2 = left and right) remove retained roots or fragments AND engage furcation region of molars Warwick James (sets of 3 = left, right and straight) used for wisdom teeth

Answer 75

Elevator&luxator techniques: Lever technique: Use your non-dominant hand to support the alveolar bone and retract soft tissues Always use it buccally Start from the mesial and move distally Ensure concave (sharp edge) surface is engaging the tooth Use it buccally and as far down the crown/slightly on to the root - ensure it’s not interdental Turn the instrument upwards engaging the tooth surface to raise the tooth Wedge: Use your non-dominant hand to support the alveolar bone and retract soft tissues Always use it buccally Start from the mesial and move distally Wedge down the PDL and wiggle the instrument Wheel and axle: Approach from buccal aspect (you can change application point- mesial, distal etc) Come almost horizontal Wedge tip so that is engaging acj (as deep as possible) Twist wrist to rotate instrument and lift the tooth This can be used with cryers when extracting retained roots If retained root is mesial- you may start with a distal application point (as this part of socket is empty), this gives you space to get the instrument in to engage the root. You may fracture some bone between the roots but then the tooth will start to elevate.

Answer 76

Function: to loosen and widen the PDL (**space**) ??? - remove retained roots - provide a point of application for forceps

Answer 77

function: to tear and sever the PDL

Answer 78

Bacterial infection of the cancellous bone, which then spreads to cortical bone and then the periosteum. (inflammation of bone marrow) This can result in a compromised blood supply (from increased tissue hydrostatic pressure) which causes ischaemic and necrotic tissue. Occurs in patients whos host defences are compromised by diabetes, alcoholism, iV drug use, malnutrition and myeloproliferative disease e.g. leukaemia, sickle cell. - Bacteria proliferate because natural blood borne defences cannot reach the tissue. - affects the mandible as it has a poorer blood supply (only one main artery) The infection will spread until arrested by antibiotics or surgery.

Answer 79

* Compromised host defence (diabetes/ Alcoholism/Leukaemia / chemotherapy treated cancer) * Fracture of the mandible * Odontogenic infection * Infected teeth (smaller odontogenic) * Bad periodontal disease

Answer 80

Referal: * Blood investigations to assess host defences * antibiotics - clindamycin/penicillins (good bone penetration) these courses are usually 6 weeks to 6 months. * Surgical treatment- clearing the infected area of non-vital teeth/ loose pieces of bones etc unitl you reach healthier bone ) Severe, acute and systemically unwell = hospital admission and IV AB

Answer 81

Max Doses- 70kg Lidocaine 2% is 4.4mg/kg – 7 cartridges Articaine 4% is 7mg/kg- 5 cartridges Prilocaine 3% is 6mg/kg- 8 cartridges Mepivacaine 3% is 4.4mg/kg- 6 cartridges

Answer 82

An inherited bleeding disorder where there is an inability of a patient to clot due to a deficiency in factor 8 (blood clotting protein).

Answer 83

An inherited bleeding disorder where there is an inability of a patient to clot due to a deficiency in factor 9. (blood clotting protein).

Answer 84

A combination of reduced platelet aggregation (from a defect in the VW protein attached to platelets) and Reduced factor 8 levels.

Answer 85

Haemophilia A Mild/moderate = DDAVP to release factor 8 & tranexamic acid (inhibit fibrinolysis) Severe = factor 8 Haemophilia B- Recombinant factor 9 (+/- transexamic acid occassionally) Von willebrand's = DDAVP (for the factor 8 deficency) & transexamic acid (to stop fibrinolysis)

Answer 86

Examination Treatments that do not manipulate the mucosa Supragingival restorations/ crowns/bridges Infiltration anaesthesia.

Answer 87

* Pain/ Swelling/ Infection/ Bleeding/ Bruising. * Medication related osteonecrosis of the jaw (Patient is on bisphosphonates) * Dry socket * increased infection risk due to the immunosuppresion.

