1
Q
basic surgical technique
basic principles
A
- risk assessment - good planning, MH
- aseptic technique
- minimal trauma to hard and soft tissues
2
Q
stages of oral surgery
A
- consent
- surgical pause/safety checklist
- anaesthesia
- access
- bone removal/tooth division as necessary
- debridement
- suture
- achieve homeostasis
- post op instructions
- post op medications
- follow up
3
Q
basic surgical technique
surgical safety checklist
A
- steps to limit error
- WHO guidelines for safe surgery 2009 - use a checklist
- ask pt in own words which tooth requires X
4
Q
basic surgical technique
surgical access summary
A
- maximal access with minimal trauma - bigger flaps heal just as quickly as smaller ones
- preserve adjavent soft tissues
- use scalpel in one firm continuous stroke
- flap reflection should be down to bone
- keep tissue moist
5
Q
basic surgical technique
types of flap
A
- 3 sided flap with mesial and distal relieving incision on buccal side- dont go too lingual
- envelope - 2 sided flap
6
Q
basic surgical technique
soft tissue retraction summary
A
- access to operative field
- protection of soft tissues
- flap design fascilitates retraction
- howarths periosteal elevator or rake retractor
- should be done with care
7
Q
basic surgical technique
bone removal and tooth division
A
- use elctrical straight handpeice with saline cooled bur (surgical handpiece)
- DO NOT use high speed as air driven handpieces may lead to surgical emphysema
- ri=ound or fissure tungsten carbide burs
- protection of soft tissues
8
Q
basic surgical technique
elevators function
A
- to loosen teeth prior to using forceps
- to provide point of application for forceps
- to extract a tooth without the use of forceps
- removal of multiple root stumps
- removal or retained roots
- removal or root apices
9
Q
basic surgical technique
elevators principles of use
A
- avoid excessive force
- support instrument to avoid injury if it slips
- ensure applied force is directed away from major structures ie antrum, ID canal, mental nerve
- always use under direct vision
- never use adjacent tooth as fulcrum unless also getting extracted
- keep elevators sharp and in good shape
- establish effective point of application
10
Q
basic surgical technique
types of debridement
A
- physical - bone file or handpiece to remove sharp bony edges, mitchells trimmer or victoria curette to remove soft tissue debris
- irrigation - sterile saline into socket and under flap
- suction - aspirate under flap to remove debris, check socket for retained apices etc
11
Q
basic surgical technique
types of suture
A
- non absorbable
- polyfilament
- monofilament
- absorbable
12
Q
basic surgical technique
suturing aims
A
- approximate tissues and compress blood vessels
- reposition tissues
- cover bone
- prevent wound breakdown
- achieve haemostasis
- encourage healing by primary intention
13
Q
suturing
non-absorbable vs absorbable
A
- non absorbable - if extended retention periods required, must be removed postoperatively, closure of OAF or exposure of canine tooth
- absorbable - if removal or suture not possible/desirable, vicryl breakdown via absorption of water into filaments causing polymer to degrade
14
Q
suturing
polyfilament vs monofilament
A
- polyfilament - several filaments twisted together, easier to handle, prone to wicking and can result in bacterial colonisation/infection
- monofilament - single strand, pass easily through tissue, resistent to bacterial colonisation
15
Q
indications for extractions
A
- unrestorable teeth
- symptomatic partially erupted teeth
- traumatic position
- orthodontic indications
- interferences with construction of dentures
16
Q
examples of unrestorable teeth
A
- gross caries
- advanced periodontal disease
- tooth/root fracture
- severe tooth surface loss
- pulpal necrosis
- apical infection
17
Q
cowhorns designed to extract
A
- tooth with elevation by squeezing handle
- NOT figure of 8
- used on tooth with 2 separate roots no fused roots
- beaks into furcation
18
Q
standing position for oral surgery if R handed
A
- stand behind patient on R side for LR
- stand infront of patient on R side for LL, UL, UR
19
Q
types of elevators
A
- couplands - concave surface faces root and corners engage roots to elevate
- cryers - used to elevate root left behind, can use either side
- warwick james
20
Q
luxators summary
A
- used to cut PDL not elevate
- have curved/pointy tip
- really sharp if slip can cut mouth
21
Q
periotome summary
A
- push up PDL to cut ligament
- takes a lot longer but very atraumatic way to remove tooth
- can be useful for pts getting immediate implants
22
Q
modes of action for elevation
A
- wheel and axel - wedge between bone and tooth then turn handle
- lever - huge amount of force so be careful
- wedge
23
Q
points of application for elevators
A
- mesial then buccal used in sequence most common
- mesial
- distal -rare
- superior - very rare, have to take away buccal plate
- mesial and distal - risk of jaw fracture, non dominant hand should be used to support jaw
24
Q
why do teeth fracture
A
- thick cortical bone
- root shape
- root number
- caries
- hypercementosis
- ankylosis
- alignment
25
list of post op complications to explain to pt
* pain
* swelling
* bruising
* jaw stiffness
* bleeding
* dry socket
* infection (unusual)
* nerve damage risk - temporary, permanent, altered
* OAC
26
what can be used for soft tissue retraction in oral surgery
* howarths periosteal elevator
* rake retractor (bowdler henry)
27
what can be used for physical debridement in oral surgery
* mitchells trimmer
* victoria curette
28
examples of resorbable suture
* monofilament - monocryl
* multifilament - vicryl rapide - most commonly used in dentistry
29
examples of non-resorbable suture
* monofilament - prolene - often used on skin as scars less, very stiff nylon like texture
* multifilament - mersilk
30
peri-operative haemostasis techniques
* LA with vasoconstrictor
* artery foreceps
* diathermy - burns tissue to stop bleeding
* bone wax - plug in hole
