Oral Surgery & Oral Pathology Flashcards

Question

Name 8 conditions that might affect the maxillary antrum?

Answer 1

1. Cleft palate 2. Acute/Chronic Sinusitis 3. Cyst 4. Tumour 5. Paget's Disease 6. Fibrous Dysplasia 7. Iatrogenic - Oral Antrum Communication/Fisulae or Antral fracture

Answer 2

1. Direct (most common) 2. Lymophatics 3. Blood Infection spread follows pathway of LEAST resistance (E.g. Periodontal abscess = Through periodontal pocket Periapical abscess = Through thinnest cortical plate)

Answer 3

1. Transexamic acid (anti-fibrinolytic) 2. Desmopressin (vasopressin analogue - stimulates release of CF8, vWF & tPA) 3. Fresh frozen plasma (with Clotting Factors) 4. Platelet transfusion 5. Antidotes: Vitamin K (Warfarin) or Andexanet alfa (Xa NOACs)

Answer 4

1. 7-10 days 2. Megakaryocytes (& activated by surface contact with damaged epithelium) 3. 150-400 x10⁹/L 4. 50 x10⁹/L (British Society for Standards in Haematology, 2013)

Answer 5

1. Maintain blood supply (BROADER at BASE) 2. Avoid vital structures 3. Suture over bone 4. Preserve papillae 5. Maintain ability to extend 6. Maintain ability to close site

Answer 6

1. Facial artery 2. Facial vein 3. Facial nerve 4. Hypoglossal Horizontal incision (parellel to lower border of mandible) made 2 fingers width below lower border of mandible

Answer 7

* 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

Answer 8

NICE - Guidance on Extraction of Wisdom Teeth 1. Unrestorable caries 2. Untreatable pulpal/periapical pathology 3. Pericoronitis (1 severe or multiple episodes) 4. Abscess / Cellulitis / Osteomyelitis 5. Cyst / Tumour (disease of tooth follicle) 6. Internal or External resorption (of TIQ or adj. tooth) 7. Tooth in line of jaw surgery 8. Fracture of tooth

Answer 9

1. Number of bacterium 2. Invasion mechanisms 3. Evasion of host defence (e.g. capsules and proteases) 4. Toxins and Enzymes (e.g. endotoxin, collagenase, hyaluronidase and fibrinolysin) 5. Time & Hose response (acute/chronic)

Answer 10

1. Treatment need - Cancer pt 2. Previous MRONJ 3. Bisphosphonate use over 5 years 4. 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

Answer 11

1. Prioritise oncology treatment (delay tx) 2. Maintain QoL (extirpate \> XLA) 3. Control pain + infection (analgesics and antimicrobials) 4. Prevent extension or formation of new osteonecrotic lesion

Answer 12

ABOVE → Buccal Space BELOW → Buccal Sulcus

Answer 13

IV = 3+ infusions or 1 year Oral = 4+ YEARS

Answer 14

1. Needle stick injury 2. Wrong tooth XLA 3. Damage to adjacent teeth or soft tissues 4. OAC or displacement of root(s) into sinus 5. Fractured tooth/apex (retained root) 6. Swallowing/Inhalation of tooth fragment 7. Fractured mandible 8. Fractured tuberosity 9. Fractured alveolar bone 10. Haemorrhage 11. Lip burn (from drill)

Answer 15

ABOVE Mentalis → Labial sulcus BELOW Mentalis → Submental (Causes swellings in these areas)

Answer 16

1. _Empty_ socket with visible _exposed bone_ 2. Erythematous and tender surrounding gingivae 3. Throbbing pain 4. Foul smelling odour PAIN: Pain starting 2-3 days post-extraction and getting progressively worse

Answer 17

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.

Answer 18

* 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

Answer 19

**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!*

Answer 20

1. Pain / Bruising / Swelling 2. Bleeding - Reactionary (loss of clot in first 48 hours) or Secondary (infection or bleeding disorder) 3. Infection (+ spread) 4. Dry socket 5. Osteomyelitis 6. Nerve damage 7. Haematoma 8. TMJ injury

Answer 21

"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

Answer 22

_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

Answer 23

# * 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

Answer 24

1. Traumatic extraction (e.g. surgical) 2. Mandibular extraction (less vascular) 3. Previous dry socket experience 4. Smoker 5. Female 6. Oral Contraceptive Pill 7. Poor OH 8. Periodontal disease 9. Excessive vasoconstricter (e.g. LA → reduced blood supply) 10. Bone disorders (e.g. Pagets)

