Flashcards in Oral surgery Deck (151):
What are the signs of reversible pulpitis?
Pain on hot and cold, sugary things
Vital (+ve PE)
On stimulus (goes away when removed)
Relieved with analgesia
What are the signs of irreversible pulpitis?
Pain on hot (also cold)
Hypersensitive or delayed PE response
Not relieved by analgesics
Keeps patient up at night
What are the signs of Acute apical periodontitis?
Can be due to progression from irreversible pulpitis or alone e.g. high spot on restoration, endo filling extruding past apex, bacterial invasion at apex and infection from gingival communication
What are the signs of Chronic apical periodontitis?
May be painless, non-vital
Large radiographic radiolucency
What are the signs of an acute exacerbation of CAP?
Longer duration but now painful
What are the signs of Acute apical abscess?
Infection after RCT/pulpal infection
When do you give antibiotics?
If systemic (i.e. fever)
What antibiotics do you give for dental infection? (SDCEP)
Amoxicillin 500mg for 5 days (if allergic use metronidazole 400mg)
(double dose for severe infections)
When should you send a patient to hospital?
When infection has spread causing cellulitis or submandibular swelling threatening the airways
Where does infection spread when apices close to the lingual cortical plate?
Above mylohyoid muscle = can spread to sublingual space = elevated tongue, swelling of floor of mouth, can force tongue upwards and close airway
Where does infection from the mandibular molars spread?
Below mylohyoid muscle into the submandibular space
What is Ludwigs angina?
When an infection affects submental, submandibular and sublingual spaces bilaterally = DANGEROUS - obstruction risk
Where do midface infections spread?
Oedema and pressure can cause blood to back up through cavernous sinus = cavernous sinus thrombosis - a sharp pain behind the eye which gradually gets worse, decreased vision, increased eye movements, dilated pupils = DANGEROUS and life threatening
How can infection lead to blindness?
Track through maxillary sinus -> orbital space = orbital cellulitis
How can infection get to the posterior mediastinum?
Behind retropharyngeal space (danger zone) = posterior medistinum
What is it called when infection gets into the bone?
What % of septicaemia cases lead to death?
What is Eryspilas?
Acute infection of deep dermis by s. pyrogens
Causes blistering rash/orange peeling of skin
Red and raised skin/fever/lymphadenopathy/vomiting and shaking within 48 hours
What are the general routes of infection for the upper teeth?
Upper 1s - labial sulcus/nose
Upper 2s- Palate/labial sulcus
Upper 3s -infraorbital/labial sulcus
Upper 4s-8s - Buccal sulcus/buccinator
What are the general routes of infection for the lower teeth?
Lower 1s and 2s - submental
Lower 3s and 4s - sublingual space (above mylohyoid)
Lower 5s to 9s - submandibular (below mylohyoid)
How does diabetes effect tooth infection?
Increased prevalence of apical infections
Increased complications from dental abscess
How does smoking and alcohol effect tooth infection?
Increase risk of infection
Decrease resistance to infection
What is the treatment for an abscess:
Incision and drainage and RCT/XLA
Antibiotics only if: systemic, cellulitis, trismus, medically compromised
If abscess is serious and life threatening what antibiotics do you give?
Amoxicillin and Clauvonic acid/metronidazole
if allergic metronidazole or clindamycin
What are the SDCEP guidelines for antibiotics?
Always get rid of infection by extirpation/XLA
May need incision if not all pus removed
Only prescribe antibiotics if: severe (AAA or trismus) or spreading infection (lymphadenopathy, cellulitis, if can't feel lower border of mandible, in ludwig's angina), systemic involvement (fever >38, malaise, loss of appetite, unwell), patient factors (immunocompromised, bleeding risk etc)
When should you consider a lower dose of antibitics?
Renal and liver function issues
What is the % risk of allergy to penicillins?
1-10% (0.05% risk of anaphylaxis)
What is a common side effect of penicillins?
What dose of amoxicillin is prescribed?
>5 y/o 500mg 3x daily for 5 days
(<1 125mg, 1-5 250mg)
What dose of phenoxymethylpenicillin is used?
