Oral Surgery Flashcards
Carry out a MRONJ risk discussion
What is MRONJ?
- medicine related osteonecrosis of the jaw
Why might patient be at risks?
Low risk:
- denusomab in last 9 months + systemic glucocorticoid
- bisphosphonate tx for under 5 years and no systemic glucocorticoid
High risk:
- bisphosphonates for longer than 5 years
- bisphosphonate for less than 5 years + systemic glucocorticoid
- anti-resorptive cancer treatment
- previous MRONJ diagnosis
Inform patient of their risk
What is a bisphosphonate and relevance to dentistry
- drugs to improve bone density by reducing bone turnover
- poorer wound healing following extraction
- important to prevent all future tooth loss
Possible management options if MRONJ occurs
- referral to oral surgery
- debridement of necrotic tissue
- antibiotic therapy
Carry out a lower third molar extraction risk discussion
- including radiographic features making them higher risk
Why need extraction
- decay in 7
- repeat pericoronitis
- decay in 8
Higher risk third molars
- deflection of the IAN canal
- darkening of the root when crossing canal
- interruption of white lines of canal
What are the risks of the procedure
- pain, bleeding, bruising, swelling, infection, trismus, bleeding, dry socket
- dysaesthesia, hypoaesthesia
IAN
- temporary anaesthesia or parasthesia of lower lip, chin, side of tongue - 10-20%
- permanent damage - <1%
Lingual nerve
- loss of taste on one side of tongue
- temp - <25%
- permanent - <1%
Complete an ORN risk discussion
Consent for and then give POI for a dental extraction
Risks of XLA
- pain, bleeding, bruising, swelling, infection, OAC/OAF, crown/root fracture, dry socket, tuberosity fracture
Benefits
- remove unrestorable tooth / remove infection
POI
Bleeding
- wet gauze and pressure for 20 mins
- if doesn’t stop, contact emergency services - or go to A&E
Rinsing
- not for 24 but after, warm saline rinse 3 times per day
Before LA wears off
- take OTC medication to take edge off
- avoid hot foods
- try not to bite lip / cheeks or tongue while numb
Do not explore socket
- with brush, tongue or finger as can dislodge clot or cause infection
- avoid or cut down on smoking to reduce risk of dry socket
Swelling
- resolve in 7 days, can use ice pack 5 min off and 5 min on
If pain worsens or does not resolve then contact us as possible infection or dry socket
Pt has dry socket
- explain what it is, and the risk factors and give the management
Dry socket / alveolar osteitis is where the blood clot is lost
- pain after extraction around 3-4 days after
- moderate to severe dull aching pain
- keeps pt up at night and can throb and radiate to the ear/jaw
- exposed bone is the source of pain
Predisposing factors
- women, manidble, molar, contraceptive pill, smoking, traumatic extraction
Management
- reassure
- LA
- saline rinse
- consider surgicel or alveogyl - a mix of LA and antiseptic iodine
- stop smoking!!!
- OTC analgesia
How would you inform patient of an OAC and give possible management options
Inform patient they have a cyst
- give types
Give possible treatment options for patient presenting with a cyst
Pt presents with facial swelling
What history would you take
When would referral would be considered for SIRS
What management options can you carry out?
SOCRATES pain history to assess where the infection is coming from
- followed by radiograph
Ask about symptoms
- drooling, trismus, trouble swallowing or breathing, inability to stick tongue out, pain, pyrexia
SIRS
- Heart rate - >90bpm
- Respiratory rate - >20bpm
- Temperature - <36 or >38
If 2 or more - SIRS
- urgent referral to OMFS / A&E
When always refer?
- ludwigs angina
- systemic manifestation and immunocompromised pt
- trouble breathing or swallowing
- rapidly progressing
Write referral to OS for extraction of lower 8
Patient details and practice details
- C/O
- my concerns - e.g. caries in 7, proximity to nerve, pt in pain etc
- MH, SH, DH
- summary of oral health status
- details of request
- supplemental info - radiographs etc
Assess a facial fracture on a phantom head
- suggest further investigations that may be done for this
- what management might i do?
Initial questions
- any loss of consciousness
- any numbness on one side
- nausea or vomiting
E/O
- pain
- numbness
- 2 point mobility
- asymmetry
- palpate mandible
- mouth opening reduced
- deviation on opening
- tenderness anywhere
I/O
- lacerations
- occlusal derangement
- loose or broken teeth
- anaesthesia on one side?
Classify
- soft tissue involvement
- simple, compound or comminuted - fractures involving teeth always expose periodontium so always compound
Site
- condylar, ramus, angle etc
Further investigations
- CBCT / OPT, PA manidble - two radiographs
Management
- urgent phone to OMFS
- pain relief and antibiotics if they advise
- may not be seen urgently if it is not displaced
TMD (6 mins) A 27-year old teacher presents with a bunch of E/O and I/O signs of TMD. Click on both sides, sore muscles, sore in morning, tongue scalloping and cheek biting (linea alba).
Please discuss the diagnosis with the patient, and conservative management for this condition. You do not need to obtain further information from the patient.
Diagnosis TMD - very common and 75% of people will suffer with this at some point in life
Explanation
- any muscles that are regularly used can become achey - like your legs if you hike up a mountain
- our muscles that control our jaw can have the same feeling
- day to day use they can withstand however sometimes things like anxiety can result in overuse of these muscles in movements such as clenching of the teeth, grinding of the teeth at night
Management
- reassure and rest the joints
- night guard to protect the teeth from grinding at night
- teeth should only be touching when you eat!
- use OTC medication to help with the pain
- mindfulness, yoga before bed, supporting the jaw when yawning, careful to not open mouth too wide - these are all things that can be done to mitigate
OAF - Take a history - Explain diagnosis from images, X-ray and history - Explain management & surgical closure
OAF patients may complain of
- fluid coming out nose
- nasally speech
- issues playing wind instrument
- problems smoking or using straw
- bad taste, odour or bad breathe
- pain / sinusitis symptoms
Explain
- communication to sinus after extraction, this has not healed and has resulted in a permanent hole
- it can be fixed with some minor oral surgery
Management
- Excise the tissue lining the communication
- buccal advancement flap to close the communication
- antibiotics
POI
- avoid nose blowing or stifling a sneeze
- inhale steam or menthol
- avoid straw
- avoid smoking
