Final Revision Flashcards
How can you protect yourself, your patients and your colleagues?
by being immunized against diseases where vaccines are available
ex: Hepatitis B
Which is the single most effective way to prevent the spread of infection?
hand washing routinely AFTER every clinical examination
Hand wash with:
soiled hands:
dirty hands:
soiled hands: soap and water
dirty hands: soap and water OR alcohol based rub/gel
What you should always do when contact with blood, mucous membranes or non –intact skin?
Always wear surgical gloves
What is S O C R A T E S?
- Site
- Onset
- Character
- Radiation
- Associated symptoms
- Timing
- Exacerbating + relieving factors
- Severity
What are the vital signs on the form?
BP, Pulse, Tm
Normal Tm:
35.8 - 37.2 degrees celsius
How to measure the Tm?
digital thermometer under the tongue, or external auditory meatus or Forehead area
Examination sequence for Arterial pulses from radial a:
- Place the pads of your 3 middle fingers over the right radial a
- Assess rate, rhythm and vol
- Count pulse rate over 15sec and multiply by 4 to obtain the bpm
Examination sequence Blood Pressure:
- patient seated or lying down
- can measure over thin clothing
- sphygmomanometer cuff to the upper arm, with the center of the bladder over the brachial a
- palpate the brachial pulse
- Inflate the cuff until the pulse is impalpable
- listen through the diaphragm of the stethoscope
- Deflate the cuff slowly
- Continue to deflate the cuff slowly until the sounds disappear
- Record the pressure at which the sounds completely disappear as the diastolic pressure
What do you examine in oral cavity examination?
mouth opening lips buccal mucosa tongue soft and hard palate uvula tonsils and pillars teeth, gums and alveolar margins stensens/parotid duct
Angina is a symptom of what?
ischemic heart disease
Angina results from what?
coronary disease
-not enought O2 supply
Which the aetiology of angina?
progressive narrowing or spasm of one/more coronary a
What are the symptoms of angina?
- heavy pressure
- radiates to left shoulder, arm and mandibular region
- intense sense of not breathing good
- nausea
- sweating
- bradycardia
When does the discomfort typically disappear?
- once the myocardial work requirements are lowered
* the oxygen supply to the heart muscle is increased
Which are the preventing measures?
- begin with taking a careful history of patient’s angina
- ask patient about the events that precipitate angina
- frequency, duration, severity of angina
- response to medications or diminactivity
- patient’s physician can be consulted about the patient’s cardiac status
When can you do an ambulatory surgery of an angina patient?
- if it arises only during moderately vigorous exertion
- if it responds readily to rest and oral nitroglycerin administration
- if no recent increase in severity
When the elective surgery should be postponed?
- if angina episodes occur with only minimal exertion
- if several doses of nitroglycerin needed to relieve chest discomfort
- if the patient has unstable angina
Controversy w/ angina patients:
for local anesthetics but benefits outweigh the risks
When does Myocardial infarction occur?
ΕΜΦΡΑΓΜΑ
- when ischemia causes myocardial cellular dysfunction and death
- when an area of coronary artery narrowing has a clot form that blocks all or most blood flow
When can you have a surgical procedure if you had Myocardial infarction?
at least 6 months after an infarction
The advent of thrombolytic-based treatment strategies and improved MI care make automatic 6-month wait to do dental work unnecessary
SOS T OR F
Pacemakers pose no contraindications to oral surgery and no evidence exists that shows the need for antibiotic prophylaxis
true
What are the symptoms of congestive heart failure?
paroxysmal nocturnal dyspnea
ankle edema
What is Orthopnea?
=respiratory disorder that exhibits shortness of breath when the patient is supine
-use of several pillows to upper body
What is Paroxysmal nocturnal dyspnea?
=respiratory difficulty 1/2 h after lying down
-Patients suddenly awake awhile after lying down to sleep feeling short of breath and are compelled to sit up to try to catch their breath.
