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ORAL SURGERYIPAIN CONTROL

Major Topic

Abbreviation

Adrenal cortex
Anatomy
Anesthesia
Biopsy
Disorders/Conditions
Drugs
Exodontia
Fractures
General Information
Implants/Grafts
Miscellaneous
TMJ
Copyright (!;) 2001 -

LEGEND

Adren Cort
Anat
Anesth
Biopsy
Disord/Cond
Drugs
Exo
Fractures
Gen Info
Impl/Grfts
Misc.
TMJ
DENTAL DECKS

ORAL SURGERY/PAIN CONTROL

Fractures

The treatment of a mandibular fracture using only intermaxillary fixat ion (IMF) is
called:
Open reduction
Closed reduction

Copyright 2001 -

DENTAL DECKS

Closed reduction
" ' It is called closed reduction because it does not Involve direct opening, exposure, and manipulation of the fractured area.
Forms of immobili zati on of a fracture :
1. A barton bandage is the simplest form of immobilization. Primarily a f irst aid measure
until definitive therapy can be instituted.
2. Intermaxill ary fixation (IMF) is establishing a proper occlusal relationship by wiring the
teeth together. This method will successfully treat most fractures of the mandible. The
main methods for such fixation are wiring, arch bars, and splints. This is the classical way
to Immobilize the fracture after closed reduction.
3. External skeletal fixation is used in most cases in which the management of a fractured
bone segment is not satisfactorily accomplished by intermaxillary fixation. It involves the
placement of screws or pins through the skin on each side of the fracture and a cold cure
acrylic bar which holds the screws in proper relationship with the fracture in the reduced position. It is cumbersome and esthetically displeasing.
4. Direct intraosseous wiring combined with a period of IMF is the traditional method of bone
stabilization after open reduction . This method of stabilization can be accomp lished through
a variety of different wiring techniques. The wire is placed through holes on either side of the
fracture and immobilization is accompli shed by tightening the wires.

ORAL SURGERYIPAIN CONTROL

Fractures

Zygomatic arch fractures can be nicely demonstrated by which radiographic view?

Water's view
Lateral skull view
Posteroanterior skull view
Submen tal vertex view

Copyright 2001 -

DENTAL DECKS

Subment&yerfex view
This type of fracture may not cause any problem other than perhaps a slight sinking of
the cheekbone area. There may be some encroachment and impairment in closure of
the jaw if it comes down and entraps the coronoid process of the mandible.
Possible complications include:
Paresthesia (most common) - usually subsides
The antrum (sinus) may be filled with a hematoma, which usually evacuates itself
Ocular muscle balance may be impaired because of fracture of the orbital process
Important: Fractures of the facial bones, particularly the zygomatic complex may
on rare occasions be complicated by damage to the contents of the superior orbital
fissure.
Note: Fracture of the infraorbital rim presents with the following symptoms:
Numbness of the following areas on the affected side: upper lip, cheek, and nose.
Remember: The Water's view is best to evaluate orbital rim areas. ....

ORAL SURGERYIPAIN CONTROL

Fractures

Which of the following is the most common pathognomonic sign of a mandibular


fracture?

Nasal bleeding
Exophthalmos
Malocclusion
Numbness in the infraorbital nerve distribution

Copyright 2001 -

DENTAL DECKS

Malocclusion

Other signs and symptons of a mandibular body or angle fracture include:


Lower lip numbness
Mobility, pain, or bleed ing at the fracture site
Anatomic distribution of mandibular fractures :
Angle (30%) most common site
Condylar neck (25%)
Symphys is area (22 %)
Body (17%)
Ramus (2%)
Coronoid process ( 1%) least common site
Notes:
1. Indications for open reduction include continued gross displacement of the bony segments
and an unfavorable fracture that is likely to result in further displacement of the fractured segments caused by muscle pull, This type of reduct ion is commonly performed for displaced
angle or body fractures. Remember: Condylar neck fractures are usually treated by closed
reduction .
2. In a fracture involving the angle of an edentulous mandible, the proximal segment is usually displaced anteriorly and super iorly.

ORAL SURGERYIPAIN CONTROL

Fractures

In patients who have a LeFort II fracture, a common finding is paresthesia over the
distribution of the:

Infraorbital nerve
Inferior alveolar nerve
Mylohyoid nerve
Hypoglossal nerve

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DENTAL DECKS

Infraorbital nerve
Midfacial fractures include fractures affecting the maxilla, the zygoma , and the nasoorbital ethmoid complex. Midfacial fractures can be classified as:
LeFort I (also called a horizontal fracture) is a horizontal segmented fracture of the alveolar
process of the maxilla, in which the teeth are usually contained in the detached portion of the
bone. Result is an open bite.
LeFort II (also called a pyramidal fracture) is a unilateral or bilateral fracture of the maxilla, in
which the body of the maxilla is separated from the facial skeleton and the separated portion
is pyramidal in shape. Signs include periorbital edema, ecchymosis, subconjunctival
hemorrhage, and nose bleeding.
LeFort III (also called a transverse fracture or craniofacial dysfunction) is a fracture in which
the entire maxilla and one or more facial bones are completely separated from the craniofacial skeleton. These patients will have restriction of mandibular movement.
Also zygomaticomaxillary complex fractures, zygomatic arch fractures, or nasoorbital ethmoid fractures.
Important: The first step in the treatment of these fractures which affect the occlusal relationship
is similar to the treatment of mandibular fractures - to reestablish a proper occlusal relationship
by placing the maxilla into proper occlusion with the mandible.
Note: Due to the slope of the sphenoid bone comprising the floor of the cranial vault, blows to
the maxilla will cause the maxilla to be driven backwards and downwards . This may result in
an open bite or Impingement of the airway.

ORAL SURGERY/PAIN CONTROL

Fractures

All of the following are weak points in the mandible where fractures are most common except

The angle
The coronoid process
The condylar neck
The symphysis area

Copyright 2001 -

DENTAL DECKS

The coronoid process


The location and extent of mandibular fractures are determined largely by the direction and intensity of the blow and the specific points of weakness in the mandible.
The angle is the most common anatomic site of fracture of the mandible (30% of fractures). Frequently third molars which are impacted are located in this region and further
add to the weakness of the mandible in this area.
The condylar neck (25% of fractures) is a safety feature which allows a blow to the
jaw to be dispersed at this point rather than driving the condyle into the middle cranial
fossa. Bilateral dislocated fractures of the condylar necks will cause an anterior open
bite and the inability to protrude the mandible. A unilateral fracture through the neck
may cause forward displacement of the head of the condyle due to pull of the lateral
pterygoid muscle.
The symphysis area or chin (22% of fractures) is usually where blows are sustained .
These blows often result in fractures of the subcondylar region. Remember: The
patient's mandible will deviate to side of injury upon opening.

Fractures

ORAL SURGERYIPAIN CONTROL


Which form of reduction listed below is best used to reduce a fracture when teeth are
missing in one or more of the fractured segments?
Open reduction
Closed reduction

Copyright 2001 -

DENTAL DECKS

Open reduction
Open reduction is the reduction of a fractured bone by manipulation after incision
into skin and muscle over the site of the fracture. The most common site for open
reduction is at the angle of the mandible. Once the incision is made, an intraosseous
wire is placed through holes made on either side of the fracture. Reduction is accomplished under direct vision, and immobilization is obtained by tightening the wires. This
procedure is usually reserved for fractures that cannot be reduced and immobilized
adequately by closed methods.
Closed reduction is the reduction of a fractured bone by manipulation without incision into the skin. It is the simplest method of reduction and is used most frequently
when both fractured segments contain teeth. After manipulation of the bone, it is usually maintained in place by intermaxillary fixation (lMF).
Remember: IMF is fixation obtained by applying wires or elastic bands between the
upper and lower jaws in which suitable anchoring devices have been attached. The
most common technique for IMF is the use of prefabricated arch bars.

ORAL SURGERY/PAIN CONTROL

Fractures

Which of the follow ing are likely signs and symptoms of a zygomatic fracture?

Nasal bleeding
Pain over zygomatic region
Numbness in the infratemporal nerve distribution
Exophtalmos
Diplopia
All of the above

Copyright 2001 -

DENTAL DECKS

All of the above


Midfacial fractures include fractures affecting the maxilla, the zygoma, and the
nasoorbital ethmoid complex. They may be classified as:
LeFort I, II, or III fractures
Zygomatic complex fractures (most common type of midfacial fracture)
Zygomatic arch fractures
Nasoorbital ethmoid fractures
--- The following radiographic views are often helpful to evaluate midfacial fractures:
Water's view PA skull view, and submental vertex view.

Important: A zygomatic arch fracture can impinge on the coronoid process or temporalls muscle, causing various degrees of trismus.
Notes:
1. The maxilla and mandible are in a critical relationship to the upper airway; therefore
displacement of fractures can cause obstruction of the airway resulting in respiratory arrest. Control of airway is vital to any treatment of a patient with facial fractures.
2. Maxillary fractures have a greater tendency towards the production of facial deformity than do mandibular fractures.

ORAL SURGERY/PAIN CONTROL

Fractures

Which muscle below is responsible for the forward displacement of the condylar
head when the neck of the condyle is fractured?

Masseter muscle
Mylohyoid muscle
Lateral pterygoid muscle
Medial pterygoid muscle

Copyright 2001 -

DENTAL DECKS

Lateral pterygoid muscle


Three groups of muscles that are responsible for the displacement of mandibular condyles:
Group I

-r

Masseter
Medial pterygoid
Temporalis

Group II

+-

Digastric
Mylohyoid
Geniohyoid
I alem! pterygo id

Group III

4-

Lateral pterygoid

Group I: elevate mandible during mastication and will cause an upward displacement of the
proximal segment.
Group II: depress the mandible and will displace the distal fractured segment inferiorly and
posteriorly.
Group III: when the neck of the condyle is fractured, this muscle will cause forward displacement of the condylar head .
Remember:
1. The proximal segment of the fracture is that segment which lies most posteriorly yet closest to the condyle.
2. The distal segment of the fracture is that segment which is most distal from the condyle
(i.e. anteriorly).

ORAL SURGERY/PAIN CONTROL

Exo

The most severe tissue reaction is seen with which type of suture material?

Plain catgut
Chromic catgut
Polyglycolic acid
Polyglactin 910

Copyrig ht 2001 -

DENTAL DECKS

Plain catgut
"""Resorb abl e sutures evoke an intense inf lammato ry reacti on. Th is Is the reason neither plain nor chromic gut is
used for suturing the surface of a skin wound.
PROPERTIES OF SUTURE MATERIALS
Non -Resorbable sutures

Resorba ble sutu res


Name

TIs sue
React iv ity

Knot
secu rity

Handling

Name

Tissue
Knot
Reactiv ity Security

Hand li ng

Plain Ca tgut

severe

poor

fair

Silk

severe

good

excellent

Chromic Catgut

moderate

good

good

Braided Polyester

good

minimal

fair

oood

Polyglycolic acid

minimal

fair

good

moderate
(if coating
sheds)

poor

Polvolactin 910

Stain less Steel Wire pract ically


none

excellent

poor

Polypropylene

minimal

good

fair

Polyethylene

minimal

poor

fair

Res~

~ from sheep intestine. susceptible to rapid digestion by proteolytic enzymes,~ns streng th for 5-7 dayi>

Chromic gut - "chromitized" to produce more resistance to proteolytic enzyme s. retains s rength for 9- 14 daY.,.
Polyglycolic ac id - does not enzym atically break down , undergoes slow hydrolysis, less sbfl than gut sutures (easier
to tie sutures), more expensive.
Nonresorbable: Silk, nylon, polyester, and polypropylene. Silk is bra ided (multifitamentous) , black , and inexpe nsive . It
is used for Int raoral suturi n g. Nylon is stro ng, not used In the mouth , and is the suture material of choice for facial lacerations. Polypropylene has the least tendency to induce inflammatio n.
~able sutures should be removed In 5-7 days..:-,

ORAL SURGERYIPAIN CONTROL


The most frequent location for a maxillary torus is:

The right side of the hard palate


The left side of the hard palate
The midline of the hard palate
On the soft palate

Copyright 2001 -

DENTAL DECKS

Exo

The midline of the hard palate


Here it is called the torus palatinus. They usually appear before the age of 30 and
affect females more frequently than males.

Maxillary tori present few problems when the maxillary dentition is present and only
occasionally interfere with speech or become ulcerated from frequent trauma to the
palate.
Indications for removal include a large, lobulated torus with a thin, mucoperiosteal
cover extending posteriorly to the vibrating line of the palate that prevents seating of
a denture and also prevents a posterior seal at the fovea palatini.
Technique for removal:
The maxillary torus should not be excised en masse to prevent entry into the
nose (the palatine bone will come out with torus).
It should be subdivided into segments by a bur.
The segments are then removed with an osteotome.
Any protuberances are smoothed out with a bone file .
The flap is loosely sutured.
A palatal splint is placed to prevent hematoma formation and to support the flap.

ORAL SURGERY/PAIN CONTROL

Exo

When removing maxillary teeth, the upper jaw of the patient should be where in relation to the dentist's shoulder?

Below
Above
At the same height
It makes no difference where the patient's upper jaw is in relation to the dentist's
shoulder

Copyright 2001 -

DENTAL DECKS

At the same height


For mandibular extractions, the patient should be positioned so that the occlusal
plane of the mandibular arch is parallel to the floor when the mouth is opened. The
chair should be as low as possible.
Positioning of the surgeon: When extracting maxillary teeth, it is usually best to
stand in front of and to the side of the patient for maximum visibility and leverage.
When extracting mandibular teeth, it is often better to stand directly to the side or
behind the patient.
The fingers of the left hand (for a right-handed dentist) serve to:
Retract the soft tissue .
Provide the operator with sensory stimuli for the detection of expansion of the alveolar plate and root movement under the plate.
Help guide the forceps into place on the tooth.
Protect teeth in the opposite jaw from accidental contact with the back of the forceps.
Support the mandible while performing mandibular extractions.

ORAL SURGERY/PAIN CONTROL

Exo

Which type of maxillary third molar impaction is most likely to be displaced into the
antrum (maxillary sinus) and infratemporal space if correct extraction techniques are
not employed?

Vertical impaction
Distoangular impaction
Mesioangular impaction
Horizontal impaction

Copyright

e 2001 -

DENTAL DECKS

Distoangular impaction
Impacted maxillary third molars are occasionally displaced into two areas:
Maxillary sinus (antrum) - from which they are removed via a Caldwell-Luc
approach
Infratemporal space - during elevation of the tooth the elevator may force the tooth
posteriorly through the periosteum into the infratemporal fossa. If access and light
are good, the tooth may be retrieved with a hemostat. If the tooth is not retrieved
after a short amount of time, the area should be closed. The patient should be
informed that the tooth has been displaced and will be removed by an oral surgeon
who will use a special technique to remove it.

ORAL SURGERY/PAIN CONTROL

Exo

Which of the following is the main reason to use water irrigat ion when cutting bone?

It helps to wash away debris


Because heat generated by the drill affects bone vitality
To decrease the smell of freshly cut bone
It helps to flush out the highspeed suct ion hose

Copyright 2001 -

DENTAL DECKS

Because heat generated by the drill affects bone vitality


Irrigation of the surgical wound during and after the procedure cannot be emphasized enough. Copious amounts of coolant spray are crucial in minimizing osseous
necrosis caused by heat generated from the bur. Irrigation serves also to cleanse the
crypt and areas beneath the flap of bony debris, tooth fragments, and blood.

ORAL SURGERY/PAIN CONTROL

Exo

Which sca lpe l below is universally used for oral surgical procedures?

No.2 blade
No.6 blade
No. 10 blade
No. 15 blade

Copyright @ 2001 -

DENTAL DECKS

No. 15 blade
Three types of incisions used in oral surgery :
1. Linear - straight line incision used for apicoectomies
2. Releasing - used when adding a vertical leg to a horizontal incision. For extractions , augmentations, etc.
3. Semi-lunar - curved incision mostly used for apicoectomies
The basic principles of oral surgical flap design:
Flap design should ensure adequate blood supply ; the base of the flap should be
larger than the apex.
Reflection of the flap should adequately expose the operative field.
Flap design should permit atraumatic closure of the wounds.
Important: The correct position for ending a vertical releasing incision is at a tooth line
angle not over the buccal surface of a tooth. If it ends over the buccal surface, the
edges are difficult to approximate and this may lead to periodontal problems.

ORAL SURGERY/PAIN CONTROL

Exo

Which of the following are local contraindications for tooth extractions?

ANUG
Irradiated jaws
Malignant disease
All of the above

Copyright 2001 -

DENTAL DECKS

All of the above


LOCAL AND
SYSTEMIC CONTRAINDICATIONS TO TOOTH EXTRACTIONS
Local

Systemic

Acute infection with uncontrolled cellulitis


Acute pericornitis
Acute infectious stomat itis
Malignant disease
Irradiated jaws
ANUG

Uncontrolled diabetes mellitus


Uncontrolled cardiac disease and dysrythmias
Severe bleeding disorders
Uncontrolled leukem ias and lymphomas
Debilitating diseases
Patients who are taking certa in medications
(e.g., immunosuppress ives, corticostero ids,
and cancer chemotherapeutic agents)

Note: An acute dentoalveolar abscess should not be a contraindication to extraction.


It has been shown that these infections can resolve very quickly when the affected
tooth is removed. However, it may be difficult to extract such a tooth, either because
the patient is unable to open sufficiently wide or because adequate local anesthesia
cannot be obtained.

ORAL SURGERYIPAIN CONTROL

Exo

Which suture pattern (or method) listed below is most commonly used in oral surgery?
Continuous pattern
Interrupted pattern

Copyright 2001 -

DENTAL DECKS

Interrupted pattern
This suture pattern or method offers strength and flexibility due to each suture being
independent to one another. If one suture is lost or becomes loose , the integrity of the
remaining sutures is not compromised. The major disadvantage is the time required
for placement.
Advantages of a continuous pattern or method:
Ease and speed of placement
Distribution of tension over the whole suture line
A more watertight closure than the interrupted pattern or method
Note:
1. Sutures should not be overtightened or closed under tension.
2. Sutures should be 2-3 mm apart, placed from mobile tissue to fixed fiSSile and from
thin tissue to thick tissue.
-

ORAL SURGERY/PAIN CONTROL

Exo

Which of the following is the primary direction of luxation for extracting maxillary
deciduous molars?

Buccal
Palatal
Mesial
Distal

Copyright 2001 -

DENTAL DECKS

Palatal
*** As opposed to the buccal direction in adults. This is because the deciduous
molars are more palatally positioned and the palatal root is strong and less prone to
fracture.
In general, the removal of deciduous teeth is not difficult. It is facilitated by the elasticity of young bone and the resorption of the root structure. Do not use the "cowhorn"
forceps for extraction of lower primary molars because the sharp beaks of these forceps could cause damage to the unerupted permanent premolar teeth.
Notes:
1. If the preoperative radiograph shows that the permanent premolar is wedged
tightly between the bell-shaped roots of the primary tooth, the best treatment is to
section the crown of the primary molar and remove the two portions separately. This
will help in not disturbing the permanent tooth.
2. After extraction of mandibular teeth on a child in which a mandibular block was
given, always advise child not to bite on lip while he or she is numb. Inform parents
as well to watch child so this does not occur.

