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4 - misc > surgery that’s not that big > Flashcards

surgery that’s not that big Flashcards

1
Q

What is infective endocarditis?

A

Inflammation of the endocardium (lining of the heart) caused by introduction of bacteria into the bloodstream
Can occur post dental procedures after a bacteraemia

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2
Q

Give 4 examples of invasive dental procedures

A

Placement of matrix band
Extractions
Incision and drainage of abscess
Full periodontal examinations including 6PPC

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3
Q

Give 4 examples of non-invasive dental procedures

A

Infiltration or block LA
BPE screening
Supragingival PMPR
Radiographs

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4
Q

What are the symptoms of IE?

A

Fever 38ºor above
Sweats or chills esp at night
Breathlessness
Weight loss
Fatigue
Muscle, joint or back pain

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5
Q

What patients are at increased risk of IE?

A

Patients with prosthetic valves
Previous IE
Acquired valvular heart disease
Hypertrophic cardiomyopathy
Congenital heart disease

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6
Q

What is the prophylactic dose for IE?

A
  1. Amoxicillin - 3g 60 minutes before
  2. Clindamycin - 2x300mg 60 before
  3. Azithromycin - 500mg 60 minutes before
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7
Q

What is the SDCEP recommendation of tx after stroke or CVA?

A

Non-emergency - postpone tx 6 months
Emergency tx - be cautious first 4-6 weeks (secondary setting only) - after 6 weeks regular dental procedures can be resumed
Follow cardiologist advice

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8
Q

What are the risks of liver disease?

A

Decreased production of clotting factors leading to inc bleeding
Splenomegaly can reduce platelet numbers
Immune system may be compromised
Increased risk of cross infection - Hep B, C, D, E
Drugs may not be metabolised effectively

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9
Q

What are the risks of kidney disease?

A

Platelet dysfunction can cause bleeding
Pt may have a weakened immune system

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10
Q

What are the recommendations for treating a pt with kidney disease?

A

Liaise with primary care physician
FBC if necessary
For dialysis pt - treat the day after
BNF for appropriate drug prescription

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11
Q

What are the risks and recommendations of treating a pt with epilepsy?

A

Risks - surgery can be stressful and might trigger a seizure
Recommendations:
- make sure pt has eaten before to maximise medication levels
- discuss frequency and type of seizures the pt experiences
- consider referral for IV sedation

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12
Q

What are the risks and recommendations for treating a pt with diabetes?

A

Risks - hypoglycaemic emergency and delayed wound healing
Recommendations:
- schedule app in the morning - blood glucose levels more predictable
- ensure pt has eaten before
- blood glucose between 5-15mmol/L
- have glucose supplements ready in case of low blood sugar

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13
Q

What are the steps of primary haemostasis?

A

Vascular constriction
Platelet adhesion
Platelet activation
Platelet aggregation
Formation of a primary platelet plug

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14
Q

What happens in the intrinsic pathway?

A

Triggered when blood contacts a negatively charged surface
Factor XII activates to XIIa
Factor XIIa activates Factor XI to XIa
Factor XIa activates Factor IX to IXa
Factor IXa with Factor VIIIa activates Factor X

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15
Q

What happens in the extrinsic pathway?

A

Starts when tissue factor is exposed to blood during tissue injury
Tissue factor binds with Factor VII activating it to VIIa
TF-VIIa complex activates Factor X

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16
Q

What happens in the common pathway?

A

Intrinsic and extrinsic pathways converge
Factor Xa with Factor Va converts prothrombin to thrombin
Thrombin converts fibrinogen to fibrin
Fibrin strands form the basic structure of a clot
Factor XII stabilises the fibrin clot

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17
Q

How do antiplatelets effect haemostasis?

A

Interfere with platelet aggregation by inhibiting steps in platelet aggregation required for primary haemostasis

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18
Q

How do anticoagulants effect haemostasis?

A

Inhibit the production or activity of factors required for the coagulation cascade and so impair secondary haemostasis

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19
Q

Name 3 coagulation disorders and what clotting factor they lack

A

Haemophilia A - lacks clotting factor VIII
Haemophilia B - lacks clotting factor IX
Von Williebrand’s disease - deficiency of the Von Willibrand factor

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20
Q

Name 5 drug groups with an increased risk of bleeding?

