Oral surgery Flashcards

Question

What is the anatomy of the soft palate?

Answer 1

- The soft palate is located posteriorly. It is mobile, and comprised of muscle fibres covered by a mucous membrane. - Anteriorly, it is continuous with the hard palate and with the palatine aponeurosis. The posterior border of the soft palate is free (i.e. not connected to any structure), and has a central process that hangs from the midline – the uvula. - The soft palate also forms the roof of the fauces; an area connecting the oral cavity and the pharynx. Two arches bind the palate to the tongue and pharynx; the palatoglossal arches anteriorly and the palatopharyngeal arches posteriorly. Between these two arches lie the palatine tonsils, which reside in the tonsillar fossae of the oropharynx.

Answer 2

There are five muscles which give the actions of the soft palate. They are all innervated by the pharyngeal branch of the vagus nerve (CN X) – apart from Tensor veli palatini – which is innervated by the medial pterygoid nerve (a branch of CN V3). 1. Tensor Veli Palatini > Attachments: Originates from the medial pterygoid plate of the sphenoid and inserts into the palatine aponeurosis. Function: Tenses the soft palate. 2. Levator Veli Palatini > Attachments: Arises from the petrous temporal bone and the eustachian tube, before inserting into the palatine aponeurosis. > Function: Elevation of the soft palate. 3. Palatoglossus > Attachments: Originates from the palatine aponeurosis, and travels anteriorly, laterally and inferiorly to insert into the side of the tongue. > Function: Pulls the soft palate towards the tongue. 4. Palatopharyngeus Attachments: Arises from the palatine aponeurosis and the hard palate, and inserts into the upper border of the thyroid cartilage. > Function: Tenses soft palate and draws the pharynx anteriorly on swallowing. 5. Musculus Uvulae > Attachments: Arises from the posterior nasal spine and the palatine aponeurosis, and inserts into the mucous membrane of the uvula. > Function: Shortens the uvula.

Answer 3

The palate receives arterial supply primarily from the greater palatine arteries, which run anteriorly from the greater palatine foramen. In addition, the anastomosis between the lesser palatine artery and ascending palatine artery provide collateral supply to the palate. Venous drainage is into the pterygoid venous plexus.

Answer 4

Sensory innervation of the palate is derived from the maxillary branch of the trigeminal nerve (CN V). The greater palatine nerve innervates most of the glandular structures of the hard palate. The nasopalatine nerve innervates the mucous membrane of the anterior hard palate and the lesser palatine nerves innervate the soft palate.

Answer 5

Cleft lip – occurs when the medial nasal prominence and maxillary prominence fail to fuse.

Answer 6

Cleft palate – can occur in isolation when the palatal shelves fail to fuse in the midline, or in combination with cleft lip.

Answer 7

The hard palate is covered superiorly by respiratory mucosa (ciliated pseudostratified columnar epithelium) and inferiorly by oral mucosa (stratified squamous epithelium).

Answer 8

Hyperalgesia – increased sensitivity to pain Allodynia – pain from a usually non-painful stimulus These could both be symptoms of trigeminal neuralgia.

Answer 9

After arising from the trigeminal ganglion, the maxillary nerve passes through the lateral wall of the cavernous sinus, before leaving the skull through the foramen rotundum. It gives rise to numerous sensory branches: Superior alveolar nerve (anterior, posterior and middle) Middle meningeal nerve Infraorbital nerve Zygomatic nerve Inferior palpebral nerve Superior labial nerve Pharyngeal nerve Greater and lesser palatine nerves Nasopalatine nerve

Answer 10

Anterior superior alveolar nerve > Exits via the infraorbital foramen > Innervates anterior maxillary antrum and incisor and canine teeth - Middle superior alveolar nerve > Exits via infraorbital foramen > Innervates medial and lateral maxillary antrum and premolars - Posterior superior alveolar nerve > Exits via the pterygomaxillary fissure > Innervates the posterior maxillary antrum and maxillary molars

Answer 11

Mandibular teeth are primary supplied by the inferior alveolar nerve, which is a branch of the mandibular nerve (V3). It carries both sensory and motor neurones, and exits via the foramen ovale. - The inferior alveolar nerve carries both sensory and motor axons to and from the respective trigeminal nuclei. - After branching from its parent nerve it gives rise to the mylohyoid nerve, a motor nerve to the mylohyoid and anterior digastric muscles. - The remaining sensory axons enter the mandibular canal, a narrow tunnel running through the mandible. Within this canal, the nerve provides branches to the mandibular teeth. - The nerve emerges through the mental foramen as the mental nerve. This provides sensory innervation to the lower lip and chin. Inferior Dental Nerve (V3) > Descends to the lateral pterygoid muscle, before then entering the mandibular foramen > Supplies lower molar and second premolar teeth Mental nerve (V3) > Exits via mental foramen > Supplies chin, lower lip, facial gingiva and mucosa from second premolar anteriorly Incisive nerve (V3) > Supplies teeth and PDL from first premolar anteriorly

Answer 12

Any technique to render part of the body insensitive to pain without affecting consciousness.

Answer 13

- Peripheral nerve conduction works via depolarisation of nerve membranes. - Na moves into the neurone in nerve excitation. --> LA works by blocking Na channels, preventing depolarisation of nerve membranes.

Answer 14

- They contain an aromatic ring and lipophilic portion. - They are broken down in the liver. - Lidocaine - Prilocaine (contains felypressin - synthetic analogue of vasopressin) - Mepivacaine - Bupivacaine

Answer 15

Felypressin can induce labour in pregnant women, hence contraindicated in pregnancy.

Answer 16

- Containing a terminal amine and a hydrophilic portion? - Broken down in plasma and cholinesterase. - Articaine - Procaine - Amethocaine and benzocaine (topical anaesthetics)

Answer 17

- Linked with permanent paraesthesia - As it is broken down in plasma, has a shorted half-life. - Used in higher concentrations which can cause paraesthesia

Answer 18

Prilocaine contains felypressin which can induce labour. Prilocaine and articaine may cause methaemoglobinemia (raised levels of methaemoglobin that can cause tissues to be deprived of adequate oxygen) which can lead to blue-baby syndrome if a pt is pregnant.

Answer 19

1. Unionised lipophilic inactive form. (uncharged) 2. Hydrophilic ionised active form (charged)

Answer 20

1. LA is a weak base (pH 7.8), requires a greater dose if injected into an acidic environment (abscess), less ionised active form. 2. Vasodilation around the abscess, means that tissue perfusion is greater. 3. Increased prostaglandins due to inflammatory response around the infected area, heightened response to pain.

Answer 21

1 cartridge of lidocaine per 10kg of patient

Answer 22

- 4.4mg/kg - 7mg/kg adr - 90 minutes - 2% Lidocaine with 1:80,000 adrenaline.

Answer 23

- 4.4mg/kg - 7mg/kg - 20 minutes - 4% articaine with 1:100,000 adr

Answer 24

- 5mg/kg - 8mg/kg - 90 minutes - 3% prilocaine with felypressin

Answer 25

- LA solution deposited around the terminal branches of nerves - Used to anaesthetise soft tissue and pulp where alveolar bone is thin - Used in maxilla and lower anterior teeth

Answer 26

In the pterygomandibular space. Lies posterior to pterygomandibular raphe and mesial to ramus of the mandible. Muscular landmarks are the masseter laterally and superior constrictor muscle. Medial pterygoid muscle lies mesially to pterygomandibular space. Lingual nerve blocked by injection on retraction of IDB.

Answer 27

Distal and buccal mucosa to lower 6-8, aim for supra periosteal distal and buccal to last standing molar.

Answer 28

- Coronoid notch - Pterygomandibular raphe - 1cm above occlusal plane with a 35mm needle. - Aim from angle of contralateral premolars. - Make contact with bone, retract, aspirate, dispense majority. retract more, dispense for lingual block.

Answer 29

- Dental pulps of all mandibular teeth to the midline. - Buccal gingivae anterior to the mental foramen. - Lingual gingivae. - Anterior 2/3rd of tongue - Floor of the mouth. - Lower lip

Answer 30

- Facial/Bell's palsy --> by inserting the needly too far posteriorly, you may deposit LA into parotid bland, blocking the Facial nerve. - Trismus --> if needle inserted too mesially, inject into the medial pterygoid. - Damage to ID nerve - Intra-vascular injection - caused by not aspirating and not slow injection. Cause pale and incr heart rate. - Bruising/haematoma - Allergic reaction - Skin blanching - Needle breakage - Trauma, either idiopathically or via patient chewing lip due to loss of sensation - Palpitations due to idiopathic injection of intravascular adrenaline causing tachycardia. - Infection - Persistent anaesthesia/paraesthesia (-if injected shallow, then sphenomandibular ligament may act as a barrier to inferior alveolar nerve)

Answer 31

The lingual gingivae/soft tissue.

Answer 32

Buccal gingivae and teeth of the lower anterior teeth. (1-5)

Answer 33

1. Nasopalatine and greater palatine nerves. 2. Superior alveolar nerve: split into anterior, middle and posterior branches. 3. Pterygovenous plexus lies close to posterior superior alveolar nerve, must aspirate first.

Answer 34

- PSA branch of maxillary division of trigeminal extending on the maxilla tuberosity. - Maxilla molars apart from the MB root of 6.

Answer 35

- anaesthetises the middle superior and anterior superior alveolar nerves (Both V2) - inject above the U4 region - innervates buccal and pulpal features 1-5 and MB root of 6.

Answer 36

Greater palatine injection anaesthetises palatal features 4-8. Lesses palatine injection anaesthetises soft palate. Naso-palatine injection, anaesthetisises 1-3.

