Oral Surgery Flashcards
What is the most important aspect of why LA is important in Oral Surgery?
pain and anxiety management
What are the main reasons LA is important in Oral Surgery?
pain and anxiety management and haemorrhage control
What is the most invasive part of dentistry?
oral surgery and tooth extractions
How can we minimise pain during LA?
topical, taught mucosa, sharp needle, slow injection, needle not against bone
How can using topical minimise pain during LA?
numbs the surface of the mucosa so no pain is felt when the needle penetrates the mucosa
How can having taught mucosa minimise pain during LA?
the tension helps to reduce the feeling of the needle penetrating mucosa
How can a sharp needle minimise pain during LA?
easier for the needle to penetrate the mucosa
How can injecting slowly minimise pain during LA?
reduces the pressure of the liquid under the mucosa
How can having the needle not against bone increase pain during LA?
if the needle is too close to the bone, you could inject under the periosteum which is very painful
How does LA help to manage the anxiety of patients?
by removing the source of pain
How can we minimise anxiety in LA?
assess the patient, listen to patient’s past experiences, set patient expectations clearly, use distraction techniques, relax yourself
Which are the two most common LA’s used in Oral Surgery?
Lidocaine and Articaine
Which part of LA helps to reduce haemorrhage?
adrenaline
How does adrenaline help reduce haemorrhage?
it is a vasoconstrictor
How long does it usually take for haemostasis to occur?
4-10mins
How long does Lidocaine last for?
2-3 hours
How long does Articaine last for?
1-2 hours
Where are the blood vessels positioned that bleed after tooth extraction?
the vessels in the apex of the tooth, the vessels in the periosteum, the blood vessels in the soft tissues
What are you looking for in the visual examination of your patient?
their general appearance and how that may impact their treatment
What are you looking for in the extra-oral examination of your patient?
temperature, vital signs, swellings, lymph node involvement, limited mouth opening
What are you looking for in the intra-oral examination of your patient?
the site of the surgery, if there is any swelling around the site, any bleeding in the mouth, any pus, a bad smell in the mouth, any food packing
What is the most common complication of oral surgery?
dry socket
What is dry socket?
When a blood clot fails to form in the socket or the blood clot becomes dislodged leaving the exposed socket open to bacterial infection
What are the symptoms of dry socket?
inflammation of the alveolar bone, unpleasant smell/taste, dull throbbing ache that is not relieved by painkillers
What percentage of routine extractions may result in dry socket?
20%
What percentage of surgical third molar extractions may result in dry socket?
30%
Does dry socket happen immediately post extraction?
no, usually 2-3 days after
What are some factors that may increase your risk of developing dry socket post extraction?
smoking, oral contraceptives, local infection, immune suppression, previous radiotherapy
Why is it not routine to use a chlorhexidine rinse before and after tooth extraction?
there have been cases of chlorhexidine associated anaphylaxsis and death in the dental chair
What could be the extra-oral examination of someone with dry socket?
normal temperature, no swelling, no limited mouth opening
What could be the intra-oral examination of someone with dry socket?
bad smell, food packing, red and tender around the socket
What could be a differential diagnosis for dry socket?
retained root
How do you manage dry socket?
irrigation of socket with 0.9% saline using monoject syringe, place dressing, smoking cessation and OHI, prescribe appropriate painkillers
What is the usual dressing placed to treat dry socket?
alveogyl
What are some appropriate painkillers for management of dry socket?
paracetamol, ibuprofen, codeine
How long do you prescribe codeine for and what dosage is prescribed?
5 days, 30mg
Why is alveogyl the favoured dressing for dry socket?
it is resorbable
What is alveogyl derived from?
eugenol
Aside from dry socket, what is another common complication from oral surgery?
socket infection
What are symptoms of a socket infection?
pain localised to socket site, fluctuant swelling of the area, bad taste, bad smell, fever, malaise
How does a socket infection occur?
bacteria colonise the socket site
What is the first thing you should check in a patient if they present with a socket infection?
determine if the airway is compromised
How can you tell if an airway is compromised?
significant swelling, patient unable to swallow own saliva, patient unable to push tongue forward
How do you manage the patient if the airway is compromised due to socket infection?
send patient to emergency care immediately
How do you manage the patient with a socket infection if the airway is not compromised?
recommend optimal painkillers, drain pus using number 15 scalpel
When might you prescribe antibiotics for an infected socket?
