Oral surgery Flashcards
1
Q
What are some examples of reasons to surgically remove a tooth?
A
- gross caries so no application point for forceps
- complex root morphology
- retained roots below the alveolar bone
- impacted teeth
- displaced teeth
- ectopic teeth
- pathology
2
Q
What is impaction?
A
occurs when there is prevention of complete eruption into a normal functional position due to lack of space or development in an abnormal position. This predisposes to pathological changes
3
Q
What kind of tissues are involved in impaction?
A
can involve only soft tissues or hard and soft tissues
4
Q
What does ectopic mean?
A
malpositioned due to congenital factors e.g. cleft palate involving laterals and canine position
5
Q
What does displaced mean?
A
malpositioned due to presence of pathology e.g. cysts causing displacement of tooth/tooth germ
6
Q
What does completely unerupted mean?
A
entirely covered by soft tissue and also partially/totally covered in alveolar bone
7
Q
What does partially erupted mean?
A
presents intra-orally
8
Q
What does ankylosed mean?
A
fused with alveolar bone, rare with 8s
9
Q
At what age does ankylosis occur?
A
after middle age
10
Q
What causes impacted teeth?
A
lack of space in the arch as a consequence of evolutionary changes and lack of an abrasive diet
11
Q
What are the most commonly impacted teeth?
A
- mandibular third molars
- maxillary canines
- mandibular premolars/canines
- maxillary incisors
- maxillary third molars
12
Q
What guidelines are referred to for the removal of third molars?
A
NICE guidelines
13
Q
At what age do mandibular third molars usually erupt and what are the statistics of their absence?
A
- between 18-24yrs but can be outwith
- fail to develop in 1:4 adults
- 72% mandibular molars impacted
14
Q
What are the indications for removal of mandibular third molars?
A
- pericoronitis
- unrestorable caries
- cellulitis/osteomyelitis
- periodontal disease
- orthodontic reasons
15
Q
What are some more uncommon indications for the removal of mandibular third molars?
A
- prophylactic removal in medically/surgically compromised patients (e.g. radiotherapy pts, prevent future issues, hypovasculated bone)
- obscure pain
- tooth in line of fracture
- disease of follicle
- orthognathic surgery
- transplant donor
16
Q
What are the relative contraindications for the removal of a mandibular third molar?
A
- weigh up all variables
- asymptomatic teeth
- non-compliant patients
- overt nerve involvement - risk of damage to IAN or lingual nerve
17
Q
What is pericoronitis?
A
inflammation of the tissues around the crown of any partially erupted/impacted tooth
18
Q
What are the presenting features of pericoronitis?
A
- trismus, pain, dysphagia, malaise, bad taste
- inflammation of pericoronal tissues, frank pus under operculum
- cheek biting and cuspal indentations on operculum
- halitosis, food packing
- can present with systemic symptoms/spread to adjacent tissue spaces
19
Q
What group of the population tend to present with pericoronitis?
A
younger patients, late teens, twenties
20
Q
What is the treatment for pericoronitis?
A
- local measures = irrigation, OH measures, remove trauma i.e. extract upper 8 or grind down cusps of opposing tooth
- general measures = analgesics, antibiotics if systemically unwell/immunocompromised
21
Q
What is the microbiology of pericoronitis?
A
- predominantly anaerobic
- streptococci, actinomyces, propionobacterium, a beta-lactamase producing prevotella, bacterioides, fusobacterium, caphocytophaga and staphylococci
22
Q
When are antibiotics given in a case of pericoronitis?
A
- only when surgical removal of cause or drainage of infection under LA not possible
- antibiotics required if there is evidence of systemic spreading infection necessitating urgent referral for hospitalisation
23
Q
What are the four treatment choices for pericoronitis?
A
1) conservative
2) operculectomy (not recommended)
3) removal
4) coronectomy
24
Q
What kind of radiograph would be taken to assess a patient before removal of mandibular third molars and what can be visualised?
A
ideally OPG - visualise all tooth and adjacent structures including bone, tooth morphology and number and shape of roots, hypercementosis, depth of bone, follicular pathology, external root resorption, caries
25
What are indications of proximity to the ID nerve?
- IDC narrowing/darkening of canal as nerve crosses root, loss of white lines, deflection/deviation of IDC, dilaceration or bifid roots, change in colour of roots when crossed by nerve so area appears darker
26
What are the four angles of impaction?
- vertical
- mesial
- distal
- horizontal
27
What is the most common angulation of impaction in mandibular third molars?
- mesioangular (40%)
- vertical (30-38%)
28
What are the radiographic signs of a close relationship between the lower third molar and IDC?
- diversion of IDC
- darkening of root as it crossed by IDC
- loss of lamina dura of IDC
- narrowing of IDC
- deflection of roots as they approach IDC
- juxta apical area - appears to be a free floating apex on one side of canal which seems to be independent of root on other side of canal
29
What is a juxta apical area?
well circumscribed radiolucent area lateral to the root rather than at the apex.
30
The majority of IAN canals sit where in relation to the third molar?
lingual aspect
31
How are the IAN bundle organised in the canal?
artery and vein in upper part of canal, nerve in lower aspect
32
How does the type of bone the IAN is running through affect its visualisation on a radiograph?
- if sitting in the lingual cortical bone, (two cortical outer plates of mandible), a lamina dura is visualised as it is formed by the cortex
- if sitting in medullary bone (in centre, sandwiched between cortical plates), no cortex to see a lamina dura so difficult to detect
33
What is the incidence of post operative alteration in sensation in the lower lip following IANB?