Patients with asthma should be questioned about:
- precipitating factors
- frequency and severity of attacks
- medications used
- response to medications
When Elective oral surgery is best undertaken?
the day AFTER a dialysis treatment has been performed
What drugs does the patient require for surgery after renal / other organ transplantation?
corticosteroids
supplemental corticosteroids in the perioperative period
Hypertension:
=chronically elevated blood pressure for which the cause is unknown
Mild to moderate hypertension:
is usually not a problem in the performance of ambulatory oral surgical care
Elective oral surgery for patients with severe hypertension should be:
Emergency oral surgery in severe hypertensive patients should be:
postponed until the pressure is better controlled
performed in a well-controlled environment or in the hospital so that the patient can be carefully monitored during surgery and acute blood pressure control subsequently arranged
When surgical procedure is planned, is it best to err on the side of hyperglycemia or hypoglycaemia?
hyperglycemia so is best to avoid an excessive insulin dose and to give a glucose source
What happens if signs of hypoglycaemia-hypotension, hunger, drowsiness, nausea, diaphoresis, tachycardia or a mood change occur?
an oral or IV supply of glucose should be administered
Ppl with well-controlled diabetes are:
Ppl with uncontrolled diabetes:
no more susceptible to infections than are persons without diabetes
have more significant difficulty in containing infections
What should be deferred in patients with uncontrolled diabetes until control is accomplished?
elective oral surgery
-may also give prophylactic antibiotics routinely to patients with diabetes undergoing any surgical procedure
Hyperthyroidism - symptoms of a thyrotoxic crisis?
restlessness, nausea, abdominal cramps, high fever, diaphoresis, tachycardia, and cardiac decompensation, death
Patients left untreated or incompletely treated can have a thyrotoxic crisis caused by the sudden release of large quantities of preformed thyroid hormones
Hereditary coagulopathies:
prolonged bleeding after the extraction of a tooth may be the first evidence that a bleeding disorder exists
-all patients should be questioned concerning prolonged bleeding after previous injuries and surgery
- epistaxis (nosebleeds)
- easy bruising hematuria
- heavy menstrual bleeding
- spontaneous bleeding
Which is the best method to standardize PT values within and between hospitals?
How to measure the anticoagulant effect of Warfarin?
INR
Quantitative problem:
Qualitative problem:
below 50 000/ mm3
higher than 50 000/ mm3
Platelet counts under 20 000/ mm3 usually require:
- presurgical platelet transfusion or
* a delay in surgery until platelet numbers rise
Patients taking heparin usually can have their surgery:
DELAYED UNTIL circulating heparin is INACTIVE
-otherwise use Protamine sulfate
SOS
Myocardial oxygen demand can be increased by:
anxiety
exertion
relaxing
anxiety
exertion
When should patients stop taking warfarin?
2 / 3d before the planned surgery
On the morning of surgery the INR value should be:
- If it is b/w 2 -3 INR: routine oral surgery
- If the PT is still greater than 3 INR, surgery should be delayed until the PT fall to 2 INR
-will allow the INR to drop to about 2
Defer surgery until the platelet-inhibiting drugs:
- have been stopped for 3 days
- on the day after surgery if no bleeding is present
Techniques of local anesthesia for oral and maxillofacial surgery:
- Topical anesthesia,
- Infiltration anesthesia,
- Regional block anesthesia
Topical anesthesia:
-on oral mucosa
-prior to local anesthetic injections in the mouth
to lessen the discomfort needle penetration
- creams,
- ointments and
- sprays
Most commonly used as topical anesthetics in the mouth are:
lidocaine
benzocaine
Infiltration anesthesia is useful in providing:
- localized skin and mucosal anesthesia
* anesthesia for some teeth and part of the jaws
Infiltration anesthesia is done in:
It is the technique of choice
- in maxilla for dental pulp
- in children mandible for dental pulp of deciduous teeth
- in mandible for incisors
ADV of Slow injection:
- reduce discomfort
- increase success
- may lessen the effects of systemic problems
The infiltration local anesthesia allows:
- 45 min for anesthesia of pulps
* soft tissue anesthesia is longer (1.5-2)
Mandibular nerve block anesthesia:
a. Inferior alveolar n block
b. Mental n block
c. Buccal n block
d. Lingual n block
Maxillary nerve block anesthesia:
a. Infra orbital n block
b. Nasopalatine n block
c. Greater palatine n block
d. Anterior superior alveolar n block
e. Middle superior alveolar n block
f. Posterior superior alveolar n block
