Oral Surgery Flashcards
(283 cards)
1
Q
Give 7 indications for surgical tooth removal.
A
- Gross caries (inability to use forceps or elevator)
- Complex root morphology
- Retained roots below alveolar bone
- Impacted teeth
- Displaced teeth
- Ectopic teeth
- Pathology (e.g. cyst)
2
Q
Define, prevention of complete eruption into a normal functional position due to lack of space or development in an abnormal position.
A
Impaction
3
Q
Define, malpositioning of a tooth due to congenital factors, such as a cleft palate.
A
Ectopic tooth
4
Q
Define malpositioning for a tooth due to presence of pathology, such as a cyst.
A
Displaced tooth
5
Q
Describe a tooth that is “completely unerupted”.
A
Entirely covered by soft tissue and also partially/totally covered in alveolar bone.
6
Q
Describe a tooth that is “ankylosed”.
A
Fused with alveolar bone
7
Q
At what age do mandibular 3rd molars tend to emerge in the oral cavity?
A
18-24 years old
8
Q
In what ratio of adults, do mandibular third molars fail to develop?
A
1:4
9
Q
What % of mandibular molars tend to be impacted?
A
72%
10
Q
What guidelines should be referred to regarding removal of third molars?
A
NICE 2000
11
Q
What % of mandibular third molars are removed as a result of pericoronitis?
A
8-59%
12
Q
What is the most common indication for removal of mandibular third molars?
A
Pericoronitis
13
Q
Define, inflammation of the tissues around the crown of any partially erupted/impacted tooth.
A
Pericoronitis
14
Q
Is one isolated incidence of pericoronitis an indication extract a third molar?
A
No, one incidence is not a reason to extract as pain is going to happen while tooth erupts. It is when there are 2 or more recurring episodes.
15
Q
What are the common features of pericoronitis? (Name 7)
A
- Trismus
- Pain
- Pus under operculum
- Dysphagia
- Malaise
- Bad taste (halitosis)
- Cheek biting and cuspal indentations on the operculum
16
Q
If patient is systemically well, what is the treatment for pericoronitis?
A
- Local measures, including:
- Irrigation with warm saline
- OH measures - Removal of trauma e.g. extraction upper 8 or grind down cusps
17
Q
If a patient is systemically unwell/immunocompromised, what is the treatment for pericoronitis should be considered, but is not a first line option?
A
Antibiotics
18
Q
What type of bacteria cause pericoronitis?
A
Predominantly anaerobic (e.g. strep, Actinomyces etc.)
19
Q
What two bacteria have been related to the increased incidence of second and third molar periodontal pockets deepening >4-5mm over two years?
A
- Prevotella intermedia
- Campylobacter rectus
20
Q
When is it appropriate to prescribe antibiotics to treat pericoronitis?
A
If there is evidence of systemic spread of infection OR surgical removal of the cause or drainage of the infection under LA is impossible
21
Q
Why is it that patients might complain of sensitivity on their 2nd molar after removal of their third?
A
Due to gum recession (usually distally), tooth becomes exposed and more sensitive
22
Q
What radiographic assessment is best for visualising 3rd molars?
A
OPG (DPT)
23
Q
Why are winters lines used in radiographic assessment?
A
A way of assessing how much bone is likely to be removed in the process of surgery
24
Q
What are the different classifications of angulation of 3rd molars to adjacent teeth?
A
- Vertical
- Mesioangular
- Distoangular
- Horizontal
25
What are 6 radiographic indications of 3rd molar proximity to the IDC canal?
1. Narrowing and darkening of canal as nerve crosses root
2. Loss of lamina dura of IDC
3. Deflection or deviation of IDC
4. Dilaceration or deflection of roots as they approach IDC
5. Change in colour of roots when crossed by the nerve so that the area appears darker
6. Juxta-apical area
26
What is the most common type of angle of impaction of 3rd molars? (Give % of cases)
Mesialangular impaction (40%)
27
What is the main consequnece of mesioangular impaction of 3rd molar?
Patient unable to clean between contact points of 3rd and 2nd molar so this becomes a plaque troop and caries can develop on surfaces of both teeth.
28
What is a juxta-apical area on a DPT?
A well circumscribed radiolucent area lateral to the root rather than at the apex
29
What are the highest risk radiographic signs of a close relationship of 3rd molar to IDC?
Darkening of roots and juxta-apex
30
What is the benefit of taking a CBCT image of high risk relationships between the 3rd molar and IDC?
The CBCT will show you exactly where the nerve canal lies in relation to roots as its a 3D image
31
For the lower lip, what is the short and long term chance of post operative alteration in sensation from extraction of a 3rd molar?
Short term - 5%
Long term- <1%
32
For the tongue, what is the short and long term chance of post operative alteration in sensation from extraction of a 3rd molar?
Short - 10%
Long - <1%
33
What is an alternative surgery that can be used if there is high risk of impact to IDN?
Coronectomy
34
What is a coronectomy?
Where you remove the crown and leave the roots in place
35
If the roots are mobile at the time of coronectomy, what should be done?
