Oral surgery Flashcards
3 effects of aspirin
Analgesic
(COX-1 & 2 inhibition, reduces prostaglandin synthesis)
Antipyretic
(prevents temperature raising effects of IL-1 - reduces elevated temperature in fever)
Anti-inflammatory
(reduced prostaglandin synthesis as prostaglandin is vasodilator which affects capillary permeability)
4 adverse effects of aspirin
GIT problems - ↑ gastric acid secretion, ↓ blood flow through gastric mucosa, ↓ mucin production & cytoprotective action
Hypersensitivity
Overdose - tinnitus, metabolic acidosis
Aspirin burns on mucosa
Groups to avoid/ caution prescribing aspirin to (14)
- Peptic ulceration
- Gastric pain
- Bleeding abnormalities
- Anticoagulant users
- Steroid users
- Renal/ hepatic impairment
- < 16 yrs
- Asthmatics
- Hypersensitivity to other NSAIDS
- Using other NSAIDS
- Elderly
- Pregnant women
- Nephrotoxicity
- G6PD-deficiency
4 absolute contraindications of prescribing aspirin
- Lactating women
- Children below 16 (Reye’s syndrome)
- Haemophilia
- Hypersensitivity to aspirin or other NSAIDS
Prescription of aspirin
300mg 2 tablets qid after food, 5 days
For odontogenic pain
Maximum adult dose of ibuprofen
2.4g
Groups to caution when prescribing ibuprofen (8)
- Active/ previous peptic ulceration
- Asthmatics
- Taking other NSAIDS
- NSAID hypersensitivity
- Pregnancy/ lactation
- Renal/ cardiac/ hepatic impairment
- Patients on long term systemic steroids
- Elderly
3 adverse effects of ibuprofen
- GI discomfort
- Hypersensitivity reactions
- Headache, dizziness, nervousness, depression, drowsiness, insomnia, vertigo, tinnitus… (see BNF)
For patients taking antihypertensive drugs, how many days should the regimen of ibuprofen be restricted to?
5 days or less
3 symptoms of ibuprofen overdose + management
Symptoms:
- nausea
- vomiting
- tinnitus
Management: Activated charcoal if more than 400 mg/kg ingested within the last hour
Prescription of paracetamol
500mg 2 tablets qid 5 days
For odontogenic pain
Mode of action of paracetamol
Indirect inhibition of COX pathway by blocking positive feedback action of hydroperoxides
3 groups to caution when prescribing paracetamol
- Hepatic impairment
- Renal impairment
- Alcohol dependance
4 (rare) side effects of paracetamol
- Rashes
- Blood disorders
- Hypotension
- Liver damage following overdose (less frequently kidney damage)
What is considered a therapeutic excess of paracetamol? (2)
More than 8g in 24 hours (recommended adult daily dose) and > 75 mg/kg
What amount/ level of paracetamol may cause severe hepatocellular necrosis?
150 mg/kg
Management of paracetamol overdose
Refer to A&E for assessment
Considerations for flap design
- Wide based
- No sharp angles
- Adequate side (size does not affect healing)
- Avoid dental papillae
1 advantage & 1 disadvantage of polyfilament sutures
Advantage
- Easy to handle
Disadvantage
- Prone to wicking, draws bacteria and can result in infection
3 advantages & 1 disadvantage of monofilament sutures
Advantages
- Passes easily through tissue
- Resistant to bacterial colonisation
- Causes less scarring
Disadvantage
- Slippery and difficult to handle
Advantages of ZOE as retrograde sealant for periradicular surgery (4)
- Cheap
- Easy to use
- Radiopaque
- Bacteriostatic
Disadvantages of ZOE as retrograde sealant for periradicular surgery (3)
- Sensitive to moisture
- May resorb
- Doesn’t promote cementogenesis
Advantages of MTA as retrograde sealant for periradicular surgery (3)
- Moisture resistant
- Promotes cementogenesis
- Very good seal
Disadvantages of MTA as retrograde sealant for periradicular surgery (3)
- Expensive
- Long setting time
- Difficult to use
Failed endodontic treatment
- Obstruction to instrumentation
-> Calcification
-> Broken instrument
-> Dilaceration
-> Root #
- Root filler error/ problem
-> Underfilled
-> Overfilled
-> Open apex - Post crown treated tooth
- Lateral perforation
- Radicular cysts/ other pathology
Causes of failure of periradicular surgery (3)
- Inadequate seal
- Inadequate support
- Miscellaneous: longitudinal root split, poor healing response, exposure of root apex
Name a monofilament & multifilament resorbable & non resorbable suture (4)
Resorbable
Monofilament - Monocryl
Multifilament - Vicryl Rapide
Non resorbable
Monofilament - Prolene
Multifilament - Mersilk
How to manage fractures of alveolar bone during XLA
- If bone completely removed from tooth socket with tooth, do not replace
- Smooth sharp edges w bone file/ rongeurs and reapproximate soft tissues
- If bone still attached to periosteum, dissect bone with soft tissue away from tooth by stabilising tooth with forceps and separating using periosteal elevator
- Reapproximate bone and soft tissues and secure with sutures
Management of jaw fractures during XLA
- Explain to patient what happened + provide reassurance
- Provide analgesia
- Fast patient
- AB (PenV/ met/ equivalent)
- Phone OMFS
List 8 immediate postoperative complications
- Pain
- Swelling
- Ecchymosis
- Trismus (limited mouth opening)
- Dry socket
- Infected socket
- Haemorhage (post-op bleeding)
- Prolonged effects of nerve damage
4 causes of post-extraction trismus?