Answer 25

1. Amoxicillin (3g) Oral Powder Sachet (1hr pre-op) 2. 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)

Answer 26

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

Answer 27

Envelope (1-sided) or Triangular (2-sided)

Answer 28

**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"

Answer 29

Mandible = Most common site (less vascular) ACUTE: "Male patient with multiple dental infections" 1. Throbbing pain (more rapid onset & severe in Acute OM) 2. Swelling (soft & becomes more hard due new bone formation) 3. Paraesthesia of lip/chin (compression of CN Viii) 4. Systemic signs: Lymphadenopathy, Pyrexia or Malaise 5. CHRONIC ⇒ Localised necrotic bone +/- suppuration or bony sequestra

Answer 30

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**

Answer 31

1. Reassure (right tooth taken out, non-serious and will resolve) 2. Irrigate with saline (or CHX) under LA * SDCEP (2013) Management of acute dental problems - "No evidence in favour of CHX use, not recommended"* 3. Place Alvogyl (*LA, Iodine & Eugenol)* or ZOE dressing 4. Pt Advice - Good OH, avoid smoking and adequate analgesia 5. Review appt (after few days and can be done over the phone)

Answer 32

1. RIVAROXABAN (OD) - Factor Xa (meausured by PT) & 5-13hr half life 2. APIXABAN (BD) - Factor Xa (measured by anti-Xa assay) & ~12hr half life 3. DABIGATRAN (BD) - Factor II (measured by aPTT) & ~13hr half life 4. EDOXABAN (OD) - Factor Xa All have short onset (2-4hr)

Answer 33

ADVANTAGES: 1. Complete cyst lining obtained for histology 2. Cavity closed - Reduced infection risk 3. Little aftercare needed DISADVANTAGES: 1. Cavity clot may become infected 2. Haemorrhage risk 3. Large cyst removal → Weakened jaw 4. Potential damage to adjacent structures or apicies of vital teeth 5. Primary closure prevents visual inspection of cyst cavity 6. Incomplete removal → Recurrence

Answer 34

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)

Answer 35

1. Full Blood Count - platelets? anaemia? 2. Prothrombin time (PT) - extrinsic pathway 3. Activated partial prothrombin time (aPPT) - intrinsic pathway 4. Specific clotting factor assays 5. Liver & kidney function tests 6. INR (for patients on Warfarin)

Answer 36

1. Distal caries in 7's (mesially impacted 8's) 2. GA - If pt undergoing GA and 8's likely to later become symptomatic 3. Non-functional 8's → Over-eruption and trauma

Answer 37

1. Caries 2. Non-vital tooth 3. Trauma 4. Deep periodontal pockets (via lateral canals) 5. Blood stream ("Anchoresis") 6. Extension of periapical infection from adjacent teeth

Answer 38

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)

Answer 39

Mandibular 3rd molar that perforates ID nerve Ideally leave (asymptomatic) but coronectomy if must be removed

Answer 40

1. Prevertebral fascia 2. Investing layer of deep cervical fascia 3. Mediastinum → Pericarditis 4. Pretracheal fascia 5. Carotid sheath

Answer 41

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*

Answer 42

_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)

Answer 43

1. Healing is slower or non-existent 2. NO periosteal reaction (no new bone growth) → Higher pathological fracture risk (& less R/O seen radiographically)

Answer 44

AVOID: Metronidazole, Erythromycin & Clarithromycin Best = Clindamycin (Can consider Amoxicillin, but monitor INR 24hr after starting antibiotic - SDCEP)

Answer 45

**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

Answer 46

**"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

Answer 47

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)

Answer 48

(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

Answer 49

1. **Enucleation** 2. **Marsupialisation** 3. Excision (Ellipse-shaped incision and excisional biopsy) 4. Curettage (raising flap and Mitchell trimmer curettage)

Answer 50

1. Anti-coagulant: Vitamin K antagnoist - Inhibits Vit K-dependent clotting factors **(2,7,9&10)** 2. Treatment or Prophylaxis for: Stroke, Atrial Fibrillation, DVT, Pulmonary Embolism, Coronary Heart Disease or Prosthetic Valve/Stent placement 3. Rashes, alopecia, bruising, liver disorders/jaundice or GI upset 4. INR (International Normalised Ratio) Normal range: 2.5-3.5 (+/-0.5) 5. Vitamin K (IV)

Answer 51

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

Answer 52

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

Answer 53

* 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

Answer 54

Untreated → Abscess enlargement and spontaneous pus drainage (through pathway of least resistance) 1. Through sinus tract, into oral cavity or facial skin 2. Through root canal or PDL 3. Through cancellous bone and cortex perforation Spontaneous drainage incomplete and does not address cause → Chronic/Reoccuring Abscess

