Oral Surgery Flashcards
(9 cards)
pt about to start bisphosphonates - discuss risk of MRONJ & XLA risks prior to pt starting therpy
- introduce self & role
- explain alendronic acid = bisphosphonate
- MoA of bisphosphonate = reduce turnover of bone & accumulate in sites of high turnover i.e. the jaw
- relevance to dentistry = risk of poor wound healing following xla, need to remove teeth with poor prognosis prior to beginning drug therapy, must do everything possible to prevent further tooth loss in future, reduced turnover of bone & reduced vascularity can lead to death of bone i.e. osteonecrosis
- specifically name MRONJ
- risk of MRONJ in osteoporosis is low
- make clinical diagnosis i.e. chronic apical periodontitis & gross caries in 36
- explain to pt i.e. left back tooth has infection and is too decayed to put a filling in it
- discuss tx options = xla is the only option as tooth grossly carious beneath the gum and if tooth kept risk of MRONJ if xla after beginning therapy
- ask pt if any questions
dry socket history diagnosis & management
signs & symptoms=
- pain often begins 3-4days post xla & can take 7-14 days to resolve
- no blood clot present in socket
- moderate to severe dull aching pain
- pain throbs & radiates to ear keeping pt up at night
- exposed bone is sensitive & source of pain
- characteristic smell / halitosis w/ pt complaining of bad taste
diagnosis:
alveolar osteitis which is a painful dental condition that is a common post op complication of xla. localised osteitis is the inflammation affecting the lamina dura; this causes dry socket which occurs when the blood blood clot at site of tooth xla fails to develop, is dislodged or dissolves before the wound is fully healed; not usually associated with infection
predisposing factors:
- molars (increased risk more posterior)
- mandible more common than maxilla
- smoking increases risk due to reduced blood supply
- females > males
- if on OCP
- excessive trauma during xla
- excessive mouth rinsing post xla
- family hx or previous dry socket
management:
initial = reassure / optimal analgesia i.e. ibuprofen 400mgx4 daily or paracetamol 1gx4 daily / advise to avoid smoking & good OH / seek urgent dental care / LA to relieve pain
subsequent = irrigate with saline to flush out food & debris / curette & debride socket / encourage bleeding & new clot formation / WHVP is a ribbon gauze sutured into socket which will require removal later on / alvogyl is a mix of LA & antiseptic which is placed in socket / both promote clotting & enhance clotting framework while protecting the bone / use of analgesia / warm salty MW / CHX MW
antibiotics not required unless signs of spreading infection, systemic infection or for immunocompromised pts
post op xla advice
bleeding:
- bite down on damp gauze for 3x20mins
- if not stopping use emergency number provided
- if continues / out of hours go to A&E
rinsing:
- do not rinse for 24hrs
- after this can rinse with warm salty MW gently 3-4x daily swirl do not gargle
care:
- caution until LA wears off to not bite or burn lip & tongue
- do not disturb socket with finger / tongue / toothbrush
- brush teeth as normal just be cautious in that area
- pain, bleeding, swelling, bruising, infection should peak at 48hrs if increasing following this contact GDP
- avoid hot / hard food, excessive exercise
- avoid smoking / alcohol for as long as possible at least 24hrs minimum
- swelling peaks at 48hrs, can take 7 days to resolve, ice pack 5mins on 5 off for an hour
- sutures dissolve on their own in about 2-4wks
pain:
- ibuprofen / paracetamol before LA wears off
- if pain worsens after 2-3days return to gdp as poss infection / dry socket
- provide emergency contact no
pericoronitis prescription for pt who is an alcoholic
metronidazole = common but contraindicated due to alcoholism
amoxicillin capsules 500mg
send - 9 capsules
label 1 capsule x3 daily for x3 days
pt name / address / CHI / no of days tx / acceptable drug dose & formulation / drug dose / frequency / duration of tx / total no of capsules / prescription signed & dated / written in ink
surgical removal of wisdom tooth go through complications, procedure & consent
procedure = L/R 3rd molar surgically removed under LA. numbed up with injection at back of mouth leaving you numb inc lower lip chin & side of tongue. won’t feel pain / only increased pressure & will test with probe. make a cut in the gum move it out of the way and remove some of the bone around the tooth - a bit like drilling when doing a filling. sometimes need to section tooth into separate pieces & remove that way. will irrigate with salty water to clean area & suture together. funny noises & pressure but no pain
complications = pain / bleeding / swelling / bruising / infection / dry socket / damage to adjacent teeth / jaw stiffness / temp or prolonged numbness, prolonged nerve pain, tingling due to damage to the nerve
- sensory nerve so damage will only affect sensation felt not your appearance o the way your mouth / jaw works. 10% temp <1% permanent but if IDN involved with roots this increases to 20% temp & 2% permanent.
