Oral Surgery Flashcards
1
Q
Classification of timings for extraction complications
A
Immediate intraoperative - within couple of hours following
Immediate/postoperative - within the later hours and days following extraction
Long term post operative - weeks and months after extraction
2
Q
What are peri-operative complications?
A
Complications during the surgery and immediately after
3
Q
For extraction good access and vision are required. Name 5 possible obstacles to this
A
Trismus
Jaw joint problems
Reduced aperture of mouth due to syndromes
Scarring or burns inside the mouth
Malpositioned/crowded teeth
4
Q
What is trismus?
A
Limited mouth opening due to spasm of muscles of mastication
5
Q
With incorrect extraction technique what is the risk to the adjacent teeth?
A
Mobilising these too
6
Q
If there is an abnormal amount of resistance to extraction what should be done?
A
Stop
Remove tooth surgically otherwise you could fracture the maxillary tuberosity, alveolar bone etc
7
Q
Examples of abnormal resistance
A
Thick cortical bone - often big guys
Shape/form of roots - divergent or hooked
Extra roots - lower molars with 3 roots
Hypercementosis - extra cementum around roots
Ankylosis - bone is fused to root of teeth
8
Q
Which structures could be fractured during extraction?
A
Tooth
Alveolus/maxillary tuberosity
Jaw - very rare
9
Q
Within the tooth itself what could fracture?
A
Crown or root
10
Q
What features increase a tooths chance of fracturing?
A
Carious
Misaligned - hard to get forceps below the crown
Size - small crown
Root - big or hooked root
11
Q
What instruments are used to loosen teeth?
A
Luxators and elevators
12
Q
Where should forceps be placed?
A
Just below the crown
13
Q
If forceps are placed incorrectly, what may happen during buccal expansion?
A
Crown may fracture off
14
Q
Why might the alveolar bone break off?
A
Tooth hasn’t been loosened enough with luxators and elevators enough before placing buccal force
15
Q
Once we have extracted a tooth, do not __ the socket
A
Squeeze - reduces bone volume which is bad if implants are wanted
16
Q
Where do alveolar fractures usually occur?
A
Buccal plate
Canines and molars where bone is thicker
17
Q
What alveolar bone fractures, what do you look for on the piece of bone?
A
Is there a bit of periosteum still attached to the bone? If it is a big bit of bone with periosteum then it still has a blood supply so you can push it back into place, suture up around it and check if it will stay in place - it should heal
18
Q
If the alveolar bone fractures and a small bit of bone or a bit of bone without periosteal attachment breaks off, why shouldn’t you put it back?
A
It will become a dead bit of bone which will cause pain until it works its way out of the socket
19
Q
It is most important to preserve bone for shape in the ____ area
A
Canine
20
Q
If the alveolar bone does break what must you do to the remaining bone in the mouth?
A
Get a bone file and file otherwise jagged ends will push through the gingivae and interfere with the wound.
Don’t run you finger on the jagged bone
21
Q
In the maxilla, the biggest fracture that can occur is usually a chunk of the alveolus, what is there risk of in the mandible?
A
Fracturing the mandible
22
Q
What is often the reason as to why the mandible fractures when a tooth is extracted?
A
Impacted wisdom teeth
Larger cyst - weakens the mandible
Atrophic mandible - weak mandible
23
Q
What test to take before mandibular extraction?
A
Radiographs to assess the thickness of the mandible
It is important to support the mandible, may want to ask a nurse to support the jaw if it requires too much pressure. Sometimes stop and surgically extract
24
Q
What to do in case of mandible fracture?
A
Tell patient
Call maxfax unit
Post op radiographs
Give analgesia
If delay give antibiotics
Talk to them about keeping it clean
If bones are rubbing together, orthodontic wire rope it around teeth to stabilise fracture
Tell patients not to eat on the way to the unit
25
When the maxillary sinus is involved what is it called immediately, and what is it called after a while?
Oro antral communication - acute
Oro antral fistula - when epithelium of oral cavity become continuous with the sinus - chronic
26
What usually gets pushed into maxillary sinus in these communications?
Root of a tooth
27
A fractured maxillary tuberosity often involves a..
Oro-antral communication
28
Oro antral communication is diagnosed by
Looking at ___ of the tooth
Can take ___ to look at position of the roots to the antrum
When removed, look at roots for ___
While patients moving look for ___ of blood
What set nose holding test
Size
Radiographs
Any additional bone that has been removed
Bubbling
Hold nose and blow to see if air can escape but don't blow too hard as cam tear membrane, creating an OAC
29
When viewing an area we want.. (3)
Direct vision
Good light
Good suction
30
What may we hear with section indication an OAC?
