Oral Surgery Flashcards
Why would be decide to raise a mucosal flap?
Gain ACCESS to an object/structure e.g. a
retained root / apex (but could also be for
intrabony pathology or ORIF of a fracture)
Flaps permit targetted bone removal
Mucosal flaps can also be useful to cover up
exposed structures such as OAC closure or
exposed dentine
Describe a One sided envelope BMPF?
crevicular incision only - at gingival margin
extend atleast one tooth each side of the tooth
in question but furtherextension improves access
Typically requires 2 sutures to close (one in each papillae mesial and distal to the extracted tooth)
What is BMPF?
Buccal MucoPeriosteal Flaps
Describe a Two sided design BMPF?
Two sided design BMPF - crevicular and one relieving
incision, usually mesial for best access
Most common flap design
Typically requires 3 sutures to close (mesial + distal papillae around extracted tooth and across the relieving incision)
Describe a Three sided BMPF?
Three sided BMPF - crevicular and two relieving
incisions mesial and distal
Typically requires 4 sutures to close – mesial + distal
papillae of the extracted socket and one in each relieving incision – but distal relieving incisions can be
difficult to suture due to limited access posteriorly
Why should you include the interdental papillae in the BMPF?
to aid closure – easier to suture the thick gingival papillae than thinner (mid)-buccal gingival mucosa
Name the 3 principles of BMPF design?
- Access
- for an application point
- to section the tooth e.g. furcation - Adjacent Structures
- nerves e.g. mental
- adjacent crown margins to avoid recession
- canine prominence - Healing
- replace the flap on bone for stability
- maintain blood supply with a wide base
What is the definition of adequate access?
Start with an envelope and
add relieving incisions as
needed.
Generally 3 sided BMPFs give
the best access to the buccal
bone adjacent to the root
What to think about when planning access for flap design?
Access to the point of application for
elevators
Changing the path of removal by sectioning
from the furcation
Avoid vital structures
What to think about when designing a flap for the lower premolars?
Place the mesial relieving incision anterior to the first premolar to avoid the mental nerve but avoid crevicular
incisions over the canine prominence to minimise recession.
How to promote healing for flap design?
by preserving blood supply – wide base
When suturing over the bone, what must you do?
Place the mesial relieving incision
away from the area of bone removal/loss
to provide support for the incision margin when closed
Describe the process to remove a mesio-angulary impacted partially eruped LL8?
- Mucoperiosteal flap margins
incised – 3 sided BMPF - Flap retracted from buccal side
- Collar of bone guttered from
buccal side of LL8 - Sectioning of tooth
The groove has been drilled only half way through the
tooth bucco-lingually to protect the lingual nerve - Elevator used to separate the 2 roots
- Distal root delivered with forceps
- Mesial root elevated into the space created by removal of the distal root – disimpacted – then
delivered - Socket debrided and washed with
copious sterile saline - Wound closure with sutures
Describe the palatal flap for buried canines?
- Sacrifice the incisive bundle – no clinical
significance to the resulting area of anaesthesia - Extensive crevicular incision extending from UR6 to UL4 on the palatal aspect as no relieving incisions possible
- Buried canine located and exposed
by drilling overlying bone
Name 2 types of flap design is for oro-antral communiction?
Buccal Advancement Flap:
- based on a 3 sided BMPF with the periosteal layer
scored to permit extension of the flap to the palatal side
- pull flap across defect and suture
Palatal Rotational Flap:
- based arounnd the greater palantine vascular bundle
What is the main side effect of a buccal advancement flap?
Results in loss of buccal sulcus depth making
subsequent denture fit difficult without further sulcus deepening surgery.
What is the definition of a palatal rotational flap?
Technically difficult so usually done under GA
when buccal advancement closure fails.
Either full thickness allowing the donor site to
granulate over OR partial thickness pedicle leaving periosteum covering the donor site on the palate
Name 2 types of peri-raduclar surgery?
