Oral Surgery YR4 Flashcards
Why would be decide to raise a mucosal flap?
Gain ACCESS to an object/structure e.g. aretained root / apex (but could also be forintrabony pathology or ORIF of a fracture)Flaps permit targetted bone removalMucosal flaps can also be useful to cover upexposed structures such as OAC closure orexposed dentine
Describe a One sided envelope BMPF?
crevicular incision only - at gingival marginextend atleast one tooth each side of the toothin question but furtherextension improves accessTypically 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 relievingincision, usually mesial for best accessMost common flap designTypically 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 relievingincisions mesial and distalTypically requires 4 sutures to close – mesial + distalpapillae of the extracted socket and one in each relieving incision – but distal relieving incisions can bedifficult 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. furcation2. Adjacent Structures- nerves e.g. mental- adjacent crown margins to avoid recession- canine prominence3. 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 andadd relieving incisions asneeded.Generally 3 sided BMPFs givethe best access to the buccalbone adjacent to the root
What to think about when planning access for flap design?
Access to the point of application forelevatorsChanging the path of removal by sectioningfrom the furcationAvoid 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 crevicularincisions 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 incisionaway from the area of bone removal/lossto provide support for the incision margin when closed
Describe the process to remove a mesio-angulary impacted partially eruped LL8?
- Mucoperiosteal flap marginsincised – 3 sided BMPF2. Flap retracted from buccal side3. Collar of bone guttered frombuccal side of LL84. Sectioning of toothThe groove has been drilled only half way through thetooth bucco-lingually to protect the lingual nerve5. Elevator used to separate the 2 roots6. Distal root delivered with forceps7. Mesial root elevated into the space created by removal of the distal root – disimpacted – thendelivered8. Socket debrided and washed withcopious sterile saline9. Wound closure with sutures
Describe the palatal flap for buried canines?
- Sacrifice the incisive bundle – no clinicalsignificance to the resulting area of anaesthesia2. Extensive crevicular incision extending from UR6 to UL4 on the palatal aspect as no relieving incisions possible3. Buried canine located and exposedby 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 layerscored to permit extension of the flap to the palatal side- pull flap across defect and suturePalatal 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 makingsubsequent denture fit difficult without further sulcus deepening surgery.
What is the definition of a palatal rotational flap?
Technically difficult so usually done under GAwhen buccal advancement closure fails.Either full thickness allowing the donor site togranulate 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 thevisible anterior region especiallynoticeable 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 inattached gingivae- Requires at least 4mm of attached gingivaeSemi-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 orhaemostatic intrasocket agents)Provide adequate tension for wound closureand promote healing by supporting tissuemargins until sufficiently healed to supportthemselves
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 forsuture 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’tleach)– Cost effective
Name the 7 ideal suture needle proeprties for MOS?
- Maintains sharpness to repeatedly incise mucosawithout tearing– Malleable to form appropriate shapes/curves forintraoral use– Strength to maintain structural integrity– Sterile– Biologically inert– Cost effective
Name the 3 types of suture materials for MOS?
ResorbableNon-resorbable
Give 2 examples of resorbable sutures?
- Vicryl - polyglactin (coated or the more rapidlyresorbing ‘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 isimportant (e.g. OAC closure) or resorption products arepossibly undesirable for healing with minimal scarringe.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 IIethilonprolene
Name 2 examples of braided sutures?
VicrylBSS
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 resorband 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 and100% in 10 days (sutures usually fall out and are swallowed/spat out rather than completely resorbed (which takes 50days).• Coated Vicryl loses 50% of its tensile strength at 3 weeks andis completely resorbed in 70 days.
What is the rule of thumb for suture gauges?
Use of the smallest suture that approximates the tissue’sown 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 indiameter 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 maceratedmucosa. Easy to pull toohard and break the suturewhen suturing.
When is 3/0 vicryl rapide used?
across sockets andapplying pressure to achievehaemostasis
What are blunt ended scissors used for?
cuttingsutures without accidentlydamaging adjacent softtissues such as the tongue orlips.