Inferior alveolar n block anesthetizes:
- teeth on same side of mandible
- mandibular bone to midline
- soft tissues of lower lip to midline
- gingiva from premolars to midline
- lingual nerve
- buccal nerve
- Halstead method
- pterygo-temporal space
- in the region of the mandibular foramen
Inferior alveolar n block technique:
- thumb on coronoid notch
- contralateral to lower premolar
- needle height: halfway of operator’s thumb nail
- until bone is contacted
- 1.5-2 ml of solution
When long-acting solutions are employed anesthesia of the teeth can last for:
6-8 hours
Mental nerve block anesthetizes:
- teeth and jaw from premolars anteriorly
- soft tissues of lower lip and chin to midline on one side
Mental alveolar n block technique:
- inserted at depth of B sulcus b/w premolars
- below premolar apices
- 1.5 ml of solution
How is Buccal n block anesthetized?
-B gingiva and mucosa and part of the cheek in the mandibular molar region
-can be anesthetized by either:
B infiltration
Regional block
Infraorbital nerve block:
intraoral or the extraoralsides
Infraorbital nerve block intraoral approach involves:
inserting a long needle high into the buccal sulcus between the premolar teeth and advancing towards the infraorbital foramen which is being palpated extraorallyby the operator’s non-syringe hand
-1-1,5ml of solution
Infraorbital nerve block anesthetizes:
•teeth and bone from P2 - I1 •gingiva adjacent to these teeth •mucosal and skin surfaces of one half of the upper lip •part of skin on lateral nose aspect •ant sup alveolar n block
Nasopalatine nerve block anesthetizes:
hard palate tissues adjacent to incisors bilaterally
- 0.2-0.5 ml of solution
- incisive papilla
Greater palatine nerve block
- palate soft tissues from foramen anteriorly to canine
- 0.5 ml of solution
Duration of anesthesia is not as long as with mandibular blocks:
Indeed both palatal infiltration and blocks provide a similar duration of around 45 minutes of soft tissue anesthesia
Anterior superior alveolar nerve block anesthetizes:
- maxillary I and C on one side of jaw
- infraorbital n block or buccal infiltration
Middle superior alveolar nerve block anesthetizes:
- buccal infiltration of P2 apex
- maxillary premolar pulps and MB pulp of the maxillary M1
Posterior superior alveolar nerve block anesthetizes:
maxillary M and bone and B gingiva associated
Intrapulpal anesthesia:
- exposure of the tooth pulp
- key to success is delivery of solution under pressure
- anesthetize one pulp canal of a multirooted tooth
- needle fitting tightly the pulpal exposure by advancement of the needle into pulp canal
Local anesthetic drugs:
in current use: amides
allergic to amides: esters
-benzoxaine and tetracaine (rare)
2 major differences b/w esters and amides:
- metabolism (hepatic metabolism amides except Articaine which is in plasma, esters in plasma)
- allergies
Conventional agents:
Long-acting agents:
- Conventional agents for better operative anesthesia
* Long-acting agents for postoperative pain control, in combination with general anesthesia
Lidocaine:
-epinephrine vasoconstrictor
for the teeth
-2% conc
Mepivacaine:
-2% conc w/ 1:100 000 epi
= lidocaine w/ epi
-3% without vasoconstrictor
Bupivacaine:
- LONG LASTING local anesthetic
- 0.25-0.75% with and without epi
Localized complications from:
- physical damage from needle
- chemically as a result of LA
a. Nerve damage
b. Motor nerve paralysis
c. Trismus
d. Intravascular injection
e. Βroken needle
Systemic complications from:
i. Allergy
ii. Infection
iii. Toxicity
iv. Drug interactions
Nerve damage:
- most commonly affected is the lingual n
- physical trauma from the needle
- can result in altered sensation lasting for a few weeks
Motor nerve paralysis:
- facial n function may be affected if solution is injected into the substance of the parotid gland
- temporary paralysis
Trismus:
- Mandibular block techniques involve deep penetration of the needle and this may cause minor bleeding
- If this occurs in the medial pterygoid muscle it can lead to muscle spasm and the inability to fully open the mouth
- This problem does usually resolve after few weeks
Intravascular injection:
-aspirating technique should reduce these chances
Allergy:
- many individuals who claim to be allergic, are found not to be so after formal testing
- ester allergy is more common than amide (rare)
Dentoalveolar abscess bacteria type, pain due to and clinical features:
- anaerobes
- severe pain and tenderness on percussion or touching the tooth during mastication, pyrexia and lymphadenopathy
-The pain is due to
the local release of inflammatory mediators such as kininsand histamines, and
fluid exudates causing increased pressure in the confines of underlying alveolar bone.
