Oral Surgery Flashcards by Luisa Davies

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

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what investigations are required when a mandibular fracture is suspected

OPT and PosterAnterior
CBCT is more commonly used now

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what will investigations show if mandible fractured

fracture line at ramus, body, coronoid

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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

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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

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what investigations are required for maxilla fracture

occipitomental radiograph at 10 and 30 degrees

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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

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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

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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

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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

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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

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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

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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

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what antibiotic should be prescribed for pericoronitis

metronidazole 400mg 3x daily for 3 days
if alcoholic - amoxicilin 500mg 3 daily for 3 days

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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

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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

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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

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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

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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

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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

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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