Oral Surgery III - The Whole Enchilada Flashcards
Fluid in or under the epithelium; a large blister
Bulla
Dried or clotted serum protein on surface of skin or mucosa
Crust
a superficial ulcer or excoriation
Erosion
A circumscribed area of color change without elevation
Macule
A large palpable mass, elevated above the epithelial surface
Nodule
A small palpable mass, elevated above the epithelial surface
Papule
A flat but elevated lesion
Plaque
A cloudy or white vesicle filled with pus
Pustule
A macroscopic accumulation of keratin
Scale
A loss of epithelium
Ulcer
A small loculation of fluid in or under the epithelium; a small blister
Vesicle
Any lesion that persists for _____ weeks with no apparent etiologic basis is a _________
2 weeks
Indication for biopsy
Any inflammatory lesion that does not respond to local Tx with _____ days is basis for a Biopsy
10-14 days
Persistent ______ changes in superficial tissue is an indication for Biopsy
hyperkeratotic
Any persistent _________ is an indication for Biopsy
tumescence (swelling)
________ Inflammatory changes of _______ is an indication for Biopsy
Persistent
unknown cause
Lesions that interfere with _________ is an indication for Biopsy
local function
Any lesion that has characteristics of ________ is an indication for Biopsy
Malignancy
7 Indications for Biopsy:
2 week lesion w/out etiologic basis
10-14 day non-responsive inflammatory lesion
Persistent superficial hyperkeratosis
Persistent tumescence
Inflammatory changes of unknown causes that persist
Lesions interfering with Local Function
Looks like Malignancy
7 things that may indicate Malignancy:
Erythroplasia (red/speckled red/white)
Ulceration
Duration longer than 2 weeks
Rapid growth
Bleeding
Induration - (loss of pliability)
Fixation - feels attached to adjacent structures
4 types of Biopsy:
Cytology
Aspiration
Incisional
Excisional
Cytology was first used as a _______
Some studies find high _______
Must be examined by ________
pap smear
false negatives
pathologist
What is the prime indication for Cytology biopsy?
Large areas of mucosal change monitored for Dysplasia
An Aspiration Biopsy must be done on what prior to surgical intervention?
Any Radiolucency
*could by high flow vascular lesion
A Fine Needle Aspiration Biopsy is indicated in the Tx of solitary ______ masses suspected to represent a tumor
___ gauge or smaller needle is used
Parotid
21
An Incisional Biopsy samples what part of a lesion?
Representative
3 Reasons to do an Incisional Biopsy:
over 1 cm/close proximity to vital anatomic structures
Difficult to excise
Suspicion of Malignancy
Shape of an Incisional Biopsy:
Include:
Do what for the pathologist?
Wedge
normal tissue at edges
orient
T/F
Incisional Biopsy should by broad and shallow
False
**narrow and deep enough to go all the way through the structure
An Excisional Biopsy should be done only in what cases?
Good for what size lesions?
Malignancy NOT expected
1 cm or less
Biopsy Technique should use regional _____ and use _____ incisions
field blocks
sharp
A Biopsy sample is placed directly into ________
10% Formalin
MRONJ =
Medication Related Osteonecrosis of the Jaws
T/F
Osteoradionecrosis of the jaws is pretty much the same as MRONJ in treatment and response
False
*NOT the same, in any way
MRONJ is defined as _______ bone that can be probed (intra/extra oral fistula) in the MF region persisting for ________
exposed
8 weeks
MRONJ does NOT refer to _______, but its causes are what 2 types of drugs?
radiation therapy
antiresorptive, antiangiogenic
T/F
MRONJ is a fairly new disease and huge numbers of people are on meds that put people at risk
True
T/F
Normal course of debriding bone and moving flaps, successful for other Tx, does not tend to work for MRONJ
True
T/F Hyperbaric Oxygen (HBO) works well for MRONJ
False
*osteoradionecrosis, etc.
With MRONJ, wounds tend to ______ with surgical intervention
enlarge
T/F
There is no definitive Tx for MRONJ
True
T/F
MRONJ pts may have to be on continuous or episodic antibiotics for the rest of their lives
True
T/F
Oral bisphosphonates, RANK-L inhibitors, monoclonal antibodies, and anti-angiogenesis drugs can all cause MRONJ
True
How many cases of MRONJ have been reported in the literature?
