Oral Surgery Flashcards
what should you check for in an exam in a patient presenting with possible mandibular fracture
facial asymmetry
lacerations
step deformity
limited tmj movement
mandibular deviation on opening
numbness or altered sensation to chin and lip
altered occlusion
sublingual haematoma
what investigations are required when a mandibular fracture is suspected
OPT and PosterAnterior
CBCT is more commonly used now
what will investigations show if mandible fractured
fracture line at ramus, body, coronoid
how is a fractured mandible treated
urgent referral to maxfacs - phone them and ask if they want you to do anything
pain management - analgesia advice
might ask to prescribe antibiotics
if displaced and symptomatic - open reduction and internal fixation
if not displaced, asymptomatic or happened more than a month ago - monitor
what are symptoms of a fractured maxilla
facial asymmetry
step deformity palpable
numbness to face
periorbital swelling and bruising
subconjuctiva ecchymosis
flattened zygoma
epitaxis
diplopia
what investigations are required for maxilla fracture
occipitomental radiograph at 10 and 30 degrees
how is a maxilla fracture treated
referral to omfs
analgesia advice
antibiotic if open to oral cavity or contaminated
might require surgical treatment - open reduction internal fixation
what are signs and symptoms of dry socket
severe pain 3-4 days after xla - pain gotten worse
o/e - no blood clot present, bone exposed
bad smell/taste in mouth
pain throbbing, keeping patient awake
explain dry socket to patient
very sore complication that can happen after an extraction. it is caused by inflammation of the lamina dura of the bone - alveolar osteitits.
it happens with the blood clot at the site of extraction either fails to develop, is dislodged or dissolves before the socket heals, leaving the bone exposed, inflammed and sensitive
it is not associated with infection so antibiotics are not required
what makes someone more at risk of developing a dry socket
smoker
oral contraceptive pill
tooth in mandible
tooth further back
females
excessive rinsing or vigorous mouthwashing
excessive trauma
how is a dry socket treated
reassurance that right tooth extracted and is common risk
LA to numb area - will provide relief
gentle irrigation and debridement of socket
placement of alvogyl - antiseptic
educate patient on how to keep clean - warm salt water but no vigorous rinsing
review patient
what information should be included in referral to OS for surgical removal of 8s
patient details
practice details
S - situation, patient information, age, complaining of
B - background, how many episodes, antibiotics required
A - assessment - angle of impaction, depth of impaction, caries, PA path, MH and SH
R - recommendation - pt is keen for surgical XLA and i think it is recommended in this case
give post op instructions after XLA
will be numbnes for next couple of hours - be careful with any food too hot or hard
take painkillers before numbness wears off - anything you would take for headache - paracetamol and ibuprofen if okay to do so, dont exceed recommended amount
we will make sure youve stopped bleeding before you leave, if any blood in saliva dont worry, but if oozing, roll handy or gauze, dampen it down and bite down for 20-30 mins, if still bleeding, repeat if still - phone ourselves or 111
avoid poking or proding area with tongue or toothbrush
have soft diet for next couple of days
take it easy for next couple of days - nothing that will raise blood pressure
avoid smoking and alcohol for as long as possible
starting tomorrow - start hot salty mouth rinses 4x daily for 5 days
if pain worsens in 2-3 days time - contact us, possible infection or dry socket - should improve every day
provide number
what antibiotic should be prescribed for pericoronitis
metronidazole 400mg 3x daily for 3 days
if alcoholic - amoxicilin 500mg 3 daily for 3 days
what should be included on a prescription
patient name, dob, address
drug name and formulation (metrondazole tablets)
drug dosage (400mg)
frequency (3x daily)
duration of treatment (for 3 days)
total number of tablets (send 9 tablets)
scored off
signed and dated
explain what pericoronitis is to a patient
inflammation of the gum surrounding the wisdom tooth
tooth is partially erupted into the mouth but the gum surrounding this is inflammed, food and bacteria get trapped around the gum and causes pain
how is pericoronitis treated