- short term - 5% (weeks or months)
- long term - less than 1%
34
What is the incidence of post operative alteration in sensation in the tongue following IANB and lingual block?
- short term - 10%
- long term - less than 1%
- taste - can be affected
35
What is thought to be a common cause of lingual nerve sensation alteration?
lingual retraction
36
What is an alternative surgery option if there is high risk to the IDN?
Coronectomy
37
What are the stages involved in a coronectomy?
- remove crown and leave roots in place
- if roots are mobile at time of coronectomy, remove
- when consenting state plan is to coronect tooth but removal may be unavoidable
- post-op risk of infection of roots 2.9%
- post-op risk of migration of roots 14-81%
38
Should CBCTs be routinely used in the radiographic assessment of mandibular third molars?
No - evidence shows no effect on outcome, increased radiation dose and cost
Only if conventional imaging shown close relationship and specific case may show findings which could alter management
39
You should warn patients of post operative complications with an incidence rate of what?
greater than 5%
40
What are the 5 points planned from radiograph (DPT) regarding third molar removal?
- what would path of eruption be?
- extrinsic/intrinsic obstacles to removal
- required bone removal
- point of application
- flap design
41
What is a mucoperiosteal flap?
A full-thickness mucoperiosteal flap includes the surface mucosa, submucosa and the periosteum
42
How is a mucoperiosteal flap raised for M3M removal?
- distal relieving incision up ascending ramus, around crown of 3M, include papilla between 3M and 2M and mesial relieving incision (triangular flap)
- envelope flap - no mesial relieving incision
- atraumatic elevation with periosteal elevator around gingival margins then Howarths or Rake retractor to retract buccal flap
- raise lingusl flap with Howarths/Mithcells/Molt to protect lingual nerve in selected cases only
43
What is the difference between a triangular flap and an envelope flap?
envelope flap has no mesial relieving incision
44
How is a triangular flap cut for the removal of a M3M?
1) distal relieving incision - landmark = ascending ramus (1 units length of crown of tooth)
2) peri-coronal incision cutting through alveolar crest fibres, includes papilla between 3M and 2M
3) mesial relieving incision down from 2M to depth of sulcus
45
How is an envelope flap cut for the removal of a M3M?
1) distal relieving incision, landmark = ascending ramus
2) peri-coronal incision cutting through the alveolar crest fibres around the 3M and extends all around the 2M
46
How is bone removed with burs?
using burs;
- to relieve impaction, create point of application, remove bone with round bur to create narrow gutter mesiobuccally avoiding adjacent roots
- fissue bur to deepen gutter
- 20,000-40,000RPM
47
How is bone removed using chisels and is this normal practice now?
lingual split technique
no longer used
48
In what orientation are crowns divided for surgical removal and when would this need to be done?
either horizontally or axially
- in horizontal impactions
- distoangular impactions to avoid excessive bone removal but ensuring a good application point is retained
49
When would roots require division before removal?
- pincer roots
- multiple roots with differing paths of removal
50
What root form related intrinsic obstacles can hinder removal?
convergent or divergent roots
51
What is the importance of the replacement of a flap back into bone?
it is essential that after surgery the flap rests on bone to avoid wound breakdown
52
What is the most important suture that is placed following removal of a M3M?
the one placed from the buccal tissues to the lingual tissues immediately distal to the second molar tooth to encourage good periodontal health
53
What quantity of suture material is best and what material is commonly used?
- the fewer sutures placed the better, to secure primary closure and haemostasis
- materials 3/0 vicryl rapide (resorbable)
54
What is the advised post operative regime following flap design and tooth removal?
- analgesics (+/- antibiotics)
- HSMW (hot salty mouthwash)
- soft diet
- topical ice packs
- suture removal at one week if not resorbable
- arrange follow up for difficult cases or immunocompromised pts
55
What are the possible complications of a flap design and surgical removal of a tooth?
- haemorrhage - primary or secondary
- loose teeth or damage to adjacent teeth/restorations/periodontium
-fractured mandible
- dry socket or infection with purulent discharge
- sensory deficit
- complications generally assoc with extractions
56
The majority of maxillary 3M are impacted in what orientation?
vertically or mesioangularly
57
What kind of bone surrounds maxillary 3Ms?
thin cortical bone
58
In what percentage of maxillary 3Ms is there just one single short root?
74%
59
Why are maxillary third molars difficult to manage and to keep clean upon eruption?
- difficult due to position behind second molars, molar buttress and buccal position, therefore OH problematic
60
GA for removal of symptomatic lower 8s merits what?
the simultaneous removal of upper 8s, patient convenience
61
How are unerupted maxillary third molars removed?
- raise buccal flap, thin friable bone removed with couplands and elevator used to move tooth down, back and buccally
- avoid excessive upwards force due to possible displacement into antrum
- one suture to reposition flap
62
Under what conditions would you leave a maxillary impacted third molar?
asymptomatic, pathology free and deeply impacted - leave unless treatment under GA
63
What are the second most commonly impacted teeth?
maxillary canines
64
Maxillary canines are more commonly ectopic in what direction?
ectopic palatal more than buccal
65
Maxillary canines are normally palpable in the labial sulcus at what age?
10-11yrs
66
What is the aetiology of canine impaction?
