Oral surgery Flashcards
What are the nerves that innervate maxillary aspects?
- Trigeminal nerve (maxillary)
- Superior alveolar nerve
- Greater palatine nerve
- Lesser palatine nerve
- Nasopalatine nerve
What are the mandibular nerves?
- Trigeminal nerve (mandibular)
- Inferior alveolar nerve
- Mental nerve
- Lingual nerve
- Long buccal nerve
What LA contains no adrenaline?
Prilocaine
- Contraindicated 3rd trimester of pregnancy
What considerations would you have treating a patient with heart conditions?
Angina, ischaemic heart disease
o GA risk
Congenital heart disease
o Infective endocarditis
Heart failure patients
o Orthopnoea – needs to be sitting up
What to do if patient has asthma?
- Salbutamol
- Give them their pump
- Avoid if severe asthma
When would you avoid giving NSAIDs
- severe Asthmatic
- Warfarin/ bleeding risks (NOAC)
- Peptic stomach ulcers
- Pregnant
What are NSAIDs?
- Non Steroidal anti inflammatory drugs
- inhibit Cox-1/2
- diclofenac/ aspirin/ ibuprofen
What does oedema mean?
- Swelling due to fluid build up
What do you need for consent to be valid
- voluntary
- Informed
- Capacity
Why is LA less effective in infected areas?
- Lower pH
- More vascularity
Problems that can be caused when injecting LA
Haematoma
o Laceration of vein causing swelling
o Reassure if happens
Intravascular injection
o Aspirate
o Tachycardia, temp blindness
Trismus
o Intramuscular injection
o Vascular bleed
Facial paralysis
o Into parotid gland
o Eye dropping
What things would indicate high risk of OAC?
- Close to the anatomical floor
- Lone standing molar
What to do if fractured tuberosity?
- Leave in situ
- Splint the tooth and bone
- Re-attempt a surgical in 6-8 weeks
What is dry socket and incidence
- Otherwise known as alveolar osteitis
- Post extraction pain 3% incidence 20% incidence surgically extracted
- Localised pain 2-3day after
- Blood clot isn’t maintained.
What are pre-disposing factors of dry socket?
- Poor OHI
- Extraction trauma
- Smoking
- Site – more common in the mandible
- Systemic – oral contraceptive use
How would you manage dry socket
- Reassure
- Irrigate with saline/chlorhexidine
- Dress socket with Alvogyl
- Enforce ohi
- Analgesics
Aims of raising a flap
- Gain access
- Maintain blood supply
- Avoid gingival scaring
- Avoid nerves
Types of flaps?
- Envelope flap
- 2 sided flap
- 3 sided flap
Intra oral suturing types
- Single interrupted suture
- Simple continuous suture
- Vertical mattress suture
- Horizontal mattress suture
What are the suture material types?
- Absorbable vs Non-absorbable
- Braided vs monofilament
- Vicryl or vicryl rapide is braided
What should you consider when giving paracetamol
- May use with NSAID due to anti-inflammatory
- Cautious with liver disease patients
What adverse effects of NSAIDs
- Cardiovascular patients, asthmatics
- history of GI bleed/ ulceration Avoided of inflammatory bowel disease
- Gastrointestinal bleeds (overcome by selective cox-2 nsaids)
What is the analgesic ladder?
- Weak opoids such as codeine
- Strong opoids such as morphine
What are side effects of opioids?
- Constiapation
- Tolerance
- Physical dependence
- Nausea and vomiting
- Respiratory depression
What is the ASA classification
- Asa 1 – healthy
- Asa 2 – mild systemic disease
- Asa 3 – severe systemic disease
- Asa 4 – severe systemic disease where there is a constant threat to life
- Asa 5 – patient that is going to die without operation
What is conscious sedation
- Drug that produces a state of depression
- Patient is in verbal contact
- Can protect themselves
What is the problem of patient taking recreational drugs for sedation
- Adverse reaction and unpredictable
- Anxious and aggressive
- 72hours before must stop
Contraindications for IVS
- Allergy to benzodiazepines
- Poor venous access
- Co-morbidities
- Pregnancy
- Impaired liver or kidney
- High bmi
- Respiratory disease
What drugs used in IVS
- Midazolam
- Flumazenil – reversal agent
Indications for GA
- Extensive procedure – over 40 mins ish
- Very anxious patient
- Uncooperative patient
Contraindications for GA
- High bmi (over 30)
- Significant comorbidities
- Allergies to the drug
Definition of general anaesthesia
- State of controlled unconsciousness
- Patient feels nothing.
What are common side effects of GA
- Nausea, sore throat, fainting, memory loss
Categories of bleeding disorders
- Vascular disorders – changes in capillaries
- Thrombocytic disorders – decreased platelet, changes in the function of platelets
- Disorders of coagulation – deficiency of certain coagulation factors (haemophilia A&B)
What is thrombocytopenia?
