MOS minor oral surgery 327 (331) Flashcards
acetylsalicyclic acid
aspirin
why use aspirin
analgesic
superior anti inflammatory properties to paracetamol
but ibuprofen more commonly used
prostaglandings in pain
trauma and infection causes breakdown of membrane phospholipids producing arachidonic acid
arachindonic acid can be broken down to form prostaglandins
these sensitise the tissue to other inflammaotyr products e.g. leikotrienes = pain
therefore if prostaglandin reduction is descreased - pain moderated
mechanism of action of aspirin
reduced prostagland production
inhibits COX1 and COX2 (150x better at COX1)
* reduces platelet aggregation and predisposes to gastric mucosa damage
mainly peripherally acting agent
antipyretic
* reduces temp raising effect of IL-1 and brain levels of prostaglandings
* reduces elevated temp in fever
* doesn’t bring temp below normal if temp normal prior to taking drug
anti inflammatory
* vasodilators and therefore affect capillary permeability
* reduced redness, swelling and pain
metabolic
* BMR inc
* platelet aggregation dec
* prothrombin dec
adverse effects of aspirin
GIT problems -care with GORD and ulcer pts; PGE2 and PGI2 )inhibit glastic acid secretion, inc blood flow through mucosa)
hypersenitivity - acute bronchospasm, skin rashes, allergies
overdose - tinnitis, metabolic acidosis
mucosa aspirin burns
aspirin interaction
WARFARIN
aspirin and warfarin
enhances warfarin
displaces from binding sites on plasma proteins inc warfarin availability
warfarin is usually bound and inactive
aspirin and warfarin
enhances warfarin
displaces from binding sites on plasma proteins inc warfarin availability
warfarin is usually bound and inactive
aspirin and pregnancy
reduces platelets in baby
inc haemorrhage risk
jaundice risk
delayed labour
reye’s syndrome - causes liver and brain swelling, seizures and coma
steroid pts and aspirin
25% develop PUD
aspirin can cause perforation
aspirin and pts with renal or hepatic issues
aspirin is metabolised in liver and excreted by kidney - so reduce dose
nephrotoxicity - PGE2 and PGI2 made in kidney; if inhibited then reduced sodium retention, poor renal perfusion and failure may result
hyperkalaemia adn interstitial nephritis possible
G6PD deficiency and aspirin
gluc-6-phos dehydrogenase
med and african populations
can develop acute haemolytic anaemia
max aspirin dose 1g per day
max dose ibuprofen
2.4g daily in adults
iburpofen caution
previous or active PUD
elderly
pregnancy/lactation
renal/cardiac impairment
hypersensitivity
asthma
taking other NSAIDs
long term systemic steroids
overdose of ibuprofen signs
3
nausea
vomiting
tinnitus
activated charcoak if more than 400mg/kg in last hour
e.g. cox-2 selective
celecoxib
use of celecoxib
useful anti-inflammatory actions
fewer damaging GI actions
has fewer upper GI effects compared to non-selectives
all NSAIDs inc selective COX-2 inhibitors are contraindicated in active PUD
selective cox-2 inhibitor
use of celecoxib
useful anti-inflammatory actions
fewer damaging GI actions
has fewer upper GI effects compared to non-selectives
all NSAIDs inc selective COX-2 inhibitors are contraindicated in active PUD
selective cox-2 inhibitor
cox-2 selectives mech of action
COX-2 enzyme resposible for generation of inflammatory prostaglandins altought sometimes COX-1 involved
PGE2 is generated in low physiolcal amounts by COX1 in gastric tissues and has protective effect
prostaglandins esp PGE2 are generated in excessive amounts during inflammation via elevated COX2 levels
* prodcues inc vasodilation, inc vascular permeablity and sensitises pain fibre nerve endings to bradykinin, 5HT and other mediators
acetaminophen
paracetamol
paracetamol mode of action
simple analgesic without anti-inflammatory action
- hydroperoxides generated from metabolism of arachidonic acid by COX and exert postive feedback to stimulate COX activity
- feedback is blocked by paracetamol which indirectly inhibits COX esp in brain
- helps reduce prostaglandin activity in the pain pathways of the CNS (e.g. thalamus)