Echo
31
What instrument is used to explore areas?
Blunt probe
32
Often we can't see an OAC, what lies under?
Mucosa often covers a larger hole in the bone
Hard to find but if mucosa is removed it is larger than expected
33
If small OAC or sinus intact what should be done?
Encourage clot
Suture margins
Antibiotics - because saliva and food will be going in
Post op instructions
34
If large OAC or torn lining what should be done?
Close with buccal advancement flap - may not be able to have tension free flaps
This may work but may breakdown
Antibiotics
Nose blowing instruction - steam inhalation
35
What is a buccal advancement flap?
Where we raise a buccal flap cut periosteum for elasticity, pull it over the OAC and suture it shut
36
If chronic OAF what to remove before pulling over buccal advancement flap?
Epithelial lining around the circumference of OAF
If we don't, communication will reform after
37
If looking for a root in the antrum what do we need?
Take a radiograph
Good lighting and vision
Do not blindly probe as could make it worse
38
How to remove a root from the maxillary sinus?
Open a window with care
May need to make it bigger using bone nibblers or using an electrical bur
Can use small curettes to see if you can grab it and pull it forward
Irrigate with saline
Can use ribbon gauze - stuff into the hole and leave a tail, pull it out and root comes with
Antibiotics and close with a buccal flap
39
When is a fractured tuberosity more likely?
When there's a single posterior tooth in the quadrant - put finger and thumb on either side of the alveolus
40
If fractured tuberosity, how to manage?
If its small, dissect it out and close the wound
If bone is bigger that hole in gum you'll tear the tissue, use a scalpel and dissect the bone
If the bone is still living put it back - reduce and stabilise
41
What instruments do we use in tuberosity fracture to place the tooth back in its original position?
Forceps or finger
42
When fixating or stabilising what are the steps?
Splint
Arch bar
Orthodontic wire arch with composite
43
How to make wire more rigid for fixations?
Include more teeth in the splint
44
How long to leave splint on in rigid fixation?
8 weeks
45
What must be considered when fixating?
Remove or teat pulp
Must be occlusion free
Antibiotics
Post op instructions
46
Sometimes once we have removed tooth, the pt will move and we lose it, what to do in this case?
Stop
Suction
Radigraph
47
If you lose a tooth, where could it be?
Under tongue
In buccal area
In maxillary sinus
Swallow - in lung or oesophagus
48
What kinds of damage can be caused to nerves during surgery?
Crushing injuries by leaning on nerve
Cutting/shredding
Transection
Damage with LA
49
What is transection of a nerve?
Cut all the way through
50
What order to extract in?
Posterior to anterior
51
Neurapraxia
Contusion of nerve/continuity of epineural sheath and axons maintained
52
Axonotmesis
Continuity of axons but epineural sheath disrupted
53
Neurotmesis
Complete loss of nerve continuity/nerve transected
54
Anaesthesia meaning
Numbness
55
Parasthesia
Tingling
56
Dydaesthesia
Unpleasant sensation
57
Hypoaesthesia
Reduced sensation
58
Hyperaesthesia
Heightened sensation
59
If you cut a vein vs artery vs arteriole what will happen?
Veins - bleed
Arteries, arterioles - spurt/haemorrhage
60
Most bleeds during OS are due to local factors such as what?
Mucoperiosteal tears, fractures of alveolar wall or plate
61
Less commonly, bleeding is due to problems such as __
Clotting abnormalities - haemophilia/von willebrands/liver disease
Medication - warfarin/antiplatelets
62
How to stop bleeding soft tissues?
Pressure
Suture
More LA with vasoconstriction
Diathermy - burn vessels
Ligatures//haemostatic forceps
63
Bleeding can be from the bone, how is this dealt with?
Pressure (via swab)
La on a swab or injected into the socket
Haemostatic agents such as surgicel or Kaltostat - oxidised cellulose for clot to form on
Blunt instrument pressure
Bone wax - not if bone is sharp, seals holes in bone
Pack
64
If TMJ is dislocated in mandibular extraction what is done?
Immediately respond before muscle spasms
Relocate immediately (analgesia and advice on supported yawning) push down and back
If unable to relocate, try local anaesthetic into masseter intraorally and try again
If still unable, immediate referral
65
When relocating the jaw after TMJ dislocation, a second person is required to do what?
Hold head in place - lots of pressure when pushing down and back
66
How could adjacent teeth become damaged during an extraction?
Hit with forceps
Crack/fracture/move with elevators
Crack/fracture/remove rests/crowns/bridges
67
How to deal with damage to an adjacent tooth during an extraction?