- Concentration of platelets are abnormally low (below 50x10^9)
- Reasons can be:
o Bone marrow doesn’t produce enough
o Platelets are trapped in an enlarged spleen
o Increased destruction of platelets
o Increased use of platelets
What is Von Willebrand disease
- Congenital bleeding disorder
- vWF protein stabilises factor 8
what is haemophilia
- type A Is defficiency of factor 8
- type B is deficiency of factor 9
what is tranexamic acid
- prevents fibrin clot lysis
- way of managing bleeding
local measures to control bleeding
- local pressure with gauze
- Suture
- Haemostatic agent (oxide cellulose – surgical)
- Local anaesthetic with adrenaline
What is MRONJ
- Medication related osteonecrosis of the jaw
- Bisphosphates and denosumab (RANKL inhibitor)
Risk factors for MRONJ
- Duration of prescription: Oral BP over 3/4 years
- Procedure that exposes bone
- Mandible > Maxilla
- Poor OH
- SDCEP Guidelines
What are the stages of MRONJ
- Stage 0 – non specific clinical findings, radiographic changes
- Stage 1 – exposed and necrotic bone, but asymptomatic
- Stage 2 – exposed bone with infection
- Stage 3 – exposed bone and infection with another issue
Who are low risk of MRONJ
- Medication for less than 4 years
Who are high risk of MRONJ
- Long term medication user
- Previous diagnosis of MRONJ
- Conditions affect the bone
- Systemic corticosteroid/ immunosuppressed
- SDCEP guidelines
Management of MRONJ patient
- Prevention advice
- Check with their GDP
- Avoid traumatic extraction and 8 week follow up appointment
What are the paranasal sinus
- Frontal sinus
- Ethmoidal cells
- Sphenoidal cells
- Maxillary sinus
What are the functions of the sinus
- Moisten the air
- Warms air
- Lighten skull
- Resonance
- Immunological for upper respiratory tract
What is the definition of OAC
- Communication between mouth and sinus
- Higher incidence in males, 3-4th decade
Pre-disposing factors of OAC
- Relationship of tooth to antrum
- Submerged teeth
- Large antrum
- Lone standing tooth
- Increasing Age
- Hypercementosis
- Loss of bone
- Excessive force
OAC clinical diagnosis
- Hollow sound with sucker
- Bubbling bleeding
- Air entry into mouth holding nose (not recommended)
- Bone/antral lining on the roots when extracting
- Radiograph shows a defect in antral floor
Treatment of OAC
- Prevention better
- Treat before infection from mouth gets into
antrum - Treatment depends on size
o Small: suture
o Large: buccal advancement flap, palatal rotational flap - Can place acrylic plate.
- Antral regime
What not to do as part of the antral regime
- Smoke for 72 hours
- Blow your nose forcefully, ( don’t hold sneeze)
- Don’t use straws or whistle or blow balloons, percussion instruments
- Go flying for next 4-6 weeks
What do you do as part of antral regime?
- Antrum should be clean (antibiotics look at FGDP antibiotic prescribing not recommended)
- Use nasal decongestants – reduce degree of swelling of nasal lining and reduces risk of sneezing
o Beware of rebound congestion (after 7-10 days of decongestant use) - Use steam inhalation (olbas oil)
- Chlorhexidine mouthwash to reduce oral bacterial load.
When to use immediate or delayed closure?
- Size of defect
o Larger defects – ideal to close at time to stop sinus contamination and nasal regurgitation - Experience level
- Will it heal spontaneously?
- Quality of tissues – inflamed then delay.
How to do surgical closure
- Incision around the fistula and excise
- Incision of the buccal mucosa to create 3 sided flap
- Subperiosteal release to allow flap to advance over the hole
- Use of Vicryl suture
- Or palatal rotational flap
o Dressing the palate (Coe pak on dressing plate)
What is oral-antral fistulae (OAF)
- OAC that has epithelialized
- Not present immediately after extraction
What are the signs and symptoms of OAF
- Regurgitation of fluids/food into the nose
- Nose bleed
- Chronic sinusitis
- Antral mucosa prolapse into the mouth
- Fluid in sinus shown on the radiograph
What increases risk of fracture of tuberosity?
- Lone standing molar
- Hypercementosis
- Bulbous roots
- Splayed roots
- Large antrum
- Excessive force
What to do on fractured tuberosity management
- Small
o Raise a flap
o Dissect fractured bone
o Close previous OAC
o Antral regime - Large
o Leave and allow to heal for 8 weeks
o Splint
What to do when displaced roots
- Prevention is key
- Attempt to remove with suction first
- 2 radiographs to parallax where they are
- GA for removal (Caldwell Luc procedure)
- Placed on an antral regime
What is acute sinusitis
- Decreased drainage and increased infection
- Pre-disposing factors
o Poor drainage
o Deviated septum
What are the signs of sinusitis?