Answer 37

1. Intra-ligamentary 2. Intra-pulpal

Answer 38

1. Operator dependent > poor technique > insufficient amount of LA used > choice of LA (articaine better infiltration perfusion) 2. Patient dependent > anatomical (variation, accessory nerves) > pathological, if inflammation is present > psychological

Answer 39

1. Unilateral facial (Bell's) palsy, due to injection to posterior into parotid gland, affecting VII facial nerve. 2. Trauma, either idiopathic or via pt chewing lip due to loss of sensation 3. Palpitations due to idiopathic injection of intravascular adrenaline causing tachycardia. 4. Skin blanching 5. Allergy 6. Needle breaking 7. Toxicity

Answer 40

1. Haematoma/bruising 2. Trismus 3. Infection 4. Persistent anaesthesia/paraesthesia 5. Tissue necrosis 6. Post-anaesthetic lesion (HSV, recurrent aphthae)

Answer 41

2% lidocaine + 1:80 000 adrenaline due to its low allergic characteristics.

Answer 42

4% articaine + 1:100,00 adrenaline is more superior to 2% lidocaine + 1:80,000 adrenaline for trx. of posterior teeth with irreversible pulpitis (Cochrane review St.Goerge G et al. 2018)

Answer 43

Articaine can lead to bronchospasm in patients with asthma or sulphites allergies.

Answer 44

1. Lidocaine 5% (onset 2-5 mins) 2. Benzocaine 20% (onset 30 secs)

Answer 45

1ml/min (cartridge volume = 2.2ml). Pain on LA delivery is due to subcutaneous tissue expansion.

Answer 46

Articaine has low pH which makes it more effective when administered in low pH environment such as abscesses as it can pass the cell membrane and get activated by blocking the Na-channels from inside the cell.

Answer 47

Lid.2%+ 1:80,000 Adr.- has total of 49.9micrograms of adrenaline and 46.9mg of lidocaine in a cartridge of 2.2ml.

Answer 48

1. Spreading infection: cellulitis, lymph node involvement, spreading swelling, trismus 2. Systemic involvement: malaise, pyrexia 3. Immunocompromised patients.

Answer 49

1. Allergy to antibiotics 2. Renal function 3. Pregnancy 4. Oral contraceptive pill

Answer 50

Age, weight, renal function, severity of the infection. - Use lowest dose possible for shortest possible time.

Answer 51

Nature of the infection Pt response to Abx - Too short results in resistance - Too long may produce unwanted side effects (antibiotic-associated colitis) - Use lowest dose possible for shortest possible time.

Answer 52

Bactericidal = kill bacteria - Penicillin - Metronidazole - Cephalosporine

Answer 53

Bacteriostatic = inhibit or slow growth of bacteria 1. Tetracycline 2. Erythromycin 3. Clindamycin

Answer 54

- Bactericidal, interferes with cell wall synthesis. - Broad spectrum - 1-10% have allergy to penicillin (rash or anaphylaxis) - Safe in pregnant patients - Inactivated by penicillinases (B lactamases), however Flucloxacillin isn't).

Answer 55

- Amoxicillin + Clavulanic acid - Combination of 2 drugs means active against penicillinases (Beta-lactamases) - Indications - severe dental infections with spreading cellulitis - Side effects: stevens-johnson syndrome - 374mg or 625mg??

Answer 56

- Effective against anaerobic bacteria and protozoa. - Bactericidal, it inhibits synthesis by breaking down bacterial DNA - Indicated for ANUG, pericoronitis, oral infections (when Pen V contraindicated) - Reacts with alcohol + don't use with warfarin - Side effect: oral candida overgrowth - 200mg tds

Answer 57

Bacteriostatic, inhibits bacterial protein synthesis. Serious side effects - pseudomembranous colitis Not routine oral Abx Indicated for bone (osteomyelitis) and skin (cellulitis) infections 150mg tds

Answer 58

- Bacteriostatic, inhibits protein synthesis. - Indicated for perio disease and sinusitis - Causes extensive staining (not indicated for children and pregnant women) - 250mg qds

Answer 59

- Bacteriostatic, inhibits protein synthesis - Interacts with simvastatin, increases plasma concentration of simvastatin - Causes increased risk of myalgias, rhabdomyolysis and renal failure - Narrow spectrum, poor absorption, GI disturbances - Limited indications

Answer 60

Non-selective inhibitors of COX1 and COX2? They are analgesic, antipyretic and anti-inflammatory agents.

Answer 61

1. Ibuprofen 2. Aspirin 3. Diclofenac 4. Naproxen

Answer 62

1. Peptic ulceration 2. Cardiac implications (arrhythmias, thromboses, MI) 3. Increased bleeding tendency

Answer 63

1. Pregnancy/breastfeeding 2. Asthma 3. Renal/liver disease 4. Peptic ulcers 5. Cardiac conditions (excluding ibuprofen) 6. Allergy

Answer 64

- Syncope or vasovagal attack due to anxiety or pain. - Symptoms include nausea, pallor, thread pulse, loss of consciousness, cyanosis and convulsions. - Lie down with feet in air, allow blood to return to brain. Ensure ABCDE and give oxygen.

Answer 65

- Poorly controlled insulin-dependent Diabetes Mellitus, fasting or infection. - Symptoms include; trembling, sweating, hunger, disorientation, slurring of worse, inability to concentrate, aggression, and LOC - Treat with glucose drink (10-20g) and complex carb. - If unconscious - glucagon 1mg I.M. - ABCDE and oxygen

Answer 66

- Poorly controlled drug regime - Sx: LOC, convulsions, incontinence, cyanosis, confusion. - Treat by protecting pt from injury during convulsions. - If prolonged or repeated convulsion in short interval - buccal midazolam 10mg/ml

Answer 67

- Caused by long term steroids and adrenal disease. - Sx: LOC, pallor, thread pulse, low BP. - Ensure ABCDE, oxygen, 100mg hydrocortisone given if need be

Answer 68

- Caused by allergic reaction to penicillin or latex. - Sx: LOC, dyspnoea, flushing, itching, anxiety, pallor, cyanosis, weak pulse, low BP, oedema and cardiac arrest. - Treat with ABCDE, oxygen, adrenaline 0.5ml of 1:1000 adrenaline IM. - Call ambulance

Answer 69

- Caused by myocardial ischaemia, MI, due to pt being stressed or exercise induced. - Sx - crushing chest pain and retrosternal pain radiating down left arm. - Tx: GTN spray sublingually and oxygen.

Answer 70

- venous dilation --> reduces venous return to hear --> decreases preload --> reduce inotropic effect --> reduced anginga

Answer 71

- Occlusion of coronary artery causing tissue death. - Sx: LOC, severe crushing retro-sternal pain, vomiting, pallor, dyspnoea and weak pulse. - Tx: MONASH - morphine - oxygen - nitrate (GTN) - aspirin - seek help - heparin

Answer 72

- Caused by MI and hypoxia, secondary to respiratory obstruction. - Sx: LOC, no central pulse. - Tx: Basic life support and Automated External Defibrillator (AED) until crash team arrives.

Answer 73

- Attack triggered by anxiety, infection, exercise and sensitivity to allergen. - Sx: dyspnoea and wheezing on expiration - Tx: Salbutamol inhaler or nebuliser - Hydrocortisone and consider adrenaline if v severe.

Answer 74

- Caused by cerebral haemorrhage, thrombosis and/or embolism. - Sx: LOC, headache, hemiplegia. FAST symptoms: > Face drooping > Arm weakness > Speech difficulty > Time to call for ambulance. - Tx with supine movement, airway, oxygen, BLS and monitor: --> don't give aspirin as risk if haemorrhage (Brain bleed), make it worse.

Answer 75

- Unconscious causes no pharyngeal reflexes, loss of muscle tone, not able to protect own airway. - Partial obstruction or complete obstruction, stridor or silence. - Clear upper airway (suction) - Triple airway manoeuvre, jaw thrust, head tilt, chin lift. - Heimlich manoeuvre if foreign body. - cricothyroidotomy.

Answer 76

- Compression of lower third sternum to depth of 5-6cm, with compression rate 100-120/minute and 30 compressions to 2 breaths.

Answer 77

Visual: - patient's general appearance E/O: - temperature - swelling - facial asymmetry - lymphadenopathy - trismus, reduced opening of the jaw I/O: - site of surgery - swelling - bleeding - suppuration - halitosis

Answer 78

Dry socket! Inflammation of the alveolar bone post extraction, due to loss of blood clot leaving exposed alveolar bone.

Answer 79

1. Extremely painful (throbbing sensation) 2. Associated with bad taste and odour 3. Not relieved by analgesics 4. Not associated with pyrexia, swelling or infection.

Answer 80

1. Smoking 2. Oral contraceptive pill 3. Local infection (ANUG, pericoronitis) 4. Excessive trauma during XLa. 5. Immunocompromised patient: diabetes, immune suppression, radiotherapy and altered bone metabolism patients.

Answer 81

1. Irrigation of socket with saline solution. (Don't use chlorhexidine as recorded death from allergic reaction) 2. Smoking cessation 3. Obtundent pack, Alveogyl, containing: > Eugenol: An analgesic + antiseptic > Iodoform: An antibacterial > Butamben: A mild anaesthetic > Penghawar djambi: Fibers from the tree fern, Cibotium barometz > Sodium lauryl sulphate: An ingredient in Alveogyl > Calcium carbonate: An ingredient in Alveogyl 4. Analgesia to treat acute pain.

Answer 82

An infection

Answer 83

1. Bleeding post XLA = primary 2. Bleed <48 hours = reactionary, due to trauma to surgical site. 3. Bleed due to infection or other causative factors = secondary

Answer 84

Assess pt for vitals signs and airway clearance. Consider treatment such as vitamin K and tranexamic acid if coagulation risk, as well as fluid transfusion. - consider pack and suture (surgicel), haemostatic acids, vasoconstrictors and suction.

