Rare complications in OS Flashcards
When should Ludwig’s angina be suspected?
Hot potato voice
Difficulty breathing
Swelling
Cellulitis
Pus draining from socket
Where does Ludwig’s angina spread to?
Bilateral pharynx, airway, mediatinitis
Tx for Ludwig’s angina
OMFS urgent ref
IV abs - co-amoxiclav 1.2g 8 hourly
May have emergency incisions and drainage under GA
May require airway management and tracheostomy
What in an OAC?
When maxillary teeth have roots in the maxillary sinus (complex XLA, bulbous roots)
Sinusitis of cysts may increase the risk of an OAC.
What are the symptoms of an OAC?
Fluid draining into the nose when they drink
Air bubbles present at the extraction site
Pain
Unpleasant taste/smell
IOE for OAC
Look for bubbles
Valsalvar manœuvre
Altered nasal resonance
Whistling
Good light and access to visualise
Pus/fluid drainage
Investigations for OAC
PA or OPG to check for loss of continuity of sinus floor
>5mm - CBCT
OAC management in primary care
Non surgical antral regime:
If <5mm, leave and monitor
Avoid nose blowing
Use decongestants - ephedrine nasal drops
If infected - consider 0.9% saline irrigation and ABs - amoxicillin or doxycycline
Removable obturator to cover defect
Refer to OMFD
Surgical OAC intervention
Large and symptomatic defects - buccal advancement flap or buccal fat pad coverage
What are the 4 extensions of the buccal fat pad?
temporal, buccal, pterygoid and pterygopalatine
What happens to long term OACs?
Become epithelialised and are then called OA fistulas
Describe the placement of a buccal fat pad over an OAC
Buccal fat pad flap
Incision made via periosteum, gentle handling of fat pad
Buccal advancement flap placed over that with mattress suture
2x layered closure and may be more robust
Option for second surgery if first advancement flap breaks down or suffers wound dehiscence
What are the managements options for larger and symptomatic OACs?
Surgical - Palatal rotation flap
- Full thickness palatal harvest - greater palatine artery
- Subepithelial dissection of the rotation region of the flap
- Flap is rotated and placed through the fistula tract underneath the tunnel
- Flap is sutured to the remaining buccal mucosa and also, the rotated area of the flap sutured to limit undesired movement during healing.
- Collagen sponge can be used to cover the denuded donor site.
Maxillary tuberosity fracture management
Surgical - small fracture <4mm:
Dissect segment from gingivae/periosteum and close primary socket
Large segment including multiple teeth - consider splinting to adjacent teeth allowing 6-8w for bone healing and then returning for XLA in a more controlled manner, e.g. surgical sectioning.
OMFD referral
When do OACs and tuberosity fractures occur?
Removal of upper 8s - particularly if bulbous/multi rooted, hypercementosis, pneumatised sinus/ sinus infection
What are the signs of a tuberosity fracture?
Crunch or bones breaking
Loosening of tooth and bone together with segment still attached to soft tissue
Observable opening to max sinus -hollow sound when suctioning socket
What are the symptoms of tuberosity fracture?
Similar to OAC
Inferior dental nerve injury mechanical causes?
Compression
Foreign body/root/instrument in the canal
Traction or sectioned nerve
LA needle
Oedema/haematoma
Bruising, stretching/severing of nerve
Thermal causes of IDN injury?
Inadequate surgical drill irrigation
Chemical causes of IDN injury?
LA
Haemostatic agents
What is neurapraxis?
One part of nerve damage
What is Seddon’s classification of nerve injury?
Neuropraxia - no anatomical disruption. Localised, physiological and transient conduction block along nerve. Can revere within days/weeks
Axonotmesis: axon damage within the nerve. Full recovery us usual but may take weeks to months
Neurotmesis: divided nerve - full revery unlikely, nerve repair required.
What scan is used to check IDN proximity to roots?
CBCT
Which signs suggest nerve/root proximity
Interruption of IDC white lamina dura lines
Diversion of canal
Narrowing of canal
What is dysaesthesia?
Abnormal, unpleasant sensation
What is allodynia?
Pain to stimulus that normally doesn’t provide pain
What is anaesthetic dolorosa?
Pain in an area that is anaesthetised
What is paraesthesia?
