Oral Surgery Flashcards
What kind of drug is alendronic acid?
Bisohosophonate
what is the mode of action of bisohosphonates?
Reduces the turnover of bone
Accumulates in sites of high bone turnover such as the jaw
what is the relevance of bisphosphonates to dentistry
Risk of poor wound healing following a tooth extraction
Need to remove any teeth of poor prognosis prior to beginning drug therapy
It’s important to do everything possible to prevent further tooth loss in the future
Reduced turnover of bone and reduced vasculsrity can lead to death of bone - osteonecrosis
What in a pt would make MRONJ risk low?
Being treated for osteoporosis with oral or IV bisphosphonates for <5 years, not with systemic glucocorticoids
Being treated for osteoporosis without systemic glucocorticoids
What in a pt would make MRONJ risk high?
Being treated for osteoporosis with oral or IV bisphosphonates for >5 years
Being treated for osteoporosis for any length of time with systemic glucocorticoids Being
Being treated with anti-resorptive or anti-angiogenic drugs to manage cancer
Pts with a previous MRONJ diagnosis
What are the signs and symptoms of dry socket
Pain 3-4 days after XLA, can take 7-14 days to resolve
No blood clot in socket
Grey slurry in socket
Moderate to severe dull aching pain
Keeps pt up at night
Pain throbs and radiates to ear
Exposed bone sensitive and source of pain
Characteristic smell, halitosis, pt complains of bad taste
What is dry socket
Localised alveolar osteitis
Post op complication of extraction - localised osteitis is inflammation affecting the lamina dura
Blood clots at the site of extraction fails to develop or dislodges or dissolves before the wound has fully healed - not an infection
What are the predisposing factors for dry socket?
Posterior teeth
Mandible more common
Smoking due to reduced blood supply
Females
Oral contraceptive pill
Excessive trauma during extraction
Excessive mouth rinsing post extraction
FH or previous dry socket
What is the initial management for dry socket?
Reassure pt
Recommend optimal analgesia - ibuprofen 400mg 4x daily (max 2.4g) or paracetamol 1g 4x daily (max 4g)
Avoid smoking and maintain good OH
Give LA to relieve severe pain
If emergency appt advise pt to seek dental care
What is the subsequent care for dry socket?
Irrigate socket with saline to flush out food and debris
Curettage/debridement of socket
Encourage bleeding and new clot formation
Alvogyl - mix of LA and antiseptic, both remote clotting and enhance clotting framework while protecting bone
Use of analgesia and warm salty mouthwash
Antibiotics not required unless signs of spreading infection, or if immunocompromised
What should be included in a referral letter to OS for XLA of lower 8
Pt details
Practice details
Pt complaint
Your concerns - why are you referring, urgent or routine, is pt in pain or have swelling
MH, DH, SH
Summary of oral health status
Details of request - for advice or to see t
Any radiographs or investigations
Explain to a pt the surgical removal of a lower 8
Treatment will be under LA
You will be awake
Numbed up by injection to back of jaw which will numb lower lip and chin and that side of the tongue
Won’t feel anything sharp but will be able to feel pressure
Procedure will involve making a cut and raising a bit of gum, removing bone around the tooth, and possibly cutting the tooth into bits and removing it piece by piece
Will involve drilling similar to the one for fillings
We will clean the area with salty water and lace some stitches to close the wound
What are the complications of a surgical 8 extraction?
Pain
Swelling
Bleeding
Bruising
Infection
Dry socket
Jaw stiffness
Damage to adjacent tooth/restorations
Temporary/permanent numbness, prolonged nerve pain, tingling due to damage to the nerve
Describe the risk of nerve damage in surgical extractions of 8s
It’s a sensory nerve and any nerve damage will have no effect on appearance of the way your mouth moves, only you will be aware of it
Risks are 10% temporary and <1% remanente
If roots involved with IDN then damage increases to 20% temporary and 2%
What initial history questions should you ask if a pt has a mandibular fracture?
Headache
Loss of consciousness
Nausea or vomiting
Numbness of face
Police involvement
Any injuries elsewhere
What should an E/O exam include for mandibular fracture?
Pain
Lacerations
Bleeding
Swelling
Facial asymmetry
Palatino of mandible bilaterally - condyle, ramus, body and symphysis
Limitation of mandibular movement - reduced Inter incisal opening
Tenderness of TMJ
Examine sensation of lower lip/chin region
What should an I/O exam include for a mandibular fracture?
Lacerations - esp gingivae
Bruising/swelling/haematoma
Occlusal derangement and step deformities
Loose or broken teeth
Anaesthesia/paraesthesia of teeth in lower jaw on side of fracture
AOB
How are mandible fractures classified?
Number - single, double, multiple
Site - condylar, subcondylar, body, coronoid, angle, ramus, parasymphyseal, symphyseal, alveolar
Side - unilateral or bilateral
Displacement - displaced, undisplaced
Direction - favourable or unfavourable
Specific - greenstick (children’s bone bends), pathological
What factors influence displacement of mandibular fractures?
Pull of attached muscle
Angular ion and direction of fracture line
Opposing occlusion
Magnitude of force
Mechanism and direction of injury
Intact soft tissue
What further investigations do you need for a mandible fracture?
TWO radiographs - OPT and PA mandible
CBCT most commonly used now
How can you manage a mandibular fracture?
Urgent phone to OMFS or A&E for advice and urgent referral
They might not see urgently if un displaced
Can ask you to prescribe pain relief and antibiotics
Surgical management - ORIF if symptomatic or displaced
Conservative management if undisplaced, asymptomatic or >1 month old
How can you explain TMD to a pt?
The jaw joint sits in the base of the skull and muscles control its opening and closing
Like any muscle it can get overworked if tired
As your jaw gets used everyday it doesnt get a break, muscles become inflamed and sore
If your sore in the morning it tells us you clench or grind your teeth at night which puts more stress on the muscles and worsens the problem
The clicking by your ear is caused when the disc between your jaw and the skull gets trapped in front of the jaw and snaps in place
How can you manage TMD
Reassure pt
It involves resting the joints:
- soft foods cut into pieces
- chewing on both sides
- avoid heavy food/gum
- stifle yawns
- avoid wide opening
- avoid habits eg - nail biting
Conservative advice including analgesia - paracetamol/ibuprofen and heat packs
Make splint to break nocturnal habits
Reduce stress
