Third molar assessment Flashcards
(103 cards)
1
Q
- Impacted 3rd molars are Developmental anomaly. So, why might we have mandibular/maxillary impacted 3rd molars?
A
a. Due to obstruction in their eruption path
b. Or pathology
c. Or lack of physical space
d. Ectopic position of the tooth
2
Q
- What is the average eruption completion of 3rd molars?
A
a. The average eruption completion is at 20 years, but can be up to 25 years
3
Q
- what are the 3 different types of impaction?
A
a. Partially erupted and partially covered by soft tissues.
b. Unerupted and completely covered by soft tissues
c. Unerupted and covered by bone and soft tissue.
4
Q
- What are the categories of third molar impaction according to the tooth position?
A
a. Mesio-angualr
b. Disto-angular
c. Vertical
d. Horizontal
e. Transverse
5
Q
- Classification of third molar according to the position of impaction – what is the most common type of impaction?
A
a. Mesio-angular
6
Q
- What is the most difficult type of impaction? Describe it
A
a. Disto-angular – where the third molar is leaning distally into the ramus
7
Q
- What does the term vertical impaction means?
A
a. Normal eruption but, impacted in the coronal surface by something like soft tissue or bone
8
Q
- What does the term transverse impaction mean?
A
a. The crown towards the buccal and the roots toward the palatal side or the other way round and in the radiograph, they look like a big ball
9
Q
- List the different impactions with their average percentage of those reported.
A
a. Vertical – 61.8%
b. Mesio-angular – 25.5%
c. Disto-angular – 6.7%
d. Horizontal – 4%
10
Q
- Differentiate between the meaning of signs and symptoms
A
a. Symptom means an indication of disease noticed by a patient. For example, Pain, swelling, restricted mouth opening, bad breath, difficulty chewing.
b. Sign means observations by a health professional indicating disease or disorder. For example, BOP, pathological pocket depth, tenderness on palaption, radiographic signs.
11
Q
- In which arch you most commonly see 3rd molar problems?
A
a. Lower arch (mandibular 3rd molars)
12
Q
- What are the reasons behind 3rd molars extractions/ or why 3rd molars can cause problem?
A
a. CYSTS / PATHOLOGY
b. PERI-APICAL DISEASE
c. ABSCESS
d. RECURRENT PERICORONITIS – which is the most common one
e. UNRESTORABLE CARIES – in the 8 itself not in the adjacent tooth
f. ORTHOGNATHIC SURGERY
g. MALIGNANT TUMOUR
h. TRAUMA INFECTION
13
Q
- What is pericoronitis?
A
a. An infection of the soft tissue around the crown of a partially impacted tooth, usually caused by normal oral flora.
14
Q
- What are the underlying causes of pericoronitis?
A
a. Compromised host defences (e.g. URTI, medication)
b. Minor trauma from opposing maxillary dentition (operculum)
c. Food trapping under the operculum
d. Bacterial infection - Strep and Anaerobes
e. Poor OH
15
Q
- What are the symptoms of pericoronitis?
A
a. Pain
b. Halitosis
c. Swelling
d. Erythema
e. Bad taste
16
Q
- What does systemic signs mean? And what systemic signs can we have of untreated pericoronitis?
A
a. Systemic signs mean not localised and spread into the body
b. Systemic signs of pericoronitis are:
- Trismus
- Pyrexia
- Lymphadenopathy
- Malaise
- Dysphagia
17
Q
- Where can the dental infection spread to in the face?
A
a. It can spread from the tooth to facial spaces (we need to know more about facial spaces)
18
Q
- Why submandibular/ submental abscess can be problematic?
A
a. Pushes the tongue up difficulty to swallow
b. Compress trachea cannot swallow their saliva lose their airways
c. Difficult to drain
d. Cannot put patient to sleep
e. Cannot open their mouth
f. Needs to put nasal tube while they are awake
19
Q
- Is the treatment for tonsilitis the same as treatment for dental infection?
A
a. No, they are different (we use different antibiotics)
20
Q
- List the steps that you would follow if you have patient coming with pain.
