Exam Flashcards
ASA II
Mild to moderate systemic disease that does not interfere with daily activity
significant health risk factor such as smoking, alcohol abuse, obesity
Patients that need prophylactic antibiotics, modification to treatment, requiring sedation
can perform normal activities without distress
ASA III
Patients with moderate to severe systemic disease that is not incapacitating but limits normal daily activities
modified dental treatment often required
ASA IV
Incapacitating severe systemic disease that is a constant threat to life.
Elective dental treatment must be postponed until ASA III
Type 1 allergy
Atopic reactions and anaphylaxis
Itching of the palate, nausea, Substernal pressure, Shortness of breath, hypotension
Swelling requires epi and O2, and diphenhydramine 50mg
Type III allergy
White, erythematous or ulcerative lesions
Topical treatment, diphenhydramine syrup, Kenalog in orabase (oracort)
Type IV allergy
contact dermatitis, transplant rejection
Topical treatment of benzydamine rinse or Oracort
The most common drugs with allergic potential
Penicillins ASA Codeine barbiturates Esther local anesthetics LA preservatives (paraben or bisulfite)
Penicillin allergy prevalence
5-10% of patients react
anaphylaxis in 0.04-0.2%
Analgesic allergy
ASA (and other NSAIDs) can cause severe reactions in asthmatics
non-allergic reactions: GI upset/bleeds, heartburn
Codiene allergy
Nausea, emesis, constipation
Non-allergic
Two main kinds of LA agents
Amides and Esters
Do not cross-react in allergy situations
Highest incidence of LA allergy
Procaine (PABA ester)
Cross-reaction with Latex allergy
Banana’s
Type I reactions possible but Type IV more common
Peanut Allergy
Avoid Coe-Pak
Formaldehyde allergy
Avoid tissue adhesives such as histoacryl
SSRI Side effect
Decrease platelet function Avoid perscribing ASA, NSAIDs, steroids Maximum 2 cartridges of 1:100,000 epi per visit maybe? - unclear, keep in mind Reduce sedation dosage Erythromycin action inhibited
Asthma precautions
Do not perscribe NSAIDs as severe reaction may develop, especially if they have nasal polyps
Bisphosphonate risk factors
Risk factors for MRONJ - 65yo+, periodontitis, 2+ years on bisphosphonate, smoking, denture wearing, diabetes
Symptoms of MRONJ
pain soft tissue swelling and infection loosening of teeth drainage and exposed bone numbness may be asymptomatic for weeks or months
Maximum dose of epi for a healthy patient
0.2mg - 11 carpules of 1:100,000 (0.018mg per carpule)
Maximum dose of epi for CVD patient
0.036mg - 2 cartridges of 1:100,000
Levonordefrin
Alternative to epi in LA
Avoid in CVD patients
LA reccomendation for longer procedures in patients with CVD
bupivocaine (marcaine) 1:200,000 epi
contraindications for epi
unstable angina recent MI (1 month) recent stroke (6 months) recent bypass surgery (3 months) severe hypertension uncontrolled uncontrolled arrhythmias uncontrolled hyperthyroidism
Categories of hypertension
pre-hypertension (120-129, 80) Stage 1 (130-140, 80-89) Stage 2 (140+, 90+)
hypertension treatment
Stage 1 single drug (usually thiazide)
Stage 2 two drug (usually thiazide and ACE)
Hypertension treatment drugs
- ipine (calcium channel blocker)
- pril (ace inhibitor)
- olol (beta blocker)
- thiazide (diuretic)
with non-selective beta blockers, epinephrine causes…
may cause uncompensated increase in BP as it vasoconstricts peripheral arterioles and is blocked from dilating muscle arterioles. Test dose LA with epi, and if no changes over 5 minutes then you are ok
Thiazide diuretics oral interactions
No vasoconstrictor limitations
dry mouth
orthostatic hypotension
Non selective Beta blocker oral interactions
potential increase in BP - max 2 carpules LA with epi
Cardioselective Beta Blockers oral interactions
No changes in dental management
Combined alpha and beta blockers
potential for adverse hypertensive effect, but unlikely
ACE inhibitors side effects
Angioedema of lips, face, tongue, taste changes, oral burning
Antiotensin receptor blocker oral interactions
angioedema of lips, face, tongue, orthostatic hypotension
Calcium Channel Blockers oral interactions
Gignival hyperplasia
Alpha adrenergic blockers
dry mouth, orthostatic hypotension
central alpha adrenergic agonists
dry mouth, orthostatic hypotension
direct vasodilators
lupus-like oral and skin lesions
orthostatic hypotension
Coumadin risk factors
dental treatment requires INR 3.5 or less
The action of warfarin is increased by ASA/NSAIDs,
Avoid metronidazole, tetracycline, a few other antibiotics to look up.