The fate of acute dentoalveolar abscess depends on:
- number and virulence of invading microorganisms
* patient’s resistance
The spread of the infection will be governed by:
- tooth position in alveolus
- relationship of infected teeth apices
- muscle attachments
- their proximity to L and B surfaces of jaw bones
The invading microorganisms may be destroyed by:
- natural body R
- antibiotics prescription
- removal of infection source by extraction or endodontic means
Chronic dentoalveolar abscesses and periapical granulomas:
- are generally asymptomatic
* unless or until, reignited in an acute phase
Chronic abscesses radiographic appearance:
radiolucent
In the acute phase, the earliest changes are:
PDL thinning
LD loss
radiolucency with ill defined margins
Which can act as barriers against spread of infection?
Bone, muscle, aponeurosis or fascia, neurovascular bundles and skin
Buccal space:
- spreads intraorally superficial to buccinator m
- swelling confined to cheek
- buccinator m can control the effect of the infection
Palate:
-infection originating from the maxillary I2 or the palatal roots of the posterior teeth
Submasseteric space:
- commonest source of infection is from lower M3 pericoronitis
- Severe TRISMUS due to spasm of the masseter muscle is a characteristic feature of involvement of this fascial space
- This space is bound medially by the masseter m and laterally by the outer surface of mandibular ramus
Submandibular space:
- below the mylohyoid m, medial to ramus and mandibular body
- Infection from the posterior mandibular teeth
- swelling of the submandibular regions
Sublingual space:
- result of perforation of the lingual cortex above the attachment of the mylohyoid m
- infection in this space will raise the floor of mouth and displace the tongue medially and posteriorly
Canine fossa:
- originates from maxillary C or upper premolars and buccinator m attachment
- swellings obliterate the nasolabial fold
Management of patients with orofacial infection:
- surgical intervention to drain localized pus
* medical support
Fluctuation of the swelling indicates:
presence of pus
Antibiotics can be provided:
- empirically
- a specific antibiotic given based on culture and sensitivity tests
Penicillin has the potential to be the first-line agent in the treatment of:
- odontogenic infections
- other beta-lactam antibiotics not as effective
- Amoxicillin is a useful broad-spectrum drug in this context, but better Metronidazole
Analgesics:
temporary relief of pain until the causative factors of infection have been brought under control
The choice of analgesic should be based on patient’s suitability:
•Non-steroidal anti-inflammatory drugs are used in mild to moderate pain
•Paracetamol, ibuprofen are adequate for most mild pain secondary to dental infection
Ludwig’s angina:
=diffuse cellulitis
-Bilateral involvement of submandibular, submental, and sublingual spaces
symptoms: swollen skin of the neck, tenderness,
elevation of the floor of the mouth, trismus, tongue edema and dysphagia
The infection of Ludwig’s angina may be:
