Oral Surgery Flashcards
GDC sedation definition
drugs used to produce depression of the CNS
communication maintained
pt will respond to command throughout period of sedation
margin of safety wide enough to render unintended loss of consciousness unlikely
components of sedation assessment
History: establish nature of fear/phobia/anxiety (cant do IV sedation for people with needle phobia)
Explain to patient:
* Escort
* No alcohol before
* No responsibilities or work following day
* No driving for 12hours
MH: drug interactions – alcohol, opioids, erythromycin, antidepressants, antihistamines, antipsychotics, recreational
drugs
ASA Classification
ASA Classifications
ASA Class I: Normal healthy patients
ASA Class II: Mild systemic disease (amber light for practice) BP< 160/95
ASA Class III: Severe Systemic Disease
ASA Class IV: Incapacitating disease which is a constant threat to life
ASA Class V: Moribund pt’s not to expected to live >24hrs
indications for sedation
MH aggravated by stress: IHD,Hypertension, Asthma, IBS, Epilepsy
Handicap/Parkinsons/learning difficulties
Phobia/Gagging/Fainting
Procedure – long, difficult, unpleasant
contraindications for sedation
COPD
hepatic insufficiently
pregnancy
severe special needs
drug used in IV sedation
midazolam 5mg/ml
reverse drug for IV sedation
flumanenil 200ug
indications for inhalation sedation
Anxiety
Needle fear
Gagging
Traumatic treatment
MH that increases stress
Unnacompanied adults needing sedation
contraindications for inhalation sedation
Common Cold
Enlarged tonsils/adenoids
COPD
1st trimester pregnancy
Limited understanding
pre op instructions for inhalation sedation
Light meal pre-appt
Routine meds
Children accompanied by adult
Adults need accompanied at 1st appt only
no alcohol
sensible clothing
arrange childcare post-appointment
plan to remain in clinic 30mins post appt.
what to include in GA referral letter
9
- Pt name and address
- Parent/Guardian name
- contact no.
- Treatment plan
- Justification (SIGN 47)
- radiographs
- Medical History
- GP details
- My details
TMD history
SOCRATES
MHx and SHx markers:Unusual posturing – chin holding, wind instrument, singer, Stressful event in life
e/o
* Mouth opening
* Palpate masseter + temporalis
* Test opening against resistance (test pterygoids by placing gentle pressure under chin)
* Listen for click
* crunch - crepitus
I/o:
* Interincisal mouth opening – normally 40-55mm
* Parafunction: Linea Alba
* Tongue Scalloping
* Cheek biting
* Occlusal, non carious TSL
* Enamel Hairline Fracture
Differential Diagnosis: Dental Pain, Sinusitis, Trigeminal Neuralgia, Referred neck pain
reversible TMD management
CONSERVATIVE - no actual pathology of joint
Pt education – explain nature of problem, why its happened, what will make it better,
how long it’ll take,
Reassure
Soft Diet - Dont incise/cut into small bits
Break Habits
Supported mouth on opening (yawn)
no wide opening
No chewing gum
Chew on both sides
stop parafunctional habits
stop postural habits – phone, resting chin on hand
Hot or cold packs
Scarf cold day
Analgesia – Paracetamol + Ibuprofen (max. respectively 1g every 4hrs, 600mg every 4 hours.. alternate)
Can also advise: Physio, massage, acupuncture, hypnotherapy
Conservative advice for 8 weeks before Rx of Hard Splint - bite raising appliance
- also protects teeth from grinding
SPLINT for TMD
after trying conservative advice for 8weeks
Won’t feel affects for several weeks – persevere
Problems wont go away without it
Cleaning – fairy liquid warm water soft bristled brushing
Excess saliva and bulkiness for 24hrs
Wear at times of parafunction activity – at work, driving, sleeping, studying.
Works by stabilising occlusion and improving function of MoM, decreasing abnormal acivity and also protects the teeth
irreversible TMD management
pathology of joint causing discomfort - crepitus; anterior disc displacement without redction
REFER
Arthrocentesis
Arthroscopy
Disc-repositioning surgery
Disc repair/removal
High condylar shave
Total joint replacement
Cranial nerve exam
Olfactory – sense of smell
Optic - Visual acuity - ask pt to count fingers; read print on Snellen chart; visual field;
Occulomotor – shine light and assess pupil size, shape and symmetry
Trochlear – move eye
Trigeminal – clench jaw muscles. touch skin, ask about altered sensation. Check all 3 branches.
Abducens – move eye in all directions
Facial – muscles of facial expression, smile, frown, rais eyebrows, screw up eyes, pout, whistle
Vestibulocochlear – whisper in one ear
Glossopharyngeal -assess pupil size, shape and symmetry
Vagus – look for deviation of uvula when saying ahh
Accessory nerve – shrug shoulders
Hypoglossal – look for any wasting/limp areas on tongue, protrude see if symm/deviation, ask to move to either cheek
lymph nodes names
Occipital
Retro Auricular
Pre- Auricular
Buccal
Submental
Submandibular
Superficial Cervical Nodes
Jugulodigastric
Deep Cervical
Jugulo-omohyoid
Supraclavicular
OAC dx
Radiographic position of roots in relation to antrum
Bone at trifurcation of roots?