31
post-operative haemostasis techniques
* pressure
* LA with vasoconstrictor
* diathermy
* whiteheads varnish pack
* surgicel
* sutures
32
general surgical principles
* maximal acess with minimal trauma
* bigger flap heals just as quickly as smaller
* use scalpel in one firm continuous stroke
* no sharp angles
* minimise trauma to dental papillae
* flap reflection should be down to bone
* no crushing
* keep tissues moist
* ensure flap margins and sutures will lie on sound bone
* make sure wounds are not closed under tension
* aim for healing by primary intention to minimise scarring
33
classification of extraction complications
* immediate/peri-operative - occur whilst extracting
* immediate/short term post operative
* long term post operative
34
peri-operative complications
* difficult access
* abnormal resistance
* fracture oftooth/root
* fracture of alveolar bone
* jaw fracture
* involvement of maxillary sinus
* fracture of tuberosity
* loss of tooth
* soft tissue damage
* damage to nerves/vessels/adjactent teeth
* haemorrhage
* dislocation of TMJ
* broken instruments
* wrong tooth
35
peri-operative complications
difficult access
* decreased visualisation
* take time, position pt appropriately to improve view, gd lighting
* trismus
* reduced aperture of mouth - microstomia, scarring etc
* crowded/malpositioned teeth - can open mouth fine but access to tooth difficult
36
peri-operative complications
abnormal resistence
* thick cortical bone
* often with upper 6s
* shape/form of roots eg divergent roots/hooked roots
* number of roots eg 3 rooted molars
37
peri-operative complications
tooth/root #
* consider caries, alignment, size
* sometimes tooth # unavoidable
* discuss if concerns during consent process
38
peri-operative complications
root morphology factors
* fused
* convergent or divergent
* extra root(s)
* hypercementosis
* ankylosis
39
peri-operative complications
alveolar bone #
* usually buccal plate
* usually canines or molars
* can happen if trying to X too quickly - when you dont properly expand pocket
* molars - periosteal attachment, suture, dissect free
* canines - stabilise, free mucoperiosteum, smooth edges
40
peri-operative complications
jaw #
* usually mandible - often impacted wisdom tooth, large cyst, atrophic mandible
* if jaw fracture occurs: inform pt, post op radiograph, ensure analgesia, stabilise
* refer to max fax - telephone referral as urgent
* ask pt to not eat
* if delay to hospital splint teeth either side of # together
* suspicions: hear crack, occlusion change, mandible moving in 2 parts, tear in gingivae
41
peri-operative complications
involvement of maxillary antrum
* OAC
* potential to lose root in antrum - confirm radiographically by OPT, occlusal or periapical
* diagnose by: size of tooth, radiographic position of roots in relation to antrum, bubbling of blood, direct vision, echo when suction, blunt probe
42
peri-operative complications
OAC risk factors
* extraction of upper molars and premolars
* close relationship of roots to sinus on radiograph
* last standing molars
* large, bulbous roots
* older pt
* previous OAC
* recurrent sinusitits
43
peri-operative complications
OAC management
* inform pt
* if small or sinus intact - encourage clot, suture margins, antibiotic if puss or infection at apex of extracted tooth (due to risk of infection), post op instructions
* if large or lining torn - close with buccal advancement flap, antibiotics and nose blowing instructions, decongestands (viscks etc)
* keep nasal passages clear - de-congestants, steam inhalation
44
peri-operative complications
tuberosit # aetiology and diagnosis
* A :
* single standing molar
* unknown unerupted wisdom tooth
* extracting in wrong order - work back to front
* inadwquate alveolar support
* D :
* noise
* movement noted both visually or with supporting fingers
* more that one tooth movement
* tear on palate
45
peri-operative complications
tuberosity # management
* dissect out and close wound or reduce and stabilise
* reduction - fingers or foreceps
* fixation - orthodontic buccal arch wire spot welded with composite, arch bar, splints
* remove or tx pulp, ensure occlusion free
* antibiotics and antiseptics
* remove tooth 8 weeks later
46
peri-operative complications
loss of tooth
* where did the tooth go - listen to pt did they feel/swallow anything
* lower teeth could dissapear into lingual sulcus into FOM - palpate and remove by pushing back up from FOM into socket
* if cannot remove - emergency referral to max fax for GA removal
* if potentially inhaled refer pt to AandE - phone ahead
47
peri-operative complications
decrease risk of soft tissue damage
* pay attention
* correct placement using correct instrument
* take time positioning instrument
* find application point before appling pressure
* controlled pressure
* sufficient but not excessive force
* careful with cowhorns
* can occur due to failure to retract tissues properly
48
peri-operative complications
damage to nerves
* crush injuries
* cutting/shredding injuries
* transectn
* damage from surgery or damage from LA
* only once LA wears off pt will realise feels different
49
damage to nerves
clinical description
* anaesthesia - numbness
* paraesthesia - altered sensation (tingling)
* dysaesthesia - unpleasant sensation/pain
sensation change can be
* hypoaesthesia - reduced sensation
* hyperaesthesia - increased sensation
50
damage to nerves
anatomical description
* neurapraxia - contusion of nerve/continuity of epineural sheat and axons maintained
* axonotmesis - continuity of axons but epineural sheath disrupted
* neurotmesis - complete loss of nerve continuity/nerve transected
51
peri-operative complications
damage to vessels
* veins - bleeding
* arteries - spurting/haemorrhage
* arterioles - spurting/pulsating blood
* vessels in muscle
* vessels in bone
52
peri-operative complications
haemorrhage causes
* most due to local factors - mucoperiosteal tears or fractures of alveolar plate/socket wall
