- Created by: Catherine Gough
- Created on: 13-10-17 09:15
Spread of oral bacterial infection. Part 1 - 1) What is an abscess?
A pus-filled pathological cavity, which can form as part of the inflammatory response to acute infection - acute exacerbations of chronic inflammation can also occur, followed by periods of quiescence
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What should you do with abscesses?
All of them should be drained
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How can abscess formation be determined clincally?
By the presence of fluctulance to gentle palpation. Pressure exerted by 1 finger should be detected by another finger as a bounch
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If there is no fluctulance present clincally (where you suspect an abscess), what is the diagnosis?
Cellulitis, which does NOT need drainage
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How are dentoalveolar abscesses usually diagnosed?
By clinical means
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Why do radiographs not typically show any change in PA tissues?
It takes 10 days for sufficient bone loss to occur to be detectable on an intra-oral film - earliest sign is widening of PDL
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Where is the clinical presentation of an apical abscess? Why?
Path of least resistance through cancellous bone and points on nearest epithelial surface - usually buccal aspect of maxillary/mandibular alveolus (where overlying bone is thinnest)
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Give 3 general measures for treating acute infection
Admission if unwell, Analgesia, Control infection
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Give 4 local measures for treating acute infection
Remove cause, Drain, Prevent spread, Restore function
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When are patients admitted to hospital for acute infection?
Patients that are toxic (systemically unwell with malaise, pyrexia, tachycardia/hypotension - they need IV antibiotics and surgical drainage + NSAIDs
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How are antibiotics used to treat toxic patients with acute infection?
Given blindly in the first instance (not practical to await culture/sensitivity tests). Amoxicillin and metronidazole combination - changes made only if there is bacterial resistance
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How is the cause of acute infection removed?
Drainage prevents spread in the acute phase e.g. XLA non-vital teeth, remove dead bone (sequestrae)/foreign bodies/calculi
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Why are abscesses drained through incision?
Pus should always be drained, and a surgical incision leaves less scarring than spontaneous drainage
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Are antibiotics used instead of drainage?
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How are intra-oral abscesses drained?
LA into overlying mucosa, Horizontal incision parallel to occlusal surface of teeth - 1-2cm in length, Use no.11 blade held backwards with upward sweep, Open abscess cavity with artery forceps (Hilton's method), Hot water rinses after.
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What do you need to take into account when draining an intra oral abscess?
The local anatomy e.g. mental nerve
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When is incising an abscess insufficient?
When pus has to pass through several tissue planes to escape - e.g. deep neck abscesses - a drain can be inserted into the abscess cavity (this is exteriorized into the mouth/skin surface)
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How is spread of acute infection prevented?
Drainage, Use of antimicrobials and rest, Rest is difficult in orofacial region - but trismus when present achieves this naturally
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How is function restored after acute infection?
Review pt after acute phase to ensure things have settled down and function restored. Sometimes trismus requires treatment - e.g. Therabite
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How are PA abscesses treated?
Drain and remove cause, if systemic - give antibiotics
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Which bacteria are found in PA abscesses? (6)
Black-pigmented anaerobes, Fusobacterium, Peptostreptococcus, Streptococcus, Non-pigmented anaerobes, Spirochaetes
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Give 3 examples of black-pigmented anaerobes
Porphrymonas gingivalis, Tanerella Forsythia, Prevotella intermedia
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Give 4 symptoms of periodontal abscesses
Pain, Swelling (small localised to diffuse), Lymphadenopathy + fever, Facial/neck cellulitis
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In periodontal abscesses, the tooth is usually vital/non-vital?
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Give 3 causes of periodontal abscesses
Pre-existing perio pockets that become occluded (e.g. by foreign body), Secondary infection of lateral perio cyst, Trauma to periodontium
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What do you see on a radiograph in periodontal abscesses?
Radiolucency on lateral aspect of root
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When are multiple periodontal abscesses seen?
In poorly controlled diabetic patients
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What is the microbial cause of periodontal abscesses?
The same as chronic perio (Porphrymonas gingivalis/Prevotella intermedia/AA/Tanerella Forsythia/Treponema Denticola/Fusobacterium nucleatum) + candida
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How are periodontal abscesses treated?
Drain and debride
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When is streptococcal gingivostomatitis most commonly seen?
In compromised patients (e.g. following tonsilitis)
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What are the signs of streptococcal gingivostomatitis?
Severe inflammation of the gingivae with marked pain
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What causes streptococcal gingivostomatitis? What are the complications?
S. Pyogenes, You need to differentiate from drug and viral causes. Complications - fascilitis, tissue destruction, rheumatic heart disease
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How is streptococcal gingivostomatitis treated?
Prompt treatment with penicillin
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Give 3 causes of acute ulcerative gingivitis
Poor OH, Smoking, Stress
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Give 3 characteristics of acute ulcerative gingivitis.
Ulceration, Destruction of interdental papilla, Invasion of tissue
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Give 4 signs of acute ulcerative gingivitis
Hallitosis, bad taste, malaise, lymphadenopathy
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Which microbes are seen in acute ulcerative gingivitis?
Trep. Denticola, Other treponemes, Fusobacterium spp, Prevotella Intermedia
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What usually precedes a Cancrum Oris/Noma?
ANUG and recent debilitating illness
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Give 3 infective causes of Noma
Viral (measles), Bacterial infection (TB/scarlett fever), Parasitic infection (malaria)
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What are the 2 causes of Noma?
Infection, Immune-supression, Malnutrition
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Which 6 microbes are found in Noma?
F.necrophorum, Prev. Intermedia, Trep. Vinventii, T. Denticola, T. Forsythia, a-streptococci
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How does TB usually present?
As a cough/cervical lymphadenopathy - rare in the oral cavity
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What is seen in the oral cavity in TB?
Deep oral ulceration, Delayed healing after tooth extraction (secondary osteomyelitis)
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How is TB investigated using a smear?
A biopsy is taken - cannot be gram stained, so Ziehl-Neelsen is used. Cultured with Lowenstein Jensen (but this takes 4-6 weeks), PCR is commonly used for investigation
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Describe the histology of TB
Granulomas seen - walled off fibrotic area. Epithelioid cells present (which are differentiated macrophages, and are long and thin). Giant cells also present. A necrotic area can be seen (described as casseated).
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What are the 5 clinical signs of the primary lesion in syphilis?
Chancre on lip/tongue, Ulcer, Local odema, Painless, Lymphadenopathy
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What does a smear show in syphilis?
Spirocheates, T. Pallidium (hard to do a gram stain on, so silver impregnation can be used - called a Fontana Stain - which shows it up black)
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When does secondary syphilis occur? Give 3 signs.
6 weeks after healing. Signs - snail track ulcers, Lymphadenopathy, Skin rash
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What is seen in tertiary syphilis?
Gumma on palate, tongue or tonsil - this is firm, has a necrotic centre surrounded by inflamed tissue. Leukoplakia is also seen on the dorsum of the tongue, and there is an increased incidence of oral cancer
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Give 2 signs of congenital syphilis
Hutchinson's incisors, Mulberry molars
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Which areas in the head and neck can be affected by gonnorhoea?
Pharynx and any part of the oral mucosa
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Give 2 signs of gonnorrhoea
Pain and lymphadenopathy
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How can the appearance of gonorrhoea vary?
Ulceration, Oedema, Pseudomembranes
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How is Gonorrhoea diagnosed?
Direct examination of smear and/or culture necessary to diagnose Neisseria Gonorrhoeae
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List 3 features of a smear to diagnose Gonorrhoea
Polymorphonuclear leukocyte, Extracellular gram-negative diplococci, Intracellular gram-negative diplococci
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What is seen clinically in actinomycosis?
A slow growing lump on the angle of the mandible
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Which bacteria cause actinomycosis?
Actinomyces israelii, A. Oris
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How is actinomycosis treated?
Surgical drainage and debridement, Antibiotics 6-8 weeks - long treatment due to slow growth of bacteria
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What are the histological features of actinomycosis?
Gram positive, filamentous chains, branching also seen. Variable staining. Fibrotic lesion in the middle. Locules of pus surrounded by fibrous septa
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What is the nature of the cause of Acute Bacterial Sialadenitis?