•secondary to the spread of infection from mandibular teeth
•penetrating injury to mouth floor
Ludwig’s angina is a life-threatening condition which demands emergency treatment
Osteoradionecrosis:
=type of bone necrosis which occurs following radiotherapy to the jaw region and often becomes secondarily infected
- reduces vascularity and renders the bone vulnerable to infection
- 55 Gy of radiation
Osteoradionecrosis treatment:
•Extraction and other surgical procedures •Primary closure of socket •pre and postoperative antibiotics •antiseptic mouthwash •good OH •hyperbaric oxygen to increase blood supply of affected bone •better radio beam collimation and protection of tissues adjacent to tumors
Causes of dentofacial infections:
•94% odontogenic etiology
Periapical infection
Periodontal
Post exodontia
•Other Causes
fractures
local surgery
contaminated needles
Clinical picture •pain •edema •fever •redness •Responsible bacteria: Gram + Gram- aerobic and anaerobic
Dentofacial infections treatment:
•Surgical drainage •Antibiotics therapy IV Penicillin 1 gr/6h Flagyl 500mg/8h •Removed the causes
Scalpel Handle:
- surgical procedures begin with an incision
- reusable handle, blade sterile and disposable
- No 15 most commonly used, it is small and is used to make incisions around teeth and through soft tissue
- No 10 large skin incision
- No 11 small stab incisions for incising into an abscess
- No 12 mucogingival procedures
Blades DULL EASILY when they come into contact with hard tissue such as bone or teeth
-hold it in the pen grasp
-The blade is held along the unsharpened edge
-The handle is held so that the male portion of the fitting is pointing upward
-slowly slid onto the handle along the grooves in the male portion until it clicks into position
-The scalpel is unloaded similarly.
•The needle holder grasps the end away from the blade and
•lifts it to disengage it from the male fitting.
-The scalpel is then slid off the handle, always away from the body
-The used blade is immediately discarded into a specifically designed, rigid-sided sharps container
When an incision is made through the periosteum, it should be reflected
from the underlying cortical bone in a single layer with a:
periosteal elevator
- pointed end to begin the periosteal reflection
- rounded end is used to continue the elevation of the periosteum from bone
Good access and vision are essential to performing excellent surgery.
A variety of retractors have been specifically designed to retract:
- cheek, tongue, and mucoperiosteal flap
- to provide access and visibility during surgery
- protect soft tissue from sharp cutting instruments
Adson forceps:
- grasp soft tissue to incise it
- stop bleeding
- pass a suture needle
-with or without small teeth at the tips
College or cotton forceps:
- loose fragments of tooth
- amalgam
- other foreign material
- placing or removing gauze packs
-angled forceps
Hemostat:
For most dentoalveolar surgery, pressure on wound is usually sufficient to control bleeding
Occasionally, pressure does not stop the bleeding from a larger artery or vein.
