Study Guide

Question 1

1. What is Punch biopsy? Where do you use it

Answer 1

a. * A surgical instrument is used to punch out a representative portion of tissue.
b. * The punch comprises a circular blade attached to a plastic handle. Diameters of two to ten millimetres are available.
c. * The punch removes a core of tissue the base of which can be simply and atraumatically released using curved scissors.
d. * The resultant wound may not require suturing if using the smaller diameter punches.

Question 2

a. Indications for antibiotics
(7)

Answer 2

i. Rapidly progressive swelling
ii. Diffuse swelling (cellulitis)
iii. Fascial space involvement
iv. Compromised host defenses
v. Severe pericoronitis
vi. Osteomyelitis
vii. Trauma

Question 3

b. Principles of Antibiotic therapy:
(5)

Answer 3

i. Use Empiric Therapy
ii. Use narrowest spectrum drug
iii. Use antibiotic with the lowest toxicity
iv. Use bactericidal antibiotic
v. Be aware of Cost

Question 4

When do you use narrow spectrum vs broad spectrum

Answer 4

?

Question 5

3. Most definitive treatment for dental infection is….
   (5)

Answer 5

i. Remove the cause of infection.
ii. Establish drainage.
iii. Choose and prescribe the appropriate Antibiotics
iv. Supportive care, including proper rest and nutrition
v. Re-evaluate the patient frequently

Question 6

a. What is cellulitis, including physiological level
(3)

Answer 6

i. Diffuse, reddened, brawny swelling that is tender to palpation.
ii. Inflammatory response not yet forming a true abscess.
iii. Microorganisms have just begun to overcome host defenses and spread beyond tissue planes.

Question 7

b. What is Abscess…..
(3)

Answer 7

i. As inflammatory response matures and an abscess develops.
ii. An abscess is a localized collection of pus.
iii. May develop spontaneous drainage intraorally or extra orally

Question 8

5. Different types of treatment for different types of Osteomyelitis

Answer 8

a. Both medical and surgical interventions are required. Medical therapy alone will not suffice, and will only delay appropriate treatment. Tissues from the affected site should be sent for microbiological exam, culture and sensitivity, and histopathological examination. Immunocompromised states should be controlled medically to achieve optimum response to therapy

Question 9

5. Different types of treatment for different types of Osteomyelitis
   b. Osteomyelitis – Medical Treatment
   (4)

Answer 9

i. Begin empiric antibiotic treatment based on Gram stain(microbiological exam) results.
ii. Best choice of antibiotic can be determined following C & S results, which can take several days
iii. IV antibiotic therapy for 6 weeks is routinely used
iv. Treatment may include carbapenems, cephalosporins, fluoroquinolones, Clindamycin, Metronidazole, or combination therapy. Infectious disease consult may be considered HBO therapy for chronic refractory osteomyelitis may be considered

Question 10

5. Different types of treatment for different types of Osteomyelitis
   c. Hyperbaric Oxygen Therapy(HBOT)

Answer 10

i. Hyperbaric oxygen is indicated in treatment of “Chronic Refractory osteomyelitis”
ii. Chronic refractory osteomyelitis is a persistent or recurrent bone infection lasting longer than six months despite appropriate surgical and medical treatment
iii. HBOT involves placing a patient in a chamber where they breathe 100% oxygen at increased atmospheric pressure.
iv. A typical course of treatment for Chronic refractory osteomyelitis consists of a 90 minute session for five days per week for 20 to 60 treatments based on their condition
v. Hyperbaric oxygen treatment – Mechanism of action
1. Enhanced leukocyte oxidative killing
2. Neo-Angiogenesis
3. Osteogenesis
4. Synergistic antibiotic activity

Question 11

5. Different types of treatment for different types of Osteomyelitis
   d. Sequestrectomy
   (2)

Answer 11

i. Sequestrectomy is the removal of infected and avascular pieces of bone.
ii. Since the sequestrum is avascular, antibiotics will not be able to penetrate into it.

