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Mr. Gary LeonardBDent Sc, FFD RCSI (OSOM), MDent Ch (OS), FFD RCSI (OS)
Specialist Oral Surgeon
58 Northumberland Rd. Ballsbridge, D4 Bon Secours Hospital, Glasnevin,
8 Kingsfurze Terrace, Dublin Rd, Naas, Co. KildareClane General Hospital
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Successful Oral Surgery in everyday practice:
Mr. Gary LeonardBDent Sc, FFD RCSI (OSOM), MDent Ch (OS), FFD RCSI (OS)
Specialist Oral Surgeon
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Treatment
Need
In House
Referral
History
Examination
Special tests
Informed consentCapable performance Duty of care
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Infective Endocarditis (IE) – Antibiotic Prophylaxis
• Journal of the Irish Dental Association– Vol. 54 (6): Dec 2008• Different recommendations:
– British Society for Antimicrobial Chemotherapy (BSAC) 2006– American Heart Association (AHA) 2007– National Institute for Clinical Excellence (NICE) 2008
• NICE guidelines:– No antibiotic cover for patients previously classified as at risk– Lack of efficacy of antibiotic – Risk of anaphylaxis (15-25 patients per million)– Patient care and professional indemnity issues– No Chief Dental Officer in Ireland– Only adopted by the UK and Austria
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Dublin Dental School & Hospital Position Statement
Patients with ‘at risk’ cardiac undergoing certain dental procedures should be covered with antimicrobial prophylaxis with:– 3 grams of oral penicillin or – 600mg of oral clindamycin (if allergy to penicillin exists)– Chlorhexidine mouthwash five minutes before the start of the
procedure– IV regimes for procedures under general anaesthesia
At risk patients:– Prosthetic cardiac valve– Previous infective endocarditis– Cardiac transplant patients who develop cardiac valvulopathy– Certain unrepaired congenital heart diseases or repaired conditions
within the first 6 months
At risk procedures– All dental procedures involving the manipulation of gingival tissues or
the periapical region of teeth or perforation of the oral mucosa.
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Spontaneous bone exposure – lingual cortex 5 years of FosamaxMarx et al., 2007
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Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ)
• Journal of the Irish Dental Association– Vol. 52 (2): Autumn 2006– Oral bisphosphonates are used in the treatment of osteoporosis; they
stop bone loss and preserve bone density by inhibiting osteoclastic resorption of bone (Fosamax, Actonel, Bonviva, Bonefos)
– Intravenous bisphosphonates are used in oncology to prevent the spread and growth of metastatic osteolytic lesions associated with certain tumours eg breast cancer, prostate cancer and multiple myeloma (Zometa, Aredia)
• Patients may be considered to have BRONJ if:– Current or previous treatment with bisphosphonates– Exposed necrotic bone that has persisted for more than 8 weeks– No history of radiation therapy to the jaws
• American Association of Oral & Maxillofacial Surgeons Position Paper on BRONJ – J Oral Maxillofac Surg 65: 369-376, 2007
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Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ)
• Incidence of BRONJ:– IV bisphosphonates
• 0.8% to 12%.– Oral bisphosphonates
• 7 per million according to manufacturer Merck (Fosamax)• Up to 0.34 % after extractions (Australia)
• Risk factors:– Duration of therapy– Other medications eg steroids, chemotherapeutic drugs– Systemic conditions eg diabetes– Local anatomy eg mandible vs maxilla, tori, myelohyoid ridge– Extent of surgery
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Alveolar bone exposure resulting form tooth extractions after 5 years of FosamaxMarx et al., 2007
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Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ)
• Management strategy for patients taking IV bisphosphonates:– Comprehensive oral assessment prior to drug initiation– Regular dental check-ups & preventive care (denture trauma lingual
flange region)– Non surgical endodontic treatment of teeth that otherwise would be
extracted (American Assoc. Of Endodontists Position Statement 2006)
• Management strategy for patients taking oral bisphosphonates:– Prevention– No alteration* or delay in planned surgery is necessary for individuals
medicated for less than 3 years.– ‘Drug holiday of 3 months’ prior to surgery for individuals medicated
for more than three years or less than three years if taking steroids concomitantly.
– Communicate with GMP if advocating ‘drug holiday’ – Risk of hip fracture in osteoporosis is 1:6.
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Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ)
*Alterations in surgery for patients taking oral bisphosphonates Journal of the Irish Dental Association– Vol. 54 (4): August/September 2008
• The vast majority of these patients can be treated in the general dental surgery
• Written informed consent• Loading dose of Amoxicillin 3g orally preoperatively and 500mg tds for five
days• Use a block injection or use local anaesthetic agents without a
vasoconstrictor for infiltrations• Atraumatic surgery with minimum disruption of periosteum and sutures not
too tight• Written post-operative instructions (Chlorhexidine & HSMW)• Follow up to ensure adequate recovery• Soft blow down splints may be of some use to prevent food collection in
socket
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Sequestrectrectomy after 6 month drug holiday (CTX 299 pg/ml)Marx et al., 2007
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Staging and treatment strategies (BRONJ)
Stage 1: Non infected and asymptomatic exposed necrotic bone
• Chlorhexidine mouthrinse• Quarterly follow-up• Review of indications for continued bisphosphonate therapy
– Discontinuation of IV bisphosphonates has no short-term benefit– Discontinuation of oral bisphosphonate therapy for 6-12 months may
result in gradual improvement with either spontaneous sequestration or resolution following debridement surgery.
