Oral Surgery Jeremy Lee Commonwealth of Australia Copyright

Oral Surgery Jeremy Lee

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Oral Surgery Placements BDS 4 -BDS 5 ● ● ● Three compulsory placements ○ BDS 4 Sem 1 ○ BDS 4 Sem 2 ○ BDS 5 Pre-placement Rosters ○ Ward Rounds ○ EXO Clinics ○ Elective Clinics ○ Outpatients ○ General Theatre (RAH/W&C) Audits ○ Head/Neck Audits ○ Orthognathic ○ Other interdisciplinary

Rosters Ward Rounds EXO Clinic Elective Outpatients Theatre 6: 30 -7: 30 am Extract Teeth Scrub up Consulting clinic GA surgery at RAH 1: 1 DA Surgical EXO’s Pre-theatre cases Dentoalveolar cases* Have fun Biopsies Reviews post-surg (Depends on no. of pts) Just follow Professional Wear Look cool Implants (not us) Consultants and senior registrars Very cool Major surgery cases* Full surgical scrub Underrated Case report Super cool

How to Extract Teeth (Note that I am not an expert and this is not comprehensive) CC MHx Informed Consent LA EXO Post-op Instructions Recall/Review

Hx Taking ● (Most important) ● CC ○ ○ MHx ○ ○ ○ Usually not necessary It’s called EXO clinic for a reason Very Important Do your usual MHx Further questions to ask: ■ Are you on any blood thinners ■ Are you taking any ‘injections’ or ‘medications’ for your bones (e. g. prolia or bisphonates) ■ Do you have any Hx of chemotx ■ Do you have any Hx of H/N radiotx ■ Why?

MHx and Extractions Cardiovascular Issues ● Could be a hint that they are on blood thinners ○ ○ ○ Hx of DVT? Valve replacement? Recently placed stent? Lung Issues ● ● #COVID-19 What are some lung issues which may be a precaution for EXO? Allergies ● Medication allergies to penicillins ○ What’s the best way to check if unsure? Other ● ● ● ● Diabetes Bleeding issues - Von Willebrand Disease? Kidney Issues* Liver Issues* Other medical related issues Name of GP Why are these important?

Blood Thinners Modes of Action ● Antiplatelets ○ ○ ○ ● Aspirin, Clopidogrel, etc. Reduce platelet aggregation ability and hence reduced thrombus formation “Clot forms, but is not maintained” Anticoagulants ○ ○ Warfarin, Heparin, Apixaban, etc. Directly affect clotting factors hence “formation of clot itself is impaired” See: Clotting cascade Which does Warfarin Inhibit? (Vitamin K? )

Blood Thinners Management ● Good Hx taking ○ ○ ● INR ○ ○ ● What are they taking? How much are they taking? What is it for? What else are they taking? *** Measurement of clotting ability ONLY FOR WARFARIN (Why? ) What’s the ‘safe limit’ for Oral Surgery What’s not safe overall Management in the Chair ○ ‘Local Haemostatic Measures’ ■ LA with Vasoconstrictor ■ Pack with Surgicel* ■ TXA - 4. 8% Tranexamic Acid (What does it do? ) ■ Sutures and wound pressure ■ Encourage them to monitor and call back if needed.

MRONJ Mx of Osteoporosis and other bone related disorders ● Bisphonates ○ ○ ○ ● Denosumab ○ ○ ● ● RANKL inhibitor IV every 6 months What’s the pathophysiology or MRONJ? New Guidelines (See TG) ○ ● Antiresorptive agent Oral Tablets or IV Bone related disorders such as osteoporosis but also cancer metastasis to bone (IV) More conservative approach Risks and Benefits of Drug holiday? ● MRONJ Position Paper (AAOMS)

Radiation Therapy - Osteoradionecrosis ● What is it used for? ○ ○ ● What does it target? Why is this important? Side effects ○ ○ ○ Risk of ORN ■ Significantly compromised healing ■ Hypovascular, hypocellular and hypoxic. Mucositis What else? Prevention of ORN ● If Prior to RTx: ○ ● Good Tx planning ■ EXO all unfavourable/questionable teeth prior to Tx If Post RTx: ○ ○ Communication with oncologist ■ Radiation dose (out of our scope) ■ Radiation fields (also out of our scope) Close monitoring of patient ■ Recalls ● 1 week ● 1 month ● 3 months