ORAL SURGERY/PAIN CONTROL


Dead space in a wound usually fills with:

Pus
Water
Blood
Tissue

Copyright 2001 -

DENTAL DECKS

Exo

Blood
Dead space in a wound is any area that remains devoid of tissue after closure of the
wound. It is created by either removing tissues in the depths of a wound or by not reapproximating tissue planes during closu re. Dead space in a wound usually fills with
blood which creates a hematoma with a high potent ial for infection.
Ways in which you can eliminate dead space :
Close the wound in layers to minimize the postope rative void.
Apply pressure dress ings
Use drains to remove any bleeding that accumulates.
Place packing into the void until bleeding has stopped.

ORAL SURGERY/PAIN CONTROL

Exo

When would you place a suture over a single extraction socket?

Routinely
Never
If the patient requests it
When there is severe bleeding from the gingiva or if the gingival cuff is torn or loose.

Copyright 2001 -

DENTAL DECKS

When there is severe bleeding from the gingiva or if the gingival cuff is torn or
loose
Normal post-extracti on procedure:
All loose bone spicules and portions of the tooth, restoration, or calculus are removed from
the socket as well as from the buccal and lingual gutters and the tongue.
The socket must be compressed by t he fin gers to reestablish the normal width present
before the buccal plate was surgically expanded. Note : The natural recontouring of the residual ridge occurs primarily by resorption of the labial-buccal cortical bone.
Sut ures are usually not placed unless the papillae have been excised.
The socket is covered with a gauze sponge that has been folded and moistened slightly at its
center with cold water.
The patient is instructed to bite down for 5-10 minutes
Remove this sponge and place another one. This should stay in place until the patient arrives
home.
A printed instruction sheet is given to the patient.
A prescription for pain is given if the need is anticipated.
If bleeding persists for some time following an extraction, it may be helpful to instruct the
patient to bite on a tea bag. The tannic acid in the tea bag will help promote hemostasis.
Remember :The most common cause of post-extraction bleeding is the failure of the patient
to follow post-extraction instructions.

ORAL SURGERY/PAIN CONTROL


A patient with dry socket develops a severe dull throbbing pain:

Two to three hours following a tooth extraction


One day following a tooth extraction
Two to four days following a tooth extraction
Immediately following a tooth extraction

Copyright 2001 -

DENTAL DECKS

Exo

Two to four days following a tooth extraction


Th'e pain is often excruciating . may radiate to the ear, and is not relieved by oral analgesics.
There may be an associated foul odor and taste. T!Jg.extraction site is filled with necrotic tissue.
which is delaying wound healing.
Dry socket results from a pathologic process combining the loss of the healing blood clot with a
localized inflammation. It is most common following extraction of the mandibular molars.
Smoking, spitting or drinking through a straw, which creates negative pressure in the oral cavity,
may encourage this condition. Note: Careful technique and minimal trauma reduce the frequency of patients developing dry socket.
Treatment:
Flush out debris with saline solution (gent/y).
Carefully dry socket.
Place strip of iodoform gauze soaked in oil of cloves (eugenol). Note: The gauze provides
and attachment for the obtundent paste so it stays in the socket.
Prescribe analgesic drugs if necessary.
Note: Dry socket is the most common complication seen after the surgical removal of a
mandibular molar. Tetracycline is sometimes given prophylactically following the removal of
impacted mandibular third molars to prevent dry socket. Dry socket is also referred to as postextraction alveolitis or localized alveolar osteitis.

ORAL SURGERYIPAIN CONTROL


The ideal time to remove impacted third molars is:

When the root is fully formed


When the root is approximately two-thirds formed
Makes no difference how much of the root is formed
When the root is approximately one-third formed

Copyright 2001 -

DENTAL DECKS

Exo

When the root is approximately two-thirds formed


- Patient would be around the age of 17-21.
- At this time, the bone is more flexible and the roots are not formed well enough
to have developed curves and rarely fracture during extraction.
When the root is fully formed, the possibility increases for abnormal root morphology and for fracture of the root tips during extraction .
If the root development is insufficient (one-third or less), the tooth is more difficult to
remove because it tends to roll in its crypt like a ball in a socket , which prevents easy
elevation.
Notes:
1. Patients who are young tolerate surgery very well. Postoperative complicat ions
are usually minimal.
2. Older individuals have the most postoperative difficulties. The bone is more
dense and usually the patient responds more slowly to the entire process (anesthesia and surgery).

ORAL SURGERY/PAIN CONTROL


The mesioangular impaction is generally acknowledged as:
The most difficult impaction to remove
The least difficult impaction to remove
Neither of the above

Copyright 2001 -

DENTAL DECKS

Exo

The least difficult impaction to remove


The mesioangular impaction is also the most common and comprises about 43% of all
impacted teeth.
For impacted mand ibu lar third molars the mesioangular is the least difficult to remove followed by the horizontal, vertical, and the most difficult to remove is the distoangular
impacti on. Important: This is the exact opposite of impacted maxillary third molars, where the
mesioangular impactions are the most difficult and the vertical and distoangular impactions are
the easiest to remove.
Once sufficient amounts of bone have been removed from around the impacted tooth, the
tooth is usually sectioned. Sectioning allows portions of the tooth to be removed separately with
elevators through the opening provided by bone removal. Note: Bone is rarely, if ever, removed
on the lingual aspect of the mandible because of the likelihood of damaging the lingual
nerve.
Section ing of the tooth is done for the following reasons:
Allows for minimal bone removal
Allows for minimal force needed to remove tooth
Shortens the entire surgical procedure
Tooth sectioning can be performed with either a bur or chisel; however, the bur is used by
most surgeons.

ORAL SURGERY/PAIN CONTROL

Misc.

Squamous cell carcinoma is most easily managed when found where?

Floor of the mouth


Palate
Lower lip
Side of the tongue

Copyright 2001 -

DENTAL DECKS

Lower lip
Squamous cell carcinoma (SCC) is the most common malignant oral tumor, representing a little over 90% of all oral malignancies. It is 9 to 10 times more frequent in
males than in females and, although seen in all ages, its highest incidence is after the
fourth decade. It is more common on the lips than intraorally.
95% of lip carcinomas occur on the lower lip. They are usually discovered early and
only a small percentage show lymph node metastasis. Prognosis is very good.
SCC of the tongue is the most common intraoral malignancy. The most common location is the posterior lateral border, followed by the posterior one-third or base of the
tongue. It is uncommon on the dorsum or tip of the tongue. These lesions usually
metastasize early and the prognosis is not as good as lip lesions.
The floor of the mouth is the second most common intraoral location of sec. It is
seen predominantly in older men, especially those who are chronic alcoholics and
smokers. These lesions metastasize early and the prognosis is very poor.
Remember: The treatment of choice for oral cancer is surgery.

ORAL SURGERY/PAIN CONTROL

Misc.

All of the following are systemic contraind ications to elective surgery except

Blood dyscras ias (i.e., hemophilia, leukemia)


Controlled diabetes mellitus
Addison's disease or any steroid deficie ncy
Fever of unexpla ined origin
Nephritis
Any debilitating disease
Cardiac disease

Copyright

2001 -

DENTAL DECKS

Controlled diabetes mellitus


"'Uncontrolled diabetes mellitus is a systemic contraindication to elective surgery
Important: Patients with these systemic conditions can be treated, but you need to
consult with the patient's physician before treatment. In most cases , these patients are
best treated in the hospital by an oral surgeon.
Note: Cardiac disease such as coronary artery disease , uncontrolled hypertension,
and cardiac decompensat ion can complicate exodontia. Usually a postinfarction
patient is not subjected to oral surgery within six months of his infarction.
However, emergency procedures can be performed provided the patient's physician
has been consulted.

Misc.

ORAL SURGERYIPAIN CONTROL


The most common site of a pericoronal infection (pericoronitis) is:

Around
Around
Around
Around

the site of a recent extraction


a newly erupted primary tooth
periodontally involved mandibular incisors
mandibular third molars

Copy right 2001 -

DENTAL DECKS

Around mandibular third molars


The most typical symptoms of a pericoronal infection about the third molar are:
Submand ibular lymphadenopathy
Trismus
Pain in the region of a mandibular third molar
Swollen , red tissue in the region of a mandibular third molar
General condition of malaise
Treatment includes:
Irrigate area
If possible, establ ish drainage
Place patient on antibiotics
Instruct patient to rinse with warm saline mouthwashes
As soon as the acute symptoms are relieved , a definitive treatment may be instituted
Important: The maxillary third molar is the most frequent contributing factor to pericoronal infections found around mandibular third molars. Always examine the maxillary
third molar, it may be supererupted or malaligned .

ORAL SURGERY/PAIN CONTROL

Misc.

Which of the following can result in masticator space infections?


Infections of the mandibular molars, especially the third molar
Nonaseptic technique in local anesthesia of the inferior alveolar nerve
Trauma to the mandible (either external or fracture into the socket of a diseased
third molar)
All of the above

Copyright 2001 -

DENTAL DECKS

All of the above


The masseteric, pterygomandibular, and temporal spaces as a group are known as
the masticator space because they are bounded by the muscles and fascia of mastication. Infections of the masticator space are practically always of dental origin, particularly the lower molar region. Note: Needle tract infections following an inferior alveolar block injection would initially involve the pterygomandibular space .
Clinically, the picture of masticator space infection is dominated by trismus , pain, and
swelling occurring within a few hours following a molar extraction or trauma to the
mandible. These signs increase rapidly to reach a peak in 3 to 7 days. Spontaneous
intraoral drainage usually takes place between the 4th and 8th day. If this does not
occur, surgical drainage is indicated.
Notes :
1. The most definite clinical sign indicating extension of an odontogenic infection into
the masticator space is trismus. Trismus is difficulty in opening the mouth due to a
tonic spasm of the muscles of mastication.
2. Trismus may also result from passing the needle through the medial pterygoid muscle during an inferior alveolar nerve block.

ORAL SURGERY/PAIN CONTROL

Misc.

The mandibu lar left second molar of a 14 year-old boy is unerupted. Radiographs show
a small dentigerous cyst surrounding the crown. What is the treatment of choice?
Surgically extrac t the unerupted second molar
Uncover the crown and keep it exposed
Prescribe an anti-inflammatory medication and schedule a follow-up appointment in
six months
No treatment is necessary at this time

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DENTAL DECKS

Uncover the crown and keep it exposed


Dentigerous cysts are those associated with the crowns of unerupted teeth. Some literature refers to these cysts as "follicular" or "primordial" cysts. Note: They are
probably the result of degenerat ive changes in the reduced enamel epithelium.
Remember: If cysts form when a tooth is erupting, they are called eruption cysts.
These cysts interfere with normal eruption of the teeth . Eruption cysts are more commonly found in the child and young adult and may be associated with any tooth. If treatment is indicated , simple incision or "deroofing" is all that is needed.

ORAL SURGERY/PAIN CONTROL

Misc.

Which of the following statements are true concerning ecchymosis?


Ecchymosis is an area of hemorrhage into the skin and subcutaneous tissue> 1 cm
in diameter
An ecchymosis is often the result of injury; however, clott ing and bleeding disorders
can predispose to the formation of an ecchymosis
Grossly, an ecchymos is presents as a bluish lesion at the earliest stages of onset
As the red blood cells in the lesion undergo progressive degeneration and the hemoglobin becomes converted through bilirubin into hemosiderin , the lesion progressively changes color from blue through green through purple to finally a brownish discoloration
All of the above statements concerning ecchymosis are true

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DENTAL DECKS

All of the above statements concerning ecchymosis are true


Postoperative ecchymosis is a result of trauma to the underlying blood vessels.
Blood escapes from the vascular tree and accumulates in the tissues. It is common
after extractions in elderly patients due to the fragility of the vessel walls. All patients
should be warned that it may occur following extractions. Note: Sometimes the patient
will complain of a diffuse, non-painful, yellowish discoloration of the skin. Moist heat
often speeds the resolution of postoperative ecchymosis.
Remember : Osteoradionecrosis is the most serious potential complication after
extractions from areas previously irradiated. It is the necrosis of bone caused by exposure to ionizing radiation.

ORAL SURGERY/PAIN CONTROL

Misc.

Incision for drainage (I & 0) in an area of acute infection should only be performed
after which of the following has occurred?

A culture for antibiotic sensitivity has been performed


Localization of the infection
A sinus tract is formed
All of the above

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DENTAL DECKS

Localization of the infection


Physiologically, it is at this time that nature has constructed a barrier around the
abscess, walling it off from the circulation and making it possible to palpate the presence of purulent material within the abscess cavity (known as fluctuance) .
Note: After you incise and drain the fluctuant mass, it may be prudent to do a culture
for antibiotic sensitivity. This should always be done if after incision and drainage the
swelling does not subside despite large doses of antibiotics.
Prior to actual abscess formation, however, the infection is capable of producing a
cellulitis in the soft tissues of the region involved. The palpable tissues take on a condition known as induration (they appear hard, dense, and brawny) . Treatment during
this period should be directed towards localizing the infection. Early employment of
antibiotics may be extremely important in a severe and life-threatening infection.
Localization of the infection may be aided by using warm compresses and warm mouth
rinses at frequent intervals.

ORAL SURGERYIPAIN CONTROL


Cavernous sinus thrombosis can be caused by:

An infection of the central face or paranasal sinuses


Bacteremia
Trauma
Infections of the ear or maxillary teeth
All of the above

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DENTAL DECKS

Misc.

All of the above


Cavernous sinus thrombosis (CST) is an unusual occurrence that is rarely the result
of an infected tooth. CST is generally a fulminant process with high rates of morbidity
and mortality. Fortunately, the incidence of CST has been decreased greatly with the
advent of effective antibiotics. Most cases are due to an acute infection in an otherwise
healthy individual. However, patients with chronic sinusitis or diabetes mellitus may be
at a slightly higher risk. Note: The causative agent is generally Staphylococcus
aureus.
Infections of the face can cause a septic thrombosis of the cavernous sinus.
Furunculosis and infected hair follicles in the nose are frequent causes. Extractions of
maxillary anterior teeth in the presence of acute infection and especially curettage of
the socket under such circumstances can cause this condition. The infected thrombus
ascends in the veins against the usual venous flow. It usually occurs in the ophthalmic vein. This is possible because of the absence of valves in the angular, facial,
and ophthalmic veins.

ORAL SURGERY/PAIN CONTROL

Misc.

Which of the following tests should be routinely performed in the preoperative


workup for a patient that is being admitted to a hospital for surgery?

A complete blood count (CSC)


A total white blood cell count
An assessment of the circulating platelets
A urinalysis
All of the above

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DENTAL DECKS

All of the above


Routine admission tests include:
A complete blood count that includes an evaluat ion of the hemoglobin and hematocrit indices
A total white blood cell count with a differential count
An assessment of the circulating platelets
A gross and microscopic urinalysis
Anyone scheduled for general anesthesia should have a chest x-ray and patients
over 40 years old should also have an E.K.G.
Factors to be considered in the decision to hospitalize a patient for an elective procedure:
Medical problems compromising treatment (diabetes , hemophilia. etc.)
Difficulty and extent of surgery
.
Consideration of the individua l patient (emotionally disturbed, handicapped, etc.)
Cost of hospitalization (time and money)

ORAL SURGERY/PAIN CONTROL

Misc.

By far and away the most commonly performed mandibular procedure for the correction of mandibular retrognathia is the:

Segmental osteotomy
Sagittal split osteotomy
Vertical ramus osteotomy
Body osteotomy

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DENTAL DECKS

Sagittal split osteotomy

***This is due primarily to its simplicity and versatility.


The mandible is split sagittally and can either be used to advance the mandible (in the
case ofretrognathia) or set back the mandible (in treating prognathia). It is the standard procedure used today. Note: The position of the condyle is unchanged during
correction of mandibular prognathism or retrognathism.
Vertical ramus osteotomy: Is used for the correction of prognathism. The objective
is vertical sectioning of the ramus in a line from the lower aspect of the mandibular
notch vertically downward over the mandibular foramen or just posterior to the lower
border of the mandible at the angle.
Body osteotomy: Is a procedure that involves extracting mandibular teeth bilaterally
(usually bicuspids) . A piece of bone is also removed from the mandible and you slide
everything back. Used for prognathism.
Segmental osteotomy: Maxillary procedure where more than one segment of bone is
removed.
Note: A LeFort I osteotomy is most commonly used to correct maxillary retrognathia.

ORAL SURGERY/PAIN CONTROL

Misc.

On physical examination, painless induration of soft tissue is suggestive of:

Normal tissue
Infection
Invasive malignant lesions
Benign lesions

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DENTAL DECKS

Invasive malignant lesions


Characteristics of lesions that raise the suspicion of malignancy :

Erythroplasia - lesion is totally red or speckled red and white


Ulceration - lesion is ulcerated or is an ulcer
Duration - more than two weeks
Rapid growth
Bleeding - bleeds on gentle manipulation
Induration - lesion and surround ing tissue is firm to the touch
Fixation - feels attached to adjacent structures

ORAL SURGERY/PAIN CONTROL

Misc.

Muscle fibers covered by a mucous membrane that attaches the cheek, lips, and/or
tongue to associated dental mucosa is called:

Gingiva
Frenum
Operculum
Abutment

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DENTAL DECKS

Frenum
When a frenum is positioned in such a way as to interfere with the normal alignment
of teeth or results in pulling away of the gingiva from the tooth surface causing recession it is often removed using a surgical process known as a frenectomy.
There are three surgical techniques that are used for a frenectomy:
Simple excision and Z-plasty are effective when the mucosal and fibrous tissue
band is relatively narrow. These techniques relax the pull of the frenum.
v-v plasty (sometimes called a localized vestibuloplasty) is often preferred when the
frenal attachment has a wide base. This technique is good for lengthening tissue and
usually results in less scarring.
Note: Local anesthetic infiltration is usually sufficient for surgical treatment of frenal
attachments. Care must be taken to avoid excessive infiltration directly in the frenum
area since it may obscure the anatomy that must be visualized at the time of excision.

ORAL SURGERY/PAIN CONTROL


Which of the following can be used for removing bo ne?

Rongeur forceps
Chisel and mallet
Bone file
Bur and handpiece
All of the above

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DENTAL DECKS

Misc.

All of the above


Rongeur forceps are the most commonl y used instruments for removing bone.
However, the technique that most oral surgeons use when removing bone is the bur
and handpiece .
Very Important: Most high-speed turbine drills used for routine restorative dentistry are
totally unacceptable for removing one. The air exhausted from these drills goes into the
wound and may be forced deeper into tissue planes and produce tissue emphysema,
a potentially dangerous situation.
Note: Acute infected tissue emphysema is usually caused by the indiscreet use of:
1. Air-pressure syringes: In drying out a root canal with a compressed air syringe,
septic material may be forced through the apical foramen into the cancellous portion
of the alveolar process and ultimately out through the nutrient foramina into adjacent
soft tissues, resulting in formation of a septic cellulitis and tissue emphysema .
2. Atomizing spray bottles activated by compressed air: A similar condition can be
induced by the use of a compressed -air spray bottle for irrigation of wounds , particularly in the retromolar region. It is safer to use a hand-activated syringe when irrigating wounds or drying root canals since it is unlikely that a tissue emphysema
would be produced under these circumstances.