Heparin considerations
Physician consult prior to NSAIDs or ASA
When to avoid giving patients NSAIDs
Patients on SSRI - increases risk of gastric bleeding
vasoconstrictor for pateints with hypertension
1:200,000 epi
Coumadin therapy timing and precautions
PT and INR should be performed withing 24 hours of planned surgery
PT time up to 1.5X normal acceptable
INR time 3 or less reccomended
INR 5+ is contraindicated
Test to order with clinical findings of bleeding problem
PT APTT TT BT Platelet Count
Test to order for ASA Therapy bleeding test
BT
APTT
Test to order for Coumadin Therapy bleeding test
PT
Test to order for possible liver disease bleeding test
BT
PT
Test to order for Chronic leukemia bleeding test
BT
Test to order for Malabsorption syndrome or long term antibiotic therapy bleeding test
PT
Test to order for renal dialysis (heparin) bleeding
APTT
Signs of Ludwig’s Angina
swelling of the Submandibular/sublingual spaces bilaterally
elevated tongue
Conditions to avoid NSAIDs
children under 14 years pregnancy alcohol dependency asthma GI disease Renal disease Existing controlled infection compromised cardiac function/hypertension SSRI Metformin?
NSAID drug interactions
anticoagulants beda adrenergic blocking agents cyclosporine, methotrexate diuretics insulin, oral hypoglycemics phenytoin
NSAID effect on ASA
Inhibits anti-platelet function
Avoid acetaminophen in
Renal disease Liver disease Alcohol dependency Anemia Cardiac, pulmonary disease pregnancy
Acetaminophen drug interactions
barbituates NSAIDs Caffeine Ethanol Warfarin Zidovudine Tetracycline
Avoid Opioids with
asthma siezure disorders cardiac dysrhythmias pregnancy alcohol dependency addison's disease liver disease
Opioid interactions
Alcohol antihistimines CNS depressants phenothiazines MAO inhibitor, tricyclic antidepressants Anticholinergics
Patients on bisphosphonates precautions post surgery
prophylactic antibiotics and CHX rinse 1-2 days before procedure. Antibiotics for 14 days after procedure and CHX for 2 months.
Treat one sextant every 2 months
Implants/regen contraindicated
Maxillary anteriors surgical risk of flap
likely to get recession due to fenestrations, thin alveolar ridge, consider soft tissue augmentation prior to flap to reduce risk.
Infections from maxillary incisors and canines path
intraorally into facial vestibule or extraorally into canine space. Causes severe swelling of the upper lip, canine fossa, and often peri-orbital tissues, can cause purulent maxillary sinusitis
surgical risk of severely pneumatized maxillary sinuses
Medullary bone may be absent between the sinus and the cortical bone surrounding the teeth. Deep infrabony pockets may also approach the sinus with possibly an absence of bone. Supporting bone may be absent. Exercise caution when elevating a flap with sinus proximity to teeth and ridges.
