Oral Surgery III - The Whole Enchilada

Question 1

Fluid in or under the epithelium; a large blister

Answer 1

Bulla

Question 2

Dried or clotted serum protein on surface of skin or mucosa

Answer 2

Crust

Question 3

a superficial ulcer or excoriation

Answer 3

Erosion

Question 4

A circumscribed area of color change without elevation

Answer 4

Macule

Question 5

A large palpable mass, elevated above the epithelial surface

Answer 5

Nodule

Question 6

A small palpable mass, elevated above the epithelial surface

Answer 6

Papule

Question 7

A flat but elevated lesion

Answer 7

Plaque

Question 8

A cloudy or white vesicle filled with pus

Answer 8

Pustule

Question 9

A macroscopic accumulation of keratin

Answer 9

Scale

Question 10

A loss of epithelium

Answer 10

Ulcer

Question 11

A small loculation of fluid in or under the epithelium; a small blister

Answer 11

Vesicle

Question 12

Any lesion that persists for _____ weeks with no apparent etiologic basis is a _________

Answer 12

2 weeks

Indication for biopsy

Question 13

Any inflammatory lesion that does not respond to local Tx with _____ days is basis for a Biopsy

Answer 13

10-14 days

Question 14

Persistent ______ changes in superficial tissue is an indication for Biopsy

Answer 14

hyperkeratotic

Question 15

Any persistent _________ is an indication for Biopsy

Answer 15

tumescence (swelling)

Question 16

________ Inflammatory changes of _______ is an indication for Biopsy

Answer 16

Persistent

unknown cause

Question 17

Lesions that interfere with _________ is an indication for Biopsy

Answer 17

local function

Question 18

Any lesion that has characteristics of ________ is an indication for Biopsy

Answer 18

Malignancy

Question 19

7 Indications for Biopsy:

Answer 19

2 week lesion w/out etiologic basis

10-14 day non-responsive inflammatory lesion

Persistent superficial hyperkeratosis

Persistent tumescence

Inflammatory changes of unknown causes that persist

Lesions interfering with Local Function

Looks like Malignancy

Question 20

7 things that may indicate Malignancy:

Answer 20

Erythroplasia (red/speckled red/white)

Ulceration

Duration longer than 2 weeks

Rapid growth

Bleeding

Induration - (loss of pliability)

Fixation - feels attached to adjacent structures

Question 21

4 types of Biopsy:

Answer 21

Cytology

Aspiration

Incisional

Excisional

Question 22

Cytology was first used as a _______

Some studies find high _______

Must be examined by ________

Answer 22

pap smear

false negatives

pathologist

Question 23

What is the prime indication for Cytology biopsy?

Answer 23

Large areas of mucosal change monitored for Dysplasia

Question 24

An Aspiration Biopsy must be done on what prior to surgical intervention?

Answer 24

Any Radiolucency

*could by high flow vascular lesion

Question 25

A Fine Needle Aspiration Biopsy is indicated in the Tx of solitary ______ masses suspected to represent a tumor ___ gauge or smaller needle is used

Answer 25

Parotid 21

Question 26

An Incisional Biopsy samples what part of a lesion?

Answer 26

Representative

Question 27

3 Reasons to do an Incisional Biopsy:

Answer 27

over 1 cm/close proximity to vital anatomic structures Difficult to excise Suspicion of Malignancy

Question 28

Shape of an Incisional Biopsy: Include: Do what for the pathologist?

Answer 28

Wedge normal tissue at edges orient

Question 29

T/F | Incisional Biopsy should by broad and shallow

Answer 29

False **narrow and deep enough to go all the way through the structure

Question 30

An Excisional Biopsy should be done only in what cases? Good for what size lesions?

Answer 30

Malignancy NOT expected 1 cm or less

Question 31

Biopsy Technique should use regional _____ and use _____ incisions

Answer 31

field blocks sharp

Question 32

A Biopsy sample is placed directly into ________

Answer 32

10% Formalin

Question 33

MRONJ =

Answer 33

Medication Related Osteonecrosis of the Jaws

Question 34

T/F | Osteoradionecrosis of the jaws is pretty much the same as MRONJ in treatment and response

Answer 34

False *NOT the same, in any way

Question 35

MRONJ is defined as _______ bone that can be probed (intra/extra oral fistula) in the MF region persisting for ________

Answer 35

exposed 8 weeks

Question 36

MRONJ does NOT refer to _______, but its causes are what 2 types of drugs?

Answer 36

radiation therapy antiresorptive, antiangiogenic

Question 37

T/F | MRONJ is a fairly new disease and huge numbers of people are on meds that put people at risk

Answer 37

True

Question 38

T/F | Normal course of debriding bone and moving flaps, successful for other Tx, does not tend to work for MRONJ

