oral surgery Flashcards
how do you control pain during and after dental treatment?
local anaesthetic during procedure
systemic analgesic drugs post-op
name 3 NSAIDS?
aspirin
ibuprofen
diclofenac
what type of drugs are aspirin, diclofenac and ibuprofen?
NSAID
what type of drug is dihydrocodeine?
opiod used for analgesia
paracetamol, carbamazepine and dihydrocodiene are all used for what in dentistry?
analgesia
what must you know about a drug to prescribe it?
mechanism of action
doses
side effects
interactions
groups of patients to avoid
what are the four properties of aspirin?
1 analgesic
2 antipyretic (reduces fever)
3 anti inflammatory
4 metabolic
what is acetylsalicylic acid commonly known as?
aspirin
how are prostaglandins produced?
trauma and infection leads to phospholipid membrane breakdown producing arachidonic acid
arachidonic acid can be broken down to form prostaglandins
what is the function of prostaglandins?
they sensitise the tissues to other inflammatory products resulting in pain
do prostaglandins cause pain directly?
no they sensitise the tissues to other inflammatory products such as leukotrienes
true or false
increasing prostaglandin production will moderate the pain
false
correct answer - decreasing prostaglandin production will moderate pain
describe how the arachidonic acid pathway causes pain and inflammation
tissue injury causes injury to phospholipid cell membrane leading to release of arachidonic acid
arachidonic acid then follows the cyclooxygenase pathway to be broken down into prostaglandin which sensitises the tissues to pain and inflammation
what is the function of thromboxane?
platelet aggregation
what are the 4 products of the arachidonic acid pathway?
from the cyclooxgenase pathway -
prostacyclin
prostaglandin
thromboxane
from the 5 - lipoxygenase pathway
leukotrienes
what is the effect of leukotrienes?
broncho constriction
asthma attacks
smooth muscle contraction
arachidonic acid can be broken down into 4 products, what are they?
prostacyclin
prostaglandin
thromboxane
leukotrienes
how does aspirin reduce the production of prostaglandins?
inhibiting cyclo-oxygenases COX1 and COX2
which cyclooxygenase is aspirin more effective in inhibiting ?
COX1
how does analgesic action of aspirin result (refer to arachidonic acid pathway)?
inhibition of prostaglandin synthesis in inflamed tissues by cyclooxygenase inhibition
what effect does interleukin 1 have on the body?
temperature raising
how does aspirin affect interleukin 1?
prevents the temperature raising effects
reduces temperature in fever
does aspirin reduce normal temperature?
no
how does aspirin display antipyretic (anti fever) properties?
prevents temperature raising effects of interleukin 1
how does aspirin display anti inflammatory properties?
reduces redness and swelling and pain at site of injury
what are the adverse effects of aspirin?
GIT problems
hypersensitivity
overdose - tetanus, metabolic acidosis
aspirin burns - mucosal
how do you avoid mucosal burns by aspirin?
ensure it is swallowed with water
what component in aspirin causes mucosal burns and how?
salicylic acid - if applied locally to oral mucosa will chemically burn
how do prostaglandins affect the GIT?
inhibit gastric acid
increase blood flow
production of mucin
most patients will experience blood loss from GIT when taking what drug?
aspirin
how do hypersensitivity reactions present?
acute bronchospasm/asthma type attacks - be careful prescribing to asthmatics
skin rashes - angiodema, urticaria
a patient overdoses on aspirin, what are the adverse effects?
tinnitus/deafness
vasodilation and sweating
metabolic acidosis - life threatening
why should a patient with peptic ulceration avoid aspirin?
gastric ulcer could perforate
what analgesic should a patient with epigastric pain avoid?
aspirin
what analgesic should a patient with bleeding abnormalities avoid?
aspirin
why should aspirin be avoided in warfarin patients
enhances anticoagulant effect of warfarin and bleeding tendency
how does aspirin affect warfarin
increases free (active) warfarin by displacing warfarin from binding sites (inactive) on plasma proteins
which trimester of pregnancy should aspirin be especially avoided?
3rd
why should breastfeeding women avoid aspirin?
