Oral Surgery Flashcards
3.1 a) Which patients should be referred to a specialise for urgent assessment according to the 2005 NICE guidelines on urgent referrals for suspected oral cancer?
i) Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:
(1) Unexplained ulceration in the oral cavity lasting for more than 3 weeks, or
(2) A persistent and unexplained lump in the neck (new NICE recommendation for 2015).
ii) Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) for oral cancer in people when assessed by a dentist as having either:
(1) A lump on the lip or in the oral cavity consistent with oral cancer, or
(2) A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia (new NICE recommendation for 2015).
iii) Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump (new NICE recommendation for 2015).
3.1 b) As a GDP, to whom would you refer a patient for management if you suspected that they had a squamous cell carcinoma of the oral cavity?
i) Oral and maxillofacial surgery consultant
ii) Oral medicine and oral surgery consultant
3.1 c) What treatment modalities are commonly used for treating squamous cell carcinoma of the OC?
i) Surgical excision with a margin or normal tissue
ii) Local radiotherapy
iii) Chemotherapy
iv) Combination of any of the above.
3.1 d) What do you understand by the term palliative care?
i) Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and the relief of suffering by means of early identification and impeccable assessment and treatment of pain and other symptoms, physical , psychosocial and spiritual.
3.2 a) What are bisphosphonates?
i) Bisphosphonates reduce bone resorption by inhibiting enzymes essential to the formation, recruitment and function of osteoclasts.
ii) They have a high affinity for hydroxyapatite and persist in skeletal tissue for significant period of time.
iii) Bisphosphonates are used to reduce symptoms and complications of metastatic bone disease (particularly that associated with breast cancer, prostate cancer and multiple myeloma). Usually high dose IV infusions.
iv) Bisphosphonates are also indicated in tx of osteoporosis and other less common disorders of bone such as Paget’s disease, osteogenesis imperfecta and fibrous dysplasia. Also used as prophylaxis to osteoporotic effects of glucocorticoids and to prevent bone-related/skeletal complications in pts with primary hyperparathyroidism and cystic fibrosis. Usually oral drugs or can be given as quarterly or yearly infusions.
3.2 b) You are a general dental practitioner who has a patient who is about to commence treatment with bisphosphonates. How would you manage them?
i) Before commencement of anti-resorptive or anti-angiogenic drug therapy, get patient as dentally fit as feasible, prioritising preventive care.
ii) Advise pt (or carer) that there is a risk of developing MRONJ but ensure they understand risk is small so that they are not discouraged from taking meds or undergoing dental tx.
iii) Give personalised preventive advise to pt to optimise oral health:
(1) Healthy diet reduced sugary snacks and drinks.
(2) Good OH
(3) Fluoride toothpaste and MW
(4) Stop smoking
(5) Limit alcohol intake
(6) Regular dental checks
(7) Report any symptoms such as exposed bone, loose teeth, non-healing sores of lesions, pus or discharge, tingling, numbness or altered sensations, pain or swelling as soon as possible.
iv) Prioritise care that will reduce mucosal trauma or may help avoid future extractions or any oral surgery or procedure that may impact on bone:
(1) Consider obtaining appropriate radiographs to identify possible areas of infection and pathology
(2) Undertake any remedial dental work
(3) Extract any teeth of poor prognosis without delay
(4) Focus on minimising periodontal/dental infection or disease
(5) Adjust or replace poorly fitting dentures to minimise future mucosal trauma
(6) Consider prescribing high fluoride toothpaste
v) For medically complex patients, consider consulting oral surgery/special care dentistry specialist with regards to clinical assessment and treatment planning.
