Oral Surgery Flashcards
What are the reasons for failure of conventional RCT? (4)
- anatomical
- root obturation error/problem
- root perforation/fracture
- pathology
What are the pathological indications for periradicular surgery? (4)
- chronic persistent periapical granuloma
- radicular cyst
- cementoma
- external root resorption
What are the contraindications for periradicular surgery? (4)
- anatomical factors e.g proximity to neuromuscular bundles
- periodontal considerations e.g presence of defects
- medical factors e.g leukaemia, neutropenia
- skill and ability of surgeon
What are the stages of periradicular surgery? (7)
- LA
- flap design
- bone removal
- curettage
- apicectomy
- retrograde preparation and filling
- closure
- POI
What are the types of full mucoperiosteal flaps? (3)
- 2 sided
- 3 sided
- horizontal/envelope
What is a full flap? (3)
- incisions through gingival margin
- papillae mesial and distal included
- relieving incision at 90* to tooth
What is a mucogingival flap? (3)
- crowned anterior teeth
- scalloped incision in middle of attached gingiva at 45*
- vertical relieving incisions straight up and down
Give an advantage of a submarginal flap
Avoids recession
Give 2 disadvantages of a submarginal flap
Scarring
Painful post op
How do you do a root end resection? (5)
- remove the apical 3mm to remove the apical delta
- slight bevel improves vision
- use fissure bur
- if post present do not section it
- all granulation tissue must be removed
What is guided tissue regeneration?
When a barrier membrane is used to treat teeth with large periapical lesions in conjunction with periodontal defects or without cortical bone
How do you do wound closure? (4)
- thorough irrigation before closure
- compression of flap to eliminate haematoma
- reapproximation of flap (suture papillae first)
- apply pressure +/- ice pack
What are the success rates of non surgical re treatment?
56-98%
What are the success rates of surgical treatment?
37-95%
What are the properties of root end filling materials? (4)
- well tolerated by apical tissues
- bactericidal or bacteriostatic
- adhere to tooth
- dimensionally stable
What are the disadvantages of amalgam? (4)
- sets slowly
- dimensionally unstable
- scatters
- leaks
What are the contents of MTA? (5)
- tricalcium silicate
- tricalcium aluminate
- tricalcium oxide
- silicate oxide
- bismuth oxide
What are the properties of MTA? (6)
- high pH
- good sealing ability
- hydrophilic
- radiopaque
- excellent biocompatibility
- regeneration of cementum
What procedures are performed using a microscope? (7)
- osteotomy
- curettage
- root end resection
- inspection of resected root surface
- root end preparation
- root end filling
- examination of surgical site
What are the valid causes of surgical failure? (4)
- failure to clean root canal throughly
- failure to seal root end
- tissue irritation
- failure to manage materials properly
What are the uncertain causes for surgical failure? (4)
- infected dentinal tubules
- infected periradicular lesion
- accessory or lateral canals
- loss of alveolar bone
What are the symptoms of sepsis in adults? (6)
- slurred speech
- extreme shivering
- passed no urine in a day
- severe breathlessness
- illness so bad they feel they’re dying
- skin mottled/discoloured/ashen
What are the symptoms of sepsis in children? (4)
- no urine >12 hours
- skin abnormally cold
- rash not fade with pressed glass
- fever
- skin colour change
- difficulty walking
- vomiting
- fast breathing
What are the clinical features of sepsis? (5)
- temp >38C or <36C
- heart rate >90
- respiratory rate >20
- WCC >12 or <4
- BP systolic <100
What bloods should you take for a patient with sepsis? (6)
- FBC
- U+E
- glucose
- CRP
- lactate
- cultures
What is the treatment of sepsis? (6)
- take blood cultures ideally before antibiotics
- take serum lactate
- give oxygen
- give empirical intravenous antibiotics
- give IV fluids
- monitor urine output
What are the synonyms for TMJ disorders? (4)
- TMJ pain dysfunction syndrome
- myofascial pain dysfunction
- facial arthomyalgia
- mandibular dysfunction
What are the types of TMJ classification? (3)
- no meniscal displacement
- anterior displacement of meniscus with reduction e.g clicks
- anterior displacement without reduction e.g locks
What is the management of TMJ disorders?(5)
- take time to explain and reassure patient
- remove the dental cause e.g traumatic occlusion
- advise soft diet/analgesics
- jaw exercises/physiotherapy/ice packs
- review 6 weeks
What could be the causes of TMJ pain? (6)
- arthritis
- pain of dental origin
- other systemic arthropathies
- atypical facial pain
- giant cell arteritis
- intracranial neoplasm
What are the classifications of oral ulceration? (6)
- traumatic
- iatrogenic
- idiopathic
- infective
- autoimmune
- neoplastic
What drugs can induce oral ulceration? (3)
- NSAIDs
- methotrexate
- nicorandil
What is methotrexate used for?
