Oral surgery Flashcards
What does the hypoglossus do?
Retract the tongue
What does the genioglossus do?
Protrude the gongue
What does the mylohyoid do?
Raises floor of the mouth
Where does the geniohyoid connect?
Genial tubercles to hyoid
What does the digastric do? connect to? innervated by?
Opens jaw
Digastric fossa to hyoid bone
Innervated by:
V - anterior belly
VII - posterior belly
Name the 4 extrinsic muscles of the tongue?
- Styloglossus (XII) - styloid to tongue. Retracts + elevates the tongue.
- Genioglossus (XII) - genial tubercles to tongue. Protrudes + depresses the tongue
- Hypoglossus (XII) - Hyoid to tongue. Retracts + depresses the tongue.
- Palatoglossus (X) - palate to tongue. Elevation of posterior tongue.
What are the intrinsic muscles of the tongue?
Names (4)
Function?
Innervation?
The intrinsic muscles originate and attach to other structures within the tongue.
There are four paired intrinsic muscles of the tongue and they are named by the direction in which they travel –
> superior longitudinal,
> inferior longitudinal,
> transverse
> vertical muscles of the tongue.
These muscles affect the shape and size of the tongue – for example, in tongue rolling – and have a role in facilitating speech, eating and swallowing.
The motor innervation to the intrinsic muscles of the tongue is via the hypoglossal nerve (CN XII).
What are the extrinsic muscles of the tongue and what are they innervated by?
The extrinsic muscles of the tongue originate from structures outside the tongue and insert onto it.
Genioglossus, Hyoglossus and Styloglossus are innervated by the hypoglossal nerve – with the exception of the Palatoglossus, which is innervated by the vagus nerve.
Genioglossus: attachments? function? innervation?
The genioglossus muscle is a large, thick muscle, which contributes significantly to the shape of the tongue.
Attachments: Arises from the mandibular symphysis. It inserts onto the body of the hyoid bone and the entire length of the tongue.
Function: Protrusion (‘sticking the tongue out’) and depression of the tongue.
Innervation: Hypoglossal nerve.
Hyoglossus: attachments? function? innervation?
The hyoglossus muscle is located in the floor of the oral cavity, immediately lateral to the geniohyoid.
Attachments: Arises from the hyoid bone and inserts onto the lateral aspect of the tongue.
Function: Depression and retraction of the tongue.
Innervation: Hypoglossal nerve.
Styloglossus: Attachments? Function? Innervation?
The styloglossus is a thin, paired muscle, located on either side of the oropharynx.
Attachments: Originates from the styloid process of the temporal bone and inserts onto the lateral aspect of the tongue.
Function: Retraction and elevation of the tongue.
Innervation: Hypoglossal nerve.
Palatoglossus: attachments? Function? Innervation?
The palatoglossus muscle is also associated with the soft palate – and is therefore innervated by the vagus nerve.
Attachments: Arises from the palatine aponeurosis and inserts broadly along the tongue.
Function: Elevation of the posterior tongue
Innervation: Vagus nerve.
Which nerves supply the 1) sensation and 2) taste the the anterior 2/3rd of the tongue?
1) In the anterior 2/3, general sensation is supplied by the trigeminal nerve (CNV). Specifically the lingual nerve, a branch of the mandibular nerve (CN V3).
* Lingual nerve (V3)
2) Taste in the anterior 2/3 is supplied from the facial nerve (CNVII). In the petrous part of the temporal bone, the facial nerve gives off three branches, one of which is chorda tympani. This travels through the middle ear, and continues on to the tongue.
* Chorda tympani (VII)
What nerve supplies sensation and taste the the posterior 1/3 or the tongue?
Both touch and taste are supplied by the glossopharyngeal nerve (CNIX).
* Glossopharyngeal nerve (IX)
Name the 4 intrinsic muscles of the tongue? What are they all innervated by?
- Superior longitudinal
- Inferior longitudinal
- Transverse
- Vertical
–> Hypoglossal nerve (XII)
What is the arterial and venous supply to the tongue?
The arterial supply to the tongue is mainly from the lingual artery (a branch of the external carotid artery). There are also contributions from the tonsillar branch of the facial artery.
Venous drainage is by the lingual vein – which empties into the internal jugular vein.
What is the lymphatic draining of the 1) anterior and 2) posterior part of the tongue?
The lymphatic drainage of the tongue is as follows:
Anterior two thirds – initially into the submental and submandibular nodes, which empty into the deep cervical lymph nodes
Posterior third – directly into the deep cervical lymph nodes
What is the foramen cecum?
The foramen cecum is a blind-ended pit located in the midline of the tongue at the junction of the anterior 2/3 and posterior 1/3.
What innervates the maxillary teeth?
Branches of the maxillary division of trigeminal.
- Anterior superior alveolar nerve (ASAN) supplies incisors to canines.