* very few due to undiagnosed clotting abnormalisites - haemophilia/VWD
* some due to liver disease (alcohol problems)
* some due to medication - anticoags/antpltls
53
peri-operative complications
haemorrhage management
* if soft tissue:
* pressure - finger or biting on damp gauze swab
* sutures
* LA with vasoconstrictor
* diathermy
* artery clips for larger vessels
* if bone : pressure via swab, LA on a swab or into socket, bone wax, surgicel packing
54
peri-operative complications
TMJ dislocation
* relocate immediately
* if unable to relocate try LA into masseter intra-orally
* if still unable to - immediate referral to maxfax
* can happen if non dominant hand not supporting mandible
* if manage to relocate - warn pt of soreness after
* to relocate - pressure on mandible downwards and backwards
55
post extraction complications
* pain
* swelling
* ecchymosis (bruising)
* trismus/limited mouth opening
* haemorrhage/post-op bleeding
* prolongued effects of nerve damage
* dry socket
* sequestrum
* infected socket
* chronic OAF/root in antrum
56
less common post extraction complications
* osteomyelitis - bone inflammation
* osteoradionecrosis ORN
* medication related osteonecrosis MRONJ
* actinomycosis - rare type of bacterial infection
* bacteraemia/infective endocarditis
57
post extraction complications
ecchymosis
* bruising
* increased by poor surgical technique - rough handling of soft tissue, pulling flaps, crushing tissue with instrument, tearing of periostium
* go through MH to check for underlying medical issues - antiplatelet meds risk
* individual variation
* gravity can pull down bruising
58
post extraction complications
trismus/limited mouth opening and how to manage
* jaw stiffness/inability to open mouth fully
* variety of causes:
* related to surgery - oedema/muscle spasm
* related to giving LA - IDB medial pterygoid spasm
* haematoma/clot in medial pterygoid or less likely masseter
* damage to TMJ - oedema/joint effusion
* monitor - may take several weeks to resolve
* can give anti-inflammatories
* gentle mouth opening exercises/wooden spatulae/trismus screw
59
SDCEP management of dental pts taking anticoag or antiplatelet drugs
procedures unlikely to cause bleeding
* LA by infiltration, intraligamentary or mental nerve block
* LA by IDB or other regional nerve blocks
* BPE
* supragingival PMPR
* direct/indirect restorations with supragingival margins
* endodontics - orthograde
* impressions and other prosthetic procedures
* fitting and adjustment of orthodontic appliances
60
SDCEP management of dental pts taking anticoag or antiplatelet drugs
procedures low risk post op bleeding
* simple extractions 1-3 teeth with restricted wound size
* incision and drainage of intra-oral swellings
* detailed 6PPC
* RSD
* direct or indirect restorations with subgingival margins
61
SDCEP management of dental pts taking anticoag or antiplatelet drugs
higher risk of post-op bleeding
* complex extractions, adjacent X that will cause a large wound or more than 3 extractions at once
* flap raising procedures - surgical X, periodontal surgery, periradicular surgery, dental implant surgery
* gingival recontouring
* biopsies
62
SDCEP management of dental pts taking anticoag or antiplatelet drugs
INR check
* for vitamin K antagonists - warfarin, acenocoumarol or phenindione
* check within 24 hours of procedure - up to 72 hours if pt stably anticoagulated
* if INR below 4 - treat without interrupting medication, consider limiting tx area/stage tx, strongly consider suturing and packing
* if INR above 4 - delay invasive tx or refer if urgent
63
SDCEP management of dental pts taking anticoag or antiplatelet drugs
antiplatelet drug guidance
* aspirin alone - treat without interrupting medication, consider limiting tx area, staging tx, use local haemostatic measures
* clopidogrel, dipyridamole, prasugrel or ticagrelor single or dual therapy (in combo with aspirin) - treat without interrupting medication but expect prolongued bleeding, limit initial tx aream consider staging tx, strongly consider suturing and packing
64
SDCEP management of dental pts taking anticoag or antiplatelet drugs
DOAC
* direct oral anticoagulant - apixaban, dabigatran, rivaroxiban or edoxaban
* low bleeding risk - treat without interrupting medication
* higher bleeding risk - advise pt to miss or delay morning dose before tx
* if delaying dose make sure no earlier than 4 hours after haemostasis has been achieved
65
post extraction complications
immediate post-operative haemorrhage
* reactionary/rebound bleed
* occurs within 48 hours of extraction
* vessels open up/vasoconstricting effects of LA wear off/sutures loose or lost/pt traumatises area with tongue/finger/food
66
post extraction complications
secondary bleeding
* often due to infection
* commonly 3-7 days
* usually mild ooze but can occasionally be a major bleed
* medication related
67
post extraction complications
if soft tissue or bone haemorrhage
* if soft tissue - pressure, sutures, LA with adrenaline, diathermy
* if bone - pressure via swab, LA on swab, haemostatic agents, blunt instrument, bone wax, pack and suture
68
haemostatic agents
* adrenaline containing LA - vasoconstrictor
* oxidised regenerated cellulose - surgicel provides framework for clot formation
* haemocollagen sponge - absorbable/meshwork for clot formation
* thrombin liquid and powder
* floseal
69
systemic haemostatic aids
* vitamin K - necessary for formation of clotting factors
* tranexamic acid - prevents clot breakdown/stabilises clot (tablets or mouthwash)
* missing blood clotting factors
* plasma or whole blood
* desmopressin
70
post extraction complications
if cannot arrest haemorrhage
* urgent hospital referral
* weekdays - dental hospital/maxillofacial outpatients
* evenings/weekends - maxillofacial on-call or local hospital A&E
* uncontrolled haemorrhage is life threatening
71
prevention of post op bleeding
* medical history/anticipate and deal with potential problems
* obtain and check good haemostasis at end of surgery
