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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
What are NOACs and give 4 examples
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
26
Why are NOACs taken?
Prophylaxis against stroke in pts with atrial fibrillation Prevention of DVT and pulmonary embolism
27
How should pts on NOACs be managed?
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
28
Give 5 examples of high bleeding risk procedures?
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
29
What are the types of bleeding?
Primary - during the procedure Reactionary - clot fails within 48 hours Secondary - infection, occurs 7-10 days later
30
Give 5 examples of local haemostatic aids?
Apply pressure with gauze LA with vasoconstrictor Suturing Diathermy Surgicel - oxidised regenerated cellulose Bone wax
31
Give 5 examples of systemic haemostatic aids
Vitamin K Tranexamic acid Missing blood clotting factors Plasma or whole blood Desmopressin
32
Give 5 risks of chemotherapy and radiotherapy
Neutropenia - decreased neutrophil count - susceptible to infection Thrombocytopenia - decreased platelet count - increased bleeding risk MRONJ ORN Infection due to immunosuppression
33
What is ORN?
Osteoradionecrosis Exposed, non-healing bone persisting over 3-6 months Pt has a history of head and neck radiotherapy
34
Describe the clinical presentation of ORN
Early - asymptomatic Advanced: - pain - halitosis - paraesthesia - formation of oral fistulae
35
What are the risk factors for ORN?
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
36
How is ORN managed?
Referral to OS Surgical debridement Bone sequestrectomy (removal of dead bone) Hyperbaric oxygen therapy Medications - ABs, vitamin E, pentoxifylline
37
What is MRONJ?
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
38
What are the symptoms of MRONJ?
Delayed healing following dental XLA or other oral surgery Soft tissue infection and swelling Numbness Paraesthesia Exposed bone May be asymptomatic
39
Which drugs can cause MRONJ?
Anti-resorptive: Bisphosphonates eg - alendronic acid RANKL inhibitors eg - denosumab Anti-angiogenic: Eg - bevacizumab, sunitnib
40
What are the risk factors of MRONJ?
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
What makes a pt high risk for MRONJ and what is the risk?
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
What makes a pt low risk for MRONJ and what is the risk?
0.001-0.01% Oral bisphosphonates for <5 years IV bisphosphonates <5 years Denosumab tx not with systemic glucocorticoids
43
What should be done pre-procedure for MRONJ pts?
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
How should high risk MRONJ pts be managed?
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
What are the indications for extracting third molars?
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
What are the radiological signs of M3M proximity to the IAN?
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
Name 8 signs and symptoms of pericoronitis
Pain Swelling Bad taste Pus discharge Occlusal trauma to operculum Evidence of check biting Dysphagia Pyrexia Malaise Regional lymphadenopathy
48
What are the different depths of M3M impaction?
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
What are the different angulations of impacted M3Ms?
Vertical - 30-38% Mesioangular - 40% Horizontal - 6-15% Distoangular - 3-15% Transverse Aberrant
50
What factors increase difficulty of M3M XLA?
Disto-angular position Long, thin roots Divergent roots Narrow PDL space Close relation to IAN Close relation to mandibular second molar Dense bone
51
What is pericoronitis?
Inflammation of the operculum overlying the M3M
52
How should mild pericoronitis be managed?
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
How is severe pericoronitis treated?
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
What are the indications of a coronectomy?
Close association with IAN Presence of hypercementosis in M3M
55
What are the contraindications of a coronectomy?
Non-vital Carious with high risk of pulpal involvement or apical infection Mobile Immunocompromised - higher risk of infection from retained tooth tissue
56
How is a coronectomy carried out?
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
What are the risks of coronectomy?
Infection of retained tooth tissue Nerve injury - temporary or permanent Root migration Development of periapical pathology Mobilisation of roots during the procedure
58
What is the mechanism of action of LA?
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
What are the local complications of LA?
Failure to achieve anaesthesia Prolonged anaesthesia Pain Trismus Haematoma Temporary facial palsy Infection Soft tissue damage Needle stick injury
60
What are the systemic complications of LA?