- Nagging pain over mid face
- Pyrexia, tenderness
- Mucopurulent discharge
- Facial swelling, cheek oedema
- Teeth TTP but vital
- Radiographic opacity
Acute sinusitis treatment?
- Bed rest and antibiotics
- Nasal decongestants and inhalations
- Surgical
o Antral washouts for antrum
What is the complication of acute sinusitis
- Spread to other sinuses
- Laryngitis
- Chronic recurrence
What symptoms chronic sinusitis
- Mucopurulent discharge
- Thickened antral mucosa
- Nasal obstruction
- Opacity on the radiograph
- Treatment same as acute
What other conditions affect sinus
- Atypical facial pain
- Myofascial pain
- Dental pain
What is indications of extractionof 8s
- Unrestorable caries/ causing caries in the 7
- Pulpal/periapical pathology
- Cellulitis, abcess
- Resorbtion of tooth or adjacent tooth
- Pericoronitis
What is Pericoronitis
- Soft tissue inflammation related to the crown of partially erupted tooth
- Streptococci and anaerobic bacteria present
What is the incidence of pericoronitis?
- 70% of partially erupted third molar
- Stress and immunocompromised patient will get more
What is acute pericoronitis diagnosis?
- localised Pain and swelling
- Radiation of pain
- Severe cases: trismus and facial swelling
- Lymphadenopathy
- Swollen operculum
What is chronic pericoronitis
- Pus exuding beneath operculum
- Radiographic signs of enlargement of the pericoronal space
What is the management of pericoronitis
- Irrigate the operculum
- Chlorhexidine mw
- Ohi and single tuft brush
- Grind the opposing third molar / extract
- Antibiotic if systemic
o Temp and unwell
o Difficulty swallowing
o Fgdp guidelines
o 1st line metronidazole 400mg Tds 5 days
o 2nd line amoxicillin 500mg tds 5 days - Extract if one severe or multiple episodes (NICE guidelines)
- Remove operculum?
How to tell issues with IDN nerve in the radiographic
- Diversion of the canal
- Darkening of the root (banding)
- Interruption of the white tram line
What’s the radiation dose of a CBCT compared to OPT
- 10x more radiation
What are the indications for CBCT?
- Third molar surgery and decision for corenectomy cant be made from the original x ray
What is Coronectomy
- Removal of the crown
- High risk of id nerve damage
- Infection and caries are contra-indications
- No enamel to be left in situ
- If roots mobilised proceed to removal
What is the incidence of permanent damage
- 0.2% tongue
- 0.5% lip and chin
What are the characteristics of benign lesions
- Excessive accumulation of cells
- Do not invade surrounding tissues
- Does not metastasize
What are the indication of removal of benign cyst
- Pain
- Function
- Aesthetics
- Continual growth
- Pressure on adjacent structures
- Damage to adjacenet structures including roots
- Infection
What are the surgical methods of removing cyst
- Excisions
- Curettage
- Enucleation
- Marsupialisation
What is a cyst of the jaw?
- Closed ‘sac like’ pocket of tissue
- May be filled with fluid, air, pus or other material
- Usually benign
- Expand via osmotic tension
What’s the classification of cysts
- Odontogenic vs non-odontogenic
- Odontogenic
o Developmental
o Inflammatory
o Neoplastic - Non-odontogenic
o Developmental
o No epithelial lining
What is the management of cysts of the jaw
- Enucleation – surgically remove intact from surrounding capsule
- Curettage – scrapping
- Marsupialisation
What is enucleation
- Removal of the lesion with the lining
- Complete healing of cyst and healing
- Complete lining available for histopathology
- Disadvantages
o Clot can become infected
o Incomplete removal
o Damage of structures
What is marsupialisation
- Decompression of the cyst by creating a surgical window
- Relieves intracystic pressure
- Needs to be kept clean
- Less damage to structures compared to enucleation
- Disadvantages
o Pateient needs to keep area clean
o Whole lining not available
o Several visits
o Bony infil may not occur
What are the advantages and disadvantages of using laser
- Advantages
o Dry surgical field
o Reduction in blood loss - Disadvantages
o Cost
o No pathology sample
What are the advantages and disadvantages of cryotherapy
- Advantages
o No cutting involved
o Tissue intact at the end so no bleeding - Disadvantage
o No pathology specimen
o Cost of equipment
o Ulceration post op
What is leukaemia?