* atraumatic extraction/surgical technique
* provide good instructions to the patien
72
post-extraction instructions
* do not rinse until next day - wash clot away
* avoid trauma - do not explpre socket with tongue or finger/hard food
* avoid hot food that day
* avoid excessive physical exercise and alcohol - increase blood pressure
* advice on control of bleeding - biting on damp tissue/gauze, pressure for at least 30 min (longer if bleeding continues) and points of contact if bleeding continues
73
post extraction complications
dry socket summary
* blood clot fails to develop in the tooth socket, or if the blood clot becomes dislodged or disappears
* common affects 2-3% of extractions
* normal clot disapears - appear to be looking at bare bone/empty socket
* main feature - intense pain (described as worse than toothache)
* often starts 3-4 days after X and takes 7-14 days to resolve
* localised osteitis - inflammation affecting lamina dura
74
post extraction complications
dry socket symptoms
* dull aching pain - moderate to severe
* usually throbs/can radiate to pts ear/often continuous and can keep pt up at night
* exposed bone is sensitive and is the source of the pain
* characteristic smell/bad odour and patient frequently complains of bad taste
75
post extraction complications
management of dry socket
* supportive - reassurace/systemic analgesia - pts often think you have X wrong tooth and another tooth is causing pain
* LA
* irrigate with warm saline to wash out food and debris
* curettage/debridement - encourage bleeding/new clot formation (some suggest not to do this as it produces more bare bone/removes ant remaining bone)
* antiseptic pack - alvogyl
* review pt/change packs and dressings - as soon as pain resolves get packs out to allow healing
* generally do not prescribe antibiotics as it is not infection
76
dry socket predisposing factors
* molars more common - risk increases from anterior to posterior
* mandible more common
* smoking - reduced blood supply
* female
* oral contraceptive pill
* escessive trauma during X
* excessive mouth rinsing post X - clot washed away
* family history/prvious dry socket
77
post extraction complications
sequestrum
* a piece of devascularised bone that becomes separated from the remainder of the bone
* quite common
* prevent healing
* usually bits of dead bone
* can also be pieces of amalgam/tooth
78
post extraction complications
infected socket
* rare complication
* dry socket more common
* occasionally see an infected socket with pus discharge
* check for remaining tooth/root fragments/bony sequestrae
* radiograph/explore/irrigate/remove any of above
* consider antibiotics
* more commonly seen after minor surgical procedures involving soft tissue flaps and bone removal
* infection delays healing
79
difference between OAC and OAF
* acute = OAC (oral antral communication) granulation tissue around as hasnt healed yet
* chronic = OAF (oral antral fistula) 6 weeks approx changes to fistula
80
oro-antral communication diagnosed by
* size of tooth
* radiographic position of roots in relation to antrum
* bone at trifurcation of roots in relation to antrum
* bubbling of blood
* look at roots when you take out
* echo sound when suction into socket
* can use blunt probe but be careful not to create OAF
81
OAC post op instructions
* no nose blowing - dab under nose with tissue
* drink through straw
* sneeze with open mouth so pressure doesnt increase in sinus
82
chronic OAF management
* excise sinus tract
* buccal advancement flap - sometimes have to score peridosteum to allow tension free closure
* buccal fat pad with buccal advancement flap - bring down pad pad and suture to palatal surface to give double protection over defect
* palatal flap - if difficult to stretch buccal mucosa over
* bone graft/collagen membrane
* try use resorbable sutures
83
describe palatal rotational flap forOAF management
* if difficult to stretch buccal mucosa over
* keeping base attached on posterior plate
* rorating round and stitching over defect
* difficult surgery to do
* need to cauterize as go along to prevent bleeding
84
OAF management
grafting/collagen
* can use haemocollagen plug and suture in place
* privides barrier to prevent stuff ingressing into wound
* collagen membrane slowly resorbs and integrated into collagen matrix of gingival architecture as it heals
85
post extraction complications
root/foreign body in antrum
* confirm radiographically by OPT, occlusal or periapical
* decision on retrieval
* how to access generally same as OAF type approach/through the socket
* flap design, suction, small curettes, irrigation or ribbon gauze, close
* if cant access through tooth socket can access laterally - buccal sulcus / buccal window to get access through lateral aspect of antrum
* flush area out
* ENT/maxfax - endoscopic approach if stuck further away - access to max sinus through middle meatus
86
post extraction complications
osteomyelitis overview
* inflammation of bone marrow - clinically implies infection of bone
* rare
* pt often systemically unwell/raised temp
* usually mandible - as maxilla has rich blood supply, mandible has dense cortical bone more likely to become ishaemic and infected
* site of extraction often very tender
* if deep seated infection may see altered sensation - due to pressure on IAN
87
post extraction complications
osteomyelitis spread
* usually begins in medullary cavity (part that contains boan marrow) involving the cancellous bone
* then extends and spreads to cortical bone
* then eventually to periosteum - overlying mucosa red and tender
* radiographically radiolucencies = areas of thinning
* can cause necrosis of soft tissue or bone or cause sequestra
88
post extraction complications
osteomyelitis development
* invasion of bacteria into cancellous bone - oedema in closed bony marrow spaces
* leads to increased tissue hydrostatic pressure
* compromised blood supply results in soft tissue necrosis
* involved area becomes ischaemic and necrotic
