oral surgery Flashcards
You assess that your patient requires removal of teeth 25 and 26 due to caries. The patient has never had teeth taken out before. When discussing their medical history, you elicit they take Warfarin for Atrial Fibrillation.
- What type of drug is Warfarin AND what is its mechanism of action? (2 marks)
anticoagulant
vitamin K antagonist
involves inhibiting the synthesis of vitamin K-dependent clotting factors (Factors II, VII, IX, and X) in the liver = inhibition interferes with the normal clotting cascade = prolongs the time it takes for blood to clot.
- Which test must be carried out prior to the extractions (1 mark)
International normalised ratio (INR)
prothrombin time (PT)
- Which guidance document would you refer to for advice on dealing with patients on Warfarin AND within what timeframe should this test be carried out prior to the extractions
(2 marks)
SDCEP - management of patients on anticoagulants
no more than 24 hours before
(up to 72 if stable)
- Below what level would it be safe to continue with extractions? (1 mark)
below 4
You arrange an appointment for treatment and this is carried out uneventfully.
They return the next day complaining they have been bleeding all night.
- Outline options that you could carry out clinically to deal with this post-operative bleeding.
(3 marks) - If following your interventions, you still could not stop the bleeding – what would you do?
(1 mark)
- apply pressure
la with vasoconstrictor
diathermy
surgicel
sutures
whitehead’s varnish pack - iodoform, gum benzoin, storax, balsam tofu, ethyl esther
transexamic mouthwash - refer to a specialist - e.g transfusion, vitamin K injection, surgical intervention
A fit and healthy patient presents to the surgery to have the surgical removal of a carious 48.
- Anatomically, which nerves must be anaesthetised to remove this tooth safely?
(3 marks)
inferior alveolar
lingual nerve
long buccal nerve
- List TWO different ways you could assess that anaesthesia has been achieved? (1 mark)
probe with a probe around the PDL
ask if the tongue and lip is numb on that side
start the procedure
- The patient presents one week later with neuro-sensory deficit affecting the right chin and lip region. Using the descriptions below provide the dental terminology.
(3 marks)
i) pins and needles feeling, or partial loss of sensation:
ii) painful, unpleasant or neuralgic sensation that lasts for a fraction of a second:
iii) total loss of sensation
i) paresthesia
ii) dysesthsia
iii) anaesthesia
- give 3 clinical reasons that can account for this neurodeficit?
damage to nerves
damage to gland
damage to muscles
A dentist plans to extract an erupted but in-standing mandibular second premolar tooth in a healthy adult.
- List FOUR common peri-operative complications associated with this procedure in a healthy dentate adult.
(4 marks)
fracture of the root or tooth
fracture of alveolar bone
soft tissue damage
damage to adjacent teeth
damage to nerves/vessels
broken instruments
haemorrhage
difficult access
- When the tooth is extracted, it is noticed that a substantial part of the root of the tooth is missing. Which radiographic image would be the most appropriate for assessment of this situation?
(1 mark)
periapical
- On the diagram below draw (or describe) the following:
i. the outline of the flap you would raise for surgical removal of the root fragment 45.
(2 marks)
outline of the gingival margin around the affected tooth
horizontal incision along gingival margin
vertical at both ends of the horizontal incision
- Give TWO anatomical structures which are supplied by the mental nerve?
(2 marks)
lower lip - skin and mucous membrane
chin and lower gingiva
lower teeth anterior to mental nerve
A patient returns to the clinic with symptoms and signs of a dry socket.
1. What is the correct terminology for this? (1 mark)
alveolar osteitis
- List THREE predisposing factors that could contribute to this?
(3 marks)
poor OH
trauma during XLA
smoking
gender - being female
molars or mandible
oral contraceptive pill
excessive mouth rinsing after extraction
- List THREE symptoms or signs that the patient may present with.
(3 marks)
severe pain
halitosis
dislodged blood clot
radiating pain
awake at night
bad odour
- How would you manage this situation? (3 marks)
pain management
irrigation with saline and alveogyl dressing
post op instructions - oh, avoid smoking, rinsing with warm salt water, no straws
curettage and cleaning
1.) a.) Two aims for raising a flap (2)
b.) 4 things that influence flap design (4)
a) provide better access to underlying tissues
good visibility and visualisation
protect soft tissues
b) type of procedure
anatomical considerations
blood supply
aesthetics and function
surrounding nerves
effect on gum recession
c.) Type of handpiece used for bone removal (1)
surgical straight handpiece
saline cooled
with a round tungsten carbide bur
d.) 3 methods of debridement (3)
physical - bone file or handpick
mitchells trimmer or victorias curette for soft tissues debris
irrigation - sterile saline/water into socket and under flap
suction - aspirate under flap, check for retainer apices
3.) a.) Drug family of apixaban (1)
b.) What does apixaban inhibit? (1)
c.) What else is apixaban used for (2)
d.) What blood tests before treatment (1)
e.) What to do with dosage for surgical treatment vs simple extraction (2)
f.) 3 methods of haemostatic control (3)
a) direct oral anticoagulants
non-vitamins K antagonists
b) Factor Xa
c) stroke and blood clot prevention
prevention of deep vain thrombosis
pulmonary embolism
d) renal function tests (e.g. serum creatinine and glomerular filtration rate)
liver function = enzymes
e) low bleeding = do not interrupt
high bleeding = miss or delay morning dose
f) local pressure
homeostatic agents - oxides cellulose, fibrin sealants
sutures
surgicel
bone wax
a) XLA of premolar. List 4 preoperative complications (4 marks)
Tooth position inadequate for access for elevators or forceps.
Patient’s medical history states bleeding tendency.
Radiograph states or shows tooth appeared to be ankylosed or infraoccluded or signs of hypercementosis.
Close to relevant anatomical structure e.g. mental foramen.
a) XLA of premolar. List 4 perioperative complications (4 marks)
- Difficulty of Access
- Fracture of tooth/root
- Fracture of alveolar plate
- Fracture of tuberosity
- Jaw fracture
- Involvement of maxillary Antrum (OAC/OAF)
- Loss of tooth
- Soft tissue damage
- Damage to nerves/vessels
- Haemorrhage
- Dislocation of TMJ
- Damage to adjacent teeth/restorations
- Extraction of permanent tooth germ
- Wrong tooth
c) Draw the flap design for a surgical extraction of 44. (2 marks)
crevicular incision with a distal relieving incision
- Oral Surgery & Anticoagulants (pp)
a) Table given, with columns of date, INR, comments and signature.
Which 2 columns would give you the most useful information on XLA a tooth of a patient on warfarin (2 marks)
INR and date
b) On which 2 dates would you not carry out the XLA? (2 marks)
INR has to be below 4 and reading should have been done no more than 24 hours
c) Circle the most appropriate analgesic for this patient, post-extraction.
Options included paracetamol, ibuprofen, aspirin and … (1 mark)
paracetamol
d) The patient’s INR is unstable. How would the GP assess this? (2 marks)
By taking a blood sample of the patient to assess the prothrombin time
e) The patient has switched their medication to apixaban. What is the mechanism of apixaban as a drug? (1 mark)
Factor Xa inhibitor