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BDS3 > Oral Surgery > Flashcards

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

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2
Q

What are peri-operative complications?

A

Complications during the surgery and immediately after

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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

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4
Q

What is trismus?

A

Limited mouth opening due to spasm of muscles of mastication

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5
Q

With incorrect extraction technique what is the risk to the adjacent teeth?

A

Mobilising these too

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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

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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

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8
Q

Which structures could be fractured during extraction?

A

Tooth
Alveolus/maxillary tuberosity
Jaw - very rare

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9
Q

Within the tooth itself what could fracture?

A

Crown or root

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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

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11
Q

What instruments are used to loosen teeth?

A

Luxators and elevators

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12
Q

Where should forceps be placed?

A

Just below the crown

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13
Q

If forceps are placed incorrectly, what may happen during buccal expansion?

A

Crown may fracture off

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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

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15
Q

Once we have extracted a tooth, do not __ the socket

A

Squeeze - reduces bone volume which is bad if implants are wanted

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16
Q

Where do alveolar fractures usually occur?

A

Buccal plate
Canines and molars where bone is thicker

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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

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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

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19
Q

It is most important to preserve bone for shape in the ____ area

A

Canine

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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

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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

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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

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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

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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

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25
Q

When the maxillary sinus is involved what is it called immediately, and what is it called after a while?

A

Oro antral communication - acute
Oro antral fistula - when epithelium of oral cavity become continuous with the sinus - chronic

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26
Q

What usually gets pushed into maxillary sinus in these communications?

A

Root of a tooth

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27
Q

A fractured maxillary tuberosity often involves a..

A

Oro-antral communication

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28
Q

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

A

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

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29
Q

When viewing an area we want.. (3)

A

Direct vision
Good light
Good suction

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30
Q

What may we hear with section indication an OAC?

A

Echo

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31
Q

What instrument is used to explore areas?

A

Blunt probe

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32
Q

Often we can’t see an OAC, what lies under?

A

Mucosa often covers a larger hole in the bone
Hard to find but if mucosa is removed it is larger than expected

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33
Q

If small OAC or sinus intact what should be done?

A

Encourage clot
Suture margins
Antibiotics - because saliva and food will be going in
Post op instructions

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34
Q

If large OAC or torn lining what should be done?

A

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

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35
Q

What is a buccal advancement flap?

A

Where we raise a buccal flap cut periosteum for elasticity, pull it over the OAC and suture it shut

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36
Q

If chronic OAF what to remove before pulling over buccal advancement flap?

A

Epithelial lining around the circumference of OAF
If we don’t, communication will reform after

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37
Q

If looking for a root in the antrum what do we need?

A

Take a radiograph
Good lighting and vision

Do not blindly probe as could make it worse

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38
Q

How to remove a root from the maxillary sinus?

A

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

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39
Q

When is a fractured tuberosity more likely?

A

When there’s a single posterior tooth in the quadrant - put finger and thumb on either side of the alveolus

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40
Q

If fractured tuberosity, how to manage?

A

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

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41
Q

What instruments do we use in tuberosity fracture to place the tooth back in its original position?

A

Forceps or finger

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42
Q

When fixating or stabilising what are the steps?

A

Splint
Arch bar
Orthodontic wire arch with composite

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43
Q

How to make wire more rigid for fixations?

A

Include more teeth in the splint

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44
Q

How long to leave splint on in rigid fixation?

A

8 weeks

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45
Q

What must be considered when fixating?

A

Remove or teat pulp
Must be occlusion free
Antibiotics
Post op instructions

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46
Q

Sometimes once we have removed tooth, the pt will move and we lose it, what to do in this case?

A

Stop
Suction
Radigraph

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47
Q

If you lose a tooth, where could it be?

A

Under tongue
In buccal area
In maxillary sinus
Swallow - in lung or oesophagus

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48
Q

What kinds of damage can be caused to nerves during surgery?

A

Crushing injuries by leaning on nerve
Cutting/shredding
Transection
Damage with LA

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49
Q

What is transection of a nerve?

A

Cut all the way through

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50
Q

What order to extract in?