17,000
3 types of Antiresorptives associated with MRONJ:
IV bisphosphonates
Oral bisphosphonates
RANK Ligand inhibitor (human monoclonal antibody)
What 4 conditions are Treated with MRONJ-causing drugs ?
Cancers that metastasize to bone (breast, prostate, lung)
Bone lesions/multiple myeloma
Osteoporosis
Soft tissue tumors
3 Common Oral Bisphosphonates:
*used for Osteoporosis
alendronate Fosamax
risendronate Actonel
ibandronate Boniva
2 IV Bisphosphonates
*used for Bone Metastases
pamidronate Aredia
zoledronate Zometa
Name of the RANK-L inhibitor
*monoclonal antibody used for Bone Metastases
denosumab Xgeva
Name of RANK-L inhibitor
*monoclonal antibody used for Osteoporosis
denosumab Prolia
Bisphosphonates and RANK-L both work by inhibiting what?
Osteoclast activity
Osteoclasts, though they break bone down, release ______ and growth factors
BMP
Antiangiogenic meds interfere with the formation of vessels/vascular supply and cause what?
Avascular Necrosis
denosumab (anti RANKL antibody) is doses via _______ injection at an interval of _______
subQ
6 months
More than ___ million osteoporotic fractures accor in the US every year
This places ________ people in nursing homes
1.5 million
180,000
T/F
Hip fracture mortality exceeds 20%
True
The annual direct care expenditure on osteoporotic fracture was ______ in 2002
*expected to double or triple by 2050
12 to 18 Billion dollars
What is the systemic marker of bone turnover to assess MRONJ risk?
What are the parameters?
Is it useful in all pts?
CTX - collagen type I C telopeptide
100 - 150 moderate risk (less than high, greater than minimal)
no
CTX - collagen type 1C telopeptide is NOT a useful test in what 3 pts?
Cancer
methotrexate (falsely low)
Steroids (falsely low)
Is the CTX test a valid systemic test for MRONJ?
No
Ideally, before IV BP therapy, you should extract nonrestorable teeth, eliminate perio, and treat caries
During therapy avoid anything invasive
Treat caries, splint, etc
True
If surgery is unavoidable with a pt taking IV BP, what is the most important thing?
Informed Consent
T/F
Pts should have a dental screening and preventative Tx PRIOR to initiating antiresporptive or antiangiogenic therapy
True
To prevent MRONJ, pts should take a drug holiday off of oral BP or denosumab for what disease?
At what time?
Osteoporosis
4 years
T/F
If MRONJ develops in a Cancer Pt, the oncologist may consider discontinuing therapy until soft tissue closure
True
MRONJ must be addressed in pts taking antiresorptive therapy b/c it is likely to exceed ____ years
4
T/F
Implant placement should be avoided in pts on IV bisphosphonates or antiangiogenic drugs for Cancer
***also avoid direct osseous injury
True
True
For Osteoporosis pts taking BP, if there are no clinical risk factors, you don’t have to alter or delay surgery on what condition?
Pt taking BP LESS than 4 years
Osteoporosis pts taking BP less than 4 years taking _____ or _______, must contact prescribing provider for a Drug Holiday for at least ____ before oral surgery and wait for osseous healing
corticosteroids, antiangiogenics
2 months
Osteoporosis pts taking BP for MORE than 4 years w/ or w/out concomitant therapy, contact prescribing provider for ________ before oral surgery and wait for osseous healing
drug holiday for 2 Months
If Ostoporosis pt taking drug over 4 years, how long of a drug holiday for Prolia (denosumab) prior to surgery?
Reclast (zolendronate)? before/after
3 months
9 months / 3 months
What are 3 indications for jaw Resection in MRONJ?
won’t respond to nonsurgical Tx
Fractures
Direct sinus
alendronate may reduce the risk of hip fx by ___%
***could prevent 100k fxs and thousands deaths
40
T/F
90% of MRONJ pts can be maintained pain free
True
T/F
MRONJ is rare, less severe, and reversible with discontinuation of IV
False
***only true for ORAL meds
T/F
3 of the 4 diognostic criteria for MRONJ are historic data so you have to ask many questions to make a diagnosis
True
What is the important time frame for the duration of dosing of Oral BP’s?
4 years
IV BP’s are significantly more likely to cause MRONJ
***often given w/ chemo, so Ask About Hx!!
Zometa, Aredia, Xgeva…
True
