Oral surgery Flashcards
1
Q
What asepsis?
A
It is the exclusion of microorganisms from the wound. Through draping isolation and no touch technique as well regulation of host bacteria through topical prophylaxis using CHx.
2
Q
What are the two sources of microrganisms in a wound?
A
Foreign or host
3
Q
What are the techniques that are used in surgery to achieve asepsis?
A
1.No touch – do not touch the instruments that may go into the patients mouth
2.Sterilisation of instruments
4
Q
When would we use GA?
A
1.Lengthy or difficult operations
2.Acute infection in the area that may denature LA
3.Young children or very nervous patients
5
Q
What are the contraindications for GA?
A
1.Inadequate facilities
2.Medical issues such as respiratory disease
6
Q
What are the 6 areas of concern that may occur in a medically compromised patient generally?
A
1.Stability – is their health easily made worse? - think coronary disease or asthma
2.Co-operation – think physical and behavioural co-operation – think epilepsy or pregnancy
3.Bleeding
4.Healing
5.Bacteremia – infective endocarditis
6.Drug interaction
7
Q
How do we manage a patient with coronary disease?
A
1.Short appointments
2.Pain control
3.Maybe it is better to treatment with supervision of trained hospital staff or hospital
4.Be trained to resuscitate
8
Q
What is the difference between angina and myocardial infarction?
A
Angina is a reversible condition, where the supply of blood to the heart muscles have been temporary effected.
Myocardial infarction is a sever restriction in supply of blood to the muscles of the heart, resulting in ischemic death of the heart muscles.
9
Q
How do we manage a patient with asthma?
A
1.Know the type of asthma the patient might have
2.Know the triggers of their condition
3.Consider hospitalisation for general anaesthetic
10
Q
How do we manage a patient with epilepsy?
A
1.Know their medication and frequency of attacks
2.Use mouth prop of rubber stopper
3.Remove all the instruments and support the patient while they having an epileptic attack
4.DO NOT ALLOW THEM TO LEAVE BEFORE THEY RECOVER put them in lateral recovery position
11
Q
How do we manage patient who might be pregnant?
A
1.Posture – lying flat may cause interference of venus return through baby pressing on vena ceva.
2.Mid-trimester – best time for treatment - reduces the probability of teratology
3.Consider postponing treatment until the patient delivers a baby. The only time you can do it is in emergency.
12
Q
What are the two major medical areas that may cause problems with bleeding?
A
1.Anticoagulats – INR – 4.5 or above is internal bleeding (send to GP) – 2-4 can perform surgery with local measures - less then 1 is sub-therapeutic amount of warfarin (send to GP) - remember aspirin still exist but it is not as potent, local measure are sufficient, for major surgery can stop aspirin for 10 days.
2.Liver disease – hepatitis – may lower the number of coagulation factors created by the liver
13
Q
What are the two most common conditions that may impare healing?
A
1.Steroid use – Addisonian crisis – steroids naturally might not be generated thus need to increase the amount of steroids - diseases such as leukemia might cause a patient to be on steroids
2.Diabetes – determine what type they are and what is there BGL or HbA1C
14
Q
What is the standard dose of antibiotic prophylaxis for infective endocarditis?
A
2mg Amoxycillin orally 1 hour preoperativley
Or
600 mg Clindamycin orally 1-2 hours preoperativley
15
Q
What are the local haemostatic measure you can use for a patient with antithrombotic treatment or conditions effecting the coagulation and platelet aggregation?
A
1.Sutures
2.Minimising tissue trauma
3.Placing cellulose and collagen
4.Using tranexamic acid 4.8% but not with DOACs
5.Provision of post-operative instructions and materials
16
Q
What is the managemnt of patient who use corticosteroids?
A
The possibility of Adesonia crisis is largely patient dependent. A large dose (above 5mg daily) for prologned period of time (2+ weeks) can be expected to cause an adesonia crisis in an event of severe stress.
Following management options:
- If non-invasive procedure like x-rays or examination – no additional dose needed
- If a procedure is invasive in outpatient setting for less than an hour (e.g. extractions or sub-gingival debridment of multiple quadrants) - additional dose may be required usually the day before and on the day of the procedure. Best to contact GP to create a dosing strategy or “action plan”
- If a procedure is invasive and longer than an hour or require sedation or fasting – better contact specialist as that will provide best patient care.
17
Q
What are the stages of osteonecrosis of the jaw?
A
Stage 0 – symptomatic, evidence of radiographic changes and no bone exposure – require follow up monitoring but no treatment
Stage 1 – asymptomatic, bone exposure evident, no evidence of inflammation or infection – require follow up monitoring but no treatment
Stage 2 – symptomatic, evidence of bone exposure, adjacent soft tissue inflammation or secondary infection – requires treament
Stage 3 – symptomatic, full thickness of bone involvement, pathological fracture and extensive soft tissue infection and fistulae – requires treatment
18
Q
What instrument are used in bone cutting?