A

Posterior to anterior

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51
Q

Neurapraxia

A

Contusion of nerve/continuity of epineural sheath and axons maintained

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52
Q

Axonotmesis

A

Continuity of axons but epineural sheath disrupted

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53
Q

Neurotmesis

A

Complete loss of nerve continuity/nerve transected

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54
Q

Anaesthesia meaning

A

Numbness

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55
Q

Parasthesia

A

Tingling

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56
Q

Dydaesthesia

A

Unpleasant sensation

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57
Q

Hypoaesthesia

A

Reduced sensation

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58
Q

Hyperaesthesia

A

Heightened sensation

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59
Q

If you cut a vein vs artery vs arteriole what will happen?

A

Veins - bleed
Arteries, arterioles - spurt/haemorrhage

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60
Q

Most bleeds during OS are due to local factors such as what?

A

Mucoperiosteal tears, fractures of alveolar wall or plate

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61
Q

Less commonly, bleeding is due to problems such as __

A

Clotting abnormalities - haemophilia/von willebrands/liver disease
Medication - warfarin/antiplatelets

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62
Q

How to stop bleeding soft tissues?

A

Pressure
Suture
More LA with vasoconstriction
Diathermy - burn vessels
Ligatures//haemostatic forceps

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63
Q

Bleeding can be from the bone, how is this dealt with?

A

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

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64
Q

If TMJ is dislocated in mandibular extraction what is done?

A

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

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65
Q

When relocating the jaw after TMJ dislocation, a second person is required to do what?

A

Hold head in place - lots of pressure when pushing down and back

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66
Q

How could adjacent teeth become damaged during an extraction?

A

Hit with forceps
Crack/fracture/move with elevators
Crack/fracture/remove rests/crowns/bridges

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67
Q

How to deal with damage to an adjacent tooth during an extraction?

A

Temporary dressing/restoration
Arrange definitive
If large rest next to extraction site, warn patient of the risk

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68
Q

In extraction of deciduous teeth, be very mindful of ___

A

Damaging developing permanent teeth

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69
Q

If instrument such as luxator breaks in use, what to do?

A

Radiograph to see where fragments are
Retrieve
If unable - refer

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70
Q

Air rotated bur not used in OS, why?

A

Traps air in soft tissues
Get surgical emphysema, takes week or 2 to go away
Can get infected

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71
Q

3 main principles of OS
Risk __
___ technique
Minimal ____ to hard and soft tissues

A

Assessment
Aseptic
Trauma

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72
Q

What 2 factors must be involved in risk assessment?

A

Good medical history
Good planning

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73
Q

How is consent taken for extractions?

A

Written consent having completed form, discussed risks of procedure

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74
Q

As part of the GDC standards, written consent must be obtained when? (2)

A

Conscious sedation is involved
GA is involved

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75
Q

Surgical safety checklist

A

Ensure correct patient
Operating on right side
Consider risks or concerns at the end

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76
Q

What may you need to raise to achieve access to surgical site?

A

Mucoperiosteal flap

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77
Q

When raising flaps, we want ___ access with ____ trauma

A

Maximum
Minimum

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78
Q

Do bigger or smaller flaps heal faster?

A

As quick as each other

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79
Q

What is the vascular connective tissue between bone and mucosa?

A

Periosteum

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80
Q

When we raise a periosteal flap, what structures do we raise?

A

Periosteum and mucosa, as one

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81
Q

What is something we want to avoid when raising a periosteal flap?

A

Raising the mucosa but leaving the periosteum attached to the bone

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82
Q

When raising a flap we want to make a wide based incision, why?

A

So we have good circulation and perfusion
We don’t want to limit the blood supply as the flap would become necrotic

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83
Q

To effectively lift both mucosa and periosteum, how should scalpel be used?

A

One firm continuous stroke

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84
Q

No ___ angles, flap reflection should be down to ___ and done ___

A

Sharp
Bone
Cleanly

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85
Q

If the periosteum is damaged what will this cause the patient?

A

More bruising
More post-op pain

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86
Q

Minimise trauma to interdental ___
Don’t ___ any soft tissues
Keep the tissues ___

A

Papillae
Crush
Moist

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87
Q

Ensure that flap margins and sutures lie on ___

A

Sound bone - to support healing

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88
Q

Make sure wounds are not closed under ___

A

Tension

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89
Q

Aim for healing by primary intention why?