- lack of space
- guidance theory suggests distal aspect of lateral incisor is guide for canine eruption
- genetic theory suggests its a product of polygenetic multifactorial inheritance;
non-resorption of deciduous teeth, ankylosis of impacted canine, contraction or collapsed maxillary arch, absence of lateral incisor to guide eruption, presence of pathology, supernumary,scar tissue in path, trauma causing disturbance in tooth germ axis, cleft lip and palate, syndromes, cleidocranial dysplasia, long path of eruption (22mm), displacement of crypt
67
What are the clinical signs/investigations for impacted canines?
- palpate
- evidence of rotation/tilting of adjacent teeth
- mobility/sensibility of adjacent teeth
- 6 months since contralateral tooth erupted
- presence of deciduous canine
68
What are the radiographic investigations for the diagnosis of impacted canines?
- parallax films - PA x2, occlusal and DPT
- CBCT
69
Explain the process of parallax views and how the radiographs indicate the positioning of the ectopic canine
if you move the cone of the X-ray machine in one direction, and the impacted tooth moves in the SAME direction, then the tooth is further away (palatal).
If it moves the opposite way = labial or buccal
70
When should you suspect that a tooth is undergoing cyst formation?
when the follicular space is enlarged beyond the general 3-4mm of space you'd expect caused by the follicle
71
Can a dilacerated tooth be orthodontically realigned?
no - left alone or surgically removed
72
What are the sequelae of canine impaction?
- resorption of incisor roots
- cystic change
- infection of cyst when close to surface mucosa, possible sinus formation
73
What are the treatment options for impacted canines?
1) conservative
2) interceptive
3) exposure
4) surgical removal
5) transplantation
74
What is the conservative treatment option for impacted canines?
do nothing
- patient unwilling to have ortho, or happy with appearance with good contact between 2 and 4 or healthy C, adjacent teeth vital
- radiographs show tooth very high, no pathology or resorption
75
What is the interceptive treatment option for impacted canines?
extract deciduous canine
- if pt 10-13yrs, minimal crowding, space maintenance
- if no change in position after 12mths on radiographs, alternative treatment
- 78% erupt normally following interceptive treatment
76
What is the exposure and alignment treatment option for impacted canines?
- well motivated pt willing to have ortho and good OH
- not grossly displaced with favourable root morphology
- best results if carried out early (open apex)
- open or closed technique
77
What are the open and closed techniques for the exposure and alignment of impacted canines?
open technique - apically repositioned flap or palatal window
closed technique - orthodontic bracket and gold chain allow ortho traction (better technique)
78
What is beneficial for pain management and healing following a palatal mucoperiosteal flap to expose and align a maxillary canine?
- have an acrylic plate (dressing plate), held on by Addams cribs to serve as protective barrier for soft tissues against masticatory wear and tear
- apply with Copack soft tissue dressing (sedative dressing) to help with pain and to cushion area
- once placed, left undisturbed for a week, pt must use mouthwash but can brush normally away from surgical site
- plate removed after a week
79
What is the advantage of the closed technique for exposure and alignment of impacted canines?
- closed technique with orthodontic bracket mimics physiological eruption, which means it will erupt through attached gingivae, giving good gingival contour
80
When would surgical removal of an impacted canine be indicated?
- patient non-compliant or satisfactory appearance with C or 2-4 contact
- advanced resorption of incisors
- malpositioned canine with difficult root morphology
81
What technique is used for the surgical removal of impacted canines?
- commonly palatal - flap as per exposure, often envelope flap, buccal = 3 sided or 2 sided flap
- remove overlying bone to maximum convexity of tooth and elevate
- sectioning may be required if root morphology complex or tight against adjacent teeth
- may need buccal approach to section
82
What is released in a bilateral envelope flap for the removal of impacted canines?
in order to cut flap bilaterally, you have to release the contents of the incisive/nasopalatine foramen
83
What kind of irrigation is required for the use of surgical drills and why?
saline irrigation to keep field moist, preventing overheating of bone
84
Why is the complete removal or follicular tissue attached at the ACJ important?
it could undergo cystic change if left behind
85
What is autotransplantation?
Autotransplantation refers to the repositioning of an autogenous erupted or unerupted tooth from one site to another in the same individual
86
What are the requirements/indications for autotransplantation?
- poor patient compliance or limited treatment time
- poorly positioned canine without ankylosis
- open apex desirable
- may simply rotate tooth around an axis
- need adequate space and bone
87
What is the technique of transplantation of a tooth?
- access as for removal but atraumatic elevation, avoiding contact with PDL/root, tooth 'parked' in tissues (often under flap just raised, somewhere moist), whilst prepare socket with bur or chisels
- socket 'friction-fit' avoiding heat generation
- minimal time >10mins
- may require splint immobilisation
- check tooth is free of occlusion
- post op check vitality and resorption
88
What is the success rate of autotransplantation and what can cause failure?
- failure rate 30% in over 9yrs often due to poor surgical technique
- internal resorption = perform RCT post op
- external root resorption = if excessive force on tooth in socket
- replacement root resorption = root replaced by bone until exfoliates
- infection
89
When does delayed eruption of maxillary incisors require monitoring or investigation?
- if contralateral teeth erupted 6/12 previously or in the case when both upper centrals missing one year after eruption of lower incisors
- deviation from normal sequence of eruption i.e. laterals before centrals
90
What is the hereditary aetiology of delayed incisor eruption?
- supernumaries
- cleft lip/palate
- cleidocranial dystosis
- odontomes
- abnormal tooth/tissue ratio
- gingival fibromatosis
- generalised retarded eruption
91
What are the environmental aetiological factors impacting delayed incisor eruption?