ORAL SURGERY/PAIN CONTROL

Misc.

Before dental treatment , prophylactic antibiotic coverage is indicated for patients with
each of the following conditions except.

Previous coronary artery bypass graft surgery


Rheumatic heart disease
Prosthetic aortic valve
Kidney damage needing hemodialysis
Total joint prosthesis
Mitral valve prolapse with valvular regurgitat ion

Copyright @ 2001 -

DENTAL DECKS

Previous coronary artery bypass graft surgery


If antibiotic prophylaxis is necessary, the following medications and dosages are
recommended by the American Heart Association :
Situation

Medication

Dosage

Standard prophylaxis

Amoxicill in

Adults: 2.0 g; children : 50 mg/kg orally 1 h


before procedure

Unable to take
oral medication

Ampicill in

Adults: 2.0 9 1M or IV; children 50 mg/kg 1M or


IV within 30 min before procedure

Allergy to Penicillin

Clindamycin
or
Cephalex in or
Cefadroxil
Azithromycin or
Clarithromycin

Adults : 600 mg; children : 20 mg/kg orally 1 hr


before procedure
Adults : 2.0 g; children 50 mg/kg orally 1 hr
before procedure
Adults : 500 mg; children: 15 mg/kg orally 1 hr
before procedure

Allergic to penicillin
and unable to take
oral medications

Clindamycin or
Cefazolin

Adults: 600 mg; children: 20 mg/kg IV within


30 min before procedure Adults : 1.0 g;
children: 25 mg/kg 1M or IV within 30 min
before procedure

ORAL SURGERY/PAIN CONTROL


The universal sign of laryngeal obstruction is:

Mydriasis
Stridor (crowing sounds)
Sweating
Tachycardia

Copyright 2001 -

DENTAL DECKS

Misc.

Stridor (crowing sounds)


"'Stridor is a high-pitched, noisy respiration, like the blowing of the wind. It is a sign of respiratory obstruction, especially in the trachea or larynx.
Because total airway obstruction usually occurs during inspiration, there is usually adequate oxygen left in the cerebral blood to permit up to 2 minutes of consciousness. If the obstruction is not
recognized and managed and oxygen delivered to the victim's lungs, blood, and brain, permanent neurologic damage occurs within 3 to 5 minutes.
Noninasive procedures for obstructed airway:
Back blows, manual thrusts, Heimlich maneuver, chest thrust, and finger sweep
Invasive procedures for obstructed airways; '-' These procedures should only be performed by
persons trained in these techniques and if proper equipment is available
Tracheotomy: Is used more for long-term airway maintenance and not for emergency airways
Cricothyrotomy: Is a procedure for establishing an emergency airway where other methods
are unsuitable or impossible. The access site is the cricothyroid membrane of the trachea,
located on the anterior neck, between the cricoid and thyroid cartilages .
Important: A cricothyrotomy may be lifesaving in an anaphylactic reaction in which a patient
shows signs of laryngeal obstruction. If a patient shows signs of laryngeal obstruction, that
is, stridor (crowing sounds), epinephrine should be given and oxygen administered . If a patient
loses consciousness and appears to be unable to breathe, an emergency cricothyrotomy may
be required to bypass the laryngeal obstruction.

ORAL SURGERY/PAIN CONTROL

Misc .

Osteo myelitis is an infection of the bone and bone marrow. It is most often caused
by:

Streptococcus pyogenes
Staphylococcus aureus
Mycobacterium tuberculosis
Neisseria meningitidis

Copyright 2001 -

DENTAL DECKS

Staphylococcus aureus
Osteomyelitis is an infection in the bones. Often, the original site of infection is elsewhere in the body, and spreads to the bone by the blood. This may be predisposed to
infection due to a recent minor trauma that results in a blood clot. In children, the long
bones are usually affected. In adults. the vertebrae and pelvis are most commonly
affected. Pus is produced within the bone, which may result in a bone abscess. The
abscess then deprives the bone of its blood supply. Note: Chronic osteomyelitis
results when bone tissue dies as a result of the lost blood supply.
Important: Acute osteomyelitis occurs more frequently in the mandible as opposed
to the maxilla. The primary reason for this is that the blood supply to the maxilla is
much richer and is derived from a number of different arteries, while the mandible
tends to draw its primary blood supply from the inferior alveolar artery. The dense overlying cortical bone of the mandible prevents penetration of periosteal blood vessels,
thus the mandibular cancellous bone is more likely to become ischemic and therefore
infected. Important point: Reduced blood supply will predispose bone to
osteomyelitis.

ORAL SURGERY/PAIN CONTROL

Misc.

Body temperature can be measured in several different ways, wh ich one is the least
accurate?

Orally
Axillary
Rectally
Aurally

Copyright @ 2001 -

DENTAL DECKS

Axillary
"'Rectally Is the most accu rate
General considerations when checking vital signs:
The patient should not have had alcohol, tobacco, caffeine, or performed vigorous exercise within 30 minutes of the
exam.
Ideally the patient should be silting with feet on the floor and their back supported . The examination room should be quiet
and the patent comfortable.
History of hypertension. slow or rapid pulse. and current medications should always be obtained.
Rout ine vital signs Include:
Blood pressure (normal 120/80)
Pulse rate (normal 72)
Respiration rate (normal 15)
Temperature can be measured in several different ways:
Oral with a glass, paper, or electronic thermometer (normal 98.6 'F/3 7"C)
AXillary with a glass or electronic thermometer (normal 97.6'FI36.3 ' C)
Rectal or ' core' with a glass or electronic thermome ter (99.6FI37.7 C)
Aural (the ear) with an electronic thermometer (normal 99.6F/37.7'C)
Note: Abnormalities of vital signs are often clues to diseases, the aneranons in vital signs are used to evaluate a panenrs
progress.
Five major areas to be discussed when taking a patient history:
1. Chief complaint
2. History of present Illness
3. Spec ific drug allegeries
4. Review of systems (heart, liver, kidney, brain , etc.)
5. Nature of symptoms
In complicated cases, don't be hesitant to call patient's physician, previous dentists, or other health professionals.

ORAL SURGERY/PAIN CONTROL

Misc.

A surgical procedure for recontouring alveolar structures, usually in preparation for


a prosthesis is called a (an):

Closed reduction
Operculectomy
Alveoloplasty
Gingivoplasty

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DENTAL DECKS

Alveoloplasty

An alveoloplasty is the surgical preparation of the alveolar ridges (i.e., removing undercuts) for the reception of dentures or shaping and smoothing the socket margins after
extractions of teeth with subsequent suturing to insure optimal healing.
The objectives of this recontouring should be to provide the best possible tissue
contour for prosthesis support , while maintaining as much bone and soft tissue as possible.
Remember:
1. A closed reduction is the closing of the space between fractured bone without cutting through the soft tissue or surround ing bond.
2. A gingivoplasty is a surgica l procedure to reshape the gingivae to create a normal, functional form.
3. An operculectomy is the removal of the operculum. which is the flap of tissue over
an unerupted or partially erupted tooth.

ORAL SURGERYIPAIN CONTROL

Gen Info

Which of the following is the most common error in recording blood pressure?

Applying the blood pressure cuff too tightly


Applying the blood pressure cuff too loosely
Overinflating the blood pressure cuff
Underinflating the blood pressure cuff
Use of the wrong size cuff

Copyright 2001 -

DENTAL DECKS

Applying the blood pressure cuff too loosely


"'This will give falsely elevated readings
Use of the wrong cuff size can result in erroneous readings. A normal adult blood
pressure cuff placed on an obese patient's arm will produce falsely elevated readings.
This same cuff applied to the very thin arm of a child will produce falsely low readings.
The width of the compression cuff should be approximately 20% greater than the diameter of the extremity on which the blood pressure is being recorded.
If you need to take additional readings, a wait of at least 15 seconds is required
before reinflating the blood pressure cuff.
Notes:
1. Elective dental care should be postponed if the systolic blood pressure is greater
than 160 mm Hg or the diastolic pressure is greater than 100 mm Hg.
2. Emergency dental care should be postponed if the systolic pressure is greater
than 180 mm Hg or the diastolic pressure is greater than 110 mm Hg.
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ORAL SURGERYIPAIN CONTROL


A prothrombin time (PT) of:

5-7 seconds is
6-9 seconds is
12-14 seconds
20-25 seconds

considered normal
considered normal
is considered normal
is considered normal

Copyright 2001 -

DENTAL DECKS

Gen Info

12-14 seconds is considered normal


"The PT (prothrombin time) results should be within 5-7 seconds of the control sample
Other tests used to measure a patient's clotting mechanisms:
PTT (partial thromboplastin time): detects coagulation defects of the intrinsic system.
Basic test for hemophilia. Normal value =25-36 seconds.
Bleeding time: (Ivy method), normal value = less than 9 minutes.
Platelet counts: normal value = 150,000-450,000 per 1 cu mm of blood. The minimal platelet count for oral surgery is 50,000.
Important: Perhaps the single most important consideration in ruling out hemorrhagic disorder is history.
Note: The PT test is the bes
st to erform in order to determine whether oral surgery can be safely performed on a patient taking coumadin (or any oral an icoequ ant.
To be a good candidate for surgery, the PT time should be within 5-7 seconds of the
control sample.

ORAL SURGERY/PAIN CONTROL


Major oral surgery includes all of the following procedures except

The treatment of maxillary and mandibular fractures


Exodontia
Pre-prosthetic surgery
Reconstructive surgery
Traumatology

Copyright @ 2001 -

DENTAL DECKS

Gen Info

Exodontia
"Including routine, multiple, and surgical extractions
Major oral surgery Includes:
The treatment of fractures
Pre-prosthetic surgery:
- Tuberosity reductions
- Vestibuloplasty
Reconstructive surgery:
- Orthognathic surgery
- Facial deformities
Traumatology:
- Treatment of wounds, injuries, and resulting disabilities
General concerns of surgery: Nutritional status of patient, body fluids & electrolytes, pre-op &
post-op information, wound healing (i.e., primary, secondary) and most importantly infection.
Note: The discipline of oral surgery is defined as "The diagnosis and surgical treatment of
injuries, diseases, and malformation of the mouth and jaws ."
Remember : The difference between acceptable and an excellent surgical outcome rests on how
the surgeon handles the tissue.

ORAL SURGERY/PAIN CONTROL

Gen Info

All of the following drugs can potentiate a patient's bleeding following an extraction

except

Aspirin
Anticoagulants
Broad-spectrum antibiotics
Antianxiety drugs
Alcohol
Anticancer drugs

Copyright 2001 -

DENTAL DECKS

Antianxiety drugs
If a patient is taking any one of these 5 drugs (aspirin, anticoagulants, broad -spectrum
antibiotics, alcohol or anticancer) , you should be prepared to take special measures
in order to control the bleeding. Note: Patients with specific systemic diseases will
also have a prolonged bleeding time. These include nonalcoholic liver disease, hepatitis, cirrhosis, and hypertension.

Five means of obtaining wound hemostasis:


1. By assisting natural hemostatic mechanisms: usually accomplished by placing a
cotton sponge with pressure on bleeding vessels or the use of a hemostat directly
on the vessel
2. By the use of heat on the cut vessels (called thermal coagulation)
3. By suture ligation of the vessel
4. By the placement of a pressure dressing over the wound: most bleeding from
oral surgery can be controlled this way
5. By placing vasoconstrictive substances (epinephrine) on the wound
Remember: Excessive bleeding causes the formation of hematomas which increase
the chance of infection.

ORAL SURGERY/PAIN CONTROL

Gen Info

Which of the following is the process by which the total removal of a cystic lesion is
achieved?

Marsupialization
Decompression
Enucleation
The Partsch operation

Copyright 2001 -

DENTAL DECKS

Enucleation
"" Enucleat ion is the treatment of choice whenever possible
Marsupialization, decompression, and the Partsch operation all refer to creating a
surgical window in the wall of the cyst. The cyst is uncovered or "deroofed" and the cystic lining made continuous with the oral cavity or surrounding structures. The cyst sac
is opened and emptied.
Enucleation is the treatment of choice for:
Congenital cysts
Mucoceles
Most odontogenic cysts
Marsupialization is the treatment of choice for:
Ranula -(Note: For a recurrent ranula treatment would also include the excision of
the sublingual gland.)
When cyst is large and close to vital structures
Whether a bone cyst or other cysts are completely enucleated or treated by marsupialization depends on the size and location to vital structures.

ORAL SURGERY/PAIN CONTROL

Gen Info

When performing CPR, if there is a pulse but the victim is not breathing, you should
give rescue breathing at a rate of:

2 breaths every 20 seconds


1 breath every 15 seconds
1 breath every 5 seconds
2 breaths every 30 seconds

Copyright 2001 -

DENTAL DECKS

1 breath every 5 seconds


"r or 12 breaths per minute

CPR
CARDIOPULMONA RY RESU SCITATION
A - A irway
Place victim flat on his/her back on a hard surface.
Shake victim at the shoulders and shout ' are you okay? '
If no response, call emergency medical system - 911 then,
Head-tll tlchin-Iift - open victim's airway by tilting their head back with one hand while lifting up their chin with your olher
hand.

B - Breathing
Position your cheek close to victim's nose and mouth, look toward victim's chest, and
Look, listen, and feel for breathing (510 seconds)
If not breathing, pinch victim's nose closed and give 2 full breaths into victim's mouth
If breathswon't go in, repositionhead and try again to give breaths. If still blocked, perform abdominal thrusts (Heimlich maneuver)

C- Circulation
Check for carotid pulse by feeling for 51 0 seconds at side of victim's neck.
If thera is a pulse but victim is not breathing, give rescue breathing at rate of 1 breath every 5 seconds or 12 breaths
per minute
If there Is no pu lse , begin chest compressi ons as follows:
Place heel of one hand on lower part of victim's sternum. With your other hand directly on top of first hand, depress sternum 1.5 to 2 inches.
Perform 15 com ressions to every 2 breaths. rate: 80-100 per minu te)
Check for return of pu se
"'Contl nue un interrupted until advanced life support Is available

Gen Info

ORAL SURGERY/PAIN CONTROL


What is the first step when init iati ng CPR?

Administer oxygen
Establish unresponsiveness
Administer epinephrine
Place a cool towel on the person's forehead

Copyright @ 2001 -

DENTAL DECKS

Establish unresponsiveness (shake and shout, "are you OK?")


Followed by ABC's:
Airway (head tilt-chin lift): in most medical emergencies, this is the easiest technique for opening a victim's airway
Breathing (look, listen, and feel)
Circulation (check carotid pulse)
Important points to remember in CPR:
If efforts are effective, the pupils will constrict
If too much pressure is incorrectly applied directly over the xyphoid process, the
liver may be injured
The result of interruptions in chest compressions while performing CPR is a reduction of the blood flow and fall in the blood pressure to zero
Remember, you should stop CPR only under the following conditions:
If another trained person takes over CPR for you
If EMS personnel arrive and take over care of the victim
If you are exhausted and unable to continue
If the scene becomes unsafe

ORAL SURGERY/PAIN CONTROL

Gen Info

Serum calcium will be increased in all of the following conditions except

Hyperparathyroidism
Chronic glomeru lonephritis
Diabetes mellitus
Hypervitam inosis D
Malignant diseases of the skeleton (i.e., multiple myeloma)

Copyright 2001 -

DENTAL DECKS

Diabetes mellitus
Calcium levels are regulated by parathyroid hormooe @ creased hormone causes bone resorIG
tion) which in turn increases calcium levels. Calcium is also regulated to some extent by the kidney tubules and GI mUcosa (iowenng pH will cause increased calcium absorption), Low serum
calcium levels will result in hyperirritabi lity of nerves and musc les,
Phosphorus concentration is also regulated by parathyroid hormone . Increased hormone
causes the kidneys to increase the rate of phosphate excretion which causes a decrease in plasma phosphate concentration .
Note '
ood health the ratio of calcium to phosphorus in the blood is 10: f there is a glandular imbalance, especia y In regard to the parat yroi g an s, en this ratio will be maintained at
a different level, causing long-term health deterioration. In particular, a high ratio of phosphorus
to calcium sensitizes the body and increases inflammatory tendencies.
BJnod glucose concentrat ion is regUlated by jnslJlin (Jowers glucose levels) !!Dd gil IcaOO-...,
(increases glucose levels) . Glucose normally does not appear in the urine although it is freely filtered because it is reabsorbed in the proximal convoluted tubule of the kidney. Serum glucose
will be increased In diabetes mellitus, adrenal tumors, Increased growth hormone, and
liver dysfunction.

Gen Info

ORAL SURGERYIPAIN CONTROL


Minor oral surgery includes all of the following procedures

Exodontia
The treatment
The treatment
The treatment
The treatment

of
of
of
of

maxillary and mandibular fractures


dental infections
hard tissue pathologies
soft tissue pathologies

Copyright 2001 -

DENTAL DECKS

except

The treatment of maxillary and mandibular fractures


***This is considered to be major oral surgery
Minor oral surgery includes:
Exodontia:
- Routine extractions, multiple extrac tions, and surgical extractions
Treating dental infections:
- Periapical
- Periodontal
- Pericornitis
- Facial infections (cellulitis)
Soft tissue pathology:
- Biopsy
- Benign lesions
Hard tissue pathology:
- Alveoloplasty

ORAL SURGERY/PAIN CONTROL


The normal serum concentration of glucose is:

20-40 mg/dl
50-70 mg/dl
80-120 mg/dl
130-150 mg/dl

Copyr ight 200 1 -

DENTAL DECKS

Gen Info

80120 mg/dl
Normal laboratory values
Blood Chemistry
Arterial blood gases:
HC03 = 18 to 21 mEq/L
pC0 2 35 to 45 mmHg
pH 7.38 to 7.44
p02 = 80 to 100 mmHg
Calcium - 9 to 11 mg/dl
Carbon dioxide - 21 to 30 mEq/L
Chloride = 98 to 105 mEq/L
Cholesterol
Total = 180 to 240 mg/dl
Esters = 100 to 180 mg/dl
Creatinine = 1 to 1.5 mg/dl
Glucose = 80-120 mg/dl

Osmolal ity = 280 to 300 mOsm/L


Phosphatase
Acid = 0.2 to 1.8 internat ional units
Alkaline = 21 to 91 international units
Phosphorus = 3 to 4.5 mg/dl, 1-1.5 mEq/L
Potassium = 3.5 to 5.0 mEq/L
Protein = 5.5 to 8.0 g/dl
Sodium = 136 to 145 mEq/L
Urea nitrogen =10 to 20 mg/dl
Urine
pH = 6.0 (4.7-8.0)
specific gravity = 1.005 to 1.025

ORAL SURGERYIPAIN CONTROL


What is the proper rate of rescue breathing in an adult?

15 times
12 times
20 times
25 times

per
per
per
per

minute
minute
minute
minute

Copyright @ 2001 -

DENTAL DECKS

Gen Info

12 times per minute


CPR READY REFERENCE
Rescue breathing, victim has
a pulse, give 1 breath every
No pulse, locate compression
landmark
Compressions are
performed with

Adults

Children

Infants

5 seconds

4 seconds

3 seconds

Follow ribs into notch ,


one finger on sternum

Same as adult

One finger width


below nipple line

2 hands stacked:
heal 01 one
on sternum

Heal of one hand


on sternum

Two or three
lingers on sternum

Rate 01 compression
per minute

80-100

80-100

At least 100

Compression depth

1-1/2-2"

1-101/2"

1/2-1 "

15:2
5:1

5:1
5:1

5:1
5:1

Ratio compressions to breath:


1 rescuer
2 rescuers

ORAL SURGERY/PAIN CONTROL

Gen Info

The American Society of Anesthesiologists would give what ASA classification to a


healthy young patient with an unremarkable medical history and no systemic disease?