Root end resection (apicectomy)
Retrograde root filling (RRF)
What is the flap design for peri-radicular surgery?
3 sided full thickness BMPF
- Risk of gingival recession in the
visible anterior region especially
noticeable with crowned teeth
What flap design can be used for peri-raducular surgery to minimise the risk of gingival recession?
Luebke –Oschenbein sub-marginal flap:
- Minimises risk of gingival recession
- Difficult to suture as the horizontal incision is in
attached gingivae
- Requires at least 4mm of attached gingivae
Semi-lunar flap:
- poor healing (flap margin not on solid bone)
- minimised gingival recession
What are the 2 main aims of suturing after MOS?
Maintain haemostasis (stabilise blood clots or
haemostatic intrasocket agents)
Provide adequate tension for wound closure
and promote healing by supporting tissue
margins until sufficiently healed to support
themselves
What other advantages are there to suture after MOS?
- Reduce post-operative pain
• Reduce recession around adjacent tooth margins
• Promote healing by primary intention
• Prevent bone exposure – reduce infection/osteomyelitis risk
• Hold grafts/membranes in position to enable function
Name the 9 ideal suture thread properties for MOS?
- Adequate and uniform tensile strength
– Predicatble resorbtion to avoid patient’s returning for
suture removal
– Appropriate tensile strength retention in vivo, holding the wound securely throughout the critical healing period, followed by rapid absorption.
– Sterile
– Biologically inert
– Prevents bacterial proliferation and ‘seeding’ of wounds – suture abscess
– High knot security
– Easy handling – low memory, bright colour (which doesn’t
leach)
– Cost effective
Name the 7 ideal suture needle proeprties for MOS?
- Maintains sharpness to repeatedly incise mucosa
without tearing
– Malleable to form appropriate shapes/curves for
intraoral use
– Strength to maintain structural integrity
– Sterile
– Biologically inert
– Cost effective
Name the 3 types of suture materials for MOS?
Resorbable
Non-resorbable
Give 2 examples of resorbable sutures?
- Vicryl - polyglactin (coated or the more rapidly
resorbing ‘Rapide’)
– Others e.g. polydiaxanone (PDS II), catgut
Give 3 examples of non-resorbable sutures?
black silk (BSS) / ethilon / prolene
When are non-resorbable preffered over resorbable sutures?
For specific tasks where maintaining tensile strength is
important (e.g. OAC closure) or resorption products are
possibly undesirable for healing with minimal scarring
e.g. aesthetic zone implants.
What is the defintion of a monofilament suture?
is made of a single strand
What is the defintion of a braided suture?
have multiple monofilaments wound around each other
What are the advantages of monofilament sutures?
cause less tissue drag and are less likely to track and harbour bacteria at the surgical sites
What are the disadvantages of monofilament sutures?
Monofilament suture materials are generally harder to handle than multifilament (braided) sutures because of their memory.
Name 3 examples of monobraided sutures?
PDS II
ethilon
prolene
Name 2 examples of braided sutures?
Vicryl
BSS
Explain how rosorbable sutures work? And which is better and why?
Hydrolysis (e.g. vicryl) is more predictable than enzymatic proteolysis and phagocytosis (e.g. catgut) with less tissue inflammatory reaction and scarring
What affects resorbability
Thicker gauges of suture material will take longer to resorb
and sutures in more vascular areas will resorb quicker.
Describe the changes in tensile strength of vicryl and coated vicryl?
Vicryl-Rapide loses 50% of its tensile strength at 5 days and
100% in 10 days (sutures usually fall out and are swallowed/
spat out rather than completely resorbed (which takes 50
days).
• Coated Vicryl loses 50% of its tensile strength at 3 weeks and
is completely resorbed in 70 days.
What is the rule of thumb for suture gauges?
Use of the smallest suture that approximates the tissue’s
own tensile strength is ideal to adequately close wounds
What suture material is best for oral mucosa?
3/0 Vicryl-Rapide or 4/0 coated Vicryl
Name the 6 types of sture needles?
