extraction complications Flashcards
1
Q
types of complications
A
peri-op
post-op
OR
peri-op
immediate post-op
long-term post-op
2
Q
perioperative complications
A
difficulty of access abnormal resistance fracture tooth/root fracture of alveolar plate fracture of tuberosity mandible fracture involvement of MS loss of tooth ST damage damage to nerves/vessels haemorrhage dislocation of TMJ damage to adjacent teeth/Rxs extraction of permanent tooth germ broken instruments wrong tooth
3
Q
causes of difficulty of access and vision
A
trismus
reduced aperture (congenital or syndromes, scarring, muscle spasm or TMJ problems)
crowded/malpositioned teeth
4
Q
abnormal resistance
A
thick cortical bone shape/form of roots e.g. divergent/hooked number of roots (3 rooted L molars) hypercementosis ankylosis
5
Q
if abnormal resistance what should you do?
A
surgical - otherwise risk fractures
6
Q
conditions that cause hypercementosis
A
sometimes none - often idiopathic over-eruption of a tooth inflammation associated with a tooth tooth repair PAGETS DISEASE of bone acromegaly goitre arthritis RF calcinosis Gardner's syndrome vit A deficiency
7
Q
causes of tooth fracture
A
caries alignment size e.g. small crown large root root - fused - convergent/divergent - extra - morphology - hypercementosis - ankylosis always examine an extracted tooth
8
Q
which jaw usually fractures?
A
mandible (if maxilla usually alveolar plate)
9
Q
causes of jaw fracture
A
impacted wisdom tooth
large cyst
atrophic mandible
force - need to support jaw
10
Q
management of jaw fracture
A
inform pt
post-op radiograph (pan)
refer - MF, if not A and E
if remote and can’t get them straight to hospital then ensure analgesia and advice on keeping clean
stabilise? - ortho/splint wire - tie around crowns on a couple of teeth both sides. not PDD teeth
if delay - antibiotic
instruct them not to eat en route in case of GA
11
Q
where does alveolar bone fracture usually occur and why?
A
usually buccal plate, canines or molars
fused or may have moved buccally too early
12
Q
management of molar alveolar bone fracture
A
periosteal attachment? - if the bit of bone is large and still attached then probably vascular supply so can push bone back in. suture so stays in place
if not good periosteal attachment/small - dissect free (don’t rip) - won’t be able to stabilise, may become sequestrum
13
Q
management of canine alveolar bone fracture
A
stabilise
free mucoperiosteum
smooth edges - bone file
can affect making of dentures if lose bone in canine area
14
Q
involvement of maxillary antrum
A
OAC/OAF
loss of root into antrum
fractured tuberosity - usually involves communication
15
Q
diagnosis of an OAC
A
size of tooth radiographic position of roots (2D) bone at trifurcation of roots bubbling of blood nose holding test - care as can create OAC if only membrane intact direct vision good light and gentle suction - echo blunt probe - care not to create OAC "salty/metallic taste" usually pus "water through nose when drink"
16
Q
what might you see if you squeeze the area of an OAF?
