OSCE DOC - Oral surgery Flashcards

Question

Talk through the stages of a surgical extraction of a 48.

Answer 1

* Anaesthesia (LA used even if patient sedated)- no pain just pressure * Access- cutting gum to raise a flap (3 sided buccal mucoperiosteal) * Attempt elevation * Bone removal as necessary- saline cooled electric handpiece with tungsten carbide bur * Tooth division as necessary- similar to drilling for filling * Removal of tooth * Debridement to clean wound- suction, curettage (Mitchell’s trimmer/Victoria curette for soft tissue), irrigation (saline) * Suture- dissolving stitches * Achieve haemostasis * Post-operative instructions- dry socket more common

Answer 2

Coronectomy- considered when roots of 8 are closely linked to IAN, involves removal of crown of wisdom tooth and leaving roots in situ. Steps of a Coronectomy 1. LA 2. Flap design will be the same- 3 sided buccal mucoperiosteal 3. Transect tooth 3-4mm below level of enamel into dentine (aim to remove all enamel) 4. Elevate and lever crown without mobilising roots (if roots mobilise, they must be removed due to infection risk) 5. Leave pulp in place untreated 6. Irrigate 7. Replace flap (can be open/closed completely) 8. Suture 9. HA 10. POIG ➔ Roots may still become infected ➔ Dry socket still possible

Answer 3

1. 97-100% 2. 90% 3. 85%

Answer 4

If dropping Stimulate patient- ask to breathe If alarm Supplemental oxygen- nasal cannulation 2L/min Reverse with flumazenil (500 micrograms / 5ml) (200mcg then 100mcg increments every 60s)

Answer 5

* Severe/uncontrolled systemic disease * Narcolepsy * Hypothyroidism * Severe disability * Severe psychiatric issues * COPD * Myasthenia gravis * Intracranial pathology * Hepatic insufficiency * Pregnancy/lactation

Answer 6

IV sedation description: IV sedation is when a sedative is given into a vein. If you are nervous about having dental treatment or you are having a procedure which may be more complex, intravenous (IV) sedation is an effective and safe treatment. IV Sedation- Midazolam * Rapid onset of 2-3 mins * Half-life of 90-150 mins (appointments last 30-45mins) * Titrated via in dwelling canula in dorsum of hand/cubital fossa * Comes in 5mg/5ml preparation * 0.5-1mg bolus- then 1 mg ever 60 seconds until suitably sedated (max of 7.5mg)

Answer 7

Drugs increasing effect of Midazolam * Alcohol * Opiods * Erythromycin * Antidepressants * Antihistamines * Antipsychotics * Recreational drugs

Answer 8

Signs of IV Sedation End Point * Slurring and slowing of speech * Relaxation * Delayed response * Willingness to accept treatment * Verrill’s sign- ptosis * Eve’s sign- loss of motor coordination -> Patient should NOT lose verbal communication

Answer 9

Reversing IV sedation- use Flumazenil 500mcg in 5ml 1.Talk, shake, hurt (encourage them to breathe) 2. Place in head tilt, chin lift, jaw thrust position 3. Administer oxygen via nasal cannula (2L/min) 4. If this fails administer oxygen via Hudson mask (5L/min) 5. Administer Flumazenil 6. Use BVM and check airways

Answer 10

Inhalation sedation description: Inhalation sedation is a light form of sedation known as ‘happy air’. It is a mixture of nitrous oxide and oxygen breathed through a nosepiece. This helps the child to feel relaxed and accept treatment. Patient never breathes less than 30% oxygen which is more than room air. IS indications * Anxiety- mild to moderate * Needle phobia * Gagging * Traumatic procedures * Medical conditions aggravated by stress (asthma) * Unaccompanied adults requiring sedation IS contraindications * Common cold- blocked nose etc * Tonsillar/adenoidal enlargement * Severe COPD * First trimester of pregnancy (patients and dentists) * Fear of “mask” / Claustrophobia * Patients with limited ability to understand (over 7 usually) BLUE- NO BLACK- OXYGEN

Answer 11

ADV- IS * Rapid onset (2-3 mins) * Rapid peak action (3-5 mins) * Depth altered either way * Flexible duration * Rapid recovery * No injection (for the sedation but obviously LA still required depending on the procedure) * Few side effects to patient * Drug not metabolised * Some analgesia (though better for ischaemic than inflammatory pain) * No amnesia (remember lack of anxiety for next time) DIS- IS * Equipment expensive * Gases expensive * Space occupying equipment * Not potent * Requires ability to breath through nose * Chronic exposure risk? * Staff addiction * Difficult to accurately determine actual dose

Answer 12

Pre-op Instructions for IS * Have a light meal before appointment * Take routine medicines as usual * Children accompanied by a competent adult (if <16) * Adults accompanied at their first sedation appt. afterwards may then attend alone * Do not drink alcohol on day of appointment * Wear sensible clothing * Arrange care of children during and after your appointment * Plan to remain in clinic for up to 30 minutes after treatment IS steps 1. Set up the machine 2. Select nasal hood (record size in notes) 3. Connect the hoses 4. Set mixture dial to 100% O2 5. Settle patient in dental chair 6. Reinforce explanations of procedure 7. Set flow to 5-6l per minute 8. Position hood on the patient’s nose- encourage nasal breathing (patient should feel comfortable within 1 min) 9. Ask patient to signal when begin to feel different 10. Reduce O2 by 10% Wait 1 minute and repeat 11. After O2 reaches 80%, -> reduce by 5% per minute 12. Stop titration when patient ready for treatment 13. Over- increase oxygen in 5-10% increments until satisfactory 14. Under- decrease oxygen in 5% increments until satisfactory 15. Once finished gradually increase oxygen by 10-20% per min or turn to 100% and administer for 2-3 mins

Answer 13

* Patient details * Practice details * Patient complaint, HPC * Your concerns- why are you referring? Urgent / routine? Patient in pain / swelling? * MH, DH, SH * Provisional diagnosis * Summary of OH status * Details of request- for advice or to see patient * Enclosing details- radiographs, investigations

Answer 14

Diagnosis: * Alveolar osteitis is a very painful dental condition that is a common post-operative complication of extractions. Localised osteitis is the inflammation affecting the lamina dura. * This causes dry socket which occurs when the blood clots at the site of a tooth extraction fails to develop, or it dislodges or dissolves before the wound has fully healed. It usually isn’t associated with an infection. Predisposing factors: * Molars are more common – increased risk anterior to posterior * Mandible more common than maxilla * Smoking increases risk due to reduced blood supply * More common in females than in males * Oral contraceptive pill * Excessive trauma during extraction * Excessive mouth rinsing post extraction * Family history or previous dry sockets Initial management: * Reassurance * Recommend optimal analgesia – ibuprofen 400mg 4x daily (max 2.4g) or paracetamol 1g 4x daily (max 4g) * Advise patient to avoid smoking and maintain good OH * Advise patient to seek urgent dental care * Give LA to relieve severe pain Subsequent care: * Irrigate the socket with saline to flush out food and debris * Curettage/debridement- encourage bleeding and new clot formation * WHVP or Alvogyl * - WHVp is ribbon gauze socked in WHVp sutured into pocket which requires removal * - Alvogyl is a mix of LA and antiseptic (contains iodine) * - Both of which promote clotting and enhance the clotting framework while also protecting the bone * - Bipp * Use of analgesia and warm salty mouthwash or CHX use * Antibiotics are not required unless there is signs of spreading infection, systemic infection or for immunocompromised patients.

Answer 15

* Correct choice of instruments- Kilner Needle Holders and Gillies Toothed Tissue Forceps 2 marks * Mount the needle 1/3 from end 2 marks * Correct grasp of needle holder * Hold the needle holders in your dominant hand by placing the thumb and ring finger into the rings and the index finger on the hinge of the blade 2 marks * Correct hold for tissue forceps * Hold in pen grip 1 mark * Atraumatic handling of flap of tissue with tissue forceps 2 marks * Insert the needle at right angles to the wound edge and perpendicular to the surface 2 marks * Insert the needle at appropriate distance from the wound edge ~2-5mm 2 marks * Pass the needle through flap and retrieve it with an instrument **not fingers 2 marks * Demonstrate adequate pronation and supination of hand 2 marks * Remount needle correctly as above without use of fingers * Remount 1/3 length from thread end 2 marks * Take a full bit on second side and retrieve it with an instrument (not fingers) * Attempt to reinsert at the same depth in the opposite side of the wound and emerge out of the tissue at the same distance from the wound edge as the insertion * Suture exits wound similar distance from wound edge as insertion point 2 marks * Needle secure during tying of knot * Accept any combination of: * - double throw then single throw +/- third throw * - 3 single throws * Must demonstrate flat knot after initial throw and throws in opposing directions to ensure a secure knot * Needle placed to side and not flying around and / or thread gathered and needle held secured / or needle clipped 4 marks * 1st throw- two turns, grasp suture at free end, approximate edges 2 marks * 2nd throw- one turn in opposite direction, grasp suture at free end and tighten 2 marks * 3rd throw- in opposite direction again No extra marks * Cut suture to length suitable for wound site and material used 2 marks * Knot to side of the wound 2 marks * Final apposition of wound * Ensure wound ends close together but no tension on wound and secure knot 2 marks * Needle disposed of safely when finished- if not, clip it 2 marks Notes: Pick up the needle holder, not the curved clip Pick the toothed tweezers Don’t give up- if you don’t complete the suture, still dispose of the needle Put the needle in the sharps Practice- kits in outreach, videos online

Answer 16

1.Patient details correctly entered onto form Sticker (CHI number, hospital number, name, sex, address, DOB) 2. Hospital department, date, time, consultant, requested by, phone no. 3. Clinical details entered onto form Pain, etc. CO, HPC, MH, DH, SH, provisional diagnosis Other relevant information- e.g., present for 6 months with gradual increase in size, MH nil of note Provisional diagnosis- e.g., fibroepithelial polyp 4. Specimen details including site Type of sample- excisional biopsy Details of site- excised lump from left dorsum of tongue 5. Investigation Culture and sensitivity testing- bacterial / fungal PCR and viral load- virus Histopathology- tissue biopsies 6. Wearing appropriate PPE when handling specimen Examination gloves worn when handling specimen 7. Place sample in path pot without touching formalin 8. Sealing syringe for transport 9. Cap tightened 10. Label syringe with patient details and placed in plastic bag attached to request form 11. Fully labelled

Answer 17

Extraction Positions- Forceps Selection (6 mins) Remember to put on light and adjust chair position Remember stand behind patient for lower right and infornt for rest. Support jaw/bone in area with other hand. Make sure lip out of the way of forceps RIght tooth is selected just always double check Show twisting or figure of 8 motion before buccal expansion Apical pressure