After the last group function where a juicy bit of dry socket has been tackled, I was again surprised by Dr. Chris Waith that managing OACs was such a simple matter of using your existing tools – there is some super real-world GDP-friendly advice in this episode.
“If the OAC is bigger than 5mm, you really get into the point where I don’t necessarily think we should be expecting GDPs to do something super courageous at that point.” – Dr. Chris Waith
In this group function we talked about:
- The Classic OAC regimen 1:31
- Oro-Antral Communication Management 6:37
- Medications for an OAC 8:55
If you loved this episode, be sure to check out the first part! Dry Sockets – How to Prevent and Manage Them?
Click below for full episode transcript:Opening Snippet: Hello, Protruserati. I'm Jaz Gulati and welcome back to another group function again, Oral Surgery, we're doing a three part for surgery with Chris Waith, we already covered dry sockets. And his answer was very surprising to me. This one OACs was a bit more of what I expected to hear. And so we're gonna jump straight in, right? You are now very familiar with these group functions. So how do you prevent and manage an OAC? Shall we move on to now?...
Main Interview: [Jaz]
OACs. Okay, so, OACs, I was taught at dental school that a lot of times when we take tooth out, we probably make an OAC without even realizing. And it’s a very common thing. And actually the probably heals up, especially when it’s less than x millimeters, maybe that’s four millimeters or whatever it might be. I was also taught and here’s why I’ve been a little bit naughty. So let’s play Zak’s stuff ‘Am I naughty, I get my, if I’m really not sure if there’s an OAC and then I want to start them on the regimen, which we’ll talk about shortly and see if our regimens are the same. But if I’m really not sure, then am I naughty if I get them to pinch their nose and try and blow out the nose aka the Valsalva maneuver, because I was taught not to but a few times, I’m really not sure whether I’m about to start this patient on the regimen. I have done it. What do you think?
I’d say yes, you are naughty. I mean, my logic is that I think we must close OACs all the time. But 99% plus they just heal. Some of the time will be because the membranes completely intact. And the whole, the communication is actually it’s just a bony break. Sometimes the hole in the membrane will be so small that your body can heal it. If you’ve got a small hole, and you squeeze your nose and blow. Essentially, what we’ve just got them to do is what we’re about to instruct them not to do for the next two weeks, because we know it might open up the OAC. So I would say if you got, if you’re going to check and grab your suction off of your Nurse (so that she’s not tempted to put it down to the bottom of the socket), just get your suction over the top of the socket, either get the light from your loupes or your chair light in a decent position. And just look. And I think if you can’t see anything obvious, it’s not to say it’s not there. But if you can’t see it, that’s good. Because I usually teach five millimeters, I say less than five millimeters, I think you can kind of sit on that. Give them the instructions. And I try and make myself feel better – I put some collagen cubes in the coronal portion of the socket. [Jaz] So do I [Chris] If it’s bigger than five millimeters, you really get into the point where I don’t necessarily think we should be expecting GDPs to do something super courageous at that point. If you were thinking that that actually needs some kind of physical closure. I think if you’re the GDP, the quickest, simplest thing you could do is just take an alginate, take an alginate send it to the lab, just say to the lab this needs to be kind of processed now. So we need a bit of a favor. And you want to clear blowdown, so clear blowdown all of the teeth but also [Jaz] Like an Essix retainer? [Chris] Yeah, Essix. Yeah, so an Essix that grips the socket. So it’s got to be tight over the socket. And the logic is then you put that in and you say to the patient, you wear this 100% of the time with the section of taking it out to brush your teeth while they’re eating and drinking. They haven’t got food and drink going up into the sinus so that you’re trying to prevent them getting a sinusitis. And really you can go two ways with it. One is it definitely needs closing. That’s great refer them but they were that until they see the surgeon or you might say Do I still try and treat this conservatively. So the last one I saw was last summer when one of our associates took a tooth out. About a week later the clot broke down and they started to get some nasal regurgitation and numbed him up and cleaned the socket out but when I looked, the hole was so small that I just thought if I take this tooth out now I wouldn’t close this. So I thought you know what, I’ll put some collagen cubes and then I’ll suture it like I would do but I’ll take the alginate and I got him a blowdown and he wore it for three weeks and three weeks we took it out and everything was fine. Everything that healed over so I think that just protect the socket. Don’t jump into thinking I need to advance a flap or something like that. I think leave that to your Oral Surgery friend down the road and then just give the patient directions. [Jaz]
I think that’s very fair. [Chris]
I think the thing we’ve closed in OAC when it does need close in most half decent dentists, I think will be able to advance a flap specially if they place implants and things. So incise the periosteum do a buccal advancement flap, but actually there are times when that’s the wrong thing to do. So, you know, the anatomy might be difficult, like they might have a prominent buttress, the sulcus might be shallow, might be seen Symbiotype, it might be a big defect, but all of those things and you starting to think right buccal flap, or palatal finger or you know, something else, and the thing you like, I still don’t see them often enough to make this a really slick process where I kind of sit and think, oh, right, let me just do this. So I think for a general dental practitioner, it’s like, you don’t need to make that kind of decision. Your job is just protect the socket. So get that splint in, speak to your colleague, and then you call the consultant, everything else. And I mean, even going back a step, I think just preempted everything we said last podcast about sectioning the tooth looks after the socket loads more, you’re much more or less likely to cause an OAC or certainly a big OAC. And then even when it does happen, either leave the socket and supports it or collagen cubes and suture it. And if it’s a big OAC that needs closing, fine, take your alginate put your splinting, refer it on. And I think then you’ve got Touchwood all bases covered. [Jaz]