A
a. History (patient’s own words, use SOCRATES for pain history)
b. Clinical examination (extra-oral + intra-oral with a focus on the area in questions) (what are your findings?)
c. Formulate a differential diagnosis (Surgical Sieve)
d. Request relevant investigations to confirm your diagnosis (vitality testing, imaging) – radiographs need to be diagnostic and acceptable
i. Appropriate radiographic interpretation is used in combination with clinical information and other tests to formulate diagnosis + treatment plan
e. Confirm diagnosis – Ensure that you exclude other causes for the patients’ symptoms
f. Discuss with patient and formulate a treatment plan (discuss pros and cons of options)
g. Must discuss warnings with the patient and risks (Montgomery Consent)
21
Q
- If a patient complains of pain of unerupted third molar, would it be possible that the main cause is that wisdom tooth if it was associated with pathology?
A
a. It is rare for third molars to cause symptoms if they are unerupted, even with associated pathology. You must consider other causes for the patients’ pain such as temporo-mandibular joint dysfunction.
22
Q
- When do we use antibiotics in case of pericoronitis?
A
a. If there is systemic involvement
23
Q
- What is the initial management of a patient comes with pericoronitis and present with no systemic features. e.g., Pain, Halitosis, Swelling, Erythema or Bad taste and there is no indication of systemic involvement?
A
a. Treat the patient with local measures:
i. irrigation with warm saline – (patients to use a monoject TM syringe if possible)
ii. hydrogen peroxide
b. Regular analgesia – NSAID / Paracetamol (check contra-indications and interactions)
c. irrigate with warm water and table salt in home
d. Caution with chlorhexidine
24
Q
- What does trismus mean?
A
a. restricted mouth opening where normal mouth opening is about 3 cm but this varies between people
25
25. What does pyrexia men?
a. Fever and the normal temperature is 37
26
26. What does dysphagia mean?
a. difficulty to swallow
27
27. what is the initial management of a patient with pericoronitis that has spread systemically where there is a sign of systemic involvement (active infection) e.g., Trismus, Pyrexia, Lymphadenopathy, Malaise or Dysphagia?
We would do 3 things:
a. Local measures: Irrigation with Warm Saline Hydrogen Peroxide
b. Analagesia
c. Metronidazole 200mg TDS for 3/7 or Amoxicillin 500mg TDS for 3/7
28
28. Is metronidazole a very strong antibiotic drug for pericoronitis? Why?
a. No, metronidazole is specific only for anaerobic bacteria. And pericoronitis is mixed infection.
29
29. Give an example of strong antibiotic that would you use to manage pericoronitis infection? Justify your answer.
a. Amoxicillin as it is broad spectrum antibiotic. And pericoronitis is mixed infection
30
30. What antibiotic would you use in case of having strong infection due to pericoronitis?
a. If it is very strong infection, you can give both antibiotics (amoxicillin and metronidazole) together
31
31. What does TDS mean?
a. 3 times a day
32
32. What does 3/7 mean?
a. for 3 days
33
33. Why do we try to reduce the time we give the patient antibiotics?
a. to avoid the risk of resistance and antibiotics side effects
34
34. what are the indications for the third molar removal according to the NICE guidelines?
a. Unrestorable caries (of the 8 not the adjacent tooth)
b. Non-treatable pulpal and/or periapical pathology
c. Cellulitis
d. Abscess
e. Osteomyelitis
f. Internal/external resorption of the third molar or adjacent tooth
g. Fracture of tooth
h. Disease of the follicle (inc cyst/tumour)
i. Tooth/teeth impeding surgery or reconstructive jaw surgery (e.g. orthognathic / trauma)
j. Tooth involved in surgical resection field for tumour
35
35. What will happen if we have caries in the distal surface of a 7 that is adjacent to an impacted third molar and according to the NICE guidelines the wisdom tooth is not indicated to be removed? Does removing the 7 helps in moving the 8?
a. If you left that wisdom tooth, the 7 would probably have a short life span because you will not be able to clean that, and that caries would progress
b. Removing the 7 will not help in moving the 8 to the position of the 7 (this is not possible, it will never, erupt to the position of the 7 (will move just a little bit))
36
36. What will happen if the patient left untreated from the local infection?
a. It will progress and lead to more serious consequences (systemic involvement)
37
37. What are the consequences of dental infections?
a. There are potential routes of spread through the facial spaces. (you need to have an appreciation of the spaces and consequences of infections in such areas)
38
38. What factors must we consider prior to removal of coronectomy of third molars?
a. patient factors
b. surgical factors.
