Oral Surgery & Oral Pathology Flashcards
What are the 2 main forms of Anti-resorptive medications?
How do they differ in:
- Method of Action?
- Method of Administration?
- Half life?
- Bisphosphonates
- RANKL Inhibitors (Denosumab)
Both indicated for: Osteoporosis, Cancer or bone disorders (e.g. Pagets)
Method of Action:
Both inhibit bone resorption by inhibiting osteoclast activity
B = via osteoclast apoptosis
R = via inhibition of RANKL (normally stimulates osteoclast function)
Method of Administration:
- *B** = Oral (often once a week) or IV (6 monthly or yearly)
- *R** = Subcutaneous (6 monthly)
Half-life:
- *B** = Longer half-life (~10 years) & binds to bone
- *R** = Shorter half-life () & does NOT bind to bone
What are 5 functions of the maxillary antrum?
- Lighten the skull
- Moistens inhaled air
- Warms inhaled air
- Voice resonance
- Immunological function for upper respiratory tract
What is the definition of an abscess?
Its aetiology is bacterium, what are the 3 main routes of entry?
A pathological cavity filled with pus and lined by a pyogenic membrane.
Bacterial entry via:
- Apical foramen
- PDL
- Bloodstream (“Anchoresis”)
What are the following flap names?
- Envelope (One-sided)
- Triangular (Two-sided)
- Trapezium (Three-sided)
- Semi-lunar
- Y-Incision
- Pedicle
Aspirin:
- What is the MOA?
- How does its affect differ to other NSAIDs?
- What is our OS management for patients taking Aspirin?
- Anti-platelet, inhibits thromboxane A2 via COX-1 pathway inhibition
- Causes IRREVERSIBLE platelet changes (lasting platelet 7-10day lifespan)
- Nothing - Don’t interupt/alter medication. Can treat with cautionary measures (e.g. limiting area/earlier in week) & local haemostatic measures
How many times a day are each NOAC usually taken?
According to SDCEP Guidelines, what instructions should be given to the patient (pre/post-op)?
Rivaroxaban - ONCE
Apixaban - TWICE
Dabigatran - TWICE
Edoxaban - ONCE
Once a day?
Morning = Delay morning dose & take 4hr after haemostasis
Evening = Take evening dose as normal (as long as 4hr after haemostasis)
Twice a day? MISS morning dose & take evening dose as normal (as long as 4hr after haemostasis)
What is the management for a patient with Acute Osteomyelitis? (6)
- URGENT OM/OS referal
- Empirical antibiotics (broad-spec antibiotics, e.g. Benzylpenicillin, Clindamycin and Metronidazole)
* N.B. Clindamycin has good bony penetration but risk of C. difficle → severe diarrhoae* - Pus sample taken
- Specific target antibiotics
- Debridement
- Long-term antibiotics 2+ weeks (Out Patient Antimicrobial Therapy, OPAT)
SDCEP says INR within 72hr is acceptable if patient has stable INR history - specifically, what does this mean?
A patient who does not require weekly INR checks & hasnt had any INR readings above 4 in the last 2 months
The first stage of infection spread is Cellulitis, what is this and what would be observed?
(Think appearance & bacterium present)
Cellulitis = Infection spread to connective tissue → Soft tissue oedema
- Redness
- Shiny
- Fluctuant (but this depends on amount of fluid present)
- Non-suppurative
- Usually streptococcus
What are the 5 aims of surgical extraction?
(THINK: Why raise flap? Why remove bone? Why suture?)
- Remove tooth (duh)
- Improve vision
- Create application point for elevation
- Minimise trauma
- Promote healing (via debridement and sutures)
In taking a good post-XLA pain history what should you ask?
What probing questions may you ask about symptoms?
SOCRATES (duh)
- When did the pain start (how many days after XLA)?
- Is it getting worse?
- Is there any foul smell/taste? - Dry socket or pus
- Is there limited mouth opening
- Is there any swelling
- Systemic features - Fever, temporature or malaise?
What are the 6 main stages involved in surgical tooth extraction?
- Plan access (flap design)
- Raise mucoperiosteal flap
- +/- Bone removal
- +/- Sectioning of tooth - Start at furcation and go to burs depth (avoid drilling through whole tooth, may cause lingual nerve damage - use space created for elevation_
- Debridement/Irrigation - Saline +/- haemostatic agent
- Wound closure with sutures
What are 5 signs of Mandibular fracture?
“Mandibles Open Now Tallulah Says”
- Mobility
- Occlusion change
- Numbness of lower lip (IAN)
- Trismus
- Sublingual haematoma (blood seen under tongue)
What is the definition of MRONJ?
Following this, what are the 4 diagnostic features that must be met?
MRONJ (Medication-Related Osteoonecrosis of the Jaw)
Severe adverse reaction to anti-resorptive or anti-angiogenic drugs → Exposed bone or bone that can be probed through an intra or extra-oral fistula in the maxillo-facial region which has persisted over 8 weeks in a patient with history of taking the above drugs and NO history of radiotherapy or obvious metastatic jaw disease.
Diagnostic Criteria:
- Currently or previously taking anti-resorptive or anti-angiogenic medication
- Exposed bone or bone that can be probed through intra or extra-oral fistula - persisting over 8 weeks
- No history of radiotherapy
- No obvious metastatic jaw disease
What are the gross characteristics of a benign oral lesion?
(e.g. size/shape) - 6
- Encapsulated
- Rounded
- Small (smaller than malignancies)
- Slowed growth
- Rare ulceration or bleeding
- Can produce hormones (e.g. in endocrine tissues)
What are 7 indications for removal of cysts or benign soft tissue lesions?
- Pain
- Infection
- Altered function
- Pressure on adjacent structures
- Weakening of adjacent structures
- Continuous growth
- Poor aesthetics
What are 4 radiographic signs that show close proximity of 3rd molar to ID nerve (/linked with ID nerve damage)?
- Interruption or Loss of white tramline (most common)
- Darkening of the root (“Banding”)
- Diversion of ID canal
- Narrowing of canal
What is the difference between primary & secondary haemostasis?
How can both be adversely affected?
PRIMARY = Platelet aggregation
- Failure in Platelet production (“Thrombocytopenia)
* Bone marrow failure, Congenital disorders or Megakaryocyte depression (e.g. via chemotherapy, infections or drugs - alcohol/heparin/thiazide diuretics)* - Failure in Platelet function
* Von Willebrand’s Disease (reduced/defective vWF) or drugs - NSAIDs (via COX-1)/ Clopidogrel (via ADP)* - Failure in Platelet survival
* Autoimmune, HIV-associated, Malaria, Lymphocytic leukaemia or Drugs - Aspirin/Cytotoxics/Valproate*
SECONDARY = Coagulation pathway into fibrin clot
- CONGENITAL (Haemophilia A/B or vWD)
- ACQUIRED (Anti-coagulant medications, Vit K deficiency, Liver disease or Large volume blood transfusions)
What are the different drugs that are implicated in MRONJ (4)?
How can they be placed into 2 main catagories?
- *1) Anti-resorptive**
- Inhibit bone resorption (impaired osteoclast function)*
-
Bisphosphonates
E.g. Zoledronate (IV) or Alendronate (Oral) -
RANK-L inhibitor
E.g. Denosumab (subcutaneous) - *2) Anti-angiogenic**
- Inhibit blood vessel formation (angiogenesis)*
-
VEGF Inhibitor
E.g. Bevacizumab (IV) -
Tyrosine Kinase Inhibitor
E.g. Sunitinib (Oral)
What is Osteomyelitis?
What are the 5 risk factors?
Osteomyelitis = Inflammation of the medullary bone due to mixed bacterial Infection
- Radiotherapy
- Trauma
- Bisphosphonates
- Bone diseases (e.g. Pagets or Osteoporosis)
- Immunodeficiency (including malnutrition, systemic corticostroids , DM & age extremeties)
What is a “Guardsman’s Fracture”?
Fracture of the right and left mandibular condyle
Also presents with chin laceration from impact
What are some signs & symptoms of MRONJ?