ASA-O
ASA-I
ASA-II
ASA-V

Copyright 2001 -

DENTAL DECKS

ASA1
American Society of Anesthesiologists (ASA)
Classification of Physical Status
ASA-1 A normal healthy patient
ASA-II A patient with mild systemic disease or significant health risk factor (such as
smoking, excessive alcohol use, and obesity)
ASA-III A patient with severe disease that is not incapacitating
ASA-IV A patient with severe systemic disease that is a constant threat to life
ASA-V A moribund patient who is not expected to survive without the operation

ASA-VI A declared brain-dead patient whose organs are being removed for donor purposes

ORAL SURGERY/PAIN CONTROL


Which surgical approach listed below is the best to expose the TMJ?
Preauricular
Submandibular
Both are the same

Copy right 2001 -

DENTAL DECKS

TMJ

Preauricular
Surgical approaches to the TMJ:
Preauricular: The best incision to expose the TMJ. A perpendicular incision is made
just anterior to the external ear parallel to the superficial temporal artery. The incision extends from one inch above the zygomatic arch to the lower extremity of the
ear. The condyle is approached from behind . Note: With this approach, care must
be taken not to damage either the facial nerve or the vessels that richly supply this
area.
Submandibular approach (Risdom approach): This is the standard surgical
approach to the ramus of the mandible and neck of the condyle. It is not the best
approach for procedures within the joint space itself.
Remember: The most common cause of TMJ ankylosis is trauma. However, ankylosis is the most common complication of rheumatoid arthritis.

ORAL SURGERY/PAIN CONTROL

TMJ

What is the best way to palpate the posterior aspect of the mandibular condyle?

Intraorally
Lateral to the external auditory meatus
Through the external auditory meatus
Any of the above

Copyright @ 2001 -

DENTAL DECKS

Through the external auditory meatus (canal)


The temporomandibular joint should be evaluated for tenderness and noise. The
joint is palpated laterally (in front of the external auditory meatus) with the mandible in
a closed and open position. The joint should also be palpated through the external auditory meatus with the mandible in a closed and open position. Note: The posterior
aspect of the condyle is rounded and convex, whereas the anteroinferior aspect is
concave.
When the articular disc (or meniscus) of the joint and condyle of the mandible lack
functional coordination, you will hear a click when a patient opens his/her mouth.
Tenderness and sensitivity should be noted as well as joint noises (clicking and crepitus). The mandibular range of motion should also be determined. The normal range of
movement of an adult's mandible is about 50 mm (opening) and 10 mm protrusively
and laterally.
Notes :
1. NSAIDs are the first line of treatment for TMJ pain
2. Benzodiazepines may be prescribed for significant muscle pain or spasms
3. Moist heat to the affected area is helpful (no longer than 15 minutes per application).
4. Educate patient about bruxism and the need to avoid clenching and grinding teeth.

ORAL SURGERY/PAIN CONTROL

TMJ

Which of the following is considered to be the most common cause of TMJ pain?

Internal derangement
Degenerative joint disease (DJD)
Myotascial pain dysfunct ion (MPD) syndrome
None of the above

Copyright 2001 -

DENTAL DECKS

Myofascial pain dysfunction (MPD) syndrome


TMJ syndrome is divided into three categories:
Myofascial pain dysfunction (MPD) syndrome: Is considered to be the most
common cause of TMJ pain. It is a disease primarily involving the muscles of mastication.
Internal derangement: Is defined as an abnormal relationship of the articular disc
to the mandibular condyle, fossa, and articular eminence (or tubercle) .
Degenerative joint disease (osteoarthritis): Is the organic degeneration of the
articular surfaces within the TMJ.
Important: The key mechanism for the cause of TMJ disorders is muscle dysfunction (or muscle spasm)
MPD syndrome is believed to be a stress related disorder. This increase in stress produces an increase in mandibular muscle tension and in combination with teeth clenching results in muscle spasm, pain, and dysfunction. Note: MPD often responds to an
acrylic night guard (also called an occlusal separator or occlusal appliance) along with
a soft diet, limited talking, and elimination of gum chewing. Moist heat applied to the
face and nonsteroidal anti-inflammatory agents are also helpful during the acute phase.

ORAL SURGERY/PAIN CONTROL


What is the only direction in whic h the TMJ can be dislocated?

Laterally
Medially
Anteriorly
Posteriorly

Copyright 2001 -

DENTAL DECKS

TMJ

Anteriorly
Internal derangement of the TMJ is present when the posterior band of the articular disc
is anteriorly displaced in front of the condyle. As the articular disc translates anteriorly,
the posterior band remains in front of the condyle and the bilaminar zone becomes
abnormally stretched. Often the displaced posterior band will return to its normal position when the condyle reaches a certain point. This is termed anterior displaced with
reduction. Note: When the articular disc reduces the patient often feels a pop or
click in the joint.
In some patients the articular disc remains anteriorly displaced at full mouth opening.
This is termed anterior displacement without reduction. Note: The articular disc can
usually be reduced by inducing downward pressure on the posterior teeth and upward
pressure on the chin, accompanied by posterior displacement of the entire mandible.
Note: The patient who has had reduction of a mandibular dislocation should be
instructed to limit opening of the mouth for two to three weeks.
Remember: The most common cause of restricted mandibular movement is disc interference disorders, which change the relationship of the disc and the condyle.

ORAL SURGERY/PAIN CONTROL

Impl/Grfts

All of the following are contraindications to implant placement except one. Which is
the exception:
The presence of pathology within the bone
The presence of limiting anatomic structures such as the inferior alveolar nerve or
maxillary sinus
Unrealistic expectations of the patient
Poor oral health and hygiene
Patient's inability to tolerate implant procedures
The patient has a pronounced gag reflex
Acute illness or uncontrolled metabolic disease

Copyright 2001 -

DENTAL DECKS

The patient has a pronounced gag reflex


This may actually be an indication for the consideration of implant placement. This
is because the patient may not be able to tolerate the placement of a removable prostheses.
Other possible indications for implant placement include:
Resorption of alveolar ridge or other anatomic considerations that do not allow for
adequate retention of conventional removable prostheses.
Patient is psychologically unable to deal with removable prostheses.
Medical condition for which removable prostheses may create a risk (i.e., seizure
disorder).
.
Loss of posterior teeth, particularly unilaterally.
Remember :
Implants placed in the maxillary anterior region have the highest failure rate.
Mobility of the implant is regarded as the most common sign of implant failure.

ORAL SURGERY/PAIN CONTROL

Impl/Grfts

Which of the following is the most common indication for tooth transplantation?

Severe decay of a central incisor


Severe decay of a first molar
Severe decay of a third molar
Severe decay of a canine

Copyright 2001 -

DENTAL DECKS

Severe decay of a first molar


The first molar is atraumatically removed, and the third molar is placed into the
socket. Success of the transplant is most predictable w h en the apices of the roots >
of the to oth to be transplanted are ana third to one-ba lf formed with open apices and
the bordering bony plates are intact. Also, you need adequate mesiodistal width of the
host implant site, the absence of acute periapical or periodontal inflammatory states,
and the general good oral health of the patient. Note: This is called an autogenous
tooth transplantation, meaning a tooth from the same individual is moved to
another site. The most likely cause of failure will be a chronic, progressive external
root resorption.
Important: The almost universal sequelae of an allogeneic tooth transplant is
ankylosis and progressive root resorption. An allogeneic tooth transplant means
that a tooth from one individual is placed in another individual.
Remember: The change in continuity of the occlusal plane observed after ankylosis
of a tooth is caused by the continued eruption of the other non-ankylosed teeth and
growth of the alveolar process.

ORAL SURGERY/PAIN CONTROL

Impl/Grfts

Which of the following are requirements for successful implant placement?

Mucosal seal
Adequate transfer of force
Biocompatibility
All of the above

Copyrig ht 2001 -

DENTAL DECKS

All of the above


Important: Mobility of the implant is regarded as the most important sign of implant
failure.
Steps in the assessment of patients prior to implant placement:

1. Dental and medical history


2. Clinical examination
3. Radiographic examination (panoramic and periapical)
The surgeon and restoring dentist must work together to ensure proper implant
placement and orientation. A surgical stent fabricated to the specifications of the
restoring dentist can be helpful to ensure proper implant placement and orientation.
Remember: Without proper planning, an implant may be successfully integrated
but impossible to restore.

ORAL SURGERYIPAIN CONTROL


The optimal bone grafting material should be of what orig in?

Foreign
Synthetic
Autogenous
Mixed

Copyri ght 2001 -

DENTAL DECKS

Impl/Grfts

Autogenous
Autogenous bone is bone from the same person (from one part of the body to
another). Autogenous grafts (also called an autograft) are usually employed to restore
large areas of lost mandibular bones following oncological surgery or trauma. Of all the
facial bones resected in oncological surgery, the mandible is the most frequently
removed.
The bone marrow for grafting defects in the mandible and maxilla is generally
obtained from the iliac crest. Also used for ridge augmentation.
Notes:
1. A costochondrial rib graft may be employed with the cartilaginous portion simulating the TMJ and condyle. When used for ridge augmentation a lot of shrinkage
is noted.
2. Bone plates, biphasic pins, titanium mesh, and intraosseous wires are used in
the fixation of bone grafts. Sutures are not generally used.

ORAL SURGERY/PAIN CONTROL

Impl/Grfts

Allaplastic grafts are:

Those where the bone to be grafted to jaw is taken , or harvest from one's own body
Taken from human donors
Inert, man made synthet ic materials
Harvested from animals

Copyright 2001 -

DENTAL DECKS

Inert, man made synthetic materials


For bone replacement a man made material that mimics natural bone is used . Most often
hydroxyapatite (HA) is used for augmentation of the mandib le. Hydro xyapatite is a dense , blocompatib le material that can be produced synthetically or obtained from biologic sources such as
coral. The granular or particle form is most commonly used for alveolar ridge augmentation.
Note: When placed in a subperiosteal envir onment, HA bonds both physically and chemically to
the bone.

Some advantages and disadvantages of restructuring an atrophic ridge with hydroxyapatite


granules:

Advantages
It is a simple surgical technique suitable as an office procedure
- No donor site is required to obtain autogenous bone graft material
Hydroxypatite is totally biocompatibie and nonresorbable

Disadvantages
Migration of the hydroxypatite granules
Poor ridge form (inadequate heigh t)
Abnormal coior under the mucosa
- Mental nerve neuropathy
Excessive augmentation

ORAL SURGERY/PAIN CONTROL

Impl/Grfts

Alloplastic materials used for augmentation genioplasty generally have a tendency


to do what?

Produce an immunologic response


Be replaced by the host bone
Migrate from the position in which they were placed at the time of surgery
Be rejected

Copyright 2001 -

DENTAL DECKS

Migrate from the position in which they were placed at the time of surgery
Genioplasty is a procedure by which the position of the chin is surgically altered. The
most common techniques for genioplasty are osteotomy or augmentation with natural
or alloplastic materials.
There are two other problems that are frequently encountered when using alloplastic
materials for genioplasty:
Erosion of the chin prominence contiguous with the implant.
Unpleasant sensation in the implant region when exposed to cold temperatures.
Note: The best way to enlarge the prominence of the chin for best long-term results is
to reposition the lower border anteriorly by osteotomy (horizontal sliding osteotomy).
Remember: Alloplastic grafts are inert, man made synthetic materials. The modern
artificial joint replacement procedures uses metal alloplastic grafts. For bone replacement a man made material that mimics natural bone is used. Most often this is a form
of calcium phosphate (i.e.. tricalcium phosphate, calcium carbonate, or hydroxyapatite).

ORAL SURGERY/PAIN CONTROL

Impl/Grfts

The most commonly used allogeneic bone is:


Freeze-dried
Artificial
Neither of the above

Copyright 2001 -

DENTAL DECKS

Freeze-dried
Allogeneic grafts (also called allografts or homografts) are composed of tissues taken
from an individual of the same species who is not genetically related to the patient.
They consist of freeze-dried bone and freeze-dried decalcified bone from another
source (usually cadaver bone).
These grafts are treated to reduce the antigenicity. However, these treatments destroy
any remaining osteogenic cells in the graft. These grafts offer a hard tissue matrix only;
.!!Jis graft is eventuallv replaced by the bast bone
Important point: The host must produce all of the essential elements in the graft bed
for an allogeneic bone graft to become resorbed and replaced.
The advantages of this type of graft are that it doesn 't require another site of preparation in the host and that a similar bone or a bone of similar shape to that being
replaced can be obtained .

ORAL SURGERYIPAIN CONTROL


Implants that are surgically inserted into the jawbone are called:

Endosseous implants
Subperiosteal implants
Transosseus implant s

Copyright 2001 -

DENTAL DECKS

Impl/Grfts

Endosseous implants
---They are the most frequently used implants today
Oral Impl ant s can be categorized into three main groups:
1. Endosseous Implants are implants that are surgically Insert ed Into the jawbone. They are the most
frequently used Implant s today. They are further subdivided into root form and blade form implants.
2. SUbperiosteal Implants are frameworks specifically fabricated to lit on top of supporting areas in the
mandible or maxilla under the mucoperiosteum.
3. Transosseous Implants are implants that are similar to endosseous implants in that they are surgically
inserted into the jawbone. However, these implants actually penetrate the entire jaw so that they actually emerge opposite the entry site, usually at the bottom 01the chin. Note : Their primary ind ication is in
the very atrophic mandible where root form implants may lurther compromise the strength of the jaw.
Remember: Osseo lntegrated implants are anchored directly to lIying bone. This determination is
..!!!.ade by radiographic and light microscopic analysis....
Root form implants:
Cylindrical in shape, can be threaded or non-threaded. 3 to 5 mm in diameter and 7 to 20 mm in length.
Typically made of titanium. Note : These implants are the most popular.
Blade implants:
Are wedge-shaped or rectangular in cross section. Typically made of titanium as well.
Two basic types of implant placement:
1. Submerged - requires a second surgical procedure (two-stage) to uncover the fixture.
2. Nonsubmerged - does not require a second surgical procedure (one-stage) .

ORAL SURGERY/PAIN CONTROL

Impl/Grfts

Allogeneic grafts (also called allografts) are composed of tissues taken from:

Another species
An individual of the same species who is not genetically related to the recipient
An individual of the same species who is genetically related to the recipient
The same individual

Copyright @ 2001 -

DENTAL DECKS

An individual of the same species who is not genetically related to the recipient
Usually cadaver bone
Classification of grafts (or implants)
Autogenous grafts (also called autografts) are composed of tissues taken from the same
Individual. Most frequently used in oral surgery.
Allogenic grafts (also called allografts) are composed of tissues taken from an individual of
the same species who is not genetically related to the patient (usually cadaver bone).
Isogen eic grans (also called isografts or syngenesioplastic grafts) are composed of tissues
taken from an individual of the same species who is genetically relate d to the recipient.
~enog e n ei c imp lants (also called xenografts or heterografts) are composed of tissues taken
from a donor of another species, for example. animal bone grafted to man (also called heterograft). Rarely used in oral surgery.
Note: Rejection of the graft is most common when allografts or xenografts of bone and cartilage are used in oral surgery. Autogenous grafts, although frequently presenting surgical and
technical problems. do not as a rule involve rejection (or immunological complications).
The ideal graft should:
Be replaced by the host bone.
Withstand mechanical forces.
Produce no immunologic response (or rejection).
Actively assist osteogenic (bone-form ing) processes of the host. The greatest osteogenic
potential occurs with an autogenous cancellous graft and hemopoietic marrow.

ORAL SURGERY/PAIN CONTROL

Fractures

If the fracture line results in a muscle pull displacing the fractured segment, it is
termed a (an):
Favorable fracture
Unfavorable fracture

Copyright 2001 -

DENTAL DECKS

Unfavorable fracture

The line of fracture will determine whether muscles will be able to displace the fractured segments from their original position:
If the fracture line prevents the displacement of the fracture by muscle pull, it is
termed a favorable fracture.
If the fracture line results in a muscle pull displacing the fractured segment, it is .
termed an unfavorable fracture.
The following radiographic views are often helpful to evaluate mandibular fractures:
Posteroanterior view
Lateral oblique view
Towne view
Panoramic view
Remember: The control of airway is vital to any treatment of a patient with facial fractures.

ORAL SURGERY/PAIN CONTROL

Fractures

A patient with a paralyzed left lateral pterygoid muscle is instructed to open his
mouth wide. Which direction will the mandible take upon opening?
To the right
To the left
Straight

Copyright 2001 -

DENTAL DECKS

To the left
-" The mandible will always deviate to the side of the injury.
A patient who sustained a subcondylar fracture on the left side would be unable
to deviate the mandible to the right. This is normally treated by a closed procedure
involving intermaxillary fixation. This procedure immobilizes the concomitant fractures and corrects the displacement of the jaws associated with the condylar fracture
thereby correcting the shift of the midline toward the side of the fractured condyle and
the slight premature posterior occlusion on that side.

ORAL SURGERY/PAIN CONTROL

Fractures

Which of the following can contrib ute to the non-healing (non-union) of a fracture?

Ischemia
Excessive mobility
Interposition of soft tissue
Infection
All of the above

Copyright @ 200 1 -

DENTAL DECKS

All of the above


Four reasons that a fracture does not heal:
1. Ischemia: The navicular bone of the wrist, the femoral neck, and the lower third of the tibia
are all poorly vascularized and therefore are subject to ischemic necrosis after a fracture.
2. Excessive mobility: Healing is prevented and pseudoarthrosis or a pseudo-joint may
occur.
3. Interposition of soft tissue: Occurs between the fractured ends.
4. Infection: Compound fractures have a tendency to become Infected.
Note: A fat embolism is most often a sequela of fractures.
Inappropriate healing (three types):
Delayed-union: satisfactory healing which requires greater than the normal six week period.
May be caused by infection, interposition of soft tissue or muscle between the fractured segments.
Non-union: failure of the fractured segments to unite properly. May be caused by infection,
improper immobilization, or interposition of soft tissue.
Mal-union: can be either delayed or complete union in an improper position. May be caused
by improper immobilization or imperfect reduction.

ORAL SURGERY/PAIN CONTROL

Fractures

A mandibular fracture that extends only through the cortical portion of the bone without complete fracture of the bone is called a:

Simple fracture
Greenstick fracture
Compound fracture
Comminuted fracture

Copyright 2001 -

DENTAL DECKS

Greenstick fracture

'Greenstick fractures are closed fractures involving incomplete fractures with flexible bone. Most often seen in children .
The following categories classify mandibula r fractures by describing the condition of the
bone fragments at the fracture site and possible communication with the external environment:
Simple - divides a single bone into two distinct parts with no external communication. These are closed fractures with no lacerations of the oral mucosa or facial tissues.
Compound - fracture comm ynicates with the outside environment (open fracture).
This may occur by laceration of the oral tissues exposing the bone fragments , fracture of the maxilla into the sinuses , or by way of skin lacerations that would expose
the fractured segments. Infection is common.
Comminuted - multiple fractures of a single bone. They may be simple or compound.
Remember: The most common complication of an open fracture is infection .