A
pus
17
Q
management of a small 1-2mm/sinus intact OAC
A
inform pt encourage clot suture margins - non-resorbing irrigation - warm saline antibiotic POI - inc steam/menthol inhalation, avoid nose blowing refer if unsure
18
Q
management of a large/lining torn OAC
A
close with BAF - tension free otherwise necrosis
need to release periosteum as gum not elastic enough - cut as little as possible for max benefit
non-resorbing sutures
irrigation - warm saline
antibiotic
nose blowing instructions
refer if unsure
19
Q
chronic OAF management
A
excise sinus tract = otherwise will reform irrigation - warm saline BAF - 3-sided buccal fat pad with BAF - sturdier palatal flap - keratinised, finger sized bone graft/collagen membrane
20
Q
reviewing pt after OAC
A
monitor
up to 2 wks to heal
1wk
remove sutures 10days-2wks
21
Q
management of a root in antrum
A
confirm radiographically - OPT, occ, (PA)
check not in suction/get pt to stand up and shake collar etc
decision on retrieval - if tiny and not causing issues some pts opt to KUR - but risk of sinusitis etc
22
Q
why shouldn’t you use an air rotor handpiece
A
surgical emphysema
air in STs
infection risk
23
Q
aetiology of fractured maxillary tuberosity
A
single standing molar (bone weak) unknown UE 8/cyst pathological gemination extracting in wrong order - ext from back forwards inadequate alveolar support
if can’t ext without excessive pressure consider surgical
24
Q
diagnosis of fractured maxillary tuberosity
A
noise
movement noted - visually or with supporting fingers
>1 tooth movement
tear on palate
- fractured bones sharp, often tear underlying mucosa
25
management of a fractured maxillary tuberosity if small
```
dissect out and close wound
fresh scalpel
cut gum around, relieving incision
remove tooth and bit of bone
often don't need BAF
```
26
management of a fractured maxillary tuberosity if large or >1 tooth
reduce and stabilise
reduction: fingers (sharp bone) or forceps - sometimes need to disimpact then reduce
fixation: keep bones against each other for bony healing
- ortho wire spot welded with composite
- arch bar
- mouthguard splints if near lab - cover with Vaseline when taking imp so don't pull it out - not ideal
rigid fixation for fracture - inc teeth that aren't moving - harder in tuberosity area as nothing posteriorly - come as anteriorly as you feel you need to
27
management of a fractured maxillary tuberosity - after initial management
remove or tx pulp if toothache/pulpitis - think reason for extraction
ensure occlusion free
- tooth will be sitting proud as odema in ligament
- if tooth to extract just reduce cusps
- if not extracting tooth make splint to relieve area - cut out a bit around those teeth
antibiotic and antiseptics
POIs - 6-12wks to heal
remove tooth 8wks later - SR
28
loss of tooth
```
where? STOP tx
- suction
- clothes, EO, ground
- IO - back/under tongue - have quick look then encourage pt to cough
radiograph
GET advice
inhaled - may need surgery
lingual plate may fracture and tooth can disappear into FOM and neck, lung
```
29
causes of damage to nerves
```
crush
cutting/shredding
transection
from surgery
from LA
swelling in 48hrs post-op can press on nerve
might not know at time
```
30
needle into IAN
pt will leap, feel burning sensation across jaw
| remove needle and replace as will have blunted it
31
neurapraxia
contusion of nerve but continuity of epineural sheath and axons maintained
32
axonotmesis
continuity of axons disrupted but not epineural sheath
33
neurotmesis
complete loss of nerve continuity/nerve transected
34
effects of nerve damage - technical
```
anaesthesia
paraesthesia
dysaesthesia
hypoaesthesia
hyperaesthesia
temp/permanent
```
35
effects of nerve damage - pt terms
```
numbness
tingling
unpleasant sensation/pain
reduced sensation
increased/heightened sensation
altered sensation
temp/permanent
```
36
treating nerve damage
refer - always label as urgent
- earlier you intervene higher success
- but longer you leave nerve more likelihood of it just settling down
speak to defence union
effects of nerve damage will follow the distribution of the nerve - but hopefully won't be the whole distribution
- if hit lingual nerve small risk of effect on taste - chords tympani
37
specialist nerve centres
clean, explore or reconnect
but risk of making it worse
most pts who decide this option have dysaesthesia
38
causes of damage to vessels during op
LA needle
scalpel (facial artery buccal aspect mandible)
sharp bone edges
lift flap and haven't put it back down tightly enough
39
causes of damage to vessels after op
pt may accidentally open stitch
vasoconstrictor effect of LA wears off
may be anticoagulated
40
damage to veins
lots of bleeding but not pulsating
41
damage to arteries
spurting
| haemorrhage
42
damage to arterioles
spurting/pulsating
43
dental haemorrhage causes
most - local factors - mucoperiosteal tears or fractures of alveolar plate/socket wall
v few - undiagnosed clotting abnormalities - pt likely to know already, maybe mild VW - GP referral
some - liver disease
some - medication
elderly - bruise easily, vessel walls, collagen etc more fragile
perio disease - lots of inflammation so lots of bleeding, just need pressure in area
44
what should you ask pre-op to reduce risk of dental haemorrhage?
do you bruise easily?
| do cuts take a long time to stop bleeding?