* bacteria proliferates - as not blood defences do not reach tissue
* spreads until arrested by anitbiotic and surgical therapy
89
post extraction complications
osteomyelitis factors
* rarely occurs when host defences are intact
* usually when underlying compromised host defences
* major predisposing factors - odontogenic infections and fractures of mandible - even then still rare
* compromised host defence can be due to diabetes/alcoholism/IV drug use/malnutrition/myeloproliferative disease
* check MH when see pt presenting
90
post extraction complications
osteomyelitis stages
* early stage can be difficult to distinguish from dry socket or localised infection in socket
* acute - shows little/no radiographic change - at least 10-12 days required for lost bone to be detectable radiographically
* chronic +/- pus - bony destruction in the area of infection
* radiographic appearance - increased radiolucency "moth eaten appearance" due to sequestra
* in long standing chronic osteomyelitis there may be an increase in radiodensity surrounding radiolucent area - involucrum (a layer of new bone growth outside existing bone) result of an inflam reaction bone production increased
91
post extraction complications
osteomyelitis main bacteria involved
* similar to those involved in odontogenic infections
* streptococci
* anaerobic cocci
* fusobacterium
* prevotella
* in other bones elsewhere in body - staphylococci predominate
92
post extraction complications
osteomyelitis tx overview
* medical and surgical tx
* take swab so know what bugs present and which antibiotics to treat with
* investigate host defences - blood investigations/glucose levels - seek medical consultation
* needs referred to local OS or OMFS unit
93
post extraction complications
osteomyelitis antibiotic tx
* amoxicillin 1st line drug - effective against odontogenic infections and good bone penetration
* longer course than normal - 6-12 weeks sometimes in acute ostemyelitis and some cases up to 6 months in chronic osteomyelitis
* severe acute ostemyelitis may require hospital admission and IV antibiotics (if systemic symptoms)
94
post extraction complications
osteomyelitis surgical tx
* drain pus if possible
* remove any non-vial teeth in the area of infection
* remove any loose pieces of bone
* in fractured mandible - remove any wires/plates/screws in area
* corticotomy - removal of bony cortex
* perforation of bony cortex
* excision of necrotic bone until reach actively bleeding bone tissue
95
post extraction complications
ORN overview
* osteoradionecrosis
* seen in pt who have recieved radiotherapy of head and neck
* bone within radiation beam becomes non-vital
* endarteritis - reduced blood supply
* turnover of any remaining viable bone is slow
* self-repair ineffective
* worse with time and dose
* mandible most commonly affected due to poorer blood supply
96
post extraction complications
ORN prevention
* scaling/chlorhexidine mouthwash leading up to extraction
* careful extraction technique
* antibiotics, chlorhexidine mouthwash and review
* hyperbaric oxygen - increase local tissue oxygenation before and after X
97
post extraction complications
ORN treatment
* irrigation of necrotic debris
* antibioics not overly helpful unless secondary infection
* loose sequestra removed
* small wounds (under 1cm) usually heal over course of weeks/months
* severe cases - resection of exposed bone, margin of unexposured bone and soft tissue closure
* hyperbaric oxygen
98
post extraction complications
MRONJ overview
* medication related osteonecrosis of the jaw
* bisphosphonates used to treat osteoporosis, pagets disease and malignant bone metastasis
* inhibits osteoclast activity so inhibit bone resorption therefore bone turnover
* drugs remain in the body for years
* higher risk in pt recieving IV bisphosphonates but still occrs in pts on oral bisphosphonates
99
names of bisphosphonates
* 'ate' suffix
* alendronate
* clodronate
* zolendronate
100
other drugs to watch out for MRONJ
* RANK-L inhibitors - denosumab
* xgeva
* prolia (cancer drug - monoclonal antibody)
* stops production of osteoclasts
* two types of antiangiogenic drugs: monoclonal antibodies and small molecules
* monoclonal antibodies that stop receptor or growth factor
* small molecules which determine the block by binding the tyrosine kinase receptor
* SUMMARY - antiresorptive and anti-angiogenic drugs
101
MRONJ SDCEP guidance
classification of pt risk
* still refers to pts as either LOW or HIGHER risk
* risk factors include:
* dental tx - impact on bone (X), trauma from dentures, infection, perio disease
* duration of bisphosphonate drug therapy - increased dose and duration increases risk
* dental implants - unknown risk but avoid implant placement for pt on high doses anti-resorptive/angiogenic drugs for cancer management, not contraindicated in pt with osteoporosis
* other concurrent medication - steroids + anti-resorptive drugs = increased risk
* concurrent use of anti-resorptive and anti-angiogenic = increased risk
* previous drug therapy - due to long half life of these drugs
102
MRONJ SDCEP guidance
drugs associated with MRONJ
* bisphosponate - alendronic acid, zolendronic acid etc
* RANKL inhibitor - denosumab
* anti-angiogenic - bevacizumab, sunitinib
103
MRONJ SDCEP guidance
low risk pt
* pt treated with oral bisphosphonates (for osteoporosis or other non-malignant disease) for less than 5 years who are NOT currently being treated with systemic glucocorticoids
* pt treated with quarterly or yearly infusions of IV bisphosphonates (for OP or non-malignant disease) for less than 5 years NOT currently on systemic glucocorticoids
* pts being treated with denosumab who are NOT being treated with systemic glucocorticoids
104
MRONJ SDCEP guidance
higher risk pt
* pt treated with oral bisphosphonates (for osteoporosis or other non-malignant disease) or quaarterly/yearly IV bisphosphonates for MORE than 5 years
* pt treated with bisphosphonates or denosumab (for osteoporosis or other non-malignant disease) for any length of time who are currently being trated with systemic glucocorticoids