Removal of the roots as they will now be non-vital and could become infected
36
What is the post-operative 1. risk of infection and 2. Risk of migration, of roots after coronectomy?
2.9% - risk of infection
14-81% - migration
37
What pre-operative warnings should you give to patients to mandibular third molar surgery?
1. Pain
2. Swelling
3. Bruising
4. Possible hypoaesthesia of lip/tongue
5. Trismus
6. Diet advice
38
What does hypoaesthesia mean?
Condition where sensation is reduced
39
What are the long-term probelms that you should warn a patient of if they chose to decline treatment of mandibular 3rd molar?
1. Development of further perio probelms
2. Caries on 2nd molar and 3rd molar
3. Cysts
4. External root resorption
5. Recurrent pericoronitis
40
What is the most common application point of an elevator for most teeth?
Mesiobuccaly
41
What flap design is used for surgical extractions of 3rd Molars?
Triangular flap
42
What is the difference between a triangular flap and an envelope flap?
There us no mesial relieving incision for an envelope flap
43
Describe the triangular flap in terms of incisions that need to be made.
1. Distal relieving incision (at ascending ramus)
2. Peri-coronal incision (cuts through alveolar crest fibres and papilla between 3M and 2M)
3. Mesial relieving incision (down from 2M to depth of sulcus)
44
What rpm should the bur to cut/remove bone be running at?
20,000-40,000rpm
45
Why is it important to use saline during bone removal?
So that bone doesn’t not overheat under use of bur
46
Why is bone removed in a surgical extraction?
1. To relieve impaction
2. To create a point of application for elevator or forceps
47
If a 3rd molar is horizontally impacted, what must be done as part of surgical extraction?
Crown and root sectioning
48
What is a major intrinsic obstacle for extraction of a 3rd molar?
Root form, dictates path of withdrawal.
49
What is the most important suture placed when suturing a flap and why?
The suture placed from the buccal tissues to the lingual tissues immediately distal to the 2nd molar tooth, so to encourage good periodontal health.
50
What material is used for suturing flaps?
3/0 Vicryl rapide
51
What post-operative regime should a patient follow after 3rd molar surgery?
1. Analgesics
2. Hot salt mouthwash
3. Soft diet
4. Topical ice packs within first 6 hours of treatment
52
Why does post-operative bleeding tend to occur more in older patients?
This is because the tissues lose their elasticity so you get bleeding into soft tissues spaces.
53
What are the 5 major complications to 3rd molar surgery that could arise?
1. Haemorrhage
2. Loose teeth or damage to adjacent teeth/restorations
3. Fractured mandible (very rare)
4. Dry socket or infection with purulent discharge
5. Sensory deficit of tongue or nerves
54
If maxillary third molars are erupted, how should they be extracted?
Either elevation or forceps extraction
55
If maxillary third molars are unerupted, how should they be extracted?
By surgical extraction. Raise a buccal flap, remove thin bone with couplins and elevate.
56
Why should you avoid excess upwards forces when elevating a maxillary 3rd molar?
Due to possible displacement of tooth into antrum
57
What is the second most commonly impacted tooth, after 3rd molars?
Maxillary canines
58
What is the prevalence of impacted maxillary canines?
1.7%
59
Are ectopic maxillary canines more likely to be found palatally or buccaly?
Palatally
60
At what age are maxillary canines normally palpable in the labial sulcus?
10-11 years old
61
What is thought to act as a guidance plane in the path of eruption for a maxillary canine?
The distal aspect of the lateral incisor
62
Clinically, how would you identify impacted maxillary canines? give 5 signs.
1. Canines can be palpated in the sulcus or palate age 12/13+ (late)
2. Evidence of rotation/tilting of adjacent teeth
3. Mobility/sensibility of adjacent teeth
4. More than 6 months since contralateral tooth has erupted
5. Presence of deciduous canine after expected age of exfoliation
63
Radiographically, how would you investigate impacted canines?
Parallax films:
1. Periapical x2
2. Occlusal
3. DPT
CBCT (In select cases)
64
What are the two treatment options for dilacerated, impacted teeth?
1. Do nothing and monitor
2. Surgical extraction
65
Can unerupted, dilacerated teeth be orthodontically aligned?
No
66
What can be sequelae of canine impaction, where a conservative treatment option is chosen?
1. Resorption of incisor roots
2. Cystic change
3. Infection of cyst close to surface mucosa may lead to sinus tract formation
67
What are the 5 treatment options for impacted canines?
1. Conservative
2. Interceptive
3. Exposure
4. Surgical removal
5. Auto-transplantation
68
What treatment option would be most appropriate in the case of impacted maxillary canines where…
- patient is unwilling to have orthodontic treatment
- patient is happy with appearance and has healthy adjacent teeth.
- radiographs show absence of pathology or resorption
Conservative treatment where the tooth is monitored over time
69
What treatment option would be most appropriate in the case of impacted maxillary canines where…
- patient is young (10-13 years old)
- minimal crowding of teeth and space can be maintained
Interceptive treatment, where the deciduous tooth is extracted in the hope that the permanent impacted tooth will have space to erupt.