May be ASYMPTOMATIC (MRONJ Stage 1) - AAOMS (2014)
Signs:
- Exposed, necrotic bone
- Gingival swelling
- Secondary Infection (+/- suppuration)
- Pain (persistent)
- Absent or delayed healing
- Pathological #
Symptoms:
- Gingival tenderness
- Halitosis
- Parasethesia
- Pathological #
How might clinical features of an abscess differ if the origin was periapical vs. periodontal?
- Periapical associated with non-vital tooth
- Periapical = history of trauma and/or caries
- Periapical = not well localised pain but TIQ painful to touch
- Periodontal = MOBILE tooth which is TTP
- Periodontal = Vital (or non)
What is the difference between acute and chronic periodontitis?
(Consider symptoms, clinical findings and radiographs)
Name 8 conditions that might affect the maxillary antrum?
- Cleft palate
- Acute/Chronic Sinusitis
- Cyst
- Tumour
- Paget’s Disease
- Fibrous Dysplasia
- Iatrogenic - Oral Antrum Communication/Fisulae or Antral fracture
What are the 3 main methods of infection spread?
Which is the most common?
- Direct (most common)
- Lymophatics
- Blood
Infection spread follows pathway of LEAST resistance
(E.g.
Periodontal abscess = Through periodontal pocket
Periapical abscess = Through thinnest cortical plate)
What are some systemic haemostatic measures which may be used in hospital (under haematologist guidance) if a patient fails to stop bleeding?
- Transexamic acid (anti-fibrinolytic)
- Desmopressin (vasopressin analogue - stimulates release of CF8, vWF & tPA)
- Fresh frozen plasma (with Clotting Factors)
- Platelet transfusion
- Antidotes: Vitamin K (Warfarin) or Andexanet alfa (Xa NOACs)
- What is the normal lifespan of a platelet?
- What cell are they produced from?
- What is the normal level of platelets?
- What level must platelets be above for (invasive) dental treatment to be carried out? (Guidelines?)
- 7-10 days
- Megakaryocytes (& activated by surface contact with damaged epithelium)
- 150-400 x109/L
- 50 x109/L (British Society for Standards in Haematology, 2013)
What are the 6 main principles of flap design in surgical extraction?
- Maintain blood supply (BROADER at BASE)
- Avoid vital structures
- Suture over bone
- Preserve papillae
- Maintain ability to extend
- Maintain ability to close site
When draining an abscess in the submandibular space, what are 4 structures you should watch out for?
How can these be avoided (where should you put your incision)?
- Facial artery
- Facial vein
- Facial nerve
- Hypoglossal
Horizontal incision (parellel to lower border of mandible) made 2 fingers width below lower border of mandible
How would you manage a patient who’s about to start taking anti-resorptive or anti-angiogenic medication?
- Pt education on MRONJ risk, dont discourage drug use
- Low incidence (0.01-0.1% in Osteoporosis & ~1% Cancer pts)*
- Thorough dental assessment:
- XLA poor prognosis unrestorable teeth
- OHI, Smoking/Alcohol cessation & Stabilisation
- Adjust/replace ill-fitting dentures
- If XLA, allow complete healing before initiation of therapy, ideally ~4weeks. (UKCB, 2019)*
- High Risk prevention:
- OHI, FV, Duraphat, F m/w, Smoking cessation & reduced recall
What are 8 indications of removal of 3rd molars?
According to what guidelines?
NICE - Guidance on Extraction of Wisdom Teeth
- Unrestorable caries
- Untreatable pulpal/periapical pathology
- Pericoronitis (1 severe or multiple episodes)
- Abscess / Cellulitis / Osteomyelitis
- Cyst / Tumour (disease of tooth follicle)
- Internal or External resorption (of TIQ or adj. tooth)
- Tooth in line of jaw surgery
- Fracture of tooth
What are 5 virulence factors for bacterium (e.g. in abscess formation)?
- Number of bacterium
- Invasion mechanisms
- Evasion of host defence (e.g. capsules and proteases)
- Toxins and Enzymes (e.g. endotoxin, collagenase, hyaluronidase and fibrinolysin)
- Time & Hose response (acute/chronic)
According to SDCEP, what places a pt at “high risk” of MRONJ? (4)
- Treatment need - Cancer pt
- Previous MRONJ
- Bisphosphonate use over 5 years
- Concurrent Bisphosphonate/Denosumab use with Systemic Glucocortocoids
N.B.
Denosumab use over 9 months ago = No risk
Denosumab use within 9 months (no SG use) = Low risk
What are the 4 management goals for a patient with MRONJ?
- Prioritise oncology treatment (delay tx)
- Maintain QoL (extirpate > XLA)
- Control pain + infection (analgesics and antimicrobials)
- Prevent extension or formation of new osteonecrotic lesion
Describe how the position of a MAXILLARY POSTERIOR infection in relation to the BUCCINATOR muscle would affect the direction of spread?
ABOVE → Buccal Space
BELOW → Buccal Sulcus
For MRONJ, what are the vague dates/duration of treatment that puts a pt at higher risk if having:
- IV bisphosphonates?
- Oral bisphosphonates?
IV = 3+ infusions or 1 year
Oral = 4+ YEARS
What are 12 intra/peri-operative complications during extraction?
- Needle stick injury
- Wrong tooth XLA
- Damage to adjacent teeth or soft tissues
- OAC or displacement of root(s) into sinus
- Fractured tooth/apex (retained root)
- Swallowing/Inhalation of tooth fragment
- Fractured mandible
- Fractured tuberosity
- Fractured alveolar bone
- Haemorrhage
- Lip burn (from drill)
Describe how the position of a MANDIBULAR ANTERIOR infection in relation to the MENTALIS MUSCLE would affect direction of spread?
ABOVE Mentalis → Labial sulcus
BELOW Mentalis → Submental
(Causes swellings in these areas)
What are the clinical features you would observe/smell in a patient with Dry Socket? (4)
What would be the presenting pain history?
- Empty socket with visible exposed bone
- Erythematous and tender surrounding gingivae
- Throbbing pain
- Foul smelling odour
PAIN: Pain starting 2-3 days post-extraction and getting progressively worse
What is meant by “empirical” antibiotics in treatment of dental abscesses?
Give examples.
Antibiotics prescribed first
“Empirical” = Observation alone
E.g.
- Penicillins (Penicillin V or Amoxycillin)
- Nitroimidazoles (Metronidazole)
- Pt with penicillin allergies = Erythromycin, Clindamycin or Tetracyclin
Pus sample obtained and sent to labs. More specific antibiotic can then be prescribed to target bacterium present.
A patient comes in with an abscess/spreading infection, in what cases would you refer them to hospital? (5)
- Obstructed airway (e.g. Ludwig’s Angina)
- Rapidly spreading infection
- Systemic signs: Pyrexic, raised BP, raised WBCs, malaise and toxic appearance
- Immunocompromised/Diabetic pt
- Severe trismus
Describe how the position of a MANDIBULAR POSTERIOR infection in relation to:
- MYLOHYOID
- BUCCINATOR
would affect direction of spread?
1) MYLOHYOID
ABOVE → Sublingual
BELOW → Submandibular
Mylohyoid runs low anteriorly + higher posteriorly; so posterior infections more likely to have submandibular spread
2) BUCCINATOR
ABOVE → Buccal sulcus
BELOW → Buccal space
This is VICE VERSA for Maxillary posterior teeth!
What are 8 post-operative complications following tooth extraction?
- Pain / Bruising / Swelling
- Bleeding - Reactionary (loss of clot in first 48 hours) or Secondary (infection or bleeding disorder)
- Infection (+ spread)
- Dry socket
- Osteomyelitis
- Nerve damage
- Haematoma
- TMJ injury
What is a coronectomy? What happens?
When may it be indicated or contra-indicated?
“Intentional Partial Odontectomy”
- Crown sectioned at CEJ
- Decorination of crown
- Drill 2-4mm below crestal bone (root surface lies here and we want no enamel left in situ)
Indication: 3rd molar removal where close ID canal proximity
Contra-indication: Caries or Mobile roots
For patients at increased bleeding risk, what pre-op & peri-op procedures can be adhered to?
Pre-op:
- Thorough medical history (are medications for limited time or lifetime? may be able to delay tx)
- Ask about patients previous extraction/bleeding experiences
- Plan treatment for earlier in day & week
Peri-op:
- Consider limiting initial treatment area & assessing bleeding
- Make as atraumatic as possible
What dental measures should be put in place for patients after undergoing cancer therapy?