Ascending infection from the mouth - mainly the parotid gland. Usually due to failure of secretion (e.g. Sjorgrens Syndrome, Gland pathology, Sialothiasis, Drugs)
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Give 7 clinical features of acute bacterial sialadenitis.
Unilateral, firm, red swelling, extreme pain, trismus, possibly febrile, milking duct releases pus
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Give 3 microbial causes of acute bacterial sialadenitis
Oral streptococci, Oral anaerobes, Staph. Aureus
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What is the problem with diagnosing acute bacterial sialadenitis?
Sampling is difficult
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How is acute bacterial sialadenitis treated?
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Which other investigation might be done for acute bacterial sialadenitis?
Sialography after resolution, possibly surgical exploration
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What might be the cause of angular cheilitis? Give 5 examples of this.
Haematological deficiency - Fe, vitamin B2/3/6/12
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How is angular cheilitis treated?
With miconazole or fusidic acid - depending on the cause
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Which bacteria cause angular cheilitis?
C.Albicans, Staph. Aureus, Strep. Pyogenes - alone or mixed
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What determines the spread of dentoalveolar infections?
The site of origin and surrounding tissue planes that are limited by fascial layers and muscle insertions
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What influences the clinical presentation of dentoalveolar infections?
The position of the apices of the originating tooth relative to muscles and fascia
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TMJ Disorders (1) - What percentage of the population have signs of TMD?
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What percentage of the population have symptoms of TMD?
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What percentage of the population seek treatment for TMD?
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Which muscle attaches the coronoid process to the skull?
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Which muscles attache into the mastoid process?
Sternocleidomastoid and digastric muscles
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What envelopes the TMJ?
Fibrous articular capsule
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What is found between the condyle and the fossa?
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The articular disc is described as being....?
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What is the role of the articular disc?
Divides the joint into upper and lower compartments
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What type of joint in the TMJ?
Hinge joint (condyle rotates about the disc), with a Moveable socket (upper compartment - as the condyle and disc translate along the articular eminence)
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What is the average amount of opening at the TMJ?
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What type of movement is the first half of opening?
First half is mainly hinging (rotation of the condyle in the fossa)
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What type of movement is the second half of opening?
Second half is mainly forward translation of the condyle along the articular eminence
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What produces rotation and translation movements of the lower jaw?
A combination of muscle action
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What is the role of the geniohyoid and digatric muscles?
Pulls the chin down and backwards
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Where does the posterior belly of digastric muscle originate from?
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Which muscle is responsible for forward translation of the condyles and discs?
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What is the role of the Temporalis muscle?
Backward translation of the condyles (particularly the posterior fibres)
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Which 3 muscles elevate the mandible?
Temporalis, Masseter, Medial Pterygoid
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How much does the lower jaw protrude? Which muscles are responsible for this, and how does it work?
10mm protrusion, Symmetrical forward translation of both condyles, Both lateral pterygoids pull the condyles and discs
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What is lower jaw retrusion, and how does it work?
Return to rest position from protrusion position. Both temporalis muscles (particularly the posterior fibres) pull the condyles
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How much lateral excursion of the lower jaw occurs? What happens on the same, and opposite sides of the moving jaw?
10mm of lateral excursion, Condyle of the opposite side is pulled forward, Condyle on the same side performs minimal rotation around a vertical axis
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Which muscles are acting in lateral excursions of the lower jaw?
Contraction of lateral pterygoid muscles on opposite side. Combined with temporalis muscle on same side contracting to hold the rest position of the condyle
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How are TMDs classified?
Non TMDs, Uncommon TMDs, Common TMDs (acute/chronic)
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When is a common TMD classified as chronic?
If it has been present for more than 3 months
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What are the 3 types of common TMD?
Muscular, Articular, Combination of both
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Give 4 examples of articular TMD problems
Disc displacement, Osteoarthrosis, Subluxation, Adhesions
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Give 3 examples of non TMDs
Dental, Salivary gland, Pharynx
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Give 3 examples of uncommon TMDs
Inflammatory arthritis, Neoplasms, Growth disturbance
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What percentage of all referrals do common TMDs account for?
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What is TMD?
A collective term embracing a number of clinical problems that involve; Masticatory muscles, TMJ and associated structures, or BOTH
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What are common musculoskeletal TMDs? How are they classified?
Problems that involve the masticatory muscles and TMJ(s), Classified based on common signs and symptoms - 1) Masticatory muscle disorders 2) TMJ disorders 3) Headache attributed to TMD 4) Mixed presentation common
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What are the 2 masticatory muscle disorders?
Local myalgia, and Myofascial pain
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What are masticatory muscle disorders associated with?
Painful guarded muscles of mastication, Parafunctional activity
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Give 3 signs and symptoms of masticatory muscle disorders
Pulling/tight aching sensation, Pain with jaw activity, Tenderness on palpation
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What is Myofascial pain? What relieves it?
Hyper-irritable taut band of muscle tissue which on palpation reproduces local and referred pain. There are trigger points present. Inactivation relieves the pain
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What causes trigger points in myofascial pain?
Not well understood. Neuro-chemical changes: - Hyperalgesia due to sensitisation of NS, Elevated levels of pain mediators have been found near trigger points in muscle
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Give 5 examples of muscles which can be responsible for myofascial referral patterns.
Masseter, Temporalis, Lateral pterygoid, Medial pterygoid, Digastric
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Give 4 examples of TMJ arthralgia
Disc displacement (with or without reduction), Osteoarthritis/osis, Hypermobility + subluxation, Adhesions
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What is disc displacement with reduction?
Progression of TMJ hypermobility. TMJ becomes more lax and the ideal disc position is no longer maintained in relation to the condyle throughout the range of motion
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Where is the disc placed in disc displacement with reduction? What happens as the patient opens?
Anteriorly displaced, As the patient opens the disc reduces (goes back into position) - this relates to a click
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What are the signs and symptoms of disc displacement with reduction?
Click with opening/closing, Deviation to ipsilateral sides
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What is disc displacement without reduction?
Progression of disc displacement without reduction, Here the disc no longer relocates
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What are the signs and symptoms of (acute/chronic) disc displacement without reduction?
Acute/subacute 'closed lock' = Limited opening (
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When is osteoarthritis/osis commonly seen?
Common and may be an added source of pain and limited range of motion
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Give 2 signs and symptoms of osteoarthritis/osis - and 3 radiographic signs. Which radiograph is taken in this case?
TMJ crepitus, Tenderness on palpation of TMJ, Radiographic - Joint space narrow/ Osteophytes/ Subchondral sclerosis (increased opacity)/ Subchondral cysts. OPG is used.
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What can TMJ hypermobility result in?
Recurrent condyle subluxation
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Give 3 signs and symptoms of hypermobility and subluxation
Excessive range of motion with opening (>40mm), Click at end of range of opening, Open lock
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What are adhesions? Give 4 possible causes.
Adhesions limit extensibility of the TMJ capsule. Causes - Chronic inflammation, History of trauma/surgery, Immobilisation, Chronic articular disc displacement without reduction
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Give 3 signs and symptoms of adhesions
Limited opening, Ipsilateral deviation with opening, Limited contralateral excursion
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Give 4 signs and symptoms of headache attributed to TMD
Ache in temple area/s, Aggravated with jaw movement + function or parafunction, Pain on movement testing, Pain on palpation of temporalis muscle/s
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Which 5 things do you need to know about a clicking jaw?
On opening/closing, Aggravating/relieving, Timing, Temporary/ persistent, Associated with pain
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Which 9 things are on a history of a TMJ problem?
Presenting complaint, Clicking, Other joint noises, Limitation of opening/trismus, Locking, Altered occlusion, Sensory disturbance, History of trauma, Parafunctional activity
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Give 3 examples of parafunctional activity which can affect TMD
Clenching/grinding, Nail biting, Lip biting
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What do you need to know about limitation of opening/trismus?
Duration, Aggravating/relieving factors, Associated with pain
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What do you need to know about locking jaw in TMD?
On opening/closing? Timing, Temporary/ persistent, Associated with pain
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What is classified as Chronic TMD pain?
TMD that lasts for a considerable period of time, which may lead to a substantial psychological distress and behavioural reactions (not working/restricted social pattern/depression)
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What is chronic TMD also referred to as?
Dysfunctional pain - when there are behavioural reactions
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What are the 3 risk factors for chronic TMD pain?