45
management of soft tissue bleeding
```
mechanical pressure
sutures
LA with vasoconstrictor
diathermy
ligatures/haemostatic forceps (artery clips) - ensure not nerves
```
46
management of soft tissue bleeding - mechanical pressure
finger/bite down on damp gauze
firm even pressure - otherwise rebound
15mins, 20mins, refer?
47
management of soft tissue bleeding - sutures
extra
suture papillae together
suture relieving incision
48
management of soft tissue bleeding - diathermy
cauterise/burn vessels
ppt proteins - form proteinaceous plug in vessel
electrocautery units
need to be sure it is vessel
49
management of bone bleeding
```
pressure
LA on swab/injected into socket
haemostatic agents - surgicel/kaltostat
blunt instrument
bone wax
pack
```
50
management of bone bleeding - pressure
bite on damp swab gauze
| ribbon gauze - pack into socket, if nerves then protect them with instruments
51
management of bone bleeding - haemostatic agents
oxidised cellulose
scaffold for clot
some acidic so ensure not near nerve
don't need to remove packs - will dissolve
52
management of bone bleeding - bone wax
get suction in
dry
apply wax
don't need to remove - you are just smearing a waterproof layer on
- puts back pressure on the vessels to stop bleeding
53
if cant stop bleeding
phone for advice
- OS, MF, A and E
if worried phone ambulance otherwise send in car with gauze pressure
54
management of TMJ dislocation
relocate immediately - muscles will spasm, v difficult to relocate earlier
- down and backwards movement, above pt, have someone supporting head as lots of pressure
analgesia
advice on supported yawning
if unable to relocate try LA into masseter IO then relocate
if unable to relocate - urgent immediate referral
55
cause of TMJ dislocation
usually lower tooth extraction - lot of pressure and not supporting mandible
occ upper extraction - if opening really wide
56
damage to adjacent teeth/restorations
only forgivable if big adjacent overhang
if large adjacent restoration warn pt of risk
if it happens put temp in then definitive later
57
extraction of permanent tooth germ
don't look for fragments of primary roots unless v easy to remove - leave to resorb as can damage permanent tooth germ
58
broken instruments
inappropriate use
radiograph
check suction, floor, get pt to shake clothes
if can't find/retrieve phone for advice and refer - document who you speak to on phone
59
wrong tooth
concentrate
check clinical situation against notes/radiographs - errors
count teeth
verify with someone else if still unsure - don't just extract if healthy tooth
phone defence union if you do
60
postop more common complications
```
pain
swelling
ecchymosis
trismus/limited mouth opening
haemorrhage
prolonged effects of nerve damage
dry socket
sequestrum
infected socket
chronic OAF/root in antrum
```
61
less common postop complications
```
osteomyelitis
ORN
MRONJ
actinomycosis
bacteraemia/IE
```
62
pain
most common
| warn pt and advise analgesia
63
what can result in more post-op pain?
rough handling of tissues
- laceration/tearing of Sts
- exposed bone
- incomplete extraction of tooth
64
swelling (oedema)
part of inflammatory reaction to surgical interference
increased by poor surgical technique e.g. rough ST handling, pulling flaps, crushing lip with forceps
wide individual variation
if doesn't begin until day 2-3 then likely to be infection
65
ecchymosis
rough handling of tissues
poor surgical technique
individual variation
66
trismus definition
limited mouth opening due to muscle spasm
67
causes of trismus/limited mouth opening
related to surgery (oedema/muscle spasm)
related to giving LA (IDB - MP haematoma/spasm)
bleed into muscle - MP/M - clot organises and fibroses
damage to TMJ - oedema/joint effusion
68
management of trismus
ensure they can still eat and drink properly - refer to oral surgeon if can't
monitor - may take a couple of weeks to resolve, see them each week
gentle mouth opening exercises/wooden spatulae/trismus screw
69
immediate post-op bleeding
```
reactionary/rebound
within 48hrs of extraction
vessels open up
vasoconstrictor effects of LA wear off
sutures loose/lost
pt traumatises area with tongue/finger/food
```
70
secondary post op bleeding
often due to infection
commonly 3-7days
usually mild ooze but can occasionally be major bleed
71
initial pt management of post-op bleeding
if severe get pressure on immediately
calm anxious pt/separate from anxious relatives
don't leave pt in waiting room
clean up/remove blood soaked towels
thorough rapid history while dealing
meds?