* Enhanced prevention & reduced recall
- Awareness of increased risk of: Xerostomia, Caries, Perio, Infections, Trismus, ORN/MRONJ or Osteomyelitis
- Choose flouride-releasing restorations where possible
- Avoid XLA if possible
- Avoid denture wear if possible (if not, make atraumatic, advise good hygiene & can incorporate Nystatin into soft lining material
Awareness of neutropenic/thrombocytopenic risk - Avoid treatment & liase with oncologist if
- Platelets below 60,000/mm3
- Neutrophils below 2000/mm3
IMP EXAM Q
What are 10 risk factors for Dry Socket?
- Traumatic extraction (e.g. surgical)
- Mandibular extraction (less vascular)
- Previous dry socket experience
- Smoker
- Female
- Oral Contraceptive Pill
- Poor OH
- Periodontal disease
- Excessive vasoconstricter (e.g. LA → reduced blood supply)
- Bone disorders (e.g. Pagets)
If a patient is deemed to require/benefit from antibiotic prophylaxis for IE risk, which (2) antibiotics could be prescribed?
What instructions (pre-op & post-op) are given to the patient?
- Amoxicillin (3g) Oral Powder Sachet (1hr pre-op)
- Clindamycin (2x 300mg) Oral Capsules (1hr pre-op)
Alternatives can be given IV or Oral Suspension if pt cannot swallow
Pre-op:
Pt to bring ABx & take in the practice 1hr pre-op (can be taken at home if no previous adverse reactions to prophylaxis)
Post-op:
Warn of risk of c. difficile (seek medical attention if severe diarrhoea)
What is the OS managment for patients taking Warfarin?
DO NOT STOP TAKING WARFARIN
- Assess patients INR ideally within 24hr of surgery (at least 72hr if patient has stable INR range 2.5-3.5 +/-0.5)
- If patient’s INR is below 4; treat without interupting
- Consider: Limiting/staging treatment area, early appt day/week & local measures (5)
- If patient’s INR is above 4; delay treatment or refer to secondary care if urgent
What is the main flap design for removal of third molars? (2)
Envelope (1-sided) or Triangular (2-sided)
What are the 3 main special investigations done when suspected Osteomyelitis?
(What would you see on the radiograph - 4/5)
1) Radiograph (PA/Sectional OPG)
- “Moth-eaten” bone appearance
- Loss of trabecular pattern
- “Rarefying osteitis” - Poorly defined radiolucency
- CHRONIC ⇒ Periosteal reaction (new bone formed) & Irregular radiopacities (bony sequestra)
2) Pus sample (& used to target antibiotic therapy)
3) Blood Tests - Raised WBCs and CRP
FGDP (2020) - “+/- CBCT or MRI to rule out bone tumours”
What is the most common site for OM & why?
What are 5 clinical features in Osteomyelitis?
Which are more likely in Chronic OM?
Mandible = Most common site (less vascular)
ACUTE: “Male patient with multiple dental infections”
- Throbbing pain (more rapid onset & severe in Acute OM)
- Swelling (soft & becomes more hard due new bone formation)
- Paraesthesia of lip/chin (compression of CN Viii)
- Systemic signs:
Lymphadenopathy, Pyrexia or Malaise - CHRONIC ⇒ Localised necrotic bone +/- suppuration or bony sequestra
What are the 3 stages of abscess infection spread?
STAGE 1: CELLULITIS
Oedema as infection spreads to connective tissue
- Red & shiny
- Fluctuant (but varied firmness dependent on amount of fluid present
- Often non-suppurative (except at source)
- Often Streptococci seen
STAGE 2: SUPPURATIVE (“PUS-PRODUCING”)
Pus produced from centre of lesion
Dependent on: Gravity, Muscle activity and Pressure
STAGE 3: GANGRENE
What is the management of Dry Socket?
- Reassure (right tooth taken out, non-serious and will resolve)
- Irrigate with saline (or CHX) under LA
* SDCEP (2013) Management of acute dental problems - “No evidence in favour of CHX use, not recommended”* - Place Alvogyl (LA, Iodine & Eugenol) or ZOE dressing
- Pt Advice - Good OH, avoid smoking and adequate analgesia
- Review appt (after few days and can be done over the phone)
What are the 4 NOACs?
What clotting factor do they affect & how can their anti-coagulant effect be measured?
How often are they taken?
What is their onset (all same) & half life
- RIVAROXABAN (OD) - Factor Xa (meausured by PT) & 5-13hr half life
- APIXABAN (BD) - Factor Xa (measured by anti-Xa assay) & ~12hr half life
- DABIGATRAN (BD) - Factor II (measured by aPTT) & ~13hr half life
- EDOXABAN (OD) - Factor Xa
All have short onset (2-4hr)
What are the advantages (3) and disadvantages (6) of Enucleation?
ADVANTAGES:
- Complete cyst lining obtained for histology
- Cavity closed - Reduced infection risk
- Little aftercare needed
DISADVANTAGES:
- Cavity clot may become infected
- Haemorrhage risk
- Large cyst removal → Weakened jaw
- Potential damage to adjacent structures or apicies of vital teeth
- Primary closure prevents visual inspection of cyst cavity
- Incomplete removal → Recurrence
What differences exist between Acute and Chronic Osteomyelitis for:
- prevalence?
- pain/clinical presentation?
- management?
CHRONIC osteomyelitis is more common!
Clinical presentation:
- Acute = Dull, throbbing pain
Chronic = LESS painful and LONGER LASTING - Chronic = Localised necrotic bone +/- suppuration & sequestra
Management:
- OS/OM referral (urgent for acute)
- Empirical antibiotics, take pus swap and target antibiotics
- Debridement
- Long term (2+ weeks ) out patient antibiotics (OPAT)
Chronic [Above] and:
Debridement, Corticotomy +/- Antibiotic bead placement (e.g. Gentamicin)
What are 6 blood tests that may be done in hospital if a patient fails to stop bleeding?
- Full Blood Count - platelets? anaemia?
- Prothrombin time (PT) - extrinsic pathway
- Activated partial prothrombin time (aPPT) - intrinsic pathway
- Specific clotting factor assays
- Liver & kidney function tests
- INR (for patients on Warfarin)
What are 3 considerations for removal of 3rd molars which are NOT covered in NICE guidelines?
- Distal caries in 7’s (mesially impacted 8’s)
- GA - If pt undergoing GA and 8’s likely to later become symptomatic
- Non-functional 8’s → Over-eruption and trauma
What are 7 causes of a dental abscess ?
(Think about routes of entry)
- Caries
- Non-vital tooth
- Trauma
- Deep periodontal pockets (via lateral canals)
- Blood stream (“Anchoresis”)
- Extension of periapical infection from adjacent teeth
What preventative measures should be put in place for a patient about to undergo cancer therapy?
What guidelines are useful for this?
RCS/BSDOH - “The Oral Management of Oncology Patients Requiring Radiotherapy, Chemotherapy and/or Bone Marrow Transplantation”
- Full dental check: Stabilisation, Restorations & XLA poor prognosis teeth (ideally 3wk before cancer therapy commences, at least 10 days)
- Enhanced provention (DBOH) & reduced recall
- Educate pt on side effects of radio/chemo therapy (mucositis, xerostomia, increased infection & caries risk)
- Denture OH (ideally dont wear, if worn ensure no trauma, cleaned & removed at night)
- Dietary advice alongside dietician (pt may be prescribed a high calorific diet, ensure dietary advice does not conflict with this - can advise use of straws/water or mw between food intake)
What is meant by a “POLO” 3rd molar?
What might be a good treatment option for its removal?
Mandibular 3rd molar that perforates ID nerve
Ideally leave (asymptomatic) but coronectomy if must be removed
Rarely, dental infections can spread to fascial planes - what are 5 potential areas of spread?
(PIMP C)
- Prevertebral fascia
- Investing layer of deep cervical fascia
- Mediastinum → Pericarditis
- Pretracheal fascia
- Carotid sheath
What is infective endocarditis?
What patients are at increased risk & of those who belong to a sub-catagory group who should be under special consideration for antibiotic prophylaxis?