- IDB
- prolonged mouth opening
- spasming of muscles from fibrosis following haematoma
- oedema and joint effusion in TMJ
How can post extraction trismus be managed?
Using trismus screws/ wooden tongue depressors
Classification of dental procedures that are likely to cause bleeding - LOW RISK of post op bleeding complications
- Simple extraction of 1-3 teeth
- Incision & drainage of IO swelling
- Full mouth 6PPC
- Subgingival PMPR
- Direct/ indirect restorations with subgingival margins
Classification of dental procedures that are likely to cause bleeding - HIGHER RISK of post op bleeding complications
- Complex extractions/ extractions of >3 teeth at once
- Flap raising procedures:
– Surgical extractions
– Periodontal surgery
– Preprosthetic surgery
– Periradicular surgery
– Crown lengthening
– Implant surgery - Gingival recontouring
- Biopsies
4 examples of DOAC + MOA of DOACs
- Apixaban - direct oral factor Xa inhibitor
- Dabigatran - direct oral thrombin inhibitor
- Rivaroxaban - direct oral factor Xa inhibitor
- Edoxaban - direct oral factor Xa inhibitor
How to manage patients requiring dental procedures with/ without bleeding risks taking:
1. Apixaban
2. Dabigatran
3. Rivaroxaban
4. Edoxaban
- Apixaban & dabigatran -> miss morning dose, resume night time dose
- Rivaroxaban & edoxaban -> delay morning dose & take 4 hours after haemostasis achieved OR take as usual in the evening
4 additional precautions for patients taking DOACs
- Stage extensive/ complex procedures
- Treat early in the day
- Limit initial tx area & assess bleeding before continuing
- Haemostatic measures - packing & suture
3 groups of patients where anticoagulant/ antiplatelet therapy should NOT be interrupted
- Prosthetic metal heart valves/ coronary stents
- PE/ DVT in last 3 months
- Cardioversion
3 examples of vitamin K antagonist (coumarins)
- Warfarin
- Acenocoumarol
- Phenindione
Briefly describe MOA of warfarin
- Vitamin K antagonist
- Vitamin K used to produce clot factors
- Inhibits vitamin K epoxide reductase
- Which is an enzyme which reduces and activates vitamin K
- Depletes functional vitamin K reserve
- ↓ active clot factor synthesis
- ↑ blood clotting time
How should a patient taking Warfarin be managed
- Check INR ideally no more than 24 hours before procedure
- If INR levels stable and <4, treat without interrupting medication
- Stage tx, limit initial tx area & assess bleeding, suture & pack
- If INR > 4, delay invasive tx & refer if urgent
3 examples of injectable anticoagulants
- Deltaparin
- Enoxaparin
- Tinzaparin
Management of patients taking injectable anticoagulants
- Low prophylactic dose - treat without interrupting medication
- Treatment (higher dose) - consult prescribing clinician
4 examples of antiplatelet drugs
- Aspirin
- Clopidogrel
- Dipyridamole
- Prasugrel
- Ticagrelor single/ dual therapy
Management of patients taking antiplatelet drugs
Treat without interrupting medication
5 local haemostatic agents that can be used to manage postoperative bleeding
- LA with vasoconstrictor
- Surgicel (oxidised regenerated cellulose)
- Haemocollagen sponge
- Thrombin liquid & powder
- Floseal
5 systemic haemostatic aids to manage post operative bleeding
- LA with vasoconstrictor
- Tranexamic mouthwash/ tablets
- Blood clotting factors
- Plasma/ whole blood
- Desmopressin - DDAVP
Management of post-operative bleeding (8)
- Reassure/ calm patient and carer
- Firm pressure with gauze on site while taking quick history
- Remove jelly like clot
- LA with vasoconstrictor
- Pack with surgicel/ bone wax and suture
- Ligate vessels/ diathermy if available
- Post op instructions
Post op instructions to prevent post op bleeding (5)
- No hot food
- Avoid traumatising with tongue/ brushing
- No strenuous activity
- Spitting on first day and avoid excessive rinsing following days
- No excess alcohol
For how long can you expect improvement from nerve damage up to?