effects of paracetamol
7
- analgesic
- antipyretic
- little anti-inflammatory action
- no effects on bleeding
- no significate warfarin interaction
- less irritant to GIT
- suitable for kids
cautions for paracetamol
3
renal impairment
hepatic impairment
alcohol dependence
side effects of paracetamol
4
rashes
blood disorders
hypotension when infused
liver damage and less freq kidney damage with OD
possible interaction with paracetamol
4
cytotoxics
domperidone (antemetic/sickness)
lipid regulating drugs
metoclopramide (antiemetic)
max dose paracetmol
4g for adults (8x500mg tablets)
risk hepatic damage (hepatocellular necrosis) and renal tubular necrosis
may not present for several days after
send to A&E for assessment
signs paracetamol overdose
3
anorexia, nausea, vomitting
for early 24hrs
persistence of nausea and start abdo pain (right subcostal - indicate hepatic necrosis)
liver damage is max at 3-4days - jaundice, renal failure, haemorrhage, hypoglyceamia, encephalopahty, cerebral oedema, death
caution to pts with paracetamol
other preparation often contain e.g. night nurse, co-codamol, coproxamol
opioid analgesic used in dentistry
dihydrocodeine
dihydrocodeine qualities
acts in spinal cord- dorsum horn pathways and associated palei-spinothalamic pathway
* specific receptors which are closely associated with neuroanl pathways that transmit pain to CNS
* withdrawal from drug will lead to psychological cravings and pt will be ill
BNF states relatively ineffective in dental pain
opioid issues
tolerance and dependence
tolerance and opioids
pt build up tolerance, dose needs progressivly inc to have same effect
opiod effect on smooth muscle
constipation
urine and bile retention
opioid side effects
constipation
vomitting
drowsiness
pupil constriction
tolerance and dependence
inc salivation
opioid interactions
enhanced by alcohol
antidepressants and mono-amine oxide inhibitors
dopaminergics (parkinsons)
dihydrocodeine caution with
hypotension
asthma
pregnancy/lactation
renal and hepatic disease
elderly and children
never in raised intracranial pressure or head injury
overdose of opioid
signs
management
degrees of come, resp depression and pupil constriction
naloxone - antidotes to coma/bradypnoea (amount dependent on severity)
carbamazepine is an
anti-epileptic/anti-neuropathic drugs
carbamzepine uses in dental setting
3
trigeminal neuralgia
post herpetic neuralgia
functional, TMD, atypical facial pain
dose for cabmazepine
100mg tablets
1 tablet, 2 times daily
send 20 tablets(10days)
build up from there
dose for paracetamol
500mg tablets
2 tablets, 4 times a day
send 40 tablets (5 day)
dose for ibuprofen
400mg tablets
1 tablet, 4 times a day
send 20 tablets (5day)
what to do when pt on carbamazepine
monitor pts bloods and liver function - FBC and liver function tests
side effects of carbamazepine
* leukopenia
* dizziness
* ataxia
* drowsiness common
contraindications to carbmazepine use
3
AV conduction abnormalities (unless paced)
history of bone marrow depression
porphyria
other useful drugs for neuropathic pain
2
not on dental list
gabapentin
phenytoin
GMP or oral med
common side effects of carbamazepine
4
leukopenia
dizziness
ataxia
drowsiness
basic stages of surgery
10
consent (written)
anaesthesia
surgical access
bone removal as necessary
tooth division as necessary
procedure
debridement
suture
achieve haemostatsis
post op instructions and medications
principels of surgical access
11
- wide based incision (circulation)
- scalpel in 1 firm continuous stroke
- no sharp angles
- adequately sized flap
- flap retraction down to bone and done clearly
- minimise trauma to ID papillae
- no crushing
- keep tissue moist
- ensure flap margins and sutures on sound bone
- ensure closure not under tension
- aim for healing by primary tension -> minimise scarring
purpose of soft tissue retraction
3
and how
- access to operative field
- protection of soft tissues
- flap design facilitates retraction
dones with care using
* Howarth’s periosteal elevator
* rake retractor
equipment for bone removal and tooth division