IE = Infection of endocardium (heart lining), often valves
Rare! 1 in 10,000
Increased risk:
- Acquired valvular heart disease with stenosis or regurgitation
- Hypertrophic Cardiomyopathy
- Previous infective endocarditis
- Prosthetic heart valve
- Congenital heart defect - Cyanotic CHD or CHD with prosthetic valve replacement
Bold & underlined = special consideration group
Liase with patients cardiologist regarding need/type of ABx prophylaxis
What are the bacterial/immunological (3) and anatomical (3) factors that affect the spread of infection?
Bacterial/Immunological:
- Number + virulence of bacterium
- Host defence (e.g. immunocompromised)
- Failure to drain pus (increased infection)
Anatomical:
- Source of infection
- Point of pus drainage through bone
- Natural barriers to spread (e.g. mucous membranes)
Osteoradionecrosis has similar features to Chronic Osteomyelitis (e.g. localised sclerotic bone, extra/intra oral fistula)… except…? (2)
- Healing is slower or non-existent
- NO periosteal reaction (no new bone growth) → Higher pathological fracture risk (& less R/O seen radiographically)
What is the safest antibiotic to take alongisde Warfarin?
Which 3 should be avoided?
AVOID: Metronidazole, Erythromycin & Clarithromycin
Best = Clindamycin
(Can consider Amoxicillin, but monitor INR 24hr after starting antibiotic - SDCEP)
What are the
- Local (5)
- Systemic (6)
risk factors for impaired socket healing post-XLA?
1) LOCAL
- Inflammation
- Foreign body presence (including dressings!)
- Bony fragment
- Remaining tooth tissue
- Radiation exposure
2) SYSTEMIC
- Medications (Bisphosphonates, Corticosteroids, OCP and Immunosuppressants)
- Smoking
- Diabetes
- Malignancy
- Nutritional deficiencies
- Vascular diseases
What staging can be used for ORN (Osteoradionecrosis)?
(HINT: 3 stages)
“Notani” Staging:
STAGE 1 = ORN confined to alveolar bone
STAGE 2 = ORN limited to alveolar bone and/or mandible (above level of mandibular canal)
STAGE 3 = ORN extends to mandible UNDER level of mandibular canal and/or skin fistula and/or pathological fracture
How can you get valid conset from the patient before extraction?
What should you warn them of (general risks)?
What is meant by 2-stage consent?
Valid consent = Voluntary, Competent patient & Informed (of benefits vs. risks and all tx options in easy to understand terminology)
Risks:
- Post-op bleeding, bruising, swelling and pain
- Infection
- Damage to adjacent teeth
- Trismus
- Surgical +/- sutures
- Upper = OAC and Fractured maxillary tuberosity
- Lower = Dry socket and Paraesthesia of lip/chin/tongue
2-Stage Consent:
1st = Information given, discussed and consent signed
2nd = Consent reconfirmed before treatment (copy of consent form to be given to patient)
What is Dry Socket?
- Alternative name
- Aetiology
(Also known as “Localised Alveolar Osteitis”)
Aetiology:
INFLAMMATION due to absence of blood clot
- Failure to form
- Dislodged/lost
- Excessive fibrinolytic activity
Bacterial colonisation → Further clot lysis
Regional inflammation prevents infection spread beyond socket
What are the 4 main methods of surgical cyst removal?
- Enucleation
- Marsupialisation
- Excision (Ellipse-shaped incision and excisional biopsy)
- Curettage (raising flap and Mitchell trimmer curettage)
WARFARIN
- What is the MOA?
- What are some indications for its use? (6)
- What are some side effects of its use? (5)
- How is it monitored? What is the normal range?
- What is the overdose antidote?
- Anti-coagulant: Vitamin K antagnoist - Inhibits Vit K-dependent clotting factors (2,7,9&10)
- Treatment or Prophylaxis for: Stroke, Atrial Fibrillation, DVT, Pulmonary Embolism, Coronary Heart Disease or Prosthetic Valve/Stent placement
- Rashes, alopecia, bruising, liver disorders/jaundice or GI upset
- INR (International Normalised Ratio)
Normal range: 2.5-3.5 (+/-0.5) - Vitamin K (IV)
What are some acute (ST) & chronic (LT) oral side effects of radiotherapy?
ACUTE
- Mucositits
ACUTE & CHRONIC
- Xerostomia
- Dysguseia (loss or change in taste)
- Dysphagia
- Increased bleeding risk (thrombocytopenia)
- Increased infection risk (neutropenia)
CHRONIC
- Radiation caries
- Increased risk of ORN or Osteomyelitis
What is the definition of “Osteoradionecrosis”?
A non-healing region of devitalised bone in a previously radiated field, which persists for a minimum of 3 months in the absence of a reoccuring malignancy.
Radiation ⇒ Reduced vascularity & Osteocyte damage
Increased radiation dose (above 60Gy) = Increased risk
A patient at high risk MRONJ has come in for an extraction, what is your management?
- Consider alternatives for XLA (e.g. extirpate)
- If XLA remains most appropriate option:
- Education patient on risks & benefitd (valid consent)
- Consider referral to secondary care (e.g. high risk cancer pt or medically complex)
- XLA can be carried out in primary care
Extraction:
- Avoid surgical
- XLA one sextant at a time and monitor healing
- CHX mouthwash before AND after XLA (2 wks)
- DO NOT prescribe antibiotics
- Safety net patient (contact if signs/symptoms)
- Review healing at 8 weeks
If a dento-alveolar abscess is left untreated, what will happen?
What are the 3 general routes of biological pus drainage?
Untreated → Abscess enlargement and spontaneous pus drainage (through pathway of least resistance)
- Through sinus tract, into oral cavity or facial skin
- Through root canal or PDL
- Through cancellous bone and cortex perforation
Spontaneous drainage incomplete and does not address cause → Chronic/Reoccuring Abscess
In cryotherapy, what happens at:
- -20°C?
- -50°C?
- Partial destruction
- COMPLETE destruction
According to NICE/SDCEP guidance on ABx prophylaxis for Infective Endocarditis, what counts as an “invasive dental procedure”?
- Sub-gingival scaling/restorations/matrix placement
- 6PPC
- PMC/SSCs
- Abscess drainage
- Endodontics (before apical stop established)
- Extractions
- MOS
- Implants
N.B. Removal of sutures, trauma to lips/mucosa & exfoliation of primary teeth all NOT included
If a patient comes in with uncontrollable post-op bleeding, what should your management be?
- Clean pt & reassure (looks worse as blood mixes with saliva)
- Assess site under good lighting & suction to determine origin
- Check underlying causes: MH/FH, past XLA experience, nature of surgery & take patients BP/pulse
- Local haemostatic measures (8):
Pressure gauze, LA (vasoconstrictor), Pack (surgicel), Suture, Tranexamic acid m/w, Diathermy, Bone wax or Suck-down splint - Sit patient up and wait 15mins for bleeding to cease - If bleeding persists send pt to hospital for further investigations & treatment
- POIG - Paracetamol (avoid NSAIDs/alcohol/smoking) & emergency out of hours contact
What is the difference between Enucleation and Marsupialisation?
Enucleation = Complete removal of lesion with in-tact lining (e.g. smaller cysts)
Marsupialisation = 2 stage process
- Marsupialisation - Incision (create largest possible window) and suture cyst lining to mucosal wall
- Cyst decompression - Return once regressed in size and remove
(e.g. larger cyst or close to vital structures )
What are the 2 main groups of medications causing increased bleeding in patients? (Give some examples)
- Anti-coagulants
Warfarin, Heparin, NOACs (Rivaroxaban, Apixaban, Dabigatran & Edoxaban)
- Anti-platelets
NSAIDs (Aspirin), Clopidogrel & Dipyridamole
Low Molecular Weight Heparin:
- What is the MOA?
- What is the administration?
- What are 3 indications for use?
- What should our OS management be?
- Anti-coagulant (anti-thrombin)
- Sub-cutaneous injection
- Pregnancy (needing anti-coagulation), Thrombosis in cancer pt or Kidney Dialysis
- Liase with medical professional & delay treatment if taken for limited time
What special investigations do you need for Dry Socket?
NONE - Clinical history and observation enough for diagnosis
No radiographs needed - if pt presents again in pain take radiograph (LCPA) to investigate alternative diagnoses.
