oral surgery

Question 1

how local anaesthetics work

Question 2

why might local anaesthetics not work?

Answer 2

incorrect technique, not enough volume of LA
infection leading to lower acidic pH of environment and prevents the anaestheitc from passing into the nerve
intravascular LA

Question 3

extractions warnings

Answer 3

pain bleeding swelling bruising infection

damage to adjacent teeth
risk of fracture
dry socket (smoker, trauma, M3Ms)
damage to IAN + trismus for lower posterior
OAC if upper
loss of tooth fragment

Question 4

warnings to patinet specifically for tooth extraction

Answer 4

risk of bleeding
dry socket
osteomyelitis
ORN
MRONJ
fracture of maxillary tuberosity upper lone standing molar

Question 5

excessive bleeding after XLA

Answer 5

local causes: mouthrinsing, exercise, alcohol
general causes: medications, liver disease, family history of disorders of hemostasis

Question 6

how to achieve haemostasis

Answer 6

socket capillaries: pack socket with absorbable haemostat surgical oxidised cellulose from wood pulp which helps to form blood clot
gingival capillaries: suture socket with vicryl absorbable synthetic sutures that permits adequate tension

Question 7

dry socket: who is predisposed

Answer 7

smoking
surgical trauma
oral contraceptive pill
the vasoconstrictor added to LA solution
poor OH

Question 8

how to manage dry socket

Answer 8

explain to pt + reassure correct tooth has been extracted
LA
irrigate with saline not chlorhexidine due to anaphylaxis
dressing of socket using alvogyl paste. iodoform dressing so be careful with allergy, and is antimicrobial. butamben local anaesthetic, eugenol analgesic, iodoform antiseptic

should resolve in 4 weeks, if after 8 weeks not healing, consider MRONJ

Question 9

when are NSAIDs contraindicated

Answer 9

COPD
asthma
allergies
anticoagulant patients
pregnancy and breastfeeding

Question 10

post op instructions

Answer 10

salt mouth rinses TDS after 24 hours
avoid food with grains get stuck into socket
LA wait to wear off so avoid hot food
no smoking for as long as possible
no alcohol or excessive exercise for 24 hours
if bleeding, place damp gauze on for 20 mins. if still bleeding contact hospital
no rinsing for 24 hours
pain relief with paracetamol

Answer 11

aspirin works irreversibly
ibuprofen works reversibly

Question 12

complications of extractions

Answer 12

bleeding
dry socket
infection
MRONJ
ORN

Question 13

MRONJ

definition

Answer 13

rare side effect of anti-resorptive and anti-angiogenic drugs

defined as:
exposed bone or bone that can be probed through an intraoral extraoral fistula in the maxillofacial region that has persisted for more than 8 weeks in pts with a history of tx with anti-resorptive drugs and where there has been NO history of head and neck radiotherapy

Question 14

Incidence of MRONJ

Answer 14

Estimated incidence of MRONJ in cancer patients treated with anti-resorptive or anti-angiogenic drugs: 1%

Estimated incidence of MRONJ in osteoporosis patients treated with anti-resorptive drugs: 0.01-0.1%

Question 15

how do anti-resorptive drugs work

Answer 15

Bone is constantly being remodelled by the action of osteoblasts, which create bone tissue, and osteoclasts, which break down (resorb) bone tissue. Anti-resorptive drugs inhibit osteoclast differentiation and function, leading to decreased bone resorption and remodelling. The jaw is known to have an increased remodelling rate compared to other skeletal sites and therefore the viability of bone in this region may be adversely affected by the action of these drugs.

Question 16

how do bisphosphonates work?

Answer 16

The bisphosphonates reduce bone resorption by inhibiting enzymes essential to the formation, recruitment and function of osteoclasts.

Question 17

half life of bisphosphonates

Answer 17

The drugs have a high affinity for hydroxyapatite and persist in the skeletal tissue for a significant period of time, with alendronate having a half-life in bone of around 10 years.

Question 18

how can bisphosphonates cause MRONJ

Answer 18

It is speculated that the bisphosphonates may also have an adverse effect on soft tissue cells by inhibiting proliferation and increasing apoptosis, which may lead to delayed soft tissue healing.16,17 There is also some evidence that these drugs can inhibit angiogenesis.18

Question 19

when is denosumab used?
what it is?

Answer 19

RANKL inhibitor monoclonal antibody which inhibits osteoclast function and associated bone resorption
indicated for treatment of osteoporosis

Question 20

who takes bisphosphonates?