Answer 55

1. Partial destruction 2. COMPLETE destruction

Answer 56

* 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

Answer 57

* 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

Answer 58

**Enucleation =** Complete removal of lesion with in-tact lining (e.g. smaller cysts) **Marsupialisation =** 2 stage process 1. Marsupialisation - Incision (create largest possible window) and suture cyst lining to mucosal wall 2. Cyst decompression - Return once regressed in size and remove (e.g. larger cyst or close to vital structures )

Answer 59

1. Anti-coagulants Warfarin, Heparin, NOACs (Rivaroxaban, Apixaban, Dabigatran & Edoxaban) 2. Anti-platelets NSAIDs (Aspirin), Clopidogrel & Dipyridamole

Answer 60

1. Anti-coagulant (anti-thrombin) 2. Sub-cutaneous injection 3. Pregnancy (needing anti-coagulation), Thrombosis in cancer pt or Kidney Dialysis 4. Liase with medical professional & delay treatment if taken for limited time

Answer 61

NONE - Clinical history and observation enough for diagnosis No radiographs needed - if pt presents again in pain take radiograph (LCPA) to investigate alternative diagnoses.

Answer 62

1. Trauma 2. TMJD 3. Large bony lesions (e.g. cysts) where soft tissue doesnt need to be visualised (would use US/MRI) 4. 3rd molar surgery - Where conventional OPG radiograph not sufficient to show relationship to ID nerve Not routinely used as x10 more radiation vs. OPG

Answer 63

1. May be taking higher NOAC dose in first 1-3weeks of treatment, if possible delay until standard dose started 2. 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 3. ABOVE & considered increased risk of Infective Endocarditis - Assess need for antibiotic prophylaxis with cardiologist

Answer 64

_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)

Answer 65

_LOCAL_ 1. Pain (often poorly localised but TIQ may be painful and _mobile_ if follows pericapical periodontitis) 2. Swelling 3. Redness 4. Heat 5. Trismus (loss of function) 6. 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)

Answer 66

1. Vitamin K 2. Andexanet alfa (very recent!)

Answer 67

Poly-microbial - Work syngeristiclly (together) Endogenous Bacteria present: * Obligate/Strict Anaerobes (most common) - *Fusobacterium, Prevotella, Porphymonas (esp. P. gingivalis)* * Facultative Anaerobes - *Streptococci*

Answer 68

1. Flattening + numbness of cheekbone 2. "Step deformity" on A-P palpation behind pt 3. Eyes - Diplopia, Restricted eye movement + Subconjunctival haemorrhage 4. Limited mandible opening (temporalis often affected)

Answer 69

1. Laser 2. Diathermy (current) 3. Cryotherapy (cold liquid nitrogen at -196ºC)

Answer 70

1. Radiographs (incl. CT and US) 2. Temperature 3. FBC - CRP 4. Pulse and BP 5. Blood glucose (poorly controlled diabetic = increased infection risk)

Answer 71

1. Submental 2. Sublingual 3. Submandibular 4. Submasseteric 5. Buccal 6. Lateral Pharngeal 7. Peritonsillar 8. Pterygomandibular

Answer 72

1. BEFORE = Consider anatomical sites to avoid (e.g. Greater Palatine Artery in Palate and Facial artery/vein/nerve + Hypoglossal nerve in Submandibular space) 2. Breakdown/disturb locules in cavity with finger or sinus forceps 3. Keep drainage site open to allow further drainage

Answer 73

1. Previous IE 2. Prosthetic valve replacement 3. Congenital Heart Disease - Cyanotic or involving prosthetic replacements Contact patient's cardiologist regarding heightened IE risk to assess need for ABx prophylaxis

Answer 74

1. Symptoms: Analgesia, 0.2% CHX Mouthwash and Debridement under Operculum (with LA) 2. Adjacent tooth: Extract or Smooth cusps if causing trauma 3. TIQ: Extract

Answer 75

1. Canine 2. Buccal 3. Palatal 4. Lateral Pharyngeal (N.B. Buccal + Lateral Pharyngeal also in Mandibular spread)

Answer 76

* 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

Answer 77

* 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

Answer 78

* 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

Answer 79

1. **Enophthalmos** (sinking of eye into sockey 2. Diplopia 3. Restricted eye movement 4. Subconjunctival haemorrhage ("Hanging drop" sign seen radiographically)