urgent referral/contact haematologist if bleeding disorder
if on warfarin get GP to do INR/urgent hospital referral if bleeding not arrested
72
procedure for post-op bleeding
```
get in mouth - good light and suction
often large jelly-like clot - not successful - remove
pressure and clean area
pt may vomit if swallowed blood
identify where bleeding from
arrest
suture socket
ligation of vessels/diathermy if available
```
contact details and review pt
73
when to refer post-op bleeding
large vol blood loss
medical problems
extremes of age
can't arrest haemorrhage
can phone if not sure how much blood loss and record who you speak to
weekdays - dental Hospital/MF outpt
weekends/evenings - MF on call or A and E
74
haemostatic agents
LA - vasoconstrictor
oxidised regenerated cellulose
- surgicel - framework for clot formation
- careful in L8 region - acidic - damage to IDN
gelatin sponge - absorbable/meshwork for clot formation
thrombin liquid and powder
fibrin foam
75
systemic haemostatic aids
vit K (need to form clotting factors)
anti-fibrinolytic e.g. TXA - prevents clot breakdown/stabilises clot (systemic tablets or MW)
missing blood clotting factors
plasma/whole load
76
preventing haemorrhage
thorough MH - anticipate and deal with potential problems
atraumatic extraction/surgical technique
haemostasis before discharge
good POIs to pt
77
prolonged effects of nerve damage
can be temp/permanent
improvement up to 18-24m - after this little chance of further improvement
if not settling after a few days then refer them
78
post ext instructions
things to help healing
-don't rinse until next day - hot salty MW
-avoid trauma - finger/tongue/hard food
-avoid hot food that day
-avoid exercise and alcohol that day
-no smoking
pain advice
control of bleeding
- damp gauze/tissue bite for 30mins, contact if can't arrest
other symptoms to expect e.g. bruising, swelling
79
dry socket technical name
alveolar/localised osteitis
80
incidence of dry socket
2-3% of all exts
| some say up to 20-35% of L8s
81
pathogenesis of dry socket
normal clot disappears - appear to be looking at bare bone/empty socket - partially/completely lost blood clot
localised osteitis - inflammation affecting lamina dura
some say clot does not form/some say clot breaks down
82
time course of dry socket
often starts 3-4 days after
- if pt C/O pain straight after LA wears off then check no fragments of tooth/bone left in socket (can radiograph)
takes 7-14 days to resolve
83
dry socket symptoms
intense dull aching pain - mod/severe
- worse than toothache/pt kept awake at night
usually throbs/can radiate to ear
often continuous
exposed bone is sensitive and is the source of the pain
characteristic smell/bad odour
bad taste
84
is dry socket an infection?
some suggest subclinical infection
BUT
does not show features of overt infection - no fever/swelling/pus, don't generally give ABs
delayed healing but not associated with infection
85
management of dry socket
supportive - reassurance/analgesia
check socket (radiograph/check other teeth?)