A

To minimise scarring

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90
Q

Most common flap used for removing a lower 3rd molar

A

3 sided
Distal incision
Crevicular incision around the tooth
Mesial incision

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91
Q

Why must distal incision not be done too lingually?

A

Risks damage to lingual nerve

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92
Q

Envelope flap

A

No mesial leaving incision
Distal incision, crevicular around the 8 continues around the 7

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93
Q

Instruments used to retract soft tissue and reduce damage to soft tissues

A

Howarths periosteal elevator
Rake retractor

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94
Q

Once periosteal flap is raised, bone removal and tooth division are carried out. What instruments are used for this?

A

Hand pieces
Saline or sterile water used to cool

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95
Q

Air driven handpieces may lead to surgical emphysema. What is this?

A

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

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96
Q

Do not use air turbine to divide teeth or remove bone. What is used instead?

A

Round or fissure tungsten carbide burs

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97
Q

How can surgical emphysema present?

A

Massive swelling to the cheek
Damage to the eye
May require hospital admission
Antibiotic required if infection develops

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98
Q

What would a buccal gutter around a lower 8 allow us to do?

A

Elevate the tooth
Remove the crown
Remove a split root

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99
Q

What can be used to elevate the teeth

A

Couplands
Warwick James
Cryers

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100
Q

Why is it important to always support the instrument during elevation?

A

Prevent instrument split causing damage

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101
Q

Any force applied with elevators should be directed away from what?

A

Any major structures e.g. the mental nerve

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102
Q

Uses of elevators (6)

A

Provide point of application for forceps
Loosen teeth prior to using forceps
Extract tooth
Remove multiple root stumps
Remove retained roots
Remove root apices

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103
Q

3 basic mechanisms using elevators

A

Wheel and axle
Wedge
Lever

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104
Q

How is wheel and axial method used to elevate?

A

Point engages tooth
Rotate wrist

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105
Q

How to debride the wound from removal of a tooth?

A

Physically
With irrigation
With suction

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106
Q

What is done in physical bone debridement?

A

Use bone file or remove sharp fragments
Mitchell’s trimmers or Victoria curette to remove soft tissue debris

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107
Q

How to irrigate for debridement of a socket?

A

Squirt sterile saline into socket and under flap

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107
Q

How to irrigate for debridement of a socket?

A

Squirt sterile saline into socket and under flap

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108
Q

How to use suction to debride a socket

A

Aspirate under flap to remove debris
Check socket for retained apices

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109
Q

How to prepare to suture

A

Line up tissues
Compress vessels

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110
Q

Aims of suturing

A

Achieve haemostasis
Prevent wound breakdown
Cover bone
Encourage healing by primary intention

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111
Q

What material is used for sutures?

A

Absorbable and non absorbable

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112
Q

When would non absorbable sutures be used?

A

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

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113
Q

Absorbable sutures are used when?

A

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

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114
Q

Monofilament vs polyfilament

A

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

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115
Q

Example of absorbable and non absorbable sutures

A

Absorbable - mersilk
Non absorbable - velosorb

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116
Q

Examples of monofilament and polyfilament

A

Prolene - mono
Velosorb - poly

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117
Q

What shape of needle is most commonly used to suture?

A

3/8 circle
1/2 circle

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118
Q

Suture needle cross sections

A

Triangular
Round

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119
Q

Why is reverse cutting used?

A

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

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120
Q

What part of the needle is the swaged end?

A

Part attached to suturing material

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121
Q

Where to hold suture needle with our tweezers?

A

1/3rd from swaged end

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122
Q

What can be used to achieve haemostasis at time of surgery?

A

LA with vasoconstrictor
Artery forceps
Pressure
Diathermy
Bone wax

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123
Q

Examples of post operative bleeding control

A

Pressure
LA
Diathermy
Sutures
Surgicel - oxidised cellulose

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124
Q

Suggested post-operative analgesics

A

Ibuprofen
Paracetamol
Cocodamol

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125
Q

Which nerves can be damaged during extraction of lower third molars?

A

Inferior alveolar
Lingual
Mylohyoid
Buccal

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126
Q

Which nerve is most at risk during lower 3rd molar extraction?