39
39. What are the patient factors?
a. Age
b. Social History
c. Medical History
d. Drug History
e. BMI
f. Ethnicity
g. Capacity
40
40. What are the surgical factors?
a. The third molar itself
b. Periodontal Status
c. Surgical Anatomy
d. Systemic factors
e. Mouth opening
f. Adjacent structures
g. Associated pathology
h. TMJ status
i. Occlusal relationship
j. The operator
41
41. How could the age of the patient impact on the third molar removal surgery (coronectomy)?
a. Complexity: Increased complication over the age of 25/ Increased age mandibular third molar extractions would be more complicated
b. Mental health: With increased age we see more mental health issues which will impact on surgery e.g., dementia, alzheimers, parkinsons, post stroke IHD
c. Bone quality: Bone get harder with older ages
d. Medical complexity
e. Caries: Retained carious teeth (inc third molars) + more carious teeth
42
42. What MH and Drug history do we need to consider when planning to remove the coronectomy of third molars?
a. Medical History: Considerations for those with co-morbidities should be accounted for e.g ischaemic heart disease, stroke, diabetes, mental health issues.
b. Medications: e.g anti-platelets, anticoagulants, steroids, bisphosphonates, Antibiotic Prophylaxis and other biologics should be taken into consideration.
i. Immunosuppressant can cause issues with healing
ii. Patients with bisphosphonate are at risk of MRONJ
43
43. Can patient’s BMI interfere with third molar surgery? Justify your answer
a. Yes, people with higher BMI have problems with small airways and short necks therefore, cause access problem
b. Also, they might have other co-morbidities that are associated with obesity such as diabetes are associated with a high BMI. Such diseases are also associated with cardiovascular disease. Do not treat such conditions in isolation.
44
44. What fact do you know about people with red hair regard to third molar surgery? What might you consider in this case?
a. Fact: if you have a bright red hair you bleed more (genetics) and your pain threshold is very low
b. So, they might bleed more and need more analgesia
45
45. What are the special investigations that you would use to assess third molar?
a. Radiographs
b. We don’t very often do vitality test for third molars
46
46. List acceptable reasons to request a radiograph imaging:
a. Presence of caries
b. Condition of existing restorations
c. Alveolar bone levels
d. Root morphology
e. Morphology of pulp chamber
f. Signs of periodontal pathology
g. Position of unerupted teeth or retained roots
h. Other pathology of the jaws
i. Form and quality of edentulous ridge and underlying bone
j. Boundaries of relevant anatomical features
47
47. Give a brief about PA radiographs
a. Intra-oral technique – An intra-oral technique which can often be difficult with regards to mandibular and maxillary third molars. Often reliant upon good technique and a co-operative patient.
b. Shows individual teeth & apical area and gives detailed information of the root formation, hard tissues and any associated pathology.
48
48. What can we investigate with PA image?
a. Detection of apical inflammation / infection
b. Assessment of the periodontal status
c. Post trauma
d. ?un-erupted teeth
e. Root morphology
f. During endodontics
g. Apical surgery
h. Apical pathology
i. Implants post op
49
49. What are the cons of PA image?
a. Technique sensitive
b. Gag reflex
c. Edentulous alveolar ridge
d. Children
e. Co-operation
50
50. What is the most common reason in oral surgery for taking periapical image?
a. post implant placement
51
51. what images are most likely to be taken in oral surgery clinic?
a. OPT and Cone Beam CT scans
52
52. What are the acceptable reasons for taking Tomography (orthopantomogram – OPT/OPG)?
a. Bony lesion / unerupted tooth not visible on IO radiograph
b. Grossly neglected mouth
c. Periodontal bone support assessment +/- PA’s
d. Assessment of third molars before surgery (not routine)
e. Orthodontic assessment
f. Trauma
g. Antral disease
h. Destrictive disease of the articular surfgace of TMJ
i. Vertical alveolar bone height and anatomy assessment for implants
53
53. Is third molar assessment a reason to take OPT?
a. if the patient came in for pericoronitis of first episode treat it clinically do not necessarily to take OPT.