CC MHx Informed Consent LA EXO Post-op Instructions Recall/Review How to take out teeth

● Informed Consent Other Treatment Considerations ○ ○ ● “Verbal consent gained for EXO of 15. Risks discussed, PIBBS, OAC, and need for surgical extraction. ” Alternatives to salvage tooth Replacement of gap options Expectations of Treatment - Risks & Benefits ○ “Look mate if we take it out it’s not gonna grow back” Jeremy 2020 ○ LA will be administered ■ ○ PIBBS ■ Pain, Infection, Bleeding, Bruising, Swelling ○ OAC ○ Nerve damage ■ ■ ■ ○ ○ Which teeth would prompt you to say this? Which nerve(s) likely? Need for Surgical EXO Other If sutures will be placed If risk of MRONJ, ORN, etc. Post-op considerations ● Discuss this after EXO ■ Questions from pt? ● “Is this gonna hurt” - Jeremy’s Pt Written Consent? ? ? ○ FDC, Surgicals. ■ ■ ■ ● They will feel pressure and nothing more i. e. no pain

Clinical Evaluation Radiographs ● Radiographic location of the subject to be extracted is mandatory ○ ○ ● Provides subject in relation to vital structures Provides difficulty and hence sets up expectations and approach considerations PA or OPG? ○ ○ Does it matter? What’s the difference?

Clinical Evaluation Tooth ● ● Access to tooth ○ Mouth opening and any TMD Tooth factors ○ Size ○ Shape ○ Rotations ○ Pathologies ■ Caries ■ PA granulation tissue ○ Mobility ○ Adjacent teeth if any ○ Need for EXO*

Local Anaesthetic

CC MHx Informed Consent LA EXO Post-op Instructions Recall/Review How to take out teeth

Extraction Technique I am not an expert Goals of Simple EXO: ● ● Tear PDL fibers Widen socket ○ ● ● ● Mobilise tooth Deliver tooth Atraumatic? Minimal Trauma? ○ ● How? Can get into quite a discussion and I’m only a student so yes. Wound toilet

Tear PDL and Expand Socket

Tear PDL and Expand Socket

Tear PDL and Expand Socket

Operator Positioning ● ● Always standing Mx dentition ○ ○ ○ ● Md dentition ○ ○ ● Patient lying flat, head around your stomach height Facing the patient Usually always on the RHS if RH, LHS if LH Patient lying almost-flat, head around your stomach height Depends on tooth Finger rests and support ○ Always support Mx or Md with your non-dominant hand ■ Prevents slip ■ Supports Md and prevents TMJ pain ■ Stabilises and braces

CC MHx Informed Consent LA EXO Post-op Instructions Recall/Review How to take out teeth

Post-Extraction ● Assess ○ ○ ● Wound Toilet ○ ○ ● Irrigation Debridement of debris ■ Curettage ■ Rongeurs ■ Extraction of labile bone ■ Alveoplasty Compress socket Apply pressure with gauze and monitor for haemostasis Post-op considerations ○ ○ ○ ● Are roots whole and complete? Is socket free of debris? ■ Any labile bone? ■ Any high septal bone? POI Surgicel? TXA? Sutures?

POIG ● Apply pressure on wound ○ ○ ● PIBBS ○ ○ ● Pain - “You will be sore tonight. You will be more sore tomorrow. It will get better*” Infection - “If it doesn’t get better, come in” ■ To prevent infection, good wound management is helpful ● Soft diet ● Light irrigation with saline ● No smoking , drinking, etc. ● Good OH Bleeding - “it’ll be a bit oozy tonight mate, just keep biting on the gauze” Bruising and swelling - “You’ll be a bit swollen bit it’ll die down. ” Pain management techniques ○ ○ ● “Bite on this for the next half-hour to hour mate” “We’ll give you some more for you to take home and roll up” Watch for MHx contraindications What can contraindicate pain control tablets? Other info such as recall, review, sutures, etc.

Questions?