- Middle superior alveolar nerve (MSAN) supplies premolars and MB root of 1st molar
- Posterior superior alveolar nerve (PSAN) supplies molars.
What is the blood supply to the maxillary teeth?
Branches of maxillary artery:
- Anterior superior alveolar artery
- Middle superior alveolar artery
- Posterior superior alveolar artery.
What innervates the mandibular teeth?
Inferior alveolar nerve which is a branch of the mandibular division of trigeminal nerve. (V3)
What is the blood supply of the mandibular teeth?
Inferior alveolar artery (branch of the maxillary artery)
What bones make up the hard palate?
The hard palate forms the anterior aspect of the palate.
The underlying bony structure is composed of (i) palatine processes of the maxilla; and (ii) horizontal plates of the palatine bones.
What are the 3 foramina in the hard palate?
- Incisive canal – located in the anterior midline, transmits the nasopalatine nerve and descending palatine artery.
- Greater palatine foramen – located medial to the third molar tooth, transmits the greater palatine nerve and vessels
- Lesser palatine foramina – located in the pyramidal process of the palatine bone, transmits the lesser palatine nerve and lesser palatine artery.
What is the anatomy of the soft palate?
- The soft palate is located posteriorly. It is mobile, and comprised of muscle fibres covered by a mucous membrane.
- Anteriorly, it is continuous with the hard palate and with the palatine aponeurosis. The posterior border of the soft palate is free (i.e. not connected to any structure), and has a central process that hangs from the midline – the uvula.
- The soft palate also forms the roof of the fauces; an area connecting the oral cavity and the pharynx. Two arches bind the palate to the tongue and pharynx; the palatoglossal arches anteriorly and the palatopharyngeal arches posteriorly. Between these two arches lie the palatine tonsils, which reside in the tonsillar fossae of the oropharynx.
What are the 5 muscles of the soft palate, their attachment, function and innervation?
There are five muscles which give the actions of the soft palate.
They are all innervated by the pharyngeal branch of the vagus nerve (CN X) – apart from Tensor veli palatini – which is innervated by the medial pterygoid nerve (a branch of CN V3).
- Tensor Veli Palatini
> Attachments: Originates from the medial pterygoid plate of the sphenoid and inserts into the palatine aponeurosis.
Function: Tenses the soft palate. - Levator Veli Palatini
> Attachments: Arises from the petrous temporal bone and the eustachian tube, before inserting into the palatine aponeurosis.
> Function: Elevation of the soft palate. - Palatoglossus
> Attachments: Originates from the palatine aponeurosis, and travels anteriorly, laterally and inferiorly to insert into the side of the tongue.
> Function: Pulls the soft palate towards the tongue. - Palatopharyngeus
Attachments: Arises from the palatine aponeurosis and the hard palate, and inserts into the upper border of the thyroid cartilage.
> Function: Tenses soft palate and draws the pharynx anteriorly on swallowing. - Musculus Uvulae
> Attachments: Arises from the posterior nasal spine and the palatine aponeurosis, and inserts into the mucous membrane of the uvula.
> Function: Shortens the uvula.
What is the arterial and venous supply of the palate?
The palate receives arterial supply primarily from the greater palatine arteries, which run anteriorly from the greater palatine foramen.
In addition, the anastomosis between the lesser palatine artery and ascending palatine artery provide collateral supply to the palate.
Venous drainage is into the pterygoid venous plexus.
How the the palate innervated?
Sensory innervation of the palate is derived from the maxillary branch of the trigeminal nerve (CN V). The greater palatine nerve innervates most of the glandular structures of the hard palate.
The nasopalatine nerve innervates the mucous membrane of the anterior hard palate and the lesser palatine nerves innervate the soft palate.
How does cleft lip occur?
Cleft lip – occurs when the medial nasal prominence and maxillary prominence fail to fuse.
How does cleft palate occur?
Cleft palate – can occur in isolation when the palatal shelves fail to fuse in the midline, or in combination with cleft lip.
What epithelium is attached to the superior and inferior aspect of the hard palate?
The hard palate is covered superiorly by respiratory mucosa (ciliated pseudostratified columnar epithelium) and inferiorly by oral mucosa (stratified squamous epithelium).
What is hyperalgesia and allodynia?
Hyperalgesia – increased sensitivity to pain
Allodynia – pain from a usually non-painful stimulus
These could both be symptoms of trigeminal neuralgia.
What is the journey of the maxillary division of trigeminal?
After arising from the trigeminal ganglion, the maxillary nerve passes through the lateral wall of the cavernous sinus, before leaving the skull through the foramen rotundum. It gives rise to numerous sensory branches:
Superior alveolar nerve (anterior, posterior and middle)
Middle meningeal nerve
Infraorbital nerve
Zygomatic nerve
Inferior palpebral nerve
Superior labial nerve
Pharyngeal nerve
Greater and lesser palatine nerves
Nasopalatine nerve
What do the ASAN, MSAN and PSAN exit and what do they innervate?