70
What treatment option would be most appropriate in the case of impacted maxillary canines where…
- well motivated patient who is willing to have orthodontic treatment
- pt with good oral hygiene
- impacted canine is not grossly displaced
Exposure and alignment of impacted tooth
71
Describe the “open technique” for exposure and alignment of an impacted tooth. what is the disadvantage of this technique?
Apically repositioned flap or palatal window, where tissue overlying tooth is removed and the gingiva is sutured at a higher position than originally placed to encourage eruption.
Disadvantage = aesthetics can be poor, risk of exposure of canine roots upon erupting
72
Describe the “closed technique” for exposure and alignment of an impacted tooth. what is the advantage of this technique?
Where an orthodontic bracket and gold chain is attached to impacted tooth to allow orthodontic traction.
Advantage = mimics physiological eruption of canine, which means the impacted canine will erupt through attached gingiva and therefore give a good gingival contour.
73
What treatment option would be most appropriate in the case of impacted maxillary canines where…
- patient is non-compliant
- patient finds appearance satisfactory with C
- advanced resorption of incisors
- malpositioned canine with difficult root morphology
Surgical removal of canine (and any other teeth with extensive root resorption)
74
What is the technique for surgical removal of an impacted maxillary canine?
1. Usually palatal envelope flap made (can be buccal)
2. Removal of overlying bone to maximum convexity of tooth (sectioning may be required if root morphology complex)
3. Elevation of maxillary canine
75
If surgically removing bilateral maxillary canines, what is required during the procedure in order to cut the flap, that can only be justified for this specific procedure?
Severing contents of the incisive foramen (neurovascular bundle)
76
When using surgical instruments, what should always be used in conjunction? And why?
Saline irrigation, to prevent bone from overheating.
77
What is the failure rate of an auto-transplanted tooth?
Failure rate of 30% (high)
78
On plain film, what are the three most significant radiographic signs of a close relationship between the 3rd molar and the inferior dental canal?
1. Diversion of IAN canal
2. Darkening of the root
3. Interruption of the cortical white line
79
What management method of M3Ms is effective in minimising inferior alveolar nerve injury upon this tooth’s removal?
Coronectomy
80
What bacteria species have been related to the increased incidence of second and third molar periodontal pockets deepening (>4-5mm) over two years?
Prevotella intermedia and campylobacter rectus
81
Define, exaggerated sensation to touch, or cold or warm stimuli.
Hyperaesthesia
82
What is the most common complication after third molar surgery?
Dry socket (alveolar osteitis)
83
When might prophylactic removal of teeth (including M3Ms) be indicated for medical procedures? Give two examples.
Prior to organ transplantation or chemotherapy
84
What is the optimal post-operative pain management for dental extractions in adults?
Ibuprofen (400mg) + paracetemol (1000mg)
85
What are the two main risk factors for displacement of molar roots into the maxillary antrum?
1. Age over 40 years
2. Lone standing molars with ridge resorption and protrusion of molar roots into the antrum.
86
What is the key criteria for coronectomy?
1. High risk of IAN injury
2. Vital M3M
3. Healthy non-immunocompromised patient
87
What are the potential complications of coronectomy?
1. Mobilisation of roots intra operatively
2. Early recurrent dry socket and need for removal of roots following coronectomy
3. Late eruption and possible infection of retained roots
4. Injury to the lingual nerve and IAN
88
What is the main risk from ectopically placed canines?
Root resorption of adjacent teeth
89
When should a dental practitioner suspect that a canine is ectopic?
If it is not palpable in the buccal sulcus by the age of 10-11 years old
90
What is meant by parallax?
The apparent displacement of an object because of different positions of an observer
91
What age of patient should you start to annually attempt to palpate the canine region?
8 years old
92
What tooth is the 3rd most commonly impacted tooth in the mouth?
Maxillary incisors
93
What signs of delayed eruption would indicate investigation of maxillary incisors?
1. If contralateral teeth erupted 6/12 months previously or in the case when both upper centrals missing one year after eruption of lower incisors
2. Deviation from normal sequence of eruption, i.e. laterals erupt before centrals
94
What is the most common hereditary cause of impacted maxillary incisors?
Presence of supernumerary tooth
95
List the hereditary causes of an impacted maxillary incisor? (7)
1. Supernumeraries
2. Cleft lip/palate
3. Cleidocranial dysostosis
4. Odontomes
5. Abnormal tooth/tissue ratio
6. Gingival fibromatosis
7. Generalised retarded eruption
96
List the environmental causes of an impacted maxillary incisor? (6)
1. Trauma or root dilaceration
2. Early loss or extraction of deciduous tooth
3. Retained deciduous tooth
4. Cyst formation
5. Endocrine abnormalities
6. Bone disease
97
What management options are most commonly carried out for impacted maxillary incisors?
Exposure or Interceptive treatment
98
What is the 4th most likely impacted tooth in the mouth?