Predisposing - trauma, Initiating - microtrauma and strain, Perpetuating - psychological and parafunctional
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Which 5 things might you look for on a past medical history, in relation to TMD?
Systemic arthritis, Previous malignancy, Mental health (depression/anxiety), Fibromyalgia, Hypermobility syndrome
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What is fibromyalgia? What is it accompanied/ caused by?
Widespread pain and sensitivity to palpation at multiple anatomically defined tissue sites, Often accompanied by depression and insomnia, It is thought to be due to CNS neurosensory amplification
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Give 13 red flag signs to look for, in TMD cases.
Cancer (metastasis), Pain, Weight loss, Fever Neurological, Swelling, Unilateral headache/tenderness/jaw claudication/visual symptoms, Nasal symptoms, Neck mass, Occlusal change, Decreased hearing, Increasing/limited function
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What may a fever suggest in TMD cases?
Septic arthritis/osteomyelitis/intracranial abscess/tooth abscess/mastoiditis
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What may neurological symptoms/signs suggest in TMD cases?
Tumour/other intracranial pathology
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What type of pain may concern you in TMD? Why?
Abrupt in onset/severe/precipitated by exertion/coughing/sneezing/interrupts sleep - May suggest intracranial pathology or cardiac ischaemia
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What may swelling of the TMJ/mandible/parotid suggest?
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What may facial asymmetry suggest in TMD?
May indicate a tumour
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What may unilateral headache suggest in TMD?
Giant cell arteritis
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What nasal symptoms may occur in TMD? What do these suggest?
Persistent loss of smell (anosmia), Purulent discharge, Nasal blockage, Epistaxis. May suggest a nasopharyngeal tumour
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What may a change in occlusion suggest in TMD?
A tumour/bone growth (acromegaly) around the TMJ / inflammatory arthritis
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What type of hearing loss is a red flag sign in TMD? Why?
On the ipsilateral side - may suggest a nasopharyngeal tumour
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What may increasing pain/limited function despite initial management suggest in TMD?
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Give 4 contributing factors to TMD
Trauma, Systemic condition, Parafunctional activity, Abnormal position
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Which factors can lead to trauma?
3rd molar removal (macrotrauma), Parafunctional activity
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Give 2 examples of systemic conditions which contribute to TMD
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Give 2 factors which can lead to abnormal position in TMD
Over closed, Occlusal interference
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Which 5 things are you observing for in examination for TMD?
Hypertrophy of muscles of mastication, Protrusive jaw, Teeth in contact at rest/when speaking, Lumps and bumps, Forward head posture
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Which cranial nerve should you test in examination for TMD?
Trigeminal nerve exam with cotton wool
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What should you check in terms of vascular factors in TMD?
Superficial temporal artery / temporal arteritis
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What are the 3 possible diagnoses for TMD in terms of lymph nodes?
Infection/ inflammation/ neoplasm
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Give 4 signs of clenching/grinding
Tongue scalloping, Buccal mucosal ridging, Attrition/wear facets, Hypertrophic masseter muscles
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Which 3 factors are involved in occlusal assessment in TMD?
Interfering contacts, Recent changes in occlusal scheme, Skeletal pattern (class II posturing)
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What can musculoskeletal examination in TMD allow you to decide?
Suppor/refute impression, Muscle /joint dominant?, Specific classification
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What is involved in musculoskeletal exam in TMD?
1. Observation / 2. Movement - opening (pattern/range/overpressure/sounds), Lateral excursions, Protrusion / 3. Palpation - TMJ, Muscles (Extra/intra oral)
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Give 6 research diagnostic criteria for TMDs
Opening, Pattern, Range of opening, Overpressure, Sounds, Lateral excursion, Palpation of TMJ, Extraoral muscles, Intraoral muscles
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What is the Bruxoprovocation test?
Ask pt to move mandible in lateral and/or protrusive positions until wear facets correspond, ask to clench and grind until symptoms are noted
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Which 9 things are involved in treating TMD?
Education, Exercises (physio), Splint therapy (MAIN 3),Medication, Occlusal adjustments, Botulinum toxin, Artherocentesis, Surgery, Review
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What is involved in education for TMD treatment?
Information, Principles of treatment, Reassurance
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What are the 5 aims of intervention in TMD treatment?
Reduce pain, Recover function, Improve psychological status, Self-manage, Be safe
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Give 12 examples of things involved in physiotherapy for TMD
Listen and acknowledge, Validate, Reassure+explain, Challenge, Advice, Habit reversal, Postural correction, Jaw relation, Exercises, Manual therapy, Acupuncture, Emphasis on SELF MANAGEMENT to promote sense of CONTROL and improve COPING
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What is persistent TMD associated with?
A complex combination of driving factors, that can coexist to maintain an ongoing cycle of pain and disability
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What are the 4 biological driving factors for TMD, according to the Biopsychosocial framework?
Patho-anatomical, Neuro-physiological, Physical, Comorbidities/genetic
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What are the 4 psychosocial driving factors for TMD, according to the Biopsychosocial framework?
Cognitive, Psychological, Social, Lifestyle
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Why do we do a biopsychosocial assessment for persistent TMD?
Identifies the primary drivers for the patient's disorder, Then you can put in place tailored patient-centred interventions to target those primary drivers
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What does physiotherapy intervention consist of?
A Psychological, and a physical element
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When are psychological interventions chosen for TMD?
For persistent orofacial pain related to TMD - psychosocial factors are more strongly associated with pain intensity, disability and prognosis than biomedical findings
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What is involved in Psychological interventions for TMD? Why are they effective?
Explanation - Crucial for addressing psychological driving factors (reassures and reduces threat of symptoms), Improves compliance with treatment (motivates by providing rationale)
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Give 3 examples of referred pain in TMD
Tooth ache, Headache, Earache
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How can ongoing cycles of TMD pain be maintained?
Homeostatic balance of the coping capacity of the system, and driving factors that load and compromise the system. System loading = perceived threat due to excessive loading = Pain threshold reached (+Homeostasis may return)
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Describe the normal jaw rest position
Teeth not in contact, Minimal amount of muscle activity
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What does excessive tooth contact lead to?
Increased muscle activity, Causes muscle loading/muscle pain and joint loading/pain
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How can a patient reduce stress/strain on the jaw joint and muscles by avoiding an oral habit?
Address emotions related to increased muscle activity, tension and pain. Monitor oral habits and related pain, especially when they occur. This will help to avoid the inappropriate muscle activity, reduce the strain and improve symptoms.
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What are oral habit? Give 6 examples.
Well-established patterns of inappropriate activity - they increase strain on TMJ and muscles. E.g. Tooth contact/clench/grind, Nail biting, Chewing, Pen chew, Lip ****, Habitual protrusion
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How should a patient check the relaxed jaw position?
Teeth apart - say emma so your jaw and mouth drop open. Tongue on roof of mouth - just behind upper front teeth, and make a cluck noise. Regularly check your rest position through the day, especially after eating, working on computer etc
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Which posture should a patient with TMD avoid?
Forward head posture
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What is the ideal posture? What happens in a poor sitting position?
Curve in the lumbar spine. In a poor sitting position, the lumbar spine curve is lost which results in forward head posture, and increase in neck and jaw muscle activity
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What can increased muscle activity in forward head posture lead to?
Muscle loading/pain, and Joint loading/pain
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How can you avoid a forward head posture?
Use lumbar support, Push your bottom to back of chair, Pull your chair in, Position keyboard and mouse within easy reach, Position monitor at eye level, Use document stand, Stand and stretch every 15 minutes
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Give 10 other ways to reduce stress/strain on your jaw
Eat soft diet, Chew slowly, Avoid caffeine, Avoid excessive mouth opening, Keep tip of tongue on roof of mouth when yawning, Do not rest chin in hands, Sleep on back, Bite appliance, Analgesics/NSAIDs, Daily exercise
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What are the 6 aspects of Psychological intervention for TMD?
Reinforce diagnosis, Explain ongoing cycles of pain, Explain driving factors for ongoing pain cycles, Ask patient about problems and goals, Develop a management plan to minimise driving factors
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Which techniques are used in physical intervention to treat TMD? What are the 2 aspects of physical intervention?
Relaxation, exercise, manual techniques - 1. Treat physical disorder, 2. Emphasis on self-management to promote sense of control and improve coping (self efficacy)
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What are the 7 stages of the jaw relaxation technique?