Anterior superior alveolar nerve
> Exits via the infraorbital foramen
> Innervates anterior maxillary antrum and incisor and canine teeth
- Middle superior alveolar nerve
> Exits via infraorbital foramen
> Innervates medial and lateral maxillary antrum and premolars - Posterior superior alveolar nerve
> Exits via the pterygomaxillary fissure
> Innervates the posterior maxillary antrum and maxillary molars
What is the mandibular teeth supplied by? What is the journey of this nerve - what does its branches innervate?
Mandibular teeth are primary supplied by the inferior alveolar nerve, which is a branch of the mandibular nerve (V3). It carries both sensory and motor neurones, and exits via the foramen ovale.
- The inferior alveolar nerve carries both sensory and motor axons to and from the respective trigeminal nuclei.
- After branching from its parent nerve it gives rise to the mylohyoid nerve, a motor nerve to the mylohyoid and anterior digastric muscles.
- The remaining sensory axons enter the mandibular canal, a narrow tunnel running through the mandible. Within this canal, the nerve provides branches to the mandibular teeth.
- The nerve emerges through the mental foramen as the mental nerve. This provides sensory innervation to the lower lip and chin.
Inferior Dental Nerve (V3)
> Descends to the lateral pterygoid muscle, before
then entering the mandibular foramen
> Supplies lower molar and second premolar teeth
Mental nerve (V3)
> Exits via mental foramen
> Supplies chin, lower lip, facial gingiva and
mucosa from second premolar anteriorly
Incisive nerve (V3)
> Supplies teeth and PDL from first premolar anteriorly
What is local anaesthetic?
Any technique to render part of the body insensitive to pain without affecting consciousness.
What is the mode of action of local anaesthetic?
- Peripheral nerve conduction works via depolarisation of nerve membranes.
- Na moves into the neurone in nerve excitation.
–> LA works by blocking Na channels, preventing depolarisation of nerve membranes.
What are Amide local anaesthetics?
- components?
- broken down where?
- examples?
- They contain an aromatic ring and lipophilic portion.
- They are broken down in the liver.
- Lidocaine
- Prilocaine (contains felypressin - synthetic analogue of vasopressin)
- Mepivacaine
- Bupivacaine
Why do we not use prilocaine (which contains felypressin) in pregnant women?
Felypressin can induce labour in pregnant women, hence contraindicated in pregnancy.
What is an ester LA?
- components?
- broken down where?
- examples?
- Containing a terminal amine and a hydrophilic portion?
- Broken down in plasma and cholinesterase.
- Articaine
- Procaine
- Amethocaine and benzocaine (topical anaesthetics)
Why is articaine not used in IDB?
- Linked with permanent paraesthesia
- As it is broken down in plasma, has a shorted half-life.
- Used in higher concentrations which can cause paraesthesia
Why are prilocaine and articaine avoided in pregnancy?
Prilocaine contains felypressin which can induce labour.
Prilocaine and articaine may cause methaemoglobinemia (raised levels of methaemoglobin that can cause tissues to be deprived of adequate oxygen) which can lead to blue-baby syndrome if a pt is pregnant.
What are the 2 forms of an LA molecule?
- Unionised lipophilic inactive form. (uncharged)
- Hydrophilic ionised active form (charged)
What are 3 reasons it is harder to anaesthetise infected areas?
- LA is a weak base (pH 7.8), requires a greater dose if injected into an acidic environment (abscess), less ionised active form.
- Vasodilation around the abscess, means that tissue perfusion is greater.
- Increased prostaglandins due to inflammatory response around the infected area, heightened response to pain.
What is the maximum safe dose of LA for Lidocaine?
1 cartridge of lidocaine per 10kg of patient
Lidocaine:
- max dose mg/kg
- max dose adrenaline mg/kg
- half life (mins)
- gold standard
- 4.4mg/kg
- 7mg/kg adr
- 90 minutes
- 2% Lidocaine with 1:80,000 adrenaline.
Articaine:
- max dose mg/kg
- max dose adrenaline mg/kg
- half life (mins)
- gold standard
- 4.4mg/kg
- 7mg/kg
- 20 minutes
- 4% articaine with 1:100,000 adr
Prilocaine:
- max dose mg/kg
- max dose adrenaline mg/kg
- half life (mins)
- gold standard
- 5mg/kg
- 8mg/kg
- 90 minutes
- 3% prilocaine with felypressin
What do infiltrations anaesthetise?
- LA solution deposited around the terminal branches of nerves
- Used to anaesthetise soft tissue and pulp where alveolar bone is thin
- Used in maxilla and lower anterior teeth
Where is the IDN situated?
In the pterygomandibular space.
Lies posterior to pterygomandibular raphe and mesial to ramus of the mandible.