Answer 85

- Debride the socket (surgical area) - Remove clot remnants and try to identify the bleeding site. - Soft tissue management by placing compressive sutures (vicryl) and surgicel or fibrin blocks. - Bone wax if the bleed is from bone - Bleeding due to infection, either localised or systemic (pyrexia) - Consider prophylactic Abx???

Answer 86

- Use as a haemostatic agent (induces blood clot) - Made of an oxidised cellulose polymer - Used to control post-surgical bleeding due to intra-bony bleeds from inferior alveolar artery - Potential neurotoxic effects in mandibular canal.

Answer 87

Polymicrobial anaerobic bacterial infections. Usually three or more causative organisms can be isolated from a dental abscess, predominantly Gram-negative anaerobic bacilli.

Answer 88

1. Systemic involvement — pyrexia, lymphadenopathy and malaise 2. Immunocompromised 3. Spreading infection — cellulitis and swelling

Answer 89

Ibuprofen and paracetamol are first-line analgesia. Codeine phosphate or alternative NSAID, diclofenac, naproxen.

Answer 90

Paracetamol and short course of codeine. No ibuprofen or other NSAID

Answer 91

1st line = paracetamol 2nd line = ibuprofen (NSAID); contraindicated in asthma, pregnancy, liver, kidney, Crohn's disease. 3rd line = paracetamol + ibuprofen 4th line = co-codamol (combination of codeine and paracetamol) 5th line = tramadol (stronger dose of codeine); trx moderate to severe pain. 6th line = oramorph (strong painkiller for severe pain); pain from cancer or heart attacks.

Answer 92

Max = 2400mg (2.4g) or 30mg/kg per day = 600mg x 4/day.

Answer 93

4000mg (4g) per day. 1g per dose, 4x/day.

Answer 94

Ibuprofen and paracetamol, alternate between both every 4 hours.

Answer 95

People with IHD, CVD, PVD, and mild, moderate, or severe HF. Available on prescription only. it is NSAID (not to be taken with other NSAIDs)

Answer 96

- Increase bleeding risk

Answer 97

Engage the furcation in mandibular first and second molars. Can be used to section the mandibular molars into 2 single roots which can be removed separately.

Answer 98

Maxillary first molars, engages buccal furcation and palatal single root.

Answer 99

Stand in front of the patient, chair should be elevated and tilted back. Stand at arm's length away from pt.

Answer 100

Chair should be lowered so that pt's shoulder is level with dentist's elbow. - LL = stand in front of pt - LR = stand behind the pt

Answer 101

1. Initial movement must be apically along the PDL, with blades beneath the gingival margin — This reduces the chance of the crown breaking due to rotational axis being more apical — Wedges the blades down the root causing more displacement — Dilates the socket 2. Second movement = apical force is maintained, with slow and deliberate movements — Conical rooted teeth movement is ROTATED — Multiple rooted teeth have a BUCCO-LINGUAL movement next — Mandibular anterior teeth should initially be moved labially 3. Final movement — Posterior teeth are delivered buccally — Anterior teeth are delivered with rotations

Answer 102

The socket should be compressed firmly with finger and thumb (digital pressure) before applying pressure from the gauze. This makes the socket a smaller wound and any fragments of buccal bone with attached mucoperiosteal are replaced.

Answer 103

1. Avoid > hot or cold foods or drinks > exercise or effort > smoking, alcohol and mouthwashes for 24 hours. > LA lasts for 2-3 hours, can last longer. > playing with wound site or stitches with tongue or fingers. 2. Salt water mouth rinses after 24 hours. Rinse after every meal for 1 week. 3. OH - avoid area 4. Bleeding - pink saliva normal. heavy bleeding use gauze 5. Signs to look out for: - uncontrolled pain - uncontrolled bleeding - bad taste, smell, pus - spreading swelling

Answer 104

- Gripping and supporting alveolus - Retracting soft tissues - Retrieve fractured restorations and fragments of tooth (preferable tooth tweezers) - protect airway - Support the lower jaw

Answer 105

Lower posterior, unless one extremely painful tooth

Answer 106

Lower R = Thumb in lingual sulcus, forefinger in buccal sulcus other 3 fingers under chin Lower L = Curl up 4th and little finger. Middle finger in lingual sulcus, forefinger in buccal sulcus, thumb under chin Upper R = Forefinger in palate, thumb in buccal sulcus curl up remaining 3 fingers Upper L = Thumb in palate, forefinger in buccal sulcus, curl up remaining 3 fingers

Answer 107

Used to loosen or deliver teeth by severing the PDL. Alveolar bone used as the fulcrum and not the adjacent tooth. Firmly help in palm of the hand by the index finger supporting the blade by fingertip close to blade. Very useful for conically rooted teeth. by inserting the instrument onto the root surface so that the concave blade engages the root, and when the handle is rotated the lower cutting edge lifts the root.

Answer 108

- Thinner and sharper than elevators. - Fit in tight apical spaces, more efficient at cutting PDL - use in circular cutting motion whilst applying apical pressure

Answer 109

Removal or upper 8s. Curved blade inserts into the concavity, with the handle then rotating and the blade turning against the root mass.

Answer 110

Blades larger and more pointed, at right angles to the hand. - Used to loosen tooth or root from boy socket prior to forceps placement. - Used for : > extraction of impacted 8s, applying concave surface against mesial aspect of the root. > for elevating fractured roots > applying pressure to buccal aspect of lower molars where furcation can be engaged

Answer 111

Examination of OC and oropharynx

Answer 112

To deflect and retract the periosteum from bone after incision

Answer 113

To retract mucoperiosteal flap only rest on bone

Answer 114

Retraction to aid vision for upper 8s

Answer 115

XLA U8s, locks behind the tuberosity.

Answer 116

History Clinical examination Radiographs Special tests Diagnosis Treatment plan

Answer 117

1. LA 2. Conscious sedation (inhalation or IV) supplemented with local anaesthetic 3. General anaesthetic

Answer 118

Flap design needs to be sufficient for surgical procedure, to ensure adequate access and minimum damage to tissue. - Incision avoids vital structures. - Ensure flap has adequate blood supply. - Incise mucoperiosteal flap ensuring that you don't separate the mucosa and periosteum. Full thickness flap. - Incise perpendicular to epithelial surface. - Include interdental papillae on the flap - At closure of mucoperiosteal flap, should rest on sound bone.

Answer 119

They relieve the tension on the flap for adequate access.

Answer 120

To avoid surgical emphysema.

Answer 121

Flat fissure 4 bur

Answer 122

Scalpel (15) used for cutting soft tissue with minimum trauma

Answer 123

Tooth forceps grasp tissue by puncturing rather than crushing. Non-teeth forceps grasp by compression of opposing serrated edges.

Answer 124

Scissor action incorporating a ratchet lock. Useful for slippery tissue or when direction or traction must be varied.

Answer 125

- Scissor action incorporating a ratchet lock. - Grasp vessel with tip projecting beyond the vessel to facilitate tying a ligature. - Compress vessel to facilitate haemostasis.

Answer 126

Designed to rotate in long axis as a pronation-supination action to drive curved needle through tissues.

Answer 127

- Cutting needles used for resistant fibrous tissues. - Round bodied needles used for fragile tissue to produce minimal damage. - Traumatic is eyeless

Answer 128

- Suture from free to fixed tissue - Ideally suture forehanded (toward yourself) - Evert skin edges - Needle should enter the tissues perpendicular to surface - Follow curve of needle by pronation, supination to avoid 'pulling through'.

Answer 129

- Simple interrupted - Continuous - Vertical mattress - double stitch with return stitch in line with the first but taking a smaller bite. - Horizontal mattress - double stitch with return stitch parallel to the first. - Sub-cuticular continuous - avoids puncture wounds on surface (skin closure)

Answer 130

Resorbable: - PDS (polydioxanone suture) provides wound support for longer period of up to 50 days) - Polyglactin - 3/0 Vicryl - Polysorb used for oral mucosa with 5/0 - Catgut - natural resorbable Non-resorbable: nylon, prolene, silk.

Answer 131

- minimum tissue reaction - not braided so microorganisms can't hide and cause infection - harder to handle as tend to spring apart.

Answer 132

Tissue that is totally freed from its donor site and placed at a recipient site to restore a defect. Derives nourishment from tissue bed or recipient site. Recipient site must be free of infection and bleeding controlled to avoid haematoma. Split skin graft only include the superficial layer of the skin and some germinal cells. Full thickness graft includes all layers of the skin (better cosmetics) Mesh graft to allow exudate to escape and not build up

Answer 133

Named blood vessels detached and inserted at a distant site by microvascular anastomosis to local blood vessels

Answer 134

Aspirate or fluid collected from a lesion (MC, cytology and biochemistry)

Answer 135

True cut biopsy, small core of tissue removed (histology)

Answer 136

Fine needle aspiration cytology

Answer 137

Whole lesion is excised, need a wide clear margin for malignancies >1mm

Answer 138

Portion of the lesion is removed, including JE and normal tissue as well

Answer 139

Temporary physiological nerve block

Answer 140

Axon divided but endoneurium remains intact, mesial part eventually reconnect with the end organ

Answer 141

Nerve divided, recovery unpredictable, may use an interposition nerve graft

Answer 142

- Pre-op preparation - Aseptic technique - Minimal trauma - Surgical debridement and saline irrigation - Drainage of purulent discharge - Adequate wound closure and haemostasis (pack and suture) - Antibiotic - Oral hygiene and post-operative care (analgesia and wound care)

Answer 143

- Caries - Abnormal wear - Prophylaxis - Trauma - Idiopathic resorption - Non-functional teeth (teeth not in occlusion) - Periodontal disease - Supernumerary - Supplemental - Systemic disease

Answer 144

- Inadequate pre-operative clinical and radiographic assessment. - Wrong tooth extracted (NEVER EVENT), Who checklist and notes correct. > Orthodontic XLA: charting may be incorrect. > Caries may be overlooked, with carious teeth changing Tx plan. > Permanent successors can be missing, therefore keep primary teeth > Orthodontic treatment plan may change.

