Oral Surgery

Question 1

What are the symptoms of pulp hyperaemia?

Answer 1

Pain lasting for seconds, stimulated by sweet or cold foods, resolves after stimulus removed

Question 2

What causes pulp hyperaemia?

Answer 2

Caries close to the pulp but not in the pulp, can be treated without treating pulp. Also known as reversible pulpitis

Question 3

What are the clinical features of acute pulpitis?

Answer 3

constant severe pain that lingers when stimulus removed, response to thermal stimuli, no response to TTP, analgesics don’t help

Question 4

If untreated, what is the pathway following acute pulpitis?

Answer 4

Becomes chronic - can flare up every now and again
Becomes acute apical periodontitis

Question 5

What are clinical features of acute apical periodontitis?

Answer 5

TTP, radiolucency at apex, unclear lamina dura, can tell you exactly where pain is coming from, tooth non-vital

Question 6

How can you differentiate between acute apical periodontitis and traumatic occlusion?

Answer 6

traumatic occlusion - the tooth will be vital, there will be widening of PDL on radiograph, need to examine occlusion

Question 7

how does acute apical periodontitis develop in the pathway

Answer 7

to an acute apical abscess

Question 8

what are the clinical features of an acute apical abscess?

Answer 8

before it erodes through bone and soft tissue - similar to acute apical periodontitis - TTP, tender in function, severe pain
After it erodes through - release of pain, as no longer a build up, initial reduction in TTP as pus escapes through soft tissue, swelling, redness heat

Question 9

how would you treat an acute apical abscess

Answer 9

incision and drainage - either intra orally or extra orally depending on swelling
removal of source of infection - extraction of tooth, pulp extirpation

Question 10

how do you assess the need for antibioitics?

Answer 10

local factors - is the swelling compromising the airway, dysphagia, trismus, toxicity
patient factors - immunocompromised patients (HIV, drug induced - steroids, blood disorders - leukemia), elderly, diabetes

systemic involvement - malaise and fever
spreading infection - cellulitis, lymph node involvement, swelling

Question 11

describe periapical granuloma (chronic apical periodontitis)

Answer 11

mass of chronically inflammed granulation tissue at apex of tooth - plasma cells, lymphocytes, fibroblasts, capillaries

Question 12

why is the mylohyoid line important in spreading dental infection

Answer 12

this is the line where mylohyoid muscle attaches to the mandible. Infection above this line will spread in to the sublingual space, whereas infection below this will spread into submandibular space

Question 13

what causes a cavernous sinus thrombosis

Answer 13

infection in facial vein (can come from dental infection in maxillary teeth), this vein drains into cavernous sinus, which has venous connections into the brain - can develop an infection in the brain

can come from infection into canine space

Question 14

name the pathways of spreading infection for upper anterior teeth

Answer 14

lip, nasolabial region - spreads buccally but below muscle attachment so spreads into mouth, lower eyelid - infraorbital more common in canine as root is longer. lateral incisor can drain into palate as root is palatal
canine space - up to eye

Question 15

name the areas where upper premolars and molars infection can spread to

Answer 15

cheek - above buccinator attachment
infratemporal region - can communicate with other areas in cheek so spreads to infra orbital
palate - uncommon
maxillary antrum

Question 16

how can infection from mandibular teeth spread

Answer 16

anterior teeth - mental and submental
posterior teeth - buccal, sublingual, submandibular initially then spreads backwards to lateral pharangeal space and can push on airways

Question 17

how do you manage spreading infection

Answer 17

drainage - intraoral or extra oral incision
removal of source - extraction or extirpate pulp
antibiotics - depends on patient and area of abscess

Question 18

what 3 things can you check in a dental chair for systemic involvement of infection

Answer 18

increased heart rate, increased temperature and increased respiratory rate

Question 19

what is ludwig’s angina

Answer 19

bilateral cellulitis of the sublingual and submandibular spaces

Question 20

what are the features of ludwigs anginga

Answer 20

extra orally - swelling and redness in submandibular region on both sides
intra orally - swelling in sublingual, difficulty breathing and swallowing, drooling

Question 21

what soft tissue surgeries can be carried out to aid denture retention?

