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3. Oral Surgery > Post Operative Complications 2 > Flashcards

Post Operative Complications 2 Flashcards

1
Q

When is osteoradionecrosis seen?

A

In pts who have had radiotherapy to treat head and neck cancer

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2
Q

WHta is osetoradionecrosis?

A

osteoradionecrosis is bone death due to radiation. The bone dies because radiation damages its blood vessels. Osteoradionecrosis is a rare side effect that develops some time after radiation therapy has ended. It usually occurs in the lower jaw, or mandible.

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3
Q

What can happen to bone within radiation beam?

A

It can become virtually non vital

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4
Q

What is most commonly affected by radiotherapy?

A

Mandible due to poorer blood supply - inferior alveolar artery is big artery supply it so turnover or any remaining viable bone is slow and self repair doesn’t occur

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5
Q

If pt has osetoradionecrosis how do we go about xla?

A

Careful routine extraction may be possible

some cases we may have to do surgical extraction and very carefully remove tooth then cut down alveoplasty to allow space to close over and then close overs oft tissue

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6
Q

What is MRONJ?

A

This is medicine related osteonecrosis of the jaw

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7
Q

What are bisphosphonates?

A

Class of drugs used to treat osteoporosis, and malignant bone metastases

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8
Q

How do bisphosponates work?

A

they inhibit osteoclastic activity preventing bone resorption and therefore bone renewal (inhibits and delays healing capacity of bone)

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9
Q

What is issue with bisphosphonates?

A

Stay in body for around 5 years even after stopping

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10
Q

When can MRONJ occur? 3

A

post extraction

äter denture trauma

spontaneous

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11
Q

What pts are at higher risk of mronj?

A

Those on IV bisphosphonates compared to oral ones

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12
Q

In pts on bisphosphonates what do we try to do?

A

avoid extraction if possible - restore tooth, remove crown, seal tooth off at gingival level leaving roots

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13
Q

What do we do if we need to extract tooth in bisphosphonate pt?

A

careful technique and consider referral or taking advice

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14
Q

What are the main types of bisphosphonates?

A

Aldenronate (fosamax) - oral

Clodronate (bones) - iv

Etironate (didronel) - oral

Ibandronate (Bonita) - oral

Pamidronate

Risedronate

Tiludronate

Zoledronate

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15
Q

What is alendronate?

A

Bisphosphonate
Alendronic acid is a drug used for the treatment of osteoporosis. It works by slowing down the production of the cells that wear down bone (osteoclasts). This helps to improve bone strength and makes the bone less fragile.

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16
Q

What is clodronate?

A

Clodronate belongs to a group of drugs called bisphosphonates. It can be used to treat: high levels of calcium in the blood caused by cancer that has spread to the bones (secondary bone cancer) bone weakness or pain caused by myeloma or breast cancer that has spread to the bones.

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17
Q

what is an anti-angiogenic drug?

A

Angiogenesis means the growth of new blood vessels. So anti angiogenic drugs are treatments that stop tumours from growing their own blood vessels. If the drug is able to stop a cancer from growing blood vessels, it might slow the growth of the cancer or sometimes shrink it.

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18
Q

What is an anti-resorptive drug?

A

antiresorptive drugs include bisphosphonates selective oestrogen receptor modulators are widely prescribed to treat osteoporosis

Antiresorptive medication prevents bone loss, may increase bone density, and lowers the risk of broken bones.

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19
Q

Who are at small risk of developing MRONJ?

A

Those taking anti-resorptive drugs

those taking anti-angiogenic drugs

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20
Q

What pts are at low risk for MRONJ?

A

Those treated for osteoporosis or other non malignant disease such as pagets disease with oral bisphosphonates for less than 5 years who are not being treated with systemic glucocorticoids

those being tx for osteoporosis or other non malignant diseases such as pagets for less than 5 years who get quarterly or yearly IV bisphosphonates and are not getting systemic glucocorticoids

Those being treated for osteoporosis and other non malig diseases of bone with denosumab who are bot being tx with systemic glucocorticoids

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21
Q

What risk category is the following pt?