>12y/o 500mg 4x daily for 5 days
(5-12 250mg, 1-5 125mg, <1 65.5mg)
What dose of metronidazole is used?
>18 y/o 400mg daily for 5 days
(<10 200mg, <7 100mg 2/day, <3 50mg 2/day)
When is metronidazole used?
Part of perio pill
With amoxicillin in severe infections
When should metronidazole not be used?
When is clindamycin used?
Allergy to penicillin and pregnancy
X Chrons Ulcerative colitis
150mg 4/day 5 days
When is clarythromycin used?
Good for patients who have shown resistance or allergy to penicillin
X pregnancy/breastfeeding/warfarin/statins/heart/kidney/liver problems
150mg 2/day for 7 days
When is Co-amoxiclav used?
Severe dental infections and spreading cellulitis
X penicillin allergy or liver problems
Side effect: Steven Johnsons syndrome
375mg 3/day for 5 days
When is tetracycline (doxycycline) used?
Dip avulsed tooth pre-implanting open apex tooth (1mg: 20 ml saline), perio (20mg 2/day for 3 months)
X pregnancy/breast feeding / under 12 -> staining
When is Floxacillin used?
Staph skin infections and cellulitis
(good for patients with resistance)
250mg 4/day for 5 days
Why is erythromycin not very useful for dental infections?
(also dont use in pregnancy or warfarin)
When is chlorhexidine used?
0.2% 10 mg for 1 min 2 x daily for perio
Reduces plaque 50-90%
Safe for pregnancy/breastfeeding
BEWARE OF ANAPHYLAXIS RISK
DOnt use in <12 y/o
What are the antibiotic cover guidelines: (NICE and SDCEP)
- not recommended for routine dental appointments (e.g. fillings and dentures)
- if platelets < 50 x 10^9 (n.b. can't give IDB at this level)
- if WBC <1.5 x10^9 (oral 3g amoxicillin or 600mg clindamycin 1 hr before XLA)
- Consult cardiologist if patients need cover for: XLA, RCT, RSD if at high risk of infective endocarditis (congenital heart disease, septal defects, previous episode of IE, prosthetic valves, hypertrophic cardiomyopathy... mid risk: IV drug users)
- Dont give for MRONJ/osteoradionecrosis prophylaxis just warn patients of risk
- cover patients: Haemophiliacs/von willebrand disease, immunocompromised (bone marrow transplant, HIV, chemo) and prosthetics with rheumatoid arthritis/infection
What are the steroid cover guidelines (at UH Bristol)?
Group A = addison's disease - see in hospital setting
Group B = long term steroids - Prednisolone >5mg 3 weeks -> double dose on day of XLA or 100mg IV hydrocortisone
When do we treat and individual on chemotherapy if required?
Just before/day of chemo
(highest risk of bacteraemia 14days post chemo), recover counts 28 days post chemo (just before next dose)
What are the guidelines for warfarin? SDCEP
Check INR within 24 hours
INR <4 proceed with XLA
INR >4 delay XLA and contact GP - ref. to hospital if XLA urgent (IV vit k)
Pack and suture
No NSAIDS - paracetamol only
No metronidazole, erythromycin or clarithromycin
What are the guidelines for Heparin (deltaparan, enoxaparin, tinazaparin)? SDCEP
Ref to hospital for XLA
Reverse by protamine sulphate
(Factor 10a inhibitors)
What are the NOACs?
Apixiban and rivaroxaban (inhibit factor 10a)
Dabigatran (inhibits thrombin)
What are the guidelines for NOACs? SDCEP
Always do XLA in morning in case of complications
Pack and suture
No NSAIDS - paracetamol only
Apixiban and dabigatran (miss morning dose)
Rivaroxaban (if taken in morning delay dose and take 4 hours post haem, if taken in evening take as normal)
What are the guidelines for anti platelets (Aspirin, clopidogrel, dipyridamole)? SDCEP
Pack and suture
What are the guidelines for SSRI + carbamezipine? SDCEP
May increase bleeding risk but no extra measures taken
What are the contraindications to ibuprofen?
