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Dentistry in a Nutshell > Oral Surgery > Flashcards

Oral Surgery Flashcards

1
Q

when to refer non 3rd molars for XLA (6)

A
  1. unsuccessful initial attempt
  2. abnormal tooth morphology
  3. periapical radiolucency requiring histological assessment i.e. suspected cyst
  4. increased risk of damage to adjacent major anatomical structures
  5. reduced access to tx site
  6. medically compromised pt
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2
Q

when to refer 3rd molar XLA (7)

A
  1. 1 or more incidences of pericoronitis
  2. unrestorable caries in 3rdM or impaction causing caries in adjacent 2nd molar
  3. risk of caries in 3rdM or adjacent tooth
  4. anatomical position of tooth inhibiting OH & acting as risk factor for pericoronitis
  5. periapical pathology
  6. prior to orthognathic surgery
  7. prior to initiating radio or chemotherapy
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3
Q

when to refer to MOS (4)

A
  1. XLA / surgical exposure of impacted teeth
  2. closure of oroantral communication or fistula
  3. root in maxillary antrum removal
  4. pre prosthetic surgery as part of restorative txp
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4
Q

when to refer TMD (1)

A

failed initial conservatory management

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5
Q

when to refer oral cancer

A
  1. abnormal lesion in mouth suspected to be oral cancer
  2. oral cancer signs subject to urgent 2wk referral:
    - non healing ulcer often painless or sore for >3wks
    - lump or thickness in cheek or elsewhere in mouth
    - persistent soreness of mouth / throat as well as difficulty chewing / swallowing
    - numbness of tongue / other areas in mouth
    - swelling of jaw
    - unexplained loosening of teeth or pain around teeth / jaw
    - voice changes
    - lump or mass on back of neck
    - unexplained weight loss
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6
Q

when to refer due to medical conditions (4)

A
  1. high MRONJ risk
  2. pt at risk of ORN
  3. unstable cardiovascular disease
  4. uncontrolled diabetes
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7
Q

medical considerations - high BP

A

risk of bleeding & MI risk
check how well controlled it is, asl for recent BP readings, consider postponing if >160/100mmHg, adrenaline containing LA is contraindicated

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8
Q

medical considerations - angina

A

risk of angina or MI during XLA
ensure GTN spray readily available & enquire re frequency of angina attacks

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9
Q

medical considerations - recent MI

A

risk of MI
no XLA within 3mths of MI, no GA within 6mths of MI (increases risk of repeat MI by 50%)

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10
Q

medical considerations - cardiac defects

A

e.g. valve replacement, previous endocarditis, hypertrophic cardiomyopathy
increased risk of infective endocarditis
ensure pt is aware of increased risk, explain symptoms, record discussion in notes, liaise with pt cardiologist, check guidelines, for high risk pt consider antibitoic prophylaxis, reinforce good OH

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11
Q

medical considerations - liver disease

A

risks - bleeding due to reduced produced of coagulation factors, splenomegaly causes reduced platelet numbers, cross infection risk due to hep B/C/D/E, reduced drug metabolism.
liaise with pt physician, consider coag screen & FBC, check BNF for appropriate drug prescription

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12
Q

medical considerations - kidney disease

A

risk - bleeding due to platelet dysfunction & immunocompromised
liaise with pt physician, consider renal profile & FBC, dialysis pt are best treated the day after dialysis for optimal renal function, check BNF for appropriate drug prescription

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13
Q

medical considerations - diabetes

A

risk - hypoglycaemic emergency, impaired wound healing
morning appt preferred as blood glucose more stable, pt safe to trear if blood glucose level is between 5-15mmol/L

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14
Q

medical considerations - epilepsy

A

risk - seizure due to stress
ensure pt has eaten prior to XLA, enquire re frequency & type of seizures, IV sedation may be recommended due to anticonvulsant effects