Temporary dressing/restoration
Arrange definitive
If large rest next to extraction site, warn patient of the risk
68
In extraction of deciduous teeth, be very mindful of ___
Damaging developing permanent teeth
69
If instrument such as luxator breaks in use, what to do?
Radiograph to see where fragments are
Retrieve
If unable - refer
70
Air rotated bur not used in OS, why?
Traps air in soft tissues
Get surgical emphysema, takes week or 2 to go away
Can get infected
71
3 main principles of OS
Risk __
___ technique
Minimal ____ to hard and soft tissues
Assessment
Aseptic
Trauma
72
What 2 factors must be involved in risk assessment?
Good medical history
Good planning
73
How is consent taken for extractions?
Written consent having completed form, discussed risks of procedure
74
As part of the GDC standards, written consent must be obtained when? (2)
Conscious sedation is involved
GA is involved
75
Surgical safety checklist
Ensure correct patient
Operating on right side
Consider risks or concerns at the end
76
What may you need to raise to achieve access to surgical site?
Mucoperiosteal flap
77
When raising flaps, we want ___ access with ____ trauma
Maximum
Minimum
78
Do bigger or smaller flaps heal faster?
As quick as each other
79
What is the vascular connective tissue between bone and mucosa?
Periosteum
80
When we raise a periosteal flap, what structures do we raise?
Periosteum and mucosa, as one
81
What is something we want to avoid when raising a periosteal flap?
Raising the mucosa but leaving the periosteum attached to the bone
82
When raising a flap we want to make a wide based incision, why?
So we have good circulation and perfusion
We don't want to limit the blood supply as the flap would become necrotic
83
To effectively lift both mucosa and periosteum, how should scalpel be used?
One firm continuous stroke
84
No ___ angles, flap reflection should be down to ___ and done ___
Sharp
Bone
Cleanly
85
If the periosteum is damaged what will this cause the patient?
More bruising
More post-op pain
86
Minimise trauma to interdental ___
Don't ___ any soft tissues
Keep the tissues ___
Papillae
Crush
Moist
87
Ensure that flap margins and sutures lie on ___
Sound bone - to support healing
88
Make sure wounds are not closed under ___
Tension
89
Aim for healing by primary intention why?
To minimise scarring
90
Most common flap used for removing a lower 3rd molar
3 sided
Distal incision
Crevicular incision around the tooth
Mesial incision
91
Why must distal incision not be done too lingually?
Risks damage to lingual nerve
92
Envelope flap
No mesial leaving incision
Distal incision, crevicular around the 8 continues around the 7
93
Instruments used to retract soft tissue and reduce damage to soft tissues
Howarths periosteal elevator
Rake retractor
94
Once periosteal flap is raised, bone removal and tooth division are carried out. What instruments are used for this?
Hand pieces
Saline or sterile water used to cool
95
Air driven handpieces may lead to surgical emphysema. What is this?
Driving gas or air underneath skin or mucosa can lead to problems
May require hospital admission
Do not use air turbine to cut teeth and remove bone
96
Do not use air turbine to divide teeth or remove bone. What is used instead?
Round or fissure tungsten carbide burs
97
How can surgical emphysema present?
Massive swelling to the cheek
Damage to the eye
May require hospital admission
Antibiotic required if infection develops
98
What would a buccal gutter around a lower 8 allow us to do?
Elevate the tooth
Remove the crown
Remove a split root
99
What can be used to elevate the teeth
Couplands
Warwick James
Cryers
100
Why is it important to always support the instrument during elevation?
Prevent instrument split causing damage
101
Any force applied with elevators should be directed away from what?
Any major structures e.g. the mental nerve
102
Uses of elevators (6)
Provide point of application for forceps
Loosen teeth prior to using forceps
Extract tooth
Remove multiple root stumps
Remove retained roots
Remove root apices
103
3 basic mechanisms using elevators
Wheel and axle
Wedge
Lever
104
How is wheel and axial method used to elevate?
Point engages tooth
Rotate wrist
105
How to debride the wound from removal of a tooth?
Physically
With irrigation
With suction
106
What is done in physical bone debridement?
Use bone file or remove sharp fragments
Mitchell's trimmers or Victoria curette to remove soft tissue debris
107
How to irrigate for debridement of a socket?
Squirt sterile saline into socket and under flap
107
How to irrigate for debridement of a socket?
Squirt sterile saline into socket and under flap
108
How to use suction to debride a socket
Aspirate under flap to remove debris
Check socket for retained apices
109
How to prepare to suture
Line up tissues
Compress vessels
110
Aims of suturing
Achieve haemostasis
Prevent wound breakdown
Cover bone
Encourage healing by primary intention
111
What material is used for sutures?