b. if you think there is something else going on and it is the second or third episode and you are thinking of removing them then take OPT
54
54. why sectional tomography might be appropriate in some cases?
a. As we need to adhere to ALARA principle where sectional tomogram may be appropriate which means ‘’ avoiding exposure to radiation that does not have a direct benefit to you, even if the dose is small’’
55
55. Give a brief about 3-D imaging Cone Beam CT
a. Digital technique that enables 3D analysis of area in question, particularly useful for third molars in both jaws with regards to local anatomy such as the inferior alveolar nerve canal, accessory canals and associated pathology.
b. All CBCT’s must be justified demonstrating that the benefits outweigh the risks of the image, and that the image should potentially add new information to aid patient management. Routine use of CBCT is not advised and is unacceptable practice.
c. Additional training is required for requesting and interpreting CBCT images (level 1 and 2 respectively) which should be completed in addition to the IRMER training as a postgraduate.
d. CBCT should not be selected unless the history and clinical examination have been performed, ‘routine’ imaging is unacceptable practice.
e. Thin slices with variable thickness <1mm
f. Can be viewed in all planes Eliminates superimposition
g. High contrast resolution
h. CBCT reduction in dose Short scan time
i. High resolution Interactive software Issues with artefacts
56
56. How to report radiographic image?
a. You must use a systematic process
b. A knowledge of normal radiographic anatomy is fundamental to reporting and recognition of abnormal findings.
c. Key areas to focus on are:
i. Teeth
ii. Apical Tissues
iii. Periodontal Tissues
iv. Body and ramus of mandible
v. Other structures
d. If an abnormal finding is discovered, then a simple mnemonic of ‘S.T.O.P.’ can be used
57
57. How to report specific lesion from a radiograph?
Describe systematically:
a. Site/ anatomical position
b. Size
c. Shape
d. Outline
e. Relative radiodensity and internal structure
f. Effect on adjacent structures
g. Time present, if known
58
58. What is mnemonic of ‘S.T.O.P.’?
a. If an abnormal finding is discovered in the radiograph, then mnemonic of ‘S.T.O.P can be used.
i. S – Site
ii. T – Translucency
iii. O – Outline
iv. P – Previous imaging, if possible, to compare with previous imaging
59
59. What radiographical finding are considered as red flag?
a. Loss of symmetry and apparent soft tissue mass
b. Distorted anatomy – displacement of teeth with no obvious cause
c. Bony erosions – irregular borders
d. Teeth floating in air – correlate with clinical finding
60
60. What do we need to consider when assessing 3rd molars radiographically?
a. Relationship to vital structures
b. Configuration of the roots
c. Condition of the surrounding bone
61
61. What are the key (adjacent) anatomical structures in relation to third molars?
a. Maxillary antrum and tuberosity
b. Inferior alveolar nerve and associated vessels Lingual nerve
c. Mylohyoid nerve
d. Long buccal nerve
62
62. What does the facial nerve branch that runs with the lingual nerve called? And what does it supply?
a. chorda tympani
b. it supplies a little bit of taste
63
63. What knowledge regard the nerves do we need to know to worn the patient?
a. We need to know what each nerve supply so we can worn the patient of the risks of the surgery.
64
64. What does the Facial nerve supply?
a. It supplies the muscles of the facial expression
65
65. Does trigeminal nerve supply facial expression?
a. It supplies sensation but, it doesn’t supply the muscles of facial expression
66
66. Where is the ID nerve located? and what does it supply?
a. Inferior alveolar nerve runs through the lingula into the mandible and supplies the sensation to all of the lower teeth and the gingiva and exists through the mental foramen (usually between the apices of the premolars but not always). That terminal branch supplies the sensation to your lip and the skin of the chin
b. The mandibular canal is present on radiographic imaging, and often can be in close association with the apices of the mandibular teeth.