Mandibular premolars
99
What is the main cause of impacted mandibular premolars?
Crowding
100
What sort of flap is cut for surgical extraction of mandibular premolars?
2 sided flap (coronal and mesial relieving incisions)
101
What condition is hyperdontia associated with?
Cleidocranial dysostosis
102
What are the two types of Odontomes?
Complex or compound
103
How are complex Odontomes formed?
By invaginations of tooth germ or a genetic malformation called a hamartoma
104
What % of all odontogenic tumours do complex Odontomes account for?
22%
105
What causes compound Odontomes to form?
Exuberant proliferation of dental lamina
106
What Odontomes are most commonly found…
1. Anteriorly
2. Posteriorly
1. Compound
2. Complex
107
Define “dilaceration”
An acute deviation of the long axis of the tooth, located to the crown or root
108
In a younger patient (<9 years old) with an impacted immature permanent maxillary incisor, what is the best initial management?
Allow up to 9-12 months for the spontaneous eruption of the incisor after the removal of an obstruction (e.g. decidious tooth)
109
In an older individual (>9 years old) with an impacted immature permanent maxillary incisor, what is the best initial management?
Consider surgical exposure with bonding of orthodontic bracket attachement at the time of removal of any obstruction.
110
What is another name for maxillary sinus?
Sinus of highmore
111
What are the 4 bilateral paranasal sinuses?
1. Frontal
2. Ethmoid
3. Sphenoid
4. Maxillary
112
What structure do sinuses drain through?
An osteum
113
Where does the maxillary sinus drain into?
The middle meatus
114
What is pansinusitis?
A condition where all paranasal sinuses are inflamed
115
What is the best radiograph to take to view the maxillary sinuses?
Occipitomental (waters’ view)
116
Name 4 types of common pathology found in maxillary sinuses?
1. Infective sinusitis
2. Non-infective sinusitis (e.g. allergic)
3. Fractures
4. Tumours/cysts
117
What is a key feature of sinusitis that a patient might tell you about which could help lead you to a diagnosis of sinusitis?
Pain is worse on bending down
118
Why is pain of sinusitis worse when bending down?
Because the sinuses are full of muco-perulent material and this moves with gravity. So when a patient bends over it moves forward and sits on the anterior superior alveolar nerve which runs down the anterior wall of the sinus, this puts pressure on the nerve which makes the pain worse.
119
What are the key clinical signs of acute infective sinusitis?
1. Pain, tenderness across sinuses
2. Posterior teeth TTP
3. Post-nasal drip
4. Mucopurulent discharge
120
What size is the osteum of the maxillary sinuses?
2.4mm
121
What are the two causes of sinusitis?
1. Mechanical obstruction of the osteum
2. Impaired mucous clearance
122
What are the three complications of sinusitis?
1. Brain abscesses
2. Orbital cellulitis
3. Cavernous sinus thrombosis
123
What are the symptoms of OAC?
1.Passage of fluid down nose
2. Passage of air into mouth
3. Alteration of voice
4. Unilateral epistaxis (bleeding) or nasal obstruction
124
If an OAC is left untreated, what will it develop into?
Oral-antral fistula
125
What is the ideal treatment for OAC?
To close immediately with a buccal advancement flap
126
What are two treatment options if OAC occurs, that aren’t a buccal advancement flap?
1. Plate or modified denture
2. Antibiotics, epinephrine drops, mucolytic inhalations
127
Why do we need to be more cautious about extracting elderly patients teeth? (give 3 reasons)
1. Because their teeth become far more brittle and predisposed to fracture (usually heavily restored).
2. They are also more liable to a fractured tuberosity or alveolus as tissue loses elasticity with age.
3. Polypharmacy can impact ability to carry out XLA.
128
How can ethnic background affect difficulty of extraction?
Asian and African Caribbean individuals can have much denser bone which can increase difficulty of extraction.
129
Why should we be wary of lone standing molars when considering extraction?
Because lone standing molars tend to have a thickened alveolar bone and PDL around the tooth due to carrying most of the occlusal forces.
This not only makes it difficult to extract but predisposes it to alveolar fracture, tuberosity’s fracture and OAC.
130
How can crowding of teeth make extraction difficult?
Crowding can prevent access for the beaks of the forceps
131
Why is access to maxillary third molars for XLA with regular molar forceps difficult? (give 2 reasons)
1. Maxillary third molars have a tendency to be buccaly inclined
2. Mouth opening brings the coronoid process into the space lateral to the maxillary third molar
132
What type of forcep is used to extract maxillary third molars?
Bayonet forcep
133
What is pneumatisation of the maxillary antrum?
Where the antrum enlarges, it can result in a union between the sinus floor and the crest of remaining bone in the most extreme of cases.
134
How do abrasion cavities on teeth make extractions more difficult?
They predispose the crown to fracture, which means the extraction has more likelihood of becoming surgical if roots are left subgingivally.
135
Why do endodontically treated teeth cause difficulty for extraction?
They are brittle and more likely to fracture than untreated teeth
136
Why might deciduous teeth become submerged?