if there is a spreading infection, systemic signs, immunocompromised patient
What is the first line antibiotic for socket infections?
amoxicillin 500mg 3 times a day for 5 days
What is the second line antibiotic for socket infections? if the patient has a true penicilin allergy?
clinadmycin 150mg 4 times a day
What is a primary hemorrhage?
bleeding at the time of surgery - continuous fresh blood from the extraction site
What level of bleeding is normal after an extraction?
blood stained saliva for the first 12-24 hours
What is a reactionary haemorrhage?
bleeding 2-3 hours post extraction as LA wears off
What is a secondary haemorrhage?
bleeding up to 2 weeks after the surgery
What is the most common cause of secondary haemorrhage?
infection
What post-op instructions are patients given regarding what they should not do after oral surgery?
rinse mouth today, drink alcohol or hot drinks, smoke, chew food for four hours, exercise today
What post-op instructions are patients given regarding what they should do after oral surgery?
sip lukewarm drinks, if area bleeds bite on damp gauze for at least 10 mins while sitting upright, after 24 hours rinse mouth with warm salt water, clean teeth as normal but be careful around extraction site
Why should patients not rinse out their mouth today?
may dislodge the clot if fibrin stabilization has not occured
Why should patients not drink alcohol today?
may increase blood pressure or induce increased bleeding
Why should patients not drink hot drinks today?
may increase blood pressure or bleeding and patient may burn themselves and not notice if still numb
Why should patients not smoke after extraction?
increased risk of dry socket
Why should patients not do exercise today?
increase blood pressure and may increase bleeding
What is vasoconstriction?
vascular spasm in the smooth muscle in the walls of blood vessels
What is platelet plug formation?
adhesion, interaction and aggregation of platelets
What is the coagulation cascade?
clotting factors in the extrinsic, intrinsic and common pathways lead to the formation of fibrin
Is clot formation a static or dynamic process?
a dynamic process
which two systems is clot formation a balance of?
haemostatic and fibrinolytic systems
When does fibrinolysis occur?
when plasminogen activates plasmin which digests fibrin fibres
How long after an extraction should the platelet plug take for form?
a few mins
How long after an extraction should fibrin formation and stabilization take?
5-6 hours
Why is it important to consider the normal mechanism of blood clotting post extraction?
to allow the clinician to interpret which patients may be at high risk of poor haemostasis
Where are the majority of clotting factors produced?
Liver
Where are platelets produced?
red bone marrow
At which clotting factor do the intrinsic and extrinsic clotting pathways converge?
factor 10
What happens when the intrinsic and extrinsic clotting pathways converge?
factor 5 and Calcium convert prothrombin to thrombin which converts fibrinogen to fibrin
What are risk factors for pre-op bleeding?
high risk medical history, anticoagulant/antiplatelet medications
What are risk factors for intra-operative bleeding?
traumatic extraction, soft tissue tears, large vessel damage
What are risk factors for post-op bleeding?
infection, loss of blood clot, failure of the patient to follow post-op instructions
Why is it important to assess the bleeding risk of patients?
do you can work with haematology or cardiology to prevent intra-op and post-op bleeding issues.
What four things can contribute to a high risk medical history?
clotting factor deficiencies, acquired liver disease, platelet deficiency, vascular anomalies
What is Haemophilia A?
low levels of clotting factor VIII
What is Haemophilia B?
low levels of clotting factor IX
What is the aetiology of Haemophilia A and B?
an x-linked recessive inherited disorder
How can you manage treatment of patients suffering from Haemophilia A and B?
discuss with haematology and consider fresh frozen plasma to replace factors and proteins
Which is the most common inherited clotting factor deficiency?
Von Willebrand’s Disease
What is Von Willebrand’s Disease?
deficiency of vWF which is bound to factor VIII and prevents it from rapid breakdown. vWF deficiency can lead to factor VIII deficiency
Which clotting factors are affected by vitamin K deficiency?