Relax, Close eyes, Teeth apart, Tongue on roof of mouth, Place hand on chest + other on tummy, Slow breathing in and out, Continue for 4 minutes for complete relaxation
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What are the massage techniques for TMD?
Massage and specific finger pressure techniques to facilitate muscle relaxation and reduce pain - followed by muscle stretching
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What is trigger-point inactivation for TMD?
Trigger-point acupuncture - facilitates muscles relaxation and reduces pain, Mechanical disruption provides a therapeutic effect. Follow this with muscle stretching
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How can a patient promote muscle relaxation and help reduce facial pain?
Gentle kneading massage of the masseter muscle. Massage jaw muscles in slow circular motion for 5 minutes using fingers, Gradually increase depth of massage, Perform 3 times daily (after each meal)
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What are the 7 stages of exercise to improve jaw control?
Tongue in clucking position, One index finger on TMJ (check no clicking), Other finger and thumb on chin, Drop lower jaw down and back (and apply gentle pressure to chin towards ear), Slowly close jaw, Look in mirror (straight opening), 10x3 daily
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How can a patient learn to retrude their lower jaw?
Start position with a tube between teeth, Slide lower teeth back along tube, Hold for 5 seconds, Repeat 5 times, 3 times daily
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Describe the passive joint stretch/self-mobilisation for TMD
On the side to be stretched, slide sticks between back teeth to take slack, maintain relaxed open position. Move in upward direction so you feel stretch on jaw on that side. Repeat 10 times every 2 hours
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Describe the active-assisted stretch for TMD
Slowly open as wide as comfortable, Assist opening with index and thumb (scissor action), 3x10 second holds (every 2 hours), Slow movements without pain/undue force
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What is an occlusal splint?
Removable device usually made of acrylic resin, which fits between maxillary and mandibualr teeth
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In which 6 ways do splints work?
Occlusal disengagement, Maxilo-mandibular realignment, Restored vertical dimension, TMJ repositioning, Cognitive awareness, Placebo effect
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What are the 2 types of splint? Give example of each.
Directive (Anterior repositioning splint/ ARPS), Permissive (1. soft bite guard + 2. anterior bite plane/lucia jig + 3. stabilisation splint/michigan/tanner)
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What are anterior repositioning splints, and what are they used for?
Used to direct mandible more anterior to ICP, Provides better condyle-disc relationship to allow time for tissues to adapt/repair
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Give 2 indications for an anterior repositioning splint
Disc derangement disorders (especially disc displacement w/reduction), Useful for intermittent/chronic locking of joint (caused by disc displacement)
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Give 3 advantages of soft splints
Tolerated better, Easily constructed, Cheap
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Give 3 disadvantages of soft splints
Difficult to adjust, Can encourage patient to brux, In some cases muscle pain either does not change/increases
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What is a Lucia jig used for?
Discludes posterior teeth and allows relaxation of muscles of mastication, Patients forget their ICP position (neuromuscular deprogramming)
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What are the 3 uses of Lucia jigs?
Help locate centric relation, Diagnositc tool for patients with TMD symptoms, Quick fix for patients with acute symptoms - prior to constructing a more definitive appliance
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Give 5 examples of stabilisation splints
Michigan splint (upper), Tanner appliance (lower), Interocclusal appliance, Occlusal splint, Ramfjord appliance
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Give 6 features of a stabilisation splint - i.e. material, arch, action. What is created with this kind of splint?
Maxillary splint, Heat-cured acrylic, Full coverage prevents over-eruption, Uniform contact in CR, Canine guidance separates posteriors in eccentric excursions, Anterior guidance separates posteriors teeth in protrusion. Artificial ideal occlusion.
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What are the clinical stages of splint construction?
Visit 1 - alginates, jaw reg in CR, facebow. Visit 2 -fit splint. Subsequent - review and adjust as necessary
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Which type of splint makes fitting much easier?
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What are you looking for when fitting a splint?
Even contacts in RCP, ICP=RCP, Adjust contacts in lateral and protrusive excursions
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When should TMD patients wear a splint?
Every night, During periods of increased muscular activity/stress, Severe symptoms - as often as possible during day also
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Give 6 design features of the Tanner appliance
Mandibular appliance, Heat-cured acrylic resin, Full occlusal coverage, Even contacts with all opposing teeth in RCP, Appropriate anterior guidance, Absence of posterior interferences
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What happens following splint therapy for TMD?
Successful therapy in reducing/eliminating symptoms - consider long term splint wear, Do not assume further intervention will provide the same benefit (occlusal adjustment)
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Which medications can be given for TMD?
Paracetamol, NSAID (ibuprofen), Anxiolytics (TCAs - for muscle relaxation + analgesia), Benzodiazepines
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Why is the Botulinum toxin used to treat TMD?
Alpha motor neuron inhibition - cleavage of SNAP-25 occurs (a presynaptic membrane protein required for fusion of neurotransmitter-containing vesicles)
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How is acute closed lock (TMD) treated?
Arthrocentesis - injection of steroids into upper joint space. Arthroscopy (minimally invasive surgery)
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Give 2 advantages, and 2 disadvantages of arthrocentesis and arthroscopy
Minimally invasive, Diagnostic information BUT Limited scope for reconstructive surgery and requires high level of operator skill
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Give 5 indications for surgery in TMD cases
Condylar hyperplasia, Trauma, Ankylosis, Tumours, Internal derangement and severe chronic pain that is refractory to non-surgical treatment
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Give 2 risks of surgery for TMD
Auriculotemporal nerve / Facial nerve damage (zygomatic and temporal branches)
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Give 2 examples of surgery for TMD
Disc repositioning (plication), Diskectomy (disc removal with/without alloplastic material/temporalis muscle flap)
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Which colleagues may you want to liase with for TMD cases?
Ortho, RD, Rheumatology, Psychiatry, Physiotherapy, Neurosurgery, ENT
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Give 7 examples of uncommon TMDs
Trauma and dislocation, Osteoarthritis, Infective arthritis, Ankylosis and limited opening, Trismus, Dislocation of TMJ, Inflammatory arthritis
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Give 3 examples of trauma to the TMJ
Traumatic arthritic/effusion, Dislocation, Fracture
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What is osteoarthritis?
Also known as degenerative arthritis/degenerative joint disease/osteoarthrosis, group of mechanical abnormalities involving degradation of joints (including articular cartilage and subchondral bone)
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Give 6 clinical features of osteoarthritis
Pain centred on joint, Tender joint, Crepitus, Limited opening, Limited translatory movement, Radiological signs (erosions, spurs)
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What are the phases of osteoarthritis?
Painful inflammatory erosive phase lasting 3 years followed by a period of resolution
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How is osteoarthritis treated?
Symptomatic - splints, BRA, NSAID. Otherwise - arthrocentesis
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What is the nature of infective arthritis? How is it treated?
Rare - may spread to middle cranial fossa so must be treated urgently. IV antibiotics/drainage
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Give 6 clinical features of infective arthritis
Pyrexia, V restricted opening, Suppuration, Erythema, Swelling, Long term ankylosis
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What is the normal amount of mouth opening?
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Give 5 extracapsular causes of ankylosis and limited opening
Trauma - fibrosis (burns/trauma/lacerations), Infection, Tumours (fibrosarcomas), Periarticular fibrosis (radiation/.prolonged immobilization), Inflammation (dental/other)
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Give 5 intracapsular causes of ankylosis and limited opening
Trauma - fracture (forcep delivery at birth), Infection, Systemic arthritis, Tumours, Synovial chrondromatosis (multiple cartilaginous nodules within TMJ = rare!)
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Give 1 other cause of limited opening/ankylosis.
Pseudo-ankylosis = mechanical interference with mouth opening (e.g. zygomatic fracture)
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Which 6 criteria are on the trismus checklist? What happens if any of the answers are yes?
Open less than 15mm, Worsening trismus, Absence of clicking history, Pain of non-myofascial origin, Swollen lymph glands, Suspicious intra-oral soft tissue lesion. Yes = consider radiograph and arrange with senior clinician
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Give 4 ways to treat recurrent TMJ dislocations
Physiotherapy, Botulinum toxin (lateral pterygoid), Fibrosis of tissues, Surgical
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Give 5 examples of inflammatory arthritis
Rheumatoid (juvenile), Psoriatic, SLE, Ankylosing spondylitis, Gout
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How is inflammatory arthritis treated?