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15
Q

medical considerations - haemophilia A/B & VWB

A

risk - bleeding due to genetic deficiency of clotting factor VIII (A), IX (B) AND VW factor (VWB)
consider factor assay, between 50-75% factor VIII levels required for tx, DDAVP & tranexamic acid may be required, high bleeding risk XLA should be carried out in hospital setting, take all haemostatic measures & refer to SDCEP, book pt in early in day & week to allow space for emergency appt, consider referral

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16
Q

drug considerations - anticoagulant therapy

A

risk of bleeding:
1. warfarin - inhibits production of vit K dependent clotting factors
2. apixaban - factor Xa inhibitor
3. dabigatran - direct thrombin inhibitor
4. rivaroxaban - factor Xa inhibitor
liaise with pt physician, check INR (should be 2-4) of warfarin pt, take all haemostatic measures, refer to SDCEP, book early in day & week to allow for emergency appt, consider referral.
for high bleeding risk procedure:
1. warfarin - INR must be below 4 and ideally checked 24hrs prior to tx
2. apixaban & dabigatran - miss morning dose
3. rivaroxaban - delay daily dose to 4hrs post XLA

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17
Q

drug considerations - antiplatelet therapy

A

risk - bleeding due to inhibition of various stages required for platelet aggregation
liaise with pt physician, take all haemostatic measures & refer to SDCEP, book pt in early in day & week to allow space for emergency appt, check BNF for drug interactions, current evidence is to not interrupt single or dual antiplatelet therapy

18
Q

drug considerations - radio / chemotherapy

A

risks:
- thrombocytopenia (decreased platelets)
- neutropenia (decreased neutrophils)
- MRONJ (if on anti-resorptive meds e.g. bisphosphonates)
- ORN due to reduced blood flow through irradiated region
- infection due to immunosuppression
thrombocytopenia - platelets >50 x10 9 / L is ok, avoid XLA if possible, atraumatic XLA, ensure pt is dentally stable prior to initiating radio/chemotherapy, ensure good OH prior to XLA, consider referral

19
Q

drug considerations - bisphosphonates

A

risks - MRONJ as anti resorptive drugs half bone turn over by inhibiting RANKL
assess risk category:
HIGH RISK - on oral or IV BPs for >5yrs, concurrent course of systemic glucocorticoids irrespective of length of tx, pt being treated for cancer irrespective of length of tx, pt has previously had MRONJ
avoid XLA if possible, atraumatic technique (reduces chance of surgical), liaise with pt physician (consider drug holiday), consider referral, 8wk review

20
Q

implications of tooth location when XLA

A

last standing upper teeth more difficult to xla as condylar translation over the articular eminence limits access upon mouth opening
long standing teeth more difficult to luxate & have greater # risk

21
Q

implications of EO swelling when XLA

A
  1. limited mouth opening
  2. difficulty in anaesthetising
22
Q

implications of adjacent structures when XLA

A

upper molar = risk of OAC / displacement of root into antrum
upper 3rd M = risk of tuberosity
lower 3rd M = risk of injury to IAN
raising lower flap = risk of damage to mental & lingual nerve

23
Q

implication of planned tooth replacement following XLA

A

if traumatic, will result in increased bone resorption & subsequent gingival recession which is unideal for planned implants & bridges

24
Q

radiographic analysis prior to XLA

A
  1. orientation & position of tooth
  2. crown - presence & extension or caries
  3. roots - no, length, curvature, presence of apical radiolucency / PDL widening
  4. bone height, width, density around tooth and in furcation area, absence of lamina dura (indicating possible ankylosis)
  5. follicular width (particularly unerupted 8s)
  6. impacted teeth around tooth in question
  7. relationship to important anatomical features i.e. IAN, tuberosity, sinus
  8. query any pathology i.e. cysts
25
Q

what to include in risks when consenting pt for XLA

A

pain, swelling, bleeding, bruising, dry socket, jaw stiffness, infection, OAC/F if upper molar, root #, maxillary tuberosity #, temp or permanent altered sensation to lip side of tongue & cheek and chin, damage to adjacent teeth, root displacement into sinus, need for surgical intervention