Antiplatelet or anticoagulant
Peptic ulcers/gastric bypass surgery
Uncontrolled hypertension (if controlled limit to 5 days)
Any heart conditions/surgery
What can cause increased risk of bleeding?
Head and neck chemo and radiotherapy <3 months
Ehlers danlos syndrome
Scurvy (low vit c)
Thrombocytopenia (platelet cover)
Haemorrhagic telangiectasia (hereditary)
Sturge Webers (CT before XLA to prevent haemorrhage)
What extra tests are needed for kidney disease?
FBC for platelets
Thrombopoietin can be given to make platelets from bone marrow
What extra tests are needed for liver disease? SDCEP
INR + FBC + LFT + clotting screen
What are the guidelines for all bleeding disorders? SFCEP
Refer to hospital for XLA
Given 1g oral tranexamic acid (stop clot breaking down)
How do we treat Haemophilia A extractions?
IV Factor 8 1 hr before, desmopressin and tranexamic acid
How do we treat Von Willebrand disease extractions?
IV factor 8 1 hr before, desmopressin and tranexamic acid
How do we treat Haemophilia B extractions?
IV factor 9 1 day before and tranexamic acid
How do we treat Haemophilia C extractions?
IV factor 11 and tranexamic acid
What are the signs of haemorrhage?
Low BP, cold extremities, increased HR
What are the guidelines for pregnancy? SDCEP
Dont lie flat
Xrays - avoid in 1st trimester, lead apron if urgent but if non urgent wait until 2nd
Urgent XLA can be done in 2nd trimester, Non urgent wait 6 weeks after birth
Sedation : none
Avoid Felypressin containing LA - induces labour
Avoid: metronidazole, tetracycline, clarithromyicn
Antibiotics: amoxicillin or clindamycin (if allergy)
RCT: No odontopaste or lefermix -> use hypo cal
Analgesia: no NSAIDS or codeine -> use paracetamol
Antifungals: No systemic -> use nystatin
If symphilis/HSV/mumps/rubella = urgent referral (tetrogenic)
What are the guidelines for paracetamol? SDCEP
2 x 500 mg 4/day every 4 hours for 5 days
Max dose = 4g (adults)
Overdose = 8 tablets or 75mg/kg in 1 day -> A and E
Contraindication = liver problems and severe renal impairment
What are the guidelines for Ibuprofen? SDCEP
400mg tablet 4/day every 4 hours with meals for 5 days
Max dose = 2.4g (adults)
Overdose = 8 tablets or 75mg/kg in 1 day -> A and E
Contraindication = uncontrolled asthma, hypersensitivity ti NSAIDs, GI sensitivity, peptic ulcers
What are the guidelines for Diclofenac? SDCEP
50mg 1 x daily for 3 days
Max dose 150mg
NOT recommended in children, ischameic heart disease, cerebrovascular disease, heart failure, hypertension, low dose daily aspirin and use with caution with warfarin and anticoags
Who is at high risk of MRONJ?
- previous MRONJ
- taking meds for cancer (breast, prostate, blood or multiple myeloma) > osteoporosis
- + bisphosphonates (>5 years = high risk)
- + steroids
- anti resorptive and anti angiogenic drug risk > anti resorptive > angiogenic
- Denosumab (monoclonal antibody) in past 9 months
What should you do when placing a patient on anti-resorpatives?
- Prioritise prevention: OHI/fluoride/diet/smoking/alcohol/regular visits + Bas
-reduce mucosal trauma (denture adjustment/perio)
- avoid future extractions
- extract poor prognosis teeth
- tell patient of risk of developing MRONJ (small risk so not discouraged from taking their medication and dental treatment)
- NO ANTIBIOTIC PROPHYLAXIS
Following extraction in high risk MRONJ patient what should you tell them?
Contact practice if:
- unexpected pain, tingling, numbness or swelling post XLA
When is it classified as MRONJ?