A
1.Burs – slow speed
2.Chisels – not ideal because when a patient is over 40 may have bone that is brittle
3.Hand instruments such as roungers - used to remove bone between teeth
4.Bone files – good for removal of mandibular tori
5.High speed bone tutting instruments – different from a dental drill
19
Q
What are the steps to risk management of medication-related osteonecrosis of the jaw?
A
1.Inform the patient of the risk
2.Advice not to get off the medication and delay treatment for denosumab closer to the repeat dose as possible (I.e 5 months after the dose ideal)
3.Do not use anti-biotic prophylaxis
4.Ensure optimal oral hygiene before and after procedure
5.Reduce plaque load
6.Minimise trauma
7.Monitor oral wound until it heals
8.Do not debride nonhealing wounds
9.Refer to a specialist if bone is still visible at 8 weeks
20
Q
What are the principle of flaps?
A
1.Adequate access
2.Adequate blood supply to flap
3.Sharp incision at edges
4.Clean dissection
5.Edges of flap away from deeper operative site
6.Avoid vital structure and parallel muscles forces
21
Q
What are the steps of the wound toilet?
A
1.Debridement – continually remove debri as you go and check at the end of the procedure and irrigate the wound
2.Drainage – ensure that puss can be drained and account for appropriate vascularisation – 1cm in diameter is appropriate as greater may result in necrosis or dead space
3.Repair – recheck the debri with scrub nurse and suture to control bleeding and promote healing
22
Q
What are incisions created with?
A
With use of scalpel at right angle of the surface towards the operator in a single firm cut
23
Q
What are the different types of dissection?
A
1.Sharp dissection – use to cut tissue
2.Blunt dissection – use to separate sittuse like muscles or mucoperiosteum seperated from the bone
24
Q
When operating on muscles, what are the two effective technique to utilise?
A
1.Splitting prallel – splitting the muscle fibers – this is good for recovery
2.T shape cut – cut the muscle fibre at right angle to the extension of fibres – this is quite bad for recovery
25
What are methods used for bone cutting?
1.Shave surface of bone with gentle sweeps
2.Postage stam method – cut round holes joined by a flat fissure bur
26
What instrument are used in bone cutting?
1.Burs – slow speed like rosehead or fissure
2.Chisels – not ideal because when a patient is over 40 may have bone that is brittle. Mandibular grain is along the occlusal plain. start at 90 degrees to the grain.
3.Hand instruments such as roungers - used to remove bone between teeth
4.Bone files – good for removal of mandibular tori
5.High speed bone tutting instruments – different from a dental drill as it does not pushes lubricating oil or water into the wound or bacteria from poor sterilisation
6. Osteomtom - dual cutting edge instrument
27
What is trigeminal neuralgia?
It is believed to be a condition where a demyelination of the nerve occurs. The demyelinated nerve is able to conduct electric signals down itself from other crossing nerves.
The result in the confusion of the PNS and manifest as pain in an area known as "trigger zone)
28
What are the treatment for trigeminal neuralgia?
First line - medications like carbamazepine or gabapentin
Second line - peripheral surgery such as cryoneurotomy
Third line - intracranial operation like Janetta procedure
29
What is the most common cause of TMJ pain localised to the joint only?
Intra-articular effusion (sprain).
Caused by:
- Direct trauma to the joint
- Repetition overload
- Internal derangement
- Arthritis
30
What are the indications for TMJ Arthrocentesis?
1. Joint effusion - localised pain in joint and pain on movement
2. Joint limitation - less then 20 mm opening
31
What is the Caldwell Luc procedure and where can we use it?
It is a procedure where the access to the maxillary sinus is made through the anterior wall of the maxilla.
It can be used fo investigation of sinus pathology, removal of foreign objects from the sinus (e.g. teeth) or fixing a large oro-antral fistulas.
32
When does taking of medical history occur?
Taking of the medical history occur upon patient presentation. Initial presentation is essential.
33
How can you take a medical history?
1.General conversation – requires skill
2.Using a questionnaire check list – a bit more suitable for starting dentist
34
Why do we ask for the name and phone number of medical doctor?
To identify at risk patients. Also, as another route of communication in gathering patient history in detail.
35
Where do you palpate the medial pterygoid muscle?
Inside the ramus of the mandible
36
Where do you palpate the lateral pterygoid muslce?
Behind the maxilla
37
How do you measure jaw opening?
Use a ruler
Normal movements: opening 45mm+, 6-8 mm laterally –
Abnormal jaw opening: 5mm very bad, 10mm difficult, 20mm problem with eating
38
How do you assess the TMJ?
Palpate on opening bilaterally.
Feel the rotation and translation.
Remember: when the jaw swings to the side (ipsilateral), the joint on the same side will rotate and contralateral side translates.