- check no tooth fragments/bony sequestra
LA block to get out of pain then start analgesia
irrigate socket with warm saline
- give pt syringe and warm salty water x2-4 per day
curettage/debridement
fill socket with antiseptic pack
hot salty MW
keep eating and drinking
review pt
takes 1-2wks to settle
86
dry socket predisposing factors
molars more common (posterior teeth)
mandible (less blood supply)
smoking (less blood supply, poorer healing)
F
OCP
LA - vasoconstrictor - if use lots shut down bv's
?infection from tooth
?haematogenous bacteria in socket
excessive trauma during extraction
excessive mouth rinsing post-extraction (clot washed away)
FH/prev dry socket
- can vary from site so doesn't mean you will get one every ext
87
management of dry socket - curettage/debridement
curette/Mitchell's trimmer
scrape out any old clot material
encourage bleeding/new clot formation
some suggest shouldn't do this as it produces more bare bone and removes any remaining clot
88
management of dry socket - antiseptic pack
often have sedative/LA/anti-inflammatory/disinfectant agents
BIP
Alvogyl
soothe pain, prevent food packing
89
management of dry socket - antiseptic pack BIP
bismuth subnitrate and iodoform pack. comes as a paste or impregnated gauze. antiseptic and astringent. not dissolving, may need mattress suture, will need to remove
90
management of dry socket - antiseptic pack Alvogyl
mixture of LA and antiseptic
disintegrates
no sutures
don't need to remove
91
dry socket review
review pt/change packs and dressings
| as soon as pain resolves get packs out to allow healing
92
ABs for a dry socket?
generally no as not infection
| only if swelling/systemically unwell
93
when would you use CHX?
only in infection
| not in fresh wounds - risk of anaphylaxis if into bloodstream
94
sequestrum
```
quite common
prevent healing
usually bits of dead bone - can see white spicules coming through gingivae - pt often thinks you have left a part of the tooth
can also be pieces of amalgam
delays healing - remove. may need LA
```
95
incidence of infected socket
rare after routine extraction
more common after MOS - flaps and bone removal
dry socket more common
96
presentation of infected socket
just socket not full jaw bone
| occ pus discharge
97
management of infected socket
check for remaining tooth/root fragments, bony sequestra, foreign bodies
check for cyst
radiograph and explore
irrigate/remove any of above
consider ABs if swelling/systemically unwell
infection delays healing
98
OAC bone vs ST deficit
bone deficit will always be bigger than ST deficit
99
retrieval of root in antrum
OAF approach/through socket - open fenestration with care - bone nibblers or electric bur
suction - efficient and narrow bore
small curettes
irrigation - last resort
ribbon gauze - damp, leave a tail so you can pull it out
close with BAF
antibiotics and monitor
Caldwell-Luc approach
- side of buccal sulcus (cut rectangular buccal window)
ENT - endoscopic approach
100
osteomyelitis
affects bigger area of bone than infected socket
inflammation of bone marrow
clinically term implies infection of the bone
rare
101
osteomyelitis symptoms
often systemically unwell
usually mandible
ext site often v tender
if deep-seated infection may see altered sensation due to pressure on IAN (lip numb/tingling)
102
OM pathogenesis
usually begins in medullary cavity involving cancellous bone
then extends and spreads to cortical bone
then eventually to periosteum (overlying mucosa red and tender)
invasion of bacteria into cancellous bone causes ST inflammation and oedema in the closed bony marrow spaces
oedema in an enclosed space leads to increased tissue hydrostatic pressure - higher than bp of feeding arterial vessels
compromised blood supply - ST necrosis
area becomes ischaemic and necrotic - so can overlying STs
bacterial proliferate because normal blood borne defences do not reach the tissue
spreads until arrested by antibiotic and surgical therapy
103
why does OM occur much more commonly in mandible?
maxilla rich blood supply - several arteries
mandible main blood supply inferior alveolar artery and dense overlying cortical bone limits penetration of periosteal blood vessels - so poorer blood supply and more likely to become ischaemic and infected
104
OM predisposing factors
rarely occurs when host defences are intact
major predisposing factors - odontogenic infections and fractures of mandible
but even in these situations still rare unless host defences compromised
- diabetes
- alcoholism
- IV drug use
- malnutrition
- myeloproliferative disease e.g. leukaemia, sickle cell disease, chemo txed cancer
but rarely can occur around infected teeth/after exts/(PDD)
105
diagnosing early OM
can be difficult to distinguish from dry socket/localised infection in socket
acute suppurative OM shows little/no change radiographically
- at least 10-12 days for lost bone to be detectable radiographically
106
diagnosing chronic OM
+/- pus
bony destruction in the area of infection
increased radiolucency = uniform or patchy with a 'moth-eaten' appearance
areas of radiopacity may occur within the radiolucent region - unresorbed islands of bone - sequestra, dead bits of bone
107
what is a possible radiographic feature of long-standing chronic OM?