Curved needles (1/4, 3/8 or 1/2 circle) and 19-22mm in
diameter are typically used intraorally due to limited access.
Straight and 1/2 curve
How to hold the suture needle using a needle holder?
Reverse cutting triangular body needles are used to minimise ‘cutting through’ at mucosal tissue margins
• Needles are held in needle holders at the (solid metal) body adjacent to the swage area to prevent fracture at the junction where the suture material joins the needle and still allow rotation of the needle body in tissue
When is 4/0 Coated vicryl used?
delicate or macerated
mucosa. Easy to pull too
hard and break the suture
when suturing.
When is 3/0 vicryl rapide used?
across sockets and
applying pressure to achieve
haemostasis
What are blunt ended scissors used for?
cutting
sutures without accidently
damaging adjacent soft
tissues such as the tongue or
lips.
What are toothed tissue forceps used for?
manipulating oral
mucosa without crushing
tissue and causing wound
margin necrosis
What are locking needle holders used for?
to securely hold the suture
needle and a smooth
joint to allow suture to
slide over when tying a
surgical knot
Main suture technique?
simple interrupted
Describe a horizontal mattress suture?
for closing
OACs to evert tissue margins and
obtain an air tight seal. Can also be
looped around a tooth to cuff the
tissue tightly to the tooth
potentially minimising post-healing
recession.
Deswcribe a continious suture?
quicker for large
wounds than multiple interrupted
sutures but if any part comes
undone the whole wound dehisces.
Surgical Sieve? Acromym VITAMIN CDEF
V - vascular
I - infection/inflammation
T - Trauma
A - autoimmune
M - metabolic
I - iatrogenic
N - neoplastic
C - congenital
D - degenerative
E - endocrine/environmental
F - functional
Name all types of cancer?
Carcinoma
Sarcoma
Chondroma
Myoma
Adenoma
Osteoma
Kaposi’s sarcoma? Where? Why? Type?
Palate
AIDS
Vascular tumour
BVs
Haematoma?
Blood in adea
Ludwig’s angina?
Infection sub-neck
Ibuprofen max dose?
2.4g
200mg tablet
12 tablets
Max dose for Paracetamol?
4g
500mg per tablet
8 tablets
What are Winter’s classification of impacted wisdom teeth?
Vertical
Mesioangular
Horizontal
Distoangular
Name 6 local reasons for the failure of eruption of 8s?
Displaced follicle (ectopic position)
Crowding
Supernumerary/supplemental teeth
Impacted into adjacent tooth
Pathology - cyst, tumour or fibrous dysplasia
Missing tooth
Name 3 general factors that cause failure if eruption of 8s?
Pathology:
- developmental conditions
- Down’s syndrome
- skeletal disorders
What are the risks of extracting an 8 or any tooth?
Pain
Swelling
Trismus
Infection
Time off work
Cost
Nerve damage
Anaesthesia definition?
Lack of sensation
Paraesthesia definition?
Spontaneous and subjective altered sensation that a patient does not find painful
Dysaesthesia definition?
Spontaneous and subjective altered sensation that a patient does find painful
Hypoaesthesia definition?
Decreased sensitivity of a nerve to stimulation
Hypoalgesia definition.
Decreased sensitivity to noxious stimulation
Hyperaesthesia definition?
Increased sensitivity if annerve to stimulation
Hyperalgesia definition?
Increased sensitivity to noxious stimulation
Allodynia definition?
Pain caused by a stimulus that does not normally cause pain
Name the 3 types in which you can damage a nerve from wisdom tooth removal?
Direct mechanical trauma - tear, sectioning, crush or stretching
Neural chemical trauma due to intracellular components during trauma, haemoglobin irritates neural tissues
Ischaemic injury due to entrapment within a bony canal with continued bleeding or scar formation
Neurapraxia definition?
Contusion of the nerve in which the continuity of the nerve is maintained - blunt trauma, traction or local ischaemia
Axonotomesis defintion?