Answer 145

1. Bone fracture 2. Root fractures 3. Nerve injury 4. Blood vessel injury 5. Soft tissue injury 6. Adjacent teeth injury: 7. Inhaled and swallowed tooth 8. Instrument fracture 9. Damage to underlying dental follicle 10. Displacement of teeth 11. Cysts: > due to operator unaware of pathology. > can happen if carious teeth or root XLA without pre-op x-ray > cysts requires proper radiographic techniques

Answer 146

- Tuberosity fracture in lone standing upper molars - Mandible fracture due to excessive trauma - Displaced bony fragments into socket - Labial plate of upper canines can be damaged, can often see buccal mucosa moving (elevator and separate periosteum)

Answer 147

- Most common surgical complication - Only leave in situ if a vital tooth with no infection and small apices. - Non-vital = remove - Orthodontic and prosthetic tx may be delayed by leaving root in situ

Answer 148

- lower 8s - IDN and lingual (lip, chin and tongue numbness and altered sensation/tingling)

Answer 149

- plan surgical flaps properly, protect with retractors - ION injury be repaired, injury due to blind instrumentation - soft tissue = identify and ligate, potential diathermy - bone: > compress bone with instrument > bone wax and pressure packs

Answer 150

- burns - crush, forceps handle on opposing lip and or forceps breaking outside gingiva - slip with instrument due to poor finger rest - rotating burs causing laceration

Answer 151

- displacing lower 7s elevating lower 8s. - upper 1s elevating impacting 3s - developing premolar teeth beneath deciduous teeth - damage and fracture to adjacent teeth and restorations

Answer 152

- can be easily avulsed or damaged by elevating retained roots or deciduous molars. Also by surgical exploration for supernumerary teeth.

Answer 153

- Maxillary antrum can become OAC > upper premolars and molars can be displaced into the maxillary antrum > removal via the caldwell-luc surgical procedure or via socket > prevention by careful use of luxator, avoid excessive upwards force - Soft tissue > lower 8s - lingual pouch, emergency as can move further into neck > upper 8s = pterygomaxillary space, risk of pterygoid venous plexus haemorrhage during incision to retrieve the displaced tooth

Answer 154

- Patient factors: age, build, race and mental capacity. - Divergent roots - root morphology. - Sclerotic bone - Ankylosis

Answer 155

- Retained swabs: WHO checklist - Pain: analgesics - Infection: no smoking, mouthwashes and saltwater bathe, good OH - Dry socket - Self-inflicted trauma when anaesthetised - Swelling: anti-inflammatories (ibuprofen) - Bleeding - Bruising - Paraesthesia/altered sensation perisistent

Answer 156

- Scalpel No15 blade - Austin and Kilner Retractors - Howarth's periosteal elevator - Handpiece and burs - Elevators (couplands, Warwick-james and cryers) - Suture, needle holders and forceps.

Answer 157

- Increase vision - gain adequate surgical access - remove appropriate amount of bone - avoid important anatomical structures - appropriate design to encourage good wound healing.

Answer 158

- Broad base to gain good blood supply. - Large enough for adequate access - Full thickness to include the periosteum - Margins of flap lie on sound bone when close - Avoid vital structures - Include interdental papillae

Answer 159

Around the gingival margins with a scalpel - No relieving incisions - Extends mesially and distally as required for access - Easy to suture closed

Answer 160

- With a relieving incision, ensure anatomical structure maintained and not damaged. Relieving incison: - Good access can be extended distally as required. - Usually move 1 tooth unit forwards - Ensure flap margins are on bone and prevent flap margin collapsing palatally - Include papilla and periosteum - Large blood supply - Combines with envelope technique.

Answer 161

Has mesial and distal relieving incision. - can be used for things like buccal advancement flap for example.

Answer 162

- Move a tooth unit beyond tooth to be extracted. - Ensure flap margins are on bone - Include locating papilla - Prevent flap margin collapsing palatally - Avoid anatomical structures such as mental nerve

Answer 163

- use the anatomy of multi-rooted tooth. - can be divided through the socket with a bur - individual roots separated, remove as separate entities > minimise bone removal required. > easy delivery of roots - Good for teeth with diverging roots (conflicting pathways of withdrawal) - Flat fissure 4 bur usually used

Answer 164

Consider area of bone removal, alveolar bone preservation provides prosthetic advantage.

Answer 165

Resorbable or silk sutures Cutting (normal or reverse) or non-cutting needle choice

Answer 166

Follow current guidelines!!! - Localised infection and multiple incidence of pericoronitis - Unrestorable caries of third or second molar - Trauma (common to operculum of lower from upper 8s) - Tumour or cyst - Orthodontics and prosthetics - Dental pathology - Prophylaxis?

Answer 167

- Type of impaction (mesial/distal/horizontal) - Depth of LL8 compared the LL7 - Proximity of roots to ID canal - Number, shape and form of roots - condition of LL7 and LL8 (caries, restorations etc) - Associated pathology - Quality/density of bone - Bone loss distal to 8 - Working space between distal of 8 and ascending ramus. - Angulation of tooth - Ankylosis?

Answer 168

1. path of withdrawal 2. point of application 3. obstacles 4. bone removal necessity 5. flap design if required

Answer 169

1. Winters lines 2. Pell and Gregory classification system

Answer 170

Vertical impaction Mesio-angular impaction Horizontal impaction Distoangular impaction

Answer 171

when a crown is deliberately removed from a vital tooth and the roots left. Sometimes used in lower 8s, when there is close association with IDN.

Answer 172

- Elevated risk of tuberosity fracture for upper 8s. >. increased risk when using elevators, use forceps instead. > if buccally placed, then able to elevate otherwise do not use. > this is because the lingual gone around an 8 is very thin, easy to # - ION or lingual nerve injury > presents via numbness, tingling, pain, difficult to manage - Lingual paraesthesia - Lip paraesthesia - Fractured mandible - Damage to LL7 - Soft tissue injuries - Pain, bleeding, bruising, swelling, infection - Trismus

Answer 173

- Infection under the operculum (gingival tissue) covering a partially erupted tooth, pain associated. - Well localised pain around a PE tooth. - Swelling of the operculum - Discomfort when swallowing - Trismus - Purulent discharge. - Might have traumatic occlusion

Answer 174

- Determine if airway is compromised, if yes, then refer to emergency care. - Optimal analgesia, no ABx unless systemic or spreading infection or immunocompromised. - Scaling or debridement under LA to remove food debris packed under operculum - Irrigate with saline - XLA if repeated episodes of periocoronitis - XLA of opposing upper 8 if tooth causing traumatic occlusion and non-functional

Answer 175

- Medication related osteonecrosis of the jaw. Exposed bone, or bone that can be probed through an intraoral or extra oral fistula, in the maxillofacial region that has persisted for more then 8 weeks in patients with a history of treatment with anti-resorptive or anti-angiogenic drugs, and where there has been no history of radiation therapy to the jaw or no obvious metastatic disease to the jaws.

Answer 176

They inhibit osteoclast differentiation and function, leading to decreased bone resorption and remodelling.

Answer 177

1. Bisphosphonates 2. Denosumab. They are used in the management of osteoporosis and other non-malignant and malignant condition. They have a significantly positive effect on the quality of life of patients by reducing or delaying onset or tx complications, such as bone fractures and bone pain.

Answer 178

They reduce bone resorption by inhibiting enzymes essential to the formation, recruitment and function of osteoclasts. The drugs have a high affinity for hydroxyapatite and persist in the skeletal tissues for a significant period of time, with alendronate having a half-life in bone of around 10 years. Bisphosphonates are used to reduce the symptoms and complications of metastatic bone disease (particularly with breast cancer, prostate cancer and multiple myeloma). These drugs are usually delivered as regular high dose intravenous infusions in this patient group. Bisphosphonates are also indicated in tx of osteoporosis and other less common disorders such as Paget's disease, osteogenesis imperfecta and fibrous dysplasia. They are additionally used as prophylaxis to counteract the osteoporotic effects of glucocorticoids and to prevent bone related/skeletal complications in pts with primary hyperparathyroidism and cystic fibrosis. Patients in these groups can take the drugs orally (usually once a week) or the drugs can be given as quarterly or yearly infusions.

Answer 179

- Bisphosphonates are used to reduce the symptoms and complications of metastatic bone disease (particularly that associated with breast cancer, prostate cancer and multiple myeloma). These drugs are usually delivered as regular high dose intravenous infusions in this patient group.

Answer 180

- Osteoporosis - Paget's disease - Osteogenesis imperfecta - Fibrous dysplasia - Prophylaxis to counteract the osteoporotic effects of glucocorticoids - Prevent bone-related/skeletal complications in pts with primary hyperparathyroidism and cystic fibrosis.

Answer 181

> Denosumab is a fully human monoclonal antibody which inhibits osteoclast function and associated bone resorption by binding to the receptor activator factor KB ligand (RANKL). > It is indicated for the prophylaxis and tx of osteoporosis and to reduce skeletal-related events relating to metastasis. > it is administered subcutaneously every 6 months in osteoporosis pts, with a higher dose given monthly in pts with metastatic disease. Denosumab does not bind to bone and its effects on bone turnover diminish within nine months of treatment completion

Answer 182

They target the processes by which new blood vessels are formed and are used in cancer treatment to restrict tumour vascularisation.

Answer 183

Anti-angiogenic drugs can be used in combination with bisphosphonates in the management of cancer and there is some evidence that this results in greater MRONJ risk. This may also be true where anti-angiogenic drugs are used in patients with a previous history of bisphosphonate use.