What are toothed tissue forceps used for?
manipulating oralmucosa without crushingtissue and causing woundmargin necrosis
What are locking needle holders used for?
to securely hold the sutureneedle and a smoothjoint to allow suture toslide over when tying asurgical knot
Main suture technique?
simple interrupted
Describe a horizontal mattress suture?
for closingOACs to evert tissue margins andobtain an air tight seal. Can also belooped around a tooth to cuff thetissue tightly to the toothpotentially minimising post-healingrecession.
Deswcribe a continious suture?
quicker for largewounds than multiple interruptedsutures but if any part comesundone the whole wound dehisces.
Surgical Sieve? Acromym VITAMIN CDEF
V - vascularI - infection/inflammationT - TraumaA - autoimmuneM - metabolicI - iatrogenic N - neoplasticC - congenital D - degenerativeE - endocrine/environmental F - functional
Name all types of cancer?
CarcinomaSarcomaChondromaMyomaAdenomaOsteoma
Kaposi’s sarcoma? Where? Why? Type?
PalateAIDSVascular tumour BVs
Haematoma?
Blood in adea
Ludwig’s angina?
Infection sub-neck
Ibuprofen max dose?
2.4g 200mg tablet12 tablets
Max dose for Paracetamol?
4g500mg per tablet8 tablets
What are Winter’s classification of impacted wisdom teeth?
VerticalMesioangularHorizontalDistoangular
Name 6 local reasons for the failure of eruption of 8s?
Displaced follicle (ectopic position)CrowdingSupernumerary/supplemental teethImpacted into adjacent toothPathology - cyst, tumour or fibrous dysplasiaMissing 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?
PainSwellingTrismusInfectionTime off workCostNerve 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 repairIf anaesthesia is present after Post-OP review - ensure no bony fragment, if present removeIf 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 specialistSome 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 cariesNon-treatable pupal and/or periapical pathologyCellulitis, abscess and osteomyelitisFracture of toothResorption of tooth or adjacent teethDisease of the following such as cyst/tumourTooth impeding surgery or reconstructive jaw surgery
When should you leave 8s in place?
Symptom freeNo evidence of diseaseRemoving the tooth may cause more harm
Name 5 non-NICE guidelines for removal?
To exclude atypical facial painTo prevent late lower incisor crowding or relapse of orthoPrior to travel Financial - >25Known 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/tumoursSymptomatic 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 cancerSymptomatic 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 rootDeflection of rootNarrowing of rootDark and bifid rootInterruption of white line of canal Diversion of canalNarrowing 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 rootsRoot resection- sectioning and removal of a diseased rootPremolarisation- 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 canalActive infectionPreexisitng numbnessPreexisiting mobilityHorizontally impacted tooth along IANMedical 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 eyeIf 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 MIOr have exceeded the recommended dose of pain relief medication
What are the 6 key signs and symptoms of facial swelling?
A firm ot soft lumpSwelling may be staic or inreases over hoursSwelling due to sepsis or ooedema around or in the tongue or pharynxUlcerated swellingA change in normal apperance to red, white or a comboA 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 dislodgedRF:- smoking- oral contraceptives- fail to follow post-OPPCO:- 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 bonepain and swellingManagement:- 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 periosteumSymptoms:- fever - swelling- warmth- weight lossTreatment:- incision and drain, followed by antibiotics - (metronidazole)
What is the defintion of trismus?
limited mouth openingAetiology:- extarctionhaematomalong opening timeTMJ damageFractureInfectionManagement:- 3 finger testMild:- reassure and manage painSevere:- pain management
How to manage nerve damage after extraction?
transientpersistent > 6 monthspermanent > 6 monthsManagement:- review 5 days - refer to MaxFac
Management of post-OP extraction bleeding?
Ensure no anticoagulationself-help measure - roll a pad for 20 mins, check for bleedingUncontrolled 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 diseaseRefer
Definition of oro-antral communication?
unnatural space that froms between max sinus and oral caity following extractionPCO: - nasal regurg- bad tasteRefer for flap
Definition of oro-antral communication?
unnatural space that froms between max sinus and oral caity following extractionPCO: - nasal regurg- bad tasteRefer for flap
Name 4 types of radiopacities?
Abnormalities of the teethCondition affecting the boneSuperimposed soft tissue calcifcationsFoerigen bodies
Name 3 dental radiolucencies?