I think that’s such great real world GDP friendly advice because you’re right man, you even you don’t see these regularly enough as an oral surgeon to make this like a autopilot kind of thing for you. So yeah, why should GDP is be expected even with implant training to know exactly which is the best route in that scenario definitely sent to an oral surgeon. Makes good sense to me. But it’s a real gem there to take that Alginate impression, get that Essix retrainer made. And then as part of the pharmacological care, obviously, the instruction you give to a patient is not to blow your nose. And now I remember taking out an upper molar at Guys hospital as a DCT. And unfortunately and see the patient when he came back, but I think he sneeze and he held his sneezing. And apparently, like it was an absolute sight, the anchor lining herniated into the mouth. And that I mean, how does he even heal from that, I mean, obviously, the body is remarkable, but that’s not a pretty sign. [Chris]
I’ve still never seen a proper antral polyp like that. But I’ve seen some big holes, and I’ve seen some long standing fistulas and particularly the fistulas. If it’s been open for a long time, and they’ve had food and drink going into the sinus, it’s horrible. You know, it’s really full of anaerobes, really smelly. Like, I’ve listened to an ENT surgeon not so long ago. And his advice I can completely get on board with which is if they get to that point, you’re actually, they need to go and see ENT to properly have a sinus cleaned out and have some drainage before they have the OAF close. So from our point of view, you want to avoid all of that just by taking care of the communication and not letting it become a fistula. And my instructions would be just like yours so dubbing the nose instead of blowing it. If they’re sneezing they’ve got to let it out. Rather than squeezing the nostrils. A little bit funny like there are obvious pressure differences like not to go dive in for a few weeks. But also plane travel and I’m bit dubious about. So somebody who’s got a maxillary tooth that’s close to the sinus. I like to know that they’re not flying in the next kind of week or two just in case. [Jaz] It’s good point. [Chris] Then, I don’t massively go into chemicals. Normal analgesic regime, I wouldn’t bother with any antibiotics. You might give them something like Beconase. And like I think I don’t know what yours was like. But when we were undergraduates, we often got told to give them Ephedrine. So Ephedrine nasal drops. Now, Jerry, the ENT surgeon that I was talking about, we chatted a lot about this because he’s very anti Ephedrine. And his logic is that you stifle the blood supply to the nasal epithelium. And in trying to treat one thing you actually create another that you get a rebound disease in the nasal epithelium. So he said for us Ephedrine is either short term, it’s just two or three days or avoid it and go steroids so just go Beconase over the counter stuff. [Jaz]
And that’s something that you prescribe. Can we get Beconase over the counter? Is it like [Chris]
Any chemist Yeah, or supermarket. [Jaz]
How about Sterimar? Are those saline rinses just to keep your nasal passage patent? [Chris]
I probably wouldn’t bother. I mean, my question would be what you’re trying to do it for. And really, that’s why I wouldn’t jump on antibiotics. Because really missing there is infected, [Jaz]
Even if you’re giving them a suck down, right? Even if it’s like a big enough that you’re gonna go to the suck down and send it to oral surgeon. [Chris]
Yeah, I think I still wouldn’t, we might be dubious of an infection, but those antibiotics that we gave them straight off, they’re probably not going to stop that. It’s going to be the physically treating it and closing everything that will prevent the infection. And also if you get to the point where you’re teetering into our way out and they have got some kind of sinusitis, the way that ENT treat that with antibiotics will be very different to our way of treating it. Jerry’s regime, he said, You know, it’s not unusual for him to give people four or five weeks worth of antibiotics, because he says the absorption so poor, that actually they need a sustained dose over a long time. Now, none of us would ever do something like that. [Jaz]
So that five days of amoxicillin that we usually give is really not doing anything! [Chris]
I mean, I wouldn’t give him amoxcillin, the use of it be something like doxycycline, something like that. [Jaz]
Well, there we are, again, you surprised me again, I’m pleased to hear it. I think that’s one less reason to reach for the prescription pad. Amazing. [Chris]
I think this is the kind of prevention is better than cure one. It’s like look after the small communication. Bigger one, sit down, splint, refer it on, closer early, it means closing and then try and stop those patients getting away and sinusitis. [Jaz]
Perfect, very happy with that. So that’s how you manage OACs. Amazing.
Jaz’s Outro: Well, there we have it, guys. Thanks for listening all the way to the end. Listen, if you’re listening on Apple, please give this show a five star rating leave a comment. I love reading them. That’s how this podcast grows. So if you’re watching on YouTube, hit that like button, give us a comment. And I really appreciate that. We’ll see you in the next group function where we cover the dreaded tuberosity fracture like this is the scary one, right? Like this is the kind of thing that you see on social media and the dentist has removed a molar but actually he’s removed like the maxilla with. So this is like the scary one, so let’s wait for that juicy one. Hope you never experienced a tuberosity fracture, but if you do, you’ll be well equipped from this next episode coming. So I’ll catch you in that one.