1. Mr. Gary Leonard
BDent 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. Kildare
Clane General Hospital
leonardoralsurgery@eircom.net

2. Successful Oral Surgery in
everyday practice:
Mr. Gary Leonard
BDent Sc, FFD RCSI (OSOM), MDent Ch (OS), FFD RCSI (OS)
Specialist Oral Surgeon

4. Treatment
History
Examination
Special tests
Need
In House Referral
Informed consent
Capable performance
Duty of care

6. 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

7. 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.

8. Spontaneous bone exposure – lingual cortex 5 years of Fosamax
Marx et al., 2007

9. 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

10. 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

11. Alveolar bone exposure resulting form tooth extractions after 5 years of Fosamax
Marx et al., 2007

12. 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.

13. 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

14. Sequestrectrectomy after 6 month drug holiday (CTX 299 pg/ml)
Marx et al., 2007

15. 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.

16. 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

17. 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

18. 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

19. • 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)

22. Treatment
History
Examination
Special tests
Need

24. Radiographic markers of proximity to IAN: Howe & Poynton (1960)
1) Loss of tramlines
2) Narrowing of tramlines
3) Alteration in direction of IA canal
4) Radiolucent band across root
Risk of damage up to 35% when all four markers present

25. Pre-operative imaging: IAN and second molar

26. Pre-operative imaging: IAN and second molar

27. Pre-operative imaging – mental nerve

31. Pneumatised antrum with displaced root and OAC:

32. Oro-antral communication R side with sinus opacity:

33. Canine teeth
- Age
- Root curvature

34. Horizontal Parallax
2x PA’s

35. Vertical Parallax
- OPG
- Upper Ant Occlusal

52. Treatment History
Examination
Special tests
Need
In House
Informed consent
Capable performance
Duty of care

53. Informed consent:

54. Informed consent: Risk of IAN damage

55. Risk of permanent IAN Damage post removal of 3rd Molars
0.04% 0.9%
Robert & Pogrel, Carmichael & McGowan,
JOMS 2005 BJOMS 1982
0.4%
Rood,
BDJ 1983
0.3%
Valmaseda-Castellon,
Triple O 2001 0.5%

56. Risk of permanent Lingual nerve damage post removal of 3rd Molars
0% 0.8%
Walters, BDJ 1995 Robinson & Smith,
BDJ 1996
Pogrel & Goldman, With lingual nerve protection
JOMS 2004
0.3%
Robinson & Smith,
BDJ 1983
Without lingual nerve protection
0.5%

57. 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.

58. Pogrel et al., JOMS 62: 1447-1452, 2004

59. Coronectomy:
Contraindications:
• Active infection
• Mobility
• Horizontally impaction
Outcome:
• Permanent IAN paraesthesia (0-1.8%)
• Infection (6%)
• Migration of remaining root (30%)

76. Post-operative duty of care:

77. 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

78. Thank You