* pt being treated with anti-resorptive or anti-angiogenic drugs (or both) as part of cancer management
* pt with previous diagnosis of MRONJ
105
MRONJ tx/management
* usually not successful - debridement/resection/hyperbaracic O2 not proved that successful
* manage symptoms/remove sharp edges of bone/chlorhexidine MW/antibiotics if suppuration (pus)
* management - prevent invasive tx, X in primary care as no benefit to referral
* guidance considers pt in two groups: initial management (prior to commencing drug or just commenced) and continuing management (established drug regime)
106
post extraction complications
actinomycosis overview
* rare bacterial infection
* actinomyces israelli/A. naeslundii/A. viscosus
* bacteria have low virulence - must be introduced into an area of injury or susceptibility
* eg recent X/severely carious teeth/bone#/minor oral trauma
* it erodes through tissues rather than follow typical fascial planes and spaces
107
post extraction complications
actinomycosis presentation
* fairly chronic
* multiple skin sinuses and swelling
* thick lumpy pus - colonies of actinomyces look like sulphur granules on histology
* responds initally to antibiotic therapy/recurs when stop antibiotics
108
post extraction complications
actinomycosis tx
* incision and drainage of pus accumulation
* excision of chronic sinus tracts
* excision of necrotic bone and foreign bodies
* high dose of antibiotics for initial control (often IV)
* long-term antibiotics to prevent recurrence
* penicillins, doxycycline or clindamycin
109
NICE guideline infective endocarditis
pt who are at risk
* adults and children with certain problems affecting structure of the heart - valve replacement or hypertrophic cardiomyopathy
* adults and children who have previously had infective endocarditis - whether or not they have underlying cardiac problems
110
other guidance available for infective endocarditis
* scottish antimicrobial prescribing group
* european cardiac society
* SDCEP 2018
111
SDCEP guidance for management of pt at increased risk of infective endocarditis
- if patient has a cardiac condition from special considerations sub group
* if cardiologist doesnt advice prophylaxis use - routine management
* if they do advise and pt wants prophylaxis to be prescribed - non routine management
* provide pt with prescription for antibiotic prophylaxis at appt prior to planned invasive procedure
* advise pt to bring antibiotic with them to dental practice on day of procedure or can take at home
* give advice on possible adverse effects such as hypersensitivty, anaphylaxis and antibiotic related colitis
112
SDCEP guidance for management of pt at increased risk of infective endocarditis
when antibiotic prophylaxis not indicated
* if pt not in special considerations sub group
* if cardiologist does not advise prophylaxis
* if pt does not want
* routine management - explain benefits and risks of antibiotic prophylaxis and why it is no longer routinely recommended, important of maintaining good oral health, symptoms that may indicate IE and when to seek advice, risks of undergoing invasive procedures
113
what is infective endocarditis
* infection of the lining of the hear
* often involving heart valves
* mainly caused by bacteria which enter the blood from outside the body
* very rare but serious condition
* 1 case per 10,000 people per year
114
benefits and risks of antibiotic prophylaxis and why no longer routinely recommended
* dental procedures no longer thought to be main cause of IE
* unclear whether antibiotic prophylaxis prevents IE and may occur whether or not prophylaxis given
* antibiotics can cause side effects such as nausea, diarrhoea and allergic reactions and in rare cases antibiotic-related colitis
115
IE risk invasive dental procedures
* anything that involves gingival manipulation
* placement of matrix band/sub-gingival rubber dam clamps
* sub-gingival restorations
* endo tx before apical stop established
* PMC/SSCs
* 6PPC
* RSD
* X
* surgery involving muco-gingival area
* implants
116
IE risk non-invasive dental procedures
* infiltration or block LA in non-infected ST
* BPE
* supragingival scale and polish
* supra-gingival restorations
* supra-gingival orthodontic bands and separators
* removal or sutures
* radiographs
* placement of ortho or RPD
117
antibiotic prophylaxis what to prescribe
* amoxixillin 3g oral powder sachet - 60 mins before procedure
* clindamycin capsules 300mg (2 capsules 600mg) 600mg given 60mins before procedure
* azithromycin oral suspension 500mg (12.5ml) 60 minutes before procedure
118
119
120
where can you find drugs dentists can prescribe
* BNF
* dental practitioners formulary
* list of drugs dentists can prescribe
121
analgesia in dental practitioners formulary
* NSAID: aspiring, ibuprofen, diclofenac
* paracetamol
* dihydrocodeine (opioid)
* carbamezapine
122
what to know when prescribing analgesia
mechanism of action
doses
side effects
interactions
groups of patients to avoid
123
describe pain pathway
* trauma and infection lead to breakdown of memrane phospholipids producing arachidonic acid
* arachidonic acid can be broken down to form prostaglandins and leukotrines
* prostaglandins sensitise the tissues ot other inflammatory products (such as leukotrines) which results in pain
124
aspirin overview
* NSAID
* effective for dental and TMJ pain
* superior anti-inflammatory properties to paracetamol
* can be bought over the counter
* also called acetylsalicylic acid
125
aspirin properties
1. analgesic
2. antipyretic
3. anti-inflammatory
126
aspirin mechanism of action
* aspiring inhibits cyclo-oxygenases (COX 1 and 2)
* reduces production of prostaglandins
* its more effective at inhibiting COX1
* COX-1 inhibition reduces platelet aggregation - predisposes damage to gastric mucosa
127
aspirin analgesic propties
* analegsic action of NSAID
* both peripherally and centrally but peripheral actions predominte