With specialist clinic, Symptomatic treatment
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When are TMJ replacements performed?
Where all other treatment modalities have failed
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Viral and fungal infections: 1) Give 4 examples of viral infections of oral importance
Herpes viruses, Coxsackie viruses, Measles, HPV
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Give 5 examples of herpes viruses
Simplex 1 and 2, Varicella zoster, Cytomegalovirus, Epstein Barr, HHV8 Kaposi's sarcoma
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Describe the Herpes Simplex virus. How is it transmitted?
Enveloped, DNA virus, highly cytolytic, infects via heparan sulfate. Transmitted by droplet spread/intimate contact.
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What percentage of individuals have antibodies to herpes simplex? What are the 2 types of HSV associated with?
90-100% have antibodies. Type 1 - skin and oral mucous membranes. Type 2 - genital mucosa
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How does HSV1 infect?
Virus enters trigeminal sensory neurones, Migrates to ganglion by retrograde axonal flow, Latency occurs, 50% of cases lie dormant
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How does reactivation of HSV1 arise?
30% of cases = reactivation. Caused by; UV/stress/illness/immunosuppression. Migrates to peripheral nerve endings where the virus is shed
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Give an example of an oral disease caused by HSV
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Give 7 signs and symptoms of HSV
Children/young adults, Incubation period 5 days, Malaise and fever, Vesicles ulcerate, Secondary infection, Erythematous gingivitis, Extra-oral lesions
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How long do primary gingivostomatitis (PGS) lesions take to heal? Are they symptomatic?
Within 10-14 days, Many are subclinical and so asymptomatic
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How is PGS diagnosed?
Made on clinical features, Patients have rising antibody titre to HSV
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What is the pathogenesis of HSV in PGS?
Virus replicates in epithelial cells and causes cell destruction and degeneration, Results in intra-epithelial vesicles, Ballooning degeneration is seen
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How does Herpes Labialis present? What is the prevalence?
Cold sore, Occurs in 30% of patients
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Give 4 clinical features of Herpes Labialis
Prodromal tingling, Vesicles on the mucocutaneous junction, These ulcerate and crust over, Lasts about 7-10 days
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What is the main difficulty diagnosing Herpes Labialis, and how is it treated?
Main difficulty differentiating erythema multiforme. Treated with acyclovir cream (zovirax), Pencyclovir - effective in the prodromal stage
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What is type 3 herpes virus also called? What is the primary and secondary infection,
Herpes (Varicella) Zoster Virus. Primary = chicken pox, Secondary = shingles.
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Which nerve is affected by the Herpes Zoster virus?
Most commonly affects one of the divisions of the Trigeminal nucleus
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What are the 3 phases of Herpes Zoster?
Pre-herpetic neuralgia, Rash, Post-herpetic neuralgia
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What is pre-herpetic neuralgia?
Pain in affected division, may mimic dental pain
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What are the features of the rash phase of herpes zoster?
Unilateral vesicles - in all 3 trigeminal divisions, Mucosal ulcers, Crusting skin lesions, Lasts 2-3 weeks
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What is post-herpetic neuralgia, and who is affected?
Burning pain, Affects 10 percent of patients, and is more common in the elderly
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How is shingles managed?
Acyclovir 800mg 5 times for 7 days, Analgesics, Opthalmic if eye involved, Post-herpetic neuralgia (treat with TCAs and neuropathic pain drugs)
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Which 4 diseases are caused by EBV (HV4)?
Infectious mononucleosis, Burkitt's lymphoma, Nasopharyngeal carcinoma, Hairy leukoplakia
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How common is infectious mononucleosis? Give 3 features of this disease.
Common (90% of adults have serological evidence), Most of the cases are subclinical, Incubation period of 1-2 months, Prolonged fatigue and malaise (up to 3 months)
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Give 7 signs and symptoms of infectious mononucleosis
Sore throat, Low grade fever, Nausea, Lymphadenopathy, Palatal petechiae, Rash, Possible jaundice
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What is HV5 also called? What is the pathogenesis of this virus?
Cytomegalovirus. Path = inclusion bodies, dormant in lymphocytes (interferes with MHC1 presentation)
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When does HV5 rarely cause problems? What are the rare appearances like in these individuals?
In healthy subjects. Glandular fever-like illness (but no lymphadenopathy), and salivary gland swelling
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How does HV5 present in immunocompromised individuals?
Large ragged oral mucosal ulcers, Salivary gland swelling, Retinitis - fundus
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What is HV5 like in new borns?
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What type of genetic information do Coxsackie A viruses contain?
**-RNA Types A and B. They are Picornaviruses
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What percentage of CSA viral infections are asymptomatic?
90% are asymptomatic
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Which types of Coxsackieviruses cause the most problems?
A4, 5, 10 and 16
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What are Koplik's spots?
White papules on the buccal and palatal mucosa during the prodromal phase of measles
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How many types of HPV exist?
More than 40
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What type of genetic information does HPV contain? Which cells does it infect?
It is a DNA virus - with just 9 genes, Only infects basal keratinocytes of stratified epithelium (via integrins)
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What are the main oral lesions of HPV?
Squamous cell papilloma, Focal epithelial hyperplasia
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Which form of HPV causes focal epithelial hyperplasia? In which patients is it more common? How is it treated?
HPV13. Common in small native communities and HIV infection. Treated with excision, imiquimod 5% cream
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What is the most common candida species?
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Give 4 examples of predisposing factors for candida
Prostheses (no exfoliation), Low saliva, Antibiotics (reduced bacterial competition), Immunosuppression
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How does low saliva predispose candida?
No flow / soluble defences, Low pH is induced by a high sugar diet
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How does Immuno-suppression predispose candida? Give 7 examples of immunosuppression
Reduced cellular defence e.g. Very young/old, HIV, Malignancy, Steroid inhalers, Immunosuppressive therapy, Corticosteroids, Diabetes
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Give 2 pathogenic factors of candida
Hypha - an invasive structure, Proteases - secreted aspartyl proteases
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What are the 2 structural forms of candida? At what pH does each take form? Which cytokines are released in recognition of each form?
Blastospores - pH7 - release of antiinflammatory cytokines.
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How are Candida infections classified?
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Give 2 examples of acute candida infections
Acute pseudomembranous candidosis (thrush), Acute atrophic candidosis (antibiotic sore mouth)
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Give 4 examples of chronic candida infections
Chronic atrophic candidosis (denture stomatitis and angular cheilitis), Chronic hyperplstic candidosis (candidal leukoplakia), Median rhomboid glossitis, Chronic muco-cutaneous candidosis
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What are the signs of acute pseudomembranous candidosis?
Creamy thick white plaques (a thick biofilm of yeast and hyphal forms), Easily rubbed off
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HIV presents as what type of candidosis?
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Give 2 causes of acute atrophic candidosis. How is it treated?
Prolonged corticosteroid/antibiotic therapy, Altered bacterial flora (allows candida to fluorish). Treatment - reduce antibiotic use if possible
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How are candida infections managed?
Confirm diagnosis (swabs/oral rinse +/- genital swab MCS), Investigate + treat cause, Topical/ systemic antifungals
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Give 3 examples of topical antifungals, and 2 systemic antifungals to treat candida infections
Topical - Miconazole oral gel/Nystatin suspension/Amphotericin B lozenges. Systemic - Fluconazole/Itraconazole
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How does Denture Related Candidosis occur?
The palate is protected from saliva, Along with poor denture hygiene.
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How is denture related candidosis treated?
Improve denture hygiene - leave out at night, clean denture and soak in Milton's/Corsodyl. Antifungals - Nystatin +/- Miconazole gel to fitting surfaces TDS, for 2-3 weeks.
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How does Median Rhomboid Glossitis present? What is seen histologically? Is it premalignant? How is it diagnosed?
Erythematous area on the dorsum of the tongue, Epithelial proliferation with candida in the epithelium, It is NOT premalignant, and is usually diagnosed on clinical grounds (but a swab can be taken)
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What are the signs of angular cheilitis? Give 3 causes.