Absorbable and non absorbable
112
When would non absorbable sutures be used?
In scenarios where we want the sutures to last longer for sufficient healing
We then need to book a later appointment to remove them
Such as closing an OAF
113
Absorbable sutures are used when?
If not required for long
If removal at a later date is not possible/desireable
Breakdown via hydrolysis as the polymer absorbs water lasts 1-2 weeks
114
Monofilament vs polyfilament
Monofilament - single strand which easily passes through tissue
Resistant to bacterial colonisation
Polyfilament - several filaments twisted together, easier to handle but more prone to infection
115
Example of absorbable and non absorbable sutures
Absorbable - mersilk
Non absorbable - velosorb
116
Examples of monofilament and polyfilament
Prolene - mono
Velosorb - poly
117
What shape of needle is most commonly used to suture?
3/8 circle
1/2 circle
118
Suture needle cross sections
Triangular
Round
119
Why is reverse cutting used?
With triangular needle, if the blade is at the top you have smooth moving needle with minimal trauma, but can tear tissue when tying suture, so we use reverse cutting where the blade is to the side
120
What part of the needle is the swaged end?
Part attached to suturing material
121
Where to hold suture needle with our tweezers?
1/3rd from swaged end
122
What can be used to achieve haemostasis at time of surgery?
LA with vasoconstrictor
Artery forceps
Pressure
Diathermy
Bone wax
123
Examples of post operative bleeding control
Pressure
LA
Diathermy
Sutures
Surgicel - oxidised cellulose
124
Suggested post-operative analgesics
Ibuprofen
Paracetamol
Cocodamol
125
Which nerves can be damaged during extraction of lower third molars?
Inferior alveolar
Lingual
Mylohyoid
Buccal
126
Which nerve is most at risk during lower 3rd molar extraction?
Lingual
127
Mouthwash to reduce risk of infection
Chlorhexidine
128
Complications of third molar removal
Pain
Swelling
Bleeding
Trismus
Bruising
Infection
Dry socket
Parasthesia
129
Excision of mucocele
Soft tissue procedure to remove the lump or sac of saliva
130
How is excision of mucocele carried out?
Usually on the lips
Lip stretched
LA given
Incision made
Sac removed by blunt dissection
May suture the wound closed
131
Peri radicular surgery
Surgery around the roots of the teeth
Want to establish a root seal at the apex of a tooth or at the point of perforation
132
Once flap is raised, what is done in peri radicular surgery?
Remove some bone if necessary
Access apex of the tooth
Remove about 3mm of the apex
Cut at a right angle to the root
133
How to clean the end of a root?
Ultrasonic
134
Retrograde seal using?
Amalgam
Zinc oxide
MTA
135
Which direction do you suture when closing a wound for peri radicular surgery?
From the papillae upwards
136
How long after surgery with non resorbable sutures do we review?
1 week
137
How long after surgery with non resorbable sutures are radiographs taken?
1-6 weeks
138
Reasons for failure of peri radicular surgery
Inadequate seal
Inadequate support
Split roots
Soft tissue defect over apex
139
Steps of oral surgery order
Consent
Surgical checklist
Access
Bone removal as necessary
Tooth division as necessary
Debridement/wound management
Suture
Achieve haemostasis
Post op instructions
Post op mediation
Follow up
140
What is the section of the BNF specifically for dentists called?
Dental practitioners formulary
141
6 main analgesics used by dentists, which are NSAIDS and which are not?
NSAIDS - aspirin, ibuprofen, diclofenac
Paracetamol, dihydrocodeine, carbamazepine
142
What type of drug is dihydrocodeine?
Opioid
Less strong than morphine
143
What is aspirin prescribed for?
Dental and TMJ pain
144
What properties do NSAIDs have that other analgesics don't?
Anti inflammatory
145
What is most common NSAID currently?
Ibuprofen
146
What effect does aspiring have on CVS diseases?
Anti platelet - decreases platelet aggregation and inhibits thrombus formation
147
Trauma and infection cause phospholipid breakdown producing what?
This is then broken down into what else?
What does the broken down product cause?
Arachidonic
Prostaglandins
Inflammation and pain
148
Prostaglandins do not directly cause pain, how do they do it?
Sensitise tissue to other inflammatory products such a leukotrienes
149
Arachidonic acid turns into prostaglandins with the help of?
COX 1 and 2
150
What do COX inhibitors do?