39
What is a good test to evaluate the source of orofacial pain?
Passive stretch test.
Make the patient open and push their lower jaw down with your finger.
They may feel discomfort allong their muscle (myofacial origin) or joint (TMD).
Also look at their neck muscles.
40
How do you determine the origin of salivary gland pathosis i.e. how do you examine each major salivary gland?
1. Parotid - pathosis apparent just behind the jaw
2. Sub-mandibular - palpate bi-manually intra and extra oraly at the angle of the mandible pushing the gland up and palpating intra-orally
3. Sub-Lingual - too small
41
What are the three branches of lymph nodes present on the face?
1. Submental
2. Submandibular
3. Facial - commonly inflamed. enlarged and tender after extraction of third molars
42
What is an improtant lymph node to palpate in oral cancer patients?
Jugulodiagastric with bi-manual technique on either side of the lymph nodes. Hard and painless - cancer
43
What are the cranial nerves?
Cranial nerve I – olfactory – function: smell – test: strong smelling object or CT scan or crubirform plate
Cranial nerve II – optic nerve – function: sight – test: reaction to light
Cranial nerve III - oculomotor nerve – function: binocular vision – test: move an object around them or close their eye lid
Cranial nerve IV – trochlear nerve - function: binocular vision - test: move an object around them
Cranial nerve V – trigeminal nerve – function: main censory nerve to the face – divisions: Opthalmic, maxillary and mandibular – there is also a motor branch to muscles of mastication
Cranial nerve VI – abducent nerve - function: binocular vision - test: move an object around them
Cranial nerve VII – facial nerve – function: motor functions of facial expression and taste through the cord of timpani – test: paulsy of muscles tested by movement and taste can be teste with sweet and salty food
Cranial nerve VIII auditory – function: auditory – whisper in their ear
Cranial nerve IX glassopharyneal nerve – function: sensory to tongue and other structure
Cranial nerve X vagus nerve – function: vagal stimulation to the heart and other
Cranial nerve XI accessory nerve – function: motor function to neck and shoulder – test: try to make the patient move their shoulder - may be effect by a tumour or neck dissection
Cnarnial nerve XII hypoglossal nerve – function: motor fucntion of the tongue – test: make the patient move their tongue
44
What are some of the sensory nerve testing?
1.Sharp or blunt testing using the syringe tip sheathed
2.2-point testing with tweezers
3.Directional sense using a sheathed syringe
4.Sensory loss using LA and a sheathed syringe
45
What are the key vital signs?
1.Blood pressure
2.Pulse
3.Respiration
4.Temperature
5.Consciousness
46
What measures blood pressure?
Sphygmomanometer
47
What are the normal values for blood pressure?
Systolic 120-140 - when heart beat begins on manual sphygmomanometers
Dyastolic 60-90 - when the head beat stops on manual sphygnomanometers
48
What is considered to be hyperventilation?
Above 20 shallow breaths per minute
49
What is considered to be a normal pulse?
60-80 beats per minute
50
Why should you not use an oral thermometer in a presence of oral infection/lesion?
An abnormally high reading will be the result. Concentration of inflammatory factors result sin higher local temperature and is not representative of systemic condition.
51
How do we assess the consciousness?
Normal responsiveness or twist their earlobe
52
What are two other useful basic assessments?
BMI and BGL
53
What is normal BGL?
3-8, 9-10 is prediabetic, 11+ is hyperglycemic
54
What are the signs of hyperventilation?
1.Blood pressure remains the same
2.Pulse decreases
3.Respiratory rate increases
4.Consciousness decreases
55
What are the sings of cardiac arrest?
1.Blood pressure drops
2.Pulse non-existent
3.Respiratory rate decreases
4.Consciousness decreases
56
What are the isntruments typically used in a soft tissue suturing?
1.Scalpel handle
2.Tissue holding forceps
3.Needle holder
4.Scissors
5.Periosteal elevator
6.Mailable retractor
7.Have curved needles with suture
57
What is the aim of suturting?
1. Haemostasis acheivement
2. Hold the tissue together to promote healing
58
How do you suture?
1.Place the suture in the right space
2.Put the knot as far away as possible to the tongue – buccal is a good spot or above the tongue
3.Grasp the tissue on one side of the wound
4.Pass the needle through it
5.Grasp the other side of the wound
6.Pass the needle through it
7.Tissue are now together
8.Wrap the string twice aroudn the needle holder and pass the loose string through ti
9.Wrap the string once aroudn the needle holder IN THE OTHER DIRECTION and pass the loose tring through it
10.Wrap the tring once around the needle holder IN THE ORIGINAL DIRACTION and pas the loose string through it
11.Cut 3-4 mm away from the knot
59
How to cute a 2 arms mucoperiosteal flap?