Surgical limitations with zygomatic bone
Zygomaticoalveolar crest will limit correction of osseous defects as well as the extent of ostectomy performed in a crown lengthening procedure.
Maxillary molar roots can have thin alveolar plates. What surgical complications arise from this?
Can have recession after flap, consider augmentation surgery prior to flap surgery.
Surgical precautions in the posterior palate
Avoid vertical incisions to prevent damage to the greater palatine nerve and artery. Flap harvest location must consider foramen location. Nerve/artery travels forward from foramen
How to stop bleeding from the greater palatine artery
Local measures if possible, however the artery may retract into the foramen. If this happens then ligation of the external carotid artery may be necessary.
Superior and inferior attachment of the pertygomandibular raphe
Hamulus superior
internal ridge of the mandible inferior
Surgical risk in the maxillary tuberosity
Incisions posterior to the maxillary tuberosity risk perforation of the pterygomandibular raphe and superior constrictor muscle.
Pterygomandubilar raphe attaches to which muscles
buccinator anteriorally
superior pharyngeal constrictor posteriorally
perforation of the pterygomandibular raphe infection risk
if medial to the medial pterygoid muscle the parapharyngeal space, or if lateral to the medial pterygomandibular muscle the pterygomandiular space. THese may spread into the sublingual, submandibular spaces or into the neck
exostoses in the palatal vault surgical limitations
A shallow flat palatal vault may preclude ostectomy (interproximal palatal ramping) gingivectomy procedures are compromised as an extremely wide incision may be necessary to achieve the desired beveled result.
Surgical limitations in the anterior mandible
A prominent mental protuberance may limit depth of anterior facial vestibule, and my limit deepening of the vestibule.
Infection considerations in the anterior mandible
elevation of mentalis muscle allows access to the submental space. Infection can spread posteriorally into the lateral pharyngeal spaces.
Anterior mandible surgical risk - root position
Roots often positioned facially, prone to recession due to fenestrations/dehiscences. Possible gingival augmentation surgery to preceed flap surgery.
Surgical limitations in the lingual anterior mandible
Osseous recontouring is limited if genial tubercles are very prominent or are located superiorly
Surgical risk of lingual aspect of anterior mandible
Sublingual space is entered whenever the lingual attached gingiva is elecated or when the mucosal lining of the floor of the mouth is perforated. Infection in this space can spread across the midline and cause cellulitis (Ludwig’s angina if spreads into the parapharyngeal space)
Surgical limitations around the external oblique ridge
Prominence and location will limit surgical correction of osseous defects that extend apical to the external oblique ridge and the extent of ostectomy during crown lengthening. May preclude procedures to deepen vestibule and mucogingival surgeries.
Infection risk in the retromolar area of the posterior mandible
Pterygomandibular space is separated from the oral cavity by only a thin wall formed by the oral mucosa and the buccinator muscle. Incisions can easily penetrate into this space.
Surgical risk buccal space, posterior mandible
Attachment site of the buccinator muscle will influence the depth of the buccal mucobuccal fold and surgical extent of the mandible.
Infection risk buccal space, posterior mandible
Buccal space may be entered if buccinator muscle is perforated during elevation of a buccal flap.
Mental foramen surgical risk
Must be avoided during surgical management. A challenge to do osseous resection or mucogingival surgery to gain attachment/deepen vestibule
Posterior mandible mylohyoid space surgical risks
Thin mucosa covering the floor of the mouth. Submandibular gland and duct, lingual and inferior alveolar nerves are in this area. Surgery should be limited to full thickness flaps and blunt dissection. Ostectomy/osteoplasty may not be possible if high muscle insertion.
Posterior mandible mylohyoid space infection
Infection apical to the mylohyoid muscle penetrates the submandibular space and infection can spread directly into the neck.
Surgical risk submandibular region posterior mandible
Care must be taken during flap elevation/reflection and retracting/depressing the tongue.