Visual with direct light - bubbling of blood
Listen for echo w/ suction
management of OAC
Inform pt
IF: SMALL <2mm/ sinus lining intact:
* Encoruage clot
* Suture margins Vicryl Rapide 4.0 (resorbable)
* Amoxixillin 500mg 7 days
* Post-op instructions: reg. Meds
* refrain from nose blowing/stifling sneeze
* avoid straws
* refrain from smoking
* steam inhalation
LARGE >2mm/ lining torn: Buccal advancement flap w/ non-resorbable sutures Prolene 7.0
dx OAF
fluid coming out nose when drinking
problems with speaking, smoking using a straw
bad taste/pus
pain/sinusitis
management OAF
Excise sinus tract
B.A.F/Buccal fat pad with B.A.F/Palatal flap/Bone graft
aetiology of maxillary tuberosity fracture
Single standing molar
XLA in wrong order 678, where it should 876
Unerupted/unknown wisdom toothbrush
Inadequate alveolar support
dx of maxiallary tuberosity #
Multiple tooth movement
Noise
Tear on palate
Feel and see movement
management of maxillary tuberosity #
Mgmt Option 1: Dissect out + close wound
Mgmt Option 2:
Reduce & Stabilise (Hold in place with fingers + Ortho buccal arch wire welded with composite)
* Teeth involved: RCTx; remove from occlusion; amoxicillin + chx; instructions post-op; SR XLA tooth 8 weeks later
management root in maxillary sinus
- Confrim radiographically
- Decision on retrieval
* Caldwell Luc approach – through buccal sulcus, cut window into bone
* OAF type approach through socket, suction, small curettes, irrigation, close. - Refer if in doubt
sinusitis
what is it
symptoms
differential dx
cant evacuate contents: build up of pressure and bacterial overgrowth.
Congestion, fever, headache,
Discomfort on palpation of infraorbital, diffuse pain max.teeth, worse pain on head movement.
Differential: Abscess, infection, caries, xla site, MFPDS, Neuralgia, Atypical Facial pain
management sinusitis
Self limiting, lasts 2.5wks
Local measures: Steam inhalation
Ephidrine Nasal Drops 0.5% (not for patients with high BP)
If persistent: Amox 500, 7days.
trigeminal neuralgia
management
Ensure pain is not odontogenic
Urgent referral to OM/GP for FBC, LFT, assess response + titrate dose
Carbamazepine tabs 100mg
Send: 20tabs
Label: 1 tab twice daily
Positive response to drug confirms diagnosis
how to name mandib #
- Type Simple/Compound/Communited
- Number Single/Double/Multiple
- Side Unilateral/Bilateral
- Site Symphyseal, Parasymphyseal, Body, Angle, Ramus, Coronoid, Subcondylar, Condylar
- Direction Fav/Unfav (increased risk of displacement)
- Specifics Green Stick (children, incomplete separation) or Pathological – BONJ, Osteomyelitis, KcOT
- Displacement- Displaced or Undisplaced (may require no tr)
possible post op complications
Trismus – monitor, gentle mouth opening excersizes, wooden spatulae, trismus screw
Soft Tissue bleeding – pressure, suture, LA, Diathermy, Haemostatic forceps, if severe A&E
Bone bleeding – Pressure, LA, Surgicel/Kaltostat/Bone wax, Pack
Dry socket
Osteoradionecrosis
how to manage post op bleeding
Calm pt
Clean pt
Take a history – rule out bleeding disorder or meds. (warf/aspirin/anti-platelets)
* Contact haematologist if bleeding disorder
* If warfarin – do INR;
* Hospital if large volume of blood loss, medical problems, extremes of age
Vision + suction
Remove large jelly clot
Identify site
Pressure
LA with adrenaline
Surgicel (oxidised celulose)
Suture
Ligation
If you cant arrest haemorrhage then refer to hospital
Give pt contact no.