3.2 c) You have a patient who has been an oral bisphosphonates for 5 years and requires a dental extraction. Describe how you would manage this patient.
i) Explore all possible alternatives where teeth could potentially be retained e.g. retaining roots in absence of infection.
ii) If extraction remaining the most appropriate tx, proceed as for low risk patients.
iii) Perform straightforward extractions and procedures that may impact on bone in primary care.
iv) Do not prescribe antibiotics or antiseptic prophylaxis unless required for other clinical reasons.
v) Advise pt to contact practice if any concerns, such as unexpected pain, tingling, numbness, altered sensation or swelling in extraction area.
vi) Review healing. If the extraction socked is not healed at 8 weeks and you suspect that the patient has MRONJ, then refer to oral surgery/special care dentistry specialist as per local protocols.
vii) Current estimates of MRONJ incidence are typically <5% for cancer patients (taking antiresorptive drugs (bisphosphonates or denosumab) and<0.05% for patients with osteoporosis although the variation between studies makes it difficult to determine accurate estimates.
3.3 a) What is the definition of MRONJ?
i) Exposed bone, or bone that can be probed through an intraoral or extraoral fistula, in the maxillofacial region that has persisted for more than 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.
3.3 b) In which conditions might a patient be prescribed bisphosphonate medication?
i) Cancer patients: used to reduce the symptoms and consequences of metastatic bone disease (particularly that associated with breast cancer, prostate cancer and multiple myeloma). These drugs are usually delivered as regular high dose of intravenous infusions in this patient group.
ii) Tx of Osteoporosis, Paget’s disease, Osteogenesis imperfecta and Fibrous dysplasia.
iii) Prophylaxis to counteract the osteoporotic effects of glucocorticoids.
iv) Prevent bone related/skeletal complications in pts with primary hyperparathyroidism and cystic fibrosis.
3.3 c) What are the common routes of administration of bisphosphonate mediation?
i) Oral and IV
3.3 d) Which patients are most at risk of getting MRONJ?
i) Pts being 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.
ii) Pts being treated for osteoporosis or other non-malignant disease of bone with bisphosphonates or denosumab for any length of time, who are being concurrently treated with systemic glucocorticoids.
iii) Pts being treated with anti-resorptive or anti-angiogenic drugs (or both) as part of management of cancer.
iv) Patients with a. previous diagnosis of MRONJ.
3.3 e) Name some local risk factors.
i) Mandibular extractions
ii) All dentoalveolar surgery
iii) Periodontitis, presence of oral abscesses or injection
iv) Poor oral hygiene
v) Denture-related trauma
vi) Thin mucosal coverage, e.g. lingual tori
3.4 a) A fit and healthy 25-year-old pt attends with a 2-day history of a painful, loose left mandibular first permanent molar after he was hit in the face with a cricket ball. What key questions would you ask the patient?
i) History and exam as usual to ascertain the C/o, HPC, MH, DH, SH.
(1) Circumstances surrounding incident?
(2) Any loss of consciousness or any other injuries?
(3) Is occlusion deranged?
(4) Any altered sensation in the disruption of the inferior alveolar/dental nerve? (numbness/tingling of chin and lower lip on that half of face?)
(5) State of tooth before incident, e.g. pain, mobility?
3.4 b) What radiological investigations if any would you carry out after examination?
i) DPT to obtain overview of dentition and mandible. If insufficient detail of region of lower left mandibular first molar tooth then a periapical radiograph may be warranted to determine whether there is a fracture in the tooth or to determine the periodontal status of the tooth.
3.4 c) Following your examination and investigations, you are concerned that the mobile tooth is a result of a fracture mandible. How would you proceed?
i) Immediately refer to nearest oral and maxillofacial surgery department for further assessment and management.
3.4 d) If there was a mandibular fracture, which radiological view(s) would demonstrate it?
i) A dental panoramic radiograph and another view at another angle, usually a posterior-anterior view of the mandible (PA mandible).
ii) An alternative would be oblique lateral view of the mandible and PA mandible, but the oblique lateral views are often inferior to a panoramic radiograph.
iii) Cone-beam computed tomography (CBCT) would also provide good information regarding the fracture but is not indicated in simple fractures due to the higher radiation dose relative to a DPT and PA mandible.