18 months
3 types of sensory change that can occur after nerve damage (clinical description)
- Anaesthesia (numbness)
- Paraesthesia (tingling)
- Dysaesthesia (abnormal sensation)
Anatomical descriptions of nerve damage
- Neuropraxia - contusion of nerve, epineural sheath and axons continuity maintained
- Axonotmesis - axons continuity maintained but epineural sheath disrupted
- Neurotmesis - complete loss of nerve continuity
Symptoms of dry socket
- Pain 3-4 days after XLA
- Worse pain than right after XLA
- Throbbing pain radiates to ear, keeps awake at night
- Bad taste, smell
Predisposing factors for dry socket
- Molars
- Mandible
- Difficult XLA
- Women
- OCP use
- Smoking
Management of dry socket
- Irrigate socket with saline
- Inspect for bony sequestrum
- Dress with alvogyl
- HSMW
Predisposing factors for osteomyelitis
- Odontogenic infections
- Fractures of the mandible
- Compromised host defence
– Diabetes
– Alcoholism
– IV drug use
– Malnutrition
– Myeloproliferative disease (leukemias, sickle cell disease, chemotherapy treated cancer)
Clinical signs of osteomyelitis
- Pyrexia
- Extraction site tender
- Altered sensation to lower lip & chin (pressure on IAN)
+/- pus in chronic infections - More common in mandible
Radiographic signs of osteomyelitis
- Acute suppurative lesions show little to no change
- Chronic osteomyelitis
– Bony destruction
– “Moth eaten appearance”
– Bony sequestrum, involucrum
Bacteria involved in osteomyelitis
- Streptococci (streptococcus anginosus)
- Peptostreptococcus
- Fusobacterium
- Prevotella
Ix for osteomyelitis
- Swabs & culture + sensitivity testing
- Bloods & glucose testing
Surgical management of osteomyelitis
- Drain pus
- Remove non vital teeth in area of infection
- Remove loose pieces of bone
- (Referral to OS/ OMFS)
- In fractured mandible remove wires, plates, screws in area
- Corticotomy
- Excise necrotic bone, until actively bleeding bone tissue reached
Non surgical management of OM
AB therapy (penicillins)
- 6 weeks after symptoms resolve - acute
- Up to 6 months - chronic
- IV if systemic and symptoms
How to prevent ORN
- Scaling/ CHX MR leading up to XLA
- Atraumatic XLA technique
- Antibiotics, CHX MR & review
- Hyperbaric oxygen b4 & after XLA
- Seek advice/ refer for XLA
Management of ORN
- Remove loose sequestrate
- Irrigate necrotic debris
- Antibiotics if 2ry infection
- In severe cases resect exposed bone, margin of unexposed bone, soft tissue closure
- Hyperbaric oxygen
MRONJ incidence in
- Cancer patients
- Osteoporosis patients
- Cancer patients <5% (5 in 100)
- Osteoporosis <0.05% (5 in 10,000)
3 types of drugs that can cause MRONJ & 2 examples of each
- Antiresorptive/ bisphosphonates
– Alendronate
– Zoledronate - RANK-L inhibitors
– Denosumab - Antiangiogenic
– Monoclonal antibodies
— Bevacizumab
— Aflibercept
– Tyrosine kinase inhibitor
— Sunitinib
— Sorafenib
Risk factors for MRONJ (3)
- Dental treatment
– Mucosal trauma from dentures
– Dental infection
– Untreated periodontal disease - Duration of bisphosphonate drug therapy (longer duration higher risk)
- Other concurrent medication
– Systemic glucocorticoids
– Bisphosphonates + anti-angiogenic drugs
Should the following groups of patients get implants? How should they be managed?
