Oral Surgery Flashcards
1
Q
what analgesic drug group would you avoid for poorly controlled male with asthma
A
NSAIDs
2
Q
post-la
what analgesia to prescribe
A
paracetamol
3
Q
list all essential information to include when writing NHS prescription
A
pt details - CHI, DoB, name, address, age in months if <12
prescriber - name, signature, designation, GDC number
NHS/hospital number or practice address
medication generic name, form, strength, dosage, direction for use, when to take, frequency, duration
date of prescription, special instructions, warnings
4
Q
BNF stands for
A
British national formulary
5
Q
how long is an NHS prescription for non-controlled drug valid for
A
6 months
from date of signature
28 if controlled
6
Q
hole in gum following xla 6 months ago
what is this called
A
oro-antral fistula
7
Q
symptoms of OAF
A
fluid escape from nose when drinking
unable to smoke/straw
congestion
whistling noise when speaking
pain/tenderness
sinus infection
altered taste/smell
nasal discharge
8
Q
tx for OAF
A
small/intact lining = encourage clot, suture, POI
excise epithelialise tract to prevent recurrence, irrigate with saline, remove granulation tissue
full thickness periosteum buccal advancement flap and suture
pen v 500mg qds 5 days
avoid nose blowing, don’t create negative pressure, decongestants, don’t hold in sneeze, good OH
9
Q
signs + symptoms of displaced body of mandible fracture
A
deviation
pain, swelling, bruising
altered sensation
step deformity
trismus
asymmetry
malocclusion
bleeding
tooth mobility
10
Q
2 standard radiographic views to establish mandibular fracture diagnosis
A
full OPT
posterior anterior mandible view
11
Q
factors which may cause mandibular fracture displacement
A
trauma
occlusal forces
muscles pull
12
Q
treatment options for a fractured mandible
A
open reduction and internal fixation
closed reduction and intermaxillary fixation
conservative
13
Q
how does LA work
A
stops nerve propagation by blocking voltage gated Na+ channels, blocking action potential generation and propagation
14
Q
what nerves fibres are most susceptible to LA
A
small, unmyelinated fibres
C fibres, a delta
15
Q
name ester LA
A
cocaine
procaine
benzocaine
16
Q
name amide LA
A
lignocaine
prilocaine
articaine
bupivacaine
17
Q
what is in a cartridge of LA
A
LA agent
vasoconstrictor
preservative
buffer
18
Q
max dose of lignocaine
A
4.4mg/kg
19
Q
max dose articaine
A
7mg/kg
20
Q
landmarks for IDB
A
between coronoid notch and pterygomandibular raphe
from contralateral premolars, slightly above occlusal plane of molars
21
Q
alternatives for IDB
A
Gow-Gates = high block, entire V3
Vazirani-akinosi = closed mouth technique, trismus
intraligamentary
22
Q
how to manage pt if you accidentally hit parotid during IDB
A
inform, reassure, keep calm
temporary, will wear off
stay in waiting room
damp cotton wool pad, corneal drops
23
Q
signs/symptoms of TMD
A
trismus
pain
limited mouth opening
clicking, popping
crepitus
tenderness MoM
jaw deviation
24
Q
what muscles to palpate in TMD E/O
A
masseter
temporalis
25
TMD conservative management
educate, relaxation
don't incise foods, don't chew gum, supported jaw yawning techniques
avoid caffiene
chew bilaterally
physiotherapy, jaw exercises
CBT, hypnotherapy
no wid opening
soft diet
splint
NSAIDs, muscle relaxants
acupuncture
botox
26
how do bite splints work
stabilises occlusion and relieves function of MoM therefore decreasing abnormal activity
prevents direct contact U+L
evenly distributes occlusal loads
reduce parafunction
can reposition mandible
protect teeth
27
what is arthrocentesis and MOA
minimally invasive procedure involving aspiration of synovial fluid
removes inflammatory mediators, improves joint mobility, repositioning of disc
can inject corticosteroids/LA
28
you xla 26 but bleeding will not stop
how to manage
bite down damp gauze
suture
LA injection
surgicel
collagen plug
haemostatic sponge
reassure
no remaining sequestra
29
local risk factor for delayed onset bleeding following xla
infection
30
2 congenital bleeding risks
haemophilia A [8]
haemophilia B [9]
von willebrand deficiency [8]
31
2 acquired bleeding risks
DOAC
warfarin
antiplatelet
cirrhosis
liver disease
32
SIRS parameters
temp <36 or >38
HR >90/min
RR >20/min
WCC <4 or >12
33
how many of the SIRS criteria are needed for diagnosis
2
34
things to make note of in facial swelling