REMEMBER FINGER REST – MAIN OBJECTIVE IS TO SEPERATE THE SOFT AND HARD TISSUE
1.Cut the 2 arms of the flap – 1st between the teeth and gingiva in the periosteal membrane in the alveolar bone – 2nd go to the bottom of the attached gingiva toward your first cut
2.Use your periosteal elevator, round flat part toward bone and slide it along from your second cut – remember more coward the vestibule the tissue is softer
3.Remove any remanence of soft tissue
4.Remove raminance of bone
5.Smooth and shine tissue is the periosteum
6.Suture the flap starting at the corner of the flap at a bisecting angle using a sliding knot
7.Move on to suturing at the first bone – line up papilla to the tooth and pass the needle from the flap papilla to the papilla on the opposite side of the jaw to the flap I.e. if the flap is on the buccal pass it to the lignual papilla
60
How do you know you are supra-periostial during flap preperation?
Large amount of bleeding from the seperate tissues. This means you have not reached bone and need to go deeper.
61
Where would you put the sutures in a double arm flap?
1. In the vertical aspect of the flap. 1-2 suture should be anough
2. In the horizontal aspect through the interdental areas. Line up the papillas and suture together as it is a good guide.
62
What are the three acceptable flaps for the palate?
Main neurovascular supply to remember: Nasopalatine and greater palatine (this one gets damage most of the time by poor flap designs).
1. SIngle midline incision. Suitable for small, superficial objects.
2. Full palatal flap around the gingival margin
3. No canine-to-canine flap. Similar to full palatal flap but does not include the nasopalatine area.
63
What are the main differences in the desing of surgical and dentine cutting burs?
1. Surgical burs have larger flutes
2. Surgical burs have more interspaces flutes
This is due to the fact that bone is different dexture then dentine thus a bur that is design to no clog is used.
64
How to chisel the bone to remove the first permanent molar?
1.Check that they are sharp
2.See the bevel – use a bi-bevel chisel known as osteotom
3.Chisel are very good at removing bone but be careful
4.Remove the crown of the tooth – cut at CEJ with round bur Mesial distally with flat fissure bur – remove with the elevator
5.Separate the roots into 4 parts – remove a root at a time – drill a vertical hole int eh tooth all the way in the middle an separate with flat fissure bur
65
What does sterile surgical field include?
1.Sterile instruments and equipment
2.Sterile consumable
3.Effective isolation of the surgical field
4.Application of hand hygiene
5.PPE
6.Scrubbing
7.Surgical gloves
8.Immune status for blood borne viruses
66
What is a sterile zone?
It is the zone that extend 1m from the chair
67
What are the two recommended techniques for scrubbing?
1.Traditional wet technique – check the hand for skin cuts, open the surgical sponge, clean under, clean your whole hand and arms up to elbow, go betweeen the fingers the finger nails, ring motion with hand till mid arm, pat dry not rub, all this minimum of 3 minutes
2.Newer Alcohol Based Hand Rub – wash your hand with soap and water, clean the finger nails, using elbow dispense 5 mL of alcohol rub around 5 pumps, circular motion, repeat for the other hand and arm, further pumps for hand only, total a minimum of 90 seconds, DONT USE HAND TOWELS
68
How to gown?
1.Pick up the gown by the neck and put your arms in the sleeves
2.Scout DA ties the back
3.Grab the gloves with the calf of the gown inside the gloves, do the next hand similarly
4.Tigh the rope at the front
5.Remain in prayer position
69
What is team time out?
The whole team stops and listens to the patient repeat:
1.Their name
2.Date of birth
3.Procedure
4.Key medical issues like allergies
70
What happens at the end of the procedure?
1.Surgeon check the patient and remove all the sharps
2.Remove drapes, bundle them and put to the waste bin
3.Remove the gown with the gloves in one motion
4.Wash rinse dry the hands
5.Remove mask and ca
6.Alcohol gel
71
What are the objective of extraction teeth?
1.To remove the whole tooth
2.To conserve the alveolar ridge for subsequence prosthesis
72
What are indications for an extraction?
1.Elimination of local pathology - caries, periodontal disease
2.As part of an overall dental treatment plan - orthodontics, prosthetics
3.As part of an overall medical treatment plan – prior to irradiation of jaws or part of special needs dentistry treatment
73
What are contraindication of extraction?
1. You can genuinley conserve the tooth
2. Systemic health of the patient
3. Can not do pre-operative assessment. Medical, clinical and radiographic
74
What are some of the factors which predispose to difficulties in extractions?
1.Abnormal number of teeth
2.Root pathology - caries or hypercementosis
3.State of periodontal attachment
4.Bone density
5.Pathology in area of bone or teeth (that is why radiographs are important)
75
What are the two processes that need to be performed to extract the tooth?
1.Rupture the periodontal membrane as periodontal membrane is one of the mechanisms of tooth retention
2.Expand the socket to eliminate the interdigitation of the tooth root and surrounding bone
76
What are the force that can be used for extractions?