- trauma = root dilaceration
- early loss or extraction of deciduous teeth
- retained deciduous tooth
- cyst formation
- endocrine abnormalities (causing abnormalities in bone density)
- bone disease
92
What investigations should be done regarding delayed incisor eruption?
- history and exam
- look for retained deciduous teeth, palpable buccal/palatal mass, lack of space, adjacent teeth for tilting/crowding, erupted mesiodens/supernumaries
- radiography - parallax (2x PAs easiest)
93
How can incisor impactions be managed?
- remove retained deciduous tooth
- create and maintain space
- remove other obstructions and expose incisors surgically
- may require brackets to realign
- severely dilacerated incisors removed
94
What is the technique of incisor exposure?
- often repositioned labially so therefore flap raised taking as much attached gingiva as possible and repositioned apically and packed = open technique
- closed technique using bracket and gold chains are preferred
95
What is a disadvantage of the open technique for apically repositioned flap for incisor exposure?
flap repositioned in a more apical position to leave crowns exposed, can lead to poor aesthetics as if teeth continue to erupt or are orthodontically aligned, the teeth will more down but often the gingivae stays put. Resulting in exposed root - sensitivity and surface loss
96
Due to the possibility of root exposure with the open technique for incisor exposure, what kind of teeth is it mainly kept to?
used for teeth that are just sitting under the gingivae i.e. short distance
97
How does the closed exposure technique work for the exposure of incisors?
- orthodontic brackets with gold chains cemented to exposed crowns
- MP flap sutured back with gold chains exposed to allow attachment to orthodontic appliance
98
What is the aetiology of impacted mandibular premolars?
crowding, pathology, ankylosed deciduous teeth, supernumaries, genetic disorders
99
What placement of impacted mandibular premolars is palpable clinically?
lingual displacement
100
What kind of flap design and procedure is required for the removal of an impacted mandibular premolar?
buccal flap, avoiding damage to mental bundle, elevate or section tooth to remove as atraumatically as possible
- removal of adjacent premolar may be preferred
101
What kind of buccal flap is used for the removal of a mandibular premolar?
2 sided MP flap
102
What are the three forms of supernumary teeth?
1) supplemental = exact copy
2) conical
3) tuberculate = malformed
103
What is a mesiodens?
Mesiodens is a supernumerary tooth present in the midline between the two central incisors
104
What is hyperdontia?
rare condition where there are >32 teeth between the arches
105
What issues do tuberculate teeth cause?
tuberculate supernumaries tend not to erupt but prevent eruption of adjacent teeth, therefore, referral warranted often performed with incisor exposure
106
What is an odontome?
tumors of odontogenic origin
complex or compound
107
What are the two types of odontoma?
complex or compound
108
What is the difference between a complex and compound odontoma?
compound odontoma recapitulates the organization of a normal tooth, while the complex odontoma appears as a disorganized mass of hard odontogenic tissue
109
What is a complex odontoma formed by?
by invaginations of tooth germ, therefore disordered dental tissues found in mandibular molar region
110
What does a compound odontoma result from?
from exuberant proliferation of dental lamina therefore consists of a number of denticles (looks like a bag of small teeth)
111
Are compound or complex odontomas malignant?
they are often referred to as odontogenic tumours but they are entirely benign
112
Where are complex and compound odontomas most common?
complex = more common posteriorly
compound = more common anteriorly
113
What do complex odontomas look like?
disordered aggregation of dentine, enamel, cementum and pulp (doesn't look like a tooth, big mass)
114
What is exsanguination?
severe loss of blood
115
During planning of surgery, what are the stages involved?
1) decide on tooth removal
2) dependent on path of withdrawal
3) dictates position of instruments to elevate
4) influences methods to overcome obstacle (ie bone removal)
5) account for obstacles
6) inform incision and reflection
7) flap design
116
During the surgery, does flap design come first or last in the stages involved?
first
flap design, incise and reflect, account for obstacles, methods to overcome obstacles, position of instruments to elevate, path of withdrawal, tooth removal
117
What scalpels are used in making an incision?
no. 15 and no.11 generally
118
What are the stages involved in making an incision?
1) scalpel - standard pen grip
2) no. 15 or no.11
3) crevicular incisions - cut parallel to long axis with gingival crevice through periosteum onto sound bone
4) relieving incisions - run from crevicular area towards apices of teeth to provide mucoperiosteal relief
5) perpendicular to mucosal surface - don't want shelving
6) single sweeping rather than multiple
7) wearing of leading cutting edge - cutting one area cutting surface but accidentally cutting with distant area of blade
119
What type of incision is limited to the superior section of the alveolus?
envelope style incision
120
What kind of incision involves a crevicular incision and no relieving incisions?
envelope style incision
121
What kind of incision involves a crevicular incision and one relieving incision?
two sided flap
122
What kind of incision involves a crevicular incision and two relieving incisions?
three sided flap
123
What are some examples of extrinsic obstacles in minor oral surgery?
bone, soft tissues, anatomical features, adjacent teeth, pathology, space (lack of), location (palatal/lingual), maxillary sinus, inferior alveolar neurovascular bundle
124
What are some examples of intrinsic obstacles in minor oral surgery?
crown (size and shape), roots (number, morphology, angulation), pathology, caries, resorption, ankylosis
125
How can obstacles to MOS be overcome?