In the management of rheumatoid arthritis, lichen planus and skin conditions
Who is more likely to get RAs? (5)
- F>M
- childhood to 40 years
- white
- non smokers
- high socio economic status
What are the causes of recurrent apthous stomatitis? (4)
- stress
- menstrual cycle
- hypersensitivity to foods
- GI tract disease
Why does anaemia/haematinic deficiency predispose to mucosal disease? (3)
- epithelial atrophy
- compromised cell mediated immunity
- cytotoxity of leucocytes reduced
What investigations should you do for recurrent oral ulcerations? (3)
- full blood count
- haematinics
- immunology for coeliac disease
What is the oral presentation of crohns disease? (4)
- mucosal tags
- lip swelling
- full width gingival inflammation
- cobblestone mucosa
Why do you get recurrent oral ulceration in GIT disease in the stomach/small intestine? (2)
- chronic blood loss secondary to gastric/peptic ulceration
- failure to absorb vitamin B12
What are the signs and symptoms of coeliac disease?(4)
- severe or persistent mouth ulcers
- unexplained iron, vitamin B12 or folate deficiency
- irritable bowel syndrome
- first degree relative of people with coeliac disease
What is the result of coeliac disease in infants 4-24 months? (3)
- reduced growth
- diarrhoea
- abdominal distension
What is the result of coeliac disease in adults? (4)
- abdominal discomfort
- bloating
- diarrhoea
- weight loss
What is the sequelae of coeliac disease? (5)
- anaemia secondary to iron deficiency and folate deficiency
- calcium deficiency
- vit D deficiency
- vit K deficiency
- GIT lymphoma
What is the treatment for coeliac disease?
Gluten free diet
How do you control ulceration in recurrent apthous stomatitis? (4)
- SLS free toothpaste
- chlorohexidine gluconate mouthwash
- hydrocortisone mucoadhesive buccal tablets 2.5mg
- doxycycline dispensable tablets as mouthwash
What are the investigations for cysts? (4)
- vitality test
- radiology
- aspiration of cyst contents
- biopsy
What are the contraindications for enucleation? (4)
- cyst is large
- involves a number of vital teeth
- difficult anatomical site
- involving a potentially useful unerupted tooth
Why do you need to eliminate dead space? (2)
- to reduce reactionary haemorrhage
- to reduce post operative infection
How do you eliminate dead space? (4)
- drain placement
- procedures to collapse the walls of the cavity
- use of biological and other materials to fill the space
- use layered soft tissue closure or secondary intention
What are the disadvantages of enucleation? (4)
- infection
- incomplete removal of lining
- damages to adjacent teeth or antrum
- weakening of bone
What are the advantages of marsupialisation? (4)
- avoids pathological fracture
- treatment for medically compromised patients
- avoids damage to adjacent structures
- allows potentially useful teeth to erupt
What are the disadvantages of marsupialisation? (4)
- orifice closes and cyst reforms
- repeat visits
- manual dexterity and compliances
- complete lining not available for histology
Name 5 developmental epithelial odontogenic cysts
- dentigerous cyst
- eruption
- odontogenic keratocyst
- lateral periodontal
- gingival
What is the treatment for keratocysts? (4)
- enucleation
- curettage of cavity
- long term radiographic follow up
- en bloc resection
Name 2 epithelial non odontogenic cysts
- nasopalatine duct cyst
- nasolabial cysts
What is the histopathology of aneurysmal bone cysts?