67
67. What does the mylohyoid nerve supply?
the mylohyoid nerve supplies a tiny bit of the skin, little part of the chin
68
68. What does the lingual nerve supply?
a. the lingual nerve supplies the sensation of the tongue
69
69. What does the long buccal supply?
a. It supplies little bit of buccal soft tissues sensation
70
70. What does the ID canal contain?
a. Inferior alveolar artery – likely posterior/postero-lateral to nerve
b. Inferior alveolar vein – no pattern, can be 2 veins, lateral to the bone
c. Inferior alveolar nerve – likely anterior to the vessel
71
71. What happen if the operator hits the inferior alveolar artery?
a. There would be a bit if arterial bleed, spurt but it’s minimal and it will stop with pressure
72
72. What happen if the operator hits the inferior alveolar vein?
a. you will get blood but again will stop with the pressure.
73
73. What problem might you face when you hit vessel and want to put pressure to stop the bleeding?
a. you don’t want to compress the nerve as you might cause nerve injury
74
74. does the ‘lingula’ (the little tongue) has 1 shape only in all people?
a. there are variety of shapes [triangular, truncated, nodular etc) where about 25% of people got prominent lingula and it is thought that has relation to the success rate of IAN Block
75
75. what are the signs on plain film imaging which suggest a close/intimate relationship between the canal and the third molar? (high-risk)
a. Deviation of the canal
b. Narrowing of the canal
c. Periapical radiolucent area
d. Narrowing of the roots
e. Darkening of the roots
f. Curving of the roots
g. Loss of the lamina dura
h. Interruptions of the white lines
i. Dark and bifid apex of the root
76
76. With these signs the damage of the inferior alveolar nerve is expected to be higher. What could you consider in this case?
a. would consider carrying a CBCT scan
77
77. Explain what Deflection of the root means?
a. If the roots appear deflected as they hit the superior boarder of the canal
78
78. Explain what Narrowing of the roots means?
a. As they are close to the canal they’ve pinched almost around
79
79. Explain what Darkening of the roots
a. Once the roots are in the canal or appears to be in the canal, the root apices are darker
80
80. What does bifid apex of the root
a. Bifid (i.e. like 2 apices)
81
81. Does inferior alveolar nerve have branches?
a. there have been many studies about different branches of the inferior alveolar nerve. So, sometimes there isn’t just one canal, we get accessory canals, retromolar canals and sometimes you only see them on CT and sometimes you cannot see them at all
82
82. What do we need to look at regarding the configuration of the roots of the third molar?
a. Number of roots
b. Curvature of roots
c. Degree of root divergence
d. Size & shape of roots
i. bulbous, conical, long, short, hooked
e. Other
i. root resorption, caries, anyklosis
83
83. What do we need to consider when look at the condition of the surrounding bone in terms of the third molar removal surgery assessment?
a. Density determines difficulty
b. Radiographs often unreliable
c. Age is a good determinant
84
84. Compare between the surrounding bone condition of 2 different age categories:
a. < 18 yo: Less dense, Pliable, Expands Bends, Easier to cut / expand
b. >35 yo: Much denser bone, Decreased flexibility, Decreased ability to expand, More bone removal required, Higher risk of #
85
85. What are the PREDICTIVE FACTOR of difficulty of surgery that dictate amount of bone required to be removed
a. Alveolar bone level
b. Tooth position
c. Application depth
d. Point of elevation
86
86. What can increase the risk of complications?
a. Underlying systemic disease
b. Age
c. Anatomical position of tooth and root morphology
d. Local anatomical relationships
e. Status of adjacent teeth
f. Access
g. Patient co-operation / compliance
h. Bone density
i. Ankylosis
j. Infection
k. Pathology
87
87. Can the maxillary third molar extractions be an issue?
a. It could be an issue but, 95% of the time are straightforward
88
88. What are the possible problems with this third molar removal?
a. OAC – oral-antral communication
b. Fracturing maxillary tuberosity which also can cause OAC. Behind that there are very big vessels (e.g. hitting the branch of maxillary artery)
89
89. What are the adjacent anatomical structures of the maxillary third molars that we need to be aware of?
a. The antrum
b. Tuberosity
90
90. What should you do If you took the tooth out and the tuberosity looks big and it’s bleeding?
a. the best thing is to put it straight back
91
91. what should you do If the soft palate starts to move, when you are moving the tooth or tears?
you need to stop
92
92. What other complication can result with maxillary third molar removal other than breaking the tuberosity and causing OAC?