ORAL SURGERY/PAIN CONTROL

Fractures

Which type of bone healing involves both endosteal and periosteal proliferation?
Primary (bone-fa-bone)
Secondary (space fills in with cal/us)

Copyright 2001 -

DENTAL DECKS

Primary (bone-to-bone)
The healing of bone can be divided into three overlapping phases:
1. Hemorrhage - occurs first and is associated with clot organization and proliferation
of blood vessels. This nonspecific phase occurs during the first 10 days.
2. Callus formation - a primary callus is formed in the next 10 to 20 days. A secondary callus forms in 20 to 60 days.
3. Functi nal reconstruc .
- mechanical forces are important in this phase..The
haversian systems are lined up according to stress lines. Excess bone is removed.
The shape of the bone is molded to conform with functional usage so that bone may
be added to one surface and removed from another. It takes 2 to 3 years to completely reform a fracture.
Secondary bone healing involves mostly endosteal proliferation into the void (the
space between two pieces of bone).
Endosteal proliferation - occurs within a bone_
Periosteal pro lifer
periosteum.

urs within the connective tissue covering all bo Ea.S

ORAL SURGERY/PAIN CONTROL

Exo

Which size suture listed below has the least st rength and the smallest diameter?

9-0
3-0

2
5

Copyright 2001 -

DENTAL DECKS

9-0
Suture size is based on strength and diameter. This system uses "0" as the baseline, average size suture. As suture diameter decreases , "D's" are added or numbers
followed by a "0" (for example, 000 and 3-0 are the same size). As suture diameter
increases above "0", numbers are assigned to the suture material.
Because suture mate rial is foreign to the human body, the smallest-d iameter suture
sufficient to keep the wound closed properly should be used. Most oral and maxillofacial surgical procedures require the use of 3-0 o r 4-0 s utures
Larger

5 Tow a car !!!


4

3
2 Horse abdominal repair

o Average size
2-0
3.0 SSUbcbuttaneous } oral surgery procedures
4 -0 u cu aneous
5-0 Vein/Art ery repa ir
Smaller
(Add "D's' )

g-O Ophthalmic

ORAL SURGERYIPAIN CONTROL

Exo

Strong apical pressure with a small straight elevator may displace root tips of maxillary premolars and molars into the:

Submandibular space
Maxillary sinus
Mandibular canal
Infratemporal fossa

Copyright @ 2001 -

DENTAL DECKS

Maxillary sinus
If the root tip is small (2 or 3 mm), noninfected, and cannot be removed through
the small opening in the socket apex, no additional surgical procedure should be
performed through the socket, and the root tip should be left in the sinus. If the root tip
is left in the sinus, measures should be taken similar to those taken when leaving any
root tip in place. The patient must be informed of the decision and given proper followup instructions.
If a large root fragment or the entire tooth is displaced into the maxillary sinus
(antrum), it should be removed. The usual method is a Caldwell-Luc approach. This
is a surgical procedure in which an opening is made into the maxillary sinus by way of
an incision into the canine fossa above the level of the premolar roots. The tooth or
root is then removed. Important: An oral surgeon to whom the patient should be
referred should perform this procedure.

ORAL SURGERY/PAIN CONTROL

Exo

Which of the following delay the hea ling process of an extraction site?

A patient that has a protein deficiency


A patient on glucocortico id therapy
An older patient
Local infections
All of the above

Copyright 2001 -

DENTAL DECKS

All of the above


There are two basic methods of wound healing:
1. Primary intention (also called first intention) occurs when wound margins are nicely
apposed. Healing occurs more rapidly with a lower risk of infection, with less scar formation
and less tissue loss than wounds allowed to heal by secondary intention. Examples include
well-repaired and well-reduced bone fractures.
2. Secondary intention (also called second intention) occurs when a wound is large and exudative. This site fills in with granulation tissue. Healing is slower and produces more scar tissue than is the case with healing by primary intention. Examples include extraction sockets,
poorly reduced fractures, and large ulcers.
Stages of wound healing:
1. Inflammatory stage (consists of a vascular and cellular phase) : neutrophils and lymphocytes
predominate.
2. Fibroblastic stage (mediated by fibroblasts ): collagen and new blood vessels are produced.
3. Remodeling stage (collagen fibers continue to increase tensile strength)
Other factors that impair wound healing: foreign material, necrotic tissue, ischemia, and tension.
Remember: 3% hydrogen peroxide is the agent of choice for the debridement of intraoral
wounds.

ORAL SURGERY/PAIN CONTROL

Exo

During extraction of a maxillary third molar, you realize the tuberosity has also been
extract ed . What is the proper treatment in this case?
Remove the tuberosity from the tooth and reimplant the tuberosity
Smooth the sharp edges of the remaining bone and replace and suture the remaining soft tissue
No special treatment is necessary
None of the above

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DENTAL DECKS

Smooth the sharp edges of the remaining bone and replace and suture the
remaining soft tissue
A fracture of the maxillary tuberosity most commonly results from extraction of an
erupted maxillary third molar - or a second molar if it happens to be the last tooth in
the arch.
If the tuberosity is fractured but intact. it should be manually repositioned and stabilized with sutures.
The complications most often seen after extraction of an isolated residual maxillary
erupted molar are:
(-r o.V'\'C)\O>\'S)
Fracture of the tUberosity
Fracture of the floor of the sinus
Important: "Beware of the lone molar"

ORAL SURGERY/PAIN CONTROL

Exo

In preparing the edentulous mandible for dentures , each of the following may be safely excised except

A labial frenum
A lingual frenum
The mylohyoid ridge
The genial tubercles
An exostos is

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DENTAL DECKS

The genial tubercles


The genial tubercles are situated on the lingual surface of the mandible at a point
about midway between the superior and inferior borders. There are four of them , two
of which are situated on each side and adjacent to the symphys is. Although usually relatively small, they may be fairly large and extend outward from the surface as spinous
processes. These tubercles are the area of muscle attachment for the suprahyoid
muscles.
Important: If the genial tubercles were removed, the tongue would be flaccid.
Notes:
1. When removing the mylohyoid ridge, be careful to protect the lingual nerve.
2. When removing a mandibular exostosis (mandibular torus) it is recommended that
an envelop flap design, which has no vertical components, be used.

ORAL SURGERYIPAIN CONTROL

Exo

While attempting to remove a grossly decayed mandibular molar, the crown fractures. What is recommended next step in order to facilitate the removal of this tooth?

Use a larger forceps and luxate remaining portion of tooth to the lingual
Separate the roots
Irrigate the area and proceed to remove the rest of the tooth
Place a sedative filling and reschedule patient

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DENTAL DECKS

Separate the roots


"""This can be done with a chisel , elevator, or most easily with a bur.
Teeth with two or more roots often need to be sectioned into single entities prior to
successful removal. A popular method of section ing is to make a bur cut between the
roots, followed by inserting an elevator in the slot and turning it 90 0 to cause a break.
The removal of a freshly fractured root is usually attempted by the closed method
(without a flap) if there is a likelihood of success . However, it is best to prepare a flap
if the technique is not successful within 5 to 10 minutes. Otherwise a half hour can be
wasted, the soft and bony tissues can be traumatized, and a flap has to be made anyway.
Teeth are resistant to crush but are not resistant to shear. Therefore :
Place the beaks of the forceps opposite to each other at the same level on the tooth.
The beaks should be applied in a line parallel with the long axis of the tooth .
Remember: When luxating a tooth with forceps , the movements should be firm and
deliberate, primarily to the facial with secondary movements to the lingual. The maxillary first bicuspid is least likely to be removed by rotation forces due to its root
structure (obviously molars are not removed by rotation).

ORAL SURGERY/PAIN CONTROL

Exo

While extracting a mandibular third molar, you notice that the distal root tip is missing. Where is it most likely to be found?

In the infratemporal fossa


In the submandibular space
In the mandibular canal
In the pterygopalatine fossa

Copyright 2001 -

DENTAL DECKS

In the submandibular space


Important: To prevent this, avoid all apical pressures when removing the roots or root tips of
all mandibular molars. If a mandibular molar root tip is displaced inferiorly, it may either be in the
mandibular canal or through the lingual cortical plate.
Note: The sybmandibular space usually drains infections from the mandibular bicllspids and
molars because their apices lie below the mylohyoid muscle attachment.
The submandibular space is a potential space of the neck bounded by the oral mucosa and
tongue anteriorly and medially; the superficial layer of deep cervical fascia laterally, and the
hyoid bone inferiorly. It comprises two spaces, the sublingual and submaxillary spaces, divided by the mylohyoid muscle.
The submental space is the medial part of the submaxillary space. It contains the submental
lymph nodes that drain the median parts of the lower lip, tip of the tongue, and the floor of
the mouth. Usually drains infections from the mandibular incisors and canines because their
apices lie above the mylohyoid muscle attachment.
The sublingual space is the superior part of the submandibular space, containing the sublingual
gland and loose connective tissue surrounding the tongue.
Remember : Ludwig's angina.is the most commonly encountered neck space infection (involves
the sublingu8J, submandibular, and submental spaces).

ORAL SURGERY/PAIN CONTROL

Exo

Arrange the following five phases of healing of an extraction site in their correct order:
Replacement of the connective tissue by fibrillar bone
Hemorrhage and clot formation
Replacement of granulation tissue by connect ive tissue and epithelialization of the
site
Recontouring of the alveolar bone and bone maturation
Organiza tion of the clot by granulation tissue

Copyright 2001 -

DENTAL DECKS

The correct order of the five phases of healing of an extraction site are:
1.
2.
3.
4.
5.

Hemorrhage and clot formation


Organization of the clot by granulation tissue
Replacement of granulation tissue by connective tissue and epithelialization of the site
Replacement of the connective tissue by fibrillar bone
Recontouring of the alveolar bone and bone maturation

Note: Glucocorticoids have been shown to have the greatest effect on granulation tissue (they
retard healing)
The same sta ges that occur in normal wound healing of soft tissue injuries (inflammation, fibroplasia, and remodeling) also occur in the repair of injured bone. However, osteoblasts and
osteoc lasts are also involved to repair damaged bone tissue.
Bone heals by primary and secondary intention as does soft tissue.
Primary intention bone repair involves both endosteal and periosteal proliferation This
type of bone repair occurs when either the bone is incompletely fractured or a surgeon closely reapproximates the fractured ends of a bone. Little fibrous tissue is produced with min imal callus formati on.
Secondary intention bone repair involves mostly endosteal proliferation. If fractured
bones remain more than a millimeter apart, this type of repair takes place. A lot of fibrous
ti ssue is formed and a callus is formed This callus eventl lally ossifies...
.

ORAL SURGERY/PAIN CONTROL

Exo

If a small communication is made with the maxillary sinus during extraction of a maxillary second molar, what treatment is recommended?

The sinus commun ication should be closed with a flap procedure


No additional surgical treatment is necessary
A figure-eight suture should be placed over the tooth socket
None of the above

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DENTAL DECKS

No additional surgical treatment is necessary


*** Allow the blood clot to form
Adv ise the pat ient to avoid : vigorous mouth washing, frequent blowing of the nose, smoking,
sucking on a straw, and violent coughing or sneezing.
The following medications may be prescribed for one week: antibiotics (usually penicillin or
erythromycin), a decongestant nasal spray, and/or an oral decongestant.
If opening is of mo derate size (2-6 rom), a figyre eight suture should be place over the tooth
socket.
If opening is large (7 mm or larger), the opening should be closed wittJ a flap procedure.
Note: If tooth or large fragment is displaced into the sinus, it should be removed. If the tooth fragment is irretrievable through the socket, it should be retrieved through a CaldwellLuc approach
ASAP. However, only perform this if you know what you are doing. If not, refer patient to an
oral surgeon.
Remember : The integrity of the floor of the maxillary sinus is at greatest risk with surgery involving the removal of a single remaining maxillary molar. The fear here is possible ankylosis.

Exo

ORAL SURGERYIPAIN CONTROL


Which lever classification is used during tooth extract ions?
Class I

Class III

Class II

6.

.......

=
=
=

Fulcrum
Load
Force

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DENTAL DECKS

Class II lever
Teeth are extracted by luxation forces perpendicular to the long axis of the tooth. not
by pulling along the long axis . The fulcrum is as close to the apex of the tooth as possible. Note: Rotation forces can be used on single rooted teeth.
Remember : The beak of extraction forceps is designed so that most of the pressure
exerted during an extraction is transmitted to the root of the tooth.

ORAL SURGERY/PAIN CONTROL


Which teeth listed below are the most frequently impacted?

Maxillary can ines


Maxillary third molars
Mandibular third molars
Mandibular premolars

Copyright 2001 -

DENTAL DECKS

Exo

Mandibular third molars


***Followed by maxillary third molars and maxillary canines
Classifications of impactions: One system employs a description of the angulation
of the long axis of the impacted third molar with respect to the long axis of the second molar.
% of all impacted teeth)
Mesioan ul
Distoangular (6% of all impacted teeth
Vertical (38% of all impacted teeth)
Horizontal (3% of all impacted teeth)
***In addition, teeth can also be angled in a buccal or lingual direction. Note: Most
mandibular third molars are angled toward the lingual direction.

Impactions are also classified based on the relationship to bone and tissue:
Soft tissue impacted: impacted by soft tissue only
Partial bony impaction: crown is partially covered by bone
Full bony impaction: tooth completely covered by bone
The most common site for a supernumerary tooth is in the maxillary incisor area.
When it occurs here, it is called a mesiodens. These teeth are usually small, pegshaped, and do not resemble the teeth normal to the site. Treatment is surgical
removal.

ORAL SURGERY/PAIN CONTROL

Drugs

Which of the following narcotics is contained in the analgesics Percodan and


Percoset?

Codeine
Oxycodone
Hydrocodone
Morphine

Copyright 2001 -

DENTAL DECKS

Oxyeodone

This narcotic is also considered to have the highest dependency liability when compared to drugs such as codeine , propoxyphene and pentazocine.
Oxyeodone (contained in Percodan and Percocet) and Hydroeodone (contained in
Lorcet, Lortab and Vicodin) are 0eioids similar in structllre to mO~FJhine and codeine.
Pereodan (Oxycodone + aspirin) is the strongest pain medication you can prescribe
and have the patient still be ambulatory. Do not take on empty stomach.
Pereoeet (Oxycodone + acetaminophen)
Loreet, Lortab and Vieodin (Hydrocodone + Acetaminophen) all combine a...lli!!::
cotic analgesic and a cough reliever (hydrocodone) with a nonnarcotic analgesic
(acetaminophen) for the relief of moderate to severe pain.
Codeine is a narcotic analgesic and antitussive (cough suppressant). It is weaker than
morphine, less addictive , and less constipat ing. Codeine is usually comb ined with other
drugs, for example , Empirin (Aspirin + Codeine) , and Tylenol #2, 3, and 4
(Acetaminophen + Codeine)

ORAL SURGERY/PAIN CONTROL

Drugs

Acetaminophen and propoxyphene are used together to treat moderate to severe


pain due to:

Dental procedures
Headache
Back pain
Arthralgias
Myalgias
All of the above

Copyright 2001 -

DENTAL DECKS

All of the above

( Ol\ ct\JoN)

/, CI? 10 """ N OP t\ , 1'J

1 (, flo l' o lC Y~HE"~'E

This combination of acetaminophen and propoxyphene is called DarvocetN or Wygesic. These


compounds are mild narcotics and analgesics prescribed for the relief of moderate to severe
pain, with or without fever. Note : Darvon compound-55 is a combination of aspirin, caffeine, and
propoxyphene.
Acetaminophen (Tylenol) is a non-salicylate analgesic with similar analgesic potency as
NSAIDs. Propoxyphene (Oarvon) is an oral synthetic opioid analgesic structurally similar to
methadone. Note: The combination of acetaminophen and propoxyphene produces additive
analgesia as compared to the same doses of either agent alone.
Notes:
1.' cetaminophen has anti retic and anal esic ro erties but no anti-inflammatory properties. It does no e ect clotting time as does aspirin.
2. Aspirin is an anti inflammatory, antipyretic and analgesic that is used to relieve headaches,
toothaches, and minor aches and pains, and to reduce fever. The GI tract rapidly absorbs it.
3. Talwin compound combines the strong analgesic properties of pentazocine and the analgesic, anti-inflammatory, and fever-reducing properties of aspirin. It is used for the relief of
moderate pain. It does not produce euphoria.
4. The most appropriate time to administer the initial dose of an analgesic to control postoperative pain is before the effect of the local anesthetic wears off.

ORAL SURGERY/PAIN CONTROL


Diazepam (Valium) can be used for:

Candida albicans infections


Sedation induction
Hypothyroidism diagnosis
Myasthenia gravis

Copyright 2001 -

DENTAL DECKS

Drugs

Sedation Induction
Benzodiazepines such as diazepam (Valium), chlordiazepoxide (Librium), lorazepam (Ativan),
clonazepam (Rivotri/), f1urazepam (Dalmane), temazepam (Restoril), triazolam (Halcion),
alprazolam (Xanax), and midazolam (Versed) are medications that are frequently prescribed for
the symptomatic treatment of anxiety and sleep disorders. They produce their effects via specitic receptors involving GABA. Benzodiazepines are the most effective oral sedative drugs used
in dentistry.
Benzodiazepines, particularly diazepam and chlordiazepoxide are frequently prescribed for
preoperative sedation . These drugs are tranquilizers and are " sed to produce consciollS seda tion in anxious patients. Diazepam is more potent than chlordiazepoxide, These drugs do not
produce hangovers like barbiturates and other sedative drugs. Note: Do not use these drugs
during the first trimester of pregnancy.
Important: Be careful when administering any sedative drug to a patient who is taking a phenothiazine drug (i.e., Chlorpromazine , Fluphenazine , Prochlorperazine). These drugs will
potentiate the action of sedative drugs.
Notes:
1. Chloral hydrate is a sedative and hypnotic that is widely used for pediatric sedation.
2. Emotional stress decreases the rate of absorption of a drug when given orally.

ORAL SURGERY/PAIN CONTROL

Drugs

Ultrashort-acting barbitura tes produce loss of consci ousness by depression of the:

Medulla oblongata
Ascending portion of the reticular activating system
Substantia nigra
Descend ing portion of the reticular activating system

Copyright 2001 -

DENTAL DECKS

Ascending portion of the reticular activating system

The reticular activating system is a functional (rather than morphologic) system in the brain
essential for wakefulness , attent ion, concentration, and introspection. 8. network of nerve fibers
in the thalamus . hypothalamus , brain stem, and cerebral cortex contribute to the system .
Ultrashort-acting barbiturates:
Thiopental (Pentothal)
Thiamylal (Surital)
Methohexital (Brevital)

84~m+ts" StJ.d1)r-~~'c:;s

Short-acting barbiturates:
Pentobarbital (Nembutal)
Secobarbital (Seconal)
Long-acting barbiturates:
Phenobarbital
(Generally not used in oral surgery)
Important: Barbiturates are contraindicated in patients with respiratory disease or those who
are pregnant.
Note: Physical dependence is likely to develop with barbiturates if abused . The dependence
has a strong psychological as well as physical basis. Sudden withdrawal from high doses can be
fatal.