- High dose anti-resorptive/ anti-angiogenic drugs for management of cancer
- Osteoporosis patients taking bisphosphonates
- Avoid implants for patients being treated with high dose anti-resorptive/ anti-angiogenic drugs for management of cancer
- Not contraindicated. Warn patients about
compromised healing at implant site
increased risk of MRONJ
advise how to minimise risk (good OH)
When should a patient who is treated with six monthly subcutaneous injections of denosumab have dental treatment done?
- 1 month before next cycle due
- Monitor for healing before resuming
Patient risk categories for MRONJ
- Low risk
- High risk
- Low risk
- Bisphosphonate use for osteoporosis
<5 yrs
- No concurrent systemic glucocorticoid use - High risk
- Bisphosphonate use for >5 years
- Concurrent use of systemic glucocorticoids
- Antiresorptive +/ antiangiogenic drugs for management of cancer
- Previous MRONJ
Management of MRONJ
- Analgesia
- Remove sharp edges of bone
- CHX MR
- Antibiotics if suppuration
- Debridement
- Major surgical sequestrectomy
- Resection
3 etiologic agents of actinomycosis
Actinomyces israelii
Actinomyces naeslundii
Actinomyces viscosus
Management of actinomycosis
- Incision & drainage
- Excise chronic sinus
- Excise necrotic bone & foreign bodies
- High dose IV AB
- Long term AB to prevent recurrence
Risk of IE in general population
1:10,000
Symptoms of IE (7)
- Fever
- Chills
- Night sweats
- Fatigue
- Breathlessness
- Weight loss
- Muscle, joint or back pain
Side effects of AB
- GI upset, nausea, diarrhoea
- Allergies - anaphylaxis
- AB resistance - less likely to work when its needed
Patients at increased risk of IE
- acquired valvular heart disease w stenosis/ regurgitation
- hypertrophic cardiomyopathy
- previous IE
- structural CHD including surgically corrected or palliated structural conditions, excluding ASD, fully repaired VSD, fully repaired PDA, closure devices judged to be endothelialised
- valve replacement
Subgroup of patients at increased risk of IE requiring special consideration
- prosthetic valve repair
- previous IE
- cyanotic CHD
- CHD prepared with prosthetic material
Routine management for patients at increased risk of IE (not subgroup requiring special consideration)
- Explain dental procedures not thought to be main cause of IE
- Unclear if AB prophylaxis prevents IE - may occur whether or not its given
- Risks of AB prophylaxis
- prevention advice: importance of good OH + diet advice
- Other invasive procedures, non medical - Body piercing + tattooing carry risks
- Contact GMP asap if they notice IE symptoms + explain that they had recent invasive dental tx
- Record discussion in notes
Non routine management for patients in subgroup requiring special consideration
- Consult cardiologist
- If needed, discuss risks and benefits of AB prophylaxis
- Prescribe AB to be taken in clinic/ at home 1 hour before procedure
- Advise to seek urgent medical attention if they develop colitis
First line prescription for antibiotic prophylaxis
3g amoxicillin 1 3g oral powder sachet 60 minutes before procedure
Precautions for amoxicillin (contraindication & caution)
- CI: Hx of anaphylaxis, urticaria, rash immediately after penicillin administration
- Caution: Warfarin users - alters anticoagulant effect, monitor INR
For patients allergic to penicillin a suitable antibiotic prophylaxis prescription is
Clindamycin 300mg capsules 2 capsules 60 minutes before procedure
For patients allergic to penicillin but unable to swallow capsules, a suitable antibiotic prophylaxis prescription is
Azithromycin oral suspension 200mg/ 5ml (12.5ml) 60 mins before procedure
4 nerves at risk during third molar surgery
Inferior alveolar nerve
Mental nerve
Lingual nerve
Long buccal nerve
3 guidelines for wisdom teeth surgery (name, year/ edition)
- NICE guidance on extraction of wisdom teeth, 2000
- SIGN no 43: Management of unerupted and impacted third molar teeth 2000
- RCS Parameters of care for patients undergoing mandibular third molar surgery 2020
Indications for therapeutic extraction of third molars (according to FDS 2020 guidelines) (7)
- Unrestorable caries of 8 or to assist restoration of 7
- Periodontal disease compromising 8/ 7
- Repeated episodes/ single severe acute episode of pericoronitis