Allergy - usually to prevervatives Loss of consciousness Respiratory depression Circulatory collapse
61
What are the signs of LA toxicity?
Circumoral numbness Dizziness/lightheadedness Metallic taste Drowsiness Sudden alteration in mental state Visual and auditory disturbances Severe agitation Loss of consciousness Cardiovascular collapse
62
What is the correct order for extractions?
Lowers before uppers Posteriors before anteriors
63
What is the max safe dose of lidocaine, prilocaine and articaine?
Lidocaine - 4.4mg/kg Prilocaine - 6mg/kg Articaine - 7mg/kg
64
What are the steps of a surgical extraction?
Anaesthesia Incision/access Bone removal as necessary Tooth division as necessary Debridement Suture Haemostasis Post-op instructions
65
Name 8 principles of flap design?
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
What is the purpose of suturing?
Reposition tissues Compress blood vessels Cover bone Prevent wound breakdown Achieve haemostasis
67
Give 4 characteristics of the ideal suture material?
Allow secure knots Adequate tensile strength Not cut through tissues Sterile Non-allergenic Good handling characteristics
68
When can a fragment of fractured tooth be left in situ?
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
Name 5 peri-operative complications of XLA
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
How are roots lodged in the maxillary sinus managed?
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
How should lingual or buccal wall fractures be managed?
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
What are the signs of a fractured tuberosity and how should it be managed?
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
List 8 post-op complications
Haemorrhage Pain Swelling Dry socket Infection Trismus ORN MRONJ
74
What is dry socket?
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
What are the general risk factors for dry socket?
Smoking Alcohol consumption Immune-compromised state Use of oral contraceptives Previous dry socket history Poor compliance with post-operative instructions
76
What are the extraction specific risk factors for dry socket?
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
What are the signs and symptoms of dry socket?
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
How is dry socket treated?
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
What is an oro-antral communication?
Communication between the maxillary sinus and oral cavity, typically occurring after extraction
80
How does an OAC present clinically?
Visible hole in socket Bubbling or whistling sound when breathing or speaking Regurgitation of fluids into nasal passage Acute sinusitis symptoms post-op
81
What are the risk factors for OAC?
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
How are small OACs (<2mm) managed?
Monitor Advise antral regime Schedule a follow up in 2 weeks
83
What is involved in an antral regime?
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
How should a large OAC (>2mm) be managed?
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
What are the risk factors for maxillary tuberosity fracture?
Hypercementosis Ankylosis Excessive force when extracting
86
What are the symptoms of maxillary tuberosity fracture?
A distinct loud crack during the procedure Mobility or complete extraction of both the tooth and a segment of bone
87
How are maxillary tuberosity fractures managed?
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
What is Ludwig’s angina?
Cellulitis of the submandibular and sublingual spaces Abscess spreads rapidly from the dentoalveolar area to surrounding tissues Presence of systemic signs and symptoms
89
What are the red flag signs of Ludwig’s angina?
Raised tongue Swelling of the floor of the mouth Deviated uvula Dysphagia Stridor
90
How is Ludwig’s angina managed?
Medical emergency Priority to maintain airway 999
91
What is the main risk of Ludwig’s angina?
Infection spreading to intracranial and parapharyngeal spaces
92
What is sepsis?
A severe condition resulting from the body’s extreme response to infection It triggers widespread inflammation leading to organ dysfunction
93
What is SIRS and how is it diagnosed?
Systemic inflammatory response syndrome Criteria: - fever or hypothermia >38, <36 - heart rate >90bmp - respiratory rate >20 breaths/min - increased WBC count
94
What is the Glasgow Coma Scale and what does it measure?
Neurological scale assessing level of consciousness Measures: - eye opening - verbal responses - motor response
95
What are the methods of debridement
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
What is SOFA?
Sequential organ failure assessment Tracks organ dysfunction during sepsis and other illness

4 - misc (10 decks)

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