Answer 20

osteoporosis
cancer
paget’s
osteogenesis imperfecta
fibrous dysplasia

used as a prophylaxis to counteract osetoporotic effects of glucocorticoids to prevent bone related complications and in patients with primary hyperparathyroidism and cystic fibrosis

Question 21

how do anti angiogenic drugs work?

Answer 21

Anti-angiogenic drugs target the processes by which new blood vessels are formed and are used in cancer treatment to restrict tumour vascularisation.

Question 22

classficiation of risk of MRONJ: risk factors for MRONJ

Answer 22

1. type of dental tx: any procedure that impacts bone is a risk factor for MRONJ, but it does not cause the disease. mucosal trauma from ill-fitting dentures can be a risk factor, tell pt to wait until mucosa to heals after XLA to wear denture. dental infection and untreated periodontal infection can increase the incidence of MRONJ
   2.

Question 23

questions to ask pt regarding bisphosphonates

Answer 23

o Have you ever been prescribed a medicine for your bones?
o Do you take a medicine once a week?
o Have you ever had a drug infusion for your bones?
o Do you take long-term steroid tablets for any condition?

Question 24

management of MRONJ

Answer 24

before commencing anti-resorptive therapy, get the pt as dentally fit as possible
advise the pt that they are at risk

Give personalised preventive advice to help the patient optimise their oral health, emphasising the importance of:
* having a healthy diet and reducing sugary snacks and drinks; * maintaining excellent oral hygiene;
* using fluoride toothpaste and fluoride mouthwash;
* stopping smoking;
* limiting alcohol intake;
* regular dental checks;
* reporting any symptoms such as exposed bone, loose teeth, non-healing sores or lesions, pus or discharge, tingling, numbness or altered sensations, pain or swelling as soon as possible.
Prioritise care that will reduce mucosal trauma or may help avoid future extractions or any oral surgery or procedure that may impact on bone:
consider obtaining appropriate radiographs to identify possible areas of infection and pathology;
undertake any remedial dental work;
extract any teeth of poor prognosis without delay;
focus on minimising periodontal/dental infection or disease;
adjust or replace poorly fitting dentures to minimise future mucosal trauma; consider prescribing high fluoride toothpaste.
refer to oral surgery or special care dentistry

Question 25

management of high risk pts of MRONJ

Answer 25

If an extraction is indicated, explore all possible alternatives where teeth could potentially be retained e.g. retaining roots in absence of infection. * If extraction remains the most appropriate treatment: o Discuss the risks and benefits associated with treatment with the patient (or carer, where appropriate) to ensure valid consent. See Appendix 4 for points to cover during this discussion; o Proceed with the extraction as clinically indicated; o Do not prescribe antibiotic or antiseptic prophylaxis unless required for other clinical reasons; o Advise the patient to contact the practice if they have any concerns, such as unexpected pain, tingling, numbness, altered sensation or swelling in the extraction area; o Review healing. If the extraction socket is not healed at 8 weeks and you suspect that the patient has MRONJ, refer to an oral surgery/special care dentistry specialist as per local protocols. If you suspect a patient has spontaneous MRONJ, refer to an oral surgery/special care dentistry specialist as per local protocols.

Question 26

how bisphosphonates work

Answer 26

Attach to hydroxyapatite binding sites Particularly on surfaces that are actively resorbing Impairs osteoclastic ability to bind to the bony surface and inhibit resorption Reduces osteoclast activity by promoting osteoclast apoptosis and inhibiting development of new osteoclasts

Question 27

who/what are bisphosphonates used for?

Answer 27

Metastasising solid cancers Multiple myeloma Hypercalcaemia of malignancy Post menopausal osteoporosis Steroid induced osteoporosis Paget’s Disease

Question 28

iv bisphosphonates

Answer 28

Incidence variable Mostly in myeloma and breast cancer Up to 16% risk in some studies Risk in prostate / myeloma higher Higher risk in combination therapy

Question 29

increased risk pts of MRONJ

Answer 29

Immunosupression Steroids / Azathioprine / Methotrexate Immunocompromised – D.M. / HIV Other meds Chemotherapy / Anti-angioenics

Question 30

brief management of MRONJ

Answer 30

Prior to treatment – dentally fit where possible (usual OH etc) Reduce risk – lifestyle factors (smoking Avoid extractions where possible Extractions - ensure follow up healing at 8 weeks NO evidence for Abx or CXD mouth-rinses ?Supporting evidence for use of PRF