Question 12

5. Different types of treatment for different types of Osteomyelitis
   e. Saucerization

Answer 12

i. Saucerization involves the removal of the adjacent bony cortices and open packing to permit healing by secondary intention after the infected bone has been removed. Here the margins of the bone which lodge the sequestra are trimmed down. This create a saucer shaped defect instead of a deep hollow cavity. This saucer shaped defect can’t accumulate a large clot

Question 13

5. Different types of treatment for different types of Osteomyelitis
   f. Decortication

Answer 13

i. Decortication – involves removal of the dense, chronically infected, and poorly vascularized bony cortex and placement of the vascular periosteum adjacent to the medullary bone to allow increased blood flow and healing in the affected area.
ii. Key element is cutting back to healthy bleeding bone – clinical judgement.

Question 14

5. Different types of treatment for different types of Osteomyelitis
   g. Additional considerations

Answer 14

i. May support weakened mandible using external fixation, reconstruction plate, or MMF.
ii. Segmental resection usually a last resort following multiple attempts at more conservative debridement

Question 15

6. Odontogenic tumor (know the demographics, treatment)
   a. AOT
   (8)

Answer 15

i. This is a tumor that is commonly found in teenagers.
ii. It occurs in the middle and anterior portions of the jaws
iii. Commonly associated with the crown of an impacted anterior tooth.
iv. Two-thirds occur in the maxilla and it is more common in females.
v. The maxillary incisor-cuspids are common sites.
vi. Painless expansion is often the chief complaint.
vii. The radiographic appearance is a unilocular radiolucency, often around the crown of an unerupted tooth in which case they resemble a dentigerous cyst.
viii. Treatment is with simple surgical enucleation and recurrence is extremely rare.

Question 16

6. Odontogenic tumor (know the demographics, treatment)
   b. Ameloblastoma (please know ameloblastoma well, this is one the crappy pathology that dentist
   i. must know well without excuse. Where do you see them, what they looks like
   ii. on x-ray…….)

Answer 16

1. Benign, but locally invasive (Except for the Malignant variant).
2. It is unencapsulated and infiltrates surrounding bone marrow.
3. Even though they are locally infiltrative, they do not metastasize (Except for the Malignant variant).
4. Occasionally arise from dentigerous cysts.
5. Clinical Subtypes –
   a. Multicystic or Solid (86%),
   b. Unicystic (13%),
   c. Peripheral (extraosseous) and Malignant variant (1%)
6. It occurs chiefly in middle age people long after odontogenesis has ceased.
7. They may occur in any part of both jaws but most are in the middle and posterior regions of the mandible.
8. Radiographic findings
   a. They may be unilocular but frequently become multilocular as they increase in size.
   b. The unilocular lesion is indistinguishable from an odontogenic cyst.
   c. Well-circumscribed, “soap- bubble appearance” (Multicystic or Solid variant).
9. Treatment
   a. According to growth characteristics and type
   b. Unicystic Ameloblastoma –
   i. Complete removal (Enucleation)
   ii. Peripheral ostectomies if extension through cyst wall
   c. Classic infiltrative (aggressive) –
   i. “Solid Ameloblastoma”
   ii. Mandibular – adequate normal bone around margins of resection
   iii. Maxillary – more aggressive surgery, 1.5 cm margins
   d. Ameloblastic carcinoma –
   i. Radical surgical resection (like SCCa) – Neck dissection