- Resorption of 8/ 7’s
- Fractured 8
- PA abscess, irreversible pulpitis or acute spreading infection from 8
- cysts / tumours associated with 8
Indications for prophylactic removal of third molars (according to FDS 2020 guidelines) (4)
- Medical factors that may complicate likely surgery of M3Ms
- anti angiogenic/ resorptive drugs,
- immunosuppressive therapy,
- chemotherapy,
- cardiac surgery,
- radiotherapy - Within field of surgery
(TMJ, mandibular fractures, orthognathic surgery, resection of benign & malignant lesions - Limited access to dental care
- GA
Microbiological aetiology of pericoronitis
Anaerobes:
- Prevotella
- Streptococci
Signs and symptoms of pericoronitis
- Pain
- Swelling
- Bleeding
- Bad taste and bad smell
- Limited mouth opening
- Fever, malaise, regional lymphadenopathy
Management of pericoronitis
- LA
- Incision and drainage of pericoronal abscess
- Debridement + irrigation with saline
- OHI
- Antibiotics if systemically unwell
– Metronidazole 400mg 1 tablet tid 5 days, no alcohol, do not prescribe to patients using warfarin - Analgesia
- Assess for potential spreading infection: SIRS, sepsis -> onwards referral to maxfacs
3 radiographic signs demonstrated to be associated with significantly increased risk of nerve injury during 3rd molar surgery according to SIGN & FDS guidelines
- Interrupted white lines of IDC
- Diversion of IDC
- Darkened areas over roots where crossed by canal
5 other radiographic signs of potential increased risk to IAN
other than:
- Interrupted white lines of IDC
- Diversion of IDC
- Darkened areas over roots where crossed by canal
- Juxta apical area
- Deflection of roots (8’s)
- Narrowing of IDC
- Narrowing of the root
- Dark and bifid root
Description of impacted M3Ms (angulation & depth)
- Angulation
– Vertical
– Mesioangular
– Distoangular
– Horizontal
– Transverse - Depth
– Superficial (crown of 7)
– Moderate (crown and root of 7)
– Deep (root of 7)
Postoperative complications of M3M surgery
- Pain, swelling, bleeding, bruising
- Damage to adjacent restorations
- Dry socket
- Limited mouth opening
- Infection
- Temporary or permanent numbness, reduced/ heightened sensation to the lower lip and chin, and one side of tongue
- altered taste
- Jaw fracture (removal of large cysts/ aberrant lower 8 close to inferior border of mandible)
Incidence of temporary numbness of lower lip and chin from IDN damage
10-20%
Incidence of permanent numbness of lower lip and chin from IDN damage
<1%
Steps in surgical removal of wisdom teeth
- LA
- Incision to create flap
- Reflection
- Removal of bone
- Sectioning tooth
- Elevate/ removal of tooth
- Debridement
- Suturing & closure
- Achieve haemostasis
- Post op instructions
4 instruments that can be used for reflection of flaps
- Mitchells trimmer
- Howarths
- Ash
- Warwick james
3 different types of instruments that can be used for retraction
- Rake
- Minnesota
- Howarths
3 ways to remove sharp bony edges
- Bone file
- Hand piece
- Bone rongeurs
2 instruments that can be used to remove soft tissue debris
Mitchells
Victoria curette
Post op instructions
- No alcohol for 24 hrs
- No smoking for 48 hours
- Analgesia don’t exceed doses
- Bite on damp gauze if bleeding
- No strenuous activity for rest of day
- Spit don’t rinse
- Mind not to traumatise area - avoid exploring with tongue, brush gently around area
- Warm salty mouth rinses tid for 7 days
- Cold pack to reduce swelling
Indications of coronectomy
Close relationship between IAN and 8 (increased risk of damage)
Contraindications of coronectomy
- Pulpitis, PA pathology of 8
- Medical contraindications: antiresorptive, antiangiogenic drug users, chemo, bleeding disorders, diabetics (higher risk of failure)
Difference in procedure between coronectomy & complete surgical removal of M3M
- Sectioning of crown 3-4 mm below enamel of crown into dentine
- Root left in situ
4 important points to consent the patient for a coronectomy
- If root is mobilised during procedure it must be removed
- Root left in situ may migrate and erupt one day which may require extraction
- Risk of infection (rare)
- Can get a slow healing/ painful socket
Causes of TMD (8)
- Myofascial pain
- Disc displacement
- Degenerative disease (OA, RA)
- Chronic recurrent dislocation
- Ankylosis