What are 4 indications of CBCT in dentistry?
Why is it not routinely used?
- Trauma
- TMJD
- Large bony lesions (e.g. cysts) where soft tissue doesnt need to be visualised (would use US/MRI)
- 3rd molar surgery - Where conventional OPG radiograph not sufficient to show relationship to ID nerve
Not routinely used as x10 more radiation vs. OPG
How might your OS assessment/management change for a patient with:
- Acute DVT?
- Coronary Stents?
- Prosthetic Heart Valves?
- May be taking higher NOAC dose in first 1-3weeks of treatment, if possible delay until standard dose started
- Increased risk of thrombolytic events, do NOT alter medication unless under written guidance from their cardiologist. Often on dual anti-platelet therapy for 12months, followed by mono AP therapy for life
- ABOVE & considered increased risk of Infective Endocarditis - Assess need for antibiotic prophylaxis with cardiologist
What is Ludwig’s Angina?
How does the patient present?
How is it treated?
Bilateral infection of the Sublingual, Submental AND Submandibular space
Presentation:
- Fever (38.5°C)
- Raised floor of mouth +/- deviated uvula
- Difficulty swallowing, speaking or breathing
(Dysphagia, Dysarthria or Dyspnoea) - May have had recent 3rd molar removal
Treatment:
MEDICAL EMERGENCY - URGENT referral to A&E
- Drainage
- IV antibiotics
- +/- Tracheostomy (airway management)
What are the local (6) and systemic (3) signs of an Acute Periapical Abscess?
Will you see radiographical changes?
LOCAL
- Pain (often poorly localised but TIQ may be painful and mobile if follows pericapical periodontitis)
- Swelling
- Redness
- Heat
- Trismus (loss of function)
- Lymphadenopathy
SYSTEMIC:
- Fever
- Elevated pulse
- Elevated WBC, Serum Proteins (e.g. CRP) and ESR
Radiographical signs vary - May be too soon to see changes (acute inflammation would take a few days to resorb bone)
What is the antidote for:
- Warfarin overdose?
- NOAC (Rivaroxaban, Apixaban & Edoxaban) overdose?
- Vitamin K
- Andexanet alfa (very recent!)
Is the bacterium within an abscess:
Mono-microbial or Polymicrobial?
Endogenous or Exogenous?
What bacteria are most often present?
Poly-microbial - Work syngeristiclly (together)
Endogenous
Bacteria present:
- Obligate/Strict Anaerobes (most common) - Fusobacterium, Prevotella, Porphymonas (esp. P. gingivalis)
- Facultative Anaerobes - Streptococci
What 4 signs might you see in a patient with a Zygomatic fracture?
- Flattening + numbness of cheekbone
- “Step deformity” on A-P palpation behind pt
- Eyes - Diplopia, Restricted eye movement + Subconjunctival haemorrhage
- Limited mandible opening (temporalis often affected)
What are 3 alternative techniques for cyst/benign lesion removal?
- Laser
- Diathermy (current)
- Cryotherapy (cold liquid nitrogen at -196ºC)
What are 5 special tests you might want to take on a patient with a suspected dental abscess?
- Radiographs (incl. CT and US)
- Temperature
- FBC - CRP
- Pulse and BP
- Blood glucose (poorly controlled diabetic = increased infection risk)
What are the EIGHT (?!) potential pathways of Mandibular infection spread?
- Submental
- Sublingual
- Submandibular
- Submasseteric
- Buccal
- Lateral Pharngeal
- Peritonsillar
- Pterygomandibular
What should you consider/do:
- BEFORE
- DURING
- AFTER
draining pus from an abscess?
- BEFORE = Consider anatomical sites to avoid (e.g. Greater Palatine Artery in Palate and Facial artery/vein/nerve + Hypoglossal nerve in Submandibular space)
- Breakdown/disturb locules in cavity with finger or sinus forceps
- Keep drainage site open to allow further drainage
What are 3 indications for “special consideration” regarding antibiotic prophylaxis for Infective Endocarditis risk?
What are the next measures for these patients?
- Previous IE
- Prosthetic valve replacement
- Congenital Heart Disease - Cyanotic or involving prosthetic replacements
Contact patient’s cardiologist regarding heightened IE risk to assess need for ABx prophylaxis
What are the different management options for pericoronitis?
(Can catagorise in 3 main groups)
- Symptoms: Analgesia, 0.2% CHX Mouthwash and Debridement under Operculum (with LA)
- Adjacent tooth: Extract or Smooth cusps if causing trauma
- TIQ: Extract
What are the 4 potential pathways of MAXILLARY infection spread?
- Canine
- Buccal
- Palatal
- Lateral Pharyngeal
(N.B. Buccal + Lateral Pharyngeal also in Mandibular spread)
What are the post-operative instructions for a patient after extraction? (7)
- LA wears off in few hours - Will get pain, take prophylactic pain relief
- Soft diet (avoid hot foods esp with LA)
- Avoid spitting/rinsing for first 24 hours
- After, salt water rinses
- Bite on gauze if bleeding/oozing
- If serious bleeding & pain (lasting more than few days) - A&E or contact emergency number given
- NO SMOKING
According to NICE/SDCEP guidance, what is the “routine management” of a patient who might be at higher risk of IE but does NOT require ABx prophylaxis?
- Explain IE (rare infection of heart lining, 1:10,000)
- Dental procedures no longer believed to be main cause, invasive dental tx can increase risk but can also be caused by everyday brushing/flossing/chewing (good OH imperitive)
- Explain risks & benefits of antibiotic prophylaxis (why not routinely used)
- Prevention of IE: Good OH, regular recall & avoid non-medical risk factors (piercings/tattoos)
- Educate patient on IE symptoms to seek treatment for (fever, malaise, weight loss, breathlessness or muscle/joint pain)
- Ensure any dental infections are promply investigated & treated
What should be considered when offering ABx prophylaxis for Infective Endocarditis risk? (5)
- Cardiologist opinion
- Patient consent
- Medical History: Current medications & Allergies
- Previous prescriptions (pt can take the same ABx for repeat invasive procedures over a short period of time BUT if taken ABx course within 6wks ago for infection, should consider different ABx class)
- Ability to swallow
What are 3 signs in a patient with an orbital fracture?
- Enophthalmos (sinking of eye into sockey
- Diplopia
- Restricted eye movement
- Subconjunctival haemorrhage
(“Hanging drop” sign seen radiographically)
What is the difference between:
- PRIMARY haemostasis?
- REACTIONARY haemostasis?
- SECONDARY haemostasis?
(think: when? why? how is it managed?)
-
PRIMARY HAEMOSTASIS
During & immediately post-op
Due to ST/vessel trauma, inflammation or infection
Often controlled with local haemostatic measures -
REACTIONARY HAEMOSTASIS
Up to 24hr post-op
Vasoconstrictor wearing off, loss of blood clot, anti-coagulant/platelet medication or underlying bleeding disorders
Local haemostatic measures & may require systemic intervention -
SECONDARY HAEMOSTASIS
7-10 DAYS post-op
Mainly due to INFECTION
Local haemostatic measures & ABx to manage infection
WARFARIN INTERACTIONS
- What medications potentiate its anti-coagulation effect?
- What medications antagonise its anti-coagulation effect?
POTENTIATE:
- Metronidazole
- Azole antifungals (e.g. Miconazole/Fluconazole)
- Omeprazole
- NSAIDs
- Erythromycin/ Clarithromycin
- Glucagon
- Acute alcohol intake
ANTAGONISE:
- Carbamazepine
- Barbiturates
- Rifampicin
- St Johns Wort
- Phenytoin
- Chronic alcohol intake
What are 3 indications (conditions) for use of Bisphonates?
- Osteoporosis
- Paget’s Disease
- Cancers - Multiple myeloma or Metastatic Bone Cancer
What anatomical muscle(s) affect the spread of infection for:
- Mandibular incisors?
- Mandibular pre-molars?
- Mandibular molars?
- Maxillary canines?
- Maxillary molars?
- Mentalis
- Mylohyoid
- Mylohyoid (lingual) AND Buccinator (buccal)
- Strap muscles
- Buccinator (and Antrum/Maxillary sinus)
AAOMS (2014) Position Paper:
What is the staging of MRONJ & associated treatment?