ORAL SURGERY/PAIN CONTROL


All of the following drugs are anticholinergic, except.

Atropine
Benztropine
Scopolam ine
Fenfluramine
Trihexyphen idyl
Dicyclomine
Glycopyrrolate
Ipratropium
Probanthine

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DENTAL DECKS

Drugs

Fenfluramine
"'Fenfluramine is an anorexigenic agent
All ant icho li nergic drugs interfere with the bind ing of acetylcholine at its receptor. The most
common method for categorizing anticholinergic drugs is to identify the ionization state of nitrogen (i.e., tertiary or quaternary) because this affects the drug's ability to penetrate the CNS.
Atropine, scopolamine, benztropine, dicyclomine, and trihexyphenidyl are all tertiary compounds, while glycopyrrolate , ipratropium , and probanthine are quaternary. Note : As a general rule , lertiary compounds penetrate the CNS more read ily than do quaternary (i.e., ionized)
compounds. One exception to this rule is atro pi ne, which at normal doses penetrates the CNS
poorly.
The principal therapeutic uses of anti cho linergic drugs in dentistry are:
To decrease the flow of saliva during dental procedures
To decrease the secretion from respiratory glands during general anesthesia
Atrop ine is the most commonly used anticholinergic drug for these purposes. Scopolamine
penetrates the CNS more readily than atropine but is rarely used.
Notes:
1. A patient premedicated with atropine will exhibit mydriasis (dilated pupils)
2. Atropine is contraind icated for nursing mothers and for patients with glaucoma.

ORAL SURGERY/PAIN CONTROL

Drugs

Which of the following are physiolog ical symptoms of a patient taking barbiturates?

Slurred speech
Shallow breathing
Sluggishness
Fatigue
Disorientation
Lack of coordination
Dilated pupils (mydriasis)
All of the above

Copyright 2001 -

DENTAL DECKS

All of the above


Barbiturates have two major effects:
1. Sedative (which decreases anxiety)
2. Hypnotic (which helps sleep)
Barbiturates depress the central nervous system, and this will last 3 to 8 hours
depending on the dose. The barbiturates of choice for the dentist usually are the shortacting variety because the onset of sedation is short (approx. 30 minutes to an hour)
and the duration of effect (3 to 4 hours) is more than sufficient for most dental procedures.
The following drugs should be avoided in a patient taking barbiturates: phenothiazines,
alcohol, antihistamines, and antihypertensives. These drugs will enhance the eNS
depression of the barbiturates.
Note: After IV administration of an ultrashort-acting barbiturate (for example Brevital or
Pentothal), the last tissue to become saturated as a result of redistribution is fat
(as compared to liver, brain, and muscle tissue).
Remember: Barbiturates are metabolized in the liver and are excreted by the kidney.

ORAL SURGERY/PAIN CONTROL

Drugs

Of the following drugs, which is most likely to cause seizures as an adverse reaction?

Aspirin
Morphine
Meperidine
Acetaminophen

Copyright ~ 2001 -

DENTAL DECKS

Meperidine (Demerol)
" ' Note: This adverse effect is very rare
Meperidine (Demerol) is a potent narcotic analgesic prescribed for the relief of moderate to severe pain and as a cough suppressant. It is probably the mostly widely used
narcotic in American hospitals . It compares favorably with morphine, the standard for
narcotic analgesics. Meperidine is the most abused drug by health professionals.
Note: It produces slight euphoria but no miosis.
Morphine is the standard drug to which all analgesic drugs are compared. It causes
euphoria, analgesia, and drowsiness along with miosis and respiratory depression.

ORAL SURGERY/PAIN CONTROL

Drugs

Clinically, scopolamine is used to:

Prevent nausea and vomiting associated with motion sickness


Reduce salivation and excess bronchial secretions prior to surgery
Reduce spastic states in parkinsonism
Produce sedation and as a pre-anesthetic medication
All of the above

Copyright 2001 -

DENTAL DECKS

All of the above


***Scopolamlne is very effective for the prevention of motion sickness and this indication represents its most common clinical use.

Scopolamine, like atropine, is generally used in surgery as a premedication for its


antimuscarinic properties, usually in combination with an oplold or barbiturate.
When you premedicate a patient with Scopolamine, the following effects will be prolonged (similar to premedication with Morphine) :
Amnesia
Psychic sedation
Decreased salivation
Notes:
1. Reduction of secretions occurs by competitive blockade of acetylcholine and other
cholinergic stimuli at cholinergic receptors sites on salivary and bronchial glands.
2. Antagonism of acetylcholine on the sphincter and ciliary body in the eye, produces
mydriasis (dilation of pupils)

ORAL SURGERY/PAIN CONTROL

Drugs

Therapeutic anticoagulation is administered to patients with all of the following

except

Postmyocardial infarction
Cerebrovascular thrombosis
Asthma
Pulmonary thrombosis

Copyright 2001 -

DENTAL DECKS

Asthma
Medical consultation is always indicated before oral surgery if the patient is currently receiving
anticoagulant or antiplatelet therapy.
Anticoagulants include dicumarol , heparin , antithrombin III, enoxaparin, and warfarin.
Remember : Aspirin and NSAID's both Inhibit platelet aggregation and if given to a patient taking an anticoagulant already, the effects can be life-threatening.
Important point for oral surgery: A patient who is on anticoagulant therapy (whether it is warfarin, heparin, aspirin, or an NSAID) will mostly likely have a prolonged prothrombin time
{p r ) and bleeding time. For elective extractions, this patient should stop taking the anticoagulant for two to three days prior to extractions. Always check with the patient's attending physician before recommending this.
When oral surgery is performed on these patients the following steps may help to prevent
hemorrhage from occurring:

Hemostatic agent placed within the socket


Multiple sutures in the surgical area
Intraoral pressure packs
Ice packs (extraoral)
The avoidance of mouth rinses
Soft diet

ORAL SURGERYIPAIN CONTROL


How long should one wait before obtaining a biopsy of an oral ulcer?

4 days
7 days
14 days
30 days

Copyright 2001 -

DENTAL DECKS

Biopsy

14 days
Almost all oral ulcers caused by trauma will heal within 14 days. Therefore, any
ulcer that is present for 2 weeks or more should be biopsied.
Biopsy is also indicated in the following instances:
Pigmented lesions (black/brown)
When tissue is associated with paresthesia, this is often an ominous sign.
If a lesion suddenly enlarges, it should be biopsied.
Note: Always aspirate a central bone lesion to rule out a vascular lesion. If a lesion
seems compressible, pulsatible, blue, or a bruit is heard, beware of a vascular lesion
and biopsy only under controlled hospital setting.
A stethoscope is used to listen for a bruit.

ORAL SURGERY/PAIN CONTROL

Biopsy

Which of the following are indications for biopsy?

A lesion that persists for more than two weeks with no apparent etiologic basis
Persistent hyperkeratotic changes in surface tissues
Bone lesions not specifically identified by clinical and radiographic findings
A lesion that has the characteristics of malignancy
An inflammatory lesion that does not respond to local treatment after 14 days
(such as removing local irritant)
A persistent swelling , either visible or palpable, beneath relatively normal tissue
All of the above are indications for biopsy

Copyright 2001 -

DENTAL DECKS

All of the above are indications for biopsy


Biopsy technique and surgical principles:
Anesthesia: Block local anesthetic techniques are employed when possible; if not,
infiltration may be used but the solution should be injected at least 1 cm away from
the lesion.
Tissue stabiization: Use fingers or clamps.
Hemostatsis: Gauze compresses (avoid high speed suction) .
Incision: Sharp scalpel.
Extent of incision: Obtain some normal tissue adjacent to lesion if possible.
Handling of tissue: Use a traction suture through the specimen, not tissue forceps
to avoid specimen trauma.
Specimen care: After removal, the tissue should be immediately placed in 10% formalin solution that is at least 20 times the volume of the surgical specimen. Note:
No other solution is acceptable.

ORAL SURGERY/PAIN CONTROL

Biopsy

Which of the following is not an indication for exicisional biopsy?

A small lesion (less than 1 em in diameter)


A lesion that can be removed comp letely without traumatizi ng the tissue
When there is a suspicion of malignancy
A pigmented or small vascular lesion

Copyri ght 2001 -

DENTAL DECKS

When there is a suspicion of malignancy


***This would be an indication for incisional bi opsy.
An incisional biopsy is a biopsy that samples only a particular or representative part of
the lesion. If the lesion is large or has different characteristics at different locations,
more than one area of the lesion may need to be sampled.
Other Indications: If the area under investigation appears difficult to excise because
of its extensive size (larger than 1 em in diameter) or hazardous location.
An excisional biopsy implies removal of the entire lesion at the time the surgical diagnostic procedure is performed. A perimeter of normal tissue surrounding the lesion is
also excised to ensure total removal.

ORAL SURGERY/PAIN CONTROL

Biopsy

Which of the following is the fixative of choice used for a routine biopsy specimen?

Hydrogen peroxide
Sodium hypochlorite
10% formalin
Saline

Copyright 2001 -

DENTAL DECKS

10% Formalin
After removal, the tissue should be immediately placed in 10% formalin solution (4%
formaldehyde) that is at least 20 times the volume of the surgical specimen. The tissue
must be totally immersed in the solution, and care should be taken to be sure that the
tissue has not become lodged on the wall of the container above the level of formalin.
Types of biopsies:
Incisional - take only part of lesion
}
Excisional - entire lesion is removed
Needle - aspirational biopsy
Exfoliative cytology - pap smear

most often used for oral lesions

Remember: A negative incisional biopsy report of a highly suspicious oral lesion


suggests that another biopsy specimen is necessary in view of the clinical impressions.
The key is a highly suspicious oral lesion.

ORAL SURGERY/PAIN CONTROL

Disord/Cond

Rheumatic fever is:


Inflammation of joints (arthritis) and the spleen (splenomegaly) resulting from a
streptococcal infection, usually of the throat.
Inflammation of joints (arthritis) and the parotid glands (parotitis) resulting from a
staphylococcal infection, usually of the middle ear
Inflammation of the jo ints (arthritis) and the heart (carditis) resulting from a streptococcal infection, usually of the throat.
Inflammation of the joints (arthritis) and the thyroid gland (goiter) resulting from a
staphylococcal infection, usually of the blood.

Copyright 2001 -

DENTAL DECKS

Inflammation of joints (arthritis) and the heart (carditis) resulting from a streptococcal
infection, usually of the throat.
.

!"

Rheumatic fever is a com Iication of an acute stre tococcal infection, almost always a
re tococca
0
a so known as~
pharyngitis (sore throatLThe offending agent i
A, B-hemolytic StreptoCOCCIJS Although rheumatic fever may follow a streptococcal infection, it
is not an infection. Rather, it is an inflammatory reaction to an infection, affecting many parts
of the body such as joints, heart, and skin.
Rheumatic fever is most common in children (5-15 years old). The onset is usually sudden.
Typically, symptoms begin several weeks after the disappearance of a streptococcal sore throat.
The major symptoms of rheumatic fever are join pain (arthritis), fever, chest pain, or palpitations caused by heart inflammation (carditis), jerky, uncontrollable movements (Syndenham 's
chorea), a rash (erythema marginatum) , and small bumps (nodules) under the skin. The treatment is penicillin and rest.
Heart inflammation (carditis), disappears gradually, usually within five months. However, it may
permanently damage the heart valves, resulting in rheumatic heart disease. The valve between
the left atrium and ventricle (mitral valve) is most commonly damaged. The valve may become
leaky (mitral valve regurgitation), abnormally narrow (mitral valve stenosis) , or both. Note: the
pulmonary valve is rarely Involved.
Note: A history of rheumatic fever should lead the dentist to an in-depth dialogue history seeking the presence of rheumatic heart disease (RHO). If RHD is present, antibiotic coverage is indicated to minimize the risk of subacute bacterial endocarditis (SSE).

ORAL SURGERY/PAIN CONTROL

Disord/Cond

Management of an acute asthmatic ep isode occurring during oral surgery includes all
of the following except

Terminate all dental treatment


Position the patient in an erect or semi-erect position
Patient should administer their own bronchodilator using an inhaler
Administer nitroglycerin
Administer oxygen
Monitor vital signs

Copyright 2001 -

DENTAL DECKS

Administer nitroglycerin
" ' Nitroglycerin is given in the management of a patient having chest discomfort (possible
anginal attack)
Note: In most severe asthmatic attacks or when the patient's bronchodilator is ineffective, epinephrine (0.3 ml of a 1:1,000 dilution) can be injected 1M or SC.
Asthma is a syndrome consisting of dyspnea, cough, and wheezing caused by bronchospasm ,
which results from a hyperirritability of the tracheobronchial tree. There are two types: allergic
asthma (most common form) and id iosyncrati c asthma.
Avoid th e use of the f oll owi ng drugs : Aspirin, NSAID's, barbiturates, narcotics, and erythromycin (if patient is taking theophylline).
Impo rtant: Nitrous oxide is safe to administer to people with asthma and is especially indicated for patients whose asthma is triggered by anxiety. If pat ient is tak ing steroid s, consult physician for the possible need for corticosteroid augmentation.
Note: The inhalation of a selective beta2-agonist (terbuta line, albuterol) is the preferred treatment
for an acute asthmatic attack.
Status asthmaticus is the most severe clinical form of asthma, usually requiring hospitalization,
that does not respond adequately to ordinary therapeutic measures. If not managed properly,
chronic part ial airway obstruction may lead to death from respiratory acidosis (which is produced by hypoxemia and hypercapnea) .

ORAL SURGERY/PAIN CONTROL

Disord/Cond

Which of the following are the most common causes of dehydration?

Fever
Vomiting
Diarrhea
Heat exhaustion
All of the above

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DENTAL DECKS

All of the above


Dehydration may also occur as a result of burns, diabetes insipidus, or an acute infection.
Important: One of the cardinal signs of dehydration is polydipsia (excess ive thirst)
Dehydration is the loss of water and important blood salts like potassium (K-) and sodium (Ne').
Vital organs like the kidneys, brain, and heart can't function without a certain amount of water
and salt.
Initially, a patient suffering from dehydration will clinically demonstrate only dryness of the skin
and mucous membranes.
However, as dehydration progresses , the t urgor (or fullness) of the skin is lost. If dehydration
persists, oli guria (reduced urine output) occurs as a compensation for the fluid loss. More severe
!egrees of fluid loss are accompanied by a shift of water from the intracellular space to the extracellular space a process that causes severe cell dvsfunction, particularly in the brain .
Systemic blood pressure falls with continuous dehydration , and declining perfusion eventually
leads to death.
Flui ds in several forms should be continually urged on the patient. In severely dehydrated individuals, they must get to the hospital right away. IV fluids will quickly reverse dehydration, and
is often life saving in young children and infants.

ORAL SURGERY/PAIN CONTROL

Disord/Cond

Which of the following are important points to remember in the management of a diabetic patient?
Defer surgery until diabetes is well-controlled; consult physician
Schedule an earl y morning appointment and avoid lengthy appointments
Cons ult physician if any questions concerning modification of the insulin regimen
arise
Watch for signs of hypoglycemia
Treat infections aggressively
All of the above

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DENTAL DECKS

All of the above

t '1Pt '!
Diabetes Mellitus is a complex disorder involving mostly carbohydrates (glucose) and lipids
owing primarily to a relative or complete lack of insulin secretion by the beta cells of the pancreas.
People with well-controlled diabetes are no more susceptible to infections than people without diabetes, but they have more difficulty containing infections (this is caused by altered leukocyte function).
Patients who take insulin daily and check their urine regularly for the sugar and ketones (controlled diabetics) usually can be treated in the normal manner without additional drugs or diet
alterations.
Important: If any doubt exists as to the patient's medical status, consultation with the patient's
physician is indicated. Do not assume anything.
Note:
The treatment of choice for hypoglycemia in an unconscious diabetic patient is IV injection
of 50% dextrose in water.
The treatment of choice for hypoglycemia in a conscious diabetic is the administration of an
oral carbohydrate (orange juice , cola beverages , candy bars, etc.)
Remember: Glossopyrosis (burning sensation in the tongue) and glossodynia (pain in the
tongue) are symptoms that are seen in the diabetic patient. This is caused by the degeneration
of the myelin sheaths of peripheral nerves.

ORAL SURGERY/PAIN CONTROL

Disord/Cond

Atel ectasis can result from which of the following after a patient has undergone oral
surgery?

Inactivity after surgery


Postoperative narcotic analgesics
An endotracheal tube which was misplaced during the oral surgery procedure
All of the above

Copyrigh t 2001 -

DENTAL DECKS

All of the above


Atelectasisis is the collapse of a lung. It is the most common anesthetic complication
occurring within the first 24 hours after surgery under general anesthesia. Symptoms
include diminished breath sounds , fever, and increas ing dyspnea. Note: Prolonged
atelectasis can lead to pneumonia.
Pneumothorax is the presence of air in the pleural cavity. It can occur as a postoperative complication of aspiration of liquid vom itus into the trachea and the bronchi. The
onset of pneumothorax is accompanied by a sudden , sharp chest pain, followed by .
difficult, rapid breathing , cessation of normal chest movements on the affected side,
tachycardia, a weak pulse, hypotension, diaphoresis, and elevated temperature, pallor,
dizziness, and anxiety.
Notes:
1. Pneumonitis (inflammation of the lung) and atelectasis are two of the most common causes of fever in a patient who has had general anesthesia.
2. The most common post-op complication of outpatient general anesthesia is nausea.

ORAL SURGERY/PAIN CONTROL


Chronic bronchitis is primarily a disease of:

Alcoholics
Cigarette smokers
Miners
Patients with a family history of allergy

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DENTAL DECKS

Disord/Cond

Cigarette smokers
Chronic Bronchitis is clinically defined as productive cough occurring for at least
three months of the year for at least two consecutive years. This condition has a
strong association with cigarette smoking (90 % of all cases occur in smokers). The
bronchial glands are enlarged, causing excess secretion of mucus. Chronic bronchitis often leads to Cor pulmonale (enLargement of the right ventricle of the heart). airway narrowing, and obstruction along with the squamous metaplasia of the bronchial
tree.
Important: Patients with chronic bronchitis may be predisposed to lung cancer (bronchogenic carcinoma).

Remember: Patients with chronic bronchitis (or any COPD) can have difficulty during
oral surgery. Many of these patients depend on maintaining an upright posture to
breathe adequately. They frequently experience difficulty breathing if placed in an
almost supine position or if placed on high-flow nasal oxygen.

ORAL SURGERY/PAIN CONTROL

Disord/Cond

Which tw o diseases below cause more than 60% of all cases of end-stage renal disease in the United States?
.

Diabetes
Leukemia
High blood pressure (hypertension)
Pernicious anemia

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DENTAL DECKS

Diabetes
High blood pressure (hypertension)
End-stage renal disease (ESRD) is a condition in which there is a permanent and almost complete loss of kidney function. The kidney functions at less than 10% of its normal capacity. In endstage renal disease, toxins slowly build up in the body. Normal kidneys remove these toxins
(i.e., urea and creatin ine) from the body through urine.
Patients with ESRD:
Are often on steroid therapy
Are more susceptible to post-op infections
Have an increased tendency to bleed
"'When oral surgical procedures are undertaken on these patients, meticulous attention to
good surgical technique is necessary to decrease the risks of excessive bleeding and infection.
Some important points to remember when treating patients with renal insufficiency and those
on hemodialysis:
Avoid the use of drugs that are metabolized or excreted by the kidney.
~ Do not use NSAID's (they are ne hrotoxic .
"' . p e d orm oral surgery e day after dialysis
~ Consult physician for possibie prophylactic antibiotics.