* results from inhibition of prostaglanding synthesis is inflamed tissues (cyclo-oxygenase inhibition)
128
aspirin antipyretic properties
* prevents temperature raising effects of interleukin 1 and rise in brain prostaglandin levels
* also reduces elevated temperature in fever
* doesnt reduce normal temperature
129
aspirin anti-inflammatory properties
* inhibits prostaglandin production
* prostaglandins are vasodilators and also affect capillary permeability
* aspiring is good anti-inflammatory and will reduce redness and swelling as well as pain at site of injury
130
aspirin problems
* adverse/side effects
* groups to avoid
* caution when prescribing
131
aspirin adverse effects
* GIT problems
* hypersensitivity
* overdose
* aspiring burns
132
aspirin adverse effects
GIT problems
* mostly on mucosal linings of stomach
* prostaglandins:
* inhibit gastric acid secretion
* increase blood flow through gastric mucosa
* help production of mucin by cells in stomach lining
* care in pt with GIT problems: ulcers, GORD
* most pts taking aspiring will suffer some blood loss from the GIT
133
aspirin adverse effects
hypersensitivity reactions
* acute bronchospasm/asthma type attacks
* skin rashes/urticaria/angioedema
* other allergies
134
aspirin adverse effects
aspirin overdose
* hyperventilation
* tinnitus
* deafness
* vasodilation and sweating
* metabolic acidosis - can be life threatening
* coma - uncommon
135
aspirin adverse effects
mucosal burn
* direct effect of salicylic acid
* aspiring applied locally to oral mucosa results in a chemical burn
* aspiring has no topical effect
* ensure aspirin is taken with water
136
aspirin groups to avoid/caution
* peptic ulceration - could result in perforation
* epigastric pain - history of this/GOR but no ulcer diagnosed
* anticoagulants
* pregnancy/lactation - especially 3rs trimester
* bleeding abnormalities - pt has known bleeding problems
* hypersensitivity to other NSAIDs
* children and adolescents under 16 years
* patients on steroids
* renal/hepatic impairment
* taking other NSAIDs
* elderly
* G6PD-deficiency
137
aspirin groups to avoid/caution
anticoagulants
* aspiring enhances warfarin and other coumarin anticoagulants
* displaces warfarin from binding sites on plasma proteins
* increases free warfarin
* when bound warfarin is inactive so if more released they will become active - increasing bleeding tendency
138
aspirin groups to avoid/caution
pregnancy/lactation
* especially 3rd trimester - nearer delivery
* may cause impairment of platelet function
* increased risk of heamorrhage
* increased risk of jaundice in baby
* can prolong/delay labour
* contraindicated in breastfeeding - reyes syndrome
139
aspirin groups to avoid/caution
patients on steroids
* approx 25% of pts on long term systemic steroids will develop a peptic ulcer
* if they have undiagnosed ulcer - aspirin may result in perforation
140
aspirin groups to avoid/caution
renal/hepatic impairment
* aspirin metabolised in liver and excreted in kidney
* if renal impairment - excretion may be reduced/delayed
* not a complete contraindication but administer with care/reduce dose and avoid if impairment is severe
* inhibition of renal prostaglandin synthesis may result in: sodium retention, reduced renal blood flow, renal failure
* NSAIDs may cause interstitial nephritis and hyperkalaemia
141
aspirin groups to avoid/caution
other NSAIDs
* contraindicated if hypersensitivity to other NSAIDs/aspirin
* avoid if taking other NSAIDs as will increase the risk of side effects
142
aspirin groups to avoid/caution
under 16s
* reyes syndrome very rare complication
* aspirin contraindicated in under 16s and breastfeeding
* fatty degenerative process in liver which can cause profound swelling in the brain - encephalopathy
* lethargy, confusion, seuzures, coma
* mortality 50% related to brain damage due to encephalopathy
143
aspirin groups to avoid/caution
asthma
* not completely contraindicated
* some asthmatics have no problems with them
* ask pt if they have used them before and if any problems
144
aspirin groups to avoid/caution
G6PD-deficiency
* glucose-6 phosphate dehydrogenase deficiency
* prevalent in individuals from parts of Africa, Asia, Oceana, Southern Europe
* individuals susceptible to developing acute haemolytic anaemia
* aspiring carries possible risk of haemolysis in some G6PD deficient pts
145
aspiring completely contraindcated in the following
1. children and adolescents under 16 years; breast feeding (reyes syndrome)
2. previous or active peptic ulceration
3. haemophilia
4. hypersensitivity to aspirin or other NSAIDs
146
aspiring prescription for pain
regime/dose
* 5 day regime
* 300mg tablets
* 2 tablets 4 times daily (40 tablets overall)
* preferably after food
147
prescribing NSAID if pt has PUD what else to prescribe
* 5 day regime to prevent gastric problem
* lansoprazole 15mg 1 capsule a day (5 capsules overall)
* omeprazole 20mg 1 capsule a day (5 capsules overall)
148
ibuprofen overview
* NSAID
* more commonly used compared to aspirin in dentistry
* available over the counter
* less effect on platelets compared to aspirin
* irritant to gastric mucosa but lower risk than aspiring
* may cause bronchospasms - care in asthmatics
* paediatric suspension available
149
ibuprofen max dose
* 2.4g
* 6 x 400mg tablets
150
ibuprofen cautions when prescribing
* previous or active peptic ulceration
* the elderly
* pregnancy and lactation
* renal, cardiac or hepatic impairment
* hisotry of hypersensitivity to aspirin and other NSAIDs
* asthma
* patients taking other NSAIDs
* pt on long term systemic steroids
151
ibuprofen side effects
* GIT discomfort, occasionally bleeding and ulceration
* hypersensitivity reactions: rashes; angioedema; bronchospasm
* others: headache; diziness; drowsiness; tinnitus; fluid retention
152
ibuprofen potential drug interactions
* ACE inhibitors
* beta-blockers
* calcium-channel blockers
* anticoagulants
* antidepressants
* corticosteroids
* ciclosporin
* clopidogrel
153
ibuprofen overdose symptoms/management