Often when there is no permanent successor
137
What are 8 radiographic features that would make XLA difficult?
1. Bulbous roots
2. Dilacerated/divergent/convergent roots
3. Fused roots
4. Multi-rooted teeth
5. Hypercementosis
6. Ankylosis
7. Lone-standing molars
8. Deeply impacted 3rd molars
138
If a root is bulbous on a tooth, what type of XLA should required?
Surgical XLA
139
Why are deciduous teeth likely to have divergent roots?
Because the permanent successor sits between the roots of the deciduous tooth.
140
When multi-rooted teeth have more than one path of withdrawal due to different curvatures of roots, what type of XLA is required?
Surgical XLA
141
Name 6 types of osteolytic lesions.
1. Cysts
2. Odontogenic tumours
3. Primary cancers
4. Metastatic cancers
5. Metabolic bone disorders
6. Fibro-osseous lesions
142
From looking at radiographs, to plan surgical XLA, what 7 things should be identified and considered prior to starting surgery?
1. Path of least resistance
2. Extrinsic obstacles
3. Intrinsic obstacles
4. Bone removal
5. Sectioning
6. Point of application
7. Flap design
143
Why should you never use a high speed instrument to section roots?
It will cause surgical emphysema and introduce air into the tissue which can lead to cellulitis.
144
Where can you refer difficult extractions to?
1. Oral surgery department
2. Maxillofacial department
3. Oral surgery specialist
145
What measure can be implicated to prevent TMJ dislocation and gain access during a surgical extraction procedure?
Use of McKesson’s Mouth prop (orange prop) which sits on the contra-lateral side from where you are working allowing the patient to stabilise their mandible.
146
How do you reposition a dislocated TMJ?
1. Place thumbs on bilateral external oblique ridges intra-orally
2. Curl fingers under inferior border of mandible extra-orally
3. Exert a downward pressure on the mandible and push TMJ over the articular eminence.
147
What are the two main special complications that can arise during oral surgery?
1. Bleeding
2. Sepsis
148
Name 5 post-operative complications associated with bone.
1. Alveolar osteitis (dry socket)
2. Sequestrum
3. Exposed bone
4. MRONJ
5. ORN (osteoradionecrosis)
149
What is the pathogenesis of dry socket? Give 2 ways it can arise.
1. Through complete absence of a blood clot or initial clot formed and is then lost.
2. Inflamed alveolar bone so release of tissue activators (plasminogen converted to plasmin)
150
What are the main risk factors for dry socket? (Name 5)
1. Women
2. Smoking
3. Trauma
4. Medications ( oral contraceptives, antidepressants and antipsychotics)
5. Anatomy
151
What is the clinical symptomatic presentation of dry socket?
1. Worsening pain 2-3 days after extraction
2. Refractory to analgesia
3. Dull aching throb
4. Bad taste
5. Halitosis
6. Discharge
152
How do you manage a dry socket?
1. LA ideally
2. Exploration of socket
3. Remove debris with saline irrigation
4. Place sedative dressing (alvogel)
153
What are the clinical signs of sequestrum?
1. Small fragments lost from extraction site
2. Patient may complain of something “spikey” on their alveolus at the extraction site.
154
How would you manage sequestrum?
1. If small and very mobile, often topical anaesthetic and alleviate with set of college tweezers
2. If large, more exploration of socket will be needed.
155
Why might bone become exposed as a post-operative complication?
Commonly from severe soft tissue trauma, which can sometimes be unavoidable.
156
Give 4 examples of bisphosphonates.
1. Alendronate
2. Ibandronate
3. Zolendronate
4. Pamidronate
157
Other than Bisphosphonates, what classes of drugs can cause MRONJ?
RANKL inhibitors (denosumab) and anti-angiogenesis (Bevaxizumab)
158
What patients might experience ORN?
Irradiated patient who have undergone head and neck cancer therapy.
159
What is ORN?
It is a state of injured bone tissue following radiation, with inadequate healing or remodelling response of at least three to six months.
160
Is ORN more common in the mandible or maxilla?
Mandible
161
What are the clinical signs of ORN?
1. Non-healing bone
2. Severe pain
3. Recurrent infections
4. Halitosis
5. Oro-facial fistula
6. Suppuration
7. Pathological fracture
162
What is the management of ORN?
Resection of necrotic bone and replace it with bone graft.
163
What is normal mouth opening usually in mm?
30-40mm
164
If a patient has mild trismus what will their mouth opening be?
20-30mm
165
If a patient has moderate trismus what will their mouth opening be?
10-20mm
166
If a patient has severe trismus what will their mouth opening be?
<10mm
167
What are causes of trismus?
1. Pain
2. Muscular
3. Haematoma
4. Infection
5. Chronic limitation
6. Trauma
7. Neoplasia
8. Osteoarthritis
9. Soft tissue fibrosis
168
Timing of bleeding can indicate the deficit. If bleeding persists from the time of injury or trauma, what is likely the reason (on a cellular level)?
Platelet related as bleeding is immediate, with time a platelet plug would form and bleeding should cease.