- Blood cancer
- Patients may be anaemic, hepatitis B or C or HIV
- Dental treatment should be postponed
- Infections should be treated aggressively
- NSAIDs should be avoided
What is lymphoma
- Hodgkin’s and non-Hodgkin’s lymphomas present as enlarged cervical lymph nodes
- Management similar as leukaemia
What does haemostasis consist of
- Vessel constriction
- Platelet plug formation
- Coagulation cascade
Should bleeding disorder patient have a local anaesthetic block?
? I think it should be avoided
What is anticoagulant therapy used for and warfarin MOA
- Prevention of venous thrombosis in heart disease patient
- Stroke prophylaxis
- Warfarin: inhibits vitamin K dependent synthesis
- Measured in prolonged prothrombin time (PT) and activated partial thromboplastin time (APTT)
- INR is also looked at: 1 is normal and patients taking anticoagulants usually in the range 2-4
- INR should be measured within 24 hours of surgery
- Local haemostatic measures necessary
- Medical emergency in hospital is slow vitamin K drip or fresh frozen plasma
- Contraindications
o Metronidazole interacts with warfarin (erythromycin instead)
o Amoxycillin interferes less with warfarin
o Aspirin and other NSAID (lesser extent) should be avoided
o Warfarin not usually effected by paracetamol
Name a NOAC which is a Factor Xa inhibitor
- Rivaroxaban
o 1 daily, rapid onset - Apixaban
o 2 daily, rapid onset - Edoxaban
Name a NOAC which is a direct thrombin (factor IIa) inhibitor
- Dabigatran
- 2 times a day, rapid onset
What is the procedure for NOACs in OS
- Low risk of bleeding
o Continue medication as normal - High risk of Bleeding
o Miss (apixaban, dabigatran)
o Delay rivoroxaban - Appointment early in the week and day
- Heamostatic measures
o Oxidised cellulose mesh and suture
Name some antiplatelet mediations
- Aspirin
- Clopidogrel
- Dipyridamole
What is the management of patients on antiplatelet medication
- Max of three extraction
- Haemostatic measures
- Aspirin + clopidogrel taker should be referred
- platelets have a long half life (1 week)
What are the issues with patients with hepatic disease
- Clotting problems
- Drug metabolism impairment
What is reactive haemorrhage?
- After effects of LA
- Several hours later
- Not very common
What is secondary haemorrhage
- Caused by secondary infection of clot
- Occurs several days later
- Relatively rare
What are the salivary glands?
- Parotid gland
- Submandibular glands
- Sublingual gland
- Minor salivary glands (600-1000)
What is the MRONJ Diagnostic criteria
- Current or previous treatment with anti-resorptive or anti-angiogenic medication
- Exposed bone that can be probed through an intra-oral/extra-oral fistula that last more than 8 weeks
- No history of radiotherapy
- No obvious metastatic disease of the jaw
Name some drugs cause MRONJ
- Bisphospanates (anti-resorptive)
- Zoledronate
- Denosumab (RANKL)
- Sunitinib
What are bisphosphonates and how they work
- Inhibit resorption of the bone
o Osteoclastic apoptosis - High affinity for bone
- Long half life
- Alendronic acid
What can you tell about Denosumab
- RANKL inhibitor
- Osteoclast function stopped
- Does not bind to bone
- Effects diminished after 6 months
What are anti-angiogenic drugs
- Interfere with formation of new blood vessels
- Treat cancers
- Bevacizumab
Whats good to do pre anti-resporptive/angiongenesis drugs
- Extract poor prognosis teeth
- Good OHI
- Smoking cessation
- Fix dentition
How would you treat MRONJ
- Pain management
- Antibacterial mouthwash (secondary infection)
- Potential debridement
What are factors that affect socket healing
- Local
o Inflammation
o Foreign bodies
o Radiation exposure - Systemic
o Medications
o Diabetes
o Smoking
o Deit/nutrition
What is osteomyelitis
- Inflammation of the bone cortex
- Usually as a result of spread of infection
- Management
o Pus sample/swab
o Radiograph, CT - Chronic osteomyelitis
o AB bead treatment
What is osteoradionecrosis?
- Defined as non-healing region of devitalised bone in radiated field, persists for over 3 months
- 3 stages
o 1 is confined to the alveolar bone
o 2 is alveolar bone and mandible above the mandibular canal
o 3 under the level of the mandibular canal with pathological fracture or skin fistula - Treatment
o Prophylactic extraction
o Dietary change and fluoride advice - antibiotics: tacpherol, pentoxifylin
- hyperbaric oxygen therapy
Where can an alveolar abscess originate from?
- Periapical periodontitis
- Pericoronitis
- Periodontal disease (periodontal abscess)
What is an operculectomy
- Surgical excision
- May regrow or damage lingual nerve
What are contra-indications of a Coronectomy
- Carious tooth
- Apical pathology
- Mobile tooth
- Medical history and risk of infection, IE