Reduce inflammation by inhibiting cyclooxygenases 1 and 2, which help the breakdown of arachidonic acid into prostaglandins
151
what is aspirin an inhibitor of?
COX 1 and 2 (more effective inhibitor of COX 1)
152
COX 1 inhibitors reduce platelet ___
Aggregation
153
What does it mean that aspirin is mainly peripherally acting?
Main action is outside of the CNA
154
What is temperature increase during infection caused by?
Interleukin 1
155
What effect do prostaglandins have on blood vessels and what properties of aspirin reduce this effect?
Vasodilation
Increased capillary permeability
Anti-inflammatory
156
Effect of aspirin on basal metabolic rate
Increase
157
Effect of aspirin on blood sugar
Reduce
158
What are the main problems with aspirin?
Side effects
Not suitable for all
159
What is the job of prostaglandins in the stomach?
Inhibit acid secretion
Increase blood flow through gastric mucosa
Help production of protective mucin in cells lining stomach
160
Why must you be careful of the prostaglandin inhibitory effect of aspirin?
Can cause or worsen ulcers, GORD, or can cause blood loss via GIT
161
How does hypersensitivity to aspirin present?
Acute bronchospasm
Minor rashes
162
Effects of aspirin overdose
Hyperventilation
Tinnitus, deafness
Vasodilation and sweating
Metabolic acidosis
Coma
163
How does aspirin cause mucosal burns?
If held in cheeks for a long time, the effect of salicylic acid results in a burn
164
How to prevent aspirin burns
Take with water
165
Groups to take care when prescribing aspirin
Peptic ulcers
Epigastric pain
Bleeding abnormality
Anticoagulants - aspirin enhances
Pregnancy/breast feeding
Patients on steroids - 25% of long term steroid patients with develop an ulcer
Renal/hepatic impairment
Under 16
Asthma
Hypersensitivity to other NSAIDs
Taking other NSAIDs
Elderly
Glucose-6-phosphate dehydrogenase deficiency
166
What is the danger of aspirin with gastric or duodenal ulcer patients?
Perforation - avoid
167
Can pregnant women have aspirin?
Avoid, especially in 3rd trimester, as can impair platelet function
Increases risk of jaundice in baby
Can prolong/delay labour
168
Breastfeeding when taking aspirin is linked to what disease in the child?
Reyes syndrome
Very rare disorder that can cause serious liver and brain damage
169
Where is aspirin metabolised and excreted?
Liver
Kidneys
170
Where are prostaglandins synthesised?
Renal medulla and glomeruli
171
Possible effects of prostaglandin inhibition on kidneys?
Reduced renal blood flow
Sodium retention
Renal failure
172
NSAIDs may cause nephritis and hyperkalaemia. What are these?
Inflamed nephrons
High potassium
173
Why should children avoid aspirin?
Reyes syndrome
Up to 50% mortality
174
G6PD deficiency risk ethnicities
African
Asian
South European
Oceana
175
What is haemolytic anaemia?
Red blood cells are destroyed faster than they can be made
176
What is G6PD deficiency a risk factor for?
Haemolytic anaemia
177
Which groups should be avoided with aspirin altogether?
Under 16
Previous or active ulcers
Haemophiliacs
Hypersensitivity to aspirin or other NSAID
178
Common dosage of aspirin for odontogenic pain for how many days?
2 tablets - 300mg each
4 times a day
5days
179
How much aspirin is given daily for maintaining and preventing CVS disease? How much after an ischaemic event?
75g
150-300mg
180
Compare ibuprofen to aspirin with regards to platelets, gastric mucosa, asthma and children?
Less effects on platelets
Irritant but lower risk
May cause brochospasms
Paediatric suspension available
181
Compare ibuprofen to aspirin with regards to platelets, gastric mucosa, asthma and children?
Less effects on platelets
Irritant but lower risk
May cause bronchospasms
Paediatric suspension available
182
What has long term use of ibuprofen recently been associated with?
Cardiac events
183
Ibuprofen for adult odontogenic pain dose
400mg (1 tablet)
4 times daily 5 days
184
Max ibuprofen dosage in adults
2.4g
185
8 groups of people to be cautious of with aspirin
Previous or active peptic ulceration
The elderly
Pregnancy and lactation
Renal/cardiac/hepatic impairment
History of hypersensitivity to NSAIDs
Asthma
Patients taking other NSAIDs
Patients on long term systemic steroids
186
Ibuprofen side effects
GIT discomfort, bleeding, ulceration
Hypersensitivity reactions - rashes
Headache
Drowsiness
Dizziness
187
Potential drug interactions of ibuprofen
ACE inhibitors
Antibiotics
Anticoagulants
Antidepressants
Beta blocker
Calcium channel blockers
188
Symptoms of ibuprofen OD
Nausea
Vomiting
Tinnitus
189
If more than 400mg/kg ibuprofen is taken what to give?