other alternative = coronectomy which is same as above but only crown is removed leaving roots in situ & avoiding risk of nerve damage; this can’t be done if tooth is carious. if roots become mobile then they must be removed as well
no need to fast, can bring someone but will be fit to drive yourself home
any questions
pt presents with mandibular #. perform exam on mannequin, further investigations & further mx
dx = L/R mandibular #
initial hx = headache / loss of consciousness / nausea or vomiting / numbness of face / police involvement / other injuries elsewhere
EO = pain / lacerations / bleeding / swelling / asymmetry / palpate mandible bilaterally / limitation of mandibular movement i.e. reduced interincisal opening / mandibular deviation on opening or lateral movement / tenderness of TMJ / sensation of lower lip / chin
IO = lacerations / bruising / swelling / occlusal derangement / step deformity / loose or broken teeth / anaesthesia / paraesthesia of teeth in lower jaw on side of # / AOB due to bilateral ramus / sub condylar #
classifications =
soft tissue - simple / compound / comminuted; # involving teeth always expose the periodontium so are always compound & high risk of infection so require ABs
no - single / double / multiple
site - condylar, subcondylar, body, coronoid, angle, ramus, parasymphyseal, symphyseal, alveolar
side - uni or bilateral
displacement - displaced or undisplaced
direction - favourable or unfavourable
specific - greenstick in children or pathological
factors influencing displacement =
pull of attached muscle / angulation & direction of # line / opposing occlusion / magnitude of force / mechanism & direction of injury / intact soft tissue
further investigations = 2x radiographs OPT & PA mandible or else CBCT
always compare RHS & LHS
mx =
urgent phone to OMFS / A&E for advice & urgent referral
surgical mx ORIF if symptomatic or displaced
conservative mx if undisplaced, asymptomatic or >1mth old
EO/IO signs of TMD; click on both sides. tongue scalloping, sore muscles, sore in AM, linea alba. DWP dx of TMD & conservative mx
very common condition >75% population get it at some point in their lives
jaw joint sits at base of skull & controls opening / closing of mouth if overworked muscles become inflamed & sore
sore in AM means clench / grind during sleep so muscles never get a rest & exacerbates problem
clicking caused when disc between jaw & skull gets trapped in front of jaw bone then snaps into place
mx - reassurance, soft diet, cut food into small pieces, avoid chewy foods/gum, avoid wide opening, avoid stifling yawns, avoid grinding during day & avoid habits such as biting nails
advice re analgesia / heat packs
evidence to show yoga & de stressing to help
make soft splint to break nocturnal habits
key = reassurance it is common & de stress is greatest help
ask if any questions
hx, explain diagnosis from images, xray & hx, explain mx & surgical closure of OAF
chronic OAF pt may c/o
- fluids from nose
- speech & singing of nasal quality
- problems playing wind instruments
- problems smoking or using straw
- bad taste / odour, halitosis, pus discharge
- pain / sinusitis type symptoms
OAC = acute communication of maxillary air sinus with oral cavity
explain this hasn’t closed over & instead has healed by epithelialising forming a sinus & permanent communication of air sinus & mouth. want to manage as makes more prone to sinus infections
OAF mx -
excise sinus / fistula removing epithelium
& buccal advancement flap
amoxicillin 500mg 7 days send 21 1x3 capsules daily
doxycycline 100mg 7 days send 8 capsules 1x1 capsule daily (2 on day1)
post op:
- refrain from blowing nose or stifling sneeze by pinching nose
- steam or menthol inhalations
- avoid using straw
- refrain from smoking
right orbitozygomatic # EO exam, further investigations & further mx
dx = # cheekbone R/L
EO - lacerations / nasal bleeding, deviation, patency (by obstructing each nostril) / palpation of zygoma bilaterally (supra/infra orbital rims, zygomatic arch) from behind / facial asymmetry / limitation of mandibular movement / sensation of infra orbital region (3 areas supplied by infraorbital nerve: upper lip, lateral nose & lower eyelid)
eye exam - periorbital ecchymosis, subconjunctival haemorrhage, vision assessment; pupillary reaction to light, ask if presence of double vision (diplopia) haematoma or muscle/nerve injury, eyeball mobility assessment; steady pt head & ask to follow finger to 6 points, particularly upwards; either superior rectus nerve supply severed or more commonly inferior rectus is trapped due to orbital floor #
IO - tenderness of zygomatic buttress / bruising / swelling / haematoma / occlusal derangement & step deformities / lacerations / loose or broken teeth / anaesthesia / paraesthesia in upper quadrant & gingivae above incisor / canine
further investigations - xrays OM15/30 or CBCT
correctly identify # & radiopacity of sinus always compare RHS V LHS
further mx - urgent phone to OMFS/A&E for advice & urgent referral
surgical mx - ORIF if symptomatic e.g. diplopia / asymmetry
conservative mx - if undisplaced, asymptomatic, >1mth old