Discontinuity of the axons but the shealth is intact - severe blunt trauma, nerve crushing and extreme traction
Neurotmesis defintion?
Complete loss of nerve continuity - mandibular fracture
What is the overall risk of nerve damage of lower wisdom tooth extractions?
Up to 5%
Describe the management of inferior alveolar nerve injuries?
If cut, then try to immediately repair
If anaesthesia is present after Post-OP review - ensure no bony fragment, if present remove
If stim-evoked paraesthesia, monitor patient recovery with light touch, pin prick and two point discrim, also with anaesthesia.
3 months post-injury = no recovery, consider surgery or referral to specialist
Some recovery present = monitor, if limited consider surgery
How successful is inferior alveolar nerve repair?
Poor prognosis - more likely to do harm
How successful is lingual nerve repair?
Better than IaN, some sensation regained
Name 7 indications for removal of 8s according the the NICE guidelines?
Unrestorable caries
Non-treatable pupal and/or periapical pathology
Cellulitis, abscess and osteomyelitis
Fracture of tooth
Resorption of tooth or adjacent teeth
Disease of the following such as cyst/tumour
Tooth impeding surgery or reconstructive jaw surgery
When should you leave 8s in place?
Symptom free
No evidence of disease
Removing the tooth may cause more harm
Name 5 non-NICE guidelines for removal?
To exclude atypical facial pain
To prevent late lower incisor crowding or relapse of ortho
Prior to travel
Financial - >25
Known later complications
When does pericoronitis become a valid indication for wisdom tooth removal?
Severe first case of pericoronitis
Second or subsequent episodes should be considered
NICE consultation 2017-2019 findings?
Removal of non-pathological 8s is not indicated, however down the line the 8s will become a problem and be extracted
Summary of the management of patients with mandibular third molars?
Asymptomstic high risk - caries, perio, resorption and cysts/tumours
Symptomatic high risk - acute pericorontis, unrestorable caries, perio disease, resorption, fracture, abscess or surrounding pathology
Asymptomatic low risk - bisphosphonates, antiangiogenics and chemo, radiotherapy H/N, immunosuppression, mandibular fracture and cancer
Symptomatic low risk - TMJ disorder, parotid disease, skin lesion, migraines, referred pain or oropharyngeal cancer
Name the 7 ways in which the root can be affected by the nerve?
Darkening of root
Deflection of root
Narrowing of root
Dark and bifid root
Interruption of white line of canal
Diversion of canal
Narrowing of canal
What to do for a horizontally impacted tooth?
Decoronation
What to do for a vertically impacted tooth..
Root separation
Complication with sectioning teeth?
Failure to split roots
Drill to far through the bone - lingual nerve damage or causing an OAC
Name other techniques for tooth sectioning.
Hemisection
- surgical separation of a multi rooted tooth and extraction of one or more roots
Root resection
- sectioning and removal of a diseased root
Premolarisation
- sectioning of lower molar crown between roots to leave 2 single teeth to allow maintainer of oral hygiene
Coronectomy
- removal of crown but leaving the roots in situ
Contraindications to coronectomy?
Too close to IAN canal
Active infection
Preexisitng numbness
Preexisiting mobility
Horizontally impacted tooth along IAN
Medical conditions
How to assess the degree of swelling?
Difficulty breathing?
Difficult to stick out or move tongue?
Swelling closing the eye?
Has the swelling worsened in the last hour?
Is the welling sudden and unexplained?
When does a swelling become an emergency?
If the swelling is rapidly inreasing and likely to obstuct the airway or close the eye
If a patient is systemically unwell (rigors, fever, dehydrated and lethargic)
If the swelling is slowly increasing in size, hot or firm to touch what should you do?
Prescribe antibiotics
If the swelling is stable, but causing pain what should you do?
Check for atypical facial pain or signs of MI
Or have exceeded the recommended dose of pain relief medication
What are the 6 key signs and symptoms of facial swelling?