(0-3)
STAGE 0
No visible exposed necrotic bone.
Non-specific symptoms or clinical & radiological features
TREATMENT:
- Symptomatic management (Analgesia & ABx)
- Consider other differentials (e.g. Osteomyelitis or F-O Dysplasia)
- Close review
STAGE 1
Exposed necrotic bone (or probable through I/O fistulae)
Asymptomatic. No signs of infection.
TREATMENT:
- CHX (0.12%) mouthwash
- Pt education & 3-monthly review
STAGE 2
Exposed necrotic bone (or probable through I/O fistulae)
Symptomatic. Signs of Infection.
TREATMENT:
- CHX (0.12%) mouthwash
- Symptomatic management (Analgesia & ABx*)
- Debridement
STAGE 3
[As Above] & one or more of the following:
- Exposed necrotic bone extending beyond alveolar bone
- Extra-oral fisulae
- Pathological #
- OAC/ONC
- Parasthesia
TREATMENT:
[As Above] & Resectioning (+/- immediate plate or obturator replacement)
* Penicillin or Metronidazole given as empirical ABX. Swab taken which can be used to target ABx treatment.
What are the main empirical antibiotics of choice for Acute Osteomyelitis? (3)
BROAD-SPEC ANTIBIOTICS
E.g.
- Benzylpenicillin
- Clindamycin
- Metronidazole
N.B. Clindamycin is good for bony penetration but risk of C.difficle bacterial infection → severe diarrhoea (cease meds)
What is the:
- OLD (3)
- NEW (2)
treatment for Osteoradionecrosis?
Outline the preventative strategies for a pt about to undergo H&N radiation therapy.
- OLD = Antibiotics, Hyperbaric Oxygen Therapy and Surgery
- NEW = Pentoxifylline (anti-fibrosis) and Tocopherol (Vit. E) (anti-oxidant)
Also: Pt education & Conservative tx (OHI, analgesia, trauma relief & CHX m/w)
Prevention
RCS & BSDOH (2018) “Oral Management of Oncology Pts requiring Radiotherapy, Chemotherapy and/or Bone Marrow Transplantation”
- Full dental assessment:
- Stabilisation
- Relieve dental trauma
- Extraction of poor prognosis teeth (at least 10 days before starting tx, ideally 3+ weeks)
- High risk Prevention
- Fluoride (TP, FV, m/w)
- Dietary advice alongside dietician
- Reduced recall
- Education on acute & chronic side effects of radiotherapy
Do you prescribe antibiotics for:
- Dry Socket?
- Osteomyelitis?
- Osteoradionecrosis?
- MRONJ?
- NO - This is primarily inflammation!
- Yes (Empirical ABs them targetted ABs based on pus sample and 2 week course, OPAT)
- Yes, if infection present (But new tx = Pentoxifylline & Tocopherol)
- No evidence for use
What are 8 local haemostatic measures that can be used to manage bleeding?
- Pressure with (saline-soaked) gauze
- LA (adrenaline vasoconstrictor)
- Pack socket with oxidised cellulose (surgicel)
- Suturing
- Transexamic acid mouthwash (5% QDS) - N.B. Not recommended by SDCEP
- Bone wax
- Diathermy (of vessel)
- Suck down splint (more often for fractures)
What is pericoronitis?
What type(s) can be considered for 3rd molar extraction?
Soft tissue inflammation related to crown of partially erupted tooth, where presence of an overlying operculum makes difficult to clean.
(Build up of plaque, streptococci and anaerobic bacterium)
Considered for XLA if: 1 severe episode or multiple reoccuring episodes
A patient presents with mucositis related to onset of chemo/radiotherapy:
What is it & how does it present? When does it present? How can it be managed?
Mucositis = Acute inflammation of mucosa
May present as: Ulceration, erythema & white/yellow sloughing. Patients may complain of pain on eating/swallowing/speaking.
Often presents 1-2wks following cancer therapy onset. Pt should be reassured - healing is often complete 2-3wk following cessation of therapy.
Management: Reassurance (above), OHI, topical agents (e.g. difflam, CHX mouthwash, lidocaine gel/ mouthwash), mucosal shields during radiotherapy & zinc supplements
What are the 3 main treatment principles/stage for dental abscesses?
How does each differ for GDP & OMFS?
1) Drain Pus (Aspiration, Intra/Extra Oral Drainage)
- GDP = Intra-oral drainage (LA)
- OMFS = Intra OR Extra-oral drainage (LA or GA)
2) Remove Cause/Source of Infection
- GDP = Extirpation or Extraction
- OMFS = Extraction
- *3) Consider Antibiotics**
- (If incomplete drainage, severe infection (spread/fever) or MH concern, e.g. diabetic)*
- GDP = Oral empirical Antibiotics (e.g. Penicillin or Metronidazole)
- OMFS = IV antibiotics (empirical initially, thenm can give more specific after lab results from sample)
What is the OS management of patients on NOACs?
How would this change if it was an emergency?
RIVAROXABAN/EDOXABAN (taken OD - morning or evening)
- DELAY morning dose & take 4hrs after hameostasis
- Take evening dose as normal (given 4hr post-haemostasis)
APIXABAN/DABIGATRAN (taken BD) = MISS morning dose & take evening dose as normal
SDCEP: “In emergencies where the patient has taken their morning NOAC dose, advisable to try and delay treatment to later in the day if possible to reduce anticoagulant effect”
What is SDCEPs stance on Tranexamic acid?
- TA is NOT included in BNF Dental Preparations list and so cannot be prescribed on the NHS
- TA not available as m/w and so must be prescribed & prepared off licence
- “Based on this guidance, not advised primary care practitioners prescribe TA but can be used in addition to local haemostatic measures if presecribed by medical practicioner”
What are the 4 para-nasal sinus’?
Which is the largest?
Frontal, Ethmoid, Sphenoid & Maxillary
Maxillary = largest (3x3x2.5cm)
Pryamid-shaped (base on lateral nasal wall & apex in zygomatic process)
What arteries & nerves are associated with the maxillary antrum?
Arteries:
- Greater Palatine
- Facial
- Maxillary
Nerves:
- Superior Alveolar
- Anterior Palatine
- Infra-orbital
What is the difference between an OAC & OAF?
OAC (Oro-Antral Communication) = full thickness open communication between oral cavity & maxillary sinus; often following XLA upper molars (esp. 2nd molars)
OAF (Oro-Antral Fistulae) = An OAC which has epitheliazed over time; NOT present immediately after XLA
What are 7 factors pre-disposing a patient to an OAC?
- Close proximity/relationship between tooth & antrum
- Excessive apical force used in XLA
- Surgery performed in close proximity to sinus (e.g. cyst removal)
- Submerged teeth
- Larger antrum
- PA Bone loss (destruction of peri-apical bone)
- Hypercementosis
What are the signs (6) & symptoms (3) of an OAC?
(N.B. Some immediate & some delayed)
Signs:
- Direct expection under good lighting - Hole evident
- Bone/antral lining on extracted tooth roots
- Blood ‘bubbling’ at socket
- Hollow sound on suction of socket
- Whistling noise from socket
- Radiographs showing antral floor defect (not always visible & not needed for acute diagnoses)
Symptoms:
- Air entry into mouth on holding nose
- Regurgitation of fluids/foods into nose
- Symptoms of sinusitis if untreated (dull pain worse on bending forwards +/- purulent discharge
Studies have suggested in untreated larger OACs, 50% develop sinusitis within 2 days & 90% within 2 weeks
What is the management & POIG/POAR for a patient with OAC?
(POAR = Post-Operative Antral Regime)
[Ideally prevention: consent for risk & elective surgical?]
Small OAC? (<2mm) = Horizontal mattress suture & review for spontaneous closure.