Answer 184

Pts with dental implants placed prior to commencement with anti-resorptive or anti-angiogenic drugs have a small risk of spontaneous MRONJ at those sites. Minimise risk with excellent OH at implant sites.

Answer 185

Osteoporosis pts considering dental implants during or after tx with anti-resorptive rugs are at risk of compromised bone healing and MRONJ following the procedure and have an additional small risk of long-term implant failure.

Answer 186

No evidence as drugs may persist in skeletal tissue for ears. However, an acceptable Mx option for pt with osteoporosis who are being treated with six monthly subcutaneous injections of denosumab is to delay any non-urgent invasive dental tx in an asymptomatic tooth until month prior to pts next scheduled drug administration. Resumption of denosumab tx following invasive dental procedure should be delayed until soft tissues/extraction socket have healed. Liaise with medical practitioners.

Answer 187

1. Pts treated for osteoporosis or other non-malignant disease of bone (e.g. patets) with oral or IV bisphosphonates for less than 5 years who are not taking concurrent systemic glucocorticoids. 2. Pts being treated for osteoporosis or other non-malignant diseases of bone with denosumab who are not being treated with systemic glucocorticoids.

Answer 188

1. Pts with a previous diagnosis of MRONJ 2. Pts being treated with anti-resorptive or anti-angiogenic drugs (or both) as part of the management of cancer. 3. Pts treated for osteoporosis or other non-malignant diseases of bone (e.g. paget's disease) with oral bisphosphonates or quarterly or yearly infusions of IV bisphosphonates for more than 5 years. 4. Pts treated for osteoporosis or other non-malignant diseases of bone with bisphosphonates or denosumab for any length of time who are being concurrently treated with systemic glucocorticoids.

Answer 189

Pts who have taken bisphosphonate drugs at any time in the past and those who have taken denosumab in the last nine months are allocated to a risk group as if they are still taking the drug.

Answer 190

- Condition being treated - Drug type/combinations - Duration of treatment - Dental treatment and other risk factors

Answer 191

1. <5% for cancer patients (taking antiresorptive drugs (bisphosphonates or denosumab). 2. <0.05% for pts with osteoporosis Variation btw studies makes it difficult to determine accurate estimates.

Answer 192

Alendronic acid Risedronate sodium Zolendronic acid Ibandronic acid Pamidronate sodium Sodium clodronate

Answer 193

1. Bevacizumab 2. Sunitinib 3. Afibercept

Answer 194

- protein kinase inhibitors: axitinib, cabozantinib, dasatinib, everolimus, imatinib, osimertinib, pazopanib, regorafenib, sorafenib, temsirolimus; - monoclonal antibodies*: adalimumab, infliximab, ipilimumab, nivolumab, ranibizumab, rituximab, romosozumab, tocilizumab; - antimetabolites: azacitidine, methotrexate; - tumour necrosis factor alpha inhibitor: etanercept.

Answer 195

Aim to get the patient as dentally fit as feasible, prioritising preventive care. - Higher risk cancer patients should preferable undergo a thorough dental assessment, with remedial dental tx where required, prior to commencement of drug therapy.

Answer 196

Exposed bone Loose teeth Non-healing sores or lesions Pus or discharge Tingling, numbness or altered sensations Pain Swelling

Answer 197

NO! Do not prescribe antibiotic or antiseptic prophylaxis following extractions or other bone-impacting treatments specifically to reduce the risk of MRONJ.

Answer 198

Perform straightforward extractions and procedures that may impact on bone in primary care. Do not prescribe antibiotic or antiseptic prophylaxis unless required for another clinical reason.

Answer 199

- Explore all possible alternatives to extraction where teeth could potentially be retained e.g. retaining roots in absence of infection. - If extraction remains the most appropriate tx, proceed as for lower risk pts.

Answer 200

8 weeks. Review healing. If the extraction socket is not healed at 8 weeks and you suspect that the patient has MRONJ, refer to an oral surgery/special care dentistry specialist as per local protocols.

Answer 201

- Anti-resorptive drugs significantly reduce the risk of fractures, and subsequent chronic pain,, in pts being treated for osteoporosis. - Anti-angiogenic drugs restrict the growth of a tumour blood vessels and are an important part of some cancer treatments. Anti-resorptive drugs reduce bone pain and the risk of fractures in pts being treated for cancer. - Drug holidays to avoid the risk of MRONJ associated with dental care are not recommended because the benefits of taking the drugs to manage the pt's medical condition are likely to outweight the small risk of developing MRONJ, and, in case of the bisphosphate or denosumab, stopping the drug does not eliminate the risk of developing MRONJ.

Answer 202

1. Blood clotting is triggered naturally in response to damage to blood vessels from injury or invasive procedures. 2. Platelets within the blood become activated locally, resulting in an increased tendency to adhere to each other and to damaged blood vessel endothelium (primary haemostasis) 3. At the same time a cascade of reactions is initiated converting inactive coagulation factors to their active form, ultimately leading the toe production of protein fibres. 4. Fibrin stabilises the platelet plug by crosslinking the platelets to each other and to the damaged blood vessel wall to prevent further blood loss (secondary haemostasis).

Answer 203

They interfere with platelet aggregation by reversibly or irreversibly inhibiting various steps in the platelet activation required for primary haemostasis.

Answer 204

They inhibit the production or activity of factors that are required for the coagulation cascade and in this way impair secondary haemostasis by inhibiting fibrin production.

Answer 205

Certain medical conditions can predispose individuals to risk of thrombosis, where a blood clot (thrombus) block a blood vessel, at either the site of formation of after travelling to another critical site (thromboembolism), with potentially catastrophic consequences such as heart attack, pulmonary embolism or stroke. Anticoags and antiplatelet drugs are prescribed to reduce the risk of such an event in: > pts with vascular, thromboembolic or cardiac conditions. > In pts with a history or stroke > Following surgical procedures such as heart valve replacements, cardiac stents and joint replacements.

Answer 206

Apixaban Dabigatran Rivaroxaban Edoxaban

Answer 207

Warfarin Phenindione Acenocoumarol

Answer 208

Dalteparin Enoxaparin Tinzaparin

Answer 209

1. Aspirin 2. Clopidogrel 3. Dipyridamole 4. Prasugrel 5. Ticagrelor

Answer 210

Single or dual antiplatelets (often clopidogrel) Lifelong NB. Occasionally warfarin

Answer 211

DOAC Lifelong Occasionally warfarin, rarely single or dual antiplatelets

Answer 212

DOAC, warfarin or injectable anticoagulant Tx usually 6 weeks to 6 months. Prophylaxis can be lifelong. NB: can be lifelong if there is recurrence or an ongoing untreatable risk factors (e.g. malignancy)

Answer 213

Injectable anticoagulant, or DOAC with or without aspirin Usually 2-6 weeks

Answer 214

Warfarin (or other VKA) or single antiplatelet Long term NB: occasionally a DOAC.

Answer 215

Usually single antiplatelet. Dual antiplatelet for 6-12 months following angioplasty or stent insertion or MI DOAc with single or dual antiplatelet if recent MI or AF. Dual therapy for up to 12 months, single therapy with aspirin or clopidogrel therafter.

Answer 216

Single or dual antiplatelets Dual therapy for up to 12 months, monotherapy lifelong

Answer 217

Heparin or injectable anticoagulant On day of dialysis

Answer 218

Aspirin (or injectable anticoag in some high-risk cases) Until delivery (or 6 weeks after for LMWH). NB: risks include obesity

Answer 219

Injectable anticoagulant Until at least 6 weeks after delivery (or until at least 3 months of treatment in total)

Answer 220

Single or dual antiplatelets, DOAC with aspirin Lifelong

Answer 221

1. Chronic renal failure 2. Liver disease (e.g. caused by alcohol dependence, chronic viral hepatitis, autoimmune hepatitis, primary biliary cholongitis) 3. Haematological malignancy or myelodysplastic disorder 4. Recent or current chemotherapy or radiotherapy 5. Advanced heart failure 6. Inherited coagulation disorders including all types of haemophilia and von Willebrand's disease 7. Acquired or inherited platelet disorders including immune thrombocytopenia (ITP) 8. Connective tissue disorders including Ehlers Danlos Syndrome (EDS)

Answer 222

Associated with platelet dysfunction.

Answer 223

1. Reduced production of coagulation factors. 2. Reduction in platelet number and function due to splenomegaly. 3. Alcohol excess can also result in direct bone marrow toxicity and reduced platelet number.

Answer 224

Impaired coagulation or platelet function (even in remission)

Answer 225

Pancytopenia including reduced platelet numbers.

Answer 226

Results in liver failure. (1. reduced production of coagulation factors. 2. reduction in platelet number and function due to splenomegaly. 3. alcohol can cause direct bone marrow toxicity and reduced platelet numbers)

Answer 227

Defective or reduced levels of coagulation factors.

Answer 228

Reduce platelet numbers or abnormal platelet function

Answer 229

Vascular fragility (particularly in the vascular subtype) and platelet function abnormalities in some patient.

Answer 230

Having received chemotherapy less than 3 months ago, or total body irradiation less than 6 months ago.

Answer 231

1. Anticoagulants or antiplatelet drugs 2. Cytotoxic drugs or drugs associated with bone marrow suppression > e.g. leflunamide, hydroxychloroquine, sulfasalazine, penicillamine, gold, methotrexate, azathioprine, mycophenolate mofetil. 3. Biological immunosuppression therapies > infliximab, adalimumab, etanercept tocilizumab, certolizumab, abatacept, anakinra 4. Non-steroidal anti-inflammatory drugs (NSAIDs) > aspirin, ibuprofen, diclofenac and naproxen 5. Drugs affecting the nervous system -> Selective serotonin reuptake inhibitors (SSRIs) -> Serotonin and noradrenaline reuptake inhibitors (SNRIs) -> Carbamazepine

Answer 232

These can reduce platelet numbers and/or impair liver function affecting production of coagulation factors.