Answer 80

1. **PRIMARY HAEMOSTASIS** During & immediately post-op Due to ST/vessel trauma, inflammation or infection Often controlled with local haemostatic measures 2. **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 3. **SECONDARY HAEMOSTASIS** 7-10 DAYS post-op Mainly due to INFECTION Local haemostatic measures & ABx to manage infection

Answer 81

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

Answer 82

1. Osteoporosis 2. Paget's Disease 3. Cancers - Multiple myeloma or Metastatic Bone Cancer

Answer 83

1. Mentalis 2. Mylohyoid 3. Mylohyoid (lingual) AND Buccinator (buccal) 4. Strap muscles 5. Buccinator (and Antrum/Maxillary sinus)

Answer 84

**_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.*

Answer 85

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)*

Answer 86

1. OLD = Antibiotics, Hyperbaric Oxygen Therapy and Surgery 2. 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

Answer 87

1. NO - This is primarily inflammation! 2. Yes (Empirical ABs them targetted ABs based on pus sample and 2 week course, OPAT) 3. Yes, if infection present (But new tx = Pentoxifylline & Tocopherol) 4. No evidence for use

Answer 88

1. Pressure with (saline-soaked) gauze 2. LA (adrenaline vasoconstrictor) 3. Pack socket with oxidised cellulose (surgicel) 4. Suturing 5. Transexamic acid mouthwash (5% QDS) *- N.B. Not recommended by SDCEP* 6. Bone wax 7. Diathermy (of vessel) 8. Suck down splint (more often for fractures)

Answer 89

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

Answer 90

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

Answer 91

**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)

Answer 92

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"

Answer 93

* 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"

Answer 94

Frontal, Ethmoid, Sphenoid & Maxillary Maxillary = largest (3x3x2.5cm) Pryamid-shaped (base on lateral nasal wall & apex in zygomatic process)

Answer 95

_Arteries:_ * Greater Palatine * Facial * Maxillary _Nerves:_ * Superior Alveolar * Anterior Palatine * Infra-orbital

Answer 96

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

Answer 97

1. Close proximity/relationship between tooth & antrum 2. Excessive apical force used in XLA 3. Surgery performed in close proximity to sinus (e.g. cyst removal) 4. Submerged teeth 5. Larger antrum 6. PA Bone loss (destruction of peri-apical bone) 7. Hypercementosis

Answer 98

_Signs:_ 1. Direct expection under good lighting - Hole evident 2. Bone/antral lining on extracted tooth roots 3. Blood 'bubbling' at socket 4. Hollow sound on suction of socket 5. Whistling noise from socket 6. Radiographs showing antral floor defect (not always visible & not needed for acute diagnoses) _Symptoms:_ 1. Air entry into mouth on holding nose 2. Regurgitation of fluids/foods into nose 3. Symptoms of sinusitis if untreated (dull pain worse on bending forwards +/- purulent discharge S*tudies have suggested in untreated larger OACs, 50% develop sinusitis within 2 days & 90% within 2 weeks*

Answer 99

[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)

Answer 100

_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**

Answer 101

**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)

Answer 102

_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

Answer 103

1. Lone standing maxillary molars 2. Excessive force 3. Hypercementosis 4. Bulbous or splayed roots 5. Large antrum Visualy & Tactile diagnosis: * Would feel/see movement of the tooth AND bone together * +/- Palatal tear * +/- Fracture sound

Answer 104

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

Answer 105

* 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

Answer 106

1. Size of lesion 2. Previous surgery 3. Pre-existing sinus pathology 4. Experience of operator 5. Surgical techniquer used 6. OH 7. Smoking 8. Medical status

Answer 107

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)

Answer 108

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

Answer 109

1. Cytotoxics (e.g. Penicillamine, Hydrochloroquine, Azthioprine, Methotrexate) - Reduce platelet numbers and/or impair liver function (production of clotting factors) 2. NSAIDs - Impair platelt function 3. Carbamazepine - Can affect liver & bone marrow platelet production (most at risk when first started medication or following dose adjustment) 4. SSRIs (e.g. Citalopram, Fluoexetine, Sertraline) - Potential to impair platelet aggregation & may increase bleeding time when used with anti-platelets

Answer 110

* Dull, throbbing pain in midface - may be worse on leaning forwards (more severe in acute) * Mucopurulent nasal discharge * Lack of transillumination * Radiographic opacity

Answer 111

_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:*** **_A_**nalgesia **_R_**eassure (if secondary to viral infection often self-limiting) **_A_**nti-biotics *(only if persistant or severe symptoms)* **_B_**ed-rest/fluids **_S_**team inhalation (& Nasal decongestants - 0.5% Ephedrine max 7 day use) If unresponsive/severe, may require surgical management: Antral wash-outs or Intra-nasal Antrostomy