ORAL SURGERYIPAIN CONTROL

Disord/Cond

Which of the following is the most common cause of bleeding disorders?

Polycythem ia vera
Thrombocytopen ia
Myelofibrosis
Chronic myelocytic leukem ia

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DENTAL DECKS

Thrombocytopenia
Thrombocytopenia is an abnormal condition in which the number of platelets is
reduced. This condition is common in people with Idiopathic thrombocytopenic purpura (ITP) in which case an autoimmune disease causes very low platelet counts.
Clinical features:
Spontaneous appearance of purpuric or hemorrhagic lesions of the skin which may
vary in size from tiny, red pinpoint petechiae to purplish ecchymoses and even massive hematomas. Patients also exhibit a bruising tendency.
Nosebleeds, GI bleeding, urinary tract bleeding.
Severe and often profuse gingival hemorrhage.
Petechiae also occur on the oral mucosa.
Important:
Two concerns with doing surgery on these patients:
Post-operative hemorrhage caused by a decrease in blood platelets.
Patients with the chronic form may be on steroids and have adrenal insufficiency.
They may be unable to handle the stress of extractions.

ORAL SURGERY/PAIN CONTROL

Disord/Cond

All of the following are causes of metabolic alkalosis except.

Use of diuretics (thiazides, furosemide, ethacrynic acid)


Vomiting
Chronic renal failure
Overact ive adrenal gland (Cushing's syndrome or use of corticosteroids)

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DENTAL DECKS

Chronic renal failure


An abnormality in one or more of the pH control mechanisms can cause one of two major disturbances in
acid-base balance.
1. Ac idosis: is a condition in which the blood has too much acid (or too little base , frequently resulting in a
decrease in blood pH. When the pH of the blood falls be ow normal, which is around 7.3, the central
nervous system becomes so depressed that the person first experiences disorientation and later may
become comatose. Note: The normal blood bicarbonate-carbonic acid ratio is 20:1. A 10:1 ralio indicates uncompensated acidosis. Severe acidosis always occurs during CPR.
2. Alkalosis: is a condition in which the blood has too much base (or too little acid); occasionally resulting
in an Increase In blood pH. The major effect on the body is overexcitability of the nervous system . This
may result in tetany (tonic spasm).
Depending on the cause ot the condition, acidosis or alkalosis may be respiratory or metabolic.
Metabolic acidosis is eJCcessilli blood acidity characterized by an inappropriately low level of blc't rf i &nate In the
blood. Major causes include chronic renal failure, diabetic ketoacidosis, lactic acidosis. poisons and diarrhea.
Respiratory acidosis is excessive blood acidiw caused by a buildup of carbon dioxide in the blood as a
result of poor lung function or slow breathing (decrease in respiratory rate). Major causes include hypovenliIalion, emphysema, chronic bronchitis, severe pneumonia, pulmonary edema, and asthma. Treatment
of acidosis is ingestion of sodium bicarbonate.
Metabolic alkalosis is a condition in which the blood is alkaline because of an inappropriately high level of
bicarbonate. Major causes include vomiting acidic gastric contents or as a result of ingesting alkaline drugs.
Respiratory alkalosis is a condition in which the blood is alkaline because rapid or deep breathing resylts

Jo a low blood carbon dl gx ide level Major causes include ItYperve ntilatiQrl (from anx iety), pain, cirrhosis of the liver, low levels of oxygen in the blood (high altitude) , and aspirin overdose. Note: It is much less
common than respiratory acidosis. Treatment of alkalosis is ingestion of ammonium chloride.

ORAL SURGERY/PAIN CONTROL

Disord/Cond

Diabetes Mellitus Type 2 is associated with all of the following characteristics . except:

Normal or increased insulin synthesis


Onset in adulthood
Autoimmune origin
Associated with obesity
Rare ketoacidosis

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DENTAL DECKS

Autoimmune origin
Diabetes is the most common pancreatic endocrine disorder. It is a metabolic disease
involving mostly carbohydrates (glucose) and lipids . It is caused by abso lute deficiency of insulin (Type 1) or resistance of insulin's action in the peri pheral tissu es (Type
2). The class ic triad of symptoms includes polydipsia, polyuria, and polyphagia.
" i\-V f ~r
"\ UI'V\.(..
t ~a hV' ')Comparison of Type 1 and Type 2 Diabetes Mellitus
Characteristic

Type 1 Diabetes

Type 2 Diabetes

Level of insulin secretion


Typical age of onset
Percentage of diabetics
Basic defect
Associated withobesity
Speed of development of
symptoms
Development of ketosis
Treatment

None or almost none


Childhood
1020%
Destruction of B cells
No

Maybe normal or exceed normal


Adulthood
8090%
Reduced sensitivity of insulin's target cells
Usually

Rapid
Common if untreated
Insulin injections,
dietary management

Slow
Rare
Dietary control and weight reduction;
occasionally oral hypoglycemic drugs

ORAL SURGERY/PAIN CONTROL

Disord/Cond

A serious condition in which the quantity of blood pumped by the heart each minute
(cardiac outpu t) is insufficient to meet the body's normal requirements for oxygen
and nutrients is called:

Heart block
Ventricular tachycardia
Congestive heart failure
Atrial fibrillation

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DENTAL DECKS

Congestive heart failure (CHF)


Usually the left ventr icle fails first, soon followed by right-sided failure. The common
signs of CHF include :
Exertional dyspnea
Paroxysmal nocturna l dyspnea (patient wakes up gasp ing for air)
**" These are the earliest and most common signs
Peripheral edema (swollen ankles)
Cyanosis
Orthopnea (sitting or standing in order to breathe comfortably)
High venous pressure
Patient treatment and dental management considerations:
Prolonged rest
Administration of oxygen
Digitalis (patients are prone to nausea and vomiting)
Diuretics/vasodilators (patients are prone to orthostatic hypotension; avoid excessive epinephrine)
Dicumarol (patients may have bleeding problem)

ORAL SURGERY/PAIN CONTROL


The unpleasant sensation of difficulty in breathing is called:

Hypercapnea
Dyspnea
Hypocapnea
Apnea

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DENTAL DECKS

Disord/Cond

Dyspnea
TERM

MEANING

Apnea

Transient cessation or absence of breathing

Hypercapnea

Excess CO2 in arterial blood

Hypocapnea

Below normal CO2 in arterial blood

Hyperapnea

Abnormally deep and rapid breathing

Respiratory arrest

Permanent cessation of breathing (unless corrected)

Hyperventilation

Increased pulmonary ventilation in excess of


metabolic requirements

Hypoventilation

Underventilation in relation to metabolic requirements

Note: H perventilation results in the loss of carbon dioxide (COz) from the blood
(hyp ocapnea), thereby causing a decrease in blood pressure an some irnes am Ing.
Hypoventilation results in an increased level of carbon dioxide (COz) in the blood
(hypercapnea).

ORAL SURGERY/PAIN CONTROL

Disord/Cond

All of the following statements concerning hemophilia are true, except:


Hemophilia A and B are inherited as a sex-linked recessive trait by which males
are affected and females are carriers.
Bleeding time is abnormally prolonged
The majority of people afflicted with hemophilia have Type A and are under the age
of 25.
The signs, symptoms and clinical manifestations include excessive bleeding from
minor cuts, epitaxis, hematomas, and hemarthroses.
Chronic complications include impaired renal function and osteoarthritis.

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DENTAL DECKS

Bleeding time Is abnormally prolonged


The defects in Hemophillia A and B (factor VIII and IX) lead to a normal bleeding time.
platelet count. and PT time In both disorders there is a prolonged PTT (partial thromboplastin time), which is a clotting test for detection of plasma factor deficiencies.
Classifications of Hemophilia:
Hemophilia A - considered the classical type caused by a deficiency of coagulation
factor VIII (antihemophilic factor).
. Hemophilia B (also cal/ed Christmas disease) - due to a deficiency in factor IX
(plasma thromboplastin component).
Hemophilia C (also cal/ed Rosenthal's syndrome) - not sex-linked, less severe
bleeding. Due to a deficiency of factor XI (plasma thromboplastin antecedent).
von Willebrand's disease - inherited as an autosomal dominant bleeding disorder,
it occurs with equal frequency in both sexes. Due to a deficiency in the von
Willebrand factor, which is a large glycoprotein that has binding sites for factor VII
and also facilitates the adhesion of platelets to collagen (important in the formation
of a platelet plug).

ORAL SURGERYIPAIN CONTROL

Disord/Cond

Chronic obstructive pulmonary disease (COPO) is a group of disorders characterized


by airflow ob struction during respiration. Which one of those disorders listed below
is marked by dyspnea and wheezing expiration caused by episodic narrowing of the
airways?

Bronchial asthma
Chronic bronchitis
Emphysema
Bronchiectasis

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DENTAL DECKS

Bronchial asthma
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Disorder

Characteristics

Bronchial asthma

Dyspnea and wheezing expiration

Chronic bronchitis

Productive cough characterized by


hypersecretion of mucus

Emphysema
(Pulmonary emphysema)

Often coexists with chronic bronchitis , labored


breathing, and an increased susceptibility to infection

Bronchiectasis

Copious purulent sputum , hemoptysis, and


recurrent pulmonary infection

Note: Secondary pulmonary hypertension is most often caused by COPD .


Dental Management Of Patients With COPD:
Use an upright chair position
Avoid bilateral mandibular or palatal blocks
Avoid the use of a rubber dam
Nitrous oxide is okay to use
\t)~r/. 0"2.
Do not use barbiturates, narcotics, antihistamines, and anticholinergics
Outpatient general anesthesia is contraindicated

,,0

Disord/Cond

ORAL SURGERYIPAIN CONTROL


Which type of shock listed below is most often associated with severe trauma and
reactive peripheral vasodilation?

Hypovolemic shock
Cardiogenic shock
Septic shock
Neurogenic shock
Anaphylactic shock

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DENTAL DECKS

Neurogenic shock
Shock consists of a set of hemodyna mic changes that diminish blood flow below a level that provides adequate oxygen for the metabolic needs of organs and tissues. The symptoms of shock
include tiredness, sleepiness, and confusion . The skin becomes cold and sweaty and often
bluish and pale. The pulse is weak and rapid; the blood pressure drops as well. Important:
Reduced cardiac output is the main factor in all types of shock .
The stages of shock include: 1) Nonprogressive (early) stage - compensatory mechanisms
(increased heart rate and peripheral resistance) maintain perfusion to vital organs , 2)
Progressive stage - I+Iptabo1ic acidosis occurs (compensatory mechanisms are no longer adequate), 3) Irreversible stage - organ damage , survival Is not possible.
Major categories of shock:
Hypovolemic shock is produced by a red!lc' iQR iR bloOd volume Causes include severe
hemorrhage, dehydration , vomiting, diarrhea , and fluid loss from burns.
Cardiogenic shock is circulatorv collapse resulting froQl.. pump failllrP of the left vent ricl ~ ,
most often caused by massive myocardial infarction
Septic shock is due to severe infection. Causes include the endotoxin from gam-negative
bacteria.
Neurogenic shock results from severe injUry or trauma to the CNS
Anaphylactic shock occurs with severe allergic reaction

Anesth

ORAL SURGERY/PAIN CONTROL


All of the following are elements of general anesthesia except.

Analgesia
Relaxation
Hyperpyrexia
Hyporeflexia
Narcosis

Copy right @ 2001 -

DENTAL DECKS

Hyperpyrexia (an elevated body temperature)

The four elem ent s of genera l an esthesi a are:


1. Analg es ia (the Jack of pain without loss of consciousness). Note: The best monitor of the
level of analgesia is the verbal response.
2. Relaxat io n
3. Hyporeflexia (weakening of the reflexes)
4. Narco sis
"'Only analgesia, relaxation, and hyporeflexia are met by using local anesthetics. Narcosis can
only be reached when local anesthetics are given in a toxic dose or IV.
Not es :
1. The medulla is the last area of the brain to be depressed during general anesthesia. This area is
the mos t vital part of the brain and contains the cardiac, the vasomotor, and respiratory centers of
the brain.
2. The most reliable sign of "oxygen want " while monitoring a patient during general anesthesia is
an increased pulse rate. Cyanosis may also be present.
3. The emergency most frequently experienced during outpatient general anesthesia is respiratory
obstruction.
4. The best anesthetic technique used in oral surgery to avoid aspiration of blood or other debris when
a patient is under general anesthesia is endotracheal Intubation with pharyngeal packs.
5. A patient with an acute resp iratory Infecti on is contraindicated for general anesthesia.
6. The eyes are taped shut prior to draping a patient before surgery to prevent .com eal abrasion.

ORAL SURGERY/PAIN CONTROL


A complete blood count (CSC) includes :

Hematocrit
Hemog lobin
White blood cell count
Red blood cell count
All of the above

CoPvrlght 2001 -

DENTAL DECKS

Anesth

All of the above


The CBC and urina lys is are two tests that should be done before deciding whether to use a general anes thetic for surgical procedures on a patient. Note : If a bleeding problem is suspected the PIT (partial
thrombop lastin time) should also be evaluated.
Complete blood co unt (CBC) inc ludes:
Hematocrit (the volume perce ntage of
red blood cells in whole blood)
- Normal men = 45-50 percent
- Normal women = 40-45 percent
Hemoglobin
- Normal men = 14-18 g1dL
- Normal women = 12-16 g1dL

Total leukocytes (WBC's)


Normal = 5,000-10 ,OOO/mm3
Dental Infection = 15,000-20,000/mm3
Total erythrocytes (RBC's)
- Normal men = 5.0 (4.5-6.0)x10 6/mm3
- Normal women =4.5 (4.3-5.5)x1()6/mm3

Importa nt: The mini mal acceptable val ue fo r the hematocrit is 30 percent for elective surgery.
Normal values for coagulati on:
Template bleeding time = 1 to 9 minutes
Prothrombin time (PT) = 11 to 16 seconds (compared to normal control)
Partial thromboplastin time (PIT) = activated, 32-46 seconds (compared to normal control)
Platelets = 140,000 to 440,OOO/ml
Urine values :
pH 6.0 (4.7-8.0)
specific gravity = 1.005 to 1.025

Anesth

ORAL SURGERY/PAIN CONTROL


Stage I of anesthesia describes which level of sedation?
Unconscious sedation
Conscious sedation

Copyright 2001 -

DENTAL DECKS

Conscious sedation
Geude l's stages of anesthesia:
Stage I (amnesia and analges ia) - begins with the administration of anesthesia and continues to the loss of consciousness. Respiration is quiet, though sometimes irregular, and
reflexes are still present.
Stage II (delirium and excitement) - beg ins with the loss of consciousness and includes
the onset of total anesthesia. During this stage the patient may move his limbs, chatter incoherently, hold his breath, or become violent. Vomiting with the attendant danger of aspiration
may occur. The patient is brought to Stage III as quickly and smoothly as possible.
Stage III (surgical anesthesia) - begins wi th establishment of a regular pattern of breathing and total loss of consciousness and includes the period during which signs of respiratory
or cardiovascular failure first appear. This stage has four planes.
Stage IV (premortem) - signals danger. This stage is characterized by pupils that are maximally dilated and skin that is cold and ashen. Blood pressure is extremely low, often unrneasurable. Cardiac arrest is imminent. Remember: The eyes appear greatly enlarged in size
and nonreactive to bright light when functional circulation to the brain has stopped.

~~ ----

- - --

- --

---'

ORAL SURGERY/PAIN CONTROL


Which of the following will produce neurolept anesthesia?

Neuroleptic agent + narcotic analgesic


Neuroleptic agent + nitrous oxide
Neuroleptic agent + narcotic analges ic + nitrous oxide
Narcotic analgesic + nitrous oxide

Copyright 2001 -

DENTAL DECKS

Anesth

Neuroleptic agent + narcotic analgesic + nitrous oxide


Neurolept anesthesia is a state of neurolept analgesia and unconsciousness, produced by the combined administration of a narcotic analgesic and a neurolept ic agent,
together with the inhalation of nitrous oxide and oxygen.
-)(Neurolept analgesia only produces an unconscious state if nitrous oxide is also
administered. (see below)
Neuroleptic agent + narcotic analgesic
(Droperidol)
(Fentanyl)

= neurolept analgesia
(conscious)

Under the influence of this combination , the patient is sedated and demonstrates
psychic indifference to the environment yet remains conscious and can respond to
questions and commands .
Neurolept + nitrous oxide = neurolept anesthesia
analgesia in oxygen
(unconscious)
Induction of anesthesia is slow, but consciousness returns quickly after the inhalation of nitrous oxide is stopped.

ORAL SURGERY/PAIN CONTROL

Anesth

Inadvertent intravascular injection of a local anesthetic with a vasoconstrictor may


cause which of the following clinical signs?

Nervousness
Tremors
Dizziness
Blurred vision
Excitation and/or depression of the eNS
All of the above

Copyright 2001 - DENTAL DECKS

All of the above


These signs may be followed by:
Drowsiness
Convulsions
Unconsciousness
Possible respiratory arrest
Remember: Injections should always be made slowly with aspiration to avoid
intravascular injection. This will prevent systemic reaction to both local anesthetic
and vasoconstrictorused in many solutions. The presence of a vasoconstrictor does
not prevent an intravascular injection or systemic absorption. The acute intravenous toxicity of a local anesthetic agent with a vasoconstrictor may be higher than
that of the anesthetic agent by itself. If drowsiness is apparent after administration of
a local anesthetic, then the reaction is probably due to the toxic effect of the anesthetic as opposed to a psychogenic reaction.
Note: In local anesthesia, the depression of respiration is a manifestation of the
toxic effects of the solution.

ORAL SURGERY/PAIN CONTROL

Anesth

All of the following are advantages of using nitrous ox ide analgesia except

Rapid onset and recovery


Pleasant induction
It is a complete pain reliever
Nonirritating to the GI tract

Cop yri ght 2001 -

DENTAL DECKS

It is a complete pain reliever


Other advantages of using nitrous oxide analgesia include:

Good analgesia
It is nonflammable
It is suitable for all ages and therapeutic
for many medically compromised patients

It has virtually no adverse effects


in the absence of hypoxia
It is tltratable and produces euphoria

Nitrous oxide is a colorless, nonirritating gas with a pleasant, mild odor and taste. It has a blood/gas
partition coefficient of 0.47 and is thus poorly soluble in blood. It is excreted unchanged by the
lungs. It is the oldest gaseous anesthetic in use today. It is the only inorganic substance used as an
anesthetic. Its primary disadvantage as a general anesthetic is its lack of potency.
Notes :
Nitrous oxide should be stored under pressure in steel cylinders painted blue.
Oxygen is stored in green tanks.
Disadvantages of nitrous oxide (N~) analgesia:
There is a "misuse" potential with both patients and dentists.
It is not a complete pain reliever; a local anesthetic is still required to do most dental procedures.
The most common patient complaint is nausea.
Diffusion hypoxia may occur; make sure you give 100% oxygen at the end of dental procedure
to prevent it. Important: The inhalation of 100% oxygen is contraindicated for a person who has
chronic obstructive pulmonary disease.