Reyes syndrome risk
why should patients on steroids avoid aspirin?
risk of a peptic ulcer with steroids and aspirin may perforate the ulcer
where is aspirin metabolised?
liver
where is aspirin excreted?
kidney
why should patients with renal/hepatic impairment be cautious taking aspirin?
aspirin is metabolised in liver and excreted in kidneys
if renal impairment - excretion reduced
what age group should aspirin be avoided?
under 16
why should under 16 avoid aspirin completely?
risk of Reyes syndrome
when is aspirin completely contraindicated?
under 16
breast feeding
patients with history of hypersensitivity to NSAIDS
haemophilia
previous or active peptic ulceration
give the two key symptoms of Reyes syndrome?
encephalopathy
liver damage
why is it important to be cautious prescribing aspirin to patients taking other NSAIDS?
combinations of NSAIDS will increase risk of side effects
why must care be taken prescribing aspirin to patients with Glucose 6-Phosphate Dehydrogenase (G6-PD) deficiency?
risk of acute haemolytic anaemia on taking a number of common drugs
which patients are susceptible to developing acute haemolytic anaemia when taking a number of common drugs?
patients with G6PD deficiency
glucose 6-phosphate dehydrogenase
for mild to moderate odontogenic pain, what dose and regimen of aspirin should be prescribed?
under 16 - do not use - Reyes risk
600mg tablets 4 x daily for 5 days
groups to avoid/take caution when prescribing aspirin? 5
asthma
pregnant
breast feeding
anticoagulants
under 16
what should be prescribed to patients with previous or active peptic ulcer disease and odontogenic pain?
omeprazole or lansoprazole (proton pump inhibitors)
prevent gastric problems
when is ibuprofen commonly used in dentistry?
post op analgesia
for mild to moderate odontogenic pain, what dose and regimen of ibuprofen should be prescribed?
1 400mg tablet 4x daily for 5 days
what is the maximum daily dose of ibuprofen for an adult?
2.4g
take caution when prescribing ibuprofen to…
elderly
pregnancy or breast feeding
asthma
taking other NSAIDS
patients on long term systemic steroids
what are the side effects of ibuprofen?
GIT discomfort (bleeding, ulceration)
hypersensitivity reactions
headaches… see BNF
ibuprofen has many drug interactions, name some
ABCD - remember these interact with ibuprofen.
ace inhibitors
beta blockers
calcium channel blockers
diuretics
anticoagulants
what are the symptoms of ibuprofen overdose?
nausea
vomiting
tinnitus
how do you treat ibuprofen overdose?
treat with activated charcoal followed by symptomatic measures if more than 400mg/kg ingested in preceding hour
management of paracetamol overdose patient
transfer to hospital IMMEDIATELY
what is acetaminophen?
paracetamol
true or false
paracetamol does not have anti-inflammatory activity
true
what are the properties and benefits of paracetamol?
analgesic
antipyretic
no effects on bleeding time
does not interact with warfarin
less irritant to GI
suitable for children
describe the mode of action of paracetamol
tissue injury leads to injury to phospholipid cell membrane and production of arachidonic acid
hydroperoxides are generated from the cyclooxygenase pathway and exert a positive feedback to stimulate COX activity
paracetamol blocks this feedback and therefore inhibits COX
when paracetamol blocks the positive feedback of hydroperoxides, what is the effect on the body?
analgesia
antipyretic
which patients should you be cautious prescribing paracetamol to?
alcohol dependent
hepatic impairment
renal impairment
what are the side effects of paracetamol?
rare
rashes
blood disorders
hypotension
liver damage following overdose
what is the effect of paracetamol on anticoagulants?
enhances the anticoagulant effects of coumarins - warfarin
for mild to moderate odontogenic pain, what dose and regimen of paracetamol should be prescribed?
adults
2x 500mg tablets 4x daily
maximum dose 4g daily
children see BNF as depends on weight/age
what is the weakest opioid?
codeine
where in the body do opioid analgesics act?
act in the spinal cord - dorsal horn pathways
what quantity of paracetamol can cause overdose?