Question 31

signs of infection local systemic

Answer 31

local: redness swelling heat pain/tenderness loss of function bad taste halitosis systemic: fever lymphadenopathy malsise trismus dysphagia rash difficulty breathing

Question 32

5 fascial space infections

Answer 32

submandibular sublingual buccal/facial submassteric gingival: more localised if infection spreads from submandibular to parapharyngeal can spread to mediastinuim

Question 33

sublingual space

Answer 33

floor of mouth

Question 34

submandibular space

Answer 34

upper neck to lower border of the mandible

Question 35

facial space

Answer 35

above the lower border of the mandible to the lower eyelid

Question 36

submasseteric

Answer 36

deep to the masseter

Question 37

gingival space infection

Answer 37

can see intraorally either buccal/palatal/lingual

Question 38

submandibular infections: problems

Answer 38

can spread into parapharnygeal space causing mediastanitis can lead to ludwigs angina

Question 39

signs of sepsis: red flags

Answer 39

high or low temperature if systemic involvement, rule out sepsis skin changes: non-blanching rash mottled appearance low blood pressure fast heart rate altered mental state: confusion, drowsiness

Question 40

if a patient has a systemic infection, what should you do first?

Answer 40

check the airway isn't compromised: e.g. could be ludwigs angina rule out sepsis if systemic

Question 41

complication of infection if bacteria gets into the cavernous sinus

Answer 41

cavernous sinus thrombosis

Question 42

how would you manage infection?

Answer 42

if airway compromise, refer to hospital look for signs of infection: local and systemic take the patient's temperature to check if it is systemic or local check if it is pain from tooth and vitality tests and pt history then extract antibiotics if systemic

Question 43

Principles of infection management

Answer 43

incise and drain abscess under LA drain abscess at apex of tooth by RCT or XLA send a sample of pus to lab for culture sensitivity if antibiotic isn't working analgesia and review pt daily

Question 44

RCS guidelines: factors for consideration of prophlactic removal of third molars

Answer 44

pt on antiresorptives limited access to services, e.g. astranout radiotherapy of head and neck, immunosuppressant therapy

Question 45

NICE guidelines for indications of removal of third molars

Answer 45

The practice of prophylactic removal of pathology-free impacted third molars should be discontinued in the NHS. limited to only evidence of pathology a. Unrestorable caries b. Fracture of tooth c. Non-treatable pulpal and/or periapical pathology d. Pathology of follicle including cyst/tumour e. Cellulitis or abscess formation f. Osteomyelitis g. Tooth/teeth impeding surgery, e.g. reconstructive jaw surgery, preprosthetic/implant surgery, orthognathic surgery, tooth involved within the field of tumour resection. Internal/external resorption of the tooth or adjacent teeth. h. at least 2 episodes of pericoronitis

Question 46

prognosis of teeth (sdcep)

Question 47

other indications for removal of third molars other than NICE: RCS guidelines

Answer 47

Restorative treatment (caries in adjacent tooth) Periodontal disease Orthodontic treatment Occupational (armed forces) Prophylactic removal for medical/surgical indications Donor transplantation.

Question 48

pericoronitis and removal of third molars: NICE guidelines

Answer 48

plaque formation is a risk factor but is not itself an indication for surgery degree to which the severity of recurrence rate of pericoronitis should influence the decision for surgical removal of third molars

Question 49

treatment options for M3Ms

Answer 49

referral active clinical monitoring extraction of M3M extraction of opposing maxillary third molar coronectomy operculectomy surgical exposure pre-surgical orthodontics

Question 50

what radiograph is suitable for impacted third molars?

Answer 50

OPT

Question 51

what are you looking for on a radiograph for impacted third molar?

Answer 51

presence or absence of disease in surrounding area the position in relation to the adjacent second molar, the eruption status, the function and occlusion, the periodontal and caries status the presence or absence of disease in the tooth or surrounding area anatomy of tooth and its root formation the relationship to the relevant structures such as IAN and second molar

Question 52

when would a CBCT be indicated in third molar surgery and its advantage?

Answer 52

3D image lower radiation dose than CT where conventional imaging (OPT) has shown a close relationship between the third molar and the IAN

Question 53

if you decide to not extract the third molar, what should you do?