1) bone removal
2) sectioning
3) soft tissue
4) Care - technical skill, awareness of anatomy, avoidance (coronectomy)
126
What is the position of instruments to elevate dictated by in MOS?
guided by eruption path
often mesial
127
What are the paranasal sinuses?
air-containing sacs lined by ciliated epithelium, communicating with the nasal cavity
128
What paranasal sinuses are there in the head?
- bilateral frontal, ethmoid, sphenoid and maxillary
129
What is another name for the maxillary sinus?
The Antrum of Highmore
130
What shape is the maxillary sinus?
pyramidal
131
What is the volume of the maxillary sinus?
15-30ml
132
At what age does the maxillary sinus reach full size?
18 years and continues to enlarge
133
At what stage of life does the maxillary sinus develop?
3 months IUL
134
What does the maxillary sinus drain?
the middle meatus through a 2.4mm diameter ostium which is 2/3 up the medial wall of the sinus
135
What is the maxillary sinus related to (structures)?
- orbit, infraorbital nerve, nasolacrimal duct, posterior teeth and lateral wall of nose, pterygopalatine fossa and maxillary artery
136
How can the maxillary sinus be investigated clinically/radiographically?
- endoscopy, antral tap
- CT scan, MRI, occipitomental radiograph, DPT, Periapicals
137
What is the importance of the maxillary sinus in dentistry?
- roots of upper molars/premolars closely related to antrum and share common innervation (middle superior alveolar nerve)
- dental procedures complicated by problems involving antrum like OA communication, fracture tuberosity, extruded root canal materials, roots in antrum
- antral pathology may incidentally be demonstrated on a dental radiograph or present intra-orally
138
What are four common pathologies of the maxillary sinus?
1) infective sinusitis - bacterial, fungal, viral, 10% dental origin
2) non-infective sinusitis - allergic, vasomotor, septal deviation predisposes, foreign body (roots/teeth)
3) fractures
4) tumours/cysts
139
What is acute infective sinusitis and what bacteria causes it?
bacterial infection which follows a viral infection, commonly caused by strep. pneumoniae, H.influenzae but moraxella catarrhalis, staph aureus and alpha haemolytic strep also found
140
What is a diagnosis of acute infective sinusitis based on?
clinical grounds, no need for radiograph (opaque sinus or fluid level seen)
141
What are the signs of acute infective sinusitis?
pain, tenderness across area worsens on bending over, without swelling, posterior teeth TTP, post nasal drip, mucopurulent discharge
- maxillary toothache
- poor response to nasal decongestants
- history of coloured discharge
- purulent nasal secretion
142
How is acute infective sinusitis treated?
- mucolytics, inhalations for 2 weeks
- antimicrobials only in severe cases or in immunocompromised
143
If antibiotics were given to a patient for acute infective sinusitis (severe case or immunocompromised), what would they need to be effective against?
- penicillinase producing bacteria therefore augmentin (375mg tablet), doxycycline (50-100mg) or clarithromycin (250mg)
144
What is sinusitis?
- mechanical obstruction of ostium - oedema of nasal mucosa, polyps, septal deviation
- impaired mucous clearance - poor ciliary action, abnormally thick or sticky mucous (cystic fibrosis)
145
What is chronic sinusitis?
ongoing low-grade symptoms, suggestive of immunocompromise in absence of OAF or possible anatomical drainage problem (eg. deviated septum)
146
What is OAF?
Oro-antral fistula - epithelialized pathological unnatural communication between oral cavity and maxillary sinus
147
How is chronic sinusitis treated?
drainage (antral lavage, intranasal antrostomy)
metronidazole with amoxicillin/erythromycin
148
What are three possible complications of sinusitis?
1) brain abscesses
2) orbital cellulitis
3) cavernous sinus thrombosis
149
What is an oro-antral communication caused by?
- caused following extraction of posterior teeth, tuberosity fracture, middle third fracture or also malignancy/pathology
150
What are the symptoms of oro-antral communication?
passage of fluid down nose, passage of air into mouth, alteration of voice, unilateral epistaxis or nasal obstruction
151
What is epistaxis?
nose bleed
152
What can occur if an oro-antral communication is left untreated?
fistula develops which can cause persistent sinusitis, unilateral nasal discharge, intra-oral antral polyp, cacogeusia and facial pain
153
What is cacogeusia?
sensation or illusion of an unpleasant taste, not related to the ingestion of specific substances and often caused by a neurological disorder
154
How do you assess for possible OAC and gain consent?
- extracting any upper molars and occasionally premolars
- if the film suggests close relationship
- inform patient of risk, what to expect afterwards if it happens
- outline how complication is managed
155
How do you manage an oro-antral communication?
- ideally close immediately - buccal advancement flap
- plate or modified denture
- antibiotics, ephedrine drops, mucolytic inhalations
- avoid nose blowing
- if communication of >5mm, spontaneous closure unlikely
156
What are the four types of complications in oral surgery?
1) Pre-operative
2) intra-operative
3) post-operative
4) special
157
What calcium channel blocker is a strong inhibitor of CYP1A2, therefore slowing metabolism of local anaesthetic?
Verapamil
158
What system metabolises local anaesthetic drugs?
CYP450
amide groups undergo hepatic cytochrome p450 metabolism
159
Name four inducers of CYP1A2, an enzyme involved in the metabolism of local anaesthetic (therefore quickening metabolism)
- smoking
- broccoli
- insulin
- omeprazole
160
What does it mean when local anaesthetic systemic toxicity is termed "biphasic"?