Activated charcoal
190
Which COX enzyme is predominantly innately responsible for producing prostaglandins?
COX 2
191
What are the effects of selective COX 2 inhibitors?
Less damage to GIT than nonselective NSAIDs
192
Properties of paracetamol
Analgesic
Antipyretic
Little/no anti inflammatory action
No effect on bleeding time
Does not interact with warfarin
Less irritant to GIT
Suitable for children
193
Paracetamol method of action
Indirectly inhibits COX
194
Main site of action for paracetamol compared to NSAIDs
Reduced prostaglandins in pain pathway of the CNS
NDAIDs act mostly peripherally
195
What is the benefit of paracetamol not acting much peripherally?
Very little effect on the GIT
196
Which patients must we be careful with when prescribing paracetamol?
Hepatic impairment
Renal impairment
Alcohol dependence
197
Side effects of paracetamol
Rashes
Blood disorders
Hypotension
Liver damage
198
Paracetamol potentially interacts with
Anticoagulants
Cytotoxins
Lipid relating drugs
199
Paracetamol dosage
500mg
4 times daily
200
Paracetamol OD management
Hospital immediately
201
What can occur in paracetamol overdose?
Severe hypocellular necrosis
Renal tubular necrosis
202
Co-codamol and co-proxamol contain what?
Paracetmol
203
Where do opioid analgesics act?
In the spinal cord
Central regulation of pain in the CNS
204
What does the BNF state about opioids and dental pain?
Relatively ineffective
205
What problems can arise with opioid use?
Dependence
Tolerance
206
Opioid effects on smooth muscle
Constipation can occur
Urinary and bile retention
207
Effect of opioids on the CNS. What do they depress?
Depresses pain centres, respiratory centres, cough centres and vasomotor
208
Effect of opioids on the CNS, what do they stimulate?
Vomiting centre
Salivary centre
Pupillary constriction
209
Side effects of opioids
Vomiting
Drowsiness
Dry mouth
Headache
Palpitations
210
Opioids are enhanced by __
Alcohol
211
Groups to be careful of with opioids?
Hypotension
Hypothyroidism
Asthma
Prostatic hyperplasia
Pregnancy
Hepatic impairment
Renal impairment
Elderly
Dependents
212
Opioids contraindications
Acute respiratory disease
Acute alcoholism
Raised intracranial pressure
213
What is codeine usually prescribed with?
NSAID/paracetamol
214
Common side effect of codeine
Constipation
215
What opioid is in the BNF dental practitioner's formulary?
Dihydrocodeine
216
Dihydrocodeine dose
30mg every 4-6 hours
217
Dihydrocodeine side effects
Vomiting
Nausea
Constipation
Drowsiness
218
Dihydrocodeine interactions
Antidepressants
Dopaminergic
219
Never prescribe dihydrocodeine in __
Increased intracranial pressure
220
What does the BNF state about dihydrocodeine's role in dental pain?
Little value
Not very effective
221
What can opioid OD cause?
Varying degree of coma
Respiratory depression
222
When to prescribe carbamazepine
Neuropathic or functional pain
Trigeminal neuralgia
Post herpetic neuralgia
Functional - TMJ or atypical facial pain
223
Main brand of carbamazepine
Tegretol
224
Drugs for trigeminal neuralgia and which are on dental list
Carbamazepine - dental list
Gabapentin
Phenytoin
225
Clinical features of trigeminal neuralgia
Electric shock type pain
Unilateral
Older age group, females more common
Not able to identify source
226
Carbamazepine dose
200mg
3-4 times daily
227
Carbamazepine side effects
Dizziness
Ataxia
Drowsiness
228
Carbamazepine contraindications
Conduction abnormalities
History of bone marrow depression
Porphyria
History of hypersensitivity
229
Which patients to be cautious of with carbamazepine?
Renal
Hepatic
Cardiac
Glaucoma
Skin reactions
Pregnancy
230
When is post op swelling normal and when to be more concerned?
Immediate swelling that lasts a week is normal
Swelling after a few days is usually infection
231
What increases postop swelling?
Poor surgical technique
Rough handling
Longer procedures
232
What is ecchymosis?
Bruising
233
What can cause more ecchymosis?
Poor technique
Poor placement of instruments and hands
Crushing lips with forceps
234
How long can trismus last?