3.4 e) What treatment is likely to be required in this case?
i) It is likely the fracture is displaced as the patient feels movement in lower left first molar. Surgical treatment in form of ORIF – open reduction and internal fixation of the fractured mandible. For a body of mandible fracture this is often accessed via an intraoral approach.
3.5 a) A fit and healthy 10-year-old child fell while playing on his scooter and is brought into surgery with evidence of injury to maxillary anterior tooth. Your worry is that the child may have sustained an alveolar or dento-alveolar fracture. What are the differences between these two terms?
i) A fracture of the alveolar process may or may not involve the alveolar socket. A dento-alveolar fracture would involve fracture of the alveolar process and the socket.
3.5 b) What features would lead you to suspect that the child has sustained a dento-alveolar fracture?
i) Segment mobility and displacement, with several teeth moving together as a unit.
ii) Occlusal disturbance due to displacement and misalignment of fractured alveolar segment.
iii) Teeth in fractured segment may not respond to pulp sensibility testing.
iv) Teeth of affected segment are often tender to percussion.
v) Gingival lacerations may be present.
3.5 c) What investigations would you carry out and what findings would you expect?
i) Vitality test of all the involved teeth – this is usually negative.
ii) Fracture lines may be located at any level, from the marginal bone to the root apex.
iii) Recommended radiographs:
(1) One parallel periapical radiograph
(2) Two additional radiographs of the tooth taken with different vertical and/or horizontal angulations.
(3) Occlusal radiograph
iv) In cases where the above radiographs provide insufficient information for treatment planning, a panoramic radiograph and/or CBCT can be considered to determine the local, extend and direction of the fracture.
v) Radiographs – usually two views are recommended for identification of fractures. Ideally, these should be at right angles to one another for better identification of fracture lines but in practice the views are usually taken with the x-ray tube head in two different positions. In the anterior region the options would be periapical views and an upper standard occlusal. A DPT or CBCT may also be useful. Radiographic findings suggestive of a dento-alveolar fracture may present as:
(1) A radiolucent line between the fragments. However, the vertical line of the fracture may be difficult to see as it may run along the PDL space. The horizontal line may be located apical at the apex of coronal to the apex.
(2) An alteration in the outline shape of root and discontinuity of PDL.
(3) An associated fracture(s) of the roots of the teeth.
3.5 d) Assuming the child is co-operative and there are not other injuries, how would you manage the dento-alveolar fracture?
i) Administer local analgesia
ii) Reposition the displaced segment with digital pressure applied both labially and palatally or with forceps if necessary
iii) Stabilise fractured segment by splinting the teeth with a passive and flexible splint for 4 weeks.
iv) Suture gingival lacerations is present.
v) RCT contraindicated at emergency appointment.
vi) Monitor pulp condition of all teeth involved, both initially and at follow ups to determine if or when endo tx become necessary.
vii) Follow up: 4 weeks S+, 6-8 weeks, 4 months, 6 months, 1 year, yearly for 5 years.
e) What post-treatment instructions would you give the patient and his parents?
i) Soft diet for 1 week
ii) Explain good oral hygiene is essential for healing of tissue and that chlorhexidine MW may be beneficial
iii) Avoid contact sports
iv) Maintain good oral hygiene
v) Analgesic advise
vi) Explain the need for longer-term follow-up, as there is a risk of:
(1) Pulp necrosis and infection
(2) Apical periodontitis
(3) Inadequate soft tissue healing
(4) Non-healing fracture
(5) External inflammatory (infection-related) resorption.
(6) Ankylosis
(7) Bone loss
(8) Loss of tooth
3.6 a) What does the term pericoronitis mean? Which teeth are most commonly affected by it?
i) Pericoronitis means infection of the tissue (operculum) surrounding the crown of a tooth (partially erupted tooth). The lower third molars are most commonly affected.
