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Oral Surgery · patient case with 5 questions

Extraction, infection and a difficult healing

demo: 44-year-old female

chief: Severe throbbing pain and a foul taste four days after an extraction, plus swelling from a separate upper tooth.

history: Osteoporosis treated with intravenous zoledronic acid for three years. She smokes. She had corrective surgery for tetralogy of Fallot in childhood with no residual defect.

meds: Zoledronic acid, calcium and vitamin D.

findings: The socket at site 32 is empty of clot with exposed bone and exquisite tenderness. There is no purulence. Separately, tooth 4 is grossly carious with vestibular swelling and tenderness.

Question 1

All of the following are true of a dry socket EXCEPT:

  1. It is straightforward to diagnose because it produces obvious swelling and pus
  2. Pain typically begins two to four days after the extraction
  3. The socket appears empty with exposed bone and a foul odour
  4. Smoking and oral contraceptive use increase the risk
Show answer and explanation

Correct answer: A. It is straightforward to diagnose because it produces obvious swelling and pus

  • A. Correct, and this is the exception. Dry socket is characteristically not accompanied by swelling, pus, fever or lymphadenopathy. It is diagnosed by the pattern of severe delayed pain with a denuded socket, and its absence of infective signs is exactly what distinguishes it from an infected socket.
  • B. This is true. The delayed onset is characteristic; immediate postoperative pain is expected surgical pain, not alveolar osteitis.
  • C. This is true. Loss of the clot exposes bare bone, which is intensely sensitive, and the socket has a distinctive foul odour and taste.
  • D. This is true. Smoking, oral contraceptives, mandibular third molars, traumatic extraction and previous history all raise the risk.

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Question 2

What is the most common site for medication-related osteonecrosis of the jaw?

  1. The posterior maxilla
  2. The posterior mandible
  3. The anterior maxilla
  4. The mandibular condyle
Show answer and explanation

Correct answer: B. The posterior mandible

  • A. The maxilla overall accounts for a minority of cases, roughly a quarter.
  • B. Correct. The posterior mandible accounts for the majority of cases, roughly two thirds. Its dense cortical bone and relatively poorer blood supply compared with the maxilla make it vulnerable, and mylohyoid ridge and lingual torus areas with thin overlying mucosa are frequent starting points.
  • C. The anterior maxilla is an uncommon site.
  • D. The condyle is not a typical site; lesions arise in tooth-bearing and alveolar regions where mucosal breach occurs.

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Question 3

The infection at tooth 4, a maxillary premolar, is most likely to spread into which space?

  1. The buccal space
  2. The sublingual space
  3. The lateral pharyngeal space
  4. The canine space
Show answer and explanation

Correct answer: A. The buccal space

  • A. Correct. The maxillary premolar root apices sit above the buccinator attachment relative to the alveolar bone in most cases, so pus that perforates the buccal plate escapes into the buccal space, producing cheek swelling.
  • B. The sublingual space is entered from mandibular teeth whose apices lie above the mylohyoid line, chiefly the premolars and first molar.
  • C. The lateral pharyngeal space is reached from mandibular third molars and from spread through the pterygomandibular space.
  • D. The canine space is entered when infection arises from the maxillary canine, whose long root apex lies above the levator anguli oris attachment. That is the classic canine space source, and it matters because of the risk of cavernous sinus thrombosis.

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Question 4

She had tetralogy of Fallot repaired successfully in childhood with no residual defect. What is the recommendation regarding antibiotic prophylaxis?

  1. Prophylaxis is required only if she also has a prosthetic valve
  2. Prophylaxis is required only for extractions
  3. No prophylaxis is required beyond six months after the repair
  4. Lifelong prophylaxis is required for all dental procedures
Show answer and explanation

Correct answer: C. No prophylaxis is required beyond six months after the repair

  • A. A prosthetic valve is a separate lifelong indication, but she does not have one.
  • B. The indication is determined by the cardiac condition, not by the type of dental procedure, though the procedure must involve manipulation of gingival tissue or the periapical region or perforation of the mucosa.
  • C. Correct. Under AHA guidance, completely repaired congenital heart disease with prosthetic material requires prophylaxis for the first six months only, the period of endothelialisation. After that, with no residual defect, prophylaxis is no longer indicated.
  • D. Lifelong prophylaxis applies to unrepaired cyanotic congenital heart disease and to repairs with a residual defect at or adjacent to the prosthetic material.

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Question 5

What is the maximum recommended dose of articaine for a healthy adult?

  1. 4.4 mg per kg
  2. 7 mg per kg
  3. 2 mg per kg
  4. 10 mg per kg
Show answer and explanation

Correct answer: B. 7 mg per kg

  • A. 4.4 mg per kg is the maximum for lidocaine with epinephrine, capped at 500 mg.
  • B. Correct. The maximum for articaine in a healthy adult is 7 mg per kg, with an absolute ceiling of 500 mg. A 4 percent cartridge of 1.7 mL contains 68 mg, so a 70 kg adult may receive up to about 7 cartridges. For children under 4, articaine is not recommended, and the paediatric maximum is also 7 mg per kg.
  • C. 2 mg per kg is close to the bupivacaine limit, which is 1.3 mg per kg to a maximum of 90 mg.
  • D. 10 mg per kg exceeds every local anaesthetic maximum in dental use.

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