169
Timing of bleeding can indicate the deficit. If bleeding stops early and haemostasis is achieved, but the subsequent bleeding occurs hours later, what is likely the reason (on a cellular level)?
This could indicate clotting mechanism or coagulation factor issues
170
Name 4 hereditary bleeding conditions.
1. Haemophilia VII & IX
2. Factor XIII
3. Von willebrands disease
4. Ehlers danlos syndrome
171
Define Ehlers danlos syndrome.
A connective tissue disorder characterised by mutations in type 5 collagen which affects the integrity of blood vessels. These patients are more likely to bleed.
172
Give 4 acquired reasons for increased risk of bleeding.
1. Medications
2. Liver disease
3. Alcoholism
4. Haematological malignancy (lymphoma or leukaemia)
173
Name 7 conditions which would instigate further investigation into risk of bleeding due to the patient most likely taking Antiplatelets or anticoagulants?
1. Deep vein thrombosis
2. Pulmonary embolism
3. Atrial fibrillation
4. MI
5. IHD
6. Ischaemic stroke
7. TIA
174
What is the use of heparin?
It is used to prevent or treat certain blood vessel, heart or lung conditions. It is also used to prevent blood clotting during surgery, dialysis and blood transfusions.
175
What can long-term use of heparin result in?
Platelet disorders
176
Define “primary bleeding”
Intra-operative soft/hard tissue bleeds which can be prolonged.
177
Define “reactionary bleeding”
Bleeding that occurs 2-3 hours post-op, usually once LA wear off.
178
Define “secondary bleeding”
Bleeding that occurs up to 14 days after operation, most likely due to infection.
179
Describe “normal” bleeding.
Lasts for 2-5 minutes
Ceases on firm pressure
180
Describe “abnormal” bleeding
Increased volume of blood for an extended duration of
Blood doesn’t seem to stop upon applying direct pressure
181
What are 6 ways to stop bleeding?
1. Pressure
2. Suture
3. Bone wax
4. Electrocautery
5. Silver nitrate
6. Haemostatic agents
182
How does bone wax stop bleeding?
You push a blob of wax into the site and this acts as a mechanical barrier to seal the wound.
183
When should you refer if someone is bleeding?
1. If there is ongoing severe haemorrhage
2. If you’ve reached the extent of your capabilities
3. If blood pressure has decreased (100/60)
4. If heart rate increases (>100bpm)
5. If there is fluid loss
184
What indicates fluid loss in a patient?
Decreased BP and increased HR
185
When do haematoma’s most commonly occur?
After 3rd molar removal or around maxillary third molars that have had swelling of the cheek often in the buccal space
186
What is the main concern over haematomas?
Issue /risk with haematoma’s other than the fact they bleed, is that they represent a really good culture medium for bacteria and are a likely a source of severe infection.
187
What is a haematoma?
A collection of blood which is located outside the blood vessel.
188
What is sepsis?
An extreme body response to an infection. It occurs when pre-existing infection initiates a systemic sequence of events.
189
How would you do a quick assessment for sepsis ?
Any patient presenting with a source of infection and two or more:
1. Temperature >38 degrees or <36 degrees
2. HR >90
3. RR >20
4. WCC >12 or <4 (x10^12/mL)
5. BP systolic >100
190
What are the 4 main risk factors for sepsis?
1. Age >75
2. Impaired immunity (e.g. diabetes, steroids etc)
3. Recent trauma/surgery/invasive procedure
4. Indwelling lines/ IVDU/broken skin
191
What are the 8 red flags for sepsis?
1. New or altered mental state
2. Unable to stand/collapsed
3. Unable to catch breath/barely able to speak
4. Very fast breathing
5. Skin that is very pale, mottled, ashen or blue
6. Rash that doesn’t fade when pressed firmly
7. Recent chemotherapy
8. Not passed urine in previous 18 hours
192
How do you manage sepsis? State the “sepsis six” model.
1. Give oxygen
2. Take blood cultures
3. Give IV antibiotics
4. Give a fluid challenge
5. Measure serum lactate
6. Measure urine output
193
Define, apicectomy.
Removal of part of a root end/ apice
194
Define, exsanguination.
Severe blood loss
195
What are the 5 principles of flap design?
1. Incise and reflect
2. Account for obstacles
3. Methods to overcome obstacles (e.g. bone removal)
4. Position of instruments to elevate
5. Path of withdrawal
196
What is the purpose of relieving incisions?
Essentially they run from the crevicular area towards the apices of the teeth in order to allow some relief so that the flap can manipulated and expose the alveolar bone.
197
What is meant by leading edge cutting and why do we want to avoid it?
Where if the blade is angled too much, it is possible to cut an area distant from where you intend to. This casues unnecessary damage to tissues.
198
What type of flap is described:
A flap with crevicular incisions but no relieving incisions.
Envelope flap
199
What type of flap is described:
A flap consisting of crevicular incisions and one relieving incision.
Two-sided flap
200
What type of flap is described:
A flap with crevicular incisions and mesial + distal relieving incisions.
