Post op complications 4 (Longer term post-operative)

Question 1

What can fall under these complications: Longer term post-operative

Answer 1

Acute oral antral communication

Chronic oral antral fistula

Root in antrum

Question 2

What are less common post operative complications

Answer 2

Osteomyelitis

Osteoradionecrosis (ORN)

Medication induced
osteonecrosis (MRONJ)

Actinomycosis

Bacteraemia/Infective endocarditis

Question 3

How can you diagnose a OAC

Answer 3

By:
Size of tooth

Radiographic position of roots in relation to antrum

Bone at trifurcation of roots

Bubbling of blood

Nose holding test (careful as can create an OAF)

Direct vision

Good light and suction - echo

Blunt probe (take care not to create an OAF)

Question 4

How do you manage a OAC

Answer 4

Inform patient

If small or sinus intact:
-Encourage clot
-Suture margins
-?Antibiotic
-Post-op instructions

Question 5

How would you manage a larger acute OAC

Answer 5

Close with buccal advancement flap

Antibiotics, decongestants, and nose blowing instructions

Question 6

How would you manage a chronic OAF

Answer 6

Excise sinus tract
Buccal Advancement Flap
Buccal Fat Pad with Buccal Advancement Flap
Palatal Flap
Bone Graft/Collagen membrane

Question 7

How are roots in antrum confirmed

Answer 7

Radiographically by OPT occlusal or periapical

Question 8

How would you retrieve a forgein body in antrum

Answer 8

OAF type approach/through the socket:

-Flap Design
-Open fenestration with care
-Suction – efficient and narrow bore
-Small curettes
-Irrigation or ribbon gauze
-Close as for OAC

Question 9

What is the caldwell luc approach and what is it used for

Answer 9

To retrieve forgein bdy in antrum

The procedure involves creating an incision in the gum line above the upper teeth, and then creating a window in the bone of the maxillary sinus to access and remove any foreign objects that may be present

Performed under GA

Question 10

What does FESS stand for

Answer 10

Functional Endoscopic Sinus Surgery

Question 11

What is osteomyelitis

Answer 11

The term means inflammation of the bone marrow

Clinically the term implies an infection of the bone

Question 12

Where is Osteomyelitis normally affecting

Answer 12

The mandible

Question 13

What are the symptoms of Osteomyelitis

Answer 13

Patient often systemically unwell/raised temperature

Site of extraction often very tender

In deep seated infection may see altered sensation due to pressure on IAN

Question 14

Where does osteomyelitis start and spread to

Answer 14

Usually begins in medullary cavity involving the cancellous bone

Then extends and spreads to cortical bone

Then eventually to periosteum

Question 15

How does osteomyelitis happen

Answer 15

Invasion of bacteria into cancellous bone causes soft tissue inflammation and oedema in the closed bony marrow spaces

Oedema in an enclosed space leads to increased tissue hydrostatic pressure – higher than blood pressure of feeding arterial vessels

Compromised blood supply results in soft tissue necrosis

Involved area becomes ischaemic & necrotic

Bacteria proliferate because normal blood borne defences do not reach the tissue

The osteomyelitis spreads until arrested by antibiotic and surgical therapy

Question 16

Why does osteomyelitis happen usually in themandible over the maxilla

Answer 16

Mandible has a poorer blood supply

Question 17

What are the predisposing factors to osteomyelitis

Answer 17

Odontogenic infections & fractures of mandible

Compromised host defence

-(Diabetes/ Alcoholism/ IV Drug Use/ Malnutrition/ Myeloproliferative Disease, chemo etc)

Question 18

How can you identify osteomyelitis in a radiograph

Answer 18

Areas of radiopacity may occur within the radiolucent region

In long-standing chronic osteomyelitis there may be an increase in radiodensity surrounding the radioluscent area – an involucrum

increased radiolucency (uniform or patchy with a ‘moth-eaten appearance)

Question 19

how would treat osteomyelitis

Answer 19

Antibiotic/ surgical treatment

Question 20

how would treat osteomyelitis

Answer 20

Antibiotic/ surgical treatment

Question 21

What is the antibiotic treatment for osteomyelitis

Answer 21

penicillins generally 1st line drug – effective against odontogenic infections & good bone penetration

Longer courses than normal

Often weeks in acute osteomyelitis (some suggest at least 6 weeks after resolution of symptoms)/months in chronic osteomyelitis (in some cases up to 6 months)

Severe acute osteomyelitis may require hospital admission and IV antibiotics (if systemic symptoms)

Question 22

What is the surgical treatment for osteomyelitis

Answer 22

Drain pus if possible

Remove any non-vital teeth in the area of infection

Remove any loose pieces of bone

In fractured mandible – remove any wires/ plates/screws in the area

Corticotomy – removal of bony cortex

Perforation of bony cortex
Excision of necrotic bone

Question 23

What is osteoradionecrosis (ORN)

Answer 23

Seen in patients who have received radiotherapy of the head & neck to treat cancer