A

Lingual

127
Q

Mouthwash to reduce risk of infection

A

Chlorhexidine

128
Q

Complications of third molar removal

A

Pain
Swelling
Bleeding
Trismus
Bruising
Infection
Dry socket
Parasthesia

129
Q

Excision of mucocele

A

Soft tissue procedure to remove the lump or sac of saliva

130
Q

How is excision of mucocele carried out?

A

Usually on the lips
Lip stretched
LA given
Incision made
Sac removed by blunt dissection
May suture the wound closed

131
Q

Peri radicular surgery

A

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
Q

Once flap is raised, what is done in peri radicular surgery?

A

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
Q

How to clean the end of a root?

A

Ultrasonic

134
Q

Retrograde seal using?

A

Amalgam
Zinc oxide
MTA

135
Q

Which direction do you suture when closing a wound for peri radicular surgery?

A

From the papillae upwards

136
Q

How long after surgery with non resorbable sutures do we review?

A

1 week

137
Q

How long after surgery with non resorbable sutures are radiographs taken?

A

1-6 weeks

138
Q

Reasons for failure of peri radicular surgery

A

Inadequate seal
Inadequate support
Split roots
Soft tissue defect over apex

139
Q

Steps of oral surgery order

A

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
Q

What is the section of the BNF specifically for dentists called?

A

Dental practitioners formulary

141
Q

6 main analgesics used by dentists, which are NSAIDS and which are not?

A

NSAIDS - aspirin, ibuprofen, diclofenac

Paracetamol, dihydrocodeine, carbamazepine

142
Q

What type of drug is dihydrocodeine?

A

Opioid
Less strong than morphine

143
Q

What is aspirin prescribed for?

A

Dental and TMJ pain

144
Q

What properties do NSAIDs have that other analgesics don’t?

A

Anti inflammatory

145
Q

What is most common NSAID currently?

A

Ibuprofen

146
Q

What effect does aspiring have on CVS diseases?

A

Anti platelet - decreases platelet aggregation and inhibits thrombus formation

147
Q

Trauma and infection cause phospholipid breakdown producing what?
This is then broken down into what else?
What does the broken down product cause?

A

Arachidonic
Prostaglandins
Inflammation and pain

148
Q

Prostaglandins do not directly cause pain, how do they do it?

A

Sensitise tissue to other inflammatory products such a leukotrienes

149
Q

Arachidonic acid turns into prostaglandins with the help of?

A

COX 1 and 2

150
Q

What do COX inhibitors do?

A

Reduce inflammation by inhibiting cyclooxygenases 1 and 2, which help the breakdown of arachidonic acid into prostaglandins

151
Q

what is aspirin an inhibitor of?

A

COX 1 and 2 (more effective inhibitor of COX 1)

152
Q

COX 1 inhibitors reduce platelet ___

A

Aggregation

153
Q

What does it mean that aspirin is mainly peripherally acting?

A

Main action is outside of the CNA

154
Q

What is temperature increase during infection caused by?

A

Interleukin 1

155
Q

What effect do prostaglandins have on blood vessels and what properties of aspirin reduce this effect?

A

Vasodilation
Increased capillary permeability

Anti-inflammatory

156
Q

Effect of aspirin on basal metabolic rate

A

Increase

157
Q

Effect of aspirin on blood sugar

A

Reduce

158
Q

What are the main problems with aspirin?

A

Side effects
Not suitable for all

159
Q

What is the job of prostaglandins in the stomach?

A

Inhibit acid secretion
Increase blood flow through gastric mucosa
Help production of protective mucin in cells lining stomach

160
Q

Why must you be careful of the prostaglandin inhibitory effect of aspirin?

A

Can cause or worsen ulcers, GORD, or can cause blood loss via GIT

161
Q

How does hypersensitivity to aspirin present?

A

Acute bronchospasm
Minor rashes

162
Q

Effects of aspirin overdose

A

Hyperventilation
Tinnitus, deafness
Vasodilation and sweating
Metabolic acidosis
Coma

163
Q

How does aspirin cause mucosal burns?

A

If held in cheeks for a long time, the effect of salicylic acid results in a burn

164
Q

How to prevent aspirin burns

A

Take with water

165
Q

Groups to take care when prescribing aspirin

A

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
Q

What is the danger of aspirin with gastric or duodenal ulcer patients?