Those treated for osteoporosis or other non malignant disease such as pagets disease with oral bisphosphonates for less than 5 years who are not being treated with systemic glucocorticoids

A

low

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22
Q

what risk category is the following pt?

those being tx for osteoporosis or other non malignant diseases such as pagets for less than 5 years who get quarterly or yearly IV bisphosphonates and are not getting systemic glucocorticoids

A

low

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23
Q

What risk category if following pt?

Those being treated for osteoporosis and other non malig diseases of bone with denosumab who are bot being tx with systemic glucocorticoids

A

low

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24
Q

When is a pt at high risk of MRONJ?

A

If pt is being tx for osteoporosis or non malig disease of bone with oral bisphosphonates with yearly or quarterly IV infusions for more than 5 years

pts being tx for osteoporosis or non malig diseases of bone with bisphosphonates or denosumab fr any length of time who are getting systemic glucocorticoids

Pts getting anti angiogenic or anti resorptive drugs for cancer tx

pts with previous mronj dx

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25
Q

What risk category?

If pt is being tx for osteoporosis or non malig disease of bone with oral bisphosphonates with yearly or quarterly IV infusions for more than 5 years

A

high

26
Q

What risk category?

pts being tx for osteoporosis or non malig diseases of bone with bisphosphonates or denosumab fr any length of time who are getting systemic glucocorticoids

A

high

27
Q

What risk category?

Pts getting anti angiogenic or anti resorptive drugs for cancer tx

A

high

28
Q

What risk category?

pts with previous mronj dx

A

high

29
Q

What are the risk factors of MRONJ occurring?

A

Extractions as they impact on bone

trauma from dentures

infections

perio disease

30
Q

What is info about implants and pts on antiresoprtive or anti angiogenic drugs?

A

Avoid implant placement in these cases in pts being tx with these drugs for cancer

not contraindicated in osteoporosis pts

31
Q

What increases the risk of MRONJ?

A

Use of steroids and anti resorptive drugs

anti resorptive drugs and anti angiogenic drugs at same time

32
Q

why are pts who previously took bisohosphonates at risk?

A

Due to long half life

33
Q

When does denosumabs effect on bone turnover diminish?

A

9 months after tx is finished

34
Q

How long do angiogenic drugs remain in body?

A

Extended periods of time

35
Q

Drug holiday and extractions to decrease mronj risk?

A

no evidence for drug holidays

we should never stop a pt front aking drugs - doctors responsibility

36
Q

What is actinomyosis?

A

Rare bacterial infection

bacteria spread from one part of the body to another through body tissues. Over time, it can result in linked abscesses, pain, and inflammation.

It can affect the skin or deeper areas within the body and sometimes the blood.

Many people have actinomycosis bacteria in their body, but the bacteria usually stay in one place and do not cause disease in healthy tissues.

If damage occurs in the area around where the bacteria live, due to injury or trauma, the bacteria can move to other areas.

As the condition progresses, the deep tissue can become inflamed and pus-filled. It can result in abscesses, tissue death, cavities, and masses of fibrous tissue in the body.

37
Q

When does actinomyosis happen?

A

Actinomycosis happens when the Actinomyces species of bacteria spread through the body because of tissue damage.

38
Q

When can actinomyosis happen to spread?

A

The bacteria live harmlessly in the body, but they become dangerous if they spread out of their usual environment.

This can happen as a result of:

disease
tissue damage due, for example, to injury or surgery
Actinomycosis can also happen if there is tooth decay or gum disease.

39
Q

how can actinomyosis happen in the mouth

A

Orocervicofacial actinomycosis affects the mouth, jaw, or neck. The bacteria that cause this infection typically live in dental plaque.

It can result from:

dental problems, such as decay and poor oral hygiene
trauma to the mouth or face, if particles of dental plaque enter the mucous membrane

40
Q

What does actinomyosis result in?

A

multiple skin sinuses and swelling

lumpy draining sinuses with thick lumpy pus

41
Q

What does actinomyosis respond to?

A

antibiotics but will recur when stopped as its deep seated and chronic

42
Q

How do we treat actinomyosis?

A

Incise and drain pus

excise chronic sinus tracts

excise necrotic bone and foreign bodies

high dose antibiotics - OFTEN NEEDED IV to get initial control

long term oral antibiotics such as penicillin to prevent recurrence

43
Q

What is infective endocarditis?