Three-sided flap
201
What is the benifit of a three-sided flap over other flap designs?
You are able to access much higher up in the alveolus
202
Why do we aim to create a flap with a broad base?
So that it maintains blood supply to the crestal or papillary areas of the flap
203
How many minimum units should a flap be extended?
1 unit either side of the tooth to be extracted
204
How would you approach designing a flap if the tooth to be extracted is a LL5 and the mental neurovascular bundle sits directly underneath?
Choose to extend incisions further anteriorly by adding another unit to the flap. This means nerve bundle is avoided but also included in the flap.
205
Name 7 extrinsic obstacles that may arise prior to surgical extraction.
1. Bone
2. Soft tissues
3. Anatomical features (e.g. maxillary sinus and IAN bundle)
4. Adjacent teeth
5. Pathology
6. Lack of space
7. Location of tooth (palatally/lingually displaced)
206
Name 6 intrinsic obstacles that can arise pre- surgical extraction.
1. Crown size and shape
2. Roots (number, morphology, angulation)
3. Pathology
4. Caries
5. Resorption
6. Ankylosis
207
What does a good flap design achieve?
1. Overcomes obstacles
2. Allows access
3. Facilitates path of withdrawal and removal of tooth
208
What two types of flap design are best suited for 3rd molar surgical extraction?
1. Triangular flap ( three-sided flap)
2. Envelope flap
209
How many days will it take the patient to heal after surgical extraction?
Can range, but is usually 3-7 days.
210
What is the difference between Spencer well forceps and needle forceps?
Spencer well forceps are corrugated at the tip so will not hold a needle well
211
What piece of equipment is commonly used by the assistant to retract the tongue?
Lacks retractor
212
What is the purpose of tooth tissue forceps during suturing?
They securely handle tissue at wound margins
213
Where should the suture needle be held with the forceps?
At the posterior 1/3rd of its length
214
What are the 4 different types of shape of suture needles?
1. Tapered
2. Blunt
3. Cutting
4. Reverse-cutting
215
What type of suture needle is least traumatic to tissues however has large puncture holes?
Reverse cutting sutures
216
Give two examples of non-absorbable suture threads.
1. Mersilk
2. Prolene
217
Give an example of an absorbable suture thread.
Vicryl rapide
218
Upon suture needle insertion, how far should it be from the wound margins?
3-5mm
219
What is the technique for tying the suture?
1. Double throw of thread over forceps in clockwise direction (2) +pull through
2. One throw of thread anti-clockwise over forceps (1) + pull through to tie.
220
Name the 7 classifications of aetiology of benign mucosal lesions.
1. Congenital
2. Traumatic
3. Autoimmune
4. Metabolic
5. Infective
6. Inflammatory
7. Idiopathic
221
Give two examples of congenital benign oral mucosal lesions.
1. Leukoedema
2. Fordyce spots
222
What is leukoedema?
White/grey discolouration of the mucosa generally (asymptomatic)
223
What are fordyce spots?
Ectopic sebaceous glands
224
Name 6 traumatic benign oral mucosal lesions.
1. Erosions/ulcers
2. Frictional keratosis
3. Polyps
4. Denture induced hyperplasia
5. Amalgam tattoos
6. Mucocoeles
225
What is the difference between an “erosion” and an “ulcer”
An erosion affects just the upper epithelial layer of mucosa, an ulcer affects the full thickness of the epithelium.
226
What is the general rule for how long it should take an ulcer to resolve?
4 days
227
When should an ulcer be investigated with biopsy?
If it doesn’t resolve within 14 days
228
Define a major aphthous ulcer.
A ulcer that is larger than 1 cm in cross section
229
What is keratosis a sign of?
Chronic and low grade trauma
230
What does an aphthous ulcer typically look like?
White ulcerated base with red “angry” margin
231
What is the term used to describe many small clusters of aphthous ulcers?
Hepetiform aphthous ulcers
232
What is the Latin term for cheek biting?
Morsicatio buccarum
233
What is the treatment for mucosal polyps?
Excision under LA
234
Why do amalgam tattoos occur?
Introduction of metal into mucosa from restoration, amalgam is taken up by macrophages forming an amalgam tattoo
235
Why should you always undertake biopsy of an amalgam tattoo?
Because it can look very similar to a melanoma
236
What is the treatment of a mucous extravasation cyst?
Excision of swelling and associated minor salivary gland
237
Give two examples of infective fungal benign oral mucosal lesions.
1. Acute pseudomembranous candidiasis
2. Candida leukoplakia
238
Give two examples of infective viral benign oral mucosal lesions.
1. HPV
2. Herpes Virus
239
What is the clinical difference between thrush and Candidal leukoplakia?
Thrush wipes free leaving a red base, whereas candidal leukoplakia does not wipe free.
240
Where is candidal leukoplakia often found in the mouth?
In the commissures of the mouth
241
What is the treatment for candidal leukoplakia?
Antifungal 1st line
Biopsy as it can look similar to some neoplasms
242
What three things can cause reactivation of latest herpes virus in the trigeminal system?
