8 - Post-op complications 4

Question 1

What is an OAC?

Answer 1

• oral antral communication
• acute problem
• self heal or surgical, if present for more than 6 weeks then becomes OAF

Question 2

What is an OAF?

Answer 2

• oral antral fistula
• chronic problem
• epithelial lined sinus tract

Question 3

How do you diagnose an OAC?

Answer 3

• size of tooth
• radiographic position of roots in relation to antrum
• bone at trifurcation
• bubbling of blood
• nose holding test
• direct vision
• good light and suction
• blunt probe

Question 4

How can you diagnose an OAC with suction?

Answer 4

Will echo if OAC present

Question 5

How do you manage an OAC?

Answer 5

• inform patient
• if small, encourage clot and suture margins
• if large or lining torn, close with buccal advancement flap
• POI

Question 6

What are POI for an OAC?

Answer 6

• use a straw
• don’t blow nose
• sneeze with mouth open
• may required decongestants

Question 7

How do you manage an OAF?

Answer 7

• excise sinus tract
• close with a flap (buccal advancement ± buccal fat pad, palatal rotation, collagen membrane)

Question 8

How do you confirm a root/foreign body has entered the antrum?

Answer 8

Radiographically by OPT, occlusal or PA

Question 9

What are the different methods of retrieving a root/foreign body from the antrum?

Answer 9

• via OAF/through socket
• Caldwell-Luc approach
• ENT via endoscope

Question 10

How do you retrieve a FB via an OAF?

Answer 10

• open fenestration with care
• use suction
• small curettes
• irrigation or ribbon
• close as OAC

Question 11

How do you retrieve a FB with the Caldwell-Luc approach?

Answer 11

• lift a buccal flap in the sulcus
• drill away bone to open a window into the antrum

Question 12

What is osteomyelitis?

Answer 12

• infection of the bone
• rare
• patient is usually systemically unwell
• most common in mandible
• site of extraction tender
• deep infection near IAN may alter sensation

Question 13

Describe the development of osteomyelitis.

Answer 13

• begins in medullary cavity in the cancellous bone
• spreads to cortical bone
• then spreads to periosteum and causes overlying mucosa to become red and tender
• oedema in the enclosed space causes ischaemia of supplying BVs and soft tissue necrosis
• blood borne defences cannot access site to combat bacteria and bacterial proliferation continues until antibiotic ± surgical therapy occurs

Question 14

Why is osteomyelitis more common in the mandible?

Answer 14

• maxilla has a rich arterial blood supply
• mandible has dense cortical bone and is supplied primarily by the inferior alveolar artery

Question 15

What are predisposing factors to osteomyelitis?

Answer 15

• odontogenic infections
• fracture of mandible
• compromised host defence (diabetes, alcoholism, IV drug use, malnutrition, cancer patients)

Question 16

How long does it take for acute osteomyelitis to be detectable on a radiograph?

Answer 16

10-12 days

Question 17

Describe the radiographic appearance of osteomyelitis.

Answer 17

• increased radiolucency
• either uniform or patch (moth-eaten appearance)
• may be patches of radiopacity within the radiolucent region due to bony sequestra
• surrounding sound bone may be more radiopaque due to inflammatory response (involucrum)

Question 18

What bacteria are involved in osteomyelitis of the jaw?

Answer 18

• streptococci
• anaerobic cocci
• anaerobic gram negative rods eg fusobacterium and prevotella

Question 19

What is the management of osteomyelitis?

Answer 19

• medical and surgical
• check culture for antibiotics
• investigate host defences (FBC, glucose levels)

Question 20

What is the antibiotic treatment of osteomyelitis?

Answer 20

• penicillin is first line drug (good bone penetration)
• 6-12 week course or via IV (can be up to 6 months for chronic cases)

Question 21

What is the surgical treatment of osteomyelitis?

Answer 21

• drain pus
• remove any non-vital teeth in area
• remove sequestra
• remove any wires/screws etc if fractured mandible
• corticotomy (removal of bony cortex)
• perforation of bony cortex
• excision of necrotic bone until actively bleeding bone is reached

Question 22

What is ORN?

Answer 22

• osteoradionecrosis
• seen in patients who receive radiation to the head and neck for cancer
• bone within beam becomes non-vital
• endarteritis (reduced blood supply)
• turnover of remaining viable bone is slow and self repair is ineffective
• effects increase with time and dose

Question 23

What are treatments for ORN?

Answer 23

• careful routine extraction
• surgical extraction, alveoplasty primary closure of soft tissues

Question 24

How do you prevent ORN?

Answer 24

• PMPR and chlorohexidine mouthwash prior to extraction
• careful technique
• antibiotics and chlorohexidine mouthwash
• hyperbaric oxygen before and after extraction

Question 25

What is MRONJ?

Answer 25

• medication related osteonecrosis of the jaw
• caused by medications that inhibit osteoclast activity and bone renewal
• occurs post XLA, denture trauma or spontaneous
• ranges from asymptomatic to bone exposure

Question 26

Give examples of bisphosphonates.

Answer 26

• alendronate
• ibandronate
• zoledronate

Question 27

What other drugs can cause MRONJ?

Answer 27

• RANKL inhibitors (denosumab)
• monoclonal antibody drugs
• antiangiogenic drugs (bevacizumab)

Question 28

What are the risk factors for developing MRONJ?

Answer 28

• impact on bone eg XLA
• trauma from dentures
• infection
• periodontitis
• duration of drug therapy
• implants

Question 29

What is the management of MRONJ?

Answer 29

• prevent invasive treatment
• XLA can be conducted in primary care

Question 30

What is actinomycosis?

Answer 30

• rare bacterial infection
• bacteria has low virulence and must be treated in the area
• erodes through tissue rather than follow fascial planes
• presents with multiple skin sinuses and swellings
• pus is thick and lumpy (like cottage cheese)

Question 31

How do you treat actinomycosis?

Answer 31

• incision and drainage of pus
• excision of chronic sinus tracts
• excision of necrotic bone and FBs
• high dose antibiotics (often IV)
• long term antibiotics to prevent recurrence

Question 32

What antibiotics can be used to treat actinomycosis?

Answer 32

• penicillins
• doxycycline
• clindamycin
• based on culture sensitivity

Question 33

What is the guidance surrounding IE?

Answer 33

• infective endocarditis
• antibiotic prophylaxis used to be standard
• now choice is discussed with patient and cardiologist regarding risk and procedure

Question 34

What prophylaxis antibiotics can be prescribed for someone at risk of IE?

Answer 34

• amoxicillin
• clindamycin
• azithromycin (second line if allergy)