A

Perforation - avoid

167
Q

Can pregnant women have aspirin?

A

Avoid, especially in 3rd trimester, as can impair platelet function
Increases risk of jaundice in baby
Can prolong/delay labour

168
Q

Breastfeeding when taking aspirin is linked to what disease in the child?

A

Reyes syndrome
Very rare disorder that can cause serious liver and brain damage

169
Q

Where is aspirin metabolised and excreted?

A

Liver
Kidneys

170
Q

Where are prostaglandins synthesised?

A

Renal medulla and glomeruli

171
Q

Possible effects of prostaglandin inhibition on kidneys?

A

Reduced renal blood flow
Sodium retention
Renal failure

172
Q

NSAIDs may cause nephritis and hyperkalaemia. What are these?

A

Inflamed nephrons
High potassium

173
Q

Why should children avoid aspirin?

A

Reyes syndrome
Up to 50% mortality

174
Q

G6PD deficiency risk ethnicities

A

African
Asian
South European
Oceana

175
Q

What is haemolytic anaemia?

A

Red blood cells are destroyed faster than they can be made

176
Q

What is G6PD deficiency a risk factor for?

A

Haemolytic anaemia

177
Q

Which groups should be avoided with aspirin altogether?

A

Under 16
Previous or active ulcers
Haemophiliacs
Hypersensitivity to aspirin or other NSAID

178
Q

Common dosage of aspirin for odontogenic pain for how many days?

A

2 tablets - 300mg each
4 times a day
5days

179
Q

How much aspirin is given daily for maintaining and preventing CVS disease? How much after an ischaemic event?

A

75g
150-300mg

180
Q

Compare ibuprofen to aspirin with regards to platelets, gastric mucosa, asthma and children?

A

Less effects on platelets
Irritant but lower risk
May cause brochospasms
Paediatric suspension available

181
Q

Compare ibuprofen to aspirin with regards to platelets, gastric mucosa, asthma and children?

A

Less effects on platelets
Irritant but lower risk
May cause bronchospasms
Paediatric suspension available

182
Q

What has long term use of ibuprofen recently been associated with?

A

Cardiac events

183
Q

Ibuprofen for adult odontogenic pain dose

A

400mg (1 tablet)
4 times daily 5 days

184
Q

Max ibuprofen dosage in adults

A

2.4g

185
Q

8 groups of people to be cautious of with aspirin

A

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
Q

Ibuprofen side effects

A

GIT discomfort, bleeding, ulceration
Hypersensitivity reactions - rashes
Headache
Drowsiness
Dizziness

187
Q

Potential drug interactions of ibuprofen

A

ACE inhibitors
Antibiotics
Anticoagulants
Antidepressants
Beta blocker
Calcium channel blockers

188
Q

Symptoms of ibuprofen OD

A

Nausea
Vomiting
Tinnitus

189
Q

If more than 400mg/kg ibuprofen is taken what to give?

A

Activated charcoal

190
Q

Which COX enzyme is predominantly innately responsible for producing prostaglandins?

A

COX 2

191
Q

What are the effects of selective COX 2 inhibitors?

A

Less damage to GIT than nonselective NSAIDs

192
Q

Properties of paracetamol

A

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
Q

Paracetamol method of action

A

Indirectly inhibits COX

194
Q

Main site of action for paracetamol compared to NSAIDs

A

Reduced prostaglandins in pain pathway of the CNS
NDAIDs act mostly peripherally

195
Q

What is the benefit of paracetamol not acting much peripherally?

A

Very little effect on the GIT

196
Q

Which patients must we be careful with when prescribing paracetamol?

A

Hepatic impairment
Renal impairment
Alcohol dependence

197
Q

Side effects of paracetamol

A

Rashes
Blood disorders
Hypotension
Liver damage

198
Q

Paracetamol potentially interacts with

A

Anticoagulants
Cytotoxins
Lipid relating drugs

199
Q

Paracetamol dosage

A

500mg
4 times daily

200
Q

Paracetamol OD management

A

Hospital immediately

201
Q

What can occur in paracetamol overdose?

A

Severe hypocellular necrosis
Renal tubular necrosis

202
Q

Co-codamol and co-proxamol contain what?