Periradicualr periodontitsApical abscessPerio-endo lesion
Name 3 cyst radiolucencies?
RadicularLateral periodontalDentigerous
Name 3 radiolucent tumours?
Odontogenic keratocystAmeloblastomaOsteosarcoma
Describe the oxygen needed for sedation?
2 x E size cylindersNot from Emergency drug kit!O2 reducing valve capable of delivering 0-15 litres O2Nasal cannula
Name the monitoring equipment necessary for sedation?
Pulse OximeterCalibrated before useAudible Alarm set for below 90%Blood pressure monitorDigitalAppropriate cuff (adult)Spare batteries
Name the sedation agent and how to use it?
Midazolam 1ml per ml for injectionRecord batch number and expiry dateStorage in locked and secure locationDraw up in 10ml syringe
Name the equipment for cannulation for sedation?
Non latex disposable tourniquetIV cannulas (Venflon)20-24 gauge (pink, blue, yellow)Water or saline for flushing5ml syringesGreen 21g IM needles to draw up solutionsLabels for syringes
Name the reversal agent for sedation?
Flumazenil 0.1mg per ml for injectionSyringe and green needle laid out(not essential to draw up)Treatment dosage 0.2mg/2mlMUST BE AVAILABLE AT EVERY PROCEDURE
Name the 7 other equipment that is necessary for conscious sedation?
Necessary paperworkClinical recording, post op instructionsPPE for patient and clinical staffEquipment for procedure: surgical drill/materials etcMouth props can be usefulGauze, elastoplasts, spare venflons, EMLA creamAwareness 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/MultidrugSedation procedures carried out by 2 sedation-trained individuals ie Dentist and Nurse12 hours CPD per 5 yearsParticipation in sedation-specific audit and local governance managementSedationist trained to Immediate Life Support levelRecord keeping including a log book and self reflection
What is the definition of midazolam?
A Benzodiazepine:AnxiolyticFast actingHalf life approx. 3 hours (1-4 clinically)Binds to area adjacent to GABA(gamma-aminobutyric acid) receptors in central nervous systemMuscle relaxant/anti convulsantUsed 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- ReversibleDis:- 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 relaxationCVS: Fall in arterial pressure (small), reduces ‘sympathetic drive’Respiratory: reduced rate and depth of breathing, muscle relaxation, affects central CO2 and peripheral O2 receptorsNEED FOR BASELINE AND PROCEDURAL PATIENT MONITORING
What is the definition of flumazenil?
Reversal agent to Midazolam in conscious sedation techniquesA 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 AgencyReducing the risk of Midazolam overdose in general useRecommended the only availability of 1mg per ml MidazolamMore concentrated solutions available only in an anaesthetic/ITU settingPrimarily 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 benzodiazepinesMechnanism not clearConsider reduced dosages, close monitoring and slower titration technique
Does conscious sedation practices chnage in children?
Midazolam commonly used orally as premedication prior to General anaestheticTastes terrible! Hidden in orange juiceVery effective but not titrated – unpredictable outcomeIV 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 checkDrug checkTrained staff availablePatient has attended with appropriate escortPMH changed?Last meal/been to toilet/comfortable clothing/available anatomy for monitoringCONSENTInitial readings : BP/O2/HR
Describe how to place the venous cannulation for sedation?
Start distally Dorsum of hand, medial wrist, antecubital fossaIdeally, different arm to BP cuff and pulse oximeter probeSecured in place with tape/dressingDate and time of cannulation notedNo of attempts recordedFlush with saline/water
Describe how to administer midazolam for sedation?
Labelled syringe of 1mg : 1ml Midazolam for injectionStart with 2mg bolus dose delivered over 30 secondsWait and monitor patient for 90 secondsContinue incremental delivery of 1mg Midazolam IV every 60 secondsWatch for signs of adequate sedationContinuous delivery of behavioural techniques: breathing awareness/systematic muscle relaxation/guided imagery
Describe how to administer midazolam for sedation? - FOR THE ELDERLY?
Reduced dosage usually requiredStart with 1mg bolus dose over 30 secondsWait 2-4 minutesContinue incremental delivery on 0.5mg every 2 minutesWatch for signs of over-sedation!
Explain how to gauge whether the patient is sedated?