1-2 weeks
235
Causes of trismus
LA
Damage to TMJ from opening for a long time
Masseter spasm
Bleed into muscle can cause spasm
236
Haemostatic agents
Adrenaline
Surgicel
Gelatine sponge
Thrombin liquid and powder
Fibrin foam
237
What factors in blood aid in clotting?
Vit K
Anti fibrinolytic tranexamic acid
Blood clotting factors
Plasma/whole blood
238
What to do when a child won't close their mouth to put pressure on a socket?
Refer for GA to have pressure applied
239
Nerve damage can be fixed until how long after surgery?
18-24 months
240
Where is dry socket most likely?
Lower posteriors (8)
241
What does dry socket look like?
Bare bone or poor quality clot
242
When does dry socket start and how long to resolve?
Slow healing socket, 3-4 days after, takes 1-2 weeks to resolved
243
What is dry socket and what is this called?
Inflammation of lamina dura
Localised osteitis
244
Symptoms of dry socket
Dull aching
Pain can radiate to ear
Keeps pt awake at night
Bad smell/taste
245
Factors increasing chance of dry socket
Posterior
Lower arch
Smoking
Female
Oral contraceptives
LA
Infection from tooth
Excessive trauma during extraction
Excessive mouth rinsing
Family history
246
How to manage dry socket
Supportive - reassurance, systemic analgesia
LA block
Irrigate with warm saline
Debridement, encourage bleeding, new clot formation
Antiseptic pack - alvogyl
247
Why should radiographs of dry socket be taken?
To check there is not root left
248
What is curettage?
Using small instrument like a curette scrape the socket, clean the bone of any old clot material to encourage new healing to start again - controversial
249
What is BIP pack?
Iodine based antiseptic pack, placed into socket. Suture in and remove after a week
250
What is alvogyl?
LA and antiseptic pack to soothe pain and prevent food packing
251
What is used to irrigate fresh wounds at home?
Salty water
252
Why is chlorhexidine not used on fresh wounds?
Can get into the bloodstream and cause anaphylactic reactions
253
Why not prescribe antibiotics for dry socket?
Not an infection, they are not systemically unwell
254
What is sequestrum?
Bits of dead bone prevent healing - quite common
Could be bit of tooth or restorative material
Makes its way to the surface of gingiva with time
Delays healing
Better to removed as it is painful until it comes out
255
If socket becomes infected, what should be done?
Radiographs to check for bony remains or cysts
Consider antibiotics
256
If OAF patient has runny nose what should they do?
Avoid blowing
Steam the nose for short periods at a time
257
Why is it important to release periosteal tissue when raising a flap?
Makes mucosa elastic so we can cover the hole without tension
258
What is osteomyelitis?
Inflammation of bone marrow
259
Where does osteomyelitis usually begin
Cancellous bone of the mandible
260
Common symptoms of osteomyelitis
Fever
261
What causes osteomyelitis?
Invasion of bacteria into the cancellous bone
262
Osteomyelitis can cause inflammation and oedema in an enclosed space, what can this cause?
Increased tissue pressure
Compromised blood supply
Soft tissue necrosis
Bacteria proliferate as the normal blood defences don't reach the tissues
Spreads until it requires antibiotics or surgical therapy
263
Why is osteomyelitis more common in the mandible?
Maxilla has richer blood supply
Mandible has dense over lying cortical bone limiting penetration of blood
264
Major predisposing factors for osteomyelitis
Odontogenic infection
Mandible fracture
265
Factors compromising host defence against osteomyelitis
Diabetes
Alcoholism
Malnutrition
Leukaemia
Chemotherapy
266
Early myelitis is hard to differentiate from what?
Dry socket or localised infection
267
Radiograph of acute suppurative osteomyelitis vs chronic osteomyelitis
Acute suppurative - usually not detectable
Chronic osteomyelitis - radiolucency, can be patches or mothy, mottles
268
What are areas of radiolucency on radiograph of chronic osteomyelitis?
Islands of dead bone called sequestra
269
What is involucrum?
Areas of increased radio density surrounding areas of radiolucency of chronic osteomyelitis
270
What is the difference between osteomyelitis in mandible vs rest of the body?
Mandible - odontogenic infections e.g. streptococci
Rest of body - staphylococci
271
How to treat osteomyelitis
Antibiotics
Surgical intervention
Get blood tests to see underlying medical causes
272
Which antibiotics for osteomyelitis?
Clindamycin/penicillin
Long course
273
How long to prescribe antibiotics with acute osteomyelitis?
Up to 6 weeks after relief of symptoms
274
How to treat severe acute osteomyelitis?