150 mg/kg within 24 hrs
what medication is used to treat neuropathic and functional pain such as trigeminal neuralgia, post-hepatic neuralgia or TMJ pain?
carbamazepine
what is carbamazepine used for?
trigeminal neuralgia control
what type of medication is carbamazepine?
anti-convulsant
what are the clinical features of trigeminal neuralgia?
severe spasms of pain/electric shock lasts seconds
usually unilateral
older age
females more affected
periods of remission
recurrences often greater severity
where is the main site of action for paracetamol ?
thalamus
what is the function of prostaglandins in the kidneys?
PGE2 and PGI2 are powerful vasodilators synthesised in the renal medulla and glomeruli and are imnvolved in control of renal blood flow and excretion of salt and water
where is PGE2 synthesised?
renal medulla
where is PGI2 synthesised?
glomeruli
how do NSAIDS have nephrotoxic effects?
inhibition of renal prostaglandin may result in sodium retention, reduced renal blood flow and renal failure
what analgesics can cause nephritis and hyperkalaemia?
NSAIDS
how do opioid analgesics prevent pain?
they bind to specific receptors which are associated with neuronal pathways transmitting pain to CNS
what are 3 major problems with opioids ?
dependence, tolerance and smooth muscle effects
opioids can cause psychological and physical dependence, what does this mean?
withdrawal of the drug will lead to psychological cravings and patient will be physically ill
what does opioid tolerance mean ?
to achieve the same therapeutic effects the dose of the drug needs to be progressively increased
what are the resultant effects of opioid action on smooth muscle?
constipation
urinary and bile retention
what are the effects of opioids of the CNS?
depresses CNS
pain centre - alters perception of pain
what are the side effects of opioids?
nausea
vomitting
dry mouth
sweating
bradycardia/tachycardia
what enhances the effects of opioids?
alcohol
which groups of patients should you be cautious prescribing opioids to?
hypotension
asthma
pregnant or breast feeding
hepatic/renal impairment
dependence
what conditions contraindicate opioid prescription?
acute respiratory depression
acute alcoholism
raised inter cranial pressure/head injury
what is the common side effect of codeine?
constipation
what are some benefits of codeine?
low dependence
effective orally
effective cough suppressant
which codeine combination is found on the dental list?
dihydrocodeine
what are some side effects of dihydrocodeine?
nausea
vomitting
constipation
drowsiness
respiratory depression and hypotension
what are serious drug interactions associated with dihydrocodeine?
antidepressants
dopaminergic
who should you never prescribe an opioid to?
patients with raised inter cranial pressure/suspected head injury
what are the groups to be cautious prescribing dihyrocodeine to?
hypotension
asthma
pregnancy/breastfeeding
renal/hepatic disease
elderly/children
what is the antidote for opioid overdose?
naloxone
when is naloxone indicated?
coma or bradypoenea
what are the signs and symptoms of opioid overdose?
coma
respiratory depression
pinpoint pupils
give examples of unrestorable teeth?
gross caries
tooth/root fracture
severe tooth surface loss
pulpal necrosis
apical infection
what are some indications for tooth extraction?
unrestorable teeth
symptomatic PE teeth
traumatic position
ortho indications
interference with denture construction
where should you stand for lower molar extraction if right handed?
left lower molars - infront
right lower molars - behind
when is the only time right handed stands behind a patient to extract tooth?
lower right molar/premolar
what are the three modes of action for tooth elevation?
wheel and axle (rotation)
lever
wedge
what are the four applications points for an elevator?
buccal - into furcation
medial
distal
superior - upper teeth
inferior - lower teeth
what are the post operative complications of MOS a patient should be warned of?
pain
swelling
bruising
bleeding
infection
Nerva damage risk - permanent, temporary or altered
jaw stiffness
dry socket
why should soft tissues be retracted?
improves access to operative field
protection
what are the general principles of oral surgery?
maximal access, minimal trauma
wide based incision
minimise trauma to dental papillae
no crushing
keep tissues moist
ensure flap margins and sutures will lie on sound bone
make sure wounds are not closed under tension
aseptic technique
why should you use a wide based incision?
circulation
true or false
bigger flaps heal just as quickly as small ones
true
what are the three stages of debridement?
physical - bone file/hand piece to remove sharp edges
irrigation - sterile saline/water into socket and under flap
suction - aspirate under flap to remove debris and check socket for retained apices etc
what are the aims of suturing?
compress BV
reposition tissue and cover bone
prevent wound breakdown
haemostasis
encourage healing by primary intention
what are the two categories of sutures?
resorbable
non-resorbable
give an example of a monofilament resorbable suture
monocryl
give an example of a multifilament resorbable suture
vicryl rapide
give an example of a non-resorbable multifilament and monofilament suture
multi - mersilk
mono - prolene
how is haemostasis achieved during operation?