Large OAC? (>5mm) = Surgical site closure: Buccal advancement, Buccal fat-pad advancement, Palatal rotational/”Pedicle” or Tongue flaps
- Consider:
- construction of suck-down acrylic plate/ essex splint to protect area for first 2 weeks
- surgicel placement (but may provoke inflammatory foreign body response)*
- Autogenous/ Allogenous/ Xenografts
POIG/POAR:
- AVOID: Nose blowing, use of straws, sneezing with mouth closed, smoking, use of wind instruments, swimming/snorkelling, airplanes or blowing balloons/mattresses for 2-3weeks
- Soft diet & avoid trauma to area
- NSAID analgesia
- Steam inhalations (Karvol/Olbas oil)
- Nasal decongestants (0.5% Ephedrine) for 7 days
- Antibiotics (FGDP 2020- Antimicrobial Prescibing in Dentistry)
- Phenoxymethylpenicillin - 500mg QDS for 5 days
- Doxycycline - 200mg OD (1day) then 100mg OD (4days)
- Clarithromycin - 500mg BD for 5 days
- Anti-septic or Saline rinses
- Safety net the patient: contact details & red-flags (sinusitis, swelling, epistaxis)
What antibiotics could be prescribed for an OAC/OAF?
(Quote guidelines)
FGDP (2020) Antimicrobial Prescribing in Dentistry
1st Line:
Pentoxymethylpenicillin - 500mg QDS for 5 days
2nd Line:
- Doxycycline - 200mg OD (1 day) & 100mg OD (4 days)
- Clarithromycin - 500mg BD for 5 days
What is an OAF?
What are the signs & symptoms?
Oroantral Fistulae = Epithelialised communication between oral cavity & maxillary sinus (epithelialisation begins to occur a few days following OAC formation)
OAF could be caused by: Non-healing OAC, draining infection, trauma or malignancy
Signs:
- Visible fistula
- Antral mucosa may prolapse into mouth (‘antral polyp’)
- Whistling sound on talking/breathing
- Fogging of dental mirror placement at site
- Radiographic: Fluid in sinus & tear in antral lining
Symptoms:
- Fluid/food regurgitation
- Epistaxis
- Chronic sinusitis (may be asymptomatic or dull throbbing pain +/- nasal discharge)
What is the treatment/management of an OAF?
What are the complicating factors in its management?
Complicating factors:
- Clean antrum required before surgery (often given ABx before)
- OAF tissue friability (two epithelialised edges wont heal) so fistulae tract must be exised
Management:
- Pre-op ABx
- Exision of fistulae tract
- Surgical closure: Buccal advancement flap/Buccal fat pad/Palatal flap
- POIG/POAG (as with OAC)
* POIG/POAR:
- AVOID: Nose blowing, sneezing with mouth closed, use of straws, use of wind instruments or blowing balloons/mattresses
- Soft diet & avoid trauma to area
- NSAID analgesia
- Steam inhalations (Karvol/Olbas)
- Nasal decongestants (0.5% Ephedrine - 7 days)
- ABx
- Anti-septic mouthrinse
- Safety net for complications & contact
What are 5 pre-disposing factors for maxillary tuberosity fracture?
How would you diagnose it?
- Lone standing maxillary molars
- Excessive force
- Hypercementosis
- Bulbous or splayed roots
- Large antrum
Visualy & Tactile diagnosis:
- Would feel/see movement of the tooth AND bone together
- +/- Palatal tear
- +/- Fracture sound
What is the management for a:
1) SMALL
2) LARGE
fracture of the maxillary tuberosity?
1) SMALL FRACTURE
- Raise buccal flap (visualisation) & dissect tooth from bone
- Extract tooth & close site (buccal flap) to avoid OAC
- POIG/POAR
2) LARGE FRACTURE
- STOP… DO NOT EXTRACT
- Splint to neighbouring tooth & leave for 6-8 weeks
- Consider placing patient on ABx
- Reassess and extract under elective surgical
What is the management of displaced roots/teeth?
(minimally invasive → most invasive)
- Suction retrieval (careful not to displace further apically)
- Radiographic visualisation (parallax or CBCT) if not visualised here, consider Chest X-ray for possible aspiration
- Close OAC & refer to OS
- POIG/POAR
OS:
- Beneath antral lining?Buccal mucoperiosteal flap & careful bone removal
- Above antral lining? Cadwell-Luc Surgery or Intra-nasal Antrosomy
BDJ Article: What are 8 factors influencing the success of surgical management of OAFs?
- Size of lesion
- Previous surgery
- Pre-existing sinus pathology
- Experience of operator
- Surgical techniquer used
- OH
- Smoking
- Medical status
What is Sinusitis?
What are the main aetiological causes? (3)
What are the 2 main types and how do they differ in presentation?
Inflammation of the paranasal sinus
Aetiology:
- Infection
- Viral (Influenza, Common Cold, Measles), Bacterial (Whooping cough or severe dental infection spead) or Fungal (rare)
- Decreased drainage (e.g. obstruction)
- Iatrogenic penetrating injury (e.g. displaced tooth)
1) ACUTE
Constant, throbbing pain with exacerbated tenderness on leaning forwards
Facial swelling, cheek oedema, teeth may be TTP (but are vital)
Systemic: Pyrexia, malaise, lymphadenopathy
2) CHRONIC (persistant inflammation, usually lasting at least 3 months)
Asymptomatic or nagging pain (less severe than acute)
What are the 2 main techniques used to surgically close an OAC?
How do they differ in advantages/disadvantages?
1) BUCCAL ADVANCEMENT FLAP
Advantages: Most common, high success rate
Disadvantages: Decreased buccal sulcus depth, Future prosthetic issues & post-op pain/swelling
2) BUCCAL FAT PAD FLAP
Advantages: Quick, good blood supply, buccal sulcus depth unaffected & high success rate
Disadvantages: Reduced mouth opening, partial necrosis & post-op pain/swelling
What are 4 drugs NOT prescribed as anti-coagulants or anti-platelets which can still effect clotting (& why)?
- Cytotoxics (e.g. Penicillamine, Hydrochloroquine, Azthioprine, Methotrexate) - Reduce platelet numbers and/or impair liver function (production of clotting factors)
- NSAIDs - Impair platelt function
- Carbamazepine - Can affect liver & bone marrow platelet production (most at risk when first started medication or following dose adjustment)
- SSRIs (e.g. Citalopram, Fluoexetine, Sertraline) - Potential to impair platelet aggregation & may increase bleeding time when used with anti-platelets
What are 4 signs/symptoms shared in both Acute & Chronic Sinusitis?
- Dull, throbbing pain in midface - may be worse on leaning forwards (more severe in acute)
- Mucopurulent nasal discharge
- Lack of transillumination
- Radiographic opacity
What are 8 signs/symptoms of Acute Sinusitis?
What are the main principles of its management?
Signs/Symptoms:
- Dull, constant throbbing pain in midface - especially on leaning forward
- Facial swelling/ cheek oedema
- Mucopurulent discharge
- Teeth TTP but vital
- Loss or altered smell/taste
- Systemic: Pyrexia, Malaise & Lymphadenopathy
- Lack of transillumination
- Radiographic opacity
Management:
ARABS: Analgesia Reassure (if secondary to viral infection often self-limiting) Anti-biotics (only if persistant or severe symptoms) Bed-rest/fluids Steam inhalation (& Nasal decongestants - 0.5% Ephedrine max 7 day use)
If unresponsive/severe, may require surgical management: Antral wash-outs or Intra-nasal Antrostomy
According to SDCEP, when should antibiotics be prescribed for Sinusitis? (2)
What antibiotics are recommended?
- Severe systemic symptoms
- Persistent symptoms and/or mucopurulent discharge lasting at least 7 days
Antibiotics:
- Amoxicillin 500mg TDS for 7days
- Doxycyclin 200mg OD for 1 day & 100mg OD for 6 days
What are 6 signs/symptoms of Chronic Sinusitis?
What is the management? How does this differ to Acute?
Signs/ Symptoms:
- Asymptomatic or dull ‘nagging’ pain
- Mucopurulent discharge
- Nasal obstruction
- Thickened antral mucosa
- Loss of transillumination
- Radiographic opacity
- Halitosis
- Loss/ altered smell & taste
Management:
ARABS: Analgesia, Reassure (non-dental), Anti-biotics (not routine), Bed-rest & fluids, Steam inhalation
Surgery: Antral washouts, Intra-nasal antrostomy, Cadwell-Luc or FESS (Functional Endoscopic Sinus Surgery)
Vs Acute: May not respond to local measures as well & avoid nasal decongestants for chronic as may worsen
What are 4 predisposing factors for Acute Sinusitis?