irrigation with saline - removal of food and debris
metrondazole or amoxicillin if systemic symptoms
analgesia advice
rinse with warm salty water after meals
keep clean with single tufted brush
if tooth impacted and recurrent pericoronitis then surgical xla
what are risks of 3rd molar xla
common - pain bleeding bruising swelling infection, dry socket, jaw stiffness, damage to adjacent teeth
nerve - temporary (10%) or permanent (<1%) damage to IAN - altered sensation or numbness, only you will know wont look diff and can still move normally, might resolve within the year
what information should be included when explaining 3rd molar xla under la
will be numb - wont feel anything sharp but will feel pressure
will be awake
should have something to eat before hand, dont need a chaperone but advise take next day off
will make a cut in gum, lift gum up, remove some bone to expose tooth then remove tooth either in one part or might have to section tooth
will involve drills - similar to the ones in a dentist, will hear these during xla
will then place a couple of stitches in mouth to help gum heal - will dissolve on their own, wont have to come back to get them out
explain TMD to a patient
you have a joint that connects the jaw to the base of the skull. there are muscles surrounding this joint that allow the jaw to move and allow you mouth to open close and move from side to side
however, in this condition, these muscles are overworked, causing pain and inflammation around the joint. therefore, when you use the joint, open or close, it can be painful. give analogy of going to gym and doing bicep curls
muscles never getting a break - due to parafunctional habits such as grinding through the night or clenching through the day
give conservative management to patient with TMD
reassurance - very common and can be reduced with simple treatment
stress management - important to reduce overall stress on health - yoga, relaxation techinques, work life balance
cut food into smaller pieces, avoid chewing gum, chew on both sides, be mindful of clenching - should always have space between teeth
support wide mouth opening - yawning
NSAID to reduce inflammation
heat and cold packs to reduce muscle inflammation
what are symptoms of an OAF
fluids coming through nose
nasally sounding voice
unable to smoke or play wind instruments - create seal
post nasal drip - bad taste in mouth
explain an OAF to patient
use radiographs to help to explain
in skull have holes to allow space for air and make skull lighter - these are close to the upper jaw and roots of upper teeth
when an upper tooth is extracted, there is a risk that a part of the lining of these air spaces is extracted with it
then forms a communication or a hole from the sinus into the mouth - bad taste, fluids going up
happened at time of extraction but has not healed so has allowed a permanent tract to form between sinus and mouth
how is an OAF treated
need to numb up then first remove the tract that has formed - tube like structure
then cut a bit of the gum up and close over the hole (buccal advancement flap)
antibiotics - phenoxymethyl penicillin
what instructions should be given to a patient following an OAF
avoid nose blowing
avoid smoking
avoid drinking through a straw
avoid singing
steam face with menthol
what are signs of SIRS
white blood cells <4 or more than >11
heart rate - above 90
temp - below 36 or above 38
respiratory rate - above 22
what should you check extra orally if patient presents with swelling
temp, hr, o2 sat, rr
feel swelling - note size, hard or soft, location
border of mandible - if palpable or not
lymphadenopathy
mouth opening
hot potato voice
mental state
what should you check for intra orally when pt has swelling
check if floor of mouth raised
check if uvula to one side
then check infection site - size of swelling
how to treat swelling and systemic infection
remove cause - pulp extirpation or xla
drain swelling - doesnt remove cause, if intra orally we can do it, can do this and then remove cause if unable to achieve anaesthesia
antibiotics - 500mg phenoxymethyl penicillin 4x daily for 5 days or 400mg metronidazole if allergic to penicillin
what general precautions should be taken when extracting a tooth on a pt on an anti coagulant
extract early in the day and early in the week
use local haemostatic agents - pressure, pack and suture
atraumatic extraction technique
good pre-op and post op advice
provide emergency contact number