26
Q

types & use of elevators

A
  1. couplands - 1/2/3, flat tip will not break pdl, used to elevate teeth & xla of retained roots
  2. cryers - L & R, elevate teeth, xla retained roots, upper 3rdM elevation
  3. warwick james - L & R & straight, curved tip used for elevating upper 3rdM, straight used for elevating roots
27
Q

luxator uses

A

rounded sharp tip used to break pdl fibres

28
Q

lidocaine 2% HCl

A

vasoconstrictor - adrenaline 1:80,000
indications - infil, IDB, mental block, intra - ligamentary
max safe dose - 4.4mg/kg
duration - infil = 60mins, block = 90, soft tissues = 180-300

29
Q

articaine 4% HCl

A

vasoconstrictor - adrenaline 1:1/2/400,000
indications - infil, IL, mental block
max safe dose - 7mg/kg
duration - infil 120mins, block N/A, soft tissues 180-300

30
Q

prilocaine HCl 3%

A

vasoconstrictor - fely/octapresisn
indications - infil, IDB, mental block, IL
max safe dose - 6mg/kg
duration - infil = 30-45mins, block = 60, soft tissues = 180-360
DO NOT GIVE TO PREGNANT WOMAN AS INDUCES LABOUR

31
Q

mepivicaine 3% plain

A

vasoconstrictor - NIL
indications - infil, block, metal block, IL
max safe dose - 3mg/kg
duration - infil = 20mins, block = 40, soft tissues = 120

32
Q

local complications of LA

A

failure to achieve anaesthesia
prolonged anaesthesia
pain (during & after)
trismus
haematoma
temporary facial palsy
infection
soft tissue damage
needle stick injury

33
Q

systemic complications of LA

A

allergy - mainly to preservatives
loss of consciousness
respiratory depression
circulatory collapse
octapressin induces labour in pregnant women

34
Q

envelope flap design, +/- & indications

A

extended horizontal sulcular incision along multiple teeth
requires minimum 2 teeth for good vision
+ no relieving incision (minimises gingival recession)
+ easy re-approximation of flap
- can tear under pressure
- difficult reflection
- limited visualisation
indicated - aesthetic region, minimally invasive perio surgery, surgical xla

35
Q

2 sided flap design, +/- & indications

A

envelope with 1 relieving incision (M or D for greater access)
acts as compromise between aesthetics & access
+ better access than envelope
+ adequate bloody supply
- gingival recession
- limited access to long roots
indication - aesthetic zone where greater access needed, minimal bone removal required, 3rdM xla, surgical xla, apicectomy, cyst removal

36
Q

3 sided flap design, +/- & indications

A

envelope with 2 relieving incisions M & D
provides optimal access & vision
+ access & vision optimal
+ easy to reapproximate flap to original position
- prone to gingival recession
indication -3rdM xla, surgical xla when >1 tooth, apical repositioning flap, buccal advancement flap, bone graft, impacted tooth exposure, cyst removal, apicectomy

37
Q

semilunar incision design +/- & indications

A

incision made across mucoperiosteum away from gingival margin
+ no gingival recession
+ pdl remains intact
- scarring
- difficult to replace flap
- limited access
- prone to tearing
- paraesthesia risk

38
Q

flap principles

A
  • gain max access with min trauma
  • large flaps heal at same rate as smaller ones
  • broader base to maintain blood supply
  • for full thickness mucoperiosteal flap cut to bone using firm incision not feathered
  • avoid sharp angles
  • either include or exclude papilla entirely
  • do not crush tissue & keep moist with saline
39
Q

elevator principles

A
  • elevator tip inserted between tooth & bone mesially
  • do not level off adjacent teeth
  • avoid excess force
  • do not apply force towards major anatomical structure i.e. IAN
  • support pt jaw & ridge
  • use under direct vision only
  • for upper xla take care not to push root into maxillary sinus
40
Q

force movements when xla

A

conical roots = apical pressure, buccal & rotational movement
multiple roots = apical pressure, buccal expansion & figure of 8
consider atraumatic technique in certain cases e.g. planned implants

41
Q

peri operative complications

A

Dentistry in a Nutshell (30 decks)

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