Muscular landmarks are the masseter laterally and superior constrictor muscle.
Medial pterygoid muscle lies mesially to pterygomandibular space.
Lingual nerve blocked by injection on retraction of IDB.
What does a long buccal block anaesthetise?
Distal and buccal mucosa to lower 6-8, aim for supra periosteal distal and buccal to last standing molar.
What are landmarks for an IDB?
- Coronoid notch
- Pterygomandibular raphe
- 1cm above occlusal plane with a 35mm needle.
- Aim from angle of contralateral premolars.
- Make contact with bone, retract, aspirate, dispense majority. retract more, dispense for lingual block.
What does the IDB anaesthetise?
- Dental pulps of all mandibular teeth to the midline.
- Buccal gingivae anterior to the mental foramen.
- Lingual gingivae.
- Anterior 2/3rd of tongue
- Floor of the mouth.
- Lower lip
What are IDB complications?
- Facial/Bell’s palsy –> by inserting the needly too far posteriorly, you may deposit LA into parotid bland, blocking the Facial nerve.
- Trismus –> if needle inserted too mesially, inject into the medial pterygoid.
- Damage to ID nerve
- Intra-vascular injection - caused by not aspirating and not slow injection. Cause pale and incr heart rate.
- Bruising/haematoma
- Allergic reaction
- Skin blanching
- Needle breakage
- Trauma, either idiopathically or via patient chewing lip due to loss of sensation
- Palpitations due to idiopathic injection of intravascular adrenaline causing tachycardia.
- Infection
- Persistent anaesthesia/paraesthesia
(-if injected shallow, then sphenomandibular ligament may act as a barrier to inferior alveolar nerve)
What does a lingual infiltration anaesthetise?
The lingual gingivae/soft tissue.
What does a mental block anaesthetise?
Buccal gingivae and teeth of the lower anterior teeth. (1-5)
Name different nerves in the maxilla:
- Nasopalatine and greater palatine nerves.
- Superior alveolar nerve: split into anterior, middle and posterior branches.
- Pterygovenous plexus lies close to posterior superior alveolar nerve, must aspirate first.
What does a posterior superior alveolar block (PSA) anaesthetise?
- PSA branch of maxillary division of trigeminal extending on the maxilla tuberosity.
- Maxilla molars apart from the MB root of 6.
What does an infra-orbital block anaesthetise?
- anaesthetises the middle superior and anterior superior alveolar nerves (Both V2)
- inject above the U4 region
- innervates buccal and pulpal features 1-5 and MB root of 6.
What nerves do palatal infiltrations anaesthetise?
Greater palatine injection anaesthetises palatal features 4-8.
Lesses palatine injection anaesthetises soft palate.
Naso-palatine injection, anaesthetisises 1-3.
Name some supplemental LA techniques:
- Intra-ligamentary
- Intra-pulpal
Why does LA failue?
- Operator dependent
> poor technique
> insufficient amount of LA used
> choice of LA (articaine better infiltration perfusion) - Patient dependent
> anatomical (variation, accessory nerves)
> pathological, if inflammation is present
> psychological
what are some immediate complications of LA?
- Unilateral facial (Bell’s) palsy, due to injection to posterior into parotid gland, affecting VII facial nerve.
- Trauma, either idiopathic or via pt chewing lip due to loss of sensation
- Palpitations due to idiopathic injection of intravascular adrenaline causing tachycardia.
- Skin blanching
- Allergy
- Needle breaking
- Toxicity
What are delayed complications of LA?
- Haematoma/bruising
- Trismus
- Infection
- Persistent anaesthesia/paraesthesia
- Tissue necrosis
- Post-anaesthetic lesion (HSV, recurrent aphthae)
What LA routinely used in paediatric dentistry?
2% lidocaine + 1:80 000 adrenaline due to its low allergic characteristics.
Which is superior: 4% articaine more or 2% lidocaine for tx of posterior teeth?
4% articaine + 1:100,00 adrenaline is more superior to 2% lidocaine + 1:80,000 adrenaline for trx. of posterior teeth with irreversible pulpitis (Cochrane review St.Goerge G et al. 2018)
Why do we avoid articaine with caution for people with asthma or sulphites allergies?
Articaine can lead to bronchospasm in patients with asthma or sulphites allergies.
What is the onset of topical anaesthetics lidocaine and benzocaine?
- Lidocaine 5% (onset 2-5 mins)
- Benzocaine 20% (onset 30 secs)
What rate should LA be delivered at to minimise pain on administration?
1ml/min (cartridge volume = 2.2ml).
Pain on LA delivery is due to subcutaneous tissue expansion.
Why is Articaine more effective when administered in low pH environments (infected areas)?
Articaine has low pH which makes it more effective when administered in low pH environment such as abscesses as it can pass the cell membrane and get activated by blocking the Na-channels from inside the cell.