- excitatory at low doses (eg. muscle twitching, agitation, auditory change - tinnitus, metallic taste)
- at higher concentrations it is depressant with perioral tingling, drowsiness, unconsciousness, respiratory arrest, reduced excitability/contractility of myocardium
161
Fatalities due to LA toxicity are generally due to what effect on the CNS?
depressant effect
162
A high incidence of LA cardiac arrest cases are resistant to what?
resuscitation measures
163
How do we prevent LA toxicity?
aspirate
slow injection
limit dose
164
What is the treatment of LA toxicity?
stop
BLS
call for help
monitor
- in hospital: lipid emulsion therapy
165
What are five bone related post-operative complications?
1) alveolar osteitis "dry socket"
2) sequestrum
3) exposed bone
4) MRONJ
5) ORN
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What is alveolar osteitis?
"dry socket"
- inflammation of bone
- commonly mandibular molars
- mostly incidence of <5%
167
What is the pathogenesis behind alveolar osteitis?
1) complete absence of blood clot or formation of initial clot subsequently lysed (fibrin formation then fibrinolysis)
2) inflamed alveolar bone - release of tissue activators (plasminogen into plasmin)
168
What are the risk factors for alveolar osteitis?
- women
- smoking - vasoconstriction
- trauma
- medications - oral contraceptive pill, antipsychotics, antidepressants
- anatomy - mandibular third molars
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What is the usual presentation of alveolar osteitis?
- post extraction
- onset any, often 2-3days
- worsening pain
- refractory to analgesia
- dull aching throb (severe)
- bad taste
- discharge
- halitosis
170
How is alveolar osteitis managed?
- LA ideally
- exploration of socket - debris? sequestrum?
- irrigation - saline
- sedative dressing - alvogyl
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What is a sequestrum?
- small (usually) bony fragments lost from extraction site
- could be entire socket alveolus
- radiograph may be useful
- tooth fragment
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What medications are associated with MRONJ?
- bisphosphonates - alendronate, ibandronate, zolendronate, pamidronate
- RANKL inhibitors - denosumab
- Anti-angiogenics - bevacizumab, sunitinib, aflibercept
173
What is Paget's disease?
disease of bone disrupts the normal cycle of bone renewal, causing bones to become weakened and possibly deformed
174
What population of patients does osteoradionecrosis (ORN) occur in?
irradiated patinets - H&N cancer
175
Which jaw most commonly experienced ORN?
mandible>maxilla
176
Is ORN reversible?
no
177
What is ORN characterised by clinically?
- non-healing bone
- severe pain
- recurrent infections
- halitosis/foul smell
- oro-facial fistula
- suppuration
- pathological fracture
178
What medication does INR level apply to?
warfarin
179
What 4 factors can be looked at in a pre-op assessment regarding bleeding?
1) vascular abnormalities
2) platelet deficit - number
3) platelet deficit - quality/function
4) clotting mechanism
180
What is ecchymosis the medical term for?
bruising
181
What is melaena?
Melaena is the passage of black, tarry stools. Indication of upper GI bleeding
182
What is haematuria?
blood in urine
183
What is haematemesis?
blood in vomit
184
What are four examples of hereditary bleeding conditions?
1) Haemophilia VIII and IX
2) Factor XIII
3) vW disease
4) Ehlers Danlos syndrome
185
What are four examples of acquired bleeding disorders?
1) medications
2) liver disease
3) alcoholism
4) haematological malignancy - lymphoma, leukaemia
186
What are two examples of haematological malignancy?
lymphoma
leukaemia
187
What is haemophilia VIII or A?
Hemophilia A, also called factor VIII (8) deficiency or classic hemophilia, is a genetic disorder caused by missing or defective factor VIII (FVIII), a clotting protein.
188
What is haemophilia IX or B?
type of clotting disorder, much rarer than Haemophilia A. A specific protein is missing from the blood so that injured blood vessels cannot heal in the usual way
189
What is Factor XIII deficiency?
abnormal blood clotting that may result in abnormal bleeding as the result of a deficiency in the blood clotting factor 13, which is responsible for stabilizing the formation of a blood clot
190
What is Ehlers Danlos syndrome?
group of conditions that cause very flexible joints and stretchy and fragile skin. unusually flexible joints and skin that stretches and breaks easily.
Easy bruising and bleeding
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What does parenteral mean?
administered or occurring elsewhere in the body than the mouth and alimentary canal
192
Name 5 anti-platelet drugs that can impact bleeding risk
1) clopidogrel
2) aspirin/NSAIDs
3) Prasugrel
4) Ticagrelor
5) Dipyridamole
193
Name four NOAC (novel oral anticoagulants) that can impact bleeding risk
1) apixaban
2) rivaroxaban
3) edoxaban
4) dabigatran
194
What are coumarins, give examples and what is their relevance to oral surgery?
- warfarin, dicumarol, phenprocoumon, acenocumarol), - interfere with vitamin K-dependent coagulation factors, are of benefit in the prevention of thromboembolic events when indicated, but concomitantly increase hemorrhagic risk
195
What are the four categories of anticoagulants that can increase bleeding risk?
1) Coumarins
2) Parenteral heparin
3) LMW heparin
4) Non-vit K (NOACs)
196
What is considered normal bleeding and how is it handled?
2-5mins
biting pressure, firm digital pressure
197
What is considered reactionary bleeding and why does it happen?
- 2-3hrs post-op
- LA wears off
198
What is considered secondary bleeding and what usually causes it?
up to 14 days
usually infection
199
What is considered abnormal bleeding and how is it managed?