Surgical limitations in the posterior lingual mandible/ramus
A shallow sublingual sulcus in posterior lingual mandible increases risk of injury to subjacent structures. Distal incisions require skewing to the buccal to avoid lingual nerve. May be necessary to avoid scalloped incisions on the lingual aspect of third and second molar region
Surgical risks of exostosis removal (mandibular or maxillary)
Presence may compromise or preclude osseous recontouring, and mucosa may be thin over the exostosis and flap perforation must be avoided.
mandibular tori removal infection concern
A full thickness flap apical to the tori is required, and the attachment for the mylohyoid may be encroached upon, leading to sublingual space and possibly submandibular
Anatomical spaces of the head summary
Buccal vestibule of mandible space of the body of mandible submentalis space submental space sublingual space submandibular space pterygomandibular space pharyngeal space buccal vestibule of the Maxilla Buccal space submasseteric space temporal space peritonsillar space
Spaces involved in Ludwig’s Angina
cellulitis bilaterally involving sublingual, submandibular, and submental spaces. Submandibular swelling extends down the anterior part of the neck to the clavicles.
Cavernous sinus thrombosis may include
venous obstruction in the retina paresis of CN 3, 4, 6 abscess formation in surrounding soft tissues septicemia meningeal infection
A patient taking warfarrin, what antibiotic cannot be perscribed
Metronidazole
Periodontal surgery considerations - the patient
Age, medical history, chief concern (sensativity, estehtics, function/costs, gagging, TMD, etc), patient compliance, LA and analgesic options with med history,
Periodontal surgery considerations - oral and radiographic findings
Level of plaque control/resolution of inflammation, Control of local factors (restorative, prosthetic, endo. occlusal) Xerostomia, gag reflex, anatomic limitations, mucogingival status, suspected osseous topography/root morphology
Periodontal surgery considerations - surgical assessment
Type of surgery (resective, inductive/regenerative, mucogingival), simplicity/predictability/efficiency of procedure, post operative sequelae of procedure (increased recession, esthetic changes, increased sensativity/mobility), follow up/expected healing
How to do incisions
Clean, definite, and smooth
Flap design
Must retain KT, mucogingival involvements due to flap design must be avoided, must provide adequate access and visibility, avoid surgical involvement of adjascent sites, avoid unnecessary exposure of bone, designed with a wide base, all tissue tags removed, primary closure if possible, and should be well stabilized to not displace.
internal bevel incision
blade is aimed towards the bone - full thickness flap
external bevel incision
removes a portion of gingiva - gingivectomy incision
Incision through the papilla at the contact point, with a discard around the buccal root of the tooth
Scalloped incision apical to the radicular free gingival margin with papillary incisions under the contact point
Incision to produce an apical papilla position but retaining the gingiva on the buccal of the tooth
intrasulcular radicular incision with inter-radicular incisions that create a new papilla apical to the existing papillary crest
Incision to produce a discard in the papilla and the buccal sulcus
scalloped radicular incision and inter-radicular incisions apical to the existing papillary crest
If papillary incision is moved apically from the contact point…
The resulting papilla will be shorter, the further from the contact point the shorter it is, if a discard is taken. Flap must be reflected apical to the MGJ if primary closure is desired.
In a repositioned flap what determines the ammount of pocket reduction
The thickness of the flap. The thinner the flap, the more pocket reduction achieved as the thicker the discard is
Incision into the sulcus and through the contact point of the papilla.
Crestal incision. Preserves the KT, not for pocket reduction
Varied incisions are part scalloped and part crestal
Incision apical to the gingival crest and apical to the papilla contact
Scalloped incision - pocket reduction and apical movement of the free gingival margin.