LA with vasoconstrictor
artery forceps
diathermy
bone wax
how is haemostasis achieved post operation?
pressure
LA with vasoconstrictor
diathemy
sutures
packing agent
what are the stages of surgery?
anaesthesia
access
bone removal and tooth division as necessary
debridement
suture
achieve haemostasis
post op instructions and medication
what will healing by primary intention minimise?
scarring
what instrument can be used to retract soft tissues?
Howarth’s periosteal elevator
why are electrical handpicks used in OS and not air driven?
air driven may lead to surgical emphysema
what should you use to remove bone in OS?
electrical straight hand piece with saline cooled round or fissure tungsten carbide bur
what are the uses of elevators?
provide application point for forceps
loosen teeth
extract teeth
remove root stumps, apices and retained roots
what instruments can you use for debridement?
bone file
hand piece
Mitchell’s trimmer
Victoria curette
when would you use a non-resorbable suture?
if extended retention periods are required
closure of OAF pr exposure of canine
when would you use an absorbable suture?
if removal of suture not desirable and tissue edges just need held together temporarily
compare bacterial colonisation on mono and multi filament sutures
monofilament are single strand and resistant to bacterial colonisation
multifilament allow oral fluids and bacteria to move along length and in-between several filaments and can result in infection
what are the 4 nerves that can be damaged in extraction of lower third molars?
inferior alveolar nerve
lingual nerve
mylohyoid and buccal - less common
what analgesia will you prescribe after third molar extraction?
ibuprofen
paracetamol
cocodamol
what are the complications of lower third molar extractions?
pain
swelling
bruising
bleeding
infection
trismus
paraesthesia/anaesthesia of lip and tongue
what is the aim of peri-radicular surgery?
establish root seal at apex of tooth/point of perforation
remove existing infection
what is the review schedule for periradicular surgery?
review at one week
post of radiographs 1-6 weeks
further review 3-6 months
what are the top reasons periraduicular surgery fails?
inadequate seal e.g. too little apex removed
inadequate support e.g. perio pockets
split roots
soft tissue defect over apex post-op
how much of the apex should be removed in periradicular surgery?
3mm
list 10 peri-operative extraction complications
difficult access
abnormal resistance
fracture of tooth/root
alveolar bone fracture
jaw fracture
maxillary sinus involvement
fracture of tuberosity
soft tissue damage
nerve damage
haemorrhage
adjacent teeth damage
wrong tooth
what might cause difficult access?
trismus
reduced aperture of mouth - congenital/syndrome
crowder/malpositioned teeth
what causes abnormal resistance during extraction?
thick cortical bone
shape/form of roots - hooked/divergent
number of roots
ankylosis
hypercementosis
what are risk factors of tooth/root fracture during extraction?
caries
alignment
size
root morphology
which teeth usually are involved in fracture of alveolar bone?
usually buccal plate and canines or molars
how do you manage a tuberosity fracture?
reduce wound and stabilise
remove or treat pulp, ensure occlusion free
antibiotics and antibiotics
remove tooth 8 weeks later
what are the causes of tuberosity fracture?
single standing molar
extracting wrong order
inadequate alveolar support
how do you diagnose an alveolar fracture?
noise
movement noted visibly or with supporting fingers
more than one tooth moving
tear on plate
how do you confirm root proximity to sinus?
radiograph
OPT periodical or occlusal
how do you manage maxillary sinus involvement?
inform patient
if small or sinus intact encourage clot, suture and prescribe antibiotic and post op instructions
if large close with buccal advancement flap
antibiotics and nose blowing instructions
what are the risk factors for involvement of the maxillary sinus?
extraction of upper molars and pre molars
close relationship of roots on radiograph
last standing molars
large bulbous roots
older pt
previous OAC
recurrent sinusitis
what are the complications of involvement of maxillary sinus?
