Third Molars 3 Flashcards
common tx options for 3rd molars
5
- Referral
- Clinical review – keep on top of BW should inc distal 7 for CRA
- Removal of M3M
- Extractions of maxillary third molar
- Coronectomy
less common tx options for 3rd molars
4
- Operculectimy
- Surgical exposure
- Pre-surgical orthodontics
- Surgical reimplantation/autotransplantation
factors to consider in decision making regarding 3rd molars
Current status of the patient and the M3M
Risk of complications
Patient access to treatment (e.g. army on deployment, long term travel)
Opposing or contralateral 3rd molars if pt undergoing GA
Patient involvement- communicate findings of assessment, risk status, treatment options (inc risks and benefits of all, inc leaving and reviewing them)
Good notekeeping, contemporaneous
what is active surveillance of 3rd molars
monitoring of tooth with regular radiographs as pt currently asymptomatic (e.g. if tooth close to IDN canal)
tx options for asym diseased/high risk of disease development 3rd molars
surgical intervention
if tooth higher risk of surgical complications (IDC) then active surveillance
* until sym develop or early disease progression proven
tx optiosn for asym non-disease/low risk disease development 3rd molars
clinical review with radiographic assessment (if indicated)
at appropriate risk intervals
factors for consideration for prophylatic removal of 3rd molars
medical factors: pt undergoing planned medical tx that may complicate likely surgery of M3Ms inc:
* pharmaceutical therapy - bisphophonates, antiangiogenics, chemo
* radiotherapy of head and neck
* immunosuppressant therapy
surgical factors: 3rd molar lie within perimeter of a surgical field
* mandibular fractures
* orthognathic surgery
* resection of disease (benign/malignant lesions)
tx options for symp diseased/high risk disease 3rd molars
therapeutic removal of M3M or coronectomy
removal of upper 3rd molars
consideration for therapeutic extraction of 3rd molars indicated for
7
- single severe or recurrent subacute pericoronitis
- unrestorable caries of teh M3M or to assist restoration of the adj tooth
- periodontal disease compromising the M3M and/or adj teeth
- resorption of the M3M and/or adj teeth
- fracture M3M
- M3M periapical abscess, irreversible pulpitis or acute spreading infection
- surrounding pathology (cysts/tumours) associated with M3M
tx options for sym non-diseased/low risk disease 3rd molar
leave deeply impacted M3M with no associated disease
manage other dx causing pain in area:
* TMD
* parotid disease
* skin lesion
* migraines or other headaches
* referred pain from angina, cervical spine
* oropharyngeal oncology
methods of anaesthesia for 3rd molars
3
LA alone
concious sedation
* IV - midazolam or propofol (anaesthetist led)
* IS
* oral
GA
7% will require conscious sedation for routine dental treatment so presumably higher for third molar surgery
Check if any adverse reactions to sedation or anesthetics in past
consent needed for GA or IV sedation
written consent form
consent needed for LA
varies from between hospitals and practices
- Written consent form is best practice
Or
- Written consent form is best practice
- Sticker in notes, patient signs it
explain procedure to pt of 3rd molar removal
If tooth is likely to need sectioned explain this
Give the patient an idea of what to expect during the procedure – pressure - no pain, like pressing on thumb
Explain minor surgical procedure, flap (press apart/cut the gum to expose more the tooth), possible drilling (water, vibration), sutures (like hairs in the mouth), etc
If 2nd molars have large restorations explain risk of restoration fracture
explain risk of jaw fracture, small risk but significant that can happen (explain would arrange to have it dealt with at appropriate hospital)
* In edentulous/atrophic mandible
* aberrant lower 8 close to lower border of mandible
* large cystic lesion associated with wisdom tooth
post op complications to tell pt
8
- Pain
- Swelling
- Bruising
- Jaw Stiffness/limited mouth opening
- Bleeding
- Infection
- Dry Socket (localised osteitis)
- nerve damage - main significant risk after M3M extractions, not a motor or appearance deficit – feeling lost
how to explain possible nerve damage to pt after 3rd molar extraction
Numbness (anaesthesia) or tingling (paraesthesia) of lower lip, chin, side of tongue
IDN (lower lip/chin):
* Temporary (may take weeks/months to improve) -10-20% will experience this
* Permanent <1% will experience this
Lingual Nerve (one side of tongue, taste)
* Temporary – Literature quotes 0.25 – 23%
* Permanent – Literature quotes 0.14 – 2%
Altered taste (rare) -nchorda Tympani - arises from Facial nerve, taste buds from anterior two thirds of tongue, carries fibres via Lingual nerve
Dysaesthesia (rare)
* painful, uncomfortable, unpleasant sensation of lower lip, chin, tongue; sometimes neuralgia type pain.
Also reduced sensation (hypoaesthesia) or heightened sensation (increased sensation).
Nerves can recover up to 18-24 months but after this time there would not much hope for any further recovery
Av figures can be higher if the tooth/roots are in close proximity to IAN canal – use radiograph
Use language the pt understands
factors affecting decision for CBCT scan
close proximity between the IDC and tooth/roots from the 2D radiograph
other factors:
* would the scan change the treatment – e.g. grossly carious lower 8 is not suitable for coronectomy;
* patient does not want a scan or a coronectomy – they want a full surgical removal regardless of higher risks to the IDN;
* or patient does want a scan as they want to know the relationship – even if they are not a candidate for coronectomy.
consent form in
pt terms
referral contains
Professional, courteous and appropriate
SBAR
* Situation (C/O and pt demographic)
* Background (HPC)
* Assessment (histories)
* Recommendation
Check pt details correct
Check your details correct