3.6 b) What are the signs and symptoms of pericoronitis?
i) Mild – swelling of soft tissues around crown of tooth, bad taste, pain, halitosis.
ii) Moderate – lymphadenopathy, trismus, extraoral swelling.
iii) Severe – fever, malaise, spreading infection and abscess formation.
3.6 c) How do you treat acute pericoronitis?
i) Tx depends on severity of the infection.
(1) Oral hygiene advice
(a) Single tufted brush
(b) Warm salt mouthrinse and chlorhexidine 0.12/0.2% mouthwash
(2) Local measures
(a) Carry out irrigation and debridement
(3) Metronidazole is drug of first choice where there is systemic involvement (malaise, pyrexia, lymphadenopathy) or persistent swelling despite local measures.
(a) Metronidazole tablets, 400mg. TDS 3/7
(4) Suitable alternative is amoxicillin.
(a) Amoxicillin capsules, 500mg. TDS 3/7
(5) Consider removal of upper 8s if traumatic occlusion.
(6) If severe infection, may need hospitalisation, intravenous antibiotics, removal of the lower third molars and/or incision and drainage.
3.7 a) What does the acronym NICE stand for?
i) National Institute of Health and clinical Excellence
3.7 b) Royal college of Surgeons Faculty of Dental Surgery – Parameter of care for patients undergoing mandibular third molar surgery 2020. List 5 indications for XLA 8s:
i) High risk of disease development + symptomatic. Consideration for therapeutic extractions is indicated for: (tx to be considered A) therapeutic removal of M3M (or coronectomy) (removal of upper third molar)
(1) Single severe acute or recurrent subacute pericoronitis
(2) Unrestorable caries of the M3M or to assist restoration of the adjacent tooth.
(3) Periodontal disease compromising the M3M and/or adjacent teeth
(4) Resorption of the M3M and/or adjacent teeth
(5) Fracture M3M
(6) M3M periapical abscess, irreversible pulpitis or acute spreading infection.
(7) Surrounding pathology (cysts or tumours) associated with the M3M
ii) Diseased/high risk of disease development + asymptomatic:
(1) Likelihood that disease will develop is assessed by clinician into high or low. If high risk, surgical intervention should be considered. If there is any doubt and the tooth has a higher risk of surgical complications (close to IDN) then active surveillance is recommended until symptoms develop or early disease progression has been proven.
(2) Quiescent pathology may include undiagnosed second or third molar
(a) Caries
(b) Periodontal disease
(c) Resorption (internal or external)
(d) Cysts of tumours
iii) Non-diseased/low risk of disease
(1) Factor for consideration of prophylactic removal
(a) Medical factors: pts undergoing planned medical treatment/therapy that may complicate the likely surgery of M3Ms including
(i) Pharmaceutical therapy (bisphosphonates, antiangiogenics, chemotherapy)
(ii) Radiotherapy of head and neck
(iii) Immunosuppressant therapy
(b) Surgical factors: the third molar lies within the perimeter of a surgical field.
(i) Mandibular fractures
(ii) Orthognathic surgery
(iii) Resection of disease (benign and malignant tumours)
3.7 c) What features on a radiograph would suggest that a wisdom tooth is associated with the inferior dental nerve?
i) Loss, deviation or narrowing of the ‘tramlines’ of the inferior dental canal, and radiolucent band across the root of the tooth.
3.7 d) What specific information must be given to a patient prior to removal of an impacted lower wisdom tooth, which you would not give if you were removing an upper wisdom tooth?
i) Numbness/tingling of lower lip, chin and tongue which may be temporary or permanent. Possibility of inferior alveolar nerve or lingual nerve damage.
ii) Risk of mandibular fracture
3.8 a) What do you understand by the term meal-time syndrome?
i) Patients who have an obstruction in a duct of a major salivary gland often complain of pain and swelling in the region of that gland on smelling or eating food and also on anticipation of food.