Question 17

6. Odontogenic tumor (know the demographics, treatment)
   c. Odontoma

Answer 17

i. Compound and Complex Odontomas
1. The tumors in which odontogenic differentiation is fully expressed are the odontomas. In these tumors, the epithelium and ectomesenchyme realize their potential and make enamel and dentin respectively. As a result, these tumors are mostly radiodense. Odontomas are the most common type of odontogenic tumors seen in the oral surgery clinic.
ii. Complex Odontoma
1. In the complex odontoma, there is little or no tendency to form tooth-like structures.
2. The dentin and enamel are entwined in a mass that bears no resemblance to teeth
iii. Compound Odontoma
1. In the compound odontoma, multiple small and malformed toothlike structures are formed creating a “bag of marbles” radiographic appearance.
iv. Complex and Compound Odontomas
1. Both types of odontoma are found in the early years, usually in the teens or early twenties.
2. Compound odontoma is more common in the anterior jaw segment whereas the complex type is found more commonly in the posterior jaws.
3. Many are associated with an unerupted tooth.
4. They have a limited growth potential and cause no pain or cosmetic deformity.
5. Treatment is elective surgery

Question 18

7. How does Odontogenic tumor classified?
   a. I. Tumors of odontogenic epithelium
   (5)

Answer 18

i. Ameloblastoma
1. Malignant ameloblastoma
2. Ameloblastic carcinoma
ii. Clear cell odontogenic carcinoma
iii. Adenomatoid odontogenic tumor
iv. Calcifying epithelial odontogenic tumor
v. Squamous odontogenic tumor

Question 19

7. How does Odontogenic tumor classified?
   b. Mixed odontogenic tumors

Answer 19

i. Ameloblastic fibroma
ii. Ameloblastic fibro-odontoma
iii. Ameloblastic fibrosarcoma
iv. Odontoameloblastoma
v. Compound odontoma
vi. Complex odontoma

Question 20

7. How does Odontogenic tumor classified?
   c. Tumors of odontogenic ectomesenchyme

Answer 20

i. Odontogenic fibroma
ii. Granular cell odontogenic tumor
iii. Odontogenic myxoma
iv. Cementoblastoma

Question 21

8. Surgical Treatment types for Odontogenic tumor
   a. Surgical Management includes:

Answer 21

i. “Surgical removal” of the odontogenic tumor followed by appropriate method for reconstruction of the defect. The type of surgical approach that is going to be employed is mainly dependent ion the type (Biologic behavior) of the tumor and it’s size. The type of reconstruction is mainly decided based on the size and extent of the defect (Both Hard and Soft tissue)

Question 22

8. Surgical Treatment types for Odontogenic tumor
   b. Enucleation
   (2)

Answer 22

i. Local removal of tumor by appropriate instrumentation in direct contact with the lesion: used for very benign types of lesions.
ii. Tumor Is Then Sent for Histopathological Examination

Question 23

8. Surgical Treatment types for Odontogenic tumor
   c. Resection
   (3)

Answer 23

i. Removal of a tumor by incising through uninvolved tissues around the tumor, thus delivering the tumor without direct contact during instrumentation (also called as en bloc rection).

Question 24

8. Surgical Treatment types for Odontogenic tumor
   ii. Marginal (Segmental) resection

Answer 24

1. Resection of a tumor without disruption of the continuity of the bone.

Question 25

8. Surgical Treatment types for Odontogenic tumor iii. Partial Resection (3)

Answer 25

1. Resection of a tumor by removing full-thickness portion of the jaw. 2. In the mandible, this can vary from a small continuity defect to a hemimandibulectomy. 3. Jaw continuity is disrupted.

Question 26

8. Surgical Treatment types for Odontogenic tumor iv. Total Resection (2)

Answer 26

1. Resection of a tumor by removal of the involved bone. 2. Eg., Hemi-Maxillectomy and Hemi-Mandibulectomy

Question 27

8. Surgical Treatment types for Odontogenic tumor v. Composite Resection

Answer 27

1. Resection of tumor with bone, adjacent soft tissues and contiguous lymph node channels (This is an ablative procedure used most commonly malignant tumors)

Question 28

9. Odotogenic cyst, histologically what is it and what kind of lining do they have inside/outside?

Answer 28

a. “A benign pathologic cavity within bone or in soft tissues, generally formed by a connective tissue wall.” b. The cystic cavity, within the oral regions, is almost always lined by epithelium. c. The cyst's lumen usually contains fluids, keratin or cellular debris.