1. Wedging
2. Expansion
3. Strongest axis of tooth
77
What are the different methods of extractions?
1.Intra alveolar – using forceps & elevators
2.Trans alveolar – surgical
78
What is a good guide for selection of a blade of the forceps?
The blade should fit the concavity of the tooth and create a 2 point contact with the tooth for better leverage.
79
80
What are the steps to application of forceps?
1.Select the forceps
2.Position the patient at the elbow height
3.Apply the hand to the alveolous
4.Apply the forceps
5.Aim to apply forcep to root not crown
6.Push blade firmly up root to cut gingival fibres of periodontal membrane and get blades onto tooth root
7.Ensure a good grip between blades of forceps and tooth roots
8.Non-dominant hand: protects, retracts, supports, monitors
81
What are the functions of non-dominant hand for extractions?
1. Protection of tissues
2. Retraction of tissue
3. Support of the anatomicals tructures
4. Monitoring the patient and force application
82
83
What is a cryer elevator?
It is an elevator with an angled spear like appearance. Allows for rotation
84
What is a warwick james elevator?
It is a fine elevator that can be angled or straight
85
What is an elevator?
It is a mechanical wedge that can be pushed or wheel and axis rotation with fulcrum as alveolar bone or a straight lever
86
What are the clinical rules for use of elevators?
1. Avoid excessive force
2. Protect the patient
3. Never apply force toward vital structures
4. Never work blind - control hemorrhage
5. Consider the fulcrum point
6. Consider the point of application for the type of force
87
What is the landmark you looking for in mandibular blocks?
1.Pterygomandibular raphe
2.Coronoid notch
3.Ptergyomandibular depression
4.Linguala
88
What are some of the other blocks that are available for maxilo-alveolar surgery?
1.Long buccal infiltration - 1 cm forward of the ramus and at the occlusal plain submucosaly
2.Akinosi block – close mouth block – medial of the ramus at the occlusal line
3.Infraorbital block – maxillary premolars, inserted into the fornix at the level of the nose
4.Maxillary block – div 2 annasthetised - behind the 8 full length of needle – PLEASE ASPIRATE
5.Gow gates technique - complicated
6.C2 block – 3 fingers below stenomastoid process subcutaniously
7.Auriculotemporal block – 1 cm below the neck of the condyle to the bone surface and after into the tmj space
89
How do you check if the anaesthetic is starting to work?
After 2-5 minutes after injection, in the soft tissue area, that is consistent with the type of anaesthesia technique used, apply pressure.
Tell patient: "You can feel me pushing, but it does not hurt". Proceed.
90
How do you extract maxillary incisors?
Rotation movement to the mesial for both central and lateral incisors. Prior to that, place the forecepts as apically as possible.
91
How do you extract maxillary canines?
Rotation movement towards the mesial with no bucco lingual movement as it will result in loss of canine eminence (buccal plate). Prior to that, place the forceps apically.
92
How do you extract maxillary molars?
Bucco-lingual movement with predominantly buccal direction. When mobilised use some rotation for bone expansion.
93
How do you extract maxillary premolars?
Primarily through bucco-lingual movement with additional buccal traction.
Second primolars may be rotated as they have a single root.
94
What are the steps for a surgical approach to extraction of teeth?
1.Anaesthesia
2.Raise a mucogingival flap
3.Remove the bone
4.Sectioning the tooth
5.Create a point of elevation
6.Elevate
7.Debride following the surgical toilet principals
95
What are example of operative complications?
1.Damage to structures which planned to remain untouched during the procedure
2.Intra-operative bleeding
3.Failure to complete the operation – through carefulness, inexperience or failures of pain control
96
What is the most common extraction complication?
Abnormal socket healing or dry socket
97
What is a dry socket?
It is exposed bone due to loss of blood clot prematurely.
it is very painful and sometime you can see yeah exposed bone.
98
How do you assist a patient with a dry socket?
1. Pain control
2. Use alvoegyl to the socket and/or resuture
99
What are the stages of tooth socket healing?
1. haemostasis and coagulation - this is where suturing in warfarin is important
2. Inflammation
3. Proliferation
4. Modeling and remodeling
100
Why does tranexamic acid work on warfarin but not apixaban?
Tranexamic acid is antifibrinolytic which means it prevents breakdown of already created clots.
Apixaban inhibits factor Xa which revents fromation of thrombin and consequently fibrin clots, which means is stop coagulation before tranexamic acid can safe the clot, by not creating a clot to begin with.
Warfarin works on vitamin K as an antagonist (affecting factors II, VII, IX and X). Which means, it reduces reduces the clotting factors but does not eliminate the. This means that tranexamic acid can work on small amoutn of forming clots.
101
How long does it take to clear aspirin?
10 days
102
What antibiotic interacts with warfarin?
Metronidozole
103
What are the key steps for removal of impacted teeth?