a. You can push the tooth hard and it disappear as it’s gone into the antrum
93
93. What does the consent need to include?
a. It must include standard surgical warnings:
i. Pain, Swelling, Bleeding, Bruising, Infection, Sutures, TMJ, A.O. Damage, OAC, Fracture, and Medical
94
94. What are the specific warnings for mandibular third molar surgery? If you are taking mandibular third molar you must worn the patient about:
a. Inferior alveolar nerve
b. Lingual Nerve
c. Chorda Tympani
d. Loss or altered sensation (often a painful sensation) which can be temporary or permanent to the lower lip, skin of the chin, gums of the teeth, lower teeth and tongue and taste.
e. The altered sensation can be painful similar to neuralgia or a 'tingling' sensation
f. >2% permanent but if high risk can be up to 10% - specific to individual >5% temporary – if it is there after 6 months then it is permanent
g. Stiff jaw because they might get TMJ pain
h. Trismus
i. Time off work
j. Significant swelling and bruising which can spread to the neck / chest
k. Rarely hospital admission requiring treatment
95
95. What are the risks and complications of the third molar surgery that need to be listed in the consent?
a. Stiff Jaw, Nerves, Sinus
b. Pain, Swelling, Bleeding, Bruising, Infection, Dry socket, and Damage to adjacent teeth
96
96. What are the trigeminal nerve branches?
a. Ophthalmic (V1)
b. Maxillary (V2)
c. Mandibular (V3)
97
97. Is there any difference between the risks of surgical extraction undertaken under LA/ GA? Justify your answer.
a. The likelihood of swelling, infection and nerve injury is much greater with junior dentist and under GA than LA because people are less carful during GA than LA as the patient is not responsive
98
98. What do you need to do if you have seen signs indicating that the patient is at high risk group?
a. If there are increased risk signs on imaging discuss with patient might be
b. SHOW the patient the image and use pictorial representation
c. CONSIDER their individual risk factors
d. AND your experience
99
99. What are the possible treatment options of third molars?
a. Conservative Management / monitor
b. Operculectomy
c. Complete extraction of third molar
d. Coronectomy of third molar
100
100. What can you provide with Conservative +/- review or monitor treatment option?
a. Review at appropriate intervals, patient to come back if deteriorates If specialist can discharge back to GDP for monitoring.
b. Useful to give patients written information which includes advice
101
101. What is operculectomy? Give a brief.
a. Mandibular third molars which are partially erupted, and food is getting trapped in the operculum – removal of the operculum may improve symptoms. This does not always relieve the symptoms sufficiently.
b. Extraction of the opposing maxillary third molar
c. As with patients suffering with the operculum, it is acceptable to remove the opposing maxillary third molar if this is likely to be non-functional and carries a low risk of complications. You should remember the specific risks relating to extraction of maxillary third molars which can include fracture of the maxillary tuberosity, which could lead to oro-antral communication
102
102. What is coronectomy? Give a brief.
a. Intentional removal of only the crown (all the enamel) of the third molar reduces the likelihood of nerve injury in those which are high risk. An awareness of this procedure is required at undergraduate level and the procedure is technique sensitive and not all patients are suitable for the procedure.
b. Although the technique has its place, it is contentious and starting to become recognised as an appropriate alternative to reduce the risk of nerve injury.
c. Patient selection, (as is additional training) key to success, non-compromised patients with good healing potential, ideally teeth which are healthy and no intra-pulpal pathology.
d. Patients should also be warned about the risks of the procedure, including that if the roots become mobile during the procedure they must be removed, the risk of post-operative infection and/or alveolar osteitis, potential for re-operation rate (0-2%), root migration rate (13-33%) and how technique sensitive it is.
103
/103. What is the technique for third molar removal?
a. Local anaesthesia
i. Maxillary third molars: Buccal and palatal infiltrations (lidocaine or articaine)
ii. Mandibular third molars: Inferior alveolar, lingual and long buccal nerve blocks (lidocaine) OR Inferior alveolar, lingual and buccal infiltrations (articaine)
b. LA + Intra venous sedation (conscious sedation)
i. Patient
ii. Procedure
c. LA + GA
i. Patient
ii. Procedure
iii. Risks