increase in radiodensity surrounding the radiolucent area
an involucrum
result of an inflammatory reaction - bone production increased
108
OM microbiology
occurs in other areas of body - not specific to jaws
mandible different from other areas of body - main bacteria similar to those involved in odontogenic infections - streptococci, anaerobic cocci, anaerobic gram - rods
in other bones - staphylococci predominate - skin-type infectious bacteria
109
overview of OM Tx
medical
(surgical)
investigate host defences - blood investigations/glucose levels - get medical consult
recognise it and refer
110
OM antibiotic tx
clindamycin/penicillins
effective against odontogenic infections and good bone penetration
longer course than usual
often weeks in acute - some suggest at least 6wks after resolution of symptoms
months in chronic - up to 6m
severe acute may require hospital and IV antibiotics - if systemic symptoms
need to monitor pts during this time
111
OM surgical tx
drain pus if possible
remove any non-vital teeth in area of infection - get rid of sources of infection
remove any loose pieces of bone
in fractured mandible - remove any wires/plates/screws in area
corticotomy - removal of bony cortex
perforation of bony cortex - if leaving bits of cortex use drill to make holes to perforate
excision of necrotic bone - until reach actively bleeding bone tissue
may need reconstructive surgery afterwards
112
ORN pathogenesis
pts who have had radiotherapy of H+N to tx cancer
bone within radiation beam becomes virtually non-vital
end arteritis - reduced blood supply
turnover of any remaining viable bone is slow
self-repair ineffective
worse with time
mandible most commonly affected - poorer blood supply
113
different suggestions for ORN
```
some - careful routine extraction
others
- surgical extraction
- alveoplasty - cutting down alveolus so gum can close over it properly
- primary closure of ST
```
114
ORN prevention
scaling/CHX MW leading up to extraction
careful ext technique
- handle STs v carefully
antibiotics, CHX MW (not open wounds), review
hyperbaric O2 - to increase local tissue oxygenation and vascular ingrowth to hypoxic areas before and after extraction
take advice/refer pt
115
ORN tx
irrigation of necrotic debris
ABs not overly helpful unless secondary infection
- often use if diabetic, worried about host defences
- not great penetration into bone
loose sequestra removed
small wounds (<1cm) usually heal over weeks/months
severe cases - resection of exposed bone, margin of unexposed bone and ST closure
- may need reconstructive surgery afterwards
hyperbaric O2
116
where does MRONJ occur?
only the jaws - both maxilla and mandible
117
when does MRONJ occur?
post-ext/following denture trauma/spontaneous
| risk higher in IV
118
MRONJ risk factors
```
IV
length of time pt on drug
diabetes
steroids
anticancer chemotherapy
smoking
```
119
range of MRONJ
from small asymptomatic areas of exposed bone to extensive bone exposure/dehiscence/pus/pain/EO draining sinus
120
bisphosphonates
class of drugs used to treat osteoporosis, Paget's disease and malignant bone metastasis
inhibit osteoclast activity so bone resorption so inhibit bone renewal
- need bone resorption for remodelling
drugs may remain in body for years
121
oral bisphosphonates
```
alendronic acid
ibandronic acid
risedronate sodium
clodronate
etidronate
```
122
IV bisphosphonates
ibandronic acid
zolendronic acid
pamidronate
123
incidence of MRONJ
cancer pts treated with anti-resorptive and antiangiogenic drugs: 1.6-14.8%
osteoporosis pts txed with anti-resorptive drugs: 0.1-0.5%
124
MRONJ prevention/tx
```
avoid ext if possible - coronectomy
if ext required - careful technique and monitor
warn pt to look for signs
take advice/refer
tx not that successful
```
manage symptoms/remove sharp edges of bone/CHX MW/ ABs if suppuration
debridement/major surgical sequestromy/resection/hyperbaric O2 have not proved that successful
- but each surgical intervention could make it better/same/worse - explain to pt
125
medication at risk for MRONJ
antiresorptive - bisphosphonates
RANKL inhibitors - Denosumab
anti-angiogenic
126
pts at low risk for MRONJ