Answer 88

Headaches (Due to Temporalis pain) Limited jaw movement (lateral or protrusive) Trismus Clicking or popping noises. Crepitus (grating noise) Deviation of the mandible to affected side. Ear pain (proximity to the auditory canal) I/O Signs: Cheek biting. Linea alba. Tongue scalloping. Occlusal non carious tooth surface loss.

Answer 89

Soft diet, Stop parafunctional habits e.g. nail biting, Support mouth upon opening e.g. yawning, Wear bite raising appliance Don’t incise foods, Chew bilaterally, Cut food into small pieces, No wide opening, No chewing gum Relaxation e.g.physiotherapy,

Answer 90

PH- Time of Pain- In the morning (bruxism) During the day habits) SH- stresses E/O- MoM hypertrophy. TMJ clicking/ crepitus. Tenderness on palpatation. Range of movement. I/O intercisial opening distance (measure with willis bite gauge) Signs of bruxism- (Wear facets, Scalloped tongue, Linea alba, occlusal NCTSL)

Answer 91

Female>Males, 18-30yrs, Stress, Habits - chewing gum/ chewing pens/ grinding/ clenching.

Answer 92

Patient education Counselling/reassurance: why its happening, how it happens, what the causes are, how we manage etc. Advice: (standard approach) * Reassurance * Soft diet * Masticate bilaterally * No wide opening * No chewing gum * Don’t incise foods * Cut food into small pieces * Stop parafunctional habits e.g. nail biting, grinding * Support mouth on opening e.g. yawning Medication - NSAIDs - Muscle relaxants - Tricyclic antidepressants (have muscle relaxant properties) - Botox of masseter = prevents clenching (last resort tx) - Steroids Physical therapy - Physiotherapy - Massage/heat - Acupuncture - Relaxation - Ultrasound therapy (not used as much) - TENS (Transcutaneous Electronic Nerve Stimulation) - Hypnotherapy and CBT Splints - Bite raising appliances - Anterior repositioning splint e.g. wenvac or Michigan splint

Answer 93

Myofascial pain syndrome: no clicky, Pericoronitis of L8- Clinical signs of pericoronitis. Dental pain- radiographs Sinusitis- get patient to bend their head forward (sinusitis has pain on movement) Atypical odontoalgia- Dental pain without dental pathology. (This is only a diagnosis if we try to treat TMD and our treatment isn't successful- ONLY DIAGNOSED when everything else is excluded.

Answer 94

We can ask for: Soft acrylic splint "A full coverage soft acrylic splint" Using the lower impression. Hard splint: (Michigan) "A full coverage hard acrylic splint" Cover all teeth, Using the Upper and lower alginate impressions with facebow registration and wax bite. Adam's clasps on the 6s (It blocks lateral movement of the teeth)

Answer 95

Full medical history- Medical conditions/ Medications/ Immunocompromised? / Any allergies- might need to prescribe antibiotics. HPC- When did the pain start? Have they had it before? - When did the swelling start? Has the swelling increased? When did the patient begin to feel unwell? - can they eat/ drink Severity of pain. Have they been taking any medications for pain relief? E/O exam: Is the swelling affecting their airway? (any changes in voice) Any swelling on the floor of the mouth? Assess mouth opening Any difficulties swallowing Any swelling around the eyes. Lymph nodes- palpable. Investigations- OPT

Answer 96

1. Reassure patient and gain consent. 2. LA infiltration around area of abscess Drainage of the pus and swelling around the 47. 3. Remove source of infection (Ideally on the day but may have to be at another appointment to allow swelling to die down) 4. Antibiotic due to spreading infection – Pen V 2x250mg 4x daily for 5 days. Or Metronidazole 400mg 3xdaily for 5 days. 5. Review patient after antibiotic treatment.

Answer 97

- Lingual nerve- Tongue - Inferior alveolar nerve- Lower lip and chin