1.Assessment – symptomatic or not, age, medical fitness, radiographs,
2.Decision to remove or leave – based on advantages or disadvantages to the patient
3.Informed consent
4.Anaesthesia – LA alone, LA with sedation, GA
5.Flap design – general flap design over the bone cavity
6.Bone removal - especially on the ligo distal
7.Tooth sectioning
8.Elevation
9.Debridement
10.Suture
11.Follow up and management of complications
104
How do we assess the radiographs for third molar extractions?
1.Vertical and horizontal relations
2.Third molar relationship to mandibular canal
Real or imaginary drawing of line on radiograph: 1st line : occlusal line (along occlusal plain), 2nd line: long axis of the third molar, 3rd line: Front of vertical ramus (any third molar will be visible after raising the flap if above this line, below will barried in bone), 4th line if perpendicula from occlusal line to point of elevation (the longer it is, the more difficult extraction will get), 5th closeness to mandibular canal
105
What is consent?
Communication process by which patient can give their voluntary and continuing permission to a health professional, for a specific treatment, based upon a reasonable knowledge of the purpose, nature, likely effects, consequences, risks, alternatives and cost of that treatment.
106
What are the principles of consent?
1.Authority – can they give consent
2.Capacity – is the person capable of understanding information
3.Information – what information do they require to consent
4.Autonomy – are they given consent under pressure?
5.Discussion – can they ask questions – information brochures are good
107
What are the risks of removing a third molar?
1.Traumatic inflammation
2.Wound infection (5%)
3.Nausea and vomiting
4.GA death rate (1/100000) - GA has higher risk
5.Long term risks – Dysathesia (0.1%)
108
How would you classify a wisdowm tooth in terms of it's anatomical position?
1.Position: fully erupted, partly erupted or unerupted
2.Angulation: vertical, mesioangular, distoangular, buccoversion, aberramt (if no pathology – just leave)
3.Roots: fused or multiple
4.Tissue covering it
109
What are the steps to lingual protection?
1.Gently lift lingual tissues posterior to the 3rd molar or ramus
2.Start to elevate flap and follow curve down around medial side of mandible – situate the cut betweent 3rd and 2nd molar – leave retractor in place
3.Do not elevate the flap near 3rd molar because that may damage the nerve
4.Do not remove the retractor
110
What are the three clinicla descriptions that can be used to describe a nerve injury?
Neuropraxia – associated with rapid recovery
Axontomesis – recovery within 2-4 months
Neurotmesis – problematic recovery
111
What are the classic radiological features of third molar clossness to the mandibular canal?
1.Nerve crosses the root
2.Lamina dura of canal is lost
3.Radiolucency of canal is greater
4.Nerve canal is narrower
112
What do you when a patient comes back after the procedures with a numb lip?
1.You must see them and do not deny it and express concerns and remind them you already warned them
2.Don't say it will get better
3.Exam
4.Offer referral
5.Recheck in 6 weeks
6.Definetly refer after to OMS
7.Remember – nerve heal slowly
113
What is the mechanism of trismus?
Damage to medial and very rarely lateral pterygoid. Need to examine and administer jaw exercises using a spatula. Number spatulas, bite on them and relax, after add another spatula. Muscles usually stretch more after relaxation.
114
What is the aim of perioperative management?
To return patient back to normal by utilizing vital signs, fluid balance (think input and output), position (need to position the patient at 45 degrees), pain control (long LA and analgesia), swelling (use of cold packs 20 to 30 mins or use of systemic steroids), nausea (why are they nauseous), antibiotic and nutrition (small amount first). Think about the whole wellbeing of the patient.
115
How do you calculate amount of blood loss?
Each gauze, small equal to 5 mL
Contents of suction bottle – amount of irrigation fluid used
116
What are the symptoms of hypovoleimic shock?
Drop in blood pressure
Weak pulse rate
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What are the principles of radiographic imaging in OMS?
1.The modality – technique, indications and contra-indications
2.View the whole are from two directions
3.Know differential diagnosis
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What is a cone beam?
It is a type of CT which is good for hard tissue but not great for soft tissue
119
What is the use of nuclear medicine?
Using radioactive substance Technetium 99 following can be shown:
1.Areas of bone growth
2.Areas of inflammation
3.Areas of malignancy
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What is a good start poitn for pathology?
Using surgical sieve:
1.Developmental
2.Inflammatory – most common (show classical signs of inflammation PSRHL) - physical causes, infectious, immunological – acute or chronic
3.Neoplastic – benign or malignant( primary or secondary) - need to know the origin tissues (usually epithelial or connective tissue)
4.Parasitic – not common
5.Idiopathic
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What are the different types of epithelial tissue of origin?
1.Skin
2.Mucosa
3.Glandular
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What are the different types of connective tissue of origin?