Answer 38

True

Question 39

``` T/F Hyperbaric Oxygen (HBO) works well for MRONJ ```

Answer 39

False *osteoradionecrosis, etc.

Question 40

With MRONJ, wounds tend to ______ with surgical intervention

Answer 40

enlarge

Question 41

T/F | There is no definitive Tx for MRONJ

Answer 41

True

Question 42

T/F | MRONJ pts may have to be on continuous or episodic antibiotics for the rest of their lives

Answer 42

True

Question 43

T/F | Oral bisphosphonates, RANK-L inhibitors, monoclonal antibodies, and anti-angiogenesis drugs can all cause MRONJ

Answer 43

True

Question 44

How many cases of MRONJ have been reported in the literature?

Answer 44

17,000

Question 45

3 types of Antiresorptives associated with MRONJ:

Answer 45

IV bisphosphonates Oral bisphosphonates RANK Ligand inhibitor (human monoclonal antibody)

Question 46

What 4 conditions are Treated with MRONJ-causing drugs ?

Answer 46

Cancers that metastasize to bone (breast, prostate, lung) Bone lesions/multiple myeloma Osteoporosis Soft tissue tumors

Question 47

3 Common Oral Bisphosphonates: *used for Osteoporosis

Answer 47

alendronate Fosamax risendronate Actonel ibandronate Boniva

Question 48

2 IV Bisphosphonates *used for Bone Metastases

Answer 48

pamidronate Aredia zoledronate Zometa

Question 49

Name of the RANK-L inhibitor *monoclonal antibody used for Bone Metastases

Answer 49

denosumab Xgeva

Question 50

Name of RANK-L inhibitor *monoclonal antibody used for Osteoporosis

Answer 50

denosumab Prolia

Question 51

Bisphosphonates and RANK-L both work by inhibiting what?

Answer 51

Osteoclast activity

Question 52

Osteoclasts, though they break bone down, release ______ and growth factors

Answer 52

BMP

Question 53

Antiangiogenic meds interfere with the formation of vessels/vascular supply and cause what?

Answer 53

Avascular Necrosis

Question 54

denosumab (anti RANKL antibody) is doses via _______ injection at an interval of _______

Answer 54

subQ 6 months

Question 55

More than ___ million osteoporotic fractures accor in the US every year This places ________ people in nursing homes

Answer 55

1.5 million 180,000

Question 56

T/F | Hip fracture mortality exceeds 20%

Answer 56

True

Question 57

The annual direct care expenditure on osteoporotic fracture was ______ in 2002 *expected to double or triple by 2050

Answer 57

12 to 18 Billion dollars

Question 58

What is the systemic marker of bone turnover to assess MRONJ risk? What are the parameters? Is it useful in all pts?

Answer 58

CTX - collagen type I C telopeptide 100 - 150 moderate risk (less than high, greater than minimal) no

Question 59

CTX - collagen type 1C telopeptide is NOT a useful test in what 3 pts?

Answer 59

Cancer methotrexate (falsely low) Steroids (falsely low)

Question 60

Is the CTX test a valid systemic test for MRONJ?

Answer 60

No

Question 61

Ideally, before IV BP therapy, you should extract nonrestorable teeth, eliminate perio, and treat caries During therapy avoid anything invasive Treat caries, splint, etc

Answer 61

True

Question 62

If surgery is unavoidable with a pt taking IV BP, what is the most important thing?

Answer 62

Informed Consent

Question 63

T/F | Pts should have a dental screening and preventative Tx PRIOR to initiating antiresporptive or antiangiogenic therapy

Answer 63

True

Question 64

To prevent MRONJ, pts should take a drug holiday off of oral BP or denosumab for what disease? At what time?

Answer 64

Osteoporosis 4 years

Question 65

T/F | If MRONJ develops in a Cancer Pt, the oncologist may consider discontinuing therapy until soft tissue closure

Answer 65

True

Question 66

MRONJ must be addressed in pts taking antiresorptive therapy b/c it is likely to exceed ____ years

Answer 66

4

Question 67

T/F Implant placement should be avoided in pts on IV bisphosphonates or antiangiogenic drugs for Cancer ***also avoid direct osseous injury

Answer 67

True True

Question 68

For Osteoporosis pts taking BP, if there are no clinical risk factors, you don't have to alter or delay surgery on what condition?

Answer 68

Pt taking BP LESS than 4 years

Question 69

Osteoporosis pts taking BP less than 4 years taking _____ or _______, must contact prescribing provider for a Drug Holiday for at least ____ before oral surgery and wait for osseous healing

Answer 69

corticosteroids, antiangiogenics 2 months

Question 70

Osteoporosis pts taking BP for MORE than 4 years w/ or w/out concomitant therapy, contact prescribing provider for ________ before oral surgery and wait for osseous healing

Answer 70

drug holiday for 2 Months

Question 71

If Ostoporosis pt taking drug over 4 years, how long of a drug holiday for Prolia (denosumab) prior to surgery? Reclast (zolendronate)? before/after

Answer 71

3 months 9 months / 3 months

Question 72

What are 3 indications for jaw Resection in MRONJ?

Answer 72

won't respond to nonsurgical Tx Fractures Direct sinus

Question 73

alendronate may reduce the risk of hip fx by ___% ***could prevent 100k fxs and thousands deaths

Answer 73

40

Question 74

T/F | 90% of MRONJ pts can be maintained pain free

Answer 74

True

Question 75

T/F | MRONJ is rare, less severe, and reversible with discontinuation of IV

Answer 75

False ***only true for ORAL meds

Question 76

T/F | 3 of the 4 diognostic criteria for MRONJ are historic data so you have to ask many questions to make a diagnosis

Answer 76

True

Question 77

What is the important time frame for the duration of dosing of Oral BP's?

Answer 77

4 years

Question 78

IV BP's are significantly more likely to cause MRONJ ***often given w/ chemo, so Ask About Hx!! Zometa, Aredia, Xgeva...

Answer 78

True