-variety of shapes, straight or curved
-long, delicate beaks used to grasp tissue and a locking handle
-used for suturing and controlling hemorrhage
-used to remove:
•granulation tissue from tooth sockets and
•to pick up small root tips,
•pieces of calculus,
•amalgam,
•fragments, and
•any other small particles that have dropped into the wound or adjacent areas
Rongeur forceps:
-has sharp blades that are squeezed together by the handles, cutting or pinching through bone
-rebound mechanism so that when hand pressure is released, the instrument reopens
-2 major designs:
•side-cutting forceps
•side and end-cutting forceps
end cutting => in sockets for removal of inter-radicular bone and to remove sharp edges of bone
side-cutting and end-cutting forceps => most dentoalveolar surgical procedures that require bone removal
•used to remove large amounts of bone in MULTIPLE bites, not in single bites
The handpiece must not exhaust air into the operative field b/c:
may produce tissue emphysema
Bone File:
- ONLY for final BONE SMOOTHENING before completing/final surgery
- double-ended instrument
Bone Curette:
- removing Soft Tissue From Bony Cavities
- to remove granulomas or small cysts from periapical lesions
Once a surgical procedure has been completed, the mucoperiosteal flap is returned to its original position and is held in place by sutures
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Needle Holder:
- locking handle and a short, blunt beak
- intraoral placement of sutures
- shorter and stronger beaks than hemostat beaks
- face of a beak is cross-hatched to permit a +ve grasp of suture needle
Needle Holders:
-thumb and ring finger are inserted through the rings
-index finger is held along the length of the needle holder
second finger aids in controlling the locking mechanism
Scissors are held in the same way as are needle holders
The materials are classified by:
- diameter,
- resorbability,
- monofilament or polyfilament
Non resorbable suture materials include:
Resorbable suture materials include:
silk, nylon, vinyl, and stainless steel
most commonly used sutures for the oral cavity is 3-0 black silk
polyglycolic acid and polylactic acid
Monofilamentsutures:
Polyfilamentsutures:
nylon, and stainless steel
Monofilament sutures do not cause this wicking action but may be more difficult to tie and tend to come untied
silk, polyglycolic acid, and polylactic acid
-A combination of the two would be preferable
Suctioning:
To provide adequate visualization, blood, saliva, and irrigating solu-tions must be suctioned from the operative site
Dental elevators:
- to loosen teeth from surrounding bone (extractions easier)
- to expand alveolar bone
- used to remove broken or surgically sectioned roots from their sockets
The three major components of the elevator are:
- the handle
- shank
- blade
- blade transmits force to tooth, bone, or both
- cross-bar or T-bar handles are used
(1) the straight type
- > most commonly used
- > displace roots and luxate teeth
- > index finger near the blade !!
(2) the triangle type -> L and R (Cryer)
- >when a broken root remains in tooth socket and adjacent socket is empty
(3) the pick type
Extraction forceps are instruments used for:
removing the tooth from alveolar bone
expand bone
The basic components of dental extraction forceps are:
- the handle
- hinge
The hinge transfers and concentrates the force applied to the handles to the beak
•beaks
The beak is designed to adapt to the tooth root near the junction of the crown and root
- beaks of maxillary forceps are usually parallel to the handles
- BEAKS of the forceps are designed to be adapted TO the ROOT structure of the tooth and not to the crown of the tooth
Maxillary forceps are held with the palm:
underneath the forceps so that the beak is directed in a superior direction
Maxillary Premolars:
- s-shaped viewed from sides
- straight viewed from above
Maxillary Molars:
-beak with a pointed design will fit into B bifurcation
Root-tip forceps or Bayonet:
are used primarily to remove broken maxillary molar roots
•but can be used for the removal of narrow premolars and for lower incisors
Forceps for the single-rooted teeth:
vertical hinge
beaks to fit near the cervical line
ONLY a single mandibular M forcep is for the both sides, in contradistinction to maxilla, for which a right-and left-paired molar forceps set is required
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Basic Necessities For Surgery:
(a) adequate visibility
- >(1) adequate access -retract tissues
(2) adequate light -continuously reposition, avoid obstructing it and more than one overhead light
(3) a surgical field free of excess blood and other fluids -High-volume suctioning
(b) assistance
Principles of surgical incisions
- The 1st principle: a sharp blade of the proper size should be used
- The 2nd principle: a firm, continuous stroke should be used when incising
- The 3rd principle: surgeon should carefully avoid cutting vital structures when incising
- The 4th principle: incisions through epithelial surfaces should be made with the blade held PERPENDICULAR to the epithelial surface, which produces squared wound edges
- The 5th principle: incisions in the oral cavity should be properly placed
Flap Design:
- gain surgical access to an area
- move tissue from one place to another
complications:
•necrosis
•dehiscence
•tearing
- apex (tip) of a flap should never be wider than the base unless a major artery is present in the base
- parallel to each other
- length of a flap should be no more than twice the width of the base
- base should be greater than the length of the flap
- axial blood supply
- base of flaps should not be excessively twisted, stretched, or grasped
3 types of properly designed oral soft tissue flaps:
- Horizontal and single vertical incisions used to create two-sided flap.