1.Fibrous
2.Cartilaginous
3.Bone
4.Vasular
5.Muscular
6.Neurological
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What are the 10 points of pain investigation
1.Location – ask patient to point
2.Type – describe the pain
3.Duration – how long have had pain
4.Onset – how did it start or what makes it worst
5.Exacerbation – what alters the pain
6.Severity – hpw sever is the pain, can they sleep
7.Are to which pain spread – where does it end?
8.Area to which pain radiates – is the radiation of pain feasible I.e. does it follow the nerve
9.Area to wwhich pain is reffered – Does the pain from one nerve to the other
10.Associated pathology – is there pathology in the area
124
How do you investigate a swelling?
Location – what anatomical structure are involved
Duration – how long has the swelling been present
Shape – diffused or well defined
Consistency – fluctuant, soft, firm, boney hard
Associated pathology – ulceration, pain and other swellings
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How do you investigate an ulcers?
1.Location – what structure are invovled
2.Duration – how long it has been present
3.Size – what is the diameter and depth
4.Shape – round or oblong
5.Edge of the ulcers – undermined, punched or raised, rolled and everted
6.Floor fo ulcer – smooth, granulated, sloughed, fungated or is there bone exposed
7.Base – is it soft under the ulces or is in indurated (firm)
8.Associated pathology – swelling, pain
9.Similar ulcers elsewhere
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What are the rules for bipsy?
1.If small, perform a total excision
2.If area is large, incisonal biopsy
3.Thin deep sections preferable
4.Spciment can sometimes include normal tissue
5.Avoid crushing or mutilating speciments
6.After removal, place specimen in 10% formo-saline or schedule for fresh pick up with transport medium
7.Provide adequate information to pathology – history and clinical findings
8.Negative biopsy does not preclude possibility of no malignancy – keep patient under regular review and re-biopsy
127
What are your surgical options for pathology?
1. Observe
2. Reduce the size of pathology
3. Completely excise the abnormal area
4. Resect – cut through normal tissue – 1cm margin for SCC, ABCC – 2cm and malignant melanoma - 3cm
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What are the key to diagnosis cycsts?
1.X-ray and other images – take 2 at different angles
2.Pulp sensibility or vitality testing
3.Aspiration-type biopsy – golden fluid (chlesterol crystal of inflammatory cysts), white fluid (keratocysts due to keratin), blood (haemangioma or aneurysmal bone cysts or contamination), no fluid (not a cyst or traumatic bone cysts), negative pressure (solid lesion or tumour)
129
How do inflammatory cyst grow?
By osmotic growth mostly
130
What is a surgical treatment of cysts?
1.Observe
2.Marsupialise – joining the lining with surface mucosa – patient need to keep a hole clean
3.Enucleation – scooping the cyst out and placing mucosa over it with prior use of carnoid solution
4.Resecteion
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What is an abscess?
It is a collection of pus
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What is cellulitis?
It is a collection of inflammatory fluid – not pus
133
Where does the pus from upper canines track to?
Usually, due to the root positioning above the insertions of muscles of facial expression, pus will track between oral and ocular muslces. This results in a swelling in the lateral side of the eye. Canine foass abscess can then track along the veins, through the orbit and into the brain (cerebral abcess). These are potentially dangerous.
134
Where does the pus from upper premolars and molars track track?
Between buccinator muscles and the skin resulting in buccal abcess. Remembers to check both upper and lower jaws.
135
Where does the pus from the lower incisors and canines track to?
Usually, intraoraly through the thin cortical plate but if beneath the mylohyoid muscle then they track into the submental space resulting in submental abscess.
136
Where does the pus from lower molars drain to?
Most commonly, beneath the mylohyoid muscle into the submandibular triangle and int the submandibular space and later drain into neck or throat or both. There is no stop in those space thus they may end up in mediastinum.
137
What is Ludwig's Andgina?
A cellulitis that involves all three spaces – submental, submandibular and sublingual bilaterally.
138
What is the management of odontogenic infections?
1.Prevention is best
2.Asessment of patient
3.Airway – If patient has trismus, not a dental problem anymore
4.Swelling – compression and displacement of the airway
5.Treatment – remove cause, drainage in situ, support host (rehydrate and antipyretic), antibiotics in high doses
139
What are the main boundaries of the maxillary sinus?
Apex – zygomatic arch
Lateral wall – Lateral nose
Anterior – cheeck
Posterior – infra-temporal fossa
Roof – floor of orbit
Floor – alveolous and teeth
Meatus – entry to nose
140
What sinuses are connected together?
The sphenoidal and ethmoidal sinuses communicate with frontal and maxillary sinuses via nose. Problem in one will flow into the other
141
What is common inflmmatory pathology of the sinuses
1.Acute maxillary bacterial sinusitis – nasal discharged, bilateral, dull ache, pain in molars
2.Acute viral sinusitis
3.Acute fungal sinusitis
4.Chronic purulent sinusitis
5.Chronic hyperplastic sinusitis
142
What is common trauma pathology sinus?
