Sunday, 16 October 2016

10 Things I've Learnt from Oral Surgery Dental Core Training

Following my previous post about what I learnt from my restorative dental core training (see here) I thought I'd write about what I 've learnt from oral surgery...



1. Communication in TMD patients

TMD was something I saw lots of during my 6 months on oral surgery but also on acute clinic. It's easy to disregard TMD as a condition with little serious consequence and therefore when you explain the diagnosis to the patient, it's easy to come across as a little flippant or not taking the patient's problem seriously. 

In fact, the pain and problems patients can present with can be debilitating for a patient - either in constant pain or have severe trismus. TMD is one of those conditions where a patient may not be accepting of the diagnosis and therefore treatment can be less effective. Patients often expect a quick fix; a magic pill to solve their problem. Treatment of TMD is prolonged and often complete resolution isn't always possible. 

It's important to communicate this to the patient from the offset. If I had a patient who wasn't very confident in the TMD diagnosis I was lucky to have colleagues on hand to give a second opinion to convince the patient. 

To read more about the management of TMD, see one of my previous posts here


2. MRONJ

I worked on clinics where we saw patients who had established medication-related osteonecrosis of the jaw as well as referrals from GDPs seeking advice regarding extractions on these patients. 

I now feel like I understand the risk of MRONJ in patients more clearly - more specifically those at most risk are not the osteoporosis patients who have been taking oral alendronic acid but patients who are having frequent IV infusions bisphosphonates or taking denosumab. 

I've also learnt that for these patients you may do treatments you otherwise would have thought hopeless in order to avoid extractions for example root treating a wisdom tooth or endodontic treatment of an unrestorable root remnant. 

To read more about MRONJ see my previous post here


3. Keep going with that tooth!

You know that feeling when you're not getting anywhere with that extraction? Whether it be a huge molar with bulbous roots surrounded by dense bone, or a fractured apex sometimes you feel like giving up?

But what I learnt from spending all that time on oral surgery is to keep going! It's hard especially when you have a nervous patient to not expect the tooth just to pop out but sometimes it takes some patient and perseverance. 

Keep going! Sometimes it's good to take a break and come back with a fresh pair of eyes to something or get a second opinion. This means that you need to book in sufficient time for the procedure and therefore be able to assess the complexity of the extraction from clinical and radiographic examination.



4. When to get out a handpiece

So following on from the above point, no matter how much you go at something with your luxator or forceps, you just need to get out the handpiece. It also may speed things up or make it easier for you, for example, sectioning a molar that's been root treated. 

Some other situations where a handpiece may help is where you need to create gutter around the tooth in order to make an application point or sinking a fissure bur into a root to allow you to use a cryers to hook the root out. 


5. Suturing

Looking back to when I started my core training, I  was so cack-handed when it came to suturing. It would take me longer to suture up a socket than to take a tooth out! I struggled with the dexterity but also the positioning of the needle and how to manipulate the needle holder.

A lot of the extractions I did were on patients with complex medical histories, most commonly on anti-coagulants so that meant that I sutured a lot. My skills improved so much and I learnt how to do other types of suture not just simple interrupted: cross mattress, horizontal and vertical mattress, continuous locking. Now I feel much more confident and enjoy suturing!


6. High risk 8s

What is a high risk 8? I remember just giving the risk for every patient prior to extraction of all lower 8s. But actually does this risk apply to all wisdom teeth?

Wisdom teeth were properly the most common teeth I saw referrals in for and often we saw the more complex ones. A good paper to read regarding ID nerve injury is by Carrio (2010) which includes the signs you can see on a radiograph that may indicate high risk:

  • Darkening of root
  • Deviation of root
  • Deviation of canal
  • Interruption of tramlines
  • Narrowing of root
  • Narrowing of canal
  • Bifid root apex
At Guy's, the staff there are major advocates of coronectomies as a treatment option of high risk 8s. This was just a theoretical treatment option until I did my core training and now I understand the indications and complication of this treatment option which may minimise the risk of nerve injury.  



7. Sedation

During my core training , we offered IV sedation to patients for treatments. I really enjoyed sedation as it can work very well for patients who are particularly anxious or to help you manage difficult procedures or where access if difficult. 

IV sedation doesn't always work - I've had patients who become more agitated under sedation or those who have vomited on me but the majority of the time it works very well and predictably. 

I've also learnt how you need to explain the difference between sedation and general anaesthetic. Patients sometimes don't perceive there is a difference especially because of the amnesic effect of sedation. More than once patients arrived expecting to be put to sleep. If you over-sedate the patient then of course they may go off to sleep but you're aiming to keep verbal contact with the patient so they can obey instructions. 


8. Who is eligible for implants?

Seeing patients who had resections as part of their cancer treatment really puts into perspective who should be eligible for implant reconstruction under the NHS. 

Someone who's had half their mandible resected from an ameloblastoma, their quality of life would be improved significantly with some implant reconstruction. 

Other instances where implants may be provided under the NHS are:
  • Trauma
  • Hypodontia
  • Implant supported overdentures in those in severely resorbed mandibles or those with severe gag reflexes
Each patient will have their funding approved by a set committee, although standards vary from trust to trust. 



9. Anticoagulants

All practitioners are aware of Warfarin and how to manage patients who are taking this blood thinner. But now there are newer drugs like clopidogrel, dabigatran, rivoroxiban which cannot be monitored in the same way as warfarin i.e. with an INR.

There's not too much different we do to manage these patients for surgery, except we provide local measures i.e. surgical and suturing and good post-operative instructions. A lot of GDPs referred in these patients for relatively simple extractions wheres sometimes their treatment can be done in primary care. 

A good reference for help with the management of these patients is the SDCEP guidelines, click here


10. Post-op pain


The amount of patients I saw for problem appointments following surgery who attended because they were worried about the pain or swelling they were experiencing. A lot of the time this pain or swelling was completely normal and was not the result of a post-op infection or dry socket. 

I don't think patients appreciate the amount of normal pain or swelling they will experience after surgery, especially if it's all 4 wisdom teeth!  We need to explain to our patients what is a normal amount to expect and how to manage this - this should be done as part of the consent procedure! 


If you have any questions please don't hesitate to get in touch!


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