site
uni/bilateral
impaired swallowing, speech, breathing, hoarse voice
altered sensation
systemically unwell
trismus
35
why is written consent gained prior to sedation process
ensure understand process, time to think, change mind
sedated pt cannot consent
36
what drug is used for intravenous sedation
what preparation
midazolam
5mg/5ml
37
vital signs to monitor throughout sedation
BP
oxygen saturation
hear rate
38
what drug is used to reverse midazlolam
MOA
flumazenil
benzodiazepine receptor antagonist
binds same receptor sites thereby reversing sedative effects
39
advice to pt post-sedation
take it easy, rest
no strenuous exercise
don't sign legal documents
dont have a dependant
stay off phone
avoid alcohol
monitor delayed sedation effects
dont make important decisions
40
indications for inhalation sedation
cooperative
able to nose breath
dental anxiety
needle phobic
MH aggravated by stress
unaccompanied adults requiring sedation
gagging
traumatic procedure
41
contraindications for inhalation sedation
claustrophobia
mouth breathers
common cold
tonsil enlargement
severe COPD
1st trimester
<7 y/o
obstruction of operative field by mask
42
advantages of inhalation over intravenous sedation
no cannulation
less risk of respiratory depression
no amnesic effects
quick onset and recovery
titrated easily
minimal side effects
adult doesn't need accompanied
43
safety features of quantiflex machine
oxygen fail safe
minimum 02 delivery [30%]
pinch index system
colour coding
reservoir bag
oxygen flush button
scavenging system
44
when may GA referral be made
extensive/complicated tx
uncooperative pt
young pt
contraindicated or unsuitable for sedation
severe anxiety/phobia
special needs
45
stages of GA
1. induction
conscious but gradual loss
2. excitement
involuntary movements, irregular breathing, fast HR
3. surgical anaesthesia
ideal
unconscious, immobile
stable vital signs
4. overdose/medullary paralysis
respiratory + CV collapse
46
what details for GA referral letter
pt details
dentist details
proposed tx
situation, assessment, recommendation
alternatives + tried outcome
parental responsibility
MH
SH
GP
radiographs
JUSTIFICATION FOR GA
47
conscious sedation definition
pharmacological technique in which sedative/anxiolytic drugs used to induce state of relaxation and reduced anxiety
while allowing pt to remain conscious, responsive and follow commands
pt retains ability to breath independently and protect airway
48
what is GABA
gamma amina butyric acid
major inhibitory neurotransmitter in CNS
49
GABA function
primary inhibitor CNS neurotransmitter, significant effect on cerebral and motor circuits
benzodiazepines bind to GABA receptors on brain + increase effect
, inhibit neuronal firing
produce calming effect and reducing neuronal excitability
calming, non anxious state
50
midazlolam half life
90-150 mins
51
IV sedation contraindications
needle phobic
allergy
<12 y/o
severe/uncontrolled systemic disease
severe mental/physical disability
severe psychiatric
narcolepsy
hypothyroid sim
pregnant/lactating
52
6 things to assess pt for before IV sedation
height
weight
BMI
MH, medications
allergies
ASA classification
vital signs
53
what is the ASA classification
American society of anaesthesiologists
assess physical status before anaesthesia
1 = healthy
2 = mild systemic disease
- controlled DM
3 = systemic disease but not incapacitating
- poorly controlled hyerptension
4 = severe systemic disease, constant threat to life
- end stage heart failure
5 = moribund pt not expected ton survive without procedure
6 = brain dead for organ donation
54
regarding SIGN guidelines, when are impacted third molars not advisable to be removed
no evidence disease/pathology
MH precludes XLA
first episode pericoronitis
risk outweighs benefit
55
SIGN guidelines
when is impacted third molars indicated for removal
caries
perio
apical pathology
cyst
recurrent pericoronitis w multiple bax
external resorption 7/8
high risk disease
dentally fit
autotransplantation
56
principles of flap design
adequate exposure for sufficient access to surgical area, tooth, underlying bone
preservation of blood supply and soft tissues
minimal soft tissue trauma
relieving incisions to allow easy reposition
reserve vital structures
include mucoperiosteal layer
57
what do you assess on radiograph before removing 8