When its been there for > 8 weeks
= Refer to oral surgery/special care dentistry
History of antiresorbative/anti-angiogenic drugs and exposed bone > 8 weeks that can be probed through an IO/EO fistula, in the maxillofacial region where there has been no history of radiation therapy or cancer to the jaw
History of radiotherapy and exposed bone > 8 weeks that can be probed through an IO/EO fistula, in the maxillofacial region, where there has been no history of antiresorbative/anti-angiogenic drugs
What are the signs and symptoms of MRONJ?
Delayed healing after XLA, non healing sores, pain/infection/swelling, loose teeth, numbness/parasthesia, exposed bone >8 weeks
What can cause MRONJ?
Any dental trauma
Which jaw is MRONJ more common in?
Mandible (less blood supply)
What is the risk of developing MRONJ if on antiresorpatives for cancer?
What is the risk of developing MRONJ if on antiresorpatives for osteoporosis?
name the antiresopative drugs:
Whats the half life of alendroate?
how long does it take for denosumabs effects to diminish?
name the anti-angiogenic drugs
Can you place implants in a cancer patient?
Generally agreed to avoid (risk currently unknown)
Can you place implants in an osteoporosis patient? SDCEP
Not currently contraindicated but BRONJ less frequent if placed before bisphosphonates taken (insufficient evidence on survival or denosumab)
Should bisphosphonate have 'drug holidays' for extractions etc,? SDCEP
No evidence to support a reduced risk in temporarily or permanently stopping prior to XLA as persists in bone for years
Whats the advice for drug holiday for denosumab? SDCEP
6 monthly IV for osteoporosis - delay non urgent XLA to 1 month before next IV scheduled and resume when socket is healed (liase with GP)
Can you extract a tooth in a high risk patient in practice?
Yes - no benefit in referral to secondary care
If suspect MRONJ - refer to oral surgery/special care and report to allow card for bone sequestral removal, antibiotic therapy and topical antiseptic
What are the contraindications to IV midazolam conscious sedation?
Prophyria (abnormal metabolism of pigment in Hb)
What are the contraindications for NO inhalation sedation?
Blocked airway/ upper respiratory tract infection
Cant communicate e.g. deaf
B12/folate deficiency - caution
Eye surgery that has used intraocular gas
Heart conditions (caution)
When can NO inhalation sedation be used?
Adults with psychiatric disorders
What are contraindications to GA?
Any heart conditions
Respiratory conditions (TB, emphysema, COPD)
Risks of extraction:
crown or root fracture
OAC (upper 4-7)
surgical required (rare)
root being displaced in adjacent structures
numbness - temp/permanent change or loss of sensation
Whats the max dose of lidocaine?
without adrenaline 4.4mg/kg
with adrenaline 7mg/kg
What LA should you use with liver problems?
Articaine or Procaine or <300mg lidocaine
What LA should you use in pregnancy?
NOT prilocaine with felypressin
What LA should you use in recent MI?
Refer to hospital (50% likely to have second MI in first 3 months)
At what platelet level should we not give and IDB?
In open apex or apical root fracture what should you irrigate RCT with?
What are the pterygomandibular borders?
Post - parotid
inferior - inferior border of mandible
mesial - mesial pterygoid
lateral - ramus
superior - lateral pterygoid
How common is IDB parasthesia?
How common is lingual nerve parasthesia?
What is neuropraxia?
temporary paraesthesia from stretching
What is axonotmesis?
Deviation of axon = temp paraesthesia
What is neurotmesis?
deviation of nerve = permanent paraesthesia
why does LA fail?
Infection/abscess -> increased permeability of blood vessel = wash away LA, prostaglandins = reduced pain threshold for nerve, acidic environment = LA can't diffuse through tissue to nerve
Poor technique (positioning and insufficient LA)
Complex anatomy (accessory nerves)
Wait 5-10 mins!
What are the contraindications to XLA?
Recent MI (3 months)
Pregnancy (best to wait until 2nd trimester)
Bleeding disorders (need prophylaxis)
Trismus (blocking access)
Infection so severe LA won't work
At what point should you refer to hospital?