Reduced vertical dimension and drooling of saliva. Causes - Iron/B12/folate deficiency, Crohn's disease, Some associated with Staph Aureus
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How is angular cheilitis treated?
Address the underlying cause, Miconazole cream/fusidic acid, depending on the cause
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How is Chronic Hyperplastic candidosis recognised clinically? Is it premalignant? How is it diagnosed?
White, sometimes red/white patch, nodular + cannot be rubbed off, Commissures seen on dorsum of tongue. Premalignant (up to 25% risk of malignant change), Diagnosed by biopsy
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What is the aetiology of chronic hyperplastic candidosis? What is seen histologically?
Not clear is candida is the cause of the lesion, or if it invaded a pre-existing lesion. Some lesions regress following antifungal therapy. Histology - hyperplastic epithelium, candida at right angles to the surface
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How is Chronic Hyperplastic Candidosis diagnosed? Treated?
Diagnosis - biopsy will establish a degree of dysplasia and risk of malignant transformation. Treatment - systemic antifungals, smoking cessation. If no improvement, and high risk of malignant transformation then excise.
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What course of systemic antifungals are given for CHC?
7-14 days fluconazole OR amphotericin B
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Complications of third molars. 1 - What are the 11 minor complications of third molar extraction?
Pain, swelling, trismus, infection, fracture, bleeding and bruising, TMJ problems, Temporary nerve damage, Perio problems, Damage to other teeth, Oral-antral communication
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When can pain occur, and what should you advise?
Guaranteed after surgical removal of lower 3rd molars (can be severe), Pre-op (warn patient and advise on analgesics)
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When can swelling and trismus occur, and what should you advise?
Guaranteed after surgical removal of lower 3rd molars, and Pre-op (warn patient, provide advice on how to minimise - NSAIDs)
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Why is infection difficult to assess?
Diagnosis is not always straightforward
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Are antibiotics used to treat infection?
There is no good evidence for routine use of antibiotics, but they do have a role e.g. cases of co-morbidity
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Give 3 ways adjacent teeth can be damaged in 3rd molar extractions
Mobilisation of second molars, Damage to restorations, Fracture of adjacent teeth
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What should you do pre-op with regards to damage to adjacent teeth?
Assess clinically and radiographically, Warn patient, Have plan in place to minimise risk and deal with complication
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When can the mandible fracture? 5 situations.
Elderly, edentulous patients with atrophic mandible, pre-existing bone pathology, large bone defects, excessive use of force (cryers + large elevators)
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What is the major complication of third molar extraction?
Trigeminal nerve damage
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How can trigeminal nerve damage occur?
Removal of third molars, implantology, trauma, soft tissue surgery
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What is the incidence of temporary and permanent IAN damage?
Temp = 5-7%, Permanent = 0.5-1%
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What is the incidence of temporary and permanent lingual nerve damage?
Temp = 3-7%, Permanent = 0.3-0.5%
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How many lingual nerve injuries occur in a year?
Minimum 300 (possibly 600)
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What are the 6 causes of nerve damage?
Third molar (majority), Implantology, Other surgery (orthognathic), Trauma, Needle stick (neuropraxia), Endodontics
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Which nerves can be damaged?
Lingual nerve, Mylohyoid nerve, Long buccal nerve, Inferior alveolar
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What do patients with nerve injuries complain of?
Pain + unpleasant burning/tingling, Dribbling, Bite their lip, Avoid eating in public, Don't enjoy kissing, Bite tongue, Loose food under tongue, Don't enjoy food
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What are the effects of trigeminal nerve damage?
Pain, Dysaesthesia, Cluster attacks, Pain in one side/both sides of face, Focused/wider spread pain, Tingling/numbness
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How is lingual nerve injury managed surgically?
Lingual flap raised and lingual periosteum divided, Central and distal nerve stumps identified and mobilised, Damaged segment excised, Direct reapposition with sutures
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What is the mean length of the lingual nerve segment removed in surgery?
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What is the mean number of sutures used to reappose the lingual nerve? Which sutures are used?
7 - Ethilon epineurial sutures
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What are patients given post lingual nerve surgery?
Dexamethasone and antibiotics
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How are outcomes of lingual nerve surgery measured?
Light touch, Pin *****, Two point discrimination, Gustatory response, Altered sensation (dysaesthesia), Subjective assessment
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Is lingual nerve repair effective?
Majority of pts regain some sensation, Fewer tend to bite tongue, Improvement shown in using - light touch/pin *****/gustatory/two point discrimination, BUT it will never return to normal
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How is division of lingual nerve noted at operation managed?
Immediate microsurgical repair or urgent referral
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After review of lower third molar removal, how are stimulus-evoked paraesthesia and anaesthesia managed?
Inform patient, Monitor recovery - light touch/pin *****/2-point discrimination
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What would you do if, after 3 months of monitoring lingual nerve damage patients, there is no evidence of recovery?
Consider referral to a specialist centre for exploration/repair
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Give 3 reasons IAN injury may occur
Due to proximity of lower third molars, Implant placement, Trauma
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Is IAN injury managed immediately?
The nerve is usually well supported in mandibular canal, Even after transection the ends do not usually retract, Primary repair not normally required, Just control bleeding with temp packing with gauze
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Which 4 things should you avoid when managing IAN injury?
Diathermy, Whitehead's varnish and other medicaments, Surgicel, Bone wax
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The mental foramen is a high risk area in implantology. How can you avoid nerve injury?
Go 4mm anterior to the mental foramen to ensure avoidance of the anterior loop. Consider surgical exposure.
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What are the intraoperative factors suggesting damage in implant surgery?
Sudden give, Electric shock, Arterial bleed (large percentage of injuries are secondary to haematoma), May be sensible to wait 2 days and then place implant (avoid compression ischaemia)
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How should nerve damage patients in implantology be managed post-op?
Neural recovery occurs (inversely proportional to time), Ideally remove the implant within 24-36 hours, Postop call (the same/following day), Short term remove implant, Inform pt, Radiograph to localise lesion, Evaluate (time/proximity/neurosensory)
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What are the 2 indications for surgical intervention post implants?
Persistent anaesthesia, Dysaesthesia/pain
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What can be done for IAN decompression/neurolysis? 4 things removed
Cannot excise complete segment, Can remove bony obstruction/ bony compression/ soft tissue tethering or tension/ neuroma (to reduce dysaesthesia)
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What is the incidence of needle-stick injury following nerve block?
1 in 20,000 and 1 in 850,000
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What should you consider with multiple injections to avoid direct trauma from LA?
Face the bevel laterally
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Which LA is best to use to avoid nerve inuries with IAN blocks?
Lidocaine - avoid articaine (high risk for permanent dysaesthesia)
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Why does nerve damage arise in endo treatment?
Sodium hypochlorite irrigation?
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Give 3 ways to minimise nerve damage, and explain why.
IAN injuries usually drill injuries, Some are crush injuries (following forceps extraction), Low threshold for sectioning, Avoid forceps, Elevator removal preferable, Avoid lingual flaps
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Why should you avoid lingual retraction?
The evidence says - there is either no difference / increase in crush injuries and drill injuries when lingual retraction is used.
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What are the 7 aspects of a radiographic assessment for nerve damage?
Type of impaction, Depth of tooth within bone, Crown form, Root form and number, Coronal or root pathology, Other pathology (cyst/caries in 2nd molar), Relationship with mandibular canal (IAN) or maxillary sinus
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What is the ABCDE assessment of the IAN?
A = radiolucency, B = deviation/constriction, C = loss of cortication, D = deviation of roots, E = narrowing of roots
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Is CT used to assess IAN?
Not routinely, but it may be appropriate in high risk cases, e.g. CBCT can be used
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Is coronectomy performed instead of lower third molar XLA?
It is controversial, there are pros and cons, it puts pts at lower risk of nerve damage BUT there is a medico-legal issue (it should be discussed with pt if at high risk of IAN damage i.e. pt choice)
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Management of third molars. 1 - When do third molars erupt? What can happen?
18-23 (last to erupt), they are often absent or fail to erupt into normal occlusion
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What is an impacted tooth?
One which is prevented from reaching normal position by the presence of other structure - usually adjacent tooth (but may include ascending ramus or overlying tissues)
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According to Kramer and Williams (1970) - The incidence of impacted teeth - a survey at Harlem hospital - What percentage had impacted teeth? What percentage with 3rd molars? Were more upper/lower?