OAC/OAF
loss of root into antrum
fractured tuberosity
how do you diagnose a maxillary sinus involvement?
size of tooth
radiographic position
bone at trifurcation of roots
bubbling of blood
nose holding test
direct vision
good light and suction
blunt probe
which jaw is more commonly fractured?
mandible
how do you manage a jaw fracture during extraction?
inform patient
post op radiograph
refer
ensure analgesia
stabilise
antibiotic if delay
what do you do when you lose a tooth during extraction?
stop
locate
suction and radiograph
how do you avoid soft tissue damage?
pay attention
correct placement of correct instrument
application point
controlled pressure
sufficient not excessive force
define neurapraxia
contusion of nerve/continuity of epieneural sheath - axons maintained
define axonotmesis
continuity of axons disrupted - epieneural sheath maintained
define neurotmesis
complete loss of nerve continuity/nerve transected
what are the different ways a nerve can be injured?
crushing
transection
damage from LA or surgery
cutting/shredding injuries
what will paraesthesia feel like
tingling
what will anaesthesia feel like
numbness
what will dysaesthesia feel like
unpleasant sensation/pain
define hypoaesthesia
reduced sensation
define hyperaesthesia
increased/heightened sensation
you have damaged a vessel during surgery nd blood is spurting/haemorrhaging, what vessel have you cut?
artery
during surgery you cut a vessel and there is a lot of bleeding flowing steadily what vessel have you cut?
vein
a spurting pulsating bleed is associated with which vessel?
arteriole
what causes haemorrhage during extraction?
local factors - mucoperiosteal tears or fractures of alveolar bone
undiagnosed clotting abnormality - willebrands
liver disease
medication - warfarin/antiplatelets
how to you manage soft tissue haemorrhage?
pressure - bite on damp gauze
sutures
LA with adrenaline
diathermy
ligatures on larger vessels
how do you manage haemorrhage in bone?
pressure via swab
LA on swab or injected into socket
haemostat agents
bone wax
pack
how do you manage TMJ dislocation?
relocate immediately - down and fwd
if unable to relocate - LA into masseter intraorally
refer if unable still
how do you manage damage to adjacent teeth during extraction?
temporary dressing/restoration
arrange definitive restoration
warn pt of risk
what do you do when an instrument breaks during OS?
radiograph and retrieve
if unable refer
how do you avoid removing wrong tooth?
concentrate
check clinical situation against notes/radiographs
safety checks
count teeth
verify with someone else
5 post extraction complications
pain/swelling
trismus
haemorrhage
dry socket
prolonged nerve damage
what is ecchymosis
bruising
what is most common complication of extraction
pain - warn and advise analgesia
how to limit post extraction pain
gentle handling of tissues
don’t leave exposed bone
complete tooth extraction
what may increase bruising and swelling
poor surgical technique
rough handling of tissues
what is truisms
inability to open mouth fully/jaw stiffness
what causes truisms - 4
surgery - oedema
giving LA - medial pterygoid
damage to TMJ
haematoma - MP or masseter
treatment for trismus
monitor
gentle mouth opening exercises - trismus screw
procedures with high risk bleeding complications
complex extraction
extraction of more than 3 teeth
flap raising procedures
biopsy
gingival re-contouring
everything else is low risk or unlikely risk
what causes immediate post op bleeding within 48hrs
LA wears off and vasoconstrictor
sutures loose
pt traumatises area with tongue or food
reactionary bleeding
what causes secondary bleeding and how long after extraction
usually infection - 3-7 days
treatment of soft tissue post op bleeding
pressure - damp gauze
suture
LA with adrenaline
diathermy
treatment of bone post op haemorrhage
pressure
LA on swab with vasoconstrictor
bone wax
pack and suture
3 haemostatic agents
adrenaline in LA
oxidised regenerated cellulose
thrombin liquid and powder
where to take caution using oxidised regenerated cellulose and why
lower 8s - acidic can damage IAN
3 systemic haemostatic aids
vitamin K
tranexamic acid
missing clotting factors
which suture is suitable when managing bleeding
interrupted or horizontal mattress
where to refer if can’t stop bleeding
weekdays - maxillofacial or dental hospital
weekends and evening - maxillofacial on call or A and E
how can you prevent intra operative and post operative extraction haemorrhage - 4