- Horizontal and two vertical incisions used to create three-sided flap.
- Single horizontal incision used to create single-sided (envelope) flap
Monofilaments ADV and DISADV:
ADV:
- cleaner
- less suture marks on
- no tendency to wick
DISADV:
- harder to knot
- more likely to become unknotted
- more likely to irritate the tongue and cheeks
Silk:
is a natural product from the silkworm used as a non-resorbablesuture material and is always braided.
It is very easy to knot and lies flat easily but does have to be removed, food does tend to stick to it, and
if not kept clean, it will cause wicking and possible infection.
On the skin, it will leave suture marks if not removed after a few days
Types of Needles:
- round-bodied needle is non-cutting and used on friable internal organs
- cutting needle is triangular in cross-section with one edge sharpened to cut through the tissues
- forward-cutting needle has the cutting edge on the inside of circle
- REVERSE -cutting needle has the cutting edge is on the OUTSIDE of the circle and is PREFERRED
->combine the best of all properties with a reverse-cutting tip and then a round-bodied needle
Suturing techniques:
- needle should enter the surface of tissue at a 60 to 90 angle
- rotation of wrist and forearm
The simple interrupted sutures:
- most frequent
- placing around 3 sutures per cm of length
- ADV: the loss of one suture may not compromise the whole suture line
The Vertical and Horizontal mattress suture:
-vertical mattress sutures can be used when suturing over a dead space such as a cyst cavity or an oroantral fistula
Continuous sutures locking or non-locking:
- can be locked for better closure and better waterproofing of the suture line
- the risk with a continuous suture is that if it does break, the whole suture is rendered worthless
- a locking: for intraoral
- a nonlocking: for cutaneous
The running subcuticular suture:
- excellent skin closure technique
- each needle pass needs to be 2—3 mm but backing up 1 mm on the previous needle pass on the opposite side of the wound
- the suture needs to come to the surface every 2 cm to facilitate removal
CBCT is based on volumetric tomography, in contrast to conventional fan-beam CT where slices are scanned.
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Radiological signs:
- location and size
- periphery and shape
- internal structures
- effects on surrounding structures
Low-dose high-resolution CT is recommended when:
failed medical treatment
complications
malignancy
- Plain films-first step
- CT provides more diagnostic information than plain films
- Bone scintigraphy has a higher sensitivity
- MRI has a high sensitivity
MRI could be helpful to differentiate between cysts and tumors
CT indicated to locate the relation of the mandibular canal to the cyst and teeth
In these cases radiography is indicated, as well as in patients with:
- polyarthritic conditions
- trauma
- tumors
- ankylosis
- developmental anomalies
CT imaging provides detail for bony abnormalities, such as:
- ankylosis
- fractures
- osseous tumors
- arthrosis
- 3D images can be produced
MRI has gradually replaced arthrography and information about:
- disk position
- joint fluid
- bone marrow changes
- bone structure at multiple levels of joint
It is important to distinguish active bleeding from surgical site oozing
active bleeding:
- mouth filling complain
- blood immediately after removing a gauze dressing or other pressure
Oozing:
- resolved w/in 36-72h post operatively
- should respond to pressure
- discomfort for patient
Patients taking clopidogrel (Plavix), aspirin and other non-steroidal anti-inflammatory medication don’t need to stop their medications prior to routine dentoalveolar procedures
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Minor oral surgical procedures, such as single tooth extraction, can be done while the patient on warfarin and a INR <2.5
•Multiple tooth extraction,(more than two) can be done while the patient on warfarin and a INR <2.0
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Arterial bleeds that cannot be controlled with local measures should be treated with ligation or electrocautery
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Pain associated with routine dentoalveolar procedures usually begins
•with the resolution of LA (6-12 hours) and
•typically peaks between 24 and 48 hours post operatively
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Post operatively the use of:
Preoperative the use of:
Post operatively:
•non-steroidal medications
•opioids
preoperative:
•non-steroidal anti inflammatory drugs
The onset of swelling is:
- b/w 12 and 24h following the procedure
- w/ a peak swelling noted 48-72h post operatively
begins to subside at 4d post operatively
•with most patients experiencing resolution of surgical edema
•within 1 week post operatively
The incidence of postoperative inflammatory complications increases with:
- age
- smoking
- pre-existing infection/pathology in the surgical area
- lack of surgical experience
These can reduce the possibility of infection:
- Careful tissue management,
- debridement/curettage of necrotic/infected tissue, and
- thorough irrigation of the wound site
Cellulitis:
•requires prompt treatment with an empiric course of antibiotics
Alveolar osteitis/dry socket:
- a severe throbbing, radiating pain to ears, eyes etc
- malodour from the surgical site
- trismus
- bad beath
- bad taste
- blood clot lost
- healing delayed
- bone becomes exposed
- 3—5 days post operatively
Alveolar osteitis/dry socket treatment :
•gentle irrigation of wound area w/ warm saline
•application of medicated packing to area
e.g. eugenol dressings, and aggressive use of oral analgesics.