A firm ot soft lump
Swelling may be staic or inreases over hours
Swelling due to sepsis or ooedema around or in the tongue or pharynx
Ulcerated swelling
A change in normal apperance to red, white or a combo
A pigmented area on the soft tissues or tongue
When do facial swellings need to be referred?
After no improvement in 3 weeks
What is the definition of a dry socket? RF? PCO? Manage?
blood clot fails to develop is is dislodged
RF:
- smoking
- oral contraceptives
- fail to follow post-OP
PCO:
- pain
- no sleep
- visible bone (pre 8 weeks)
management:
- debride and wash and dress to alveogyl
What is the defintion of bony sequestrum?
fragment of dead bone
pain and swelling
Management:
- reassure
- LA
- remove
- irrigation with saline
- haemostatsis
What is the definition of osteomyelitis? Symptoms? Treatment?
Inflammaotry conditon of the bone, which begins as an infection of the medullary cavity, rapidly involves the bones system and inloves the periosteum
Symptoms:
- fever
- swelling
- warmth
- weight loss
Treatment:
- incision and drain, followed by antibiotics - (metronidazole)
What is the defintion of trismus?
limited mouth opening
Aetiology:
- extarction
haematoma
long opening time
TMJ damage
Fracture
Infection
Management:
- 3 finger test
Mild:
- reassure and manage pain
Severe:
- pain management
How to manage nerve damage after extraction?
transient
persistent > 6 months
permanent > 6 months
Management:
- review 5 days
- refer to MaxFac
Management of post-OP extraction bleeding?
Ensure no anticoagulation
self-help measure - roll a pad for 20 mins, check for bleeding
Uncontrolled bleeding:
- LA
- clean
- MH
- haemosttic agent into socket
- suture
- no haemostasis - A&E
Definition of MRONJ?
exposed bone or bone probed via intra or extraoral fistula, more than 8 weeks in patient with anti-resorptive or anti-angiogenic drugs, no radiotherapy or metastaic disease
Refer
Definition of oro-antral communication?
unnatural space that froms between max sinus and oral caity following extraction
PCO:
- nasal regurg
- bad taste
Refer for flap
Definition of oro-antral communication?
unnatural space that froms between max sinus and oral caity following extraction
PCO:
- nasal regurg
- bad taste
Refer for flap
Name 4 types of radiopacities?
Abnormalities of the teeth
Condition affecting the bone
Superimposed soft tissue calcifcations
Foerigen bodies
Name 3 dental radiolucencies?
Periradicualr periodontits
Apical abscess
Perio-endo lesion
Name 3 cyst radiolucencies?
Radicular
Lateral periodontal
Dentigerous
Name 3 radiolucent tumours?
Odontogenic keratocyst
Ameloblastoma
Osteosarcoma
Describe the oxygen needed for sedation?
2 x E size cylinders
Not from Emergency drug kit!
O2 reducing valve capable of delivering 0-15 litres O2
Nasal cannula
Name the monitoring equipment necessary for sedation?
Pulse Oximeter
Calibrated before use
Audible
Alarm set for below 90%
Blood pressure monitor
Digital
Appropriate cuff (adult)
Spare batteries
Name the sedation agent and how to use it?
Midazolam 1ml per ml for injection
Record batch number and expiry date
Storage in locked and secure location
Draw up in 10ml syringe
Name the equipment for cannulation for sedation?
Non latex disposable tourniquet
IV cannulas (Venflon)
20-24 gauge (pink, blue, yellow)
Water or saline for flushing
5ml syringes
Green 21g IM needles to draw up solutions
Labels for syringes
Name the reversal agent for sedation?
Flumazenil 0.1mg per ml for injection
Syringe and green needle laid out(not essential to draw up)
Treatment dosage 0.2mg/2ml
MUST BE AVAILABLE AT EVERY PROCEDURE
Name the 7 other equipment that is necessary for conscious sedation?