give examples of a low bleeding risk procedure
simple extraction of 3 teeth or less (provided not adjacent to one another)
restorations with subgingival margins
6ppc
rsd
incision and drainage of wounds
what are examples of a high risk bleeding procedure
simple extraction of more than 3 teeth or adjacent to one another (large wound created)
anything requiring flap to be raised - surgical extraction, periodontal surgery etc
biopsy
how should high bleeding risk procedures be managed
stage intial treatment and see how pt responds
miss morning dose (if take 2 tablets daily), delay morning dose (if 1 tablet daily) - at least 4 hours after bleeding stopped
if a patient is on warfarin, how should the extraction be managed
INR should be checked 24-48 hours prior to XLA
should be <4 - if not, procedure cannot be carried out, if urgent - referral to OMFS
if <4 then tx can be safely carried out - pressure, pack and suture
what medications interact with anti coagulants
ibuprofen - increases bleeding risk
miconazole/fluconazole - increase bleeding risk
what is infective endocarditis
rare but life threatening infection of endocardium surrounding heart (primarily valves), caused by transient bacteria that can come from oral cavity
who are most at risk of infective endocarditis
those who have previously had IE
those with a prosthetic heart valve
those with congenital heart disease
what procedures are high risk for IE
anything manipulating gingival margin
-matrix band + subgingival restorations
- subgingival scaling
- extractions
- incision and drainage
- lifting a flap
when should you be worried about IE and what should you do
high risk patient with a high risk procedure - contact cardiologist for advice and if ABX prophylaxis is requried
what is MRONJ
medication related osteonecrosis of the jaw
when a patient is on an antiresorptive or anti angiogenic medication for bone cancer or osteoporosis - prevents bone turnover so if bone manipulated, more difficulty in healing
bone may become exposed and infected
what is required for a diagnosis of MRONJ
must be on a medication - bisphosphonate, RANK-L
have had delayed healing post XLA
have never had radiotherapy
what makes someone low risk for developing MRONJ
on bisphosphonate medication for less than 5 years - even if it was years ago, stays in bones
0.01-0.1% chance
what makes someone higher risk of developing MRONJ
on bisphosphonate medication for 5 years
on bisphosphonate medication for cancer
on bisphosphonate medication for less than 5 years but also on corticosteroid
0.1-1% chance
how are those with low risk of MRONJ treated
explain to PT need for good OH and importance of avoiding XLA
diet advice
smoking cessation
toothbrushing and fluoride advice
regular exams to catch any decay early
how are those with high risk of MRONJ treated
high prevention - toothbrushing, fluoride, smoking cessation, alcohol advice
explore all treatment options to avoid XLA - decoronation, retained roots - avoid manipulating bone
if XLA required, carry out atraumatically
if no healing after 6-8weeks - referral to OS
explain in patient terms what bisphosphonate drugs do and importance in dentistry
bisphosphonate medication reduce the turnover of bone - prevents bone being broken down - can accumulate in the jaw as this is a high area of bone turnover
if a tooth is to be taken out whilst you are on this medication, there is a chance of poor healing - which we call MRONJ. this means that the bone cannot repair itself because of the medication you are on. the risk of it is low but if it does happen, it can be very painful, bone can become exposed and can become infected. therefore it is important that we take any teeth out before you start the medication
what drug is used for sedation and how is it titrated
midazolam 5mg/5ml - 2ml given initially, watch response then give 1ml every minute
what drug is used to reverse midazolam
flumazenil
what should oxygen levels be through iv sedation and when is intervention required
should be 97-100
at 95 - oxygen should be given through nasal cannula
at 90 - oxygen should be given through hudson mask
what information should be given to the pt at a sedation assessment appointment
should be aware they will require chaperone for day
no responsibilities for day
no driving
no loss of consciousness or amnesia
should also take bp, hr, bmi and o2 on this day
what are contraindications to IV sedation
copd, hepatic insufficiency, preganacy and breast feeding, hypothydroidism