Answer 112

1. Severe systemic symptoms 2. 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

Answer 113

_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

Answer 114

1. Poor drainage 2. Deviated septum 3. Virulent infection 4. Immunocompromised/Dehabilitated patient

Answer 115

As theyre surrounded by less dense air

Answer 116

1. **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*** 2. **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)

Answer 117

ASA 1 = Normal, healthy patient ASA 2 = Mild systemic disease ^{(includes smoker, drinker & obesity!)} 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

Answer 118

_Clinical Presentation_ * Blue-ish, translucent swelling * Fluctuant * Sessile (fixed) * Painless * May burst to release "salty" mucous _Types:_ 1. Mucous Extravasation Cyst - Related to trauma so often on lower lip - No epithelial lining (seen histologically alongside inflammatory cells) 2. 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) 3. Ranula - (Often MEC) affecting SM/SL gland in FoM (uniform ~2-3mm) - "Plunging Ranula" if extends through Mylohyoid

Answer 119

1. No tx & monitor (may spontaneously resolve) 2. Surgical excision or marsupialisation 3. Cryotherapy (if reoccurance)

Answer 120

_Inflammatory:_ 1. Radicular Cyst *(most common, 65%)* 2. Residual Cyst 3. Paradental Cyst _Developmentary:_ 1. Dentigerous Cyst (Follicular/Eruption) - *25%* 2. Odontogenic Keratocyst - *5%* 3. Lateral Periodontal Cyst 4. Gingival Cyst of the Adults 5. Glandular Odontogenic Cyst

Answer 121

**_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:_** 1. Sensibility tests (Radicular cysts associated with non-vital teeth) 2. Radiographs (often: well-defined, well-corticated radiolucencies) 3. 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)

Answer 122

_Epithelial:_ 1. Naso-Palatine 2. Naso-Labial 3. Median Palatine 4. Mucous Retention Cyst _Non-Epithelial:_ 1. Solitary Bone Cyst 2. Aneurysmal Bone Cyst 3. Mucous Extravasation Cyst *(N.B. Bone Cysts most often associated with children/adolescents)*

Answer 123

_Mucocele Clinical Features:_ Swelling (salivary gland cyst): * Blue-ish * Translucent * Fluctuant * Sessile * Painless * May burst to release "salty" mucous 1. **Mucous Extravasation Cyst** Associated with trauma (often on lower lip), NOT epithlieal lined Histology: No epithelium, mucous & inflammatory cell infiltrate 2. **Mucous Retention Cyst** Associated with saliva retention (often older pt \>50y & not commonly found on lower lip) Histology: Epithelial lined, mucous & NO inflammatory infiltrate 3. **Ranula / "Plunging Ranula"** Often **MEC** of SL/SM gland on FoM (unilateral, 2-3cm) **"PR****"** if extends through mylohyoid _Treatment Options:_ 1. No treatment/ Monitor (can spontaneously resolve) 2. Surgical: Excision or Marsupialisation 3. Cryotherapy (e.g. if recurrence)

Answer 124

Radiolucency or/and Radiopacity: 1. Site (& any association with unerupted teeth - e.g. Dentigerous/OKC) 2. Size 3. Shape (cysts often oval or round) 4. Margin (cysts often well-defined & well-corticated) 5. Locularity -Uni/Multi 6. Effect on adjacent structures (e.g. root resorption or displacement)

Answer 125

_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 *

Answer 126

_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

Answer 127

_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 Cell**s (in cyst wall) * **Prominant Basal Cells** (dark stain & reverse nuclear polarity)

Answer 128

``` Cancer pt (Anti-Angiogenics or Anti-Resorptives) = ~1% **(2.9% after XLA)** ``` ``` Osteoporosis Pt (Anti-Resorptive) = 0.01-0.1% **(1.5% after XLA)** ```

Answer 129

* Prioritise oncology * Preserve Quality of Life through: - Pt education & reassuremetn - Control pain & secondary infection - Prevent lesion extension & new necrosis

Answer 130

1. Radiation dosage (above 60Gy) 2. Large dose fraction & high frequency of fractions 3. Trauma to area of irraduation 4. Immunocompromised pt

Answer 131

If sterile, necrotic bone may remain asymptomatic. _Infected:_ * Pain (deep-seated/throbbing) * Necrotic bone * Suppuration * Bony sequestra * LT ⇒ Pathological # risk

Oral Surgery & Oral Pathology Flashcards

(155 cards)