thorough medical history
atraumatic extraction technique
check good haemostasis at end if surgery
good post op instruction
post extraction instructions - 5
don’t rinse for several hours - avoid vigorous
avoid trauma - hard foods or touching with tongue
avoid hot food
avoid excessive exercise and alcohol
bleeding control info
why do you avoid exercise and alcohol after OS
increases blood pressure and decreases clot quality
after how many months is there little chance that nerve damage will improve
18
what are the three types of sensory change after nerve damage
anaesthesia
paraesthesia
dysaesthesia
what is hypoaesthesia
reduced sensation
what is hyperaesthesia
increased sensation
what percentage of all extraction is affected by dry socket
2-3%
what percentage of lower 8 is affected by dry socket
20-35%
signs and symptoms of dry socket
normal clot gone - empty socket - bare bone
intense pain - kept up at night, throbs, dull ache
sensitive
bad smell
bad taste
3-4 days after extraction
predisposing factors of dry socket - 5
molars
female
mandible
smoker - low blood supply
oral contraception
management of dry socket
reassure
systemic analgesia
LA
irrigate with warm saline
curettage and debridement
antiseptic pack alvogyl
2 things that delay healing
infection
sequestrum
what is sequestrum
bits of dead bone
tooth or amalgam fragments
how to diagnose OAC
radiographic position of roots in relation to antrum
bone at trifurcation on roots
bubbling of blood
direct vision
why cautious for nose holding test or blunt probe test when assessing for OAC
can create OAF
management of small OAC
encourage clot
suture
post op instruction
management if large OAC
buccal advancement flap
bone graft
antibiotics
nose blowing instruction
what is osteomyelitis
inflammation of bone marrow
implies bone infection
describe spread of osteomyelitis
bacteria in cancellous bone
inflammation and oedema
compromises blood supply and leads to tissue necrosis
will spread until arrested by antibiotics or surgery
why is osteomyelitis less common in maxilla
rich blood supply - several arteries
why is osteomyelitis more common in mandible
IAA is primary blood supply
dense cortical bone limits penetration of periosteal blood vessels
poorer blood supply means more likely to become ischaemic and infected
risk factors of osteomyelitis
odontogenic infection
compromised host defence e.g. diabetes
radiographic radiolucency with moth eaten appearance - diagnosis ?
osteomyelitis
what is an involucrum
increased radio density surrounding radiolucency
bacteria associated with mandibular osteomyelitis
anaerobic bacteria
effect of radiotherapy on bone
bone becomes non-vital
turnover is slow
self repair ineffective
reduced blood supply
why is mandible more affected by ORN
poor blood supply
prevention of ORN
chlorhexadine mouthwash
antibiotics
what are bisphosphonates used to treat
osteoporosis
pagets disease
malignant bone metastases
example of bisphosphonate
end in onate
alendronate
drugs involved in MRONJ
antiresorptive
antiangiogenic
when can MRONJ occur
post extraction
following denture trauma
spontaneous
increased dose and increased duration of bisphosphonates increases the risk of what
MRONJ
using anti resorptive drugs concurrently with which 2 drugs increases MRONJ risk
steroids
or
antiangiogenic drugs
treatment of MRONJ
manage symptoms - remove sharp bone
chlorhexadine mouthwash
what is actinomyetosis
rare bacterial infection caused by actinomycetes israelii (there’s more)
signs of actinomycosis
skin sinuses and swelling
lumpy pus
actinomycosis treatment
high dose antibiotics
antibiotic prophylaxis dose and time
amoxicillin 3g 60mins before procedure
basic principles of surgery
risk assess
aseptic technique
radiological assessment
minimal trauma to hard and soft tissues
what kind of flap is used in OS in regards to what tissues are lifted
mucoperiosteal flap - lift mucosa and periosteum
3 principles of lifting flap
maximal access minimal trauma
preserve adjacent soft tissues and papillae
wide base incision for circulation and perfusion
what is a mucocele
blocked minor salivary gland - saliva build up
what hand piece is used for bone removal and why
electric straight handpiece with saline or sterile water cooled bur
air driven - surgical emphysema
why are air driven handpicks not used in surgery
surgical emphysema risk - air between soft tissues and bone and can cause sepsis