How many micrograms of lidocaine and adrenaline is there is a 2.2ml cartridge of Lidocaine 2% + 1:80 000 adr?
Lid.2%+ 1:80,000 Adr.- has total of 49.9micrograms of adrenaline and 46.9mg of lidocaine in a cartridge of 2.2ml.
What are indications for antibiotics prescription?
- Spreading infection: cellulitis, lymph node involvement, spreading swelling, trismus
- Systemic involvement: malaise, pyrexia
- Immunocompromised patients.
What patient factors do you need to think of before prescribing Abx?
- Allergy to antibiotics
- Renal function
- Pregnancy
- Oral contraceptive pill
What does the dose of the antibiotics depend on?
Age, weight, renal function, severity of the infection.
- Use lowest dose possible for shortest possible time.
What does the duration of the antibiotic depend on?
Nature of the infection
Pt response to Abx
- Too short results in resistance
- Too long may produce unwanted side effects (antibiotic-associated colitis)
- Use lowest dose possible for shortest possible time.
What Abx are bactericidal? (3)
Bactericidal = kill bacteria
- Penicillin
- Metronidazole
- Cephalosporine
What ABx are bacteriostatic? (3)
Bacteriostatic = inhibit or slow growth of bacteria
1. Tetracycline
2. Erythromycin
3. Clindamycin
What is Amoxicillin?
- how does it work?
- spectrum?
- % allergy
- pregnant women?
- inactivated by what
- Bactericidal, interferes with cell wall synthesis.
- Broad spectrum
- 1-10% have allergy to penicillin (rash or anaphylaxis)
- Safe in pregnant patients
- Inactivated by penicillinases (B lactamases), however Flucloxacillin isn’t).
What is Co-amoxiclav?
- What is it?
- active against penicillinases?
- indications?
- Side effects?
- Doses?
- Amoxicillin + Clavulanic acid
- Combination of 2 drugs means active against penicillinases (Beta-lactamases)
- Indications - severe dental infections with spreading cellulitis
- Side effects: stevens-johnson syndrome
- 374mg or 625mg??
What is metronidazole?
- Effective against?
- Indications?
- contraindications
- side effects?
- typical dose?
- Effective against anaerobic bacteria and protozoa.
- Bactericidal, it inhibits synthesis by breaking down bacterial DNA
- Indicated for ANUG, pericoronitis, oral infections (when Pen V contraindicated)
- Reacts with alcohol + don’t use with warfarin
- Side effect: oral candida overgrowth
- 200mg tds
What is clindamycin?
How does it work?
Serious side effects?
routine?
Indications?
Typical dose?
Bacteriostatic, inhibits bacterial protein synthesis.
Serious side effects - pseudomembranous colitis
Not routine oral Abx
Indicated for bone (osteomyelitis) and skin (cellulitis) infections
150mg tds
What are tetracycline antibiotics?
How do they work?
Indications?
side effects?
Normal dose?
- Bacteriostatic, inhibits protein synthesis.
- Indicated for perio disease and sinusitis
- Causes extensive staining (not indicated for children and pregnant women)
- 250mg qds
What is erythromycin?
How does it work?
What does it interact with?
Risks?
- Bacteriostatic, inhibits protein synthesis
- Interacts with simvastatin, increases plasma concentration of simvastatin
- Causes increased risk of myalgias, rhabdomyolysis and renal failure
- Narrow spectrum, poor absorption, GI disturbances
- Limited indications
How do NSAIDs work?
Non-selective inhibitors of COX1 and COX2?
They are analgesic, antipyretic and anti-inflammatory agents.
What are 4 examples of NSAIDS?
- Ibuprofen
- Aspirin
- Diclofenac
- Naproxen
What are 3 side effects of NSAIDs?
- Peptic ulceration
- Cardiac implications (arrhythmias, thromboses, MI)
- Increased bleeding tendency
What are contraindications for NSAIDS? (6)
- Pregnancy/breastfeeding
- Asthma
- Renal/liver disease
- Peptic ulcers
- Cardiac conditions (excluding ibuprofen)
- Allergy
Fainting:
- cause?
- symptoms?
- management?
- Syncope or vasovagal attack due to anxiety or pain.
- Symptoms include nausea, pallor, thread pulse, loss of consciousness, cyanosis and convulsions.
- Lie down with feet in air, allow blood to return to brain. Ensure ABCDE and give oxygen.
Hypoglycaemia:
- cause?
- symptoms?
- management?
- Poorly controlled insulin-dependent Diabetes Mellitus, fasting or infection.
- Symptoms include; trembling, sweating, hunger, disorientation, slurring of worse, inability to concentrate, aggression, and LOC
- Treat with glucose drink (10-20g) and complex carb.
- If unconscious - glucagon 1mg I.M.
- ABCDE and oxygen
Eplipsy:
- cause?