Necessary paperwork
Clinical recording, post op instructions
PPE for patient and clinical staff
Equipment for procedure: surgical drill/materials etc
Mouth props can be useful
Gauze, elastoplasts, spare venflons, EMLA cream
Awareness of emergency drugs/AED location and procedures
What is the definition of conscious sedation?
A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation should carry a margin of safety wide enough to render loss of consciousness unlikely.
Deep sedation is commonly used in medical and international practice, where a sedated patient responses are suppressed: responding to painful stimuli
Alert
Verbal
Confused
Pain
Unresponsive
What does IACSD 2015 recommend for conscious sedation?
Appropriate formal training by a certified educational centre in the desired sedation technique eg Inhalation/IV/Multidrug
Sedation procedures carried out by 2 sedation-trained individuals ie Dentist and Nurse
12 hours CPD per 5 years
Participation in sedation-specific audit and local governance management
Sedationist trained to Immediate Life Support level
Record keeping including a log book and self reflection
What is the definition of midazolam?
A Benzodiazepine:
Anxiolytic
Fast acting
Half life approx. 3 hours (1-4 clinically)
Binds to area adjacent to GABA(gamma-aminobutyric acid) receptors in central nervous system
Muscle relaxant/anti convulsant
Used in patients over 12 years of age
Name the advantages and disadvantages of midazolam?
Adv:
- Fast acting
- Titratable
- Anterograde amnesia
- Full recovery usually within same day of administration
- Well tolerated by patients
- Reversible
Dis:
- Respiratory depression
- Can suppress inhibitions
- Technique-sensitive, risk of over-sedation in Conscious techniques
- Short-acting
- Patients can have tolerances to Benzodiazepines
Describe the pharmaodynamic effects of midazolam on CNS, CVS and resp?
CNS: Amnesia, Anxiolysis, Hypnosis, Muscle relaxation
CVS: Fall in arterial pressure (small), reduces ‘sympathetic drive’
Respiratory: reduced rate and depth of breathing, muscle relaxation, affects central CO2 and peripheral O2 receptors
NEED FOR BASELINE AND PROCEDURAL PATIENT MONITORING
What is the definition of flumazenil?
Reversal agent to Midazolam in conscious sedation techniques
A benzodiazepine antagonist:
- Preferentially binds to CNS receptors over midazolam
- Shorter half life - ? Risk of re-sedation?
- Must be available during clinical session for emergency use
What did the rapid response documne 2008, impact midazolam concious sedation?
Published by NHS National Patient Safety Agency
Reducing the risk of Midazolam overdose in general use
Recommended the only availability of 1mg per ml Midazolam
More concentrated solutions available only in an anaesthetic/ITU setting
Primarily aimed at medical sedation practices, Conscious sedation in Dentistry has very low complication record!
Does concious sedation practices chnage in the elderly?
Much more susceptible to the effects of benzodiazepines
Mechnanism not clear
Consider reduced dosages, close monitoring and slower titration technique
Does conscious sedation practices chnage in children?
Midazolam commonly used orally as premedication prior to General anaesthetic
Tastes terrible! Hidden in orange juice
Very effective but not titrated – unpredictable outcome
IV techniques safe in aged 12 and over, more commonly practiced in aged 16 and over
Name the 8 things to check off before sedation prep can occur?
Equipment check
Drug check
Trained staff available
Patient has attended with appropriate escort
PMH changed?
Last meal/been to toilet/comfortable clothing/available anatomy for monitoring
CONSENT
Initial readings : BP/O2/HR
Describe how to place the venous cannulation for sedation?
Start distally
Dorsum of hand, medial wrist, antecubital fossa
Ideally, different arm to BP cuff and pulse oximeter probe
Secured in place with tape/dressing
Date and time of cannulation noted
No of attempts recorded
Flush with saline/water
Describe how to administer midazolam for sedation?