relationship with IAC
caries
bone loss
root resoprtion
pathology
58
describe the surgical removal of impacted 8
adequate LA
access =
buccal muscoperiosteal flap, raised as base of relieving incision, undermine free papillae, periostea elevator on bone, atraumatic and passive retraction
bone removal =
straight handpick, saline cooled tungsten carbide bur, deep + narrow gutter
tooth division =
as necessary
remove
debridement =
physical - remove sharp bony edges w Mitchell and Victoria sift tissues
irrigate saline, suction under flap, clean debris and follicular tissue
suture =
approximate tissues, compress blood vessels
aims = reposition tissues, cover bone, prevent wound breakdown, achieve haemostasis
59
what is the use of iodine for lower 8 xla
antiseptic
applied surgical site before to reduce bacterial load and minimise risk of infection
sterilises mucosal and periostea tissues
60
name 3 types of nerve damage
neuropraxia
axonotmesis
neurotmesis
61
risk of temporary vs perm damage to IAN
temp = 10-20
perm = <1
62
signs of lower 8 indicating proximity to IDC
interruption of white lines/lamina dura of canal
deflection of roots
darkening of roots
narrowing of roots
narrowing canal
juxta apical area
63
alternative to xla lower 8
coronectomy
64
ideal imaging method for lower 8 xla
OPT to assess
CBCT if significant increased risk of nerve injury
close relationship seen on OPT
65
initial management of swelling around unerupted lower 8
facial swelling, slightly unwell
LA
incise and drain if localised abscess
irrigate saline/chx 10-20ml syringe and blunt needle
MW
analgesia
soft diet
abx as systemic metronidazole 400mg tds 3 days
66
2 nerves at risk of lower 8 surgery and what do they supply
IAN - lower lip, chin, mucosa of teeth
lingual - anterior 2/3 tongue
67
what may pt complain of if they have sialolith
dry mouth
pain worse around meal times
burning
uncomfortable
swelling intermittent
pain
pus
lump
change in taste
68
what gland is most affected by sialolith and why
submandibular
direction of duct against gravity
size of gland
location of duct
viscous + mucous content
long, narrow duct
69
what investigations for sialolith
clinical - palpation, look for pus, stones
lower occlusal +/- OPT
sialography - injection of contrast into duct and take radiograph
ultrasound
MRI/CT
70
how to manage sialolith
conservative =
hydration, massage, citrus, warm compress, hydration, OH, analgesia
stone removal =
lithotripsy, sialoendoscopy, balloon dilation, basket removal
abx if infection
71
risk factors for OAC
xla upper molar/premolar
last standing molar
previous
close relationship on xray
large bulbous roots
older
recurrent sinusitis
72
signs + symptoms of OAC
nose discharge when drinking
unable to create pressure e.g. smoking, straw
bubbling of blood
sinusitis
pain
echo noise with suction
whistling sound on speaking
visible hole
73
guidelines for removal of impacted 3rd molars
SIGN
NICE
74
post-op complications of xla 3rd molar
pain
swelling
bruising
bleeding
infection
alveolar osteitis
damage to nerve
jaw stiffness
fracture roots
75
76
radiographic signs of 3rd molar intimate to IAN
interruption of white lines/lamina dura on canal
darkening of roots
diversion/relfection of canal
77
what is a juxta apical area
radiolucent region lateral to apex
NOT just absolute apex
not pathological area
78
what is warfarin and how does it work
vitamin K antagonist
anticoagulant
inhibits synthesis of clotting factors 2, 7, 9, 10 protein C+S
79
what is warfarin used for
AF
DVT
stroke prevention
PE
mechanical heart valves
80
what to do before xla
measure INR
2-4
ideally 24hrs but no more than 72hrs
81
how to manage xla for pt on warfarin
simple one tooth
atraumatic, 1-3 only
check INR 2-4
local haemostatic measures
gauze and pressure
LA w adrenaline
surgicel
haemostatic sponge
collagen plug
suture
82
you are planning xla for pt on bisphosphonates
what is this and what conditions for
antiresoprtive drug
reduces/inhibits osteoclast mediated bone resoprtion
causes decreased cell turnover
osteoporosis, metastatic cancer, Paget's disease, osteogenesis imperfecta
83
how is MRONJ diagnoses
exposed bone, or bone that can be probed through an intraoral or extraoral fistula, in the maxillofacial region that has persisted for more than eight 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.