Answer 233

These can cause thrombocytopenia and/or impair liver function.

Answer 234

Impair platelet function to various extents.

Answer 235

SSRIs and SNRIs have the potential to impair platelet aggregation and, although unlikely to be clinically significant in isolation, may in combination with other antiplatelet drugs, increase the bleeding time. Carbamazepine can affect both liver function and bone marrow production of platelets. Patients most at risk are those recently started on this medication or following dose adjustments.

Answer 236

Vitamin K antagonist. It inhibits vitamin k-dependent modification of prothrombin and other coagulation factors, which is required for their normal function.

Answer 237

A narrow therapeutic range Sensitivity to diet and drug interactions The requirement for frequent monitoring and dose adjustment

Answer 238

1. Dabigatran (direct inhibitor of coagulation factor thrombin). 2. Apixaban (factor Xa inhibitor) 3. Rivaroxaban (factors Xa inhibitor) 4. Edoxaban (factors Xa inhibitor) These drugs produce a more predictable level of anticoagulation than warfarin and do not require the same degree of monitoring, are easier to manage and are potentially more effective and safer.

Answer 239

Idarucizumab for dabigatran Andexanet alfa for apixaban and rivaroxaban

Answer 240

Heparin, Low molecular weight heparin (LMWH), dalteparin, enoxaparin and tinzaparin, are administered intravenously or by subcutaneous infection.

Answer 241

- Plan tx for early in day and week to allow for management of prolonged bleeding or rebleeding episodes, should they occur. - Provide pre-tx instructions (e.g. INR testing or modifications of meds schedule) - Treat as atraumatically as possible, use appropriate local haemostatic measures and only discharge the pt once haemostasis has been achieved. - Advise pt to take paracetamol, unless contraindicated, for pain relief rather than NSAIDs such as ibuprofen, aspirin, diclofenac, or naproxen. - If travel time to emergency care is a concern, place particular emphasis on use of measure to avoid complications - Provide pt with written post-tx advise and emergency contact details. - if pts is on time-limited courses, delay, non-urgent, invasive dental procedures where possible until meds have been discontinued. - if pt has another relevant medical condition(s) or is taking other meds that may increase bleeding risk, consult with pts prescribing clinician.

Answer 242

1. Treat early in the day + week --> to allow time for management of prolonged bleeding or rebleeding episodes, should they occur. 2. Limit initial treatment area and assess bleeding before continuing. 3. Consider staging extensive or complex procedures 4. Strongly consider packing and suturing.

Answer 243

1. pts with prosthetic metal heart valves, or coronary stents. 2. Pts who have had a pulmonary embolism or deep vein thrombosis in the last three months.. 3. Pts on anticoagulant therapy for carioversion

Answer 244

1. LA by infil, intralig or mental nerve block. 2. LA by IANB, or other regional nerve blocks 3. BPE 4. Supra scale 5. Direct or indirect restorations with supragingival margins 6. Endodontics 7. Impressions 8. Fitting and adjustment of orthodontic appliances

Answer 245

- Simple extractions (1-3 teeth with restricted wound size) - Incision and drainage of intra-oral swellings - 6PPC - Root surface debridement (RSD) - Direct or indirect restorations with subgingival margins

Answer 246

Complex extractions, adjacent extractions that will cause a large wound or more than three extractions at once. Flap raising procedures: - elective surgical extractions - periodontal surgery - preprosthetic surgery - periradicular surgery - crown lengthening - dental implant surgery Gingival recontouring Biopsies

Answer 247

Treat without interrupting medication. Treat early in the day; limit initial treatment area and assess bleeding before continuing; stage extensive of complex procedures; strongly consider suturing and packing.

Answer 248

Advise pt to miss or delay morning dose before treatment - apixaban or dabigatran > take 2x/day --> miss morning dose --> usual time in evening - rivaroxaban or edoxaban > once a day, morning or evening --> if take morning dose, delay morning dose and take 4 hours after haemostasis has been achieved. --> if take evening dose, take at usual time in evening. Treat early in the day; limit initial treatment area and assess bleeding before continuing; stage extensive or complex procedures; strongly consider packing and suturing. - advise pts when to restart their meds.

Answer 249

1. Apixaban 2. Dabigatran - miss morning dose and take evening dose at usual time.

Answer 250

1. Edoxaban 2. Rivaroxaban - if take morning dose. Miss the morning dose and take 4 hours after haemostasis has been achieved. - if take evening dose, just take the evening dose at the usual time.

Answer 251

Check the INR, ideally no more than 24 hours before procedure (up to 72 hours if the patient is stably anticoaglated) ((--> A stable pt does not require weekly monitoring and who has not had any IRN measures >4 in the last 2 months. ))

Answer 252

- Treat without interrupting medication - Treat early in the day; limit initial treatment area and check bleeding before continuing; consider staging complex or extensive procedures; strongly consider packing and suturing.

Answer 253

Delay invasive treatment or refer if urgent.

Answer 254

Treat without interrupting medications. - Treat early in the day; limit initial treatment area and check bleeding before continuing; consider staging complex or extensive procedures; strongly consider packing and suturing.

Answer 255

Consult with prescribing clinician for more information.

Answer 256

Treat without interrupting medication. Treat early in the day; limit initial treatment area and check bleeding before continuing; consider staging complex or extensive procedures; use local haemostatic measures: packing and suturing.

Answer 257

Treat without interrupting medication Expect prolonged bleeding. limit initial treatment area and consider staging extensive or complex procedures; strongly consider suturing and packing.

Answer 258

Consult with the patient's prescribing clinician in order to assess the likely impact of the particular drug combination and the patient's medical condition on their bleeding risk.

Answer 259

1. Absorbant gauze 2. Haemostatic packing material (e.g. oxidised cellulose, collagen spone) 3. Suture kit (needle holder, tissue forceps, suture material, scissors)

Answer 260

While there is evidence that tranexamic acid reduces the bleeding risk from dental treatment in patients on antithrombotic therapies when compared to placebo, it may not have significant benefit when compared to other haemostatic measures. It is not included in the list of dental preparations in the BNF, can't be prescribed by NHS. This guidance does not advise primary care practitioners to prescribe transexamic acid for dental procedures.

Answer 261

NSAIDs - ibuprofen, aspirin, diclofenac, naproxen Macrolide antibiotics: Clarithromycin, erythromycin, azithromycin

Answer 262

Carbamazepine

Answer 263

1. metronidazole 2. any other abx, including: - penicillins (phenoxymethylpenicillin, amoxicillin, co-amoxiclav) - macrolides (clarithromycin, erythromycin, azithromycin) - clindamycin - tetracylines 3. NSAIDs (aspirin, ibuprofen, diclofenac) 4. Miconazole, fluconazole - azole antifungals

Answer 264

Carbamazepine

Answer 265

NSAIDs, ibuprofen, diclofenac. (may increase bleeding risk although note that the antiplatelet affect of aspirin may be reduced by ibuprofen if used regularly)

Answer 266

- NSAIDs: aspirin, ibuprofen, diclofenac

Answer 267

- Erythromycin - Fluconazole - Omeprazole

Answer 268

- NSAIDs: aspirin, ibuprofen, diclofenac

Answer 269

NSAIDs: aspirin, ibuprofen, diclofenac Clarithromycin, azithromycin

Answer 270

Carbamazepine

Answer 271

NSAIDs: aspirin, ibuprofen, diclofenac

Answer 272

The escape of blood from any part of the vascular system, either external or internal

Answer 273

- Increased heart rate - Decreased blood pressure - Cold pale extremities

Answer 274

immediate (primary) Reactionary (<48 hours) Delayed (secondary), 7-10 days Post-op, indicative of infection.

Answer 275

Vasoconstriction --> platelet aggregation --> fibrin formation 1. Vasoconstriction a. limits the amount of blood 2. Platelet aggregation a. recruit further platelets to form a plug (primary haemostasis) 3. Clotting cascade a. works via activation of clotting factors made by the liver due to proteolysis b. both an extrinsic (exposed tissue factor) and intrinsic (platelets) pathway c. intrinsic pathway works by clotting factors produced in the liver (XIII, IX, XI) d. activation of prothrombin --> thrombin e. activation of fibrinogen --> fibrin which causes a stable clot.

Answer 276

Rinse the mouth with warm water to remove excess blood. Place a rolled-up piece of cotton or gauze swab with saline and apply pressure for 20 mins Avoid alcohol, smoking or exercise for 24 hours of XLA to avoid disturbing blood clot. If bleeding will not cease > apply surgicel dressing (oxidised cellulose) > suture the wound to achieve soft tissue closure and stabilise socket edges.

Answer 277

1. haemophilia, A, B or C 2. von willebrand disease 3. hereditary haemorrhagic telangiectasia 4. haemangioma

Answer 278

1. Crush wounds 2. Penetration injuries 3. Fractured bones that sever vessels.

Answer 279

1. Warfarin, effects clotting factors, II, VII, XI and X 2. Heparin, effects anti-thrombin activity. 3. Liver disease, effecting vitamin K 4. Inherited conditions affecting clotting cascade - haemophilia, Von Willebrand.

Answer 280

Thrombocytopenia Aspirin (thrombocytopathy)

Answer 281

1. Scurvy due to lack of vitamin C 2. hereditary, haemorrhagic telangiectasia 3. haemangioma (Sturge Weber syndrome) 4. Ehler Danlos syndrome affective connective tissue 5. Anaphylactoid purpura.

Answer 282

It inhibits activation of factor X, inhibiting prothrombin --> thrombin. Used for DVT prophylaxis post-op as short acting.