- Hyperplasia
- Neoplasia
- Infection
- Macro trauma
- Microtrauma - chronic joint overloading, stress related repetitive clenching/ bruxism
- Occlusal factors: deep bite, high filling, lack of teeth
- Anatomical: Class II jaw relation
Special investigations for TMD
- OPT
- MRI
- Arthrography/ arthroscopy
- USS
- CT/ CBCT
- Transcranial view
- Nuclear imaging
Clinical features of TMD
- Muscle, joint or ear pain esp on waking
- Clicking of joints
- Limited mouth opening
- Crepitus
- Headaches
DDx of TMD
- Dental pain
- Sinusitis
- Headache
- Trigeminal neuralgia
- Atypical facial pain
- Ear pathology
- Salivary gland pathology
- Referred neck pain
- Angina
- Condylar fracture
- Temporal arteritis
Conservative management options of TMD
- Patient education & reassurance
- CBT
- Physiotherapy, jaw exercises, warm compress
- Self help, meditation, yoga
- Acupuncture
- Ultrasound therapy
- TENS (transcutaneous electronic nerve stimulation)
- Bite raising appliance
- Medications: NSAIDs, muscle relaxants, tricyclic antidepressants, botox for muscles, steroids for joints
- Soft diet, food in small pieces, stop parafunctional habits + gum chewing
Surgical management options for TMD
- Disc repositioning
- Disc repair/ removal
- High condylar shave
- Total joint replacement
2 signs and symptoms of anterior disc displacement with reduction
- Jaw tightness/ locking for short period of time until disc reduces
- Mandible deviates to affected side before returning to midline
Management of anterior disc displacement with reduction
1. Symptomatic
2. Asymptomatic
- Symptomatic
- Counselling
- Limit mouth opening
- BRA
- Surgery occasionally may be required - Asymptomatic
- No tx, reassure
3 potential causes of trismus
- Prolonged dental procedure
- Infection spread to masseteric spaces
- IDB (medial pterygoid m spasm)
3 management options of trismus if not resolved after acute phase
- Physiotherapy
- Therabite
- Jaw screw/ multiple tongue depressors
Risk factors for OAC
- Extraction of upper molars and premolars
- Single lone standing molar
- Close relationship of roots to sinus on radiograph
- Large bulbous roots
- Older patient
- Previous OAC
- Recurrent sinusitis
Signs of OAC
- Bubbling of blood in socket
- Bone removed at trifurcation
- Change in suction sound
- Directly visible
- (valsalva manoeuvre, probing)
Management of OAC
- Small OACs (<2mm) (10)
- Large (2)
- Small OACs
- Inform patient and gain consent to monitor/ close/ refer
- Encourage clot
- Suture margins
- Conservative advice:
- No nose blowing, do not stifle sneezes, do not agitate area, avoid using straws
- HSMW/ CHX
- Smoking cessation advice
- Steam inhalation
- Antibiotics: PenV 250mg 2 tablets qid 5 days
- Large OACs (>2mm)
Closure with buccal advancement flap
Signs of OAF (chronic)
- Fluid leaking from nose when drinking
- Nasal tone when speaking singing
- Unable to use straw, smoke cigarette, play wind instruments
- Bad taste/ odour/ halitosis/ pus discharge
- Non healing socket
- Sinusitis: headache, nasal congestion
Management of OAF
- Excise sinus tract
- Raise flap + antral washout (not always done) + closure
4 types of flap design options for OAF closure
- Buccal advancement flap
- Buccal and fat pad advancement flap
- Palatal rotational flap
- Bone graft/ collagen membrane
4 risk factors which increases risk of fracture of maxillary tuberosity
- Last standing molar
- Pathological gemination/ concrescence
- Inadequate alveolar bone support
- Extracting in wrong order
4 signs of maxillary tuberosity fracture
- Teeth moving together
- Movement noted visually or with supporting fingers
- Tear in soft tissue of palate
- Noise audible
2 management options of fractured tuberosity
- Reduce and stabilise with splint
- Dissect out and primary closure of wound
3 methods of fixation for tuberosity fractures
- Orthodontic buccal arch wire spot welded with composite
- Arch bar
- Splints
5 important measures when deciding to splint & stabilise fractured segment
- Remove or treat pulp of tooth
- Ensure it is out of occlusion
- Consider antibiotics & antiseptics
- Post op instructions
- Extract at later date surgically 4-8 weeks later
What is a critical factor in deciding between retrieval of roots that’s been displaced into the maxillary sinus?