Question 29

10. How does Odontogenic cyst classified? i.e. developmental vs….?? a. Histogenic Classification (Based on where the cyst is derived from) (4)

Answer 29

i. 1. Cyst derived from rest cell of Malassez 1. Periapical cyst 2. Residual cyst ii. 2. Cyst derived from reduced enamel epithelium 1. Dentigerous cyst 2. Eruption cyst iii. 3. Cyst derived from dental lamina (Rest of Serrae) 1. Odontogenic keratocyst 2. Dental lamina cyst of new born 3. Lateral periodontal Glandular cyst iv. 4. Unclassified 1. Paradental cyst

Question 30

10. How does Odontogenic cyst classified? i.e. developmental vs….?? b. Inflammatory vs Developmental (6)

Answer 30

i. Inflammatory Cysts 1. Radicular Cyst 2. Paradental Cyst ii. Developmental Cysts iii. Dentigerous Cyst iv. Odontogenic keratocyst v. Developmental lateral periodontal Cyst vi. Glandular odontogenic Cyst

Question 31

11. Common treatment for Odontogenic cyst (5)

Answer 31

a.  Curettage b.  Enucleation c.  Marsupialization d.  Marsupialization followed by cystectomy e.  Enucleation followed by Peripheral ostectomy

Question 32

12. Please know everything about OKC (treatment, clinical appearance, x-ray appearance) a.

Question 33

13. Did I said Treatments of OKC? YES, I did and please include Carnoy Solution) a. Enucleation followed by use of Carnoys solution

Answer 33

i. Carnoy's solution is a substance used as a complementary treatment after the conservative excision of odontogenic keratocyst. The application of Carnoy's solution promotes a superficial chemical necrosis and is intended to reduce recurrence rates. The application of Carnoy’s solution, a chemical solution composed of 60% ethanol, 30% chloroform, and 10% acetic acid, in conjunction with surgery, is known to reduce the rate of KOT recurrence. An FDA ban in 2013 on the use of chloroform for compounding led a number of surgeons to adopt a modified Carnoy’s solution in the use of Odontogenic Keratocyst ii. Enucleation followed by peripheral ostectomy and removal of overlying attached mucosa + use of Carnoys solution iii. Surgical resection for very large –recurrent lesions

Question 34

14. Biopsy… What is incisional vs excisional biopsy? a.  Incisional biopsy –

Answer 34

Larger lesions prior to definitive therapy i. Some lesions are too large to excise initially without having established diagnosis or are of such a nature that excision would be inadvisable. In such instances a small section is removed for examination called incisional or diagnostic biopsy. ii. Use: For large lesions or when there is a suspicion of malignancy iii. Principles of Incisional Biopsy 1. Representative areas of lesion should be incised in wedge fashion. 2. Selected in an area that shows complete tissue changes (the lesion extends into normal tissue at the base and/or margin of the lesion). 3. Necrotic tissue should be avoided 4. Taken from the edge of the lesion to include some normal tissue 5. A deep, narrow biopsy rather than a broad, shallow one

Question 35

14. Biopsy… What is incisional vs excisional biopsy? b.  Excisional biopsy –

Answer 35

Smaller cysts i. Excisional Biopsy Definition: 1. Total excision of a lesion for microscopic study is called “Excisional biopsy”. a. Slow growing lesions that appear benign on clinical examination. b. Removal of the entire lesion c. A perimeter of normal tissue surround the lesion is also excised to ensure total removal d. Constitute definitive treatment ii. The entire lesion, along with 2 to 3 mm of normal appearing surrounding tissue, is excised