18% impacted teeth, 94% were 3rd molars, More upper than lower
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According to Oksala (1972) - An orthopantomographic study of prevalence of impacted teeth - what percentage of patients had impacted teeth? What percentage were 3rd molars? Were there more upper/lower?
14% impacted teeth, 70% were 3rd molars, Same number of uppers as lowers
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What are the 3 non-erupted states of 3rd molars?
Un-erupted fully enclosed within bone, Un-erupted partially enclosed within bone, Partially erupted
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Give 9 problems associated with 3rd molars
Abnormal position (cheek biting), Caries + pulp+PA pathology in 2nd and 3rd molars, Perio problems, Pericoronitis, Resorption (internal and external for 7s), Cyst formation, OH difficulty, Crowding of lower incisors, In way of orthognathic surgery
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Which patients are at risk in the future due to problems with 3rd molars?
Vulnerable and medically compromised patients
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What is pericoronitis?
Inflammation in the soft tissues around the crown of a partially erupted tooth, caused by bacterial infection and/or trauma, which is the most commonly cited reason for extraction of 8s
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What are the 7 symptoms of pericoronitis?
Pain/discomfort, Soft tissue swelling, Difficult eating/swallowing/opening, Tenderness on closing, Unpleasant taste/smell, May feel unwell with pyrexia, Recurring problem?
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Give 6 signs of pericoronitis
Inflammation in soft tissues around crown of partially erupted tooth, Localised intra-oral swelling, Evidence of trauma from opposing tooth, Pus, Local lymphadenopathy, Facial swelling
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What are the 6 local measures to manage pericoronitis?
Irrigate with saline/chlorhexidine, Remove upper 8 (traumatic occlusion), Advise HSMW/chlorhexidine and analgesics, Antibiotics if spreading/compromised pt (metronidazole 200mg tds), Drain pus, Formal review
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What should you do at review when managing pericoronitis?
Assess outcome of treatment and manage, Assess 3rd molar (1. Likely to erupt and be functional = monitor, 2. Unlikely to erupt = consider removal if not then leave and monitor, 3. Persistent/recurrent or severe problems = removal)
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What are the 3 clinical guidelines on 3rd molar management?
Royal college of surgeons of England 1997, National Institute for Clinical Excellence 2000/3, American Association of Oral and Maxillofacial Surgery (2007) (recommends removal at young age)
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What is the NICE guidance on removal of wisdom teeth?
Routine practice of prophylactic removal of pathology-free impacted third molars should be discontinued in the NHS, Removal is limited to patients with evidence of pathology
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What are the 4 additional points of guidance from NICE on removal of third molars?
Surgical removal of impacted 3rd molars should be limited to pts with evidence of pathology, Plaque formation is a risk factor but is not in itself an indication for surgery, Adherence to guidelines audited, History and justification documented
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Maxillary Antrum 1 - What is the anatomy of the maxillary antrum?
Pyramidal shape, apex facing laterally
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What is the roof of the antrum?
The orbital floor (brittle and thin), Infraorbital nerve bundle suspends underneath it
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What is the medial wall of the antrum?
Lateral wall of nose, Contains ostium (drainage channel), It contains bone but is cartilaginous in places (soft)
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What is the floor of the antrum? Where is it thinnest? Where is it in children and adults?
The alveolar process of the maxilla, and hard palate. Thinnest near the tooth bearing the alveolus. In children it is adjacent to the nasal floor - in adults it is 5-10mm lower. Lies close to the apices of the teeth.
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What is the anterior wall of the antrum? What does it contain? What is the thinnest part? What is this wall used for?
The cheek area, also forms the lateral wall with the lateral maxilla (should be called the antero-lateral wall. It contains the canine fossa. Thinnest part
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How does the antrum drain?
Drains into nose via ostium (1/2 way up medial wall), Not dependent on gravity. Efficient cilia beat towards the ostium.
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What are the 4 functions of the maxillary antrum?
Respiration (warm/humidify), Speech, Weight, Crumple zone (design/accident)
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Where can oro-antral communication occur?
The floor can extend from molar region to canine, where the root apices are closely assocaited with it. The most common place is the palatal root of the first molar.
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What are the pre-operative stages to assess OAC?
Avoidance, Age, Ankylosis, Root fractures/RCT, Warn pt of possibility
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Give 6 diagnostic features of OAC.
May be unnoticed, not by forced expiration, Not by probing/poking, Gentle observation, Suspicion, Radiograph
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What is the conservative management of OAC?
Many are undetected - heal spontaneously, Instructions (no blowing/ OHI), Antibiotics (broad spec penicillin), Splints, Decongestants
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What is the active treatment for OAC?
Suturing (resorbable/non-resorbable), Packing (resorbable oxidised cellulose / non-resorbable - fistula e.g. BIPP or ribbon gauze), Antibiotics, Decongetants
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Give 2 examples of non-resorbable packing for OAC.
Bismuth Iodoform Paraffin Pste (BIPP), Ribbon Gauze
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What is an oro-antral fistula?
An abnormal connection or passageway between 2 epithelium lined organs or vessels that normally do not connect. An OAF may form as an OAC heals.
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What are the symptoms of an OAF?
Purulent discharge, Bad taste, Liquid discharge through the nose, Air escape, Episodic sinusitis, Communication, Radiographic
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How is air escape assessed to diagnose an OAF?
Air escapes in both directions (using the Valsalva manoeuvre), However, you can have a false negative result due to infection/debris.
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What lines a fistula?
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Why would a buccal advancement flap be used to surgically close an OAF?
Good success rate, Low morbidity, Good blood supply
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Give a disadvantage of buccal advancement flap surgery
Decrease in vestibular sulcus depth - prosthetic implications
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What are the stages of buccal flap advancement?
Raise 3 sided buccal flap, Remove bone at OAF, Periosteal release, Suture over flap to palatal side and suture over base of bone, Put collagen membrane under flap, Treat as per conservative regimen post-op, Non-resorb sutures?
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Give another surgical option for OAF What are the important factors in this surgery? When is it used?
Palatal rotation flap. Relies on greater palatine artery. Length/width ratio important (>2.5=flap necrosis), Painful donor site, Seldom used (for larger OAFs)
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How does the donor site heal in palatal rotational flap?
Leave to heal by secondary intention
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What is the post op care for palatal rotational surgery?
Analgesics, Amoxicillin 250mg tds 5 days, Ephedrine hydrochloride 0.5%, Good OH (corsodyl), No nose blowing 4 weeks, No singing
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How is ephedrine hydrochloride taken?
0.5% 1-2 drops into left nostril up to 4 times/day for 7 days
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What is the incidence of displaced foreign objects in the antrum?
Upper 6 palatal root, more than 3rd molar (whole tooth), which occurs more than 2nd molar root
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How can you avoid displaced foreign objects?
Awarenes (radiograph - Age, RCT, ankyloses, proximity), Avoid apical pressure, Controlled force
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What are the 3 options for displaced foreign objects?
Retrieve, Delay, Refer
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How can you retrieve displaced foreign objects? Where can they be?
Light, Suction, Irrigation and gentle suction, Radiograph, Failure (refer). It can be between mucosa and alveolar bone / between intact sinus lining and floor of sinus
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What should you do if you decide to delay treating displaced foreign objects?
Document (size/position), Radiograph, Suture socket, Antibiotics, Refer, Inform pt
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Give 5 reasons for removing a dispalced foreign object
Sinusitis, Antral polyps, Embarrassment, Infection, Sinus pathology
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How are displaced foreign objects removed?
Transalveolar - only suitable for low down and early repairs, Caldwell (Luc/GA technique), Endoscopic, Workup, 2 radiographs or better (CT preferable), Consider supine lateral Ceph radiograph
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What is the transalveolar approach?
Surgical approach - Extending socket opening, Remove buccal bone, Enter sinus floor, Buccal flap to close, May have prosthetic implications
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What is the Caldwell-Luc surgical approach? When is it used?
Trapdoor approach, Good access, Preserves alveolar bone, Risl of injury to adjacent teeth, Method of choice for delayed procedures
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What is the post op management of removal of displaced foreign objects?
Similar to conservative regiment. Decongestants, Antibiotics, Avoidance of nose blowing, OH
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What is the cause of chronic sinusitis? What are the symptoms?