- increased volume, extended duration
- light, physical access, suction, pressure (immediate general), suture (pressure immediate local), bone wax, crush, electrocautery, silver nitrate
200
What are 6 examples of haemostatic agents?
1) gelatin
2) collagen
3) cellulose based
4) adhesives
5) topical thrombin
6) antifibrinolytics (tranexamic acid)
201
When should you refer a bleeding patient?
- ongoing severe haemorrhage
- reached extent of capabilities
- decreased BP (100/60)
- increased HR (>100bpm)
202
What is sepsis?
an extreme body response to an infection
life threatening medical emergency
occurs when a pre-existing infection initiates systemic sequence of events
203
Why is sepsis important in oral surgery?
failure to recognise or implement appropriate treatment can result in rapid progression leading to tissue damage, organ failure and death
204
Who is most at risk of sepsis?
- less common in women
- higher in non-whites
- age >75yrs
- recent trauma, injury, surgery
- indwelling lines, IVDU, broken skin
- HIV/AIDs
- Cirrhosis, asplenia, autoimmune disease, organ transplant, neutropenia, cancer, inflammatory disorder, immunodeficiency
205
What are the four most common sites for onset of sepsis?
1) lungs 64%
2) abdomen 20%
3) bloodstream 15%
4) renal or genitourinary tract 14%
206
What are the five presenting symptoms of sepsis?
1) temp >38 or <36
2) HR >90bpm, high risk >130bpm
3) resp rate >20, high risk >25 breaths/min
4) WCC >12 or <4 (x10 to 12/mL)
5) BP systolic <100, high risk <90mmHg
207
What are the red flags for spotting sepsis?
- altered mental state/confusion
- unable to stand/collapse
- unable to catch breath/speech
- fast breathing
- skin pale, mottled, ashen or blue
- rash won't fade
- recent chemotherapy
- oliguria (low urine output)
208
What does the acronym SEPSIS stand for?
Slurred speech
Extreme shivering
Passed no urine in a day
Severe breathlessness
Illness so bad they feel they're dying
Skin mottled/discoloured/ashen
209
Does the rash seen in sepsis blanch upon pressure?
no
210
What are the sepsis 6 for management?
1) give 02 to keep sats above 94%
2) take blood culture (before ABx)
3) give IV antibiotics
4) give a fluid challenge
5) measure lactate
6) measure urine output
211
What does BUFALO stand for in sepsis management?
Blood cultures and septic screen, U+E's
Urine output - monitor hourly
Fluid resuscitation
Antibiotics IV
Lactate measurement
Oxygen - to correct hypoxia
212
How does ethnic background affect degree of difficulty of extractions?
relates to quality/quantity of bone (afro caribbean/asian patients = more dense bone)
213
What is impaction?
the tooth is prevented from achieving a functional occlusal position
214
What is an operculum?
piece of gum lying over biting surface of a tooth
215
What is an operculum over a tooth classified as?
soft tissue impaction
216
What is crowding?
teeth affected are the teeth that erupt later and can often get impacted if there is a lack of space or the teeth are poorly positioned
217
How does crowding create difficulty in extraction?
prevents access for the beaks of forceps
218
Why is access difficult for the extraction of maxillary third molars?
mouth opening brings the coronoid process into the space lateral to the maxillary third molar
teeth often slightly buccally inclined so difficult to engage with forceps - may need bayonets
219
How can lone standing molars present difficulty in extraction?
- heavy occlusal loading
- pneumatisation of the maxillary antrum - antrum erodes into space where adjacent tooth may have been
- OAC
- fractured tuberosity
- thickened PDL and bone due to heavy occlusal loading
220
How can the antrum present issues for extractions?
- always assess proximity of maxillary antrum
- predict/assess risk of OAC
221
How can abrasion present issues for extractions?
- predisposes crown to fracture so if the beaks of the forceps are not firmly on solid root, then crown will fracture
222
How do endodontically treated teeth present issues for extraction?
they are brittle and likely to fracture
223
How does caries/the condition of the crown present complications for extractions?
inadequate tooth tissue to engage beaks of forceps
need some root above level of alveolus to get grip
224
How can retained roots be removed?
if root has sound tissue above the alveolus then elevation may be possible but if the tooth has fractured beneath the level of the alveolus then surgery is required
225
What is a submerged tooth?
Submerged tooth is the one that is depressed below the occlusal plane. Dental ankylosis is thought to be a major cause of submergence
226
How are submerged teeth managed?
surgery
227
How does periodontal disease impact extraction difficulty?
periodontally involved teeth are simple forceps extractions as you can engage well down the root of the tooth and if it is mobile, very little force is required to remove the tooth
228
Name 8 radiographic features of difficulty for extraction
1) bulbous roots
2) dilacerated/divergent/convergent roots
3) fused roots
4) multi-rooted teeth
5) hypercementosis
6) ankylosis
7) lone-standing/last-standing molar
8) deeply impacted 3rd molars
229
What are bulbous roots and how do they impact extraction difficulty?
- roots can be bulbous apically or along whole length of root
- require surgical approach
230
Curvature of lower molar teeth roots indicates what?
close relationship to the IDC
231
Teeth with hypercementosis of root and root tips present with what?
bulbous roots
232
How do you section roots for surgical removal?
- never with a high speed handpiece, causes surgical emphysema and introduces air in the tissue and can lead to cellulitis
- surgical handpieces that do not introduce air into the tissues
233
What are two examples of congenital benign mucosal lesions?
leukoedema
fordyce spots
234
What is leukoedema and how does it present?