Varied incisions are part scalloped and part crestal
Modified widman flap characteristics
Full thickness flap
repositioned flap (coronal to MCJ)
Scalloped incision
Vertical mattress independent sutures
Full thickness Apically positioned flap characteristics
internal bevel incision at the crest of the gingiva
disection past MCJ
Pocket reduction
Partial thickness Apically positioned flap
Internal bevel incision at the crest of the gingiva
disection past the MCJ
Pocket reduction and increase in KT the objective, with KT growing over the retained periosteum
envelope flap definition
Only horizontal incisions used
Pedicle flap definition
lateral releasing incisions used with the horizontal incisions.
Avoid lateral releasing incisions
Palate and lingual mandible due to anatomical considerations, and must be used with caution on the facial aspect between mandibular bicuspids
Where should releasing incisions be placed
Should be placed at the line angles. Avoid placement in the middle of the interdental papilla or over the radicular aspect of a tooth
How should releasing incisions be designed
Do not compromise the blood supply to the flap, must have a wider base. Also avoid long apically directed incisions with short mesial-distal horizontal flaps
Scalloped flap design
Apical portion of the incision is tapered to be narrower than the radicular width between the line angles.
3 important objectives of an internal beveled incision
a sharp, thin flap margin is created for adaptation of the tooth-bone junction
outer surface of gingiva is preserved to become attached gingiva
the pocket lining is removed - there is always a discard, this is not a sulcular incision to the tooth root
Location of primary incision for internal bevel design
if KT is abundant faical incision is 1-3mm apical to gingival crest
If KT is adaquate (2mm) then crestal incision indicated
If KT is inadequate (<2mm) a sulcular incision and partial thickness flap indicated (from the sulcus directed to the alveolar crest, not the tooth)
what determines amount of discard in an internal bevel incision
how apical is the initial incision, and the acuity of the bevel
Internal bevel incision - if made too close to the tooth (coronal)
A soft tissue pocket may be created as the flap extends coronal to the bone-tooth junction
Internal bevel incision - if made too far from the tooth (apical)
Primary closure may not be achieved.
Designing a palatal flap in terms of discard
2/3 rule - 2/3 of the MP and DP measurements of each tooth. Make a bleeding point at the midpoint of the tooth, and the interproximal point where the 2/3 rule calculates. Careful to avoid greater palatine artery. a scalloped line between bleeding points is the incision line.
3 approaches for design of a palatal flap
full thickness palatal flap
partial thickness palatal flap
modified partial-thickness ledge and wedge flap
Common errors with palatal flaps
Incisions made beyond the height of the alveolus risk cutting the palatal artery.
thinning of palatal tissue on low, broad palate risks damage to the palatal artery
flap positioned coronal to alveolar crest (poor adaptation)
flap is too short exposing the bone
Scallop is too wide/round resulting in exposed bone
Things to avoid with suture knots
Tying too tight (avoid blanching the tissues)
Knot should not be on an incision line
Ends cut 2-3mm away from the knot
non-resorbable sutures to be removed in 7-10 days
Suture material selection
resorbable sutures should be used on mucosa (where retrieval is difficult)
regenerative procedures require longer lasting sutures
mucogingival procedures require finer suture materials.
types of non-resorbable sutures
Silk Nylon PTFE polyester fibers Knots more likely to untie with all of the synthetic sutures.
Types of resorbable sutures
GUT (plain (3-5 days) or chromic (7-10 days))
Synthetic (PGA (21-28 days) good for sited where sutures must resist muscle pull
Size of sutures chosen for different procedures
4.0 - periodontal flap surgery
5.0 - mucogingival surgery
Smaller will cause less tissue trauma, but has less tensile strength
Reverse cutting needle design
the area towards the tissue pull is flat (inside of the curve)
Conventional cutting needles
The point is facing hte pull of the tissue (towards the inside of the circle)
interrupted mattress sutures advantages
Provide greater flap and papillary placement and stability, and more precise flap placement
Can be vertical or horizontal
Papillary interrupted suture
THe papillas on only the buccal or lingual side are engaged, with the sutures slung aorund the tooth. For when only a single side was flapped.