Consists of mass of blood filled spaces with scattered giant cells
What is an ameloblastoma?
Odontogeni tumour arising from a tooth forming structure. Essentially benign but can be locally aggressive and invasive
When would you do an excisional biopsy? (2)
- when there is small benign lesions
- malignancies where primary repair is possible
What are the problems with biopsies? (4)
- inappropriate specimen
- specimen too small
- can’t orientate specimen
- lab not informed for need for frozen section
What do frozen sections do?
Allow rapid diagnosis of malignancy within 1 hour
What is exfoliative cytology?
Removal of surface cells by scraping with a spatula or cytobrush
When would you do a labial gland biopsy?
Diagnosis of sjogrens syndrome
What is toluidine blue?
A cationic metachromatic dye that selectively binds in vivo to acidic tissue components of DNA and RNA
What is the vizilite system used for?
The vizilite system is used to detect the mucosal tissue undergoing metabolic or structural changes that by their nature have different absorbance and reluctance profiles when exposed to various forms of light sources
What concerns you about a lesion? (4)
- site
- size
- colour
- risk factors
Name 4 intra oral detection methods
- toluidine blue
- exfoliative cytology
- biopsy
- PDD
What are the changes in exfoliative cytology for oral cancer? (2)
- decreased CA
- increased proliferation markers
What is the p53 wild type gene? (5)
- normal tumour suppressor gene
- half life 20 mins
- 393 amino acids
- cell cycle arrest
- repair or apoptosis
What is the p53 codon 72 gene? (3)
- loss of control
- no repair
- most common gene affected in cancer
How do you do a sentinel lymph node biopsy? (3)
- inject radioactive dye into cancer
- use device to identify radioactivity
- incise down onto node and remove for biopsy
What are synchronous 2nd primary tumours?
Within 6/12 index tumour
What are metachronous 2nd primary tumours?
More primary tumours >6/12
Name 4 potentially malignant lesions
- erythroplakia
- erythroleukoplakia
- leukoplakia
- erosive lichen planus
What is dyskeratosis congenital? (3)
- leukoplakia
- nail dystrophy
- increased skin pigmentation
What common pathology affect the salivary glands? (4)
- inflammatory disorders
- obstruction/trauma
- neoplasms
- autoimmune/degenerative
What are the systemic causes of bacterial sialadenitis? (4)
- immunosuppression
- medication
- dehydration
- irradiation
What is the acute management of sialadenitis? (4)
- antibiotics
- fluids
- sialogogues
- analgesics
What are the causes of sialolithiasis? (3)
- stasis of saliva
- mucous plug
- duct stricture
What are the symptoms of obstructive sialadenitis? (4)
- recurrent episodes of transient prandial salivary gland swelling
- no symptoms between attacks as saliva escapes from the gland
- the bigger the stone becomes the more severe the symptoms
- complete obstruction causes stasis of saliva and allows commensals from the oral cavity to enter the gland
What is the presentation of acute sialadenitis secondary to obstruction? (4)
- stasis allows ascending infection
- increasing painful swelling of 24-72 hours duration
- oral discharge of pus
- systemic manifestation
What are the investigations for salivary gland tumours? (4)
- radiographs
- FNA
- ultrasound
- CT/MRI
What are the indications for salivary gland surgery? (3)
- chronic pain
- repeated acute or chronic sialadenitis
- benign/malignant tumours +/- nerve reconstruction
What will the patient experience post removal of the submandibular gland? (4)
- pain, swelling, brusing
- scar
- numbness of tongue
- weakness of lower lip
What are the types of parotid surgery? (4)
- extra capsular dissection
- lobar resection
- superficial parotidectomy
- total parotidectomy
What are the post operative complications of salivary gland surgery? (4)
- facial nerve injury
- gustatory sweating
- numbness around ear lobe
- salivary fistula
How long does radiotherapy for oral cancer last?
