Gary leonard oral surgery ifpdc presentation to email compressed
Mr. Gary Leonard BDent Sc, FFD RCSI (OSOM), MDent Ch (OS), FFD RCSI (OS) Specialist Oral Surgeon58 Northumberland Rd. Ballsbridge, D4Bon Secours Hospital, Glasnevin,8 Kingsfurze Terrace, Dublin Rd, Naas, Co. KildareClane General Hospitalleonardoralsurgery@eircom.net
Successful Oral Surgery in everyday practice: Mr. Gary LeonardBDent Sc, FFD RCSI (OSOM), MDent Ch (OS), FFD RCSI (OS) Specialist Oral Surgeon
Treatment History Examination Special tests Need In House Referral Informed consent Capable performance Duty of care
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
Dublin Dental School & Hospital Position StatementPatients 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 anaesthesiaAt 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 monthsAt risk procedures – All dental procedures involving the manipulation of gingival tissues or the periapical region of teeth or perforation of the oral mucosa.
Spontaneous bone exposure – lingual cortex 5 years of FosamaxMarx et al., 2007
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
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
Alveolar bone exposure resulting form tooth extractions after 5 years of FosamaxMarx et al., 2007
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.
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
Sequestrectrectomy after 6 month drug holiday (CTX 299 pg/ml)Marx et al., 2007
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.
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 irritationStage 3: With extraoral fistula, osteolysis extending to inferior borderor 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
Healing of bone exposure without surgery after a 6 month drug holiday Spontaneous bone exposure After 6 month drug holiday after 5 years of Fosamax
The anti-coagulated patient: Anti-platelet Warfarin Aspirin drugs• 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
• 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)
Treatment History Examination Special tests Need
Radiographic markers of proximity to IAN: Howe & Poynton (1960)1) Loss of tramlines2) Narrowing of tramlines3) Alteration in direction of IA canal4) Radiolucent band across rootRisk of damage up to 35% when all four markers present
Risk of permanent IAN Damage post removal of 3rd Molars0.04% 0.9%Robert & Pogrel, Carmichael & McGowan,JOMS 2005 BJOMS 1982 0.4% Rood, BDJ 1983 0.3% Valmaseda-Castellon, Triple O 2001 0.5%
Risk of permanent Lingual nerve damage post removal of 3rd Molars0% 0.8%Walters, BDJ 1995 Robinson & Smith, BDJ 1996Pogrel & Goldman, With lingual nerve protectionJOMS 2004 0.3% Robinson & Smith, BDJ 1983 Without lingual nerve protection 0.5%
Coronectomy:Coronectomy: A Technique to protect the inferior Alveolar Nerve.Pogrel et al., JOMS 62: 1447-1452, 2004Coronectomy (intentional partial odontectomy of lower third molars)O’Riordan, Oral Surg Oral Med Oral Pathol 2004:98:274-80A randomised controlled clinical trial to compare the incidence of injuryto the IAN as a result of coronectomy and removal of third molarsRenton et al., BJOMS (2005) 43, 7-12.