1. UV light
2. Stress
3. Immunocompromised
243
What are the signs of reactivation of latent herpes virus?
Tingling sensation before vesicles develop on lip
244
Give three examples of inflammatory benign oral mucosal lesions.
1. Geographic tongue
2. Lichenoid reactions
3. Epulis
245
What medication can have associated lichenoid reaction?
1. Antihypertensives
2. Hypoglycaemics
3. NSAID’s
246
What are the two different types of epulis?
Fibrous epulis and pyogenic epulis
247
What causes fibrous epulis? What is the treatment?
Chronic irritation
Treatment = excision
248
What causes pyogenic epulis? What is the treatment?
Change in hormones (most commonly occurs in pregnant females)
Treatment = excision if very large, can also resolve on its own
249
What is Addisons disease? how does it present in oral cavity?
A primary adrenal insufficiency where there is a deficiency in cortisol and aldosterone. Presents as dark skin pigmentation in oral cavity.
250
What are vesiculobullous conditions?
These are autoimmune inflammatory conditions characterised by painful blisters that rupture into erosions and ulcers.
251
What is an example of an idiopathic benign mucosal lesion?
Lipoma
252
What is a lipoma?
Benign mesenchymal neoplasm with unknown cause. It is made up of fat cells surrounded by a thin fibrous capsule.
253
What is the treatment for lipoma?
Excision
254
How do you manage OAC? What are the two options?
1. If OAC is small enough, give antibiotics and review in a few weeks to see if spontaneous closure has occured.
2. Complete buccal advancement flap
255
What local measures would you perform for someone with acute pericoronitis of their lower right partially erupted 8?
1. Saline irrigation
2. OH advice
3. Alvogel placement under operculum
4. Grinding of upper 8 cusps or extraction if it is causing trauma to operculum of lower 8
256
If pericoronitis presents with systemic signs of infection, what drug should be prescribed to treat this and what dose/duration?
Metronidazole 400mg 3x daily for 5 days
257
Why must saline irrigation be used when drilling bone?
So that bone does not overheat and necrose upon drilling
258
What is the most appropriate suture material to use to close a wound?
3/0 vicryl rapide
259
What is your provisional diagnosis of a white patch in FOM?
Thrush
Frictional keratosis
260
What is your differential diagnosis of a white patch in FOM?
Oral cancer
261
How would you investigate a white patch in the FOM?
Incisional Biopsy
262
Who would you refer a patient to and in what time frame if they required biopsy for a large white lesion on the FOM?
Urgent 2 week referral to Maxillofacial department
263
What is the major risk of biopsy on FOM?
Risk of incising tissues of submandibular ducts
264
How do you plan surgical extraction? Give the 5 steps.
1. Path of withdrawal
2. Obstacles
3. Point of elavation
4. Bone removal
5. Flap design
265
What flap is most commonly used for lower 8 surgical extraction?
3-sided (triangular) flap
266
How do you check for OAC?
If no blood clot forms after extraction, this would suggest OAC.
267
What flap design would you use to close OAC?
Buccal advancement flap
268
What antibiotics could you prescribe for OAC, give dose and frequency.
1.Pen V (500mg 4x daily for 5 days)
OR
2. Amoxycillin + cluvlanic acid (1g 2x daily)
OR
3. Clindamycin (300mg 3x daily for 5 days)
269
How can you reduce a patients risk of MRONJ?
By attempting to make extraction as minimally traumatic as possible. Avoid surgical extraction wherever possible.
270
How long would you review a patient at risk for MRONJ following extraction for?
Review for 8 weeks, if no mucosalisation of socket occurs suspect MRONJ.
271
What is the significance of prednisolone in regards to risk of MRONJ?
High dose corticosteroids cause osteoperosis and are associated with increased risk of MRONJ.
272
What type of trauma is denture induced hyperplasia?
Chronic low grade trauma
273
What is the recommended treatment for denture induced hyperplasia?
Make new dentures, excise lesion, OHI.
274
What flap design is required for surgical extraction of a submerged deciduous tooth?
3-sided flap
275
What condition might cause supernumerary teeth?
Cleidocranial dysostosis
276
What would the flap design be for a lingually placed supernumerary tooth? And why?
Envelope flap, must avoid placing multiple relieving incisions as there is risk of damaging lingual nerve.
277
Would conservative treatment be appropraite for an impacted canine with an associated follicular cyst?
No, due to pathology this tooth must be removed.
278
How long before IV sedation must a patient not consume any alcohol or recreational drugs for?
At least 48 hours
279
Why do patients have to remove nail varnish or false nails prior to IV sedation?
Because they interfere with the monitoring systems
280
Can a pregnant patient undergo IV sedation?
No
281
On the day of IV sedation, what should the patient be advised not to do beforehand?
Do not eat or drink anything during the 4 hours before your appointment time.
282
What drug is used in IV sedation?
Midazolam
283
What drug is used to revere the effect of midazolam in emergency situations?
Fluomazenil