A

Paracetmol

203
Q

Where do opioid analgesics act?

A

In the spinal cord
Central regulation of pain in the CNS

204
Q

What does the BNF state about opioids and dental pain?

A

Relatively ineffective

205
Q

What problems can arise with opioid use?

A

Dependence
Tolerance

206
Q

Opioid effects on smooth muscle

A

Constipation can occur
Urinary and bile retention

207
Q

Effect of opioids on the CNS. What do they depress?

A

Depresses pain centres, respiratory centres, cough centres and vasomotor

208
Q

Effect of opioids on the CNS, what do they stimulate?

A

Vomiting centre
Salivary centre
Pupillary constriction

209
Q

Side effects of opioids

A

Vomiting
Drowsiness
Dry mouth
Headache
Palpitations

210
Q

Opioids are enhanced by __

A

Alcohol

211
Q

Groups to be careful of with opioids?

A

Hypotension
Hypothyroidism
Asthma
Prostatic hyperplasia
Pregnancy
Hepatic impairment
Renal impairment
Elderly
Dependents

212
Q

Opioids contraindications

A

Acute respiratory disease
Acute alcoholism
Raised intracranial pressure

213
Q

What is codeine usually prescribed with?

A

NSAID/paracetamol

214
Q

Common side effect of codeine

A

Constipation

215
Q

What opioid is in the BNF dental practitioner’s formulary?

A

Dihydrocodeine

216
Q

Dihydrocodeine dose

A

30mg every 4-6 hours

217
Q

Dihydrocodeine side effects

A

Vomiting
Nausea
Constipation
Drowsiness

218
Q

Dihydrocodeine interactions

A

Antidepressants
Dopaminergic

219
Q

Never prescribe dihydrocodeine in __

A

Increased intracranial pressure

220
Q

What does the BNF state about dihydrocodeine’s role in dental pain?

A

Little value
Not very effective

221
Q

What can opioid OD cause?

A

Varying degree of coma
Respiratory depression

222
Q

When to prescribe carbamazepine

A

Neuropathic or functional pain
Trigeminal neuralgia
Post herpetic neuralgia
Functional - TMJ or atypical facial pain

223
Q

Main brand of carbamazepine

A

Tegretol

224
Q

Drugs for trigeminal neuralgia and which are on dental list

A

Carbamazepine - dental list
Gabapentin
Phenytoin

225
Q

Clinical features of trigeminal neuralgia

A

Electric shock type pain
Unilateral
Older age group, females more common
Not able to identify source

226
Q

Carbamazepine dose

A

200mg
3-4 times daily

227
Q

Carbamazepine side effects

A

Dizziness
Ataxia
Drowsiness

228
Q

Carbamazepine contraindications

A

Conduction abnormalities
History of bone marrow depression
Porphyria
History of hypersensitivity

229
Q

Which patients to be cautious of with carbamazepine?

A

Renal
Hepatic
Cardiac
Glaucoma
Skin reactions
Pregnancy

230
Q

When is post op swelling normal and when to be more concerned?

A

Immediate swelling that lasts a week is normal

Swelling after a few days is usually infection

231
Q

What increases postop swelling?

A

Poor surgical technique
Rough handling
Longer procedures

232
Q

What is ecchymosis?

A

Bruising

233
Q

What can cause more ecchymosis?

A

Poor technique
Poor placement of instruments and hands
Crushing lips with forceps

234
Q

How long can trismus last?

A

1-2 weeks

235
Q

Causes of trismus

A

LA
Damage to TMJ from opening for a long time
Masseter spasm
Bleed into muscle can cause spasm

236
Q

Haemostatic agents

A

Adrenaline
Surgicel
Gelatine sponge
Thrombin liquid and powder
Fibrin foam

237
Q

What factors in blood aid in clotting?

A

Vit K
Anti fibrinolytic tranexamic acid
Blood clotting factors
Plasma/whole blood

238
Q

What to do when a child won’t close their mouth to put pressure on a socket?

A

Refer for GA to have pressure applied

239
Q

Nerve damage can be fixed until how long after surgery?

A

18-24 months

240
Q

Where is dry socket most likely?

A

Lower posteriors (8)

241
Q

What does dry socket look like?