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Staging and treatment strategies (BRONJ)
Stage 2: Infected and symptomatic exposed/necrotic bone • Antibiotic therapy – Amoxicillin, Metronidazole, Clindamycin,
Lymecycline (Tetralysal 300mg po bd)• Analgesia• Chlorhexidine mouthrinse• Limited superficial debridement only to relieve soft tissue
irritation
Stage 3: With extraoral fistula, osteolysis extending to inferior border
or pathologic fracture• As in stage 2 with extraction of symptomatic teeth in
necrotic bone and surgical debridement/resection• Hyperbaric oxygen (HBO2) not as effective as in
osteoradionecrosis– Freiberger et al., J Oral Maxillofacial Surgery 65: 1321-1327, 2007
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Healing of bone exposure without surgery after a 6 month drug holiday
Spontaneous bone exposure after 5 years of Fosamax
After 6 month drug holiday
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The anti-coagulated patient:
• Why is the patient anti-coagulated?– Deep vein thrombosis (DVT)– Embolization secondary to myocardial infarction– Atrial fibrillation– Renal dialysis– Heart valve replacements– Cerebral thrombosis– Ischaemic heart disease– Peripheral vascular disease
• What drug interactions are likely with Warfarin?– Metronidazole, Erythromycin, aspirin and some antifungals increase the
risk of bleeding– Carbamazepine (Tegretol) can decrease the effectiveness of Warfarin
Warfarin AspirinAnti-
platelet drugs
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• How can I perform surgery safely?Warfarin– Enquire after INR history and obtain new reading 24 hours before
procedure– Warfarin must not be stopped unless under special medical supervision– Simple extraction of 2-3 teeth possible if INR less than 3.5– Regional blocks should be avoided– Atraumatic surgery – Haemostatic material (Surgicel, collagen) & suturing of sockets– Tranexamic acid mouthrinse 5% solution (antifibrinolytic)– Further bleeding – consult haematologist (FFP, Vitamin K, Tranexamic
acid)
Aspirin– 100mg or less – no action required– >100mg and bleeding time >20 mins or aspirin and another anti-
platelet drug – stop aspirin in consultation with physician
Other anti-platelet drugs– Clopidogrel (Plavix), Dipyridamole (Asasantin)
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Treatment
Need
History
Examination
Special tests
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Radiographic markers of proximity to IAN: Howe & Poynton (1960)
1) Loss of tramlines 2) Narrowing of tramlines3) Alteration in direction of IA canal4) Radiolucent band across root
Risk of damage up to 35% when all four markers present
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Pre-operative imaging: IAN and second molar
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Pre-operative imaging: IAN and second molar
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Pre-operative imaging – mental nerve
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Pneumatised antrum with displaced root and OAC:
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Oro-antral communication R side with sinus opacity:
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Canine teeth- Age- Root curvature
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Horizontal Parallax2x PA’s
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Vertical Parallax- OPG - Upper Ant Occlusal
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Treatment
Need
In House
History
Examination
Special tests
Informed consentCapable performance Duty of care
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Informed consent:
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Informed consent: Risk of IAN damage
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Risk of permanent IAN Damage post removal of 3rd Molars
0.04% 0.9%
0.3%
0.4%
Robert & Pogrel, JOMS 2005
Valmaseda-Castellon, Triple O 2001
Rood, BDJ 1983
Carmichael & McGowan, BJOMS 1982
0.5%
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Risk of permanent Lingual nerve damage post removal of 3rd Molars
0% 0.8%
0.3%
Walters, BDJ 1995
Robinson & Smith, BDJ 1983Without lingual nerve protection
Robinson & Smith, BDJ 1996With lingual nerve protection
0.5%
Pogrel & Goldman, JOMS 2004
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Coronectomy:
Coronectomy: A Technique to protect the inferior Alveolar Nerve.
Pogrel et al., JOMS 62: 1447-1452, 2004
Coronectomy (intentional partial odontectomy of lower third molars)
O’Riordan, Oral Surg Oral Med Oral Pathol 2004:98:274-80
A randomised controlled clinical trial to compare the incidence of injury
to the IAN as a result of coronectomy and removal of third molars
Renton et al., BJOMS (2005) 43, 7-12.
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Pogrel et al., JOMS 62: 1447-1452, 2004
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Coronectomy:
Contraindications:• Active infection• Mobility• Horizontally impaction
Outcome:• Permanent IAN paraesthesia (0-1.8%)• Infection (6%)• Migration of remaining root (30%)
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Post-operative duty of care:
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Pharmacological control of post-operative pain
Level 3 – Opiate analgesia– Tramadol 50-100mg po 6 hourly (Zydol, Tradol)
Level 2 – Addition of a mild opiate– Paracetamol/codeine 500/8mg tablets x 2 po 6 hourly (Solpadeine)– Paracetamol/codeine 500/30mg tablets x 2 po 6 hourly (Solpadol,
Tylex)
Level 1 – Non-opiate analgesia– Paracetamol 500mg x 2 po 6 hourly– Ibuprofen 200mg x 2 po 6 hourly– Difene Retard 75mg tablet x 1 every 12 hours (use with omeprazole
10mg od)
Journal of the Irish Dental Association– Vol. 53 (3): Autumn 2007
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Thank You