* nausea
* vomiting
* tinnitus
* activated charcoal indicated if more than 400mg/kg ingested within the preceding hour
154
paracetamol overview
* traditionally included under the banner of NSAIDs
* simple analgesic without anti-inflammatory activity
155
paracetamol properties
1. analgesic
2. antipyretic
3. little or no inflammatory action
4. no effects on bleeding time
5. does not interact significantly with warfarin
6. less irritant to GIT
7. suitable for children
156
prescribing ibuprofen
* 1 400mg tablet taken 4 times daily
* preferably after food
* 5 day regime
* 20 tablets overall
157
paracetamol mode of action
* hydroperoxides are generated by metabolism of arachinodic acid to COX
* hydroperoxides exert a positive feedback to stimulate COX acvitity
* feedback blocked by paracetamol - indirectly inhibiting COX - especially in the brain - reducing prostaglanding in pain pathways
* main site of action is central nervous system pain pathways such as the thalamus
* results in: analgesia; antipyretic action
* no decrease in peripheral inflammation
158
why is paracetamol described as safe analgesic
* does not have much effect on peripheral prostaglandins so little/no gastric irritation
* described as safe but can cause severe problems in overdose
159
paracetamol cautions when prescribing
1. hepatic impairment
2. renal impairment
3. alchohol dependance
160
paracetamol side effects
* rare
* rashes
* blood disorders
* hypotension reported on infusion
* liver damage following overdose
161
paracetamol interactions
* anticoagulants: prolongues regular use possibly enhances anticoagulant effect of coumarins
* cytotoxics
* domperidone
* lipid-regulating drugs
* metoclopramine
162
prescribing paracetamol
* 5 day regime
* 500mg tablets
* 2 tablets four times daily
* 40 tablets altogether
* max dose: 4g daily (8 tablets)
163
paracetamol overdose
* 10-15g (20-30 tablets) or 150mg/kg taken within 24 hours
* may cause severe hepatocellular necrosis
* less frequently renal tubular necrosis
* liver damage maximal 3-4 days after ingestion
* therefore despite lack of early symptoms pt should still be transferred to hospital immediately
164
opioid analgesia overview
* act on the spinal cord - especially in dorsal horn pathways
* central regulation of pain
* examples (strongest to weakest): fentanyl; methadone; morphine; dihydrocodeine; codeine
* produce thier effects via specific receptors which are closely associated with neuronal pathways that transmit pain to CNS
165
opioid problems
* dependance: psychological and physical; withdrawl of drug will lead to psychological cravins/pt be physically ill
* tolerance: to achieve same therapeutic effects dose of drug needs to be progressively increased
* effect on smooth muscle: constipation can occur after just a few doses; urinary and bile retentio
166
opioid cautions
* hypotension
* hypothyroidism
* asthma
* decreased respiratory rate
* pregancy/breast feeding
* opioid interactions: sdee BNF
* effects of opioids enhanced by alcohol
167
opioid contraindications
* acute respiratory depression
* acute alcoholism
* raised intracranial pressure/head injury - interferes with respiration and affects pupillary response vital for neuralogical assessment
168
opioid side effects
* most common: nausea; drowsiness; vomiting
* dry mouth
* sweating
* facial flushing
* headache
* vertigo
* bradycardia
* rashes
* palpitations
169
opioid CNS effect
it depresses
1. pain centre: alters awareness/perception of pain
2. higher centres
3. respiratory centres
4. cough centre
170
codeine overview
* found in opium poppy
* low dependance
* usually in combination with NSAIDs or paracetamol: co-codamol 8mg codeine:500mg paracetamol
* effective cough suppressant
* common side effects: constipation
* available over the counter
* codeine phosphate not on dental list: only dihydrocodeine available
171
dihydrocodeine overview/preparation
* routes: SC/IM/Oral
* only oral route is on dental list
* oral dose: 30mg every 4-6 hours as necessary (other higher doses not on dental list)
* used for moderate to severe pain
* BNF states due to side effects of nausea and vomiting it is of little value for dental pain and also not very effective for post-operative dental pain
172
dihydrocodeine
interactions
* see BNF
* serious interactions: antidepressants MAOIs; dopaminergics (parkinsons)
173
dihydrocodeine
side effects
* nausea
* vomiting
* constipation
* drowsiness
174
opioid overdose
* causes varying degrees of coma, respiratory depression and pinpoint pupils
* specific antidote: naloxane
* naloxane indicated if there is coma or bradypnoea
* nolaxane has short duration of action than many opioids so pt needs close monitoring and repeated infusion may be necessary
175
neuropathic and functional pain examples
* trigeminal neuralgia
* post-herpetic neuralgia
* functional: TMJ or atypical facial pain
* carbamezapine on dental prescribers formulary
* other drugs used to tx: gabapentin, phenytoin
176
trigeminal neuralgia clinical features
1. severe spasms of pain "electric shock"
2. usually unilateral
3. older-age group
4. trigger spot identified
5. females>males
6. periods of remission
7. recurrence often greater severity
177
carbamezapine overview/doses
* used to manage trigeminal neuralgia /neuropathic and functional pain
* 100 or 200mg tablets
* starting dose 100 once or twice daily
* increase gradually according to response
* usual dose 200mg 3-4 times daily
* up to 1.6g daily in some pt
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179
removal of third molars
4 nerves that can be damaged
* lingual
* inferior alveolar
* mylohyoid
* buccal
* lingual and inferior alveolar nerve more commonly affected
180
peri-radicular surgery
flap design types
* semi-lunar: reduced access; only good for apical lesions; less gingival recession
* triangular
* rectangular
181
peri-radicular surgery
retrograde seal material options
* Zinc oxide/eugenol
* mineral trioxide aggregate
BDS3 - CDS
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