If root has perforated sinus membrane lining
3 approaches to retrieving roots displaced into the maxillary sinus
- Through extraction socket
- Caldwell Luc approach
- ENT: endoscopic retrieval
Signs and symptoms of sinusitis
- Facial pain and pressure
- Nasal congestion & obstruction
- Headaches
- Hyposmia
- Dental pain
- Fever, fatigue, cough
- Ear pain
- anaesthesia/ parasthesia over cheek
Dental causes which may mimic sinusitis like pain
- Deep caries
- Periapical abscess
- Periodontal infection
- Recent extraction socket
- TMD
- Neuralgia/ atypical facial pain/ chronic midfacial pain
4 indicators which can differentiate between sinusitis and dental pain
- Discomfort on palpation of infraorbital region
- Diffuse pain in maxillary teeth
- Equal sensitivity from percussion of multiple teeth in same region
- Pain which is worse with head or facial movements
Management of sinusitis
Decongestants
Steam inhalations with menthol crystals
When should antibiotics be used for sinusitis?
If source of sinusitis is bacterial + if symptoms severe/ condition worsens after 7 days
Antibiotic prescription for sinusitis
PenV 250mg 2 tablets qid 5 days
2 adverse reactions of using PenV
Diarrhoea
Allergies: rash, anaphylaxis
Alternative to PenV for sinusitis
Doxycycline
4 contraindications of prescribing doxycycline
Reduced hepatic function
Hepatotoxic drugs
Pregnant women
Warfarin
Prescription of doxycycline as alternative to penV for management of sinusitis
100mg 2 capsules for first day, 1 capsule daily for next 6 days (7 day regimen)
6 adverse reactions of doxycycline
- Nausea
- Vomiting
- Diarrhoea
- Dysphagia
- Esophageal irritation
- Photosensitivity
- Affects tooth development: staining of teeth, dental hypoplasia
4 methods to promote homeostasis perioperatively
LA with vasoconstrictor
Diathermy
Artery forceps
Bone wax
5 methods to achieve hemostasis post operatively
LA with vasoconstrictor
Diathermy
Bone wax
Packing (surgicel) & suturing
Sequelae of OAC
Infection
Sinusitis
Impaired healing
food/ saliva accumulation in sinus
Management of dislodged roots into sinus
- PA +/- OPT to confirm presence of roots
- If small consider monitoring but advise always possibility of infection
- refer/ raise buccal advancement flap
- Adequate irrigation with saline & aspiration to attempt to retrieve it from socket
- Widen socket with bur to increase chances of retrieval of root
- Consider endoscopic/ Caldwell luc procedure
5 presentations which should be referred as urgent suspicion of head and neck cancer
- unexplained ulceration or unexplained swelling/ induration of oral mucosa persisting >3 weeks
- Unexplained, red and white patches > 3 weeks
- Unexplained head and neck lumps > 3 weeks
- Persistent hoarseness lasting > 3 weeks
- Persistent pain in throat or pain on swallowing > 3 weeks
Investigations for spreading dental infections (7)
- Bloods
- Swabs/ aspirate, microbiological culture & sensitivity testing
- Nasendoscopy
- Frozen section/ pathology
- OPG, CT
Muscle which determines submandibular/ sublingual spread of infection
Mylohyoid muscle
4 masseteric spaces
- Superficial temporal
- Masseteric
- Infratemporal
- Pterygomandibular
3 posterior spaces where infection can spread into
- Retropharyngeal
- Lateral pharyngeal
- Prevertebral
Technique for drainage of abscesses
Hilton technique
What is Ludwig’s angina? What is the E/O features
Bilateral cellulitis of sublingual and submandibular spaces
Diffuse E/O swelling bilaterally in submandibular region
What are the I/O features of Ludwig’s angina
Raised tongue
Compromised airway - difficulty breathing
Difficulty swallowing
Drooling
What are systemic signs in Ludwig’s angina
↑ Heart rate
↑ Respiratory rate
↑ Temperature
↑ WBC
What does SIRS stand for and what is it?