Question 36

15. Aspirational biopsy? How does it work and what “instrument” do you use?

Answer 36

a. Aspiration is the use of a needle and syringe to penetrate a lesion for aspiration of its content. b. A 18-gauge needle is connected to a 5 or 10 ml syringe i. The tip of needle may have to be repeatedly repositioned to locate a fluid center c. Aspiration should be carried out on all lesions thought to contain fluid or any intraosseous lesion before surgical exploration d. A fluctuant mass in the soft tissues should also be aspirated to determine its contents e. Any radiolucency in the bone of the jaw should be aspirated to rule out a vascular lesion that can cause life threatening hemorrhage. f. Fine Needle Aspiration Biopsy i. Technique: Uses very thin needle and a syringe to take out a small amount of fluid and very small pieces of tissue from tumor/mass. 1. In cases where the tumor is deep seated, then you can use C.T.Scan guided or ultrasound guided Fine Needle Aspiration

Question 37

16. What’s that liquid in the biopsy jar?

Answer 37

a. 10% formalin

Question 38

17. Osteomyelitis occurs in …… where? What kind of bone? (4)

Answer 38

a. Osteomyelitis is Inflammation and infection of the bone marrow with a tendency to progression. b. This process starts of in the medullary bone and then continues to involve adjacent cortical plates and often periosteum (More frequently seen in the Mandible) c. The disease if untreated progresses from inflammatory destruction of bone, to necrosis (sequestra). d. In the oral region, it is usually a result of bacterial infection secondary to odontogenic infections, trauma.

Question 39

18. Demographics of Osteomyelitis

Question 40

19. Facial bone osteomyelitis is different from long bone osteomyelitis, How?

Question 41

20. In the Acute phase of Osteomyelitis, what laboratory should be order and what do you expect to see?

Question 42

21. Osteomyelitis seen in –x-ray. When do you see it and or do you see it? Why do you or don’t you see it on the x-ray?

Question 43

22. How to treat dead bone ( sequestrum)?

Answer 43

a. Sequestrectomy is the removal of infected and avascular pieces of bone. i. Since the sequestrum is avascular, antibiotics will not be able to penetrate into it.

Question 44

23. Surgical treatments of osteomyelitis are (3)

Answer 44

a. Sequestrectomy b. Saucerization c. Decortication

Question 45

24. Medical Treatment of Osteomyelitis is

Answer 45

a. Begin empiric antibiotic treatment based on Gram stain(microbiological exam) results. b. Best choice of antibiotic can be determined following C & S results, which can take several days c. IV antibiotic therapy for 6 weeks is routinely used i. Treatment may include carbapenems, cephalosporins, fluoroquinolones, Clindamycin, Metronidazole, or combination therapy. Infectious disease consult may be considered HBO therapy for chronic refractory osteomyelitis may be considered

Question 46

25. Facial infection.. Know what is primary, secondary space a. Primary maxillary spaces includes… (4)

Answer 46

i. Canine/infraorbital space ii. Buccal space iii. Infratemporal space iv. Temporal space

Question 47

25. Facial infection.. Know what is primary, secondary space b. Primary Mandibular spaces includes… (4)

Answer 47

i. Sub lingual space ii. Submandibular space iii. Submental space iv. Buccal Space

Question 48

25. Facial infection.. Know what is primary, secondary space c. Secondary facial spaces includes….. (4)

Answer 48

i. Masticator (Sub-masseteric) space ii. Pterygomandibular space iii. Lateral pharyngeal space iv. Retropharyngeal Space

Question 49

26. When you do an I&D, you have seen puss ( alfredo sauce) what do you do with it beside suction it out? a. Still don’t get it? Let me give you a hint, you need to send it to lab…

Answer 49

?

Question 50

27. Pathway to very bad news… not you. I mean if you were have a bad infection. How does bacteria / puss travel from tooth (maxillary or mandibular) to brain, to mediastinum, or close up trachea? (There is a slide in the lecture talking about common progression of facial space infection..) KNOW IT

Answer 50

a. Common Progression Of Fascial Space Infections In The Head And Neck i. Masticator Space Lateral Pharyngeal Space Retropharyngeal Space Danger Space MEDIASTINITIS ii. Submandibular Space Submental Space Contralateral Submental Space Sublingual Ludwigs Angina AIRWAY OBSTRUCTION iii. Canine Space Infraorbital Space Angular Vein CAVERNOUS SINUS THROMBOSIS