A

Infective endocarditis is an infection in the heart valves or endocardium. The endocardium is the lining of the interior surfaces of the chambers of the heart. This condition is usually caused by bacteria entering the bloodstream and infecting the heart. Bacteria may originate in the: mouth.

44
Q

Until a few years ago what did we do to prevent IE?

A

Antibiotic coverage was always given as bacteria from mouth after extraction was seen as risk to IE in risk groups

45
Q

What is the guidance on antibiotic prophylaxis in pts?

A

Not routinely recommended for those undergoing dental procedures however prophylaxis prescribed in groups at risk still

46
Q

What should we do as dentists to pts at increased risk of IE?

A

Benfits and risks of antibiotic prophylaxis and why its no longer routinely recommended

need to maintain good oral health

symptoms that can indicate IE and how and when to seek help

risks of any invasive procedures such as piercings or tattoos

47
Q

What should not be offered as prophylaxis against IE to those at risk of IE?

A

CHX mouthwash

48
Q

Who’s is at risk of IE?

A

ADULTS AND KIDS WITH PROBLEMS AFFECTING HEART STRUCTURE (REPLACEMENT VALVE, HYPERTROPHIC CARDIOMYOPATHY)

THOSE WHO HAVE HAD IE BEFORE

49
Q

What are the special consideration sub group for antibiotic prophylaxis?

A

Pts with prosthetic valve (transcatheter valve, prosthetic material used for valve repair)

previous IE

pts with congenital heart disease (ANY TYPE OF CYANOTIC CHD, or any CHD REPAIRED WITH PROSTHETIC MATERIAL)

50
Q

What congenital heart disease always needs antibiotic prophylaxis?

A

cyanotic chd

51
Q

What do we do if pt falls into special consideration sub group for IE?

A

We contact their cardiologist or GP for advice on invasive procedures and see what they think and if recommended then we discuss risks and benefits with pt and then provide with prophylaxis

52
Q

How can we discuss IE to a pt with heart condition/preious IE episode?

A

We let them know that due to this there is a very small risk of developing IE following an invasive dental procedure but this risk is very low

53
Q

What is IE?

A

Infection of the lining of heart often involving heart valves and is caused bu bacteria that enters the bloodstream

it is very rare but serious and risk is 1 in 10,000 people however they are at increased risk

54
Q

How do we explain invasive tx and IE link to pt?

A

During invasive procedures such as extractions we may increase the chance of bacteria entering the blood stream however every day activities such as brushing, chewing, flossing which can cause transient bacteremia

55
Q

what can flossing brushing and chewing do?

A

causes transient bacteremia

need to stress importance of good oh to reduce risk from oral bacteria

56
Q

How do we explain risks and benefits of IE prophylaxis to pt?

A

dental procedures no longer though to be main cause of IE and its unclear wether antibiotic prophylaxis prevents IE and therefore it may occur whether or not we provide prophylaxis

Antibiotics can cause Side effects such as nausea, diarrhoea and allergic reactions and in rare cases anaphylaxis and antibiotic resistance

57
Q

What are some symptoms if IE?

A

Flu like illness
High temp/fever of 38 or above

sweats or chills at night

breathlesness

weight loss

fatigue

muscle joint or back pain unrelated to physical activity

58
Q

How does antibiotic prophylaxis have to be taken for dentistry?

A

in surgery on hour before planned procedure and they must remain here for that

or

may take it at home and phone to let us know it will go ahead

59
Q

What are invasive dental procedures?

A

matrix band placement

sub gingival rubber dam clamps

sub gingival restorations

endo treatment before apical stop

PMCs

Full perio exams - pocket charting

RSD

incising and draining abscesses

extractions

surgical procedures where flap is raised

implants

60
Q

What are some non invasive dental tx?

A

Radiographs

supragingivbal scale and polish

supra gingival restos

removal of sutures

bpe

infiltrations or blocks in non infected soft tissues

ortho appliances

61
Q

What do we prescribe for prophylaxis?

A

Amoxicillin 3g oral powder sachet - 60 mins prior to procedure

if allergic then clindamycin capsule - 300mg 2x capsule 60mins before procedure

if no to above then azithromycin 200mg/5ml x2 60 mins before

3. Oral Surgery (9 decks)

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