The bone within radiation beam becomes virtually non-vital

Endarteritis – reduced blood supply

Turnover of any remaining viable bone is slow

Self-repair ineffective

Worse with time and dose

Question 24

What is more likely to be affected by ORN and why

Answer 24

Mandible due to poor blood supply

Question 25

How could you prevent ORN

Answer 25

Scaling/Chlorhexidine mouthwash leading up to extraction Careful extraction technique Antibiotics, chlorhexidine mouthwash and review Hyperbaric oxygen (to increase local tissue oxygenation & vascular ingrowth to hypoxic areas) before and after extraction Take advice/refer patient for extraction

Question 26

What is the treatment for ORN

Answer 26

Irrigation of necrotic debris Antibiotics not overly helpful unless secondary infection Loose sequestra removed Small wounds (under 1cm) usually heal over a course of weeks/months Severe cases – resection of exposed bone, margin of unexposed bone and soft tissue closure Hyperbaric oxygen

Question 27

What are bisphonates used to treat and how

Answer 27

osteoporosis, Paget’s Disease & malignant bone metastases They inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal

Question 28

How long do bisphosponates stay in the body for

Answer 28

10 years

Question 29

Name some bisphosphonates

Answer 29

Alendronate-Fosamax– Oral Clodronate – Bonefos – IV Etidronate – Didronel – Oral Ibandronate – Boniva – Oral Pamidronate – Aredia – IV Risedronate – Actonel – Oral Tiludronate – Skelid – Oral Zoledronate – Zometa - IV

Question 30

Who has highr risk of MRONJ

Answer 30

Those that take IV bisphosphonates but theres still risk in others

Question 31

What other drugs could put a patient at risk of MRONJ

Answer 31

anti-angiogenic and anti-resorptive drug

Question 32

What are the SDCEP 2017 guidance on MRONJ incidence on thos who take anti-angiogenic and anti-resorptive drugs

Answer 32

cancer patients treated with anti-resorptive and anti-angiogenic drugs: 1.6-14.8% osteoporosis patients treated with anti-resorptive drugs: 0.1-0.5%

Question 33

When would MRONJ occur and where

Answer 33

Occurs post extraction/following denture trauma/spontaneous Exclusive to the jaws Both mandible and maxilla

Question 34

What are the risk factors of MRONJ

Answer 34

Dental treatment: -impact on bone(extractions)/ trauma from dentures/ infection/ perio Duruation of bisphosphonate drug therapy Dental implants -General consensus is to avoid implant placement in high doses of anti-resoprtive or anti-angiogenic drugs for the management of cancer, Its not contraindicated in patients with osteoporosis Other concurrent drug use -Concurrent use of steroids + anti-repsorptive drugs = increased risk of MRONJ -Concurrent use of anti-resporptive and anti-angiogenic = increased risk of MRONJ previous drug history Drug holidays

Question 35

What puts a patient at low risk of MRONJ

Answer 35

PAtient being treated for osteoporosis or other nonmalignant disease of bone with oral bisphosphonates for less than 5 years who are not systemically being treated with glucocorticoids Patients being treated for osteoporosis or other nonmalignant disease of bone with quarterly or yearly infusions of IV Bisph for less than 5 years who are not systemically being treated with glucocorticoids Patients being treated for osteoporosis or other nonmalignant disease of bone with denosumab who are not systemically being treated with glucocorticoids

Question 36

What puts apatient at high risk of MRONJ

Answer 36

Patients being treated for osteoporosis or other nonmalignant disease of bone with oral BisPh or quarterly or yearly infusions of IV BisPh for more than 5 years Patients being treated for osteoporosis or other nonmalignant disease of bone with BisPh or denosumab for any length of time who are currently being treated with systemic glucocorticoids Patients being treated with anti resorptive or anti-angiogenic drugs as part of management of cancer Patients with previous history of MRONJ

Question 37

How would you treat MRONJ

Answer 37

Treatment of Medication Induced / Related Osteonecrosis is not that successful Manage symptoms/remove sharp edges of bone/chlorhexidine mouthwash/antibiotics if suppuration

Question 38

What is actinomycosis and what is it caused by and how

Answer 38

Rare bacterial infection Actinomyces israelii/ A. naeslundii/ A. viscosus The bacteria have low virulence and must be inoculated into an area of injury or susceptibility -E.g. recent extraction/severely carious teeth/bone fracture/minor oral trauma

Question 39

What are symptoms of Actinomycosis

Answer 39

Multiple skin sinuses and swelling Thick lumpy pus – colonies of Actinomyces look like sulphur granules on histology Responds initially to antibiotic therapy/recurs when stop antibiotics

Question 40

How do you treat Actinmycosis

Answer 40

I&D of pus accumulation Excision of chronic sinus tracts Excision of necrotic bone & foreign bodies High dose antibiotics for initial control (often IV) Long-term oral antibiotics to prevent recurrence Antibiotics: Penicillins, doxycycline or clindamycin

Question 41

With regards to Infective endocarditis what is an invasive dental treatment

Answer 41

Placement of matrix band/ subgingival rubber dam clamps SubG resorations Endo treatment before apical stop established Preformed metal crowns Full perio exam RSB Icision and drainage of abscess Extractions Surgergy involving flaps Dental implants

Question 42

With regards to Infective endocarditis what is an non-invasive dental treatment

Answer 42

Infiltration or block BPE screening SupraG scale and polish SupraG restoration SupraG ortho bands and seperators Removal of sutures Radiographs placement of ROA