Answer 283

Decrease platelet aggregation and inhibit thrombus formation in artery. used in management of stroke, IHD and intracerebral haemorrhage.

Answer 284

- Levels of platelets - Haemoglobin - Haematocrit - Baseline rpt at 24 hours

Answer 285

- Identify site of haemorrhage - Apply pressure and elevate area, act fast - Application of LA as adrenaline is vasoconstrictor - Pack with surgicel and apply gauze - Suture and ligate the vessels - Diathermy to area if possible.

Answer 286

- Monitor vital signs - Consider fluid replacement - Consider analgesia - Consider therapeutics: FFb, clotting factors, tranexamic acid, desmopressin and vit K) - Consider antibiotics

Answer 287

- Hypovolaemic shock - Fluid replacement: haemodilution, fluid overload, renal failure or dehydration if inadequate. - Blood transfusion - Retro maxillary haemorrhage can cause airway obstruction - Retrobulbar haemorrhage can cause blindness.

Answer 288

No, it is contra indicated due to potential haematoma causing an obstructed airway, instead use infiltration and intraligarmentary techniques.

Answer 289

150-400 x 10^9 / ltr

Answer 290

IE is a rare condition with significant morbidity and mortality. It may arise after bacteraemia in a person with a predisposing cardiac condition. It is an infection of the lining of the heart, often involving the heart valves, caused mainly by bacteria which enter the blood from outside the body.

Answer 291

Antibiotic prophylaxis is NOT recommended routinely for people undergoing dental procedures.

Answer 292

1. Acquired valvular heart disease with stenosis or regurgitation 2. Hypertrophic cardiomyopathy 3. Previous infective endocarditis 4. Structure congenital heart disease, including surgically corrected or palliated structural conditional, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully replaced patent ductus arteriosus, and closure devices that are judged to be endothelisalised. 5. Valve replacement.

Answer 293

1. Previous infective endocarditis 2. Structural congenital heart disease 3. Valve replacement

Answer 294

1. benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended. 2. The importance of maintaining good oral health 3. Symptoms that may indicate infective endocarditis and when to seek expert advise 4. The risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.

Answer 295

Antibiotic prophylaxis against infective endocarditis is not recommended routinely: > for people undergoing dental procedures. Chlorhexidine mouthwash should not be offered as prophylaxis against infective endocarditis to people at risk of IE undergoing dental procedures.

Answer 296

- Any episodes of infection in people at risk of IE should be investigated and treated promptly to reduce the risk of endocarditis developing. - If a person at risk of IE is receiving antimicrobial therapy because they are undergoing a GI or genitourinary procedure at a site where there is a suspected infection, the person should receive antibiotics that covers organisms that causes infective endocarditis.

Answer 297

- Prosthetic valve, including trascatheter valves, or where any prosthetic material was used for valve repair. - Previous infective endocarditis - Congenital heart disease (CHD): > any type of cyanotic CHD > any type of CHD repaired with a prosthetic material, whether placed surgically or by percutaneous techniques, up to 6 months after the procedure or lifeling if residual shunt or valvular regurgitation remains.

Answer 298

Assess whether the patient should be considered for routine or non-routine management based on their specific cardiac condition. - pts who have a cardiac condition from the special consideration subgroup may require non-routine management. These special consideration pts should be assess in consultation with their cardiology consultant, cardiac surgeon or local cardiology centre. --> routine management, where invasive dental treatment is provided without antibiotic prophylaxis, will be appropriate for the vast majority of pts at increased risk of IE.

Answer 299

Invasive procedures are those that involve manipulation of dento-gingival junction, periapical regions or perforation of the oral mucosa (excluding local anaesthetic injections in non-infected soft tissues). e.g. placement of matrix bands - subgingival restorations, including fixed pros - endo tx before apical stop has been establised - PMCs - Full periodontal exams - RSD/sub PMPR - Incision and drainage of abscess - Dental extractions - Surgery involving elevation of muco-periosteal flap or muco-gingival area - Placement of dental implants including temporary anchroage devices, mini-impants - Uncovering implant sub-structures.

Answer 300

Ensure that any episode of dental infection in pts at incr risk or IE are investigated and treated promptly to reduce the risk of IE developing. - where tx of dental emergency is beyond your competency, seek advise from an appropriate expert based on your clinical judgement and the individual circumstances. If a pt with a cardiac condition who is not registered with the practice presents with a dental emergency, consider seeking advise on the appropriateness of antibiotic prophylaxis from your local cardiology centre. - Where it has not been possible to obtain advice from pt's cardiology consultant, cardiac surgeon or local cardiology centre, it may be necessary to make a shared decision on antibiotic prophylaxis, based on a discussion with the patient regarding their values and preferences.

Answer 301

- Treatment with beta-lactam antibiotics, such as amoxicillin, can result in hypersensitivity reactions. --> reports of anaphylactic reactions to amoxicillin prophylaxis are extremely rare. --> however, pts with a history of penicillin allergy are at increased risk of immediate hypersensitivity and amoxicillin prophylaxis should not be prescribed for this pts. - The use of broad spectrum Abx, such as amoxicillin or clindamycin, is associated with the rise in Clostridium difficile-associated disease observed in both primary and secondary cares.

Answer 302

Provide the pt with a prescription for Abx prophylaxis at the appointment prior to the planned procedure unless you hold a supply of Abx in your practice. - Consult pt cardiologist, cardiac surgeon or local cardiology centre. They may suggest a regimen.

Answer 303

Give advice on possible adverse events such as hypersensitivity, anaphylaxis and antibiotic-related colitis. It may also be helpful to discuss the issues surrounding antibiotic resistance with the patient. Ensure that patients prescribed an antibiotic are aware that they should seek urgent medical attention if they develop colitis (diarrhoea, which can be severe).

Answer 304

Arrange for the Abx to be taken in practice 60 mins before the planned procedure is due to commence. - Advise pt to bring the abx with them to the dental practice on the day of the procedure and ensure that the patient remains in the practice in the interval between taking the antibiotic and the start of treatment. -Alternatively, if the pt expresses a preference to take the Abx at home or at another location outside the practice, and has not previously had an adverse reaction to prophylaxis, it is acceptable to agree this.

Answer 305

Select a drug from a different antibiotic class for the prophylaxis prescription. If the following amoxicillin or clindamycin regimens are unsuitable, contact an expert, such as a consultant microbiologist or community pharmacist, for advise on an alternative drug regimen.

Answer 306

A. Amoxicillin, 3g oral powder sachet. - give 3g (1 sachet) 60 minutes before procedure. B. Clindamycin capsules, 300mg. - 600mg (2 capsules) 60 minutes before procedure. C. Azithromycin oral suspension 200mg/5ml - 500mg (12.5ml) 60 minutes before procedure. D. Amoxicillin - 1g i.v. just before procedure or at induction of anaesthetic E. Clindamycin - 300mg i.v. just before the procedure or at induction of anaesthesia.

Answer 307

It is a very rare but serious condition. The risk of infective endocarditis in the general population is less than 1 case per 10,000 people per year. However, their cardiac condition puts them at increased risk of developing infective endocarditis. Invasive dental procedure, such as an extraction, may increase the chances of bacteria entering the blood stream. Everyday activities, such as toothbrushing, flossing and chewing can also cause transient bacteraemia and stress importance of good OH to reduce the risk from oral bacteria.

Answer 308

Contact their GMP ASAP if they notice any of the following symptoms, particularly if they occur together as a flu-like illness: - high temperature (fever) of 38 or above - sweats or chills, especially at night - breathlessness, especially during physical activity - weight loss - tiredness (fatigue) - muscle, joint or back pain (unrelated to recent physical activity) > Emphasise that these symptoms are more likely to be caused by a less serious type of infection but should be investigated. > Ensure that the pt known to tell any medical professional they seek advise from about any recent invasive dental treatment they may have had.

Answer 309

- Presence of peri-radicular disease - Non-surgical RCT has failed - Re-RCT cannot be undertaken - Trauma - Perforations and fractured instruments - Developmental anomalies prevent non-surgical RCT.

Answer 310

- Patient specific factors - Anatomical factors, such as lack of access, associated nerves and structures - Periodontal disease - Operator skill

Answer 311

1. Semilunar flap: full thickness flap in alveolar mucosa at level of tooth apex. > Seldom used due to poor access and scarring > Haemostasis often an issue > No involvement of margin and interdental gingiva 2. Leubke-Ochsenbein flap (sub marginal) > Scalloped horizontal incision in attached gingiva and two vertical relieving incisions. > Adequate attached gingiva present (3-5mm) > Best for epithelial wound closre > However unable to extend flap if needed and rarely indicated in the mandible. > Disruption of blood supply to marginal tissues 3. Muco-periosteal flap: two vertical relieving incisions > Horizontal intrasulcular incision > Enhanced surgical access, visibility and wound healing > Minimal vascular supply causing more difficult wound closure than other techniques.

Answer 312

Remove resorptive processes Remove anatomical variation Remore perforations Gain access to diseased soft tissue Evaluate and create apical seal

Answer 313

Remove apical delta (3mm) to allow adequate visual access for canal and apical instrumentation. - Angle of resection should be 90 degrees - Bevels improve access but have disadvantages - Acute angle may miss canals, better to have a flat resection.

Answer 314

- root apex resection - incision for drainage of by-products of tissue breakdown - trephination to alleviate acute pain due to purulent material at apex - retrograde filling of canal

Answer 315

> Clean and prepare apical 3mm > Hermetically seal apex > Material must be non-resorbable and biocompatible to allow cementoblasts to repair the tissue, must also be radiographically visible. > Mineral Trioxide Aggregate (MTA) used

Answer 316

STEROID COVER

Answer 317

Adrenal crisis - life threatening hypotension, severe drop in blood pressure. Dental procedures have attributed to 4.6-9% of adrenal emergencies. Patients at risk of adrenal crisis require consideration for steroid replacement within the dental setting to prevent this occurrence.