- symptoms?
- management?
- Poorly controlled drug regime
- Sx: LOC, convulsions, incontinence, cyanosis, confusion.
- Treat by protecting pt from injury during convulsions.
- If prolonged or repeated convulsion in short interval - buccal midazolam 10mg/ml
Adrenal insufficiency:
- cause?
- symptoms?
- management?
- Caused by long term steroids and adrenal disease.
- Sx: LOC, pallor, thread pulse, low BP.
- Ensure ABCDE, oxygen, 100mg hydrocortisone given if need be
Anaphylaxis:
- cause?
- symptoms?
- management?
- Caused by allergic reaction to penicillin or latex.
- Sx: LOC, dyspnoea, flushing, itching, anxiety, pallor, cyanosis, weak pulse, low BP, oedema and cardiac arrest.
- Treat with ABCDE, oxygen, adrenaline 0.5ml of 1:1000 adrenaline IM.
- Call ambulance
Angina:
- cause?
- symptoms?
- management?
- Caused by myocardial ischaemia, MI, due to pt being stressed or exercise induced.
- Sx - crushing chest pain and retrosternal pain radiating down left arm.
- Tx: GTN spray sublingually and oxygen.
How does GTN work?
- venous dilation –> reduces venous return to hear –> decreases preload –> reduce inotropic effect –> reduced anginga
Myocardial infarction:
- cause?
- symptoms?
- management?
- Occlusion of coronary artery causing tissue death.
- Sx: LOC, severe crushing retro-sternal pain, vomiting, pallor, dyspnoea and weak pulse.
- Tx: MONASH
- morphine
- oxygen
- nitrate (GTN)
- aspirin
- seek help
- heparin
Cardiac arrest:
- cause?
- symptoms?
- management?
- Caused by MI and hypoxia, secondary to respiratory obstruction.
- Sx: LOC, no central pulse.
- Tx: Basic life support and Automated External Defibrillator (AED) until crash team arrives.
Asthma:
- cause?
- symptoms?
- management?
- Attack triggered by anxiety, infection, exercise and sensitivity to allergen.
- Sx: dyspnoea and wheezing on expiration
- Tx: Salbutamol inhaler or nebuliser
- Hydrocortisone and consider adrenaline if v severe.
Stroke or CVA:
- cause?
- symptoms?
- management?
- Caused by cerebral haemorrhage, thrombosis and/or embolism.
- Sx: LOC, headache, hemiplegia.
FAST symptoms:
> Face drooping
> Arm weakness
> Speech difficulty
> Time to call for ambulance. - Tx with supine movement, airway, oxygen, BLS and monitor:
–> don’t give aspirin as risk if haemorrhage (Brain bleed), make it worse.
Airway management:
- cause?
- symptoms?
- management?
- Unconscious causes no pharyngeal reflexes, loss of muscle tone, not able to protect own airway.
- Partial obstruction or complete obstruction, stridor or silence.
- Clear upper airway (suction)
- Triple airway manoeuvre, jaw thrust, head tilt, chin lift.
- Heimlich manoeuvre if foreign body.
- cricothyroidotomy.
What is BLS?
- Compression of lower third sternum to depth of 5-6cm, with compression rate 100-120/minute and 30 compressions to 2 breaths.
How do you examine a pt with returning problems?
Visual:
- patient’s general appearance
E/O:
- temperature
- swelling
- facial asymmetry
- lymphadenopathy
- trismus, reduced opening of the jaw
I/O:
- site of surgery
- swelling
- bleeding
- suppuration
- halitosis
What is alveolar osteitis?
Dry socket!
Inflammation of the alveolar bone post extraction, due to loss of blood clot leaving exposed alveolar bone.
What are 4 symptoms of dry socket?
- Extremely painful (throbbing sensation)
- Associated with bad taste and odour
- Not relieved by analgesics
- Not associated with pyrexia, swelling or infection.
What are 5 factors that increase the risk of dry socket?
- Smoking
- Oral contraceptive pill
- Local infection (ANUG, pericoronitis)
- Excessive trauma during XLa.
- Immunocompromised patient: diabetes, immune suppression, radiotherapy and altered bone metabolism patients.
How do you manage dry socket?
- Irrigation of socket with saline solution.
(Don’t use chlorhexidine as recorded death from allergic reaction) - Smoking cessation
- Obtundent pack, Alveogyl, containing:
> Eugenol: An analgesic + antiseptic
> Iodoform: An antibacterial
> Butamben: A mild anaesthetic
> Penghawar djambi: Fibers from the tree fern, Cibotium barometz
> Sodium lauryl sulphate: An ingredient in Alveogyl
> Calcium carbonate: An ingredient in Alveogyl - Analgesia to treat acute pain.
What is delayed bleeding after an extraction usually due to?
An infection
What is primary, reactionary and secondary bleeding after an extraction?