Answer 21

excision - removal of frenulum (lingual, buccal, labial) removal of denture induced hyperplasia, removal of flabby ridges, reduction of retromolar pad and maxillary tuberosity

Question 22

what is denture induced hyperplasia

Answer 22

denture flanges are over extended, or given an immediate and told to come back for a new one and dont - digs in and causes ulceration and keratosis

Question 23

what is a knife edge ridge and why does it interfere with denture

Answer 23

when the alveolar ridge is sharp (normally mandibular anterior) but covered by gingiva, when patient wears denture it digs into this sharp ridge and is uncomfortable, can be smoothed in surgery

Question 24

how can flabby ridges affect denture fit

Answer 24

they bend and move when pressed against - remove soft tissue and cover bone

Question 25

what hard tissues can be removed to improve denture fit

Answer 25

mandibular tori, palatine tori, retained roots, unerupted teeth, ridge defect

Question 26

why are retained roots/teeth a problem for denture fit

Answer 26

the alveolar bone resorbs due to lack of teeth and the teeth/roots can come to the top, painful for the denture to sit on and risk of infection

Question 27

what are common causes of temporomandibular joint dysfunction

Answer 27

inflammation of muscles of mastication or TMJ due to parafunctional habits - clench teeth, grinding. Joint dysfunction or myofascial pain

Question 28

what is the pathophysiology of TMD

Answer 28

when closed, PT puts pressure on disc - clenching - this causes disc to slip forward. When patient goes to open their mouth there is an obstruction (disc) so condyle cannot move. The patient manipulates jaw slightly (move to one side) to get disc back in place. Can then open jaw as condyle can move forward. This can cause pain in joint and ear. Can have popping sound as disc goes back into place. This is anterior displacement with reduction.

Question 29

How is TMD treated

Answer 29

counselling - reassurance, education, stop habits - bite raised appliance. soft diet, dont open too wide, support jaw on opening. Can advise NSAIDs and muscle relaxants

Question 30

what are less common causes of TMD

Answer 30

ankylosis, hyperplasia, degenerative disease, infection, chronic recurrent dislocation, neoplasia

Question 31

what does impacted mean

Answer 31

eruption is blocked

Question 32

what is a result of impaction

Answer 32

caries, pericoronitits, cyst formation

Question 33

what nerves are at risk during M3M surgery

Answer 33

lingual nerve, inferior alveolar nerve, nerve to mylohyoid, long buccal nerve

Question 34

what is the location of the lingual nerve

Answer 34

lies on the superior attachment of the mylohyoid muscle - close relationship to lingual plate in mandibular and retromolar area

Question 35

what were the previous guidelines for extraction of M3M and why were they updated

Answer 35

previously - do not extract unless clinical evidence of disease. High risks of surgery so would have to justify removal. This has changed as it was thought to be postponing the inevitable - if left in situ, infection would develop and would make the surgery more complicated and risks would be greater.

Question 36

what are therapeutic indications for extraction of 3rd molars

Answer 36

infection - pericoronitis, caries cyst formation tumours external resorption of 7 or 8

Question 37

what are other indications for extraction (not therapeutic)

Answer 37

within surgical field medical reasons - to be dentally fit, beginning radiotherapy treatment, heart surgery, immunosupressed high risk of disease developing acessibility - not in the country submariners eg getting a GA - wouldnt want risk of needing another GA soon

Question 38

what is pericoronitis

Answer 38

inflammation around the crown of the tooth. Tooth is normally partially erupted, inflammation of gum on eruption - formation of operculum - flap of gum preventing eruption. Food trapping at operculum - inflammation and infection, caused by anaerobic microbes

Question 39

what are signs and symptoms of pericoronitis

Answer 39

pain, swelling intra oral and extra oral, occlusal trauma to operculum, cheek biting, limited mouth opening, lymphadenopathy, fever, malaise, suppurating pus, bad taste in mouth

Question 40

how is pericoronitis treated

Answer 40

if pericoronal abscess - incise and drain use blunt needle to irrigate gently at operculum - with saline or chlorhexidine - remove food and bacteria. If trauma to operculum from maxillary 3rd molar - may remove this. Should only prescribe antibiotics if systemic involvement - fever, malaise, lymphadenopathy. Advice on analgesia

Question 41

what should be included in your history taking for assess 3rd molars?