bisphosphonates: tx for osteoporosis/non-malignant bone diseases, oral, <5yrs, not concurrently being txed with systemic glucocorticoids
bisphosphonates: tx for osteoporosis/non-malignant bone diseases with 1/4 or yearly infusions of IV for <5yrs and not concurrently being txed with systemic glucocorticoids
pts txed for osteoporosis/non-malignant bone diseases with denosumab who are not being txed with systemic glucocorticoids
127
pts at higher risk for MRONJ
non-malignant bone diseases
- oral/IV bisphosphonates >5yrs
- bisphosphonates/denosumab for any length of time who are being concurrently txed with systemic glucocorticoids
pts being txed with ant-resorptive /antiangiogenic drugs for cancer
pts with prev MRONJ diagnosis
128
MRONJ risk factors
```
dental tx
duration of bisphosphonates
implants
other concurrent meds
prev drug history
```
129
MRONJ risk factors - dental tx
impact on bone - extractions
trauma from dentures
infection
PDD
130
MRONJ risk factors - duration of bisphosphonates
increased dose and increased duration
131
MRONJ risk factors - implants
unknown
general consensus is to avoid implant placement in high doses of anti-resorptive/anti-angiogenic drugs for cancer
not contraindicated in pts with osteoporosis - need to weigh up risks w pt so they understand
insufficient evidence to indicate whether bisphosphonates have a negative impact on implant survival. failure rates similar to those not on bisphosphonates
132
MRONJ risk factors - other concurrent meds
steroids
| anti-angiogenics
133
MRONJ risk factors - prev drug history
no evidence to inform the assessment of risk for pts who have prev taken antiresorptive/antiangiogenic drugs
consider at risk due to long 1/2 life of these drugs
Denosumab's effect on bone turnover diminishes after 9m of finishing tx
anti-angiogenic drugs are not thought to remain in the body for extended periods of time
134
MRONJ risk factors - drug holidays
no evidence
dentists should not take responsibility for stopping a patients drug
responsibility of prescribing physician
pts with osteoporosis who are being txed with 6monthly SC injections of denosumab may have tx one month prior to drug administration. resume drug after ST closure
135
extractions in pts at risk of MRONJ
in primary care
| no benefit of referral to secondary care based purely on their exposure to these drugs
136
actinomycosis
rare bacterial infection
| fairly chronic
137
actinomycosis microbiology
actinomyces israelii/ A naeslundi / A viscosus
bacteria have low virulence and must be inoculated into an area of injury or susceptibility (susceptible host e.g. diabetic)
e.g. recent ext/severely carious tooth/bone fracture/minor oral trauma
138
actinomycosis pathogenesis and symptoms
erodes through tissues rather than follow typical fascial planes and spaces
- normally infection would go through path of least resistance
multiple skin sinuses and swelling
thick lumpy pus
responds initially to AB therapy, recurs when stop AB - quite deep-seated and chronic
139
actinomycosis tx
I+D of pus accumulation
excision of chronic sinus tracts
excision of necrotic bone and foreign bodies
high dose ABs for initial control (often IV)
long-term oral ABs to prevent recurrence - weeks/months
- penicillins, doxycycline or clindamycin
140
actinomycosis histology
colonies of actinomyces look like sulphur granules
141
IE NICE 2016
not recommended routinely for those undergoing dental procedures
142
IE
inflammation of endocardium particularly affecting heart valves or CMP caused by bacteria
rare
mortality about 20%
143
IE defined at risk groups
acquired valvular heart disease
previous IE
structural CHD
valve replacement
144
IE advice to give pt
benefits and risks of ABP and explanation of why no longer routinely recommended
importance of maintaining good oral health
symptoms that may indicate IE and when to get advice
risks of undergoing invasive procedures inc non-medical procedures such as body piercing or tattooing
CHX should be offered as prophylaxis
145
SDCEP IE ABP dose
```
single dose 60mins before
amoxicillin/ampicillin 3g
if allergy to penicillin
- clindamycin 600mg
- azithromycin 500mg
```
146
dental procedures for which ABP may be recommended
manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa
