Post Op Complications Long Term

Question 1

How would you diagnose an OAC?

Answer 1

Pre op radiograph - see size of tooth, position of tooth and position of root vs sinus

Bone at trifurcation of roots

Bubbling of blood

Nose holding test - can cause OAF

Direct vision with good light

Blunt probe

Question 2

How manage a small OAF?

Answer 2

Inform patient

If small or sinus intact:
- encourage clot
- suture margins
- consider antibiotics

Give post op instructions

Question 3

How manage a large or lining torn OAF?

Answer 3

Close with buccal advancement flap - may have to score periosteum to have tension free closure of flap

Antibiotics, decongestants and nose blowing instructions

Question 4

How might one manage a chronic OAF?

Answer 4

Buccal advancement flap

Palatal rotational flap

Buccal fat pad flap

Collagen grafting

Question 5

What might one do if a root is retained within the antrum?

Answer 5

Radiographically locate - OPT, occlusal or periapical

and make a decision on the retrieval

If can’t access through socket, go through lateral surface on antrum and get foreign body

Question 6

What is osteomyelitis ?

Answer 6

Infection of the bone

Often systemically unwell

Usually in mandible due to less blood flow

Site of XLA very tender

Radiographically areas of radiolucency - sequestra, surrounded by areas of radiodensity - an involucrum

Question 7

How does osteomyelitis occur?

Answer 7

Invasion of bacteria causing inflammation and oedema in closed bone marrow spaces

Oedema raises pressure

Compromises blood vessels resulting in ischaemia and necrosis

Bacterial proliferation due to no defence from blood circulation

Osteomyelitis spreads until arrested

Question 8

Who is at risk of osteomyelitis?

Answer 8

Usually due to underlying issues

Odontogenic infections or mandibular fractures can rise risk but even then rare unless host defence compromised\

Diabetes

Alcoholism and IV drug use

Myeloproliferative disease e.g. leukaemia, chemotherapy treated cancers etc

Question 9

How treat osteomyelitis?

Answer 9

Antibiotic and surgical treatment

Penicillin 1st line drug, may require hospital admission and IV drugs

Surgical

Drain pus

Remove non vital teeth in area

Remove loose pieces of bone

Remove any wires or screws if mandible fractured

Corticotomy - remove bony cortex

Perforate bony cortex

Remove necrotic bone until reach actively bleeding bone tissue

Question 10

What is ORN? Where seen?

Answer 10

Osteoradionecrosis

Seen in patients who received radiotherapy in head and neck

Question 11

How does ORN develop?

Answer 11

Bone within radiation beam becomes virtually non vital

Endarteritis occurs - reduced blood supply

Bone turnover is now slow

Self repair ineffective

Becomes worse with time and dose

Question 12

How prevent ORN?

Answer 12

Scaling and chlorhexadine mouthwash leading to XLA

Careful extraction technique

Antibiotics, chlorhexadine and review

Possible hyperbaric oxygen to increase local tissue oxygenation

Question 13

How treat ORN?

Answer 13

Irrigate necrotic debris and remove loose sequestra

Hyperbaric oxygen

Small wounds typically heal over weeks/months

Large wounds may need bone resection and soft tissue closure

Question 14

Give some oral bisphosphonates

Answer 14

Alendronate

Etidronate

Ibandronate

Risedronate

Tiludronate

Question 15

Give some IV bisphosphonates

Answer 15

Clodronate

Pamidronate

Zolendronate

Question 16

What increases risk of MRONJ?

Answer 16

Bisphosphonates, antiangiogenic or antiresorptive drugs

Higher risk in IV patients

Question 17

Give example of anti resorption drug and antiangiogenic drug

Answer 17

Anti R = denusomab

Anti A = bevacizumab, sunitinib

Question 18

What does SDCEP say is a patient at high risk of mronj?

Answer 18

Patient treated with drugs associated for over 5 years

Patient treated with drugs associated for any period of time who are also being treated with systemic glucocorticoids

Patients on drugs for cancer

Patients with previous risk of MRONJ

Question 19

How might manage patient with MRONJ?

Answer 19

Manage symptoms

Remove sharp edges of bone

Chlorhexadine mouthwash

Antibiotics if pus

Question 20

What considerations would I take treating a patient with MRONJ

Answer 20

Prevent invasive treatment

Extractions in primary care

No benefit of referral based purely on drug exposure

Question 21

What is actinomycosis?

Answer 21

Rare bacterial infection caused by actinomyses bacteria that are flora normally found in the oral cavity / GIT

Bacteria has low virulence and is usually in area of injury or susceptibility such as recent extraction site or carious tooth

Abscess and pus formation in the head and neck region

Question 22

What might actinomycosis present as?

Answer 22

Multiple skin sinuses and swellings

With thick lumpy pus

Question 23

How might treat actinomycosis?

Answer 23

Incise and drain pus

Excise chronic sinus tracts

Excise foreign bodies or necrotic bone

High dose antibiotics for initial control (often IV)

Long term oral antibiotics to prevent recurrence

Penicillins

Question 24

Risks factors for Infective endocarditis?

Answer 24

Change in heart structure
- heart valve replacement or hypertrophic cardiomyopathy

Adults and children who have previously had IE

Question 25

What would you prescribe for IE?

Answer 25

Amoxicillin 3G oral powder sachet 60 min b4 procedure

Or

Clindamycin 300mg (x2 capsules) 60 mins b4 procedure