- Poor drainage
- Deviated septum
- Virulent infection
- Immunocompromised/Dehabilitated patient
Why do lesions that are normally radio-lucent (e.g. cysts) appear radio-opaque in the maxillary sinus?
As theyre surrounded by less dense air
What are two classifications for impacted wisdom teeth?
-
Winter’s Classification (8)
Using Winter’s Lines, assess if application point is mesial/distal and above or below the ‘amber’ line (bone level) or ‘white’ line (occlusal plane)
Mesio-angular, Disto-angular, Vertical, Horizontal, Inverted, Buccal-oblique, Lingual-oblique or Transverse -
Pell & Gregory Classification
Class: A-C (height of impacted tooth) & I-III (space available between distal border of 7 & anterior border of the ramus for the 8s eruption)
What is the ASA Classification?
ASA 1 = Normal, healthy patient
ASA 2 = Mild systemic disease <em>(includes smoker, drinker & obesity!)</em>
ASA 3 = Severe systemic disease (includes uncontrolled DM)
ASA 4 = Severe systemic disease, constant threat to life
ASA 5 = Moribund patient, not expected to survive without surgery
ASA 6 = Clinically brain-dead
What is the general appearance of a mucocele?
What are the 3 main types & how do they differ in aetiology/appearance/histology?
Clinical Presentation
- Blue-ish, translucent swelling
- Fluctuant
- Sessile (fixed)
- Painless
- May burst to release “salty” mucous
Types:
- Mucous Extravasation Cyst
- Related to trauma so often on lower lip
- No epithelial lining (seen histologically alongside inflammatory cells) - Mucous Retention Cyst
- Related to saliva retention, not often on lower lip and more common in older pt (>50y)
- Epithelial lined (seen histologically & NO inflammatory infiltrate) - Ranula
- (Often MEC) affecting SM/SL gland in FoM (uniform ~2-3mm)
- “Plunging Ranula” if extends through Mylohyoid
What are the 3 main treatment options for a mucocele?
- No tx & monitor (may spontaneously resolve)
- Surgical excision or marsupialisation
- Cryotherapy (if reoccurance)
What are 8 types of Ondontogenic Cysts?
Which 3 are the most common?
Inflammatory:
- Radicular Cyst (most common, 65%)
- Residual Cyst
- Paradental Cyst
Developmentary:
- Dentigerous Cyst (Follicular/Eruption) - 25%
- Odontogenic Keratocyst - 5%
- Lateral Periodontal Cyst
- Gingival Cyst of the Adults
- Glandular Odontogenic Cyst
What are the GENERAL:
- Clinical features
- Special Investigations
- Treatments
For all Odontogenic cysts?
Clinical Features:
- Painless swelling (may become painful if secondary infection)
- Egg-shell crackling (breaking of overlying periosteal bone) or Fluctuance (ST or perforated bone)
- Displacement or mobility of teeth
Special Investigations:
- Sensibility tests (Radicular cysts associated with non-vital teeth)
- Radiographs (often: well-defined, well-corticated radiolucencies)
- Biopsy
- Aspiration (OKC - White-yellow semifluid & low soluble protein level <4g/100mL)
- Incisional Biopsy (larger lesion)
- Excisional Biopsy (smaller lesion)
Treatments:
Enucleation or Marsupialisation
(RCT considered for small Radicular Cysts & Eruption cysts may spontaneously resolve)
What are 8 Non-Odontogenic Cysts?
(Epithlial & Non-Epithelial)
Epithelial:
- Naso-Palatine
- Naso-Labial
- Median Palatine
- Mucous Retention Cyst
Non-Epithelial:
- Solitary Bone Cyst
- Aneurysmal Bone Cyst
- Mucous Extravasation Cyst
(N.B. Bone Cysts most often associated with children/adolescents)
What are the general clinical features of a Mucocele? (6)
What are the 3 main types & how do they differ?
What are the 3 main treatment options?
Mucocele Clinical Features:
Swelling (salivary gland cyst):
- Blue-ish
- Translucent
- Fluctuant
- Sessile
- Painless
- May burst to release “salty” mucous
-
Mucous Extravasation Cyst
Associated with trauma (often on lower lip), NOT epithlieal lined
Histology: No epithelium, mucous & inflammatory cell infiltrate -
Mucous Retention Cyst
Associated with saliva retention (often older pt >50y & not commonly found on lower lip)
Histology: Epithelial lined, mucous & NO inflammatory infiltrate -
Ranula / “Plunging Ranula”
Often MEC of SL/SM gland on FoM (unilateral, 2-3cm)
“PR“ if extends through mylohyoid
Treatment Options:
- No treatment/ Monitor (can spontaneously resolve)
- Surgical: Excision or Marsupialisation
- Cryotherapy (e.g. if recurrence)
When assessing radiograph of potential cyst/tumour - What should be described?
Radiolucency or/and Radiopacity:
- Site (& any association with unerupted teeth - e.g. Dentigerous/OKC)
- Size
- Shape (cysts often oval or round)
- Margin (cysts often well-defined & well-corticated)
- Locularity -Uni/Multi
- Effect on adjacent structures (e.g. root resorption or displacement)
What are the specific clinical, radiographical & histological features for a Radicular Cyst?
Clinical Features:
Associated with NON-VITAL tooth (apex or laterally)
Radiographic Features:
- Well-defined & Well-corticated R/L
- Round or Ovoid
- Unilocular
- Associated with apex of non-vital tooth, growth continuous with lamina dura of TIQ
- LT ⇒ Root Resorption or Displacement
Histological Features:
- Non-keratinised SS Epithelium
- Acute & Chronic Inflammatory Infiltrate
- Cholesterol Clefts (in cell wall & lumen)
- Mucous Metaplasia
- Lumen: Pink serous exudate, Inflammatory cells, Desquamated epithelial cells & Cholesterol Clefts
- May see GP/Amalgam if root-filled
*
What are the specific Clinical, Radiographical & Histological features of a Dentigerous Cyst?
Clinical Features:
Associated with UNERUPTED tooth (often 8s or 3s)
Radiographic Features:
- Well-defined & well-corticated radiolucency
- Unilocular (or pseudo multilocular)
- Unerupted TIQ lies centrally with cyst attached at CEJ
- Follicular space > 3mm (if less, consider if enlarged follicle)
Histological Features:
- Non-keratinised SS Epithelium
- Flat Basement Membrane (uniform, 2-5 cells thick)
- “Blue myxoid” Cell wall
- Mucous Metaplasia
- Lumen: Pink serous exudate & Cholesterol Clefts
What are the specific Clinical, Radiographic & Histological features of an Odontogenic Keratocyst?
Clinical Features:
- Associated with unerupted tooth
- Aspiriation ⇒ White/Cream semi-fluid & Low protein level (<4g/100mL)
- Multiple Cysts - Gorlin Goltz Syndrome
- High (60%) recurrence rate! (diffiucult removal & daughter cells)
Radiographical Features:
- Well-defined & Well-corrugated (“scalloped”) radiolucency
- Multi-locular (or uni)
- Common: Angle of Mandible or Ramus
Histological Features:
- Keratinised & Corrugated SS Epithelium
- Flat Basement Membrane
- Daughter Cells (in cyst wall)
- Prominant Basal Cells (dark stain & reverse nuclear polarity)
What is the incidence of MRONJ?
(HINT: By treatment need & rate increases for post-extraction)
Cancer pt (Anti-Angiogenics or Anti-Resorptives) = ~1% **(2.9% after XLA)**
Osteoporosis Pt (Anti-Resorptive) = 0.01-0.1% **(1.5% after XLA)**
According to AAOMS (2014 Position Paper), what are the MRONJ treatment goals? (4)
- Prioritise oncology
- Preserve Quality of Life through:
- Pt education & reassuremetn
- Control pain & secondary infection
- Prevent lesion extension & new necrosis
What are 4 risk factors for ORN?
- Radiation dosage (above 60Gy)
- Large dose fraction & high frequency of fractions
- Trauma to area of irraduation
- Immunocompromised pt
What are some clinical features of ORN?
If sterile, necrotic bone may remain asymptomatic.
Infected:
- Pain (deep-seated/throbbing)
- Necrotic bone
- Suppuration
- Bony sequestra
- LT ⇒ Pathological # risk