- white/grey discolouration of mucosa generally
- asymptomatic
- most obvious on buccal mucosa but can affect any area in mouth
- due to slight thickening of mucosa itself
- in area outwith areas that can be traumatised by teeth so tends to be more extensive by trauma related lesions
- pts generally unaware, often FH
- completely benigin
235
What are fordyce spots and how do they present?
- ectopic sebaceous glands
- appear as small, cream-coloured spots within buccal mucosa
- seen within cheek or sometimes within lips
- harmless, common and benign
236
What are six examples of traumatic benign mucosal lesions?
1) erosions/ulcers
2) frictional keratosis
3) polyps
4) denture induced hyperplasia
5) amalgam tattoos
6) mucocoeles
237
What can cause traumatic ulcers and how are they handled?
dentures, restorations, direct trauma
irradicate source and 14 day resolution
238
What are aphthous ulcers and what causes them?
typically a solitary round or oval punched-out sore or ulcer inside the mouth on an area where the mucosa is not tightly bound to the underlying bone.
trauma, genetic, food stuffs, haematinic deficiency, hormonal, self resolving
239
What is morsicatio buccarum?
chronic cheek biting
240
What is linea alba?
- traumatic benign mucosal lesion
- white tissue line at level of occlusal plane
- asymptomatic
- associated with clenching, sucking habits
241
What are polyps and what are they an example of?
- traumatic benign mucosal lesion
- benign growths from the mucosa - either sessile or pedunculated
- normal overlying mucosa with fibrous centre
- asymptomatic unless traumatised
- treatment = excision
242
What is an amalgam tattoo?
- traumatic benign mucosal lesion
- metal inclusion in the mucosa
- benign, biopsy to establish diagnosis
243
What is denture induced hyperplasia?
- traumatic benign mucosal lesion
- ill fitting dentures worn 24/7
- superimposed candida infection
- asymptomatic, treatment is excision of excess tissue, candida treatment and new dentures
244
What is a mucocoele?
-traumatic benign mucosal lesion
- painless fluid-filled cyst on the inner surface of your mouth
- mucous extravasation cyst
- saliva escapes from damaged duct into surrounding lip and causes swelling
treatment = excision
245
What are two examples of fungal infective benign mucosal lesions?
- acute pseudomembranous candidiasis
- candidal leukoplakia
246
What are two examples of virus mediated infective benign mucosal lesions?
- human papilloma virus
- herpes virus
247
What is candidiasis?
fungal infective benign mucosal lesion
thrush - white plaques that wipe free leaving red base
248
What is candidal leukoplakia?
fungal infective benign mucosal lesion
- white/red lesion
- does not wipe free
- treated with systemic antifungals and biopsy
249
What are papillomas?
- viral infective benign mucosal lesion
- HPV
- sessile or pedunculated
- asymptomatic but can become traumatised
- treatment = excision
250
What is secondary herpes?
- viral infective benign mucosal lesion
- reactivation of latent virus in trigeminal system - UV light, stress, immunocompromise
- tingling sensation before vesicles develop on lip
- cold sore treated with topical antiviral
251
What are three examples of inflammatory benign mucosal lesions?
- geographic tongue
- lichenoid reactions
- epulis
252
What is geographic tongue?
- inflammatory benign mucosal lesion
- fissured tongue, possible link to psoriasis
- often asymptomatic
- 2-3% population, FH
253
What is a lichenoid reaction?
- inflammatory benign mucosal lesion
- reaction to metal (contact lesion)
- or medications - antihypertensives, hypoglycaemics, NSAIDs
- often asymptomatic
- biopsy to diagnose
254
What is an epulis?
growth on the gum grows over/around tooth
Epulides (plural of epulis) arise from the periodontal ligament
255
What is a fibrous epulis?
- inflammatory benign mucosal lesion
- associated with gingival margin of teeth
- usually caused by chronic irritation
- normally overlying mucosa and fibrous centre
- treatment = excision
256
What is a pyogenic granuloma?
- inflammatory benign mucosal lesion
- same site as fibrous epulis but more vascular lesion and associated with females during pregnancy so possible hormonal association
- treatment = excision
257
What is Addison's disease?
- metabolic disease that presents with metabolic benign mucosal lesions
- primary adrenal insufficiency
- deficiency of cortisol and aldosterone
- in addition to skin pigmentation there is oral pigmentation
258
What mucosal lesions present in Addisons disease?
metabolic disease
oral mucosal pigmentation
259
What is a melatonic macule and what causes them?
- traumatic or idiopathic benign mucosal lesion
round or oval benign hyperpigmented macule that may be found on the lips or oral mucosa
develops in 50+ age group
asymptomatic
biopsy for diagnosis, excise for aesthetics
260
What are two examples of autoimmune benign mucosal lesions?
1) lichen planus
2) vesiculobullous conditions
261
What is lichen planus?
- autoimmune inflammatory condition
- various forms and symptoms
- bilateral, biopsy for diagnosis
262
What are vesiculobullous conditions?
- autoimmune inflammatory condition
- painful blisters that rupture into erosions and ulcers
- biopsy to determine diagnosis
263
What are idiopathic lesions?
lesions of unknown aetiology e.g. lipoma
264
What is a lipoma?
idiopathic benign mucosal lesion
- benign mesenchymal neoplasm
- cause unknown
- made up of fat cells surrounded by thin fibrous capsule
- treatment = excision