May require hospital
IV antibiotics
275
Surgical interventions required to removed or extract osteomyelitis
Pus drain
Remove non vital teeth and loose pieces of bone
Remove outer cortex of bone
Remove necrotic bone until healthy bone is reached
Can require reconstructive treatment
276
How are osteoradionecrosis and osteonecrosis different to osteomyelitis?
Can effect much larger areas of bone
Harder to cut back to reach healthy bone
MRONJ - entire mandible is altered
277
What causes osteoradionecrosis?
Patients who have received head and neck therapy for cancer
Bone within scope of radiation beam becomes non-vital
278
What is endarteritis and what can it be caused by? What is the consequence of this?
Reduced blood supply
Osteoradionecrosis
Therefore self repair is not possible
279
How to carry out an extraction in osteoradionecrosis patient?
Some say routine - very careful
Some suggest surgical
Liaise with cancer team
280
What is the caries risk factor for radiotherapy patients?
Dry mouth
281
What is hyperbaric oxygen therapy and when would it be suggested?
Increased oxygenation to certain tissues
Before and after extraction in osteoradionecrosis patient
282
Describe treatment of osteoradionecrosis
Irrigate necrotic areas
Consider antibiotics for secondary infection
Remove loose sequestra
Small wounds under 1cm often heal over weeks or months
Larger wounds may require surgery - resection of exposed bone to get soft tissue closure
283
What is the out of date name for MRONJ?
BRONJ
284
What are bisphosphonates prescribed for?
Osteoporosis
Pagent's disease
Malignant bone metastasis
285
How long do bisphosphonates remain in the body?
Years
286
Is MRONJ more common in oral bisphosphonate or IV bisphosphonate patients?
IV
287
When does MRONJ occur?
Following extraction or denture trauma
288
Factors affecting chance of MRONJ
Length of time on drug
Diabetes
Smoking
Steroids
Chemotherapy
289
With MRONJ, avoid __
Extractions, if possible
290
What is the danger of MRONJ surgery to remove dead sequestra?
Can make MRONJ worse
291
Bisphosphonate drug examples
Alendronate
Clodronate
292
What other drugs can cause MRONJ (other that bisphosphonates?
Antiangiogenic drugs
Antiresorption drugs
RANKL inhibitor
293
RANKL inhibitor example
Denosumab
294
Most bleeds are due to local factors such as mucoperiosteal tears. What are the rarer reasons for bleeds?
Undiagnosed clotting abnormalities
Liver disease
Medications such as warfarin
295
Low risk MRONJ categories
Non malignant disease, oral bisphosphonates for less than 5years. Not concurrent with glucocorticoids
Non malignant disease, IV bisphosphonates less than 5 years not concurrent with glucocorticoids
296
High risk bisphosphonate groups
Non malignant disease, bisphosphonates 5+ years or bisphosphonates concurrent with glucocorticoids
Malignant disease with antiangiogenic or antiresorptive drugs
MRONJ history
297
Which nearby structure can be affected, causing altered sensation by a osteomyelitis in the mandible?
IAN
298
Are implants contraindicated in osteomyelitis or osteonecrosis patients?
No but risk of worsening it must be explained
299
MRONJ is often tucked behind a ___
Mandibular torus
300
What could be confused with osteonecrosis radiographically?
Cancer
301
What is actinomycosis?
Rare bacterial infection
302
How is actinomycosis caught and how does it spread?
Must be inoculated into a wound in a patient with weak defence - actinomycin has low virulence
Erodes through tissue
303
How to initially treat actinomycosis?
Antibiotics, can recur if stopped
304
Describe a clinical presentation of actinomycosis?
Lumpy pus
305
How to treat chronic sinus tract?
Excision
306
How do bacteraemia cause infective endocarditis?
Bacteria in the bloodstream can vegetate or colonise on heart valves
307
What percentages of infective endocarditis patients die?
20%
308
What is the prophylaxis after dental procedures if thought necessary to prevent infective endocarditis?
3g amoxycillin 60 mins before
600mg clindamycin 60 mins before
309
What causes hypercementosis?
Too much cementum on the root
Many reasons - increased load most common
310
What happens to PDL in ankylosis?
Lose PDL space
311
What are the consequences of a flap that is too small?
It will tear and scar more
More bleeding and more pain
312
If dental papillae is damaged in OS what is increased?
Gingival recession
313
Which incision should we begin with?
Crevicular - between tooth and gingival crevice
314
Easiest place to remove bone for an extraction?
Buccally
315
Instruments for debridement of soft tissues?
Mitchells trimmer
Victoria curette
316
Where would monofilament be used over multifilament and why?
Lips - aesthetics