1.Facial fractures
2.Dental trauma – endodontics
3.Breach during extractions – oroantral communications or breaching of teeth
143
What is common other pathology in sinus?
1.Mucoceles (minor mucous glands)
2.Aggressive mucoceles – epithelial inclusions – related to LeForte 1
3.Odontogenic pathology
4.Osteogenic – bone pathology
144
How do you test for OAC?
Oroantral communications can be tested by asking patient to blow through their nose – bubles will appear at the socket.
145
What is the management of OAC?
1.Make sure no sinusitis
2.If small – push the buccal plate and suture
3.If large – use buccal approach and close over the extraction site with buccal gingivae with prior reduction of buccal bone
4.POIG: Avoid negative pressure, use decongestants, consider antibiotics
146
What is the common pathology of minor salivary glands?
Developmental – rare
Inflammatory :
Bacterial: sialadenitis or sialoliths (more common in submandibular)
Viral: mumps
Trauma: fistula or extravasation
Irradiation: xerostomia
Drugs: xerostomia
Neoplasms (usually asymptomatic swellings):
Benign: pleomorphic adenoma
Malignant: Mucoepidermoid adenoid cystic carcinoma (most likely malignant in minor glands)
147
How much radiotherapy is given to a person with head and neck cancer?
Usually 55+ grays over 6 weeks
148
What are the steps to assisting a patient with facial trauma?
1.ABC – airway, breathing consciousness
2.Neurological symptoms
3.Stability - is patient stable
4.Full secondary survey with primary care pshycision at the hospital. Head to toe with all histories taken if the patient is awake.
5.Diplopia – eye movement exams. Up,down, side to side
6.Nose, upper and lower jaw examination
7.Assessment of cranial nerves especially 5 + 7 but also all other nerves
8.Intra-oral examination - find all teeth, order chest x-ray if one is missing
9.Radiology order – plain x-rays first with OPG, PA skull, submentovortex and Lat ceph
10. Treatment planning for surgery including history
11. Consent from patient
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What is pre-opertaive set up for a facial traum surgery?
1. Order of toxicology report for recent drug use
2. Order a blood cell count (full blood count test)
3. Order blood glucose level test if they have diabetes
4. Order IV antibiotics to reduce the chance of infection as well as IV fluids and alagesia
4. Order 1 bag of blood if need, tho not very common for facial fracutre surgery
5. Contact naethetis and book an operating room
150
What is the treatment for a mandbiular and condyle fracture?
1. Direct epihpyseal fracture of the mandible, single, closed
2. Indirect fracture of the RHD condular head
Treatment for 1 - exposure of the fracture at site at the mandible and placement of direct plating of the fracture (ORIF)
Treatment for 2 - intermaxillary fixation with use of arch bars to allow the condyle to heal if it is not displaced, comminuted or severely damage in other way. This will manage the occlusion. TMJ ficxation with direct bars may be possible.
Remember:
Soft food, and wire shut jaw for the next 3 months at least.
After the surgery, patient needs to be observed until reasching 12 hour stability.
Review 24 hours, a week, a month and 3 months after. If any complications occur, review.
Remove arch bars when the condyle is healed. A period of physiotherapy might be needed.
151
What is osseointegration?
It is the integration of artificial material into the bone
152
What kind of bonds does implant make with the bone?
Van de Waals bonds
Chemical bonding
Specialised biological attachment through cellular hemi-desmosomes
153
What are the essential for osseointegration?
1.Material compatibility – titanium
2.Proper implant design – medical drage titanium, titanium oxide surface
3.Surface compatibility
4.Biologic bed
5.Surgical technique – slow speed and high torque to reduce heat generation with carbon steel surgical drills
6.Prosthetic load
7.No prosthodontic load – 500 newtons is normal force
154
What is the result of sleep apnoea?
Blocking of airways and reduced amount of oxygen reaching the brain. Apnoe – is when breathing completely stops for a few minutes.
155
What is the clinical evaluation for sleep apnoe?
1.Airway
2.Sleep retrusions
3.Obesity
4.Polysomnogram
5.Sleep endoscopy
6.Epworth Sleepiness Scale
156
What are the treatment for sleep apnoea?
1.CPAP
2.Mandibular advancement splints
3.Surgical options – soft and hard tissue
4.Loosing weight
157
How can we reduce the amount of host oral bacteria to improve asepsis?
With use of pre-operative phorphylaxis with topical mouth washes like CHx.
158
What are part of the assessment plan?
1.Fitness examination – does it match for what you want to do
2.History taking
3.Examination
4.Special tests
5.Any extras
6.Differential diagnosis
7.Treatment portions
8.Proposed treatment
9.Plan steps to accomplish procedure
10.Pre-operative management
11.Operative management
12.Post operative management