A

Bare bone or poor quality clot

242
Q

When does dry socket start and how long to resolve?

A

Slow healing socket, 3-4 days after, takes 1-2 weeks to resolved

243
Q

What is dry socket and what is this called?

A

Inflammation of lamina dura
Localised osteitis

244
Q

Symptoms of dry socket

A

Dull aching
Pain can radiate to ear
Keeps pt awake at night
Bad smell/taste

245
Q

Factors increasing chance of dry socket

A

Posterior
Lower arch
Smoking
Female
Oral contraceptives
LA
Infection from tooth
Excessive trauma during extraction
Excessive mouth rinsing
Family history

246
Q

How to manage dry socket

A

Supportive - reassurance, systemic analgesia
LA block
Irrigate with warm saline
Debridement, encourage bleeding, new clot formation
Antiseptic pack - alvogyl

247
Q

Why should radiographs of dry socket be taken?

A

To check there is not root left

248
Q

What is curettage?

A

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
Q

What is BIP pack?

A

Iodine based antiseptic pack, placed into socket. Suture in and remove after a week

250
Q

What is alvogyl?

A

LA and antiseptic pack to soothe pain and prevent food packing

251
Q

What is used to irrigate fresh wounds at home?

A

Salty water

252
Q

Why is chlorhexidine not used on fresh wounds?

A

Can get into the bloodstream and cause anaphylactic reactions

253
Q

Why not prescribe antibiotics for dry socket?

A

Not an infection, they are not systemically unwell

254
Q

What is sequestrum?

A

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
Q

If socket becomes infected, what should be done?

A

Radiographs to check for bony remains or cysts
Consider antibiotics

256
Q

If OAF patient has runny nose what should they do?

A

Avoid blowing
Steam the nose for short periods at a time

257
Q

Why is it important to release periosteal tissue when raising a flap?

A

Makes mucosa elastic so we can cover the hole without tension

258
Q

What is osteomyelitis?

A

Inflammation of bone marrow

259
Q

Where does osteomyelitis usually begin

A

Cancellous bone of the mandible

260
Q

Common symptoms of osteomyelitis

A

Fever

261
Q

What causes osteomyelitis?

A

Invasion of bacteria into the cancellous bone

262
Q

Osteomyelitis can cause inflammation and oedema in an enclosed space, what can this cause?

A

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
Q

Why is osteomyelitis more common in the mandible?

A

Maxilla has richer blood supply
Mandible has dense over lying cortical bone limiting penetration of blood

264
Q

Major predisposing factors for osteomyelitis

A

Odontogenic infection
Mandible fracture

265
Q

Factors compromising host defence against osteomyelitis

A

Diabetes
Alcoholism
Malnutrition
Leukaemia
Chemotherapy

266
Q

Early myelitis is hard to differentiate from what?

A

Dry socket or localised infection

267
Q

Radiograph of acute suppurative osteomyelitis vs chronic osteomyelitis

A

Acute suppurative - usually not detectable

Chronic osteomyelitis - radiolucency, can be patches or mothy, mottles

268
Q

What are areas of radiolucency on radiograph of chronic osteomyelitis?

A

Islands of dead bone called sequestra

269
Q

What is involucrum?

A

Areas of increased radio density surrounding areas of radiolucency of chronic osteomyelitis

270
Q

What is the difference between osteomyelitis in mandible vs rest of the body?

A

Mandible - odontogenic infections e.g. streptococci
Rest of body - staphylococci

271
Q

How to treat osteomyelitis

A

Antibiotics
Surgical intervention

Get blood tests to see underlying medical causes

272
Q

Which antibiotics for osteomyelitis?

A

Clindamycin/penicillin
Long course

273
Q

How long to prescribe antibiotics with acute osteomyelitis?

A

Up to 6 weeks after relief of symptoms

274
Q

How to treat severe acute osteomyelitis?

A

May require hospital
IV antibiotics

275
Q

Surgical interventions required to removed or extract osteomyelitis

A

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
Q

How are osteoradionecrosis and osteonecrosis different to osteomyelitis?

A

Can effect much larger areas of bone
Harder to cut back to reach healthy bone
MRONJ - entire mandible is altered

277
Q

What causes osteoradionecrosis?