eletrical straight handpience with saline cooled bur
air driven handpiece - may lead to surgical emphysema
bur made of tungsten carbide
* round bur for buccal gutter
* fissure bur for separation
protect soft tissues and caution of nerves if bur slips
priciples of elevator use
mechanical advantage, avoid excessive force
support instrument to avoid injury to pt should it slip
ensure applied force away from major structures e.g. antrum, IDC, mental nerve
always use in direct vision
movements
* wheel and axle
* wedge
* lever
3 modes of surgical debridement
physical
* bone file or nibblers to remove sharp bony edges
* mitchell’s trimmer or victoria currette to remove soft tissue debris
irrigation
* sterile saline into socket and under flap#
suction
* aspirate under flap to remove debris
* check socket for retained apices etc
aims of suturing
5
- reposition tissues
- cover bone
- prevent wound breakdown
- achieve haemostasis
- encourage healing by primary intention
types of suture
monofilament (monocryl R, nylon, prolene NR)
single stranded, pass easily through tissue, resistance to bacterial colonisation
polyfilament (vicryl R, silk NR)
severeal filaments twisted together, easier handling, prone to wicking
resorbable or non resorable (silk)
peri-operative haemostasis
4
LA with vasoconstrictor
artery forceps
diathermy
bone wax
post operative haemostatsis
5
pressure and damp gauze
LA infiltration
diathermy
surgicel - oxidised cellulose
sutures
causes of tooth fracture
6
thick cortical bone
root shape and number (splayed, bulbous, kinks)
hypercementosis
ankylosis
caries
alignment
difficult access causes
4
microstomia (small mouth)
scarring
tooth crowding
trismus
abnormal extraction resistance causes
4
thick cortical bone
shape/form/no roots
hypercementosis
ankylosis
causes for buccal alveolar plate fracture
3s and 6-8s
excess force
fractures peri op situations
tooth
root
bone - maxilla tuberosity, mandible, alveolar plate
locate fracture and decide if need to go surigcal to get rest out
beware - sinus, IDC
maxiallary tuberosity # aetiology
5
- single standing molar
- unknown unerupted 8
- patholgical gemination
- extraction in wrong order - should be back to front, lower then upper
- inadequate alveolar support
tx of maxillary tuberoisty #
- remove/tx pulp
- splint and ensure occlusion free
- antibiotics and antiseptics
- post op instructions
- remove tooth 8 weeks later
aetiology of mandible # peri op
impacted 8
large cyst/atrophic mandible
excessive force and inadequate support
dx of oro-antral communication
7
- radiographic position of roots in relation to sinus
- bone came out with roots
- bubbling of blood
- nose holding test (can create an OAF)
- direct vision
- good light and suction - change in sound
- probe - careful, avoid as can create
management of OAC if small
post op instructions - avoid nose blowing, muscial instruments, straws, smoking
review
managment of OAC if large
suture over
post op instruction
antibiotics cover?
loss of tooth management
stop
where is it
suction
radiograph - into sinus/inhaled
damage to nerves/vessels perio op can be by
4
crush
cutting/shredding
transection
from LA
may not know at the time
neurapraxia
contusion of nerve/continuity of epineural sheath and axons maintained
axontemesis
continuity of axons but not epineural sheath (disrupted)
neurotemesis
complete loss of nerve
anaesthesia
numbness
paraesthesia
tingling
dyseasthesia
unpleasant sensation/pain
hypoaesthesia
reduced sensation
hyperaesthesia
inc/heightened sensation
dislocation of TMJ management
relocate immedaiated (analgesia and advice - support)
unable to relocated - try LA into masseter intraorally or referral A&E
muscle spasm
how manage broken instruments peri op
stop
where
can retrieve?
radiograph?
consent for XLA
pain, bleeding, brusing, swelling, infection
damage to adj teeth/restorations,
damage/extraction to developing tooth (if primary XLA)
temporary or permanent altered senation
jaw stiffness/fracture
need for another procedure/RR
sinus involvement - radiograph