Answer 41

presenting complaing, HPC (SOCRATES + how many episodes) history of swelling - how long, has it gotten bigger - MH any relevant medications or diseases that would interfere with treatment, SH - if they have a job, are a carer - might be affected for a couple fo days after surgery - DH - have they had dental treatment before, dentally anxious

Question 42

what should be included in the clinical history when assessing 3rd molars

Answer 42

extra oral: TMD - can have pre-auricular pain, might think it is M3M MOM, lymph nodes, asymmetry, mouth opening intra oral: soft tissues, current dentition - carious etc., status of M2M, eruption status of M3M - pus, caries, operculum, occlusion to maxillary, working space distal to ramus of mandible - periodontal status

Question 43

when should you take a radiograph of M3M

Answer 43

only if surgical intervention is happening - do not expose dose if just monitoring, it is not necessary. OPT is preferred but PA can also be done

Question 44

what should be recorded on radiographic report of OPT for 3rd molar

Answer 44

presence or absence of disease anatomy of 3M - crown shape, root shape, no. of roots, caries orientation of impaction depth of impaction working space - 3M to ramus of mandible follicular status periodontal status relationship of 3M to maxillary sinus or inferior alveolar nerve canal

Question 45

what radiographic signs are most commonly associated with an increase risk of damage to inferior alveolar nerve during 3M surgery

Answer 45

diversion of the inferior dental canal - as canal passes 3M it bends to take outline of root - normally inferior darkening of the root where crossed by the canal - dark band across root interruption of the white lines of the canal - white line disappears

Question 46

when might further imaging be required prior to 3M surgery

Answer 46

if conventional imaging has shown a potential close relationship between 3M roots and IAN canal - CBCT can be used If concerned of caries - PA could be used

Question 47

what are potential orientations of impaction of 3M

Answer 47

mesial, distal, vertical, horizontal, transverse, aberrant

Question 48

how do you confirm angulation of impaction of a M3M

Answer 48

draw a horizontal line along curve of spee, then draw line vertical from roots of 3M - the angulation of where these lines meet will tell you the angulation of tooth. Can also compare to vertical line of 7

Question 49

what would be the definition of a superficially impacted M3M

Answer 49

crown of 8 is related to crown of 7

Question 50

what would be the definition of a moderately impacted M3M

Answer 50

crown of 8 is related to crown and roots of 7

Question 51

what would be the definition of a deeply impacted M3M

Answer 51

crown of 8 is only related to roots of 7

Question 52

what are common treatment options for M3M

Answer 52

referral - to oral surgery department in dental hosp, MFDS unit, specialist clinical review - monitor extraction of maxillary 3M coronectomy

Question 53

when might no treatment be required for M3M

Answer 53

if no disease or low risk of disease associated

Question 54

what should be included during the consent process

Answer 54

procedure - what is involved in a way that the patient understands, if there is a need to drill bone or section tooth or raise a flap and place a stitch complications - risks involved

Question 55

what post operative complications are common in M3M surgery

Answer 55

pain, bleeding, bruising, swelling, infection, limited mouth opening, dry socket numbess/altered sensation to chin/lip/tongue - damage to IAN - may be permanent or temporary altered taste - damage to lingual nerve, chorda tympani runs in this

Question 56

how long after surgery can nerves recover

Answer 56

18-24 months, after this, recovery is rare

Question 57

what should be included in a referral for M3M surgery

Answer 57

Situation - PT presents with pain associated with impacted 48 Background - HPC, how many episodes, were antibiotics prescribed Assessment - moderate mesially impacted, caries, OHI difficult, food packing - include MH and SH Recommendation - PT is keen for surgical removal and i think this is indicated in this case

Question 58

what are the functions of the maxillary sinus

Answer 58

vocal resonance, warming inspired air, lightening the skull

Question 59

how is a OAC diagnosed

Answer 59

lining at the trifuraction of molar, radiographic view of roots in sinus, investigate with blunt probe, good lighting can see dark hole, blood bubbling when breathing, air gushing through into mouth, good suction causing echoing in sinus

Question 60

how is an OAC treated

Answer 60

if small - less than 2mm - encourage bleeding and clot formation then close over with silk sutures. post op instructions - avoid blowing nose, smoking, drinking through straw, singing and review. if larger - close with buccal advancement flap - 3 sided flap, remove buccal bone, release from periosteum, then ensure no tension when pulling over defect and suture. same post op and antibiotics

Question 61

what are the differences in OAC and OAF

Answer 61

OAC is acute, just happened right after extraction. OAF is established, epithelial lining between two areas. chronic. OAF is treated differently - incision circular around defect up to sinus, to remove epithelium then close with buccal advancement flap

Question 62

how is a fractured maxillary tuberosity diagnosed and what is the aetiology

Answer 62

extraction of a lone standing molar, extraction in the wrong order, unknown unerupted molar and poor alveolar support is the aetiology, diagnosed by seeing or feeling movement of the aveolar bone, bone on the tooth extracted, hearing a crack