-The packing should be changed every 24 hours until symptoms subside
-As the condition is self-limiting,
•the treatment is supportive,
•with pain control being the primary goal
Root fracture Prevalence and etiology:
- excessive forces applied during extraction
- inadequate separation of roots
- commonly unavoidable due to the root anatomy and bone quality
Root fracture prevention:
- proper surgical technique,
- minimizing excessive forces, and
- carefully ensuring that teeth are adequately elevated and mobilized prior to luxation
Displacement of tooth fragments can occur into:
infratemporal fossa
maxillary sinus
submandibular space
inferior alveolar canal
Oroantral communication may result from:
- excessive manipulation of operative site
- poor technique
- intimate anatomic associations b/w roots of teeth and maxillary sinus floor
Any patient with a communication should be placed on:
- sinus precautions
- antibiotics
- nasal decongestants
first intention or primary intention:
is closed primarily with sutures and healing proceeds rapidly with no dehiscence and minimal scar formation
second intention associated with:
avulsed injury,
local infection,
or inadequate closure of the wound
third intention:
secondary healing with delayed primary closure
Stages of Wound Healing:
The healing continuum of •hemostasis •inflammatory •proliferative •remodeling .
You must remember that
•no wound in skin, oral mucosa, or muscle,
heals without scar formation
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Local Factors That Impair Wound Healing:
- Foreign material
- Necrotic tissue
- Ischemia
- Tension
General factors affecting the healing of oral wounds:
- Location of wounds
- Physical factors
- Circulatory factors
- Nutritional factors
- Age of patient
- Infection
- Hormonal factors
Bone healing process after fracture is similar to skin healing except that it also involves calcification of the CT matrix.
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Urgent situation definition:
suddenly fall into beyond the usual clinical condition of the patients
Principal Causes of Complications and Emergency Situation:
A. Stress
B. Decreased body defense
C. Bad medical manipulations and assessment
Absolute Contraindications for any oral surgery procedure:
- Unstable angina or newly installed
- Acute or recent stroke (3-6 months)
- Uncontrolled arrhythmia
- Malignant uncontrolled hypertension
Measure for Prevention:
- Appropriate patient approach
- Familiarity with the environment
- Drug coverage -physician instructions
- Depth of analgesia
- Avoid abusive interventions
Suppression Stress -Anxiety:
- NIGHT: Sedative before sleep
* ONE HOUR BEFORE THE SURGERY: Sedative
Sudden Tachycardia: A.B.C.
•100 to 160 bpm –sinus arrhythmia no treat •160-200 bpm -paroxysmal arrhythnia bulb or carotid irritation •200-300 bpm -risk for infarction or arrest
Hypertension> 160 mmHg
Wait 5-10 minutes and repeat antihypertensive
Management:
Stop any intervention
•Blood pressure measure
•Pain control with analgesia
•Stress control