A

Anticoagulants or antiplatelets
Cytotoxics
Biologics
NSAIDs
Drugs affecting the nervous system (SSRIs, SNRIs, carbamazepine)

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21
Q

What is the mechanism of action of warfarin?

A

Vitamin K dependent antagonist
Prevents liver from utilising vitamin K to make clotting factors II, VII, IX and X
Inhibits vitamin K dependent modification of prothrombin

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22
Q

Why is warfarin taken?

A

Prophylaxis against stroke in pts with atrial fibrillation
Prevention of DVT, pulmonary embolism
Congenital heart disease
Prosthetic valves

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23
Q

How should pts on warfarin be managed?

A

Check INR - within 24 hours but can be within 72 if stable
If INR is <4 - treat without interruption

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24
Q

What is the INR?

A

International Normalised Ratio
Tests prothrombin time - how quickly blood clots
Eg - 3 means blood takes 3 times longer to clot than the average person

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25
Q

What are NOACs and give 4 examples

A

Non-vitamin K antagonists that prevent blood from clotting
Apixaban - factor Xa inhibitor
Edoxaban - factor Xa inhibitor
Rivaroxaban - factor Xa inhibitor
Dabigatran - direct thrombin inhibitor

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26
Q

Why are NOACs taken?

A

Prophylaxis against stroke in pts with atrial fibrillation
Prevention of DVT and pulmonary embolism

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27
Q

How should pts on NOACs be managed?

A

For high risk of bleeding procedures:
Rivaroxaban and Edoxaban (OD) - take 4 hours post-op
Apixaban and Dabigatran (BD) - pt should miss morning dose, take in evening as usual

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28
Q

Give 5 examples of high bleeding risk procedures?

A

Complex or adjacent XLA with large wound or more than 3 XLAs
Surgical - flap raising, surgical XLA
Periodontal and preprosthetic surgery
Crown lengthening surgery or dental implant surgery
Gingival and mucosal biopsy

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29
Q

What are the types of bleeding?

A

Primary - during the procedure
Reactionary - clot fails within 48 hours
Secondary - infection, occurs 7-10 days later

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30
Q

Give 5 examples of local haemostatic aids?

A

Apply pressure with gauze
LA with vasoconstrictor
Suturing
Diathermy
Surgicel - oxidised regenerated cellulose
Bone wax

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31
Q

Give 5 examples of systemic haemostatic aids

A

Vitamin K
Tranexamic acid
Missing blood clotting factors
Plasma or whole blood
Desmopressin

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32
Q

Give 5 risks of chemotherapy and radiotherapy

A

Neutropenia - decreased neutrophil count - susceptible to infection
Thrombocytopenia - decreased platelet count - increased bleeding risk
MRONJ
ORN
Infection due to immunosuppression

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33
Q

What is ORN?

A

Osteoradionecrosis
Exposed, non-healing bone persisting over 3-6 months
Pt has a history of head and neck radiotherapy

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34
Q

Describe the clinical presentation of ORN

A

Early - asymptomatic
Advanced:
- pain
- halitosis
- paraesthesia
- formation of oral fistulae

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35
Q

What are the risk factors for ORN?

A

Tumour location - proximity of neoplasm to bone
Affected bone areas - mandible is higher risk than maxilla, posterior higher risk than anterior
Immunosuppression
Poor OH
Ill-fitting dentures

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36
Q

How is ORN managed?

A

Referral to OS
Surgical debridement
Bone sequestrectomy (removal of dead bone)
Hyperbaric oxygen therapy
Medications - ABs, vitamin E, pentoxifylline

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37
Q

What is MRONJ?

A

Medication related osteonecrosis of the jaw
Side effect of anti resorptive and antiangiogenic drugs
Progressive bone destruction in the maxilla or mandible - can be very difficult to treat
Exposed bone for >8 weeks in pts with history of anti resorptive or antiangiogenic drugs and where there is no history of radiation therapy

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38
Q

What are the symptoms of MRONJ?