Review
Haemostatic agents: LA w/ adrenaline, Surgicel, Gelatin Sponge, Thombin powder, fibrin foam
Systemic – Vit K, Tranexamic Acid (anti-fibrinolytic) Missing Clotting factors
dry socket
what is it
starts 3-4 days postXLA
1-2wks to resolve
mod-severe dull throb/ache
can radiate to ear
bad smell/taste
no fever or pus
‘clot fails to form or breaks down’ due to smoking; contraceptive pill; Local Anaesthetic
F>M
Molars
excessive rinsing/traumatic xla
previous dry socket/FH
dry socket management
Reassure + Analgesia
LA block
Saline, check for bony fragments
Alvogyl (LA+antiseptic) to soothe pain and prevent food packing
Advise analgesia + hot salty mouthwash
Review and change dressing every 2 days
osteomyelitis
what is it
inflammation of bone marrow
‘infection of the bone’
Rare, mandible
fever, may have altered sensation
Predisposed by: mandibular fracture or odontogenic infection
No radiographic changes until 10-12 days, increased radiolucency – uniform/patchy with a moth-eatenappearance.- areas of radiopacitity within sequestrae
osteomyelitis
management
FBC, Glucose, seek medical consult
Up to 6months of high dose antibiotics
Severe – may need hospital admission and IV abx
Drainage
Remove non-vital teeth @ site of infection
remove loose bone
Excise necrotic bone
osteroradionecrosis
what is it
radiation causes bone’s blood supply to be reduces, doesnt heal well after xla so need to
prevention
prevention for osteoradionecrosis
prevent need for XLA- dentally fit prior to radiotherapy; OHI, Scaling, Chx
Antibiotics post xla
Hyperbaric O2
Refer for extraction
tx for osteoradionecrosis
Irrigation of necrotic debris
Loose sequestrae removed
Small wounds <1mm heal over 1month
Larger ones need bone resection and suturing
Hyperbaric O2
signs and symptoms of severe orofacial infection
Swelling/fluctuant/induration
Airway Compromise
Fevere
Lethargy
Malaise
Dehydration
Induration
Trismus
Dysphagia
Sytemic Inflammatory Response Syndrome: 2 out of 4 needed for Sepsis Syndrome: Urgent referral
* Temp <35ºC or >38ºC
* Heart Rate >90bpm (tachycardia)
* Resp Rate >20 breaths per minute or PaCO2 <4.3kPa
* (WBC count <4, >11)
cellulitis Vs abscess
Cellulitis: warm, diffuse, erythematous, indurated and painful swelling.
* Acute
* Large
* Diffuse borders
* Doughy/induration
* No pus
* Greater degree of seriousness
Abscess: pocket of necrotic tissues, bacterial colonies, dead white cells
* Chronic
* Small
* Well circumscribed
* Fluctuant
* Pus
* Less degree of seriousness
SIRS
Sytemic Inflammatory Response Syndrome:
2 out of 4 needed for Sepsis Syndrome: Urgent referral
* Temp <35ºC or >38ºC
* Heart Rate >90bpm (tachycardia)
* Resp Rate >20 breaths per minute or PaCO2 <4.3kPa
* (WBC count <4, >11)
principles of management of dental infection
- Drainage – xla/endo/incision I/o or e/o
- Remove cause – xla/endo/periradicular surgery
- Supportive antibiotic therapy – severe spreading infection/ systemic involvement/ medically compromised.
REVIEW 24hrs
4 indications for culture and sensitivity testing for infection
rapidly progressing
non responisve
previous antibiotics therapy
recurrent infeciton
indications for antiobiotics
4
trismus
lymphadenoapthy
temp >38
severe periocorontitis
cyst
pathological cavity containing fluid, semi-fluid or gaseous contents & not formed by accumulation of pus.
odonotgenic cysts types
2 categories
Inflammatory -
* Radicular: Apical
* Lateral
* Residual
Developmental
* Keratocystic Odontogenic Tumout (kcot)
* Dentigerous cyst
* Eruption cyst
* lateral periodontal cyst
* gingival cyst
non-odontogenic cysts
nasopalatine duct cysts
special investigations for cysts
Vitality testing (teeth associated with radicular cysts are non-vital)
Radiology: Panoramic, PA, Sinus views
Aspiration
Biopsy of cyst lining
reasons for endo failure
Misdiagnosis
Inadequate cleaning - not using NaOCl, not under rubber dam
Inadequate shaping
aim of peri radicular sugery
apical seal
remove existing infeciton
indications for peri-radicular surgery
Failure of endodontics due to
1. Nerves left in lateral canals near apex, leading to chronic irritation
2. Obstruction to instrumentation (instrument, root fracture, dilaceration)
3. RCT underfilled, overfilled, open apex
4. Poor host tissue response
5. Poor natural drainage of infection
TMD
signs/symptoms
click of joint
sore muscles
hypertrophic MOM
sore in AM
tongue scalloping
cheek biting
wear facets
prevalance of TMD
75% of population get it at some point in their life
explanantion of TMD
The jaw joint sits in base of skull and muscles control opening and closing. Now, like any muscle in the body, if overworked they get tired e.g. if you climb a mountain legs are sore for next few days.’
‘However, as your jaw joint gets used all day everyday like for speaking and eating it never gets a rest. Muscles become inflamed and sore.’
‘The fact that you’re sore in the morning also tells us that you clench or grind your teeth at night as well which puts more stress on those muscles and exacerbates the problem even more’
‘The clicking by your ear is caused when the disc between your jaw and the skull gets trapped in front of the jaw bones and snaps in place’
Could draw a wee diagram to show disc and explain that when muscles not in harmony the disc is pulled at wrong time to create clicking noise or disc trapped in front of jaw bones crushing the tissue that can cause pain.
management of TMD
reassurance
resting theh join - soft food, cut in small pieces, chew on both sides, avoid chewy stikcy foods, avoid wide opening, support jaw when yawn, avoid habits (nail biting)
analgesia
heat packs
stress reduction
bite splint for night time
summary for TND
Reassurance - common condition with simple conservative management
Important to reduce stress
Inform that other symptoms like tongue scalloping and linea alba are caused by the clenching and also go away on management of condition.
Ask if any questions
Actor marks for communication, simplicity of language and empathy