Abnormal sensation that isn’t unpleasant - pins and needles
What is synesthesia?
Sensation felt in an area when another area is stimulated
What is ageusia?
Loss of taste perception
What is dysgeusia?
Altered taste perception
What instruments can be used to test this response?
Gauze - light touch
Probe - sharp
College forceps - 2 point discrimination
How to manage intra-operative nerve injury
Inform patient - legal duty of candour
If bleeding from canal, apply pressure with damp gauze, avoid haemostatic agents
Apply topical steroid to nerve for 1-2 mins (1ml of IV dexamethasone (4mg/ml) - weak evidence
If nerve transected, repair with loupes or refer to a specialist
What other steps can be taken to help with nerve injury?
Thorough irrigation of foreign body fragments which can cause infection, swelling, or can migrate into canal causing mechanical damage
Surgicel (ox regenerated cellulose) owing to its low pH when placed in contact with sensory nerve altered neural fn for a period of 2 weeks as can Whitehead’s varnish.
What post op instructions should be given to patients?
Conservative - 24 hour ice pack intensely and then periodically for following week, reduce perineural swelling
Pharmacological - high dose NSAIDS - ibuprofen 800mg TDS for 3w
Oral dex - 8mg OD for 3 days and then 4mg OD for 3 days
Consider vit B (weak evidence)
Review - 6 hour post op call
2w
How do corticosteroid aid nerve injury repair?
Shown to minimise neuropathy after nerve injuries if administered in high doses within 1w of injury
Corticosteroids inhibit axon sprouting centrally and ectopic discharges from injured axons and prevent neuroma formation
What drugs cause MRONJ?
Anti-resorptives - bisphosphonates, denosumab
Anti-angiogenics - sunitinib
Whom is likely to get ORN?
Irradiated bone failing to heal after 3m
Which other conditions can be confused with ORN/MRONJ?
Acute and chronic osteomyelitis
Chronic osteomyelitis with proliferative periostitis
Actinomycosis
NOMA - Cancrum Oris
What is the incidence of MRONJ?
1%
What is the recall time for suspected MRONJ?
8W
What is the MoA of bisphosphonates?
Inhibit enzymes essential to formation, function and recruitment of osteoclasts
Reduce bone resorption
What is denosumab?
Fully human monoclonal AB which inhibits osteoclast fn and associated bone resorption by binding to RANKL
How do anti-angiogenic drugs work?
Prevent vessel formation and vascularisation
What is osteomyelitis?
Infection and inflammation of the bone marrow in the maxilla or mandible
Who is considered a low risk patient re bisphophonates?
tx for osteoporosis or non-malignant diseases for bone, e.g. pagets - with oral quarterly or yearly infusions of IV bisphosphonates for less than 5y who are not currently being treated with systemic glucocorticoids
Who is considered to be high risk patient re bisphosphonates?
Tx for more than 5y with bisphosphonates and patients being treated with anti resorptive or anti-angiogenic drugs or both as part of management of cancer or anyone who has had a previous diagnosis of MRONJ.
Notani class of ORN
I - ORN confined to dentoalveolar bone
II - ORN limited to dentoalveolar bone or mandible above the IDC or both
III - ORN involving mandible below IDC, pathological fracture or skin fistula
Management of ORN
Prevention as for MRONJ - SPCEP guidelines
Targeted intensity modulated radiation therapy (IMRT) to spare structures and reduce dose
Hyperbaric o2 chamber = Marx protocol
(revascularise irradiated tissue and to improve the fibroblastic cellular density
Pentoxifylline (increases erythrocyte flexibility, dilates blood vessels, inhibits inflammatory reactions) - 400mg BD and Tocopherol (vit E scavenges ROS generated during oxidative stress by protecting cell membrane against peri-oxidation of liquids, partial inhibition of TGF and expression of procollagen gene to reduce fibrosis) 1000IU
Saline irrigation/loose sequestrate debridement
Surgical resection - severe cases
What are the causes of osteomyelitis?
Trauma
Difficult XLA
Immunocompromised individuals/diabetes
What is Garré’s osteomyelitis?
Osteomyelitis and periostitis
Require surgical resection to remove XS proliferative bone. Onion skin appearance on fils
Actinomycosis is caused by which pathogen?
Actinomyces bacterial species
Thick yellow exudate with sulphur granules