A

Delayed healing following dental XLA or other oral surgery
Soft tissue infection and swelling
Numbness
Paraesthesia
Exposed bone
May be asymptomatic

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39
Q

Which drugs can cause MRONJ?

A

Anti-resorptive:
Bisphosphonates eg - alendronic acid
RANKL inhibitors eg - denosumab
Anti-angiogenic:
Eg - bevacizumab, sunitnib

40
Q

What are the risk factors of MRONJ?

A

The underlying health condition for which the pt is being treated
Mandible > maxila
Anterior > posterior region
Third molars
Poor OH, untreated perio
Traumatic XLA
Ill-fitting dentures
Smoking

41
Q

What makes a pt high risk for MRONJ and what is the risk?

A

1-10%
IV bisphosphonates for >5 years
Treated with systemic glucocorticoids
Anti-resorptive or anti-angiotensin drugs as part of cancer tx
Previous MRONJ

42
Q

What makes a pt low risk for MRONJ and what is the risk?

A

0.001-0.01%
Oral bisphosphonates for <5 years
IV bisphosphonates <5 years
Denosumab tx not with systemic glucocorticoids

43
Q

What should be done pre-procedure for MRONJ pts?

A

Stabilisation - OHI, flouride, diet advice
Smoking cessation
Explain all risks and get valid informed consent
Invasive tx before anti-resorptive, anti-angiogenic therapy
Liaise with GP

44
Q

How should high risk MRONJ pts be managed?

A

Explore alts to XLA - decoronate
Discuss all benefits/risks, get valid consent
Atraumatic technique
Remove sharp residual bone
Advise pt to contact you if any concerns or side effects
Review after 8 weeks - if MRONJ suspected refer to oral surgery

45
Q

What are the indications for extracting third molars?

A

Unrestorable pathology - caries, perio compromising M3M or second molar, pulpal/periapical pathology, tooth fracture, resorption of M3M or adjacent teeth
Cyst or tumour
Cellulitis, abscess, osteomyelitis
M3M in surgical field, impeding surgery
2x mild or 1x severe bout of periocoronitis

46
Q

What are the radiological signs of M3M proximity to the IAN?

A

Darkening of root
Deflection of root
Narrowing of root
Dark and bifid apex of root
Interruption of white line of canal
Diversion of canal
Narrowing of canal
Juxta-apical area

47
Q

Name 8 signs and symptoms of pericoronitis

A

Pain
Swelling
Bad taste
Pus discharge
Occlusal trauma to operculum
Evidence of check biting
Dysphagia
Pyrexia
Malaise
Regional lymphadenopathy

48
Q

What are the different depths of M3M impaction?

A

Superficial - crown of 8 related to crown of 7
Moderate - crown of 8 related to crown and root of 7
Deep - crown of 8 related to root of 7

49
Q

What are the different angulations of impacted M3Ms?

A

Vertical - 30-38%
Mesioangular - 40%
Horizontal - 6-15%
Distoangular - 3-15%
Transverse
Aberrant

50
Q

What factors increase difficulty of M3M XLA?

A

Disto-angular position
Long, thin roots
Divergent roots
Narrow PDL space
Close relation to IAN
Close relation to mandibular second molar
Dense bone

51
Q

What is pericoronitis?

A

Inflammation of the operculum overlying the M3M

52
Q

How should mild pericoronitis be managed?

A

Analgesia for pain relief
Irrigate with saline
Debridement area under LA
Monitor for worsening of symptoms
Antibiotics only if signs of spreading infection - metronidazole 400mg TTD for 5 days

53
Q

How is severe pericoronitis treated?

A

Consider coronectomy or XLA
Consider elective XLA of opposing 8
Operculectomy - uncommon
Antibiotics if signs of spreading infection - metronidazole 400mg TTD for 5 days

54
Q

What are the indications of a coronectomy?

A

Close association with IAN
Presence of hypercementosis in M3M

55
Q

What are the contraindications of a coronectomy?

A

Non-vital
Carious with high risk of pulpal involvement or apical infection
Mobile
Immunocompromised - higher risk of infection from retained tooth tissue

56
Q

How is a coronectomy carried out?

A

Administer LA
Raise a full thickness muco-periosteal flap
Buccal bone removal
Section the crown at the CEJ
Reduce root to 3mm below the crestal bone
Suture

57
Q

What are the risks of coronectomy?

A

Infection of retained tooth tissue
Nerve injury - temporary or permanent
Root migration
Development of periapical pathology
Mobilisation of roots during the procedure

58
Q

What is the mechanism of action of LA?

A

Reversible bind to intracellular receptors blocking Na+ channels - no influx of Na+ into cells
LA must be lipid soluble and charged to interact with Na+ receptors
pH can reduce its effectiveness

59
Q

What are the local complications of LA?

A

Failure to achieve anaesthesia
Prolonged anaesthesia
Pain
Trismus
Haematoma
Temporary facial palsy
Infection
Soft tissue damage
Needle stick injury

60
Q

What are the systemic complications of LA?

A

Allergy - usually to prevervatives
Loss of consciousness
Respiratory depression
Circulatory collapse

61
Q

What are the signs of LA toxicity?

A

Circumoral numbness
Dizziness/lightheadedness
Metallic taste
Drowsiness
Sudden alteration in mental state
Visual and auditory disturbances
Severe agitation
Loss of consciousness
Cardiovascular collapse

62
Q

What is the correct order for extractions?

A

Lowers before uppers
Posteriors before anteriors

63
Q

What is the max safe dose of lidocaine, prilocaine and articaine?

A

Lidocaine - 4.4mg/kg
Prilocaine - 6mg/kg
Articaine - 7mg/kg

64
Q

What are the steps of a surgical extraction?

A

Anaesthesia
Incision/access
Bone removal as necessary
Tooth division as necessary
Debridement
Suture
Haemostasis
Post-op instructions

65
Q

Name 8 principles of flap design?

A

Wide based incision for circulation
Use scalpel in one firm continuous stroke
No sharp angles
Big flaps heal just as quickly as small ones
Minimise trauma to papillae
Keep tissue moist
Flap reflection down to bone
Aim for healing by primary intention
Make sure wounds are not closed under tension

66
Q

What is the purpose of suturing?

A

Reposition tissues
Compress blood vessels
Cover bone
Prevent wound breakdown
Achieve haemostasis

67
Q

Give 4 characteristics of the ideal suture material?

A

Allow secure knots
Adequate tensile strength
Not cut through tissues
Sterile
Non-allergenic
Good handling characteristics

68
Q

When can a fragment of fractured tooth be left in situ?

A

No greater than a third of the root
It has not been displaced
It is not infected
It doesn’t pose a long term risk to the pt

69
Q

Name 5 peri-operative complications of XLA

A

Failing to complete XLA
Fractured tooth during
Damage to adjacent teeth
Loss of tooth or roots - airway or maxillary sinus
Fracture of alveolus or mandible

70
Q

How are roots lodged in the maxillary sinus managed?

A

Radiograph to identify risks pre-XLA
Avoid excessive force on roots to minimise risk of pushing into sinus
Retrieve visible fragments from sinus with suction or refer to specialist
Small fragments can be left in situ
Larger fragments will need referral to be retrieved using a trans alveolar approach or Caldwell-Luc approach

71
Q

How should lingual or buccal wall fractures be managed?

A

If fractured portion of bone still attached to rest of alveolar bone, then gently reposition and secure
If loose bone - remove to prevent issued with healing

72
Q

What are the signs of a fractured tuberosity and how should it be managed?

A

Tearing of palatal mucosa and/or joint movement of multiple teeth together
Stop procedure and splint the fragment for 4 weeks
Plan for tooth removal with surgical approach 4 weeks later
OAC regime carried out
Refer if outwith your scope

73
Q

List 8 post-op complications

A

Haemorrhage
Pain
Swelling
Dry socket
Infection
Trismus
ORN
MRONJ

74
Q

What is dry socket?

A

Alveolar osteitis
Results from the premature loss of a blood clot within an extraction socket, leading to exposed bone that becomes colonised by anaerobic bacteria and spirochaetes

75
Q

What are the general risk factors for dry socket?

A

Smoking
Alcohol consumption
Immune-compromised state
Use of oral contraceptives
Previous dry socket history
Poor compliance with post-operative instructions

76
Q

What are the extraction specific risk factors for dry socket?