Question 63

how is a fractured tuberosity treated

Answer 63

if tooth is extracted, dissect and close over, if stopped before extraction - splint tooth on adjacent teeth, take it out of occlusion and extirpate pulp, then extract surgically in 4-6 weeks. antibiotics or antispetics may be required

Question 64

what are the signs and symptoms of sinusitits

Answer 64

congested - feeling heavy, headache, facial pain, ear pain, dental pain (sensitivity of all upper teeth), pain when moving head (downwards then upwards), pressure, nasal voice, fever

Question 65

how can sinusitis be treated

Answer 65

primarily treat symptoms - decongestant - 0.5% ephedrine nasal drops - one in each nostril 3 times a day as required for maximum 7 days if ongoing, antibtioics may be required - look this up as to which ones to use - SIGN GUIDELINES

Question 66

what are the sepsis signs

Answer 66

HR - increased above 91, higher than 130 very worried BP - systolic below 90-80 O2 - below 95% RR - above 22 temperature - above 38 or below 36 confused mental state not passed urine in over 12-18 hours

Question 67

what is the sepsis 6

Answer 67

3 in. - IV antibiotics - metronidazole and phenoxymethylpenicillin until culture tells us specific ones IV fluids and oxygen 3 out - blood for cultures, lactace levels and urine output

Question 68

what is MRONJ

Answer 68

medication related osteonecrosis of the jaw. Patients on specific medication which reduces bone turnover and blood supply to bones - for prostate or breast cancer, osteoporosis. delayed healing after extraction due to reduced action of osteoblasts and reduced blood supply to bone

Question 69

what medications can cause MRONJ

Answer 69

bisphosphonates - alendronic acid, zolendronic acid RANKL inhibitors - densosumab anti-angiogenic

Question 70

what must be fulfilled for a diagnosis of MRONJ

Answer 70

must be on one of the medications never had radiotherapy to h&n delayed healing 8 weeks after extraction

Question 71

what constitutes no risk of MRONJ

Answer 71

never been on medication or stopped denosumab more than 9 months ago

Question 72

what constitutes low risk of MRONJ

Answer 72

on denosumab in the last 9 months bisphosphonate medication for less than 5 years and no systemic glucocorticoid taken

Question 73

what constitutes higher risk of mronj

Answer 73

on bisphosphonates for more than 5 years or on it for less than 5 years but also taken glucocorticoid

Question 74

how are patients with low risk of MRONJ treated

Answer 74

advise of risk, give ohi, diet advice, alcohol advice, smoking cessation if extraction required - treat as normal and gain valid consent by advising them of risk review 8 weeks after xla and refer is MRONJ present

Question 75

how are patients with high risk of MRONJ treated

Answer 75

advise of risk, make xla last resort, exhaust all other measures first - retained roots, decoronation review 8 weeks post xla for MRONJ and refer if there

Question 76

what are the classifications of MRONJ

Answer 76

0 - previous MRONJ but no evidence of exposure 1 - evidence of exposure but no symptoms or infection 2 - exposure with symptoms and infection 3 - as 2 but with extra-oral fistula/extending past alveolar bone/ oral-antral communication

Question 77

what general advice should be followed for all patients on anti-coagulant medication

Answer 77

should be carried out earlier in the day and week pre and post instructions should be given local measures should be carried out to prevent bleeding - pressure, pack, suture initial treatment should be limited and bleeding assessed before progress complex and invasive treatment should be staged emergency contact details should be given patient should not leave until haemostasis has been achieved

Question 78

what constitutes a high risk bleeding procedure for patients on NOACs and how is this managed

Answer 78

any procedure raising a flap biopsy gingival contouring if take two doses a day - miss morning dose but take evening as normal if take one morning dose - delay morning dose until 4 hours after haemostasis has been achieved

Question 79

what constitutes a low risk bleeding procedure for patients on NOACs and how is this managed

Answer 79

simple extractions of 1-3 teeth, provided they are not adjacent to one another RSD, subgingival restoration, 6PPC no changes to their medication dosage

Question 80

how are patients on warfarin managed

Answer 80

should have INR checked 24 hours before procedure (can be up to 72 but only if well controlled) if above 4 - delay treatment or if urgent, refer if below 4 - continue as normal but carry out general advice

Question 81

what medications can anti-coagulant interact with

Answer 81

NSAID - increased risk of bleeding carbmazepine - increased risk of thrombosis fluconazole and miconazole - warfarin - increased bleeding risk