84
how is pt risk determined for MRONJ
SDCEP
low =
oral/IV bisphosphonates <5 yrs, not concurrent systemic glucocorticoids
or denosumab not systemic glucocorticoids
high =
oral/IV bisphosphonates >5 yrs
concurrent systemic glucocorticoids at all
cancer management
previous MRONJ
85
how to manage MRONJ risk pt in primary care
advise risk but small
personalised OH advice, prevention, stop smoking, regular checks
prioritise care to avoid future xla
high fluoride
low = straightforward xla, risk/benefits, no prophylaxis, to contact if any unexpected pain, tingling, numbness, altered sensation or swelling, review 8 weeks, if suspect then refer
high = explore alternatives e.g. RR, same, review 8 weeks
86
pt attends with dry socket
what is this
alveolar osteitis
blood clot fails to form or been lost
exposed underlying bone and nerves
typically 2-4 days post xla
87
what should an xla site be healed
7-10 days
gums/bone 2-3 weeks
88
alveolar osteitis risk factors
mandible
female
oral contraceptive
smoking
use of straw
poking/prodding
previous
excessive rinsing
poor OH
89
how is alveolar osteitis managed
reassure
analgesia
LA, irrigation
curettage/debridement
encourage bleeding + new clot formation
check no fragments
antiseptic/alveogyl
POI
90
what is pericoronitis
what teeth most affected
inflammation and infection of gingivae around crown surrounding PE
lower 8
upper 3
91
signs + symptoms pericoronitis
halitosis
bad smell
bleeding
pus
swelling
pain
head/neck pain
fever
malaise
lymphadenopathy
92
how to manage acute episode pericoronitis
reassure
LA
irrigate saline
abx if systemic
93
how to manage pericoronitis in long term
occlusal adjustment upper 8 if trauma to operculum
operculectomy
xla
coronectomy
94
post-op advice following xla
take it easy
no strenuous excercise
analgesia 2hr increments interchanging
no poking
don't smoke, avoid alcohol
little bleeding normal
take gauze and use if need
come back if needed
soft food
careful with hot
95
you are xla lone standing upper molar
3 potential complications
tuberosity fracture
OAC
loss of roots into antrum
96
how to diagnose fractured tuberosity
management
crack
movement of segment
sudden excessive bleeding
mobility bone/mucosa
communication
small/non displaced = remove fractured bone, smooth sharp, primary closure
large/displaced, mobile = don't fully remove fractured segment, stabilise, suture soft tissue, splint to any teeth if can, defer xla 6-8 weeks to allow healing
surgical removal if completed detached, buccal advancement, close
97
how to diagnose OAC
bubbling blood
good light/suction
blunt probe
small hole
nose blow test
whistling noise
pressure difference
liquid through nose
98
xla of tooth
how to achieve haemostasis
atraumatic
bite down
pressure
suture
surgicel
haemostatic sponge
collagen plug
99
after xla, what tissue responsible for prolonged bleeding
PDL
100
risk factors for prolonged bleeding post xla
traumatic technique
warfarin
DOAC
antiplatelets
bleeding disorder
liver disease
infection
inflammation
101
what is Ludwig's angina
bilateral cellulitis of sublingual and submandibular space
life-threatening
102
name 4 maxillary spaces
buccal space
palatal space
canine space
infra temporal
103
name 4 maxillary spaces
submental
sublingual
submandibular
pterygomandibular
104
what is osteoradionecrosis
necrosis of the bone following trauma e.g. xla
in radiated area
typically mandible
105
ORN risk factors
radiation H+N
high dose >60 gy fraction
mandible
large field of radiation
traumatic procedure
large fraction dose
immunodeficient
malnourish
106
how can ORN be prevented
xla poor prognosis before starting
education
prevention!!!!!!
rct over xla
[pextoxylfyline + vit E]
107
ORN management
pentoxyllfyline + vit e
conservative - chx, analgesia, reassure
remove necrotic bone
hyperbaric oxygen
sever = sequestrectomy, resection with free flap construction, bone graft
108
xla lower left premolar
what vital structure close by
mental foramen which has mental nerve
109
mental nerve innervation
sensory
chin, lower lip. buccal mucosa
110
peri-operative complications of surgical xla
damage to adjacent
damage to nerve
tooth fracture
bone fracture
loss in antrum
111
aims of suturing
approximate tissues
promote healing
achieve haemostasis
minimise scarring
protection of wound
112
name 4 types of sutures
give examples
absorbable =
- vicryl
- monocryl
non-absorbable =
- nylon
- proline
113
give 6 different forceps and their use
upper straights - anterior/canine
upper universal - premolars
upper molars - molars
upper bayonet - third molars
lower universal - incisors, canines, premolars
lower cowhorns - molars
lower roots
114
name 3 types of elevators
warwick James
criers
couplands
115
use of elevators
rotational
lever
wheel and axle
wedge
116
use of luxator
break PDL
117
what is osteomyelitis
bone infection/inflammation via bacteria
118
risk factors of osteomyelitis
mandible
odontogenic infections
fracture
immunocompromised/host defence
DM
alcoholism
IV drug use
malnutrition
leukaemia
119
management of osteomyelitis
abx
investigate host defence w bloods
what bacteria
drain pus
xla non vital
remove loose bone
excise necrotic bone
REFER
120
what is haemophilia A
x-linked recessive genetic disorder
deficient factor 8
bleeding disorder
121
management of haemophilia A
desmopressin [DDAVP]
recombinant factor 8
122
what is haemophilia B
x-linked recessive genetic disorder
deficient factor 9
bleeding disorder
123
management of haemophilia B
recombinant factor 9
124
what is von willebrand disease
genetic bleeding disorder by deficiency/dysfunction of factor
which helps platelets adhere to blood vessel wall and supports factor 9
defect vW on platelets, poor interact w factor 8 = poor clot
tx w desmopressin
125
what tx would you carry out as GDP in pt with bleeding disorder
MH, tx regimen, collaborate with haematologist
mild/carriers
normal restorative, LA buccal infiltration/intra papillary/ligamentary
mod-severe
hospital or haemophilia unit
126
signs + symptoms of maxillary fracture
epistaxis
pain
swelling
facial deformity [flattening midface]
bruising around eye
maxilla mobility
diplopia
CSF rhinorrhoea
paraesthesia
malocclusion
127
what is Le Fort classification
described maxillary fractures based on level of fracture in midface
1 = horizontal, separate maxilla + nasal floor
2 = pyramidal fracture nasal bridge, maxilla, orbital
3 = severe, separates midface from skull base
128
special investigations for maxillary fracture
airway management
palpate
CT + OPT
cranial nerve function
129
signs of zygomatic-orbital fracture
suborbital swelling
flattening cheekbone
asymmetry
periorbital swelling
diplopia
infraorbital nerve paraesthesia
step deformity
blue eye discolouration
130
imaging for zygomatic-orbital fracture
CT
occipitomental
lateral skull
OPT
131
tx options for zygomatic-orbital fracture
conservative = analgesia, soft diet, avoid nose blowing
surgical =
closed reduction [gillies]
open reduction + internal fixation [Ti]
zygomatic frontla suture [eyelid]
132
post-op advice for zygomatic-orbital fracture
analgesia
oh
chx if intraoral lesions
soft diet
cold compress
avoid heavy lifting
133
signs + symptoms of mandibular fracture
step deformity
paraesthesia lower lip/chin
trismus
unable to close
swelling, pain, bruising
crepitus
sublingual haematoma
drooling
difficulty speaking/swallowing
malocclusion
134
how can mandibular fracture be classified
location = body, ramus, condyle, coronoid, angle
fracture type = simple, comminuted, open fracture, green stick
displacement = favourable, unfavourable
135
investigations for mandibular fracture
OPT
CT
assess, palpate border, mobility, sensation, trismus
136
management of mandibular fracture
conservative
closed reduction + internal fixation = wired, 4-6wks
open reduction + internal fixation = plates/screws
condylar fractures = orif if displacement
137
what is a cyst
pathological cavity filled with fluid, semi fluid or gaseous content
not by accumulation of pus
138
name inflammatory cysts
radicular
residual
lateral radicular
paradental
139
name developmental cysts
dentigerous cyst
eruption cyst
keratocyst
lateral periodontal
140
name non-odzntogenic cysts
nasopalatine duct cyst
solitary bone cyst
aneurysmal bone cyst
141
enucleation
adv
disadv
complete removal of cyst + lining
adv =
full removal, all content for histopathology, single stage, aims for no recurrence
disadv =
may not get all, may cause damage to vital structures, difficult in large cyst, risk of fracture
142
marsupialisation
adv
disadv
partial removal of cyst where it is opened and window created for drainage and edges sutures to create permanent open pouch
adv =
reduce risk of damage to vital structures/fracture
disadv =
two stage, risk of infection, not definitive
143
where does odontogenic keratocyst develop from
developmental cyst
rest of serres
remnants of dental lamina
144
how does keratocyst appear histologically
thin stratified squamous
basal cells palisading, daughter cells
parakeratosis
145
how does keratocyst appear radiologically
scalloped margins
may be multilocular
mandible
well-defined
may have teeth displacement
MESIAL DISTAL ENLARGEMENT FIRST
146
why is keratocyst problematic
high risk of recurrence
due to thin friable lining and proliferation of daughter cells
147
what condition is keratocyst associated with
basal cell nevus syndrome
gorlin goltz
148
what does radicular cyst develop from
rests of malassez
remnants of hertwigs epithelium root sheath
inflammatory
149
how does radicular cyst appear histologically
incomplete lining
connective tissue capsule with inflammation inside
non-keratinised strat squam
150
how does radicular cyst appear radiographically
corticated
continuous with lamina dura of non-vital
well defined, round
may displace
151
what does a dentigerous cyst develop from
reduced enamel epithelium
remnants of enamel organ
152
how does dentigerous cyst appear histologically
thin non keratinised strat squam
cuboidal cells
compression and fibrous tissue capsule
153
how does dentigerous cyst appear radiographically
corticated margins attached to CEJ
may envelope tooth root or displace
154
where is dentigerous cyst commonly seen
lower 8
upper 3
155
name an epithelial derived odontogenic tumour
ameloblastoma
156
how does ameloblastoma appear histologically
cystic changes
palisaded basal layer
stellate reticulum like central cells
reverse polarity
157
name a mixed epithelium and mesenchyme tumour
odontoma
158
name a mesenchyme tumour
odontogenic myxoma
159
indications for orthognathic surgery
large skeletal discrepancy
trauma
functional difficulties
aesthetics
cancer
obstructive sleep apnoea
CLP
cysts
160
risks of orthognathic surgery
paraesthesia
infection
bleeding
damage
TMJ dysfunction
scarring
GA risks
161
investigations pre orthognathic surgery
clinical
radiograph
lateral ceph w eastman analysis
study models
CBCT
162
2 types of mandibular orthognathic surgery
bilateral sagittal split osteotomy
vertical subsigmoid osteotomy
163
2 types of maxillary orthgnathic surgery
le fort 1 osteostomy
segmental maxillary osteotomy
164