II, VII, IX, X
Why is acquired liver disease a contributor to a high risk medical history?
most clotting factors are made in the liver
Why is it bad if the liver becomes severely scarred?
it’s harder for the blood to move through which leads to an increase in blood pressure around the intestines and the blood begins to use smaller blood vessels to transport the blood back to the heart which can weaken and damage the vessels causing long term bleeding leading to anaemia
How can you manage patient’s with acquired liver disease?
check liver function and complete a full blood count and clotting screen
What is the technical term for platelet deficiency?
thrombocytopenia
What does the platelet count need to be below in order for the decrease in platelets to be classed as thrombocytopenia?
less than 100 x 10^9/L
What can be the cause of thrombocytopenia?
immune disease, secondary to disease, drug-induced
Which drugs can cause drug-induced thrombocytopenia?
NSAIDs, alcohol, heparin
What is an example of a disease that can cause thrombocytopenia?
leukaemia
What are examples of some vascular anomalies?
arterio-venous malformation, HHT, Collagen disorders
How should you manage the treatment of patients with vascular anomalies?
further investigations with a clinical specialist before treatment
What should you always consider if treating a patient that is taking anticoagulant/antiplatelet drugs?
consulting a specialist in haematology or cardiology
What is Warfarin?
a vitamin K antagonist
Which clotting factors does Warfarin affect?
II, VII, IX, X
How should you manage treating a patient that is taking Warfarin?
check INR ideally within 24 hours of treatment but up to 72 hours before the procedure, pack and suture, stage and limit treatment as much as possible
What should the INR be below in order for treatment to occur?
4
How does a low dose of aspirin affect the clotting system?
blocks thromboxane A2 in platelets which inhibits platelet aggregation
How does aspirin work as an NSAID?
inhibits COX-1 and COX-2 which inhibits proinflammatory prostaglandins
How does clopidogrel affect the clotting system?
inhibits ADP receptor which prevents the activation of platelets and the eventual cross-linking by fibrin
Which two medications are commonly prescribed together for dual antiplatelet therapy?
Aspirin and Clopidogrel
When might dual antiplatelet therapy be used?
following coronary stent placement
How should you manage a patient taking anticoagulants/antiplatelets?
limit intial treatment, consider staging, suture and pack, use local haemostatic measures
What is Dabigatran?
DOAC
How does Dabigatran affect the clotting system?
reversibly binds to thrombin preventing activation of coagulation factors and may enhance fibrinolysis
What are Apixaban and Rivaroxaban?
DOACs
How do Apixaban and Rivaroxaban affect the clotting system?
inhibit clotting factor Xa
What is the difference between Apixaban and Rivaroxaban?
apixaban is taken twice a day but rivaroxaban is taken once a day
How should patients taking dabigatran or apixaban adapt their medication schedule before a dental procedure?
miss their morning dose and take dose as usual in the evening
How should patients taking rivaroxaban adapt their medication schedule before a dental procedure?
if taking in the morning, delay morning dose until 4 hours after haemostasis has been achieved, if taking in the evening, take as usual
How can leukaemia result in bleeding problems?
proliferation of immature WBCs can affect the number of platelets resulting in bleeding
How can you manage a patient with an unexplained post-op bleed?
full blood count, check platelet count and function, clotting screen, find out if there is a clotting factor deficiency
When should you consider referral to OMFS in general dental practice?
for a persistent of severe bleed which you can’t stop with the measure available in general practice
What are the steps you should take to manage an intra-op or post-op bleed?
visualize area, irrigate socket with 0.9% saline, suction and remove ‘liver clot’, apply pressure using damp gauze, administer LA, pack with haemostatic aids, seal bleeding points, suture well, give 5% tranexamic acid if needed
What is a liver clot?
red, jelly-like clot that is rich in hemoglobin from erythrocytes within the clot, and characterized by slow, oozing, dark (venous) blood hemorrhage
Why should you take care with placing pressure with damp gauze?
excess pressure could damage buccal bone
Why is it important to administer LA?
for the vasoconstrictor effects and to prevent any discomfort as you apply haemostatic measures
What are the haemostatic aids you can use to pack the bleeding socket?
surgicel
What is surgicel?
a resorbable dressing
What is silver nitrate?
a powerful chemical cauterizing agent that can aid haemostasis
What is diathermy?
a cautery device that can be applied to specific bleeding points to seal them
What suture styles can be used to close a socket?
simple interrupted, horizontal mattress, X-suture
What is tranexamic acid 5%?
anti-fibrinolytic that reduced clot breakdown
What are the observations that indicate hypovolaemic shock and are indicators of when you should refer a patient to the emergency department?
diastolic BP less than 60, systolic BP less than 100, heart rate over 100bpm