Extends over 3-7 weeks with daily or week ends off
What are the side effects of chemotherapy?
- low rbc +/- abc +/- platelets
- mucositis
- impaired wound healing, bleeding, infection
- change in taste, tricky to swallow, halitosis
What are the side effects of radiotherapy? (4)
- osteoradionecrosis
- altered taste
- infection
- dental caries
What are the management strategies for oral mucositis? (4)
- bland rinses
- topical anaesthetics
- analgesics
- low level laser treatment
What are the management strategies for a sore mouth? (4)
- avoid strong foods
- eat bland, soft diet
- avoid alcohol MWs
- topical lignocaine, benzydamine HCL
What is the treatment for sialadenitis? (4)
- flucloxacillin or augmentin
- drain pus
- keep well hydrated
- encourage saliva flow
How does amifostine treat a painful mouth? (3)
- protects damage to salivary glands by radiotherapy
- promotes repair of damaged tissue
- bind to harmful free radicals
How does sucralfate treat a painful mouth?
Sucralfate treats a painful mouth as it is a sucrose sulphate aluminium complex that binds to the ulcer creating a physical barrier that protects the gastrointestinal tract and prevents the degradation of mucus
What does denosumab do?
Inhibits osteoclast function and bone resorption
What is osteoradionecrosis?
exposed irradiated bone that fails to heal over 3/12 without residual or recurrent cancer
What is the medical management of osteoradionecrosis? (4)
- 250mg tetracycline x4 day for 14 days
- then 250mg x2 for several months
- if severe infection add flagyl 200mg x3
- pentoxyfylline +tocopherol for 6/12
What does pentoxifylline do? (5)
- increases intracellular cAMP
- activates PKA
- inhibits TNF alpha and leukotriene synthesis
- reduces inflammation and innate immunity
- decreases blood viscosity and decreases potential for platelet aggregation and thrombus formation
What biological therapies can be used to treat oral cancer? (4)
- vaccines e.g perception
- anti angiogenic therapy
- anti p53 antibodies
- nivolumab immunotherapy
What does the biological therapy cetuximab do?
Blocks the surface of cancer cells that can trigger growth
How do biological therapies work? (3)
- stop cancer cells dividing
- seek out cancer cells and kill them
- get the immune system to attack the cancer cells
What are the indications for the use of foscan PDT? (4)
- licensed for palliative therapy
- failed or unsuitable for surgery
- failed or refused radiotherapy
- curative therapy
What are the potential problems of foscan PDT? (4)
- extravascular injection
- light deprivation
- immediate post operative pain
- depth of tumour necrosis limited
What are the potential benefits of foscan PDT? (4)
- possible under LA
- quick
- repeatable
- preserves aesthetics/function
In PDT how much foscan is given?
0.15mg/kg
What are the clinical effects of fiscal PDT? (4)
- impressive tumour reduction and necrosis
- marked reduction in trismus
- arrest of bleeding
- marked halitosis
What are the classifications of zygoma fractures? (7)
- type 1 undisplaced
- type 2 arch fracture only
- type 3 tripod fracture f-z suture intact
- type 4 tripod fracture f-z suture distracted
- type 5 blow out fracture only
- type 6 orbital rim fracture
- type 7 comminuted and other fractures
What are the symptoms of zygoma fractures? (4)
- pain
- numb cheek
- double vision
- restricted jaw movement
What are the signs of zygoma fractures? (5)
- swelling
- depressed cheek bone
- periorbital bruising
- surgical emphysema
- palpable deformity