Labelled syringe of 1mg : 1ml Midazolam for injection
Start with 2mg bolus dose delivered over 30 seconds
Wait and monitor patient for 90 seconds
Continue incremental delivery of 1mg Midazolam IV every 60 seconds
Watch for signs of adequate sedation
Continuous delivery of behavioural techniques: breathing awareness/systematic muscle relaxation/guided imagery
Describe how to administer midazolam for sedation? - FOR THE ELDERLY?
Reduced dosage usually required
Start with 1mg bolus dose over 30 seconds
Wait 2-4 minutes
Continue incremental delivery on 0.5mg every 2 minutes
Watch for signs of over-sedation!
Explain how to gauge whether the patient is sedated?
General state of relaxation
Muscle tension reduced: relaxed shoulders, neck neutral, fingers soft not clenched
Slow eye blinking
Slowed responses: physical and verbal
Sleepy feeling
Patient able to respond to verbal commands
Patient is accepting of treatment: eg ‘can I start numbing up the teeth?’
Clinical judgement
Describe the symptoms/signs of a patient that has been over-sedated?
Patient is unresponsive to verbal commands - AVPU
Patient un-rousable from sleeping
Patient does not respond to painful stimuli eg LA injection
Drop in O2 saturation – suppression of spontaneous breathing
Consider Flumazenil administration and aborting procedure
Anticipate over-sedation: low BMI, elderly patient, poly pharmacy, Midazolam administered too quickly
Name the 7 complications of conscious sedation?
No effect
Paradoxical effect
Nausea/vomiting
Hiccups
Hypoxia (usually due to oversedation)
Hypotension
Suppression of gag reflex – airway protection!
WHat must be monitored during the sedation process?
Sedationist and nurse in constant state of awareness of patient
Pulse oximetry: audible heart rate, calibrated alarm to sound below 90%
Can provide supplemental O2 through nasal cannula if patient breath-holding or speaking throughout procedure
Maintain verbal communication with patient throughout procedure
If patient falls asleep, ensure observations are satisfactory
AT NO POINT SHOULD A MEMBER OF THE TEAM BE LEFT ALONE WITH A SEDATED PATIENT
Describe what must be carried out during recovery?
Working time 30-40 minutes
Ensure patient is warm and comfortable after dental procedure completed
Repeat observations: BP/HR/O2
Assess patient interactions: speech becomes more coherent, patient more alert, eye movements returning to normal
Name the 4 discharge parameters for sedation?
Discharge parameters:
- Can stand unaided
- Can touch finger to nose
- Can read the time on a clock
- Can walk a few steps without losing balance
What post OP instructions must be given to a sedation patient?
At least 1 hour after last increment of Midazolam administered
Invite Escort into recovery area
Discuss post operative instructions with patient and escort
- Straight home to rest
- No driving 24 hours
- No operating machinery 24 hours including cooking
- No management of legal documents 24 hours
- No alcohol until next day
- Specific post op instructions re procedure eg pain relief/sutures etc/follow up
WRITTEN AND VERBAL ADVICE TO BE GIVEN including emergency contact details
What must be recorded in the notes for sedation?
Reflective practice
Log book
Adverse events
Use of Reversal agent – justification
Controlled drugs
Describe how to assess anxiety for a patient that may qualify for sedation?
Clinical judgement – phobia/anticipated difficult procedure
Patient request?
Questionnaire useful aid
Alternatives to conscious sedation?
Name the 7 categories needed to be involved for a clinical assessment?
Clinical observations – O2, pulse, BP
BMI
ASA (see next slide)
General Mobility
IV access/nasal airway patency
Large tongue/retrognathic mandible/sleep apnoea
Current and previous medical history: Medications, Allergies
Relevant GA/sedation history and experience
Describe the ASA 1-5 levels?
ASA I: A healthy patient
ASA II: A patient with mild systemic disease
ASA III: A patient with systemic disease which is not incapacitating
ASA IV: A patient with incapacitating systemic disease with is a constant threat to life
ASA V: A moribund patient who is not expected to survive more than 24 hours without medical or surgical intervention
Does the patient have someone that can accompany them after the sedation?