Answer 53

active clinical monitoring for signs and symptoms can develop caries in second molar in 30% of cases can develop a dentigerous cyst

Question 54

what does a CBCT show in third molars

Answer 54

the tooth's position, root morphology, bone coverage, relationship between the tooth and the nerve canal

Question 55

on plain film what are the 3 most radiological signs of a close relationship to IAN

Answer 55

diversion of IAN canal darkening of root interruption of the cortical white line

Question 56

factors to consider prior to removal of M3Ms

Answer 56

1. therapeautic: infection (pericoronitis, osteomyelitis, ORN), caries in M3Ms, M2Ms, periapical abscess, periodontal disease, cysts, tumours, external resorption of the third or second molar 2. surgical indications: orthognathic surgery 3. high risk of dental disease 4. prevent ORN or MRONJ. if decision to start medications like bisphosphonates, full dental assessment including third molars will be undertaken, threshold for XLA of third molars will be lowered 5. accessibility: dental services restricted, e.g. in army 6. pt age: recovery time increased with age. more dense bone over age of 35 7. pt involvement MOST important!!!!!!***** The findings of the assessment, the risk status, and the treatment options along with their risks and benefits all need to be communicated clearly and effectively at a level the patient can comprehend.

Question 57

when is a coronectomy indicated?

Answer 57

M3Ms in close proximity to IAN and is effective in minimising IAN injury

Question 58

risks of coronectomy

Answer 58

infection and pain potential need for removal of the roots

Question 59

contraindications of coronectomy: tooth factors patient related factors

Answer 59

tooth factors: non-vital third molars caries with risk of pulpal involvement tooth mobility apical disease association with cystic tissue that is unlikely to resolve if the root is left in situ and tumours patient related factors: immunocompromised patients previous radiotherapy to head and neck or treatment before radiotherapy diabetes pts who are unable to return for a period of time after should complications occur

Question 60

risks of M3M surgery

Answer 60

paratheisa trismus dry socke4t

Question 61

when surgery of M3M is indicated, what pre-op consideration can be given

Answer 61

pre-op steroids to reduce pain, swelling and trismus

Question 62

pericoronitis: risk factors

Answer 62

partial eruption and vertical or distoangular impaction opposing maxillary M3M or M2M causing mechanical trauma upper respiratory tract infections as well as stress and fatigue prior OH and plaque accumulation white race full dentition

Question 63

microbiology of pericoronitis

Answer 63

microbiota is predominantly anaerobic : streptococci actinomyces

Question 64

flap design for mandibular third molars

Answer 64

a three-sided (or trapezoidal) flap design is often favored, especially for mandibular impacted teeth. This design provides excellent access while preserving the vascular supply and avoiding significant tissue tension. full thickness mucoperiosteal flap used disadvantages for increased bledin, difficulty in achieving primary wound closure lingual nerve may be damaged if need to raise a lingual flap if tooth is deeply impacted

Question 65

risks of third molar surgery: mandibular and maxillary

Answer 65

pain bleeding swelling bruising infection damage to adjacent teeth trismus dry socket OAC/OAF/fractured tuberosity Temporary or Permanent altered or loss of sensation to the : Lower lip, skin of the chin, gums of the lower teeth, the lower teeth, tongue and taste The altered sensation can be painful similar to neuralgia or a 'tingling' sensation Trismus Time off work Significant swelling and bruising which can spread to the neck / chest Rarely hospital admission requiring treatment damage to nerves: IAN, lingual, long buccal, mylohyoid

Question 66

go over minor oral surgery lecture

Question 67

pericoronitis: definition

Answer 67

An infection of the soft tissue around the crown of a partially impacted tooth, usually caused by normal oral flora.

Question 68

pericoronitis: causes

Answer 68

Pericoronitis Causes Compromised host defenses (e.g. URTI, medication) Minor trauma from opposing maxillary dentition (operculum) Food trapping under the operculum Bacterial infection - Strep and Anaerobes Poor OH

Question 69

mild pericoronitis: symptoms

Answer 69

* Pain * Halitosis * Swelling * Erythema * Bad taste

Question 70

severe pericoronitis: symptoms

Answer 70

* Pain * Halitosis * Swelling * Erythema * Bad taste PLUS trismus pyrexia lymphadenopathy malaise dysphagia

Question 71

can pericoronitis spread to fascial spaces?

Answer 71

pericoronitis, an infection around a partially erupted tooth, can spread to surrounding fascial spaces. If left untreated, the infection can extend into various head and neck spaces, including the sublingual, submandibular, parapharyngeal, pterygomandibular, infratemporal, submasseteric, and buccal spaces. This spread can lead to significant complications, including airway compromise and life-threatening infections. can spread to submandibular space, buccal space can lead to ludwig's angina which can also be caused by roots of teeth can lead to sepsis if left untreated

Question 72

who is at risk of sepsis?