Answer 318

Primary adrenal insufficiency - Addison's disease Secondary adrenal insufficiency - glucocorticoid/steroid therapy

Answer 319

(Addisons is when the adrenal glands are damaged and they don't produce enough cortisol) a. Recurrent bacterial infections - chronic oral candidsosis b. Mucosal hyperpigmentation c. Hypotension d. Skin hyperpigmentation e. Weight loss - anorexia f. Low blood pressure, dizziness, faints, fatigued, run down. --> These pts will need steroid cover for dental tx.

Answer 320

Common in specialities such as: - rheumatology (arthritis), - gastroenterology (Crohns, UC) - dermatology - COPD - asthma i.e. anti-inflammatory and immunosuppressive properties.

Answer 321

1. Cortisone - 25mg 2. Hydrocortisone - 20mg 3. Prednisone - 5mg 4. Prednisolone - 5mg 5. Triamcinolone - 4mg 6. Methylprednisolone - 4mg 7. Dexamethasone - 0.75mg

Answer 322

Pts taking 5mg prednisolone or more, for one month or longer, may be at risk of adrenal insufficiency.

Answer 323

Double normal oral dose for 24 hours - > Day of, one our prior to surgery > Day after treatment double normal dose. Then return to normal.

Answer 324

a. Major dental surgery - Pre op = 100mg hydrocortisone IM just before anaesthesia - Post op = double dose oral medication for 24 hours. Then return to normal dose. b. Dental surgery - Pre op = double oral dose (up to 20mg hydrocortisone) one hour prior to surgery - Post op = double dose oral med for 24 hours. Then return to normal dose. c. Minor dental surgery - Pre op = take an extra oral dose, 60 minutes ahead of the procedure Post op = an extra dose when hypoadrenal symptoms occur afterwards. Then return to normal dose.

Answer 325

A healthy patient e.g. healthy, non smoker, no/minimal alcohol

Answer 326

A patient with mild systemic disease e.g. smoker, pregnancy, anxiety, well controlled diabetes, well controlled hypertension

Answer 327

A patient with severe systemic disease e.g. Poor controlled diabetes, poor controlled hypertension, history of MI, COPD, CVA, TIA

Answer 328

A patient with a severe systemic disease which is a constant threat to life e.g. Recent History of MI/CVA (<3/12) Ongoing cardiac ischaemia, valve dysfunction.

Answer 329

Moribund patient not expected to live more than 24 hours with or without an operation e.g. Rupture aortic or thoracic aneurism, intra-cranial bleed with mass effect.

Answer 330

1. Beta blockers - hypertensive response - limit to 3-4 cartridges 2. TCA anti-depressants - increased SNS response - limit to 3-4 cartridges

Answer 331

1. Warfarin 2. Aspirin 3. DOACs > Increase bleeding risk > Consult with doctor 4. ACE- inhibitors 5. Beta-blockers 6. Diuretics > Decrease hypotensive effect of the drugs > Consult doctor 7. SSRIs > Increased bleeding risk > Careful NSAID use

Answer 332

1. Warfarin 2. DOACs > Increased bleeding risk > Prescribe nystatin instead

Answer 333

1. Warfarin 2. Clopidogrel 3. Simvastatin 4. Ca channel blockers > Increase bleeding risk > Avoid - use alternative Abx

Answer 334

1. Warfarin > Increase bleeding risk > avoid - use alternative

Answer 335

1. Warfarin > Increase bleeding risk > advise vigilance 2. Contraceptive pill > decreased effect > advise other pills

Answer 336

1. Warfarin 2. NSAIDS > Increased bleeding risk > Avoid use 3. Phenytoin > Synergistic response > Monitor closely

Answer 337

- Floating palate involves lateral bony margin of the nasal opening - Swelling of the upper lip and ecchymosis in buccal sulcus beneath zygomatic arch - Malocclusion and mobility of teeth may be present - Test by grasping maxillary teeth, characteristic grate felt

Answer 338

- Dish face deformity, gross oedema of soft tissue in mid face region. - Step deformity in infraorbital margin - Mobile mod face - Paraesthesia of cheek

Answer 339

- Separation of frontozygomatic suture - Depression of ocular levels (enophthalmos) - Tilted occlusal plane

Answer 340

- Lacerations, bleeding, swelling. - Malocclusion and step deformity of teeth. - Paraesthesia of mandible due to IDN damage - Sublingual haematoma

Answer 341

DPT and PA mandible

Answer 342

Bilateral condylar fractures and mental bone fracture

Answer 343

Digastric Geniohyoid Genioglossus Mylohyoid

Answer 344

Masseter Temporalis Medial pterygoid Lateral pterygoid

Answer 345

- Favourable = # whereby the muscles pull resists the displacement of the fragments. - Unfavourable = # whereby the muscle pull distracts the fragments away from each other, causing a displacement.

Answer 346

1. Reduction - open: surgically viewing the fracture line and repositioning to ensure no step deformity. - closed: judgement as to avoid damage to internal structures (VII if Condylar #) 2. Fixation - Internal: surgery to access the fracture, fixed via arch bars, screws and plates - External: inter-arch wires, Leonards buttons 3. Immobilisation 4. Rehabilitation (may have to Extn tooth if in the way of a mandibular fracture).

Answer 347

Flattened zygomatic prominence (assess looking down) Swelling and bruising over cheek Steep deformity Periorbital ecchymosis and subconjunctival haemorrhage Paraesthesia or infraorbital nerve

Answer 348

1. Supraorbital 2. Infraorbital 3. Maxillary sinus/Supramaxillary 4. Mandible and occlusal plane Trapnell line = 5. Lower border or mandible

Answer 349

1. Cosmetic deformity due to flat face. 2. Impaired mandibular movement 3. Diplopia due to damage to inferior rectus muscle 4. Retrobulbar haemorrhage, due to ciliary artery damage, blocking blood vessels, supplying oxygen to the optic nerve = anterior ischaemic optic neuropathy.

Answer 350

History (medical, social and dental) Clinical examination Appropriate radiological investigations

Answer 351

1. Patient age and medical status 2. Risk of complications (e.g. risk of inferior alveolar nerve injury, risk of leaving M3M in situ) 3. Patient access to appropriate treatment (e.g. Army personnel on long deployment, Long-term travel) 4. Opposing third molar/contralateral third molar status, if patient. is undergoing a general anaesthetic.

Answer 352

- The likelihood that disease will develop is assessed by the clinician into high or low risk. If the risk is high, surgical intervention should be considered. - IF there is any doubt and the tooth has a higher risk of surgical complications (close approximation to the inferior alveolar nerve) then active surveillance is recommended until symptoms develop or early disease progression has been proven. Quiescent pathology may include undiagnosed second or third molar: - Caries - Periodontal disease - Resorption (internal or external) - Cysts of tumours

Answer 353

- Single severe acute or recurrent subacute pericoronitis - Unrestorable caries of the M3M or to assist restoration of the adjacent tooth. - Periodontal disease compromising the M£M and/or adjacent tooth - Resorption of the M3M and/or adjacent tooth - Fractured M3M M3M periapical abscess, irreversible pulpitis or acute spreading infection - Surrounding pathology (cysts or tumours) associated with the M3M Tx to be considered: - Therapeutic removal of M3M (or coronectomy) - Removal of upper third molar

Answer 354

Clinical review is required, supplemented with radiographic assessment if indicated. An assessment of risk of disease needs to be made and review interval made accordingly.

Answer 355

Medical factors: patients undergoing planned medical treatment/therapy that may complicate the likely surgery of M3Ms include: - Pharmaceutical therapy (bisphosphonates, antiangiogenics, chemotherapy) - Radiotherapy of head and neck - Immunosuppressant therapy Surgical factors: The third molar lies within the perimeter of a surgical field. > Mandibular fractures > Orthognathic surgery > Resection of disease (benign and malignant lesions). --> Leave deeply impacted M3Ms with no associated disease.

Answer 356

1. Temporomandibular disorders. 2. Parotid disease 3. Skin lesions 4. Migraines or other primary headaches 5. Referred pain from angina, cervical spine. 6. Oropharyngeal oncology

Answer 357

Lack of space Obstruction Development in an abnormal position May be associated with pathological changes including: - pericoronitis - an increased risk of caries and periodontal disease in adjacent teeth - orthodontic problems in later life.

Answer 358

1. Temporary or permanent nerve damage 2. Alveolar osteitis (Dry socket) 3. Infection 4. Haemorrhage 5. Temporary local swelling, pain and restricted mouth opening.

Answer 359

1. Slurred speech 2. Extreme muscle shakes 3. Passing urine in 24 hours (kidneys failing) - in children 12 hours 4. Severe breathlessness 5. It feels like you're going to die - sense of impending doom 6. Skin rash - mottled or discoloration of any parts of body

Answer 360

1. Very young (under 1 year) and older people (over 75 years) or very frail people 2. Recent trauma or surgery or invasive procedures (within the last 6 weeks). 3. Impaired immunity due to illness (for example, diabetes) or drugs (for example, people receiving long-term steroids, chemotherapy or immunosuppressants). 4. Indwelling lines, catheters, intravenous drug misusers, any breach of skin integrity (for example, any cuts, burns, blisters or skin infections). 5. Additional risk factors for women who are pregnant or who have been pregnant, given birth, had a termination or miscarriage within the past 6 weeks: > gestational diabetes, diabetes or other comorbidities > needed invasive procedure such as caesarean section, forceps delivery, removal of retained prodcuts of conception > prolonged rupture of membranes > close contact with someone with Group A streptococcal infection > continued vaginal bleeding or an offensive vaginal discharge.

Oral surgery Flashcards

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