8s that are close to IDN (need CBCT) or >5mm winters line
Airway risk (stride, hot potato voice, can't feel lower border of mandible, can't stick out tongue, can't swallow)
Ludwigs (dont take tooth out if has soft tissue infection because infection could track back to airway)
Medical emergency risk - uncontrolled condition (diabetes, angina)
MI < 3 months ago
High risk of OAC
Bleeding disorder/risk/INR >4
Tooth is in tumour
Severe trismus blocking access (alkinosi not working)
Infection severe so LA won't work
Unerupted teeth close to mucosa
Infra-occluded deciduous teeth (most commonly E's)
Impacted 8's -> caries to distal of 7
Ectopic 3's -> resorption of laterals
What are the indications for XLA in practice?
Caries non restorable (below level of alveolar bone)
Severe perio (grade 2 mobile)
Pt uncompliant or poorly motivated
Cant do RCT (8's/roots already resorbed/sclerosed canal/strange morphology)
Trauma (dentoalveolar fracture, bertical root fracture, teeth in line of fracture)
Dental clearance prior to screen (MRONJ, chemo, radiation, bone marrow transplant)
What do you do if you have a maxillary tuberosity fracture?
If not infected = stop and splint tooth for 4-6 weeks
If infected = remove it and do buccal flap
What increases the risk for a maxillary tuberosity fracture?
lone standing tooth, bulbous roots, increased age, wrong elevator use, ankylosis, sinusitis, osteoporosis or very dense bone and upper 8's
What do you do if you have an OAF?
Decongestants (xylometazoline, phenyl ephedrine hydrochloride)
Menthol steam inhalation
Buccal flap + vertical mattress suture 10-14 days and ref to ENT if there is pathology in antrum
What do you do if fractured root?
Non vital/infectedd = remove
Vital/not infected = leave to resorb if <5mm apical
What do you do if tooth is displaced not maxillary antrum?
In practice - if can see XLA
If can't - raise flap and suture? ref to O/S immediately
Hospital/GA: caldwell luc
What is the prevention for displacement into maxillary antrum?
Never use forceps on upper PM/M root fractures or RR
What do you do if you damage the mandible?
Refer to O/S
What do you do if tooth displaced into pterygomandibular space
What do you do if tooth displaced into lingual much?
If can see it - get it out ASAP
If can't - Refer for GA referral = need LSO, lateral oblique and PA
What do you do if 8s in pterygomasseteric space/infratemporal fossa?
Wha do you do if inhale tooth?
Refer for chest xray
Heimlich x 5 if needed
What do you do if you extract the wrong tooth?
tell patient, contact ortho + defence society
extract right tooth if non vital/infected etc.
What do you do if the crown fractures?
Use luxator or go surgical
What do you do if LA failure?
AB's for 3-4 days + try again or refer if an emergency
What do you do if fails XLA?
Look at X-ray for sclerosis, root morphology, ankylosis (use smaller forceps/luxator or go surgical and divide roots with fissure bur)
What do you do if nerve damage?
should have been part of consent
2 week review + second opinion
What do you do with post op pain?
Take a history diagnose
If too tight sutures/sutures not dissolved = remove sutures
Hot salt mouth rinse
What do you do with dry socket?
take temp, saline rinse, alveogyl, return if not improved in 24 hours
(No chlorhexidine - anaphylaxis risk)
How common is a dry socket?
Routine extractions 0.5-5%
Surgical impacted L8s 30%
How do you prevent dry socket?
Chlorhexidine but study showed that although it reduced frequency anaphylaxis and antibiotic resistance meant it does more harm than good
Some dentists debride socket to encourage bleeding
What are the post op instructions for extraction?
No rinsing for 24 hours
After 24 hours hot salt water rinses after eating
No heavy exercise for next 24 hours
Take OTC analgesia within dose
20 mins compression if starts bleeding
What are the risk factors for dry socket?
Poor blood supply
Mandible (collects more food debris)
Molar (larger defect)
Smoking (nicotine causes vasoconstriction)
Traumatic/surgical XLA (crushes blood vessels)
Sclerotic bone (pagets, hypoparathyroidism, chronic osteomyelitis, bone cancer, osteopetrosis, cement-osseous dysplasia)
Diabetes (damage to blood vessels)
Loss of clot - mouth rinsing, local trauma (brushing), OCP oestrogen, prexisting perio/anug/pericorinitis less likely to cause dry socket when extracted)
What are the signs and symptoms of a dry socket?