Answer 72

people with chronic conditions people who are immunosuppressed infants elderly

Question 73

pericoronitis treatment: mild

Answer 73

local measures irrigation with warm saline, avoid chlorhexidine analgesia

Question 74

severe pericoronitis: management

Answer 74

local measures irrigation with warm saline, avoid chlorhexidine analgesia antibiotics: metronidazole or amoxicillin

Question 75

general indications for XLA of third molars

Answer 75

Unrestorable caries Non-treatable pulpal and/or periapical pathology Cellulitis Abscess Osteomyelitis Internal / External resorption of the tooth or adjacent teeth Fracture of tooth Disease of the follicle inc cyst/tumour Tooth / teeth impeding surgery Reconstructuve jaw surgery Tooth is involved in the field of tumour resection

Question 76

what are you looking for on the radiograph prior to third molar surgery?

Answer 76

resence of caries Condition of existing restorations Alveolar bone levels Root morphology Morphology of pulp chamber Signs of periodontal pathology Position of unerupted teeth or retained roots Other pathology of the jaws Form and quality of edentulous ridge and underlying bone Boundaries of relevant anatomical features

Question 77

CBCT

Answer 77

advantages: Digital technique Thin slices with variable thickness <1mm Can be viewed in all planes Eliminates superimposition High contrast resolution CBCT reduction in dose Short scan time High resolution Interactive software Issues with artefacts

Question 78

important structures near for third molar surgery

Answer 78

IAN canal, lingula

Question 79

signs of close relationship to id canal: general radiographic

Answer 79

dark and bifid apex of root deflection of root narrowing of root narrowing of canal darkening of roots interruption of cortical white line diversion of canal

Question 80

when looking at third molar radiology what are the signs you look for?

Answer 80

relationship to vital structures configuration of roots condition of surrounding bone

Question 81

configuration of roots: what do you look for in a radiograph prior to third molar removal?

Answer 81

Number of roots Curvature of roots Degree of root divergence Size & shape of roots bulbous, conical, long, short, hooked Other root resorption, caries, anyklosis

Question 82

condition of surrounding bone: relevancve

Answer 82

density determines difficulty under 18 less dense easier to cut over 35 more dense higher risk of fracture

Question 83

third molar surgerry: increase risk of complications

Answer 83

Underlying systemic disease Age Anatomical position of tooth and root morphology Local anatomical relationships Status of adjacent teeth Access Patient co-operation / compliance Bone density Ankylosis Infection Pathology

Question 84

operculectomy: advantages and disadvantages

Answer 84

Enables oral hygiene to be effective Often ineffective Careful selection of cases

Question 85

post op care for surgical removal of third molars

Answer 85

Post-operative care Standard instructions Expect the worse Regular analgesia (NSAIDs most effective) No Smoking or Vaping for 1/52 Written and verbal instructions Post op call next day Written contact details for emergency / advice NO evidence for routine antibiotics

Question 86

protocol for surgical removal of third molars

Answer 86

Pre-op 400 mg Ibuprofen providing no contra-indications [?evidence for pre-op oral rinse + steroids] Local Anaesthesia Inferior alveolar nerve block with Lidocaine 2% & 1:80,000 Adrenaline Buccal infiltration with 4% Articaine & 1:100,000 Adrenaline Check anaesthesia Post-operative 400mg Ibuprofen TDS + 1g Paracetamol QDS for AT LEAST 48 hours Warm Salt Water Rinses QDS for 1/52

Question 87

complication of third molar surgery

Answer 87

LA Damage to adjacent teeth Extraction of the wrong tooth Bleeding Displacement of root/tooth/fragment Aspiration Instrument # Soft tissue damage TMJ dislocation Mandible fracture Nerve injury Fractured tuberosity Oro-antral communication Burn

Question 88

coronectomy guidelines

Answer 88

Teeth with associated infection should be excluded Teeth that are mobile should be excluded No evidence for the treatment of the exposed pulp of the tooth and RCT appears to be contraindicated Leaving the retained root fragment at least 3mm inferior to the crest of the bone seems appropriate – encourages bone formation over the fragment Late migration of the root fragment may occur in some cases, but is unpredictable. Operative site should be closed in a tension free manner Dry socket can be treated in the conventional way

Question 89

coronecrtomy: considerations

Answer 89

Caries with pulpal involvement - potential infection risk Apical Disease - progressing to chronic disease Mobility of roots - potential infection Association pathology - e.g. cyst Pre-orthognathic surgery - in line of cuts Immunocompromised - risk of infection Pre-radiotherapy - risk of ORN MUST involve pt in the decision