- Bleeding post XLA = primary
- Bleed <48 hours = reactionary, due to trauma to surgical site.
- Bleed due to infection or other causative factors = secondary
What is the management of post XLA bleeding?
Assess pt for vitals signs and airway clearance.
Consider treatment such as vitamin K and tranexamic acid if coagulation risk, as well as fluid transfusion.
- consider pack and suture (surgicel), haemostatic acids, vasoconstrictors and suction.
What do you do for haemophilia patients if they come back bleeding?
- Debride the socket (surgical area)
- Remove clot remnants and try to identify the bleeding site.
- Soft tissue management by placing compressive sutures (vicryl) and surgicel or fibrin blocks.
- Bone wax if the bleed is from bone
- Bleeding due to infection, either localised or systemic (pyrexia)
- Consider prophylactic Abx???
What is surgicel used for and how does it work?
- Use as a haemostatic agent (induces blood clot)
- Made of an oxidised cellulose polymer
- Used to control post-surgical bleeding due to intra-bony bleeds from inferior alveolar artery
- Potential neurotoxic effects in mandibular canal.
What bacteria cause dental abscesses?
Polymicrobial anaerobic bacterial infections.
Usually three or more causative organisms can be isolated from a dental abscess, predominantly Gram-negative anaerobic bacilli.
when are the only times Abx are appropriate for oral infections?
- Systemic involvement — pyrexia, lymphadenopathy and malaise
- Immunocompromised
- Spreading infection — cellulitis and swelling
What is the first line analgesia for dental pain?
If pain is not tolerable, then was can be prescribed?
Ibuprofen and paracetamol are first-line analgesia.
Codeine phosphate or alternative NSAID, diclofenac, naproxen.
What analgesics can be used in pregnancy?
Paracetamol and short course of codeine.
No ibuprofen or other NSAID
What is the analgesic ladder?
1st line = paracetamol
2nd line = ibuprofen (NSAID); contraindicated in asthma, pregnancy, liver, kidney, Crohn’s disease.
3rd line = paracetamol + ibuprofen
4th line = co-codamol (combination of codeine and paracetamol)
5th line = tramadol (stronger dose of codeine); trx moderate to severe pain.
6th line = oramorph (strong painkiller for severe pain); pain from cancer or heart attacks.
What is the maximum dose of ibuprofen?
Max = 2400mg (2.4g) or 30mg/kg per day = 600mg x 4/day.
What is the maximum dose of paracetamol?
4000mg (4g) per day.
1g per dose, 4x/day.
What is best analgesic advise post op?
Ibuprofen and paracetamol, alternate between both every 4 hours.
Who is diclofenac contraindicated in?
People with IHD, CVD, PVD, and mild, moderate, or severe HF.
Available on prescription only. it is NSAID (not to be taken with other NSAIDs)
What drug interactions does warfarin have with NSAIDs and azole antifungals some antibiotics?
- Increase bleeding risk
What can happen if statins are taken with azoles, erythromycin and clarithromycin??
myopathy
What medication can exacerbate asthma?
NSAIDs
What are cowhorn forceps designed to do?
Engage the furcation in mandibular first and second molars.
Can be used to section the mandibular molars into 2 single roots which can be removed separately.
What can eagle beaks be used for?
Maxillary first molars, engages buccal furcation and palatal single root.
What is the operator position for maxillary teeth?
Stand in front of the patient, chair should be elevated and tilted back. Stand at arm’s length away from pt.
What is the operator position for mandibular teeth?
Chair should be lowered so that pt’s shoulder is level with dentist’s elbow.
- LL = stand in front of pt
- LR = stand behind the pt
Describe holding the forceps and correct application:
- Initial movement must be apically along the PDL, with blades beneath the gingival margin
— This reduces the chance of the crown breaking due to rotational axis being more apical
— Wedges the blades down the root causing more displacement
— Dilates the socket - Second movement = apical force is maintained, with slow and deliberate movements
— Conical rooted teeth movement is ROTATED
— Multiple rooted teeth have a BUCCO-LINGUAL movement next
— Mandibular anterior teeth should initially be moved labially - Final movement
— Posterior teeth are delivered buccally
— Anterior teeth are delivered with rotations
What should you do once you extract a tooth?
The socket should be compressed firmly with finger and thumb (digital pressure) before applying pressure from the gauze.
This makes the socket a smaller wound and any fragments of buccal bone with attached mucoperiosteal are replaced.
What are post op instructions after an XLA?
- Avoid
> hot or cold foods or drinks
> exercise or effort
> smoking, alcohol and mouthwashes for 24 hours.
> LA lasts for 2-3 hours, can last longer.
> playing with wound site or stitches with tongue or fingers. - Salt water mouth rinses after 24 hours. Rinse after every meal for 1 week.