Stages of healing
2 days - epithelium covers over the wound
7-14 days granulation tissue under the epithelium forms CT
Apical positioned flap with bone left exposed
Wilderman 1964 found that there was more attached gingiva after but the dogs lost 2-4mm alveolar bone height.
Healing of the FGG
first 48 hours graft appears pale, nutrition from periosteal bed, clot formed between graft and recipient bed
3-5 days graft colour has improvedm capillaries formed at the cut margins of the recipient bed into donor tissue. proliferation of epithelium at the graft margins, clot being replaced with loose CT
6-10 days blood vessels increase greatly, epithelium is thinned, mitosis increased in the basal layers, edema and inflammation persist along the root, collagen increases, peak bone resorption at day 8
11-21 days decreased inflammatory response, increased thickness and keratinization, bone formation
beyond 21 days epithelium appears normal, decreased vascularity as CT matures, at 4-6 weeks dentogingival junction and collagen are fully repaired
difference between modified Widman flap and internal bevel gingivectomy
Modified Widman flap goal is reattachment/attachment gain vs internal bevel gingivectomy is pocket elimination by resection.
Goal of osseous resective surgery
create physiologic contours that the gingiva will follow for pocket elimination
ostectomy vs osteoplasty
Ostectomy removes supporting bone, osteoplasty removes non-supporting bone
Contraindications for ostectomy
sites with deep probing depths (9-12mm) as too much attachment must be sacrificed to create positive architecture
Difference between crown lengthening and osseous surgery
Crown lengthening is performed in a healthy environment vs osseous surgery is an attempt to resolve a pocket.
Biologic width height of junctional epithelium
0.97mm
Biologic width height of supra-alveolar connective tissue
1.07mm
biologic width height of the sulcus
0.69mm
ENAP procedure technique
partial thickness inverse beveled incision from the gingival crest to the base of the sulcus and papilla thinned, the internal tissue incised, interproximal interrupted sutures placed.
modified Widman flap technique
requires perfect interproximal adaptation of the flap
a primary thinning partial thickness inverse bevel incision made parallel to the long axis of the teeth, on the palate an exaggerated scalloped incision.
demineralized freeze-dried bone vs freeze dried bone for allograft
demineralized has osteoinductive potential, freezedried has osteoconductive potential, can have osteoinductive if mized with autogenous bone
alloplast vs allograft
alloplast is synthetic, allograft is from a person
What is Emdogain
growth factors, enamel matrix proteins that induce mesenchymal differentiation on the root surface. used to regenerate bone, cementum, and PDL.
clean root with EDTA for 2 minutes, need to keep blood out
3 reasons GIngival augmentation is reccomended
suspected etiologies causing recession cannot be eliminated
inflammation cannot be controleld
recession continues to increase
factors to consider when considering gingival augmentation
age of aptient
level of OH
teeth involved
existing or potential esthetic concerns
recession wiht associated esthetic or sensitivity complaints
the patients overall dental/restorative needs and previous dental treatment
When is gingival augmentation not needed around natural teeth
when the recession is not progressing and if associated etiologies are controleld or eliminated
Miller classifications and root coverage predictibility
Class 1 - recession not reacing the MCJ. Complete root coverage expected
Class 2 - recession past the MCJ with no interproximal tissue loss. 100% root coverage can be anticipated
Class 3 recession with interproximal tissue loss, negates the chances for complete root coverage
Class 4 severe recession and soft and hard tissue loss. Root coverage should not be expected.
Thickness required of a FGG flap donor site
at least 1-1.5mm thickness. The bevel of a 15 blade is 1mm
Reasons for failure of FGG
Mobile graft, failure to remove adipose or glandular tissue, failure to obtain root coverage (wide posterior root where collateral circulation is inadequate.
For an FGG attempting to gain root coverage flap thickness
2-2.5mm - very thick graft
