Oral surgery and bone biology

Question 1

SOP for preventing WSS

Answer 1

Confirm pt is in for XLA
Tell me which tooth
Point to the tooth
Check with clinical records

Question 2

Ludwig’s angina

Answer 2

– mandible infection risk…
Bilateral involvement of the submandibular, submental, sublingual and parapharyngeal, retropharyngeal spaces – glottis oedema – AIRWAY CONCERN.

Question 3

Mediastinitis

Answer 3

Mandibular infections can spread down the retropharyngeal/parapharyngeal space to the mediastinum (chest area), and result in mediastinitis.

Question 4

Cavernous sinus thrombosis

Answer 4

Can’t move the eye, pressure behind the eye (proptosis)

Question 5

Signs of sepsis

Answer 5

S - shivering
I - incontinence
G - grey and blue
N - nervous of dying
E - exasperated (breathless)
D - drunk (slurred speech)

“SIGNED”

Question 6

routes of spread mandibular molar

Answer 6

4

Question 7

routes of spread maxillary molar

Answer 7

5

Question 8

Characteristic of canine space infection

Answer 8

Obliteration of nasolabial fold

Question 9

Management of Submandibular/sublingual space infections

Answer 9

o COULD excise sublingual space infection
o NOT submandibular (as this would be an extra-oral surgery)

Question 10

Teeth likely to give rise to submental space infections

Answer 10

o Lower incisors with long routes
o Firm swelling under chin

Question 11

Dental infection antibiotics - first line

Answer 11

• First line for dental infection
  Penicillin V: 500mg x 4 (5 day course)

Question 12

Dental infection antibiotics - Anaerobic conditions (such as periocornitis)

Answer 12

Metronidazole: 400mg x 3 (5 day course)

Question 13

When would you be concerned with referring pt on to specialist care?

Answer 13

o Sever trismus
o Fever symptoms (>39 degrees)

Question 14

Pyrexia vs sepsis

Answer 14

o Pyrexia: means elevated body temperature/fever/muscle aches etc.
o Sepsis: infection causing widespread inflammation, rapid HR, breathing, low BP.

Question 15

Which gland controls bone turnover?

Answer 15

parathyroid gland (controls Ca2+ levels in the blood)

Question 16

Increases calcium levels in the blood?

Answer 16

Calcitriol (increases calcium levels – “TRI help increase!”)

Question 17

Calcitonin

Answer 17

Hormone produced from thyroid gland

Decreases calcium levels in the blood – “tone it down a bit!”

Through inhibiting bone resorption (bone remains therefore Ca2+ cannot be released into the bloodstream)

Question 18

Calcitriol

Answer 18

An active from of vitamin D.

Increases calcium levels in the blood – “TRI help increase!”

Through promotion of Ca2+ uptake into the blood from he intestines.

Question 19

Bone remodelling after an extraction finishes after ___ months

Answer 19

6

Question 20

An analogue of pyrophosphate (which stimulates bone growth). Also works by inhibiting osteoclast function.

Answer 20

Bisphosphonates

Question 21

Non-nitrogen containing bisphosphonates

Answer 21

Clodronate

 These resemble pyrophosphate allowing them to be incorporated into the phosphate chain of ADP making it unusable for energy production in osteoclasts.

Question 22

Nitrogen containing bisphosphonates

Answer 22

Alendronate

 These block the enzyme farnesyl diphosphate synthase in the HMG-CoA reductase pathway to prevent the formation of key isoprenoid lipids in osteoclasts which anchor proteins to the cell membrane and without these death occurs.

Question 23

SDCEP high risk patients for MRONJ

Answer 23

 Previous MRONJ
 Taking for malignant conditions
 For Paget’s disease
 Osteogenesis imperfecta
 Concurrent use of systemic corticosteroids or other immunosuppresants
 Coagulopathy, chemotherapy, radiotherapy.

Question 24

SDCEP low risk patients for MRONJ

Answer 24

 Not yet started taking bisphosphonates
 Taking bisphosphonates for the prevention or management of osteoporosis.

Question 25

Diagnosis criteria for MRONJ (RED)

Answer 25

o R – RADIATION FREE: no history of radiation therapy to the jaws
o E - EIGHT WEEKS: of exposed bone in the maxillofacial region or bone that can be probed that has persisted for more than 8 weeks.
o D - DRUGS: taking, or previously was taking bisphosphonates, antiangiogenic drugs or RANKL inhibitors.

Question 26

RANKL inhibitor?

Answer 26

Denosumab (Prolia)

Question 27

What does denosumab do and when’s the best time to do extractions for a patient on this drug?

Answer 27

o Mimics the function of endogenous osteoprotegerin (OPG)
 TREATMENT WINDOW – best to do treatment just before theyre due their next injection

Question 28

What are other drugs that could cause MRONJ?

Answer 28

Steroids
Long-term NSAIDs use

Question 29

Sharing patients information to the incorrect patients?

Answer 29

Breach of patient confidentiality
General data protection regulation

Question 30

What should you do if you perform WSS?

Answer 30

1. Apologies to the patient
2. Incident reporting on DATIX form
3. Significant event analysis

Question 31

How would local anatomy determine whether infection from a lower molar spreads to the sublingual space or the submandibular space?

Answer 31