Question 51

28. Radiographic/ imaging work up for complex odontogenic infection are……

Answer 51

a. Periapical b. Panorex c. Plain Films d. CT Scan with contrast e. C.T. Scan with contrast i. C.T. Scan with contrast helps as follows, 1. It clearly delineates the position and size of the infection process as well as its relationship with the adjacent anatomic structures. 2. It is also useful to evaluate any changes to the patient’s upper airway (due to edema) as it occurs in more advanced infections of the head and neck. ii. CT Scan with contrast helps us to evaluate the extent of the complex oro-facial infection in the head and neck region. A rim enhancement around the area of infection is observed whenever we use a C.T. Scan along with a contrast.

Question 52

29. What is the definition of Ludwig’s Angina and what are the spaces involved?

Answer 52

a. Ludwig’s Angina is a fulminating, bilateral sublingual, submandibular, submental and cervical infection or cellulitis displacing the tongue with potential airway obstruction. Life-threatening condition b. Etiology: Usually related to periapical abscess related to the lower molar teeth

Question 53

30. What is Cavernous sinus Thrombosis? Definition, pathophysiology and classic sign and symptom

Answer 53

a. Serious condition that is recognized by the appearance of marked oedema and congestion of the eyelids and conjunctiva as a result of impaired venous drainage. b. This start as a unilateral and rapidly becoming bilateral. c. This condition is not as common as Ludwig’s Angina d. - Hematogenous spread of infection from the jaw to the cavernous sinus may occur anteriorly via the inferior or superior ophthalmic vein or posteriorly via emissary veins from the pterygoid plexus. Direct extension through the opening in the cranial bones.

Question 54

skipped 30. What is Cavernous sinus Thrombosis? Definition, pathophysiology and classic sign and symptom e. Signs & Symptoms (6)

Answer 54

i. Ocular pain. ii. High fluctuating fever, chills, and sweating. iii. Periorbital and conjunctival oedema, starting unilaterally and progressing to bilateral as a result of thrombophlebitis. iv. Pulsating exophthalmos and retinal hemorrhage v. Ophthalmoplegia, paralysis, dilated pupils and loss of corneal reflexes vi. Other cranial nerve involvement e.g. trigeminal nerve

Question 55

30. What is Cavernous sinus Thrombosis? Definition, pathophysiology and classic sign and symptom f. Management (4)

Answer 55

i. Hospitalization. ii. Neurosurgical consultation. iii. Intensive antibiotic therapy. iv. Heparin to prevent extension of thrombosis.

Question 56

31. What’s the purpose of complete blood count with differential?

Answer 56

a. CBC (Complete Blood Count) with differential count – large outpouring of immature granulocytes indicate severe infection.

Question 57

32. In early odontogenic acute infection, what types of bacteria is more dominant?

Answer 57

a. Gram positive aerobes

Question 58

33. How does facial infection spread? (3)

Answer 58

a. Generally, infections follow the path of least resistance. b. This is dictated by anatomic location of teeth, position of muscle attachments, bone density, etc. c. Infective processes can spread by disruption of intervening fascial planes

Question 59

34. Classic signs of inflammation (7)

Answer 59

a. Dolor - Pain b. Tumor - Swelling c. Calor - Warmth d. Rubor – Redness e. Loss of function f. Trismus g. Difficulty in breathing, swallowing, chewing

Question 60

35. The main objective of performing I&D (5)

Answer 60

a. Drainage of pus b. Reduction of tissue tension c. Increased blood flow d. Increases delivery of host defenses e. Obtain specimen for culture and sensitivity(C&S)

Question 61

36. Indications for antibiotic treatment of odontogenic infection are? (7)

Answer 61

a. Rapidly progressive swelling b. Diffuse swelling (cellulitis) c. Fascial space involvement d. Compromised host defenses e. Severe pericoronitis f. Osteomyelitis g. Trauma