General state of relaxationMuscle tension reduced: relaxed shoulders, neck neutral, fingers soft not clenchedSlow eye blinkingSlowed responses: physical and verbal Sleepy feelingPatient able to respond to verbal commandsPatient 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 - AVPUPatient un-rousable from sleepingPatient does not respond to painful stimuli eg LA injectionDrop in O2 saturation – suppression of spontaneous breathingConsider Flumazenil administration and aborting procedureAnticipate over-sedation: low BMI, elderly patient, poly pharmacy, Midazolam administered too quickly
Name the 7 complications of conscious sedation?
No effectParadoxical effectNausea/vomitingHiccupsHypoxia (usually due to oversedation)HypotensionSuppression of gag reflex – airway protection!
WHat must be monitored during the sedation process?
Sedationist and nurse in constant state of awareness of patientPulse oximetry: audible heart rate, calibrated alarm to sound below 90%Can provide supplemental O2 through nasal cannula if patient breath-holding or speaking throughout procedureMaintain verbal communication with patient throughout procedureIf patient falls asleep, ensure observations are satisfactoryAT 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 minutesEnsure patient is warm and comfortable after dental procedure completedRepeat 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 administeredInvite Escort into recovery areaDiscuss 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 upWRITTEN AND VERBAL ADVICE TO BE GIVEN including emergency contact details
What must be recorded in the notes for sedation?
Reflective practiceLog bookAdverse eventsUse of Reversal agent – justificationControlled drugs
Describe how to assess anxiety for a patient that may qualify for sedation?
Clinical judgement – phobia/anticipated difficult procedurePatient request?Questionnaire useful aidAlternatives to conscious sedation?
Name the 7 categories needed to be involved for a clinical assessment?
Clinical observations – O2, pulse, BPBMIASA (see next slide)General MobilityIV access/nasal airway patencyLarge tongue/retrognathic mandible/sleep apnoeaCurrent and previous medical history: Medications, AllergiesRelevant GA/sedation history and experience
Describe the ASA 1-5 levels?
ASA I: A healthy patientASA II: A patient with mild systemic diseaseASA III: A patient with systemic disease which is not incapacitatingASA IV: A patient with incapacitating systemic disease with is a constant threat to lifeASA 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/ChaperoneLives alone/cohabitsDependantsDependants of chaperoneTransport home after treatmentWork and social commitments
Describe the process and documentation for consent for conscious sedation?
Carried out at assessment and revisited at treatment sessionA written and verbal processSpecific details of proposed procedureWill not be deviated from, therefore plan number of sedation treatments in advance if lots of treatment required- NB 30-40min working timeRisks/warnings/alternativesConsider consent for Escorts
Name the 6 contraindications for IV sedation in a dental setting?
ASA III/IV – consider referral to hospital setting for inpatient treatmentBMI >35Poor IV access: ex IVDU, increased cutaneous fatObstructive sleep apnoeaUnable to arrange appropriate post op supervision/chaperonePoor response to Benzodiazepines in the past/unsuccessful IV sedation
What records are essential to carry out during a sedation procedure?
NEWS chartDischarge checklistPost op patient leafletsPre op assessmentSedation procedural sheetPost 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 drinkthe most alcohol
What history may be of concern when trying to identify alcohol dependence?
Ask about alcohol intake* Medications- vitamin supplements especiallythiamine/B1 to prevent Alcohol BrainDisease (Korsakoff syndrome /Wernicke’s encephalopathy)- Diazepam / Chlordiazepoxide foralcohol 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-specificindicators of liver damage* High gamma-glutamyltransferase (γGT) more specificfor alcoholic liver diseaseBloods - Clotting screen* Clotting factors produced in the liverand/or reduced vitamin K absorption(bile)* Prolonged prothrombin time (PT)AND activated partial thromboplastintime (APTT) and thrombin time (TT)but essentially normal plateletactivity (bleeding time, plateletfunction 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 onDNA or acting as a solvent for othercarcinogens e.g. tobacco products
Alcohol dependence - liver disease and dentistry - bleeding risk? drug metabolism? transplantation?
In primary care - assess bleeding risk and ifsignificant refer to specialist/secondary careservices:- 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