Systemic inflammatory response syndrome
SIRS is an exaggerated defence response of the body to a noxious stressor to localise and then eliminate the endogenous or exogenous source of the insult
What are the 4 criteria for SIRS
Any 2 of the following:
- T < 36C / 38C and above
- HR > 90 BPM
- RR > 20/ minute// ppCO2 < 32mmHg
- Leukocyte count >12,000 // < 4,000/ microL OR over 10% immature forms or bands
8 sepsis red flags
- Deterioration of AVPU
- Systolic BP ≤ 90mmHg
- HR ≥ 130 BPM
- RR ≥ 25/ min
- Needs O2 to keep SpO2 92%
- Non blanching rash/ mottled/ ashen/ cyanotic
- Not passed urine in last 18 hours
- Recent chemotherapy in last 6 weeks
What does SBAR stand for?
SBAR is a method of communication by medical colleagues which helps to structure handover of information
- Situation
- Name, job role & unit/practice you’re calling from
- State reason for contact (advice, opinion, hope to refer)
- Outline concern for patient
Provide patient details - Background
- Reason for problem
- MH, meds (including painkillers taken), allergies
SH (smoking & alcohol), parental responsibility
- Tx Hx & treatment so far (extractions/ antibiotic/ diagnostic results) - Assessment
- Vital signs
- Fasting status
- Dental assessment: key teeth involved
- Ix, radiographic assessment
- Tx carried out - Recommendation
- expectations/ recommended tx
- If referral accepted, confirm next steps, expected timeframe, how pt will be travelling & ETA
How to do a vital sign assessment
- Airway
- Breathing
Symmetry
Rate
O2 saturation - Circulation
Colour
Perfusion
Pulse rate
BP - Disability
Alert status: AVPU
Alert
Verbal stimulus (responds to)
Responds to pain
Unresponsive - Exposure
Temperature
Blood glucose
nausea/ vomiting
Red flag signs of infection (potential airway compromise)
- Eye closure/ double vision/ pain on eye movement
- Swelling crossing midline in submental/ submandibular region
- True trismus
- Patient visibly drooling
- FOM raised
- Uvula deviated
- Dysphonia: Hot potato voice (infection spread to parapharyngeal space and is affecting the vocal cords)
- Limited movement of tongue (infection in parapharyngeal space)
2 methods of antibiotic resistance (and examples of each)
- Altered target site - modified penicillin binding proteins (streptococcus mitis)
- enzymatic deactivation - beta lactamases (prevotella, fusobacterium)
2 microbes in dental abscesses
Prevotella intermedia
Streptococcus anginosus
2 microbes in periodontal abscesses
Prevotella intermedia
Anaerobic streptococci
(P Gingivalis)
(Fusobacterium nucleatum)
2 microbes in pericoronitis
Prevotella intermedia
Streptococcus anginosus
2 microbes in osteomyelitis
Streptococcus anginosus
Staphylococcus aureus
2 microbes in MRONJ
Streptococcus anginosus
Actinomyces israelii
2 microbes in salivary gland infections
Staphylococcus aureus
Mixed anaerobes
4 ABCDs when pre-assessing a trauma case
- Airway (+ C spine protection)
- Breathing
- Circulation (+ haemorrhage control)
- Disability (GCS)
5 signs of mandibular fracture
- Sublingual haematoma
- 2 point vertical mobility of mandible
- Abnormal sensation in contralateral side of injury
- Pain on contralateral side of injury
How should mandibular fractures be investigated?
Full mouth OPT
PA mandible
Immediate management of mandibular fractures in primary care (4)
Fast
Analgesics
Antibiotics for open fractures - amox/ met/ equivalent
Liquid diet
Call OMFS
10 signs of midface fractures including the zygoma
- Epistaxis with no direct blow to nose
- V2 numbness without direct blow to the nerve
- Mobility of maxilla, sunken face/ appearance, swelling after nose blowing
- Surgical emphysema around eye, subconjunctival bleed, diplopia
- Malocclusion
- CSF leakage
Signs of zygomatic fractures (2)
- IO paresthesia
- Subconjunctival bleed
- Unilateral epistaxis when nose has not been injured
- Eyebrow sign
- Buttress tenderness/FZ tender/IOR tender/Arch tender when not punched discretely in all these areas
Management of suspected zygomatic fractures (4)
No nose blowing
Soft diet
Warn re retrobulbar bleed
Call OMFS
Signs of orbit injury (3)
IO paraesthesia
Subconjunctival bleed
diplopia
Management of suspected orbit fractures (4)
No nose blowing
Document VA & diplopia
Warn retrobulbar bleed
Call OMFS
Management of maxillary fractures (Le-fort type)
Fast
Antibiotics
Liquid diet
No nose blowing
Call OMFS