Not infection (no fever/lymphadenopathy or pus)
Severe dull aching throbbing pain not relieved by analgesia, may radiate to ear/temple/neck
2-4 days post XLA
mild trismus (post. XLA)
empty socket with exposed bone
Halitosis (food debris stagnating in pocket)
n.b. swelling may hide dry socket from clinical exam
What is in alveogyl?
Eugenol, iodoform, butamben, peppermint oil
What patients should you not use alveogyl on?
Allergy to procaine
Allergy to iodine
When are wisdom teeth removed?
Resorption of 7's
Causing caries on 7
Periodistal to 7 can cause communication to 8 so should extract 8
Denture wearing resorb alveolar ridge exposing and carious 8
What do you need to assess 8's?
OPG (depth of impaction shows if surgical, winters line, angulation of tooth and IDB)
PA (root form, length and curve of root, adjacent teeth carious)
What are the radiographic signs that 8 is close to IDB?
Loss of tram lines
Diverging tram lines
Radiolucency at end of root
What is pericoronitis?
inflammation of the operculum due to:: occluding tooth, erupting 8 or stagnation of food under operculum
What are the signs of pericoronitis?
Lower 8s and primary teeth
Dull constant pain
Swelling of operculum
What is the treatment for pericoronitis?
1st line: irrigate with mono jet and saline, RSD under LA, salt water rinses, analgesia, soft diet
Pus and systemic involvement: metronidazole 400mg 3/day for 3 days
On 3rd occurence refer for surgical XLA
(consider XLA upper 8s or smooth if opposing tooth is traumatising operculum)
(operculotomy - but usually grows back
What are the complications of pericoronitis?
Spread of infection to pterygomandibular, reropharyngeal and submassetric space, tonsillar fossa
What is the aetiology of ANUG?
Increased in males
Immunocompromised and HIV patients
What is the cause of ANUG?
Spirochetes and fusiform bacteria (anaerobic)
Whats the signs of ANUG?
Punched out lesions in interdental papilla, grey sloughing, feeling of tightness around teeth (pain), bleeding gums, metallic taste and halitosis
Whats the treatment for ANUG?
1st line: OHI, debridement of calculus (chronic phase as less painful), hydrogen peroxide/ chlorhexidine m/w
If severe: metronidazole 200mg 1x daily for 3 days (SDCEP) or amoxicillin 500mg 3x day for 5 days - adults
What do you do if a patient faints?
Lie patient flat, raise legs, give O2
What do you do if a patient has an epileptic fit?
Ambulance (more than 5 mins or first fit)
Buccal midzolam ro 10mg diazepam (rectal) immediately, protect head and give O2
What do you do if a patient is hypoglycaemic?
n.b. signs aggressive, confused, act drunk, slurred speech, act drunk
Concious - glucose drink, semiconscious - buccal glucose gel, unconscious 1mg Glucagon IM or 50ml IV glucose, give O2
What do you do if a patient has a steroid crisis (adrenal insufficiency)?
n.b. long term steroid use, addisons or stress
signs look pale, thready pulse, low BP
Lie them flat
What do you do if a patient goes into anaphylaxis?
adrenaline 1ml 1:1000 IM (epipen)
repeat every 5 mins
If doesnt work hydrocortisone 100mg IV, if it doesnt work 5% dextrose IV 1-2L
What do you do if a patient has an asthma attack?
Salbutamol 2 puffs (nebuliser if needed)
Status asthmaticus: IV hydrocortisone 100mg, adrenaline IM 0.5-1ml 1:1000 IM
What do you do if a patient had an angina attack?
Lie them flat, GTN spray sublingual (500mcg), oxygen
What do you do if a patient has a heart attack?
Oxygen, low dose aspirin (300mg) and GTN
What do you do if a patient goes into cardiac arrest?
What do you do if a patient has a stroke?
Lie them back