Bacterial/viral cause. Can mimic toothache, Nasal discharge, Pressure, Pain when bedning over/lying down
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How is chronic sinusitis treated?
Bacterial - antibiotics/decongestants. Chronic - antral wash out/nasal surgery
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Where can fractured maxillary tuberosity occur? Why is it a concern?
Most distal aspect of maxilla, Contains socket of third molar, Concern - Large OAC/stability issue later for prosthetics, Associated with upper molar extractions (usually 7 and 8)
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Which 7 factors increase the chances of fractured maxillary tuberosity?
Large sinus, Thin walls, Lone standing tooth, Age, Divergent roots, 8>7>6, Hypercementosis
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How can fractured tuberosity be avoided?
Assessment, Surgical removal, Elevators
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Howare fractures immediately treated?
Infection/surgical expertise - raise flap, surgical removal or advancement flap
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What is the delayed treatment for fractures?
Splint 4 weeks - composite/****-down, Allow bone to heal, Surgical removal
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Management of Third Molars (Part 2) - 1. What are the 3 pieces of advice from NICE in relation to Pericoronitis?
Degree to which severity /recurrent rate of pericotonitis should influence decision for surgical removal is unclear, First episode = no surgery, Second/subsequent episodes = considered for surgery
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What is the rationale for not surgically removing wisdom teeth?
Potential annual saving = £5,000,000 if prophylactic removal discontinued, Numbers of patients on WL might reduce if these criteria are applied, Not ethical to expose pts to unnecessary procedures
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Give 4 justifications for prophylactic removal of third molars.
Prevent crowding, Reduce complications in older individuals, Better able to cope when young, If a GA then do all at once
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What does the 2002 (edited in 2008) Cochrane Review say about removal of third molars?
No difference in clinical effectiveness / cost-effectiveness, No clear evidence to support or refute the benefits of prophylactic third molar removal other than prevention of later lower incisor crowding
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How many third molars were surgically removed 2014-2015?
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With current guideline, would you be deemed negligent for wisdom tooth prophylactic removal with subsequent nerve damage?
Yes this would be negligent
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What are the 8 things to look for radiographically when assessing third molar for removal?
Diagnosis, Type of impaction, Depth of tooth within bone, Crown form, Root form and number, Coronal or root pathology, Other pathology (cyst, caries in 2nd molar), Relationship with mandibular canal
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What is the significance of Vertical impaction?
Easiest to extract, risk of pericoronitis
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What is the significance of mesio-angular impaction?
More difficult, risk of food packing and caries in 2nd molar
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What is the significance of horizontal impaction?
Even more difficult, risk of food packing and caries in 2nd molar
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What is the significance of disto-angular impaction?
Very difficult, risk of pericoronitis
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How can you assess the depth of impaction within bone?
Compare level of ACJ at the mesial aspect of 3rd molar with the distal aspect of 2nd molar - unless 3rd molar is distally inclined in which case the distal aspect of third molar ACJ compared with 2nd molar
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Which questions are asked after diagnosis is reached?
Does pt need immediate care? e.g. a dressing to treat acute pulpitis. Should extraction be considered? What are the risks and benefits of various treatment options? Consent gained?
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Give 4 treatment options for third molars
Removal, Observation, Operculectomy, Coronectomy
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What are the 4 management options for third molars?
LA, LA + sedation, GA (day case), GA (in-patient)
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What is the Coronectomy Technique?
Raise buccal flap, Cut at 45 degrees to crown - passing completely through (minimise risk of mobilising roots) - dangerous, Use fissure bur to reduce root to 3mm below alveolar crest, Periosteal release and primary closure
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How are patients selected for coronectomy?
Close proximity to IAN, No evidence of active infection/tooth mobility, Avoid horizontal/severe mesioangular - increased risk of IAN damage during sectioning
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When is coronectomy used? Is it successful? When is it not indicated?
Used with high risk cases, Valid for reducing risk of IAN damage, Must be warned of potential for second procedure, Mobility of roots is a factor for success, Not indicated for co-morbidity pts (chemotherapy/diabetes/immunosupressed/bisphosphonates)
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Spread of oral bacterial infection. Part 2 - 1) What is the neck surrounded by?
Multiple layers of fascia, of which the deep cervical fascia is the most important. They continue superiorly and split around various structures to form tissue spaces
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What are fascial planes and tissue spaces for?
They are an anatomical framework for understanding how infection can spread
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What are the 3 separate parts to the deep cervical fascia?
Investing layer, Visceral layer, Prevertebral fascia
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What does the spread of infection from a mandibular tooth depend on?
The relation of the tooth to the insertion of 2 muscles - buccinator and mylohyoid
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Where do the buccinator and mylohyoid muscles attach to?
Buccinator attaches to the lateral (buccal) cortex of the mandible, adjacent to the molar teeth. Mylohyoid attaches to the mylohyoid ridge, which is on the medial (lingual) cortex.
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Where do abscesses point if they track above or below the buccinator muscle?
Abscesses that track laterally ABOVE buccinator point in the mouth, Those below buccinator point onto the fasciao skin/
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Where do abscess point if they track above or below the mylohyoid muscle?
Those that track medially above mylohyoid point in the sublingual space, THose below mylohyoid point into the submandibular space.
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Where else can infection from lower 2nd and 3rd molars also track?
Posteriorly into either the masticator space or the parapharyngeal spaces
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Why is spread into the parapharyngeal and/or retropharyngeal spaces dangerous?
Due to possible airway compromise and tracking of pus into the chest via the retropharyngeal space
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Where do abscesses track in the maxilla? Where do they point?
Most track bucally, as the bone is thinnest here, to point in the mouth - abscesses arising from upper laterals and palatal roots of 6's can point palatally
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Where can infection from an upper canine tooth present, and why?
Because the apex of the upper canine can be situated above the origin of the muscles of facial expression, infection can present at the medial canthus of the eye, deep to the levator labii superioris muscle
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What is the origin of deep neck space infection?
Rare, but most are dental in origin, typically from mandibular 2nd/3rd molars as their apices are often below the mylohyoid muscle.
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What are the 5 presenting features of deep neck space infection?
Fever, Pain, Sore throat, Difficult or painful swallowing (dysphagia, odynophagia), Trimus
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What imaging is required for deep neck space infection?
Need imaging with MRI or CT to establish extent
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How is deep neck space infection managed?
Same principals of management of intra-oral abscesses apply - general and local measures. Airway management, IV antibiotics, Surgical drainage
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What are the complications of orofacial infection?
Airyway: Obstruction due to oedema/swelling, aspiration (food/saliva). Vascular: venous thrombosis (IJV, cavernous sinus), carotid blowout. Osteomyelitis. Mediastinitis.
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When does orofacial infection need antibiotic support?
Swelling, fever, malaise
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Give 5 situations when antibiotics are indicated for abscesses
Systemic symptoms, Spreading infections, Chronic infection despite drainage (actinomycosis), Immuno or medically compromised pt, Conditions difficult to resolve without or that speed up recovery (ANUG/osteomyelitis/sialadenitis)
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How must antimicrobials be used?
Must be aimed at the organisms present, Dose must achieve 4-8 times MIC in blood (keep up to date with BNF), Must be present long enough to penetrate adequately to the site (but not too long)
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What are broad spectrum agents associated with?
Rise in C.Difficile disease, take care when prescribing to elderly and GI disease (including proton pump inhibitors and reflux disease)
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What is the empirical use of antimicrobials?
Main drugs = amoxicillin, pen V, metronidazole and erythromycin (clindamycin + co-amoxiclav + clarithromycin have no advantage)
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What are antimicrobials not prescribed?
Pulpitis, Prevention of dry socket (in difficult extractions in immunocompromised)
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Give 4 reasons why antibiotics fail
Agent does not reach the site, Imapried defences, Inappropriate agent (resistance - inherent/acquired due to mutation/plasmids), Poor pt compliance
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Why might an agent not reach the site of infection?
Inadequate drainage, Poor blood supply, Presence of a foreign body, Inadequate duration
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Other cards in this set
What should you do with abscesses?
All of them should be drained
How can abscess formation be determined clincally?
If there is no fluctulance present clincally (where you suspect an abscess), what is the diagnosis?
How are dentoalveolar abscesses usually diagnosed?