A

Patients who have received head and neck therapy for cancer
Bone within scope of radiation beam becomes non-vital

278
Q

What is endarteritis and what can it be caused by? What is the consequence of this?

A

Reduced blood supply
Osteoradionecrosis
Therefore self repair is not possible

279
Q

How to carry out an extraction in osteoradionecrosis patient?

A

Some say routine - very careful
Some suggest surgical
Liaise with cancer team

280
Q

What is the caries risk factor for radiotherapy patients?

A

Dry mouth

281
Q

What is hyperbaric oxygen therapy and when would it be suggested?

A

Increased oxygenation to certain tissues
Before and after extraction in osteoradionecrosis patient

282
Q

Describe treatment of osteoradionecrosis

A

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
Q

What is the out of date name for MRONJ?

A

BRONJ

284
Q

What are bisphosphonates prescribed for?

A

Osteoporosis
Pagent’s disease
Malignant bone metastasis

285
Q

How long do bisphosphonates remain in the body?

A

Years

286
Q

Is MRONJ more common in oral bisphosphonate or IV bisphosphonate patients?

A

IV

287
Q

When does MRONJ occur?

A

Following extraction or denture trauma

288
Q

Factors affecting chance of MRONJ

A

Length of time on drug
Diabetes
Smoking
Steroids
Chemotherapy

289
Q

With MRONJ, avoid __

A

Extractions, if possible

290
Q

What is the danger of MRONJ surgery to remove dead sequestra?

A

Can make MRONJ worse

291
Q

Bisphosphonate drug examples

A

Alendronate
Clodronate

292
Q

What other drugs can cause MRONJ (other that bisphosphonates?

A

Antiangiogenic drugs
Antiresorption drugs
RANKL inhibitor

293
Q

RANKL inhibitor example

A

Denosumab

294
Q

Most bleeds are due to local factors such as mucoperiosteal tears. What are the rarer reasons for bleeds?

A

Undiagnosed clotting abnormalities
Liver disease
Medications such as warfarin

295
Q

Low risk MRONJ categories

A

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
Q

High risk bisphosphonate groups

A

Non malignant disease, bisphosphonates 5+ years or bisphosphonates concurrent with glucocorticoids
Malignant disease with antiangiogenic or antiresorptive drugs
MRONJ history

297
Q

Which nearby structure can be affected, causing altered sensation by a osteomyelitis in the mandible?

A

IAN

298
Q

Are implants contraindicated in osteomyelitis or osteonecrosis patients?

A

No but risk of worsening it must be explained

299
Q

MRONJ is often tucked behind a ___

A

Mandibular torus

300
Q

What could be confused with osteonecrosis radiographically?

A

Cancer

301
Q

What is actinomycosis?

A

Rare bacterial infection

302
Q

How is actinomycosis caught and how does it spread?

A

Must be inoculated into a wound in a patient with weak defence - actinomycin has low virulence

Erodes through tissue

303
Q

How to initially treat actinomycosis?

A

Antibiotics, can recur if stopped

304
Q

Describe a clinical presentation of actinomycosis?

A

Lumpy pus

305
Q

How to treat chronic sinus tract?

A

Excision

306
Q

How do bacteraemia cause infective endocarditis?

A

Bacteria in the bloodstream can vegetate or colonise on heart valves

307
Q

What percentages of infective endocarditis patients die?

A

20%

308
Q

What is the prophylaxis after dental procedures if thought necessary to prevent infective endocarditis?

A

3g amoxycillin 60 mins before
600mg clindamycin 60 mins before

309
Q

What causes hypercementosis?

A

Too much cementum on the root
Many reasons - increased load most common

310
Q

What happens to PDL in ankylosis?

A

Lose PDL space

311
Q

What are the consequences of a flap that is too small?

A

It will tear and scar more
More bleeding and more pain

312
Q

If dental papillae is damaged in OS what is increased?

A

Gingival recession

313
Q

Which incision should we begin with?

A

Crevicular - between tooth and gingival crevice

314
Q

Easiest place to remove bone for an extraction?

A

Buccally

315
Q

Instruments for debridement of soft tissues?

A

Mitchells trimmer
Victoria curette

316
Q

Where would monofilament be used over multifilament and why?

A

Lips - aesthetics

BDS3 (20 decks)

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