- OH - avoid area
- Bleeding - pink saliva normal. heavy bleeding use gauze
- Signs to look out for:
- uncontrolled pain
- uncontrolled bleeding
- bad taste, smell, pus
- spreading swelling
What is the function of the supporting hand during an extraction?
- Gripping and supporting alveolus
- Retracting soft tissues
- Retrieve fractured restorations and fragments of tooth (preferable tooth tweezers) - protect airway
- Support the lower jaw
If doing full mouth clearance, where do you start?
Lower posterior, unless one extremely painful tooth
How do you position your supporting hand during and extraction?
Lower R = Thumb in lingual sulcus, forefinger in buccal sulcus other 3 fingers under chin
Lower L = Curl up 4th and little finger. Middle finger in lingual sulcus, forefinger in buccal sulcus, thumb under chin
Upper R = Forefinger in palate, thumb in buccal sulcus curl up remaining 3 fingers
Upper L = Thumb in palate, forefinger in buccal sulcus, curl up remaining 3 fingers
What is the function of elevators?
Used to loosen or deliver teeth by severing the PDL.
Alveolar bone used as the fulcrum and not the adjacent tooth.
Firmly help in palm of the hand by the index finger supporting the blade by fingertip close to blade.
Very useful for conically rooted teeth.
by inserting the instrument onto the root surface so that the concave blade engages the root, and when the handle is rotated the lower cutting edge lifts the root.
What is the function of a luxator?
- Thinner and sharper than elevators.
- Fit in tight apical spaces, more efficient at cutting PDL
- use in circular cutting motion whilst applying apical pressure
What are warwick-james elevators used for?
Removal or upper 8s.
Curved blade inserts into the concavity, with the handle then rotating and the blade turning against the root mass.
What are cryer’s elevators used for?
Blades larger and more pointed, at right angles to the hand.
- Used to loosen tooth or root from boy socket prior to forceps placement.
- Used for :
> extraction of impacted 8s, applying concave surface against mesial aspect of the root.
> for elevating fractured roots
> applying pressure to buccal aspect of lower molars where furcation can be engaged
What are lacks tongue depressor used for?
Examination of OC and oropharynx
What is Austin retractor used for?
To deflect and retract the periosteum from bone after incision
What is Minnesota retractor used for?
To retract mucoperiosteal flap only rest on bone
What is kilner cheek retractor used for?
Retraction to aid vision for upper 8s
What is lasters retractor used for?
XLA U8s, locks behind the tuberosity.
What is bowdler henry retractor used for?
XLA 8s
What should be assess pre-operatively before extractions?
History
Clinical examination
Radiographs
Special tests
Diagnosis
Treatment plan
What are anaesthetic choices for extractions?
- LA
- Conscious sedation (inhalation or IV) supplemented with local anaesthetic
- General anaesthetic
What are the principles of flap design?
Flap design needs to be sufficient for surgical procedure, to ensure adequate access and minimum damage to tissue.
- Incision avoids vital structures.
- Ensure flap has adequate blood supply.
- Incise mucoperiosteal flap ensuring that you don’t separate the mucosa and periosteum. Full thickness flap.
- Incise perpendicular to epithelial surface.
- Include interdental papillae on the flap
- At closure of mucoperiosteal flap, should rest on sound bone.
What do relieving incisions do?
They relieve the tension on the flap for adequate access.
Why do you need irrigation when using a bur on bone?
To avoid surgical emphysema.
What bur do you use for bone removal?
Flat fissure 4 bur
What scalpel is used for raising a flap?
Scalpel (15) used for cutting soft tissue with minimum trauma
What are tooth forceps use for?
Tooth forceps grasp tissue by puncturing rather than crushing.
Non-teeth forceps grasp by compression of opposing serrated edges.
How do tissue forceps work?
Scissor action incorporating a ratchet lock.
Useful for slippery tissue or when direction or traction must be varied.
What are artery forceps used for?
- Scissor action incorporating a ratchet lock.
- Grasp vessel with tip projecting beyond the vessel to facilitate tying a ligature.
- Compress vessel to facilitate haemostasis.
How are needle holders designed?
Designed to rotate in long axis as a pronation-supination action to drive curved needle through tissues.
What are the different types of needles and their uses?
- Cutting needles used for resistant fibrous tissues.
- Round bodied needles used for fragile tissue to produce minimal damage.
- Traumatic is eyeless
Rules of suturing:
- Suture from free to fixed tissue
- Ideally suture forehanded (toward yourself)
- Evert skin edges
- Needle should enter the tissues perpendicular to surface
- Follow curve of needle by pronation, supination to avoid ‘pulling through’.
What are different types of sutures:
- Simple interrupted
- Continuous
- Vertical mattress - double stitch with return stitch in line with the first but taking a smaller bite.
- Horizontal mattress - double stitch with return stitch parallel to the first.
- Sub-cuticular continuous - avoids puncture wounds on surface (skin closure)