Escort/Chaperone
Lives alone/cohabits
Dependants
Dependants of chaperone
Transport home after treatment
Work and social commitments
Describe the process and documentation for consent for conscious sedation?
Carried out at assessment and revisited at treatment session
A written and verbal process
Specific details of proposed procedure
Will not be deviated from, therefore plan number of sedation treatments in advance if lots of treatment required
- NB 30-40min working time
Risks/warnings/alternatives
Consider consent for Escorts
Name the 6 contraindications for IV sedation in a dental setting?
ASA III/IV – consider referral to hospital setting for inpatient treatment
BMI >35
Poor IV access: ex IVDU, increased cutaneous fat
Obstructive sleep apnoea
Unable to arrange appropriate post op supervision/chaperone
Poor response to Benzodiazepines in the past/unsuccessful IV sedation
What records are essential to carry out during a sedation procedure?
NEWS chart
Discharge checklist
Post op patient leaflets
Pre op assessment
Sedation procedural sheet
Post op patient leaflets
Alcohol misuses side effects on OH?
High incidence of dental disease:
- poor OH (caries / perio)
- tooth surface loss (erosion)
- oral cancer
- trauma / interpersonal violence
- halitosis / staining
* Patient management issues
* Alcohol Related Liver Disease (ARLD)
* Alcohol reduction advice
Explain how to identify an ‘at-risk’ patient of alcohol dependence?
Middle aged and high earners drink
the most alcohol
What history may be of concern when trying to identify alcohol dependence?
Ask about alcohol intake
* Medications
- vitamin supplements especially
thiamine/B1 to prevent Alcohol Brain
Disease (Korsakoff syndrome /
Wernicke’s encephalopathy)
- Diazepam / Chlordiazepoxide for
alcohol withdrawal symptoms
What clinical examination signs/symptoms may be of concern when trying to identify alcohol dependence?
- Smell of alcohol on breath (chewing gum / mints to mask)
- Signs/symptoms of Alcohol Related Liver Disease (ARLD) - stigmata
- yellow scler
- Dupuytren’s contacture
What special investigations may be of concern when trying to identify alcohol dependence?
Bloods – Liver Function Tests (LFT)
* Deranged alkaline phosphatase,
ALT, AST levels are non-specific
indicators of liver damage
* High gamma-glutamyl
transferase (γGT) more specific
for alcoholic liver disease
Bloods - Clotting screen
* Clotting factors produced in the liver
and/or reduced vitamin K absorption
(bile)
* Prolonged prothrombin time (PT)
AND activated partial thromboplastin
time (APTT) and thrombin time (TT)
but essentially normal platelet
activity (bleeding time, platelet
function assay (PFA))
What patient management issues could occur in the dental practice?
Alcohol (misuse) associated behaviours – disinhibition, aggression , unpredictability
* Poor dietary habits
* Poor oral hygiene / neglect
* Poor attendance / engagement
* High levels of smoking / recreational drug use
* ‘Masked’ pain – delayed presentation
Cancer risk for patients with alcohol dependence?
30% of oral cancer cases – alcohol related
* 5x increased risk in heavy drinkers (>4 drinks/
day)
* Increased risk synergistic effect with smoking
* Mechanism unknown - direct effect of EtOH on
DNA or acting as a solvent for other
carcinogens e.g. tobacco products
Alcohol dependence - liver disease and dentistry - bleeding risk? drug metabolism? transplantation?
In primary care - assess bleeding risk and if
significant refer to specialist/secondary care
services:
- e.g. does it continue to bleed if you cut yourself shaving?
- do you suffer from nose bleeds?
- do you bruise easily?
Drug metabolism:
- Lignocaine toxicity
* Analgesia – paracetamol, NSAIDs, aspirin
* Disulfiram reactions - metronidazole
- Immunosuppression
- impaired healing: prevention of dental disease
- drug reactions: cyclosporin – gingival hyperplasia
- Graft versus Host Disease (GvHD)
- extensive lichenoid reactions
- sclerosis / trismus