A

Surgical or traumatic extraction
Mandibular extraction, esp third molars
Infection or recent site infection
Periodontal disease or necrotising ulcerative gingivitis
Reduced blood supply eg - Paget’s disease or radiotherapy
Excessive LA use - vasoconstrictor in excess around socket may prevent clot formation

77
Q

What are the signs and symptoms of dry socket?

A

Dull aching pain 24-48 hours post extraction
Inflamed non-healing socket
Grey slurry in socket
Trapped food debris
Bad taste
Halitosis
Trismus
Lymphadenopathy

78
Q

How is dry socket treated?

A

Look for signs of spreading infection - avoid ABs unless necessary
LA
Debride socket
Irrigate with saline
Alvogyl pack (eugenol based dressing)
OHI, smoking cessation
Recommend salt water rinses 3-4x a day
Review in 1 weeks

79
Q

What is an oro-antral communication?

A

Communication between the maxillary sinus and oral cavity, typically occurring after extraction

80
Q

How does an OAC present clinically?

A

Visible hole in socket
Bubbling or whistling sound when breathing or speaking
Regurgitation of fluids into nasal passage
Acute sinusitis symptoms post-op

81
Q

What are the risk factors for OAC?

A

Close anatomical relationships of the tooth roots and maxillary sinus
Existing bone loss in the region
Hypercementosis or ankylosis of the tooth
Application of excessive force during tooth extraction

82
Q

How are small OACs (<2mm) managed?

A

Monitor
Advise antral regime
Schedule a follow up in 2 weeks

83
Q

What is involved in an antral regime?

A

Avoid nose blowing or sneezing with pinched nostrils
Avoid smoking
Avoid sucking through straws
Avoid blowing up balloons
Avoid playing wind or brass instruments
Avoid snorkelling or scuba diving

84
Q

How should a large OAC (>2mm) be managed?

A

Implement an antral regime to ensure proper healing and prevent complications
Monitor for primary closure of OAC
Or refer to OMFS for buccal advancement flap

85
Q

What are the risk factors for maxillary tuberosity fracture?

A

Hypercementosis
Ankylosis
Excessive force when extracting

86
Q

What are the symptoms of maxillary tuberosity fracture?

A

A distinct loud crack during the procedure
Mobility or complete extraction of both the tooth and a segment of bone

87
Q

How are maxillary tuberosity fractures managed?

A

Assess size and evaluate sinus for involvement
If small - raise a flap, surgical dissection of segment and suture if required
If large - refer to OMFS, splint segment for 4 weeks, review in 6-8 weeks post-op

88
Q

What is Ludwig’s angina?

A

Cellulitis of the submandibular and sublingual spaces
Abscess spreads rapidly from the dentoalveolar area to surrounding tissues
Presence of systemic signs and symptoms

89
Q

What are the red flag signs of Ludwig’s angina?

A

Raised tongue
Swelling of the floor of the mouth
Deviated uvula
Dysphagia
Stridor

90
Q

How is Ludwig’s angina managed?

A

Medical emergency
Priority to maintain airway
999

91
Q

What is the main risk of Ludwig’s angina?

A

Infection spreading to intracranial and parapharyngeal spaces

92
Q

What is sepsis?

A

A severe condition resulting from the body’s extreme response to infection
It triggers widespread inflammation leading to organ dysfunction

93
Q

What is SIRS and how is it diagnosed?

A

Systemic inflammatory response syndrome
Criteria:
- fever or hypothermia >38, <36
- heart rate >90bmp
- respiratory rate >20 breaths/min
- increased WBC count

94
Q

What is the Glasgow Coma Scale and what does it measure?

A

Neurological scale assessing level of consciousness
Measures:
- eye opening
- verbal responses
- motor response

95
Q

What are the methods of debridement

A

Physical - bone file or handpiece to remove sharp bony edges, Mitchell’s trimmer or Victoria curette to remove soft tissue debris
Irrigation - sterile saline into socket and under flap
Suction - aspirate under flap to remove debris and check socket for retained apices

96
Q

What is SOFA?

A

Sequential organ failure assessment
Tracks organ dysfunction during sepsis and other illness

4 - misc (10 decks)

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