ORAL SURGERY/PAIN CONTROL

Anesth

The initial event in a vasovagal syncope episode is the stress- induced release of
increased amounts of catecholamines that cause all of the following except

A decrease in peripheral vascular resistance


Tachycardia
Sweating
Bradycardia

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DENTAL DECKS

Bradycardia
"'Bradycardia appears after the initial event in a vasovagal syncope episode.
The most common emergency seen after the use of local anesthetics is syncope
(fainting) . The patient may complain of feeling a generalized warmth with nausea and
palpitations.
As blood pools in the periphery, a drop in blood pressure appears , with a corresponding decrease in cerebral blood flow. The patient will then complain of feeling dizzy or
weak. Compensatory mechanisms attempt to maintain adequate blood pressure, but
they soon fatigue, which leads to vagally mediated bradycardia. Once the blood pressure drops below levels necessary to sustain consciousness , syncope occurs.
Placing the patient in a supine position together with the administration of 100% oxygen is often all that is required. Additional treatment is based on symptoms.
Note: The primary airway hazard for an unconscious dental patient in a supine position is tongue obstruction. Remember: Head tilVchin lift.

ORAL SURGERY/PAIN CONTROL

Anesth

Which of the following is the maximum allowa ble dose for 2% lidocaine with 1:100,000
epinephrine?

2.0 mg lidocaine/per lb.


3.5 mg lidocaine/per lb.
6.0 mg lidocaine/per lb.
7.0 mg lidocaine/per lb.

Copyright 2001 -

DENTAL DECKS

3.5 mg lidocaine/per lb.


For example: 70 lb. Patient x 3.5 mg = 245 mg (maximum allowable dosage) + 36 mg
(amount of Lidocaine in 2 % carpule) = approximately 7 carpules.
Note: 1 kg = 2.2 pounds
For carbocaine without epinephrine, the maximum allowable dose is 3.0 mgllb.
Remember:
The maximum allowable dose of epinephrine that can be administered to a cardiacrisk patient is 0.04 m9:. In terms of local anesthetics this would be equivalent to:
1 carpule (1.8 cc) with anesthetic cone. 1:50,000
2 carpule (3.6 cc) wi anesthetic cone. 1:100,000
4 carpule (7.2 cc) wi anesthetic cone. 1:200,000

ORAL SURGERYIPAIN CONTROL

Anesth

The following signs are indicative of a patient having which type of reaction (a somato genic reaction or a psychogen ic reaction) ?

Nausea
Pallor and cold perspirat ion
Widely dilated pupils
Eyes rolled up
Brief convuls ions

Copyright 2001 -

DENTAL DECKS

A psychogenic reaction
A psychogenic reaction is caused by psychological factors rather than physical factors
(drugs)
Vasovagal syncope, a psychogenic reaction, is the most commonly experienced complication
associated with the use of local anesthetic solutions. The clinical signs closely resemble those of
shock. These psychogenic reactions readily respond to placing the patient in a supine position.
The foll owing dru gs, when administered on e hour prior to the dental appointment , are safe and
effective ways to allay the fears of an apprehensive adult dental patient and possibly avoid a
psychogenic reaction in the dental chair:
Diazepam (Valium): 5-10 mg orally (PO)
Pentobarbital (Nembutal): 50-100 mg orally (PO)
Secobarbital (Seconal): 50-100 mg orally (PO)
Promethazine (Phenergan): 25 mg orally (PO)
Note dosa ges and route of admin istration.
These drugs are not recommended un less you have experience with them and can handle any
complications that may happen from their use.
Note: A so mato genic reaction is the development of a reaction from an organic pathophysiologic cause.

ORAL SURGERYI PAIN CONTROL

Anesth

Phlebitis of a vein after administration of IV valium is usually attributed to the presence of which of the following in the mixture?

Hydroquinone
Water
Alcohol
Propylene glycol

Copyright 2001 -

DENTAL DECKS

Propylene glycol
Phlebitis (also called thrombophlebitis), which is irritation or inflammation of a yeio. is
sometimes seen after IV administration of valium. This is usually attributed to the presence of propylene glycol in the mixture .
Phlebitis is more likely to occur if a vein in the hand or wrist is used and may be more
common following repeated injections, especially in heavy smokers, the elderly, and
women taking oral contraceptives.
Clinical observations of phlebitis:
The vessel feels hard and thready or cord-like
The site is extremely sensitive to pressure
The surrounding area may be erythematous and warm to the touch
The entire limb may be pale, cold, and swollen
Treatment: Elevate limb, apply moist heat, and possibly use anticoag ulants.

ORAL SURGERY/PAIN CONTROL

Anesth

Postoperative hypotension may be due to the effect of:

Transfusion reactions
A fat embolism
The anesthetic or analgesics on the myocardium - > ~ wr to ~ ...o~
Liver failure
Anaphylaxis
All of the above

Copyright 2001 -

DENTAL DECKS

fl\ t..""{o1l..

All of the above


***It is usually due to the effect of the anesthetic or analgesics on the myocardium.

The treatment is narcan (a narcotic antagonist) if hypotension is due to narcotics . Use


atropine (an anticholinergic) if bradycardia is present.
Note: Postoperative ~ension is most often due to post-op pain. Treat with narcotics and sedatives. Other causes include hypercarbia (greater than normal amounts
of carbon dioxide in the blood), or administration of a vasopressor or catecholamine
agents.

ORAL SURGERY/PAIN CONTROL

Anesth

All of the following drugs can reduce salivary flow during dental treatment. Which one,
however, works by reducing anxiety and sensitivity during the procedure?

Scopolamine
Atropine
Local anesthesia
Benztropine

Copyright 2001 -

DENTAL DECKS

Local anesthesia

Local anesthesia acts by reducing sensitivity which therefore reduces the anxiety and
stress related to treatment; salivation is also decreased.
Scopolamine, atropine and benztropine are anticholinergic drugs. Not only do they
decrease the flow of saliva, but also decrease the secretion from respiratory glands
during general anesthesia.

ORAL SURGERY/PAIN CONTROL

Anesth

Which of the following is a peculiar thermal alteration that occurs during surgery in
susceptible persons?

Malignant hypothermia
Heat stroke
Malignant hyperthermia
Hyperreflexia

Copy right 2001 -

DENTAL DECKS

Malignant hyperthermia
Malignant hyperthermia is an autosomal dominant inherited cond ition, occurring in
patients undergoing general anesthesia. It is characterized by a sudden, rapid rise
in body temperature assoc iated with signs of increased muscle metabolism, such as
tachycardia , tachypnea, sweating, and cyanosis; increased carbon dioxide production;
and usually muscle rigidity. It occurs usually in apparently healthy children and young
adults at an average age of 21 years . There is no sex differential.
Treatment includes the admin istration of Dantrolene and 100% oxygen , coo ling procedures, and the correction of acidosis and hyperkalemia. People who have malignant
hyperthermia are informed of their condition and advised that one-half of their firstdegree relatives are likely to have the trait.

ORAL SURGERY/PAIN CONTROL


Ketamine is most common ly used to obtain:

Neuroleptanest hesia
Local anesthesia
Dissociative anesthesia
Regional anesthesia

Cop yrig ht 2001 -

DENTAL DECKS

Anesth

Dissociative anesthesia
Ketamine hydrochloride (Kela/ar) is a rapid acting, non-barbituate , parenterally adminthat produces dissociative anesthesia. Dissociative anesthesia is
characterized by analgesia and amnesia wi th out the loss of respiratory fllOction Or.
"pharyngeal and laryngeal reflexes. The patient appears to be awake, but detached
from the environment and unresponsive to pain. Ketamine administration produces a
catatonic state in which the patient does not respond to noxious stimuli.
~ a n esthet ic

Ketamine is particularly useful for brief, minor surgical procedures and for the induction
of inhalation anesthesia .in pediatric geriatric and disturbed patients The onset of
action is about 1 minute after IV injection and 5 minutes after 1M injection. The duration
of anesthesia is about 5 to 10 minutes for IV, and 10 to 20 minutes for 1M. Recovery
takes much longer. There are no known antagonists.
Ketamine:
Increases secretions of the salivary and bronchial glands
Increases BP, muscle tone and heart rate, but not respirations
Side effects include: hypertension , increased pulse and delirium

ORAL SURGERY/PAIN CONTROL

Anesth

Which drug listed below is most commonly used to attain general anesthesia?

Valium
Chloral Hydrate
Phenergan
Brevital

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DENTAL DECKS

Brevital (Methohexital)
Brevital is an IV barbiturate and is prescribed for the induction of anesthesia in short
surgical procedures as a supplement to other anesthetics . 1.1 is metabol ized in the liver
..and excreted by the kidney Brevital induction is characterized by being rapid and
there is also rapid recovery. The side effect most often seen is hiccoughs. This is
believed to be caused by rapid injection of the Brevital. Note: A primary advantage of
IV sedation is the ability to titrate individualized dosage.

The general anesthetics most frequently used are inhalation alone, barbiturates alone,
barbiturates with oxygen , and nitrous in combination with a more potent agency such
as halothane. In addition, a local anesthetic is sometimes used for vasoconstriction and
to decrease the amount of barbiturate used in lengthy procedures.
Note: The most effective agent in the initial treatment of respiratory depression due
to overdose of barbiturat es is oxygen under positive pressure.
Some reasons to use sedation :
For a patient who is very apprehensive or scared
To decrease stress in a medically compromised patient
To perform several procedures on a patient who is extremely anxious

ORAL SURGERY/PAIN CONTROL


All of the following are considered to be what type of anestheti c?

Nitrous Oxide
Cyclopropane
Ethylene
Halothane
Isoflurane
Methoxyflurane

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DENTAL DECKS

Anesth

Inhalation anesthetics
Inhalation anesthetics are drugs inhaled as gases or vapors. These diverse drugs are
relatively simple lipophilic molecules, ranging from the inorganic agent nitrous oxide
(N20 ) to ethers such as ethyl ether, hydrocarbons such as cyclopropane and halogenated hydrocarbons such as halothane.
Administration of an inhalation anesthetic (except nitrous oxide) is usually preceded by intravenous or intramuscular administration of a short acting sedative hypnotic
drug, often a barbiturate. The procedure almost always requires endotracheal intubation.
Cyclopropane, halothane and methoxyflurane are inhalation general anesthetics
that have a relatively low therapeutic index, but their clinical safety is greatly increased
by the extreme ease in reversing tissue concentration . General anesthesia with
halothane is commonly preceded by administration of atropine to reduce salivation and
bronchial secretions caused by halothane.
The rapidity of anesthesia with an inhalation anesthetic agent is primarily related to
its degree of blood solubility.
Inhalation anesthetics are absorbed and primarily excreted through the lungs.

ORAL SURGERY/PAIN CONTROL

Anesth

All of the following are contraindications to the use of nitrous oxide excep t.

Hypoxemia
Respiratory disease
Children
Emotional instability
Contagious diseases

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DENTAL DECKS

Children
*** Nitrous oxide is very appropriate for use on a child who is fearful and timid.

Nitrous oxide is contraindicated in patients with:


1 Hypoxemia - an abnormal deficiency of oxygen in the arterial blood
2. Respiratory disease (emphysema, asthma , upper respiratory obstruction)
3. Emotional instability
4. Contagious diseases (can't sterilize entire tube)
Nitrous oxide is a gas used as an anesthetic in surgery. It provides light anesthesia and is delivered
in various concentrations with oxygen. Nitrous oxide alone does not provide deep enough anesthesia
for major surgery, for which it is supplemented with other anesthetic agents. It is often given for induction of anesthesia, preceded by the administration of a barbiturate or an analgesic narcotic. Induction
and recovery are both rapid. Note: Sedation can rapidly be reversed when using inhalation as the
route for administration of drugs.
Nitrous oxide is the only safe conscious sedation technique for the pregnant patient (use only
in second and third trimester). Barbiturates, narcotics, and tranquilizers all pass the placental barrier.
Note: Elective extractions in pregnant patients is contraindicated.
The most common complication associated with nitrous oxide sedation is a behavioral problem
(laughing, giddy).
.
The difference between conscious sedation and general anesthesia as far as patient response is
concerned: the patient retains all his reflexes under conscious sedation, but not under general anesthesia.

ORAL SURGERYIPAIN CONTROL

Anesth

Which local anesthetic listed below may possibly manifest its toxicity clinically by initial
depression and drowsiness rather than stimulation and convuls ion?

Lidocaine
Procaine
Benzocaine
Tetracaine

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DENTAL DECKS

Lidocaine
The initial effect upon the brain for local anesthetics is usually stimulation and then depression.
However, it is also possible that the excitatory phase of the reaction may be extremely brief or
may not occur at all. This is true especially with lidocaine and mepivacaine. With these
agents, patients exhibit drowsiness. Also note that lidocaine and mepivacaine can also show
cross-allergy.
Allergic reactions to amide type local anesthetics are rare but may occur as a result of hypersensitivity to the local anesthetic agent itself or due to an allergy to methylparaben or other
preservatives used in many solutions. These reactions are characterized by cutaneous
lesions of delayed onset or urticaria, edema, and other manifestations of allergy.
Amide type local anesthetics undergo biotransformation in the liver by microsomal enzymes but
some is excreted unchanged (10-20%). Ester type local anesthetics undergo rapid biotransformation in the blood plasma. The major portion of this inactivation process occurs within the
blood through hydrolysis to paraaminobenzoic acid by the enzyme pseudocholinesterase.
Patients with pseudocholinesterase inactivity are unable to detoxify ester type agents at a normal rate. Amide type anesthetics are recommended in these patients.
Important: For those patients allergic to both ester and amide type local anesthetics,
Diphenhydramine is a safe and effective alternative.

ORAL SURGERY/PAIN CONTROL

Anesth

How many milligrams of epinephrine are in each cartridge (1.8 cc) of 2% lidocaine
with 1:100,000 epinephrine?

0.018 mg
18 mg
0.036 mg
36 mg

Copyright 2001 - DENTAL DECKS

0.018 mg (1.8 cc x .0 1 mg epi. = .018 mg)


Important:
1 cc of 2% lidocaine with epinephrine 1:100,000 contains the following:
- 20 mg of lidocaine
- 0.01 mg of epinephrine
- 6 mg of NaCL
- 0.5 mg of sodium-metabisulfate (preservative to stabilize epinephrine)
- 1 mg of methylparaben (a preservative)
- NaOH to stabilize pH
1.8 cc of 2% lidocaine (which is a carpule) with epinephrine 1:100,000 contains
the following:
- 36 mg of lidocaine (1.8 x 20 mg)
- .018 mg of epinephrine (1.8 x .01 mg)
- 10.8 mg of NaCI (1.8 x 6 mg)
- .90 mg of sodium-metabisulfate (1.8 x 0.5)
- 1.8 mg of methylparaben (1.8 x 1 mg)
- NaOH to stabilize pH

ORAL SURGERY/PAIN CONTROL

Anesth

Which two of the following are useful for sedation and analgesia only?

Halothane
Methoxyflurane
Cyclopropane
Nitrous oxide
Ethylene

Copyright 2001 -

DENTAL DECKS

Nitr ous oxide


Ethylene
Nitrous oxide: 10-20% (maxim um 35%)-rapid induction and recovery.
Ethylene: 25-35%--rapid induction and recovery, not used often due to explosiveness
and disagreeable odor.
Agents useful for surgical anesthesia:
Cyclopropane: 20-35% for stage 3, rapid induction and recovery, good muscle relaxant, sensitizes heart to catecholamines.
Halothane: 3% induction and 1-2% maintenance, relatively slow induction and recovery. Not a good muscle relaxant. Side effects include sensitizing heart to the catecholamines, hypotension and cardiac arrhythmias. Not a good analgesic, used as an
adjunct. Note: Halogenated hydrocarbo ns are associated with liver damage if toxic
doses are used.
Methoxyflurane: 1-3%, slow induction and recovery, good muscle relaxant, sensitizes
the heart to catecholamines, respiratory depressant , good analges ic.
Note: Ventricular fibrillation is least likely to occur during anesthesia with nitrous oxide.
The principal danger associated with the use of nitrous oxide anesthesia in concentrations exceeding 80% is hypoxia.

ORAL SURGERY/PAIN CONTROL

Anesth

During an inferior alveolar nerve block injection, the needle passes through the
mucou s membrane and the buccinator muscle and lies lateral to the:

Masseter muscle
Temporalis muscle
Medial pterygoid muscle
Lateral pterygoid muscle

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DENTAL DECKS

Medial pterygoid muscle


If the needle mistakenly passes posteriorly at the level of the mandibular foramen, it
will penetrate the parotid gland and the patient will state that his/her cheek feels
numb (may develop paralysis of the muscles of facial express ion). If the tip of the needle is resting well below the mandibular foramen, you will be penetrating the medial pterygoid muscle. Remember: Trismus is most likely caused by irritation of this
muscle during an inferior alveolar nerve block.
Following an inferior alveolar or mental injection, a prickly or tingling sensation (paresthesia), even complete numbness in the lower lip, may result and persist for a considerable time. This is usually considered to be due to direct trauma or
piercing of the nerve trunk by the needle. This happens more often in the case of
the mental injection. The symptoms of paresthesia gradually diminish (may last from
two weeks to six months), and recovery is usually complete.
Remember: The most common cause of paresthesia of the lower lip is the removal
of a mandibular third molar (espec ially horizontally impacted ones).

ORAL SURGERY/PAIN CONTROL

Anesth

From the choices listed below, what are the two most important steps in the initial
management of a laryngospasm?

Administering epinephrine
Applying oxygen under positive pressure
Administering succinylcholine
Placing the patient in the Trendelenburg position

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DENTAL DECKS

Applying oxygen under positive pressure


Administering succinylcholine
A patient under general anesthesia loses the laryngeal reflex. If blood and saliva collect near the voca l cords , this stimulates the patient to go into spasm (laryngospasm)
and the vocal cords will close. When this happens , air cannot pass through and hence
the problem.
Note: Succinylcholine is a skeletal muscle relaxant that is used when performing
endotracheal intubation and endoscopy procedures.

ORAL SURGERY/PAIN CONTROL

Anesth

All of the following are reasons that vasoconstrictors are included in local anesthetics

except

They prolong the duration of action of the local anesthetic


They reduce the chance of an allergic reaction to the local anesthet ic
They reduce the toxicity because less local anesthet ic is necessary
They reduce the rate of vascular absorption by causing vasoconstriction
They help to make the anesthesia more profound by increasi ng the concent rations of the local anesthetic at the nerve membrane.

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DENTAL DECKS

They reduce the chance of an allergic reaction to the local anesthetic


***This is false

The most important reason for the use of vasoconstrictors is to pro long the duration of action of the local anesthetic.
SOME VASOCONSTRICTORS USED IN LOCAL ANESTHETICS
Available
Concentrations

Local Anesthetics Which


Conta in These Agents

Epinephrine

1:50,000
1:100,000
1:200,000
1:200,000

Lidocaine 2%
Lidocaine 2%
Prilocaine 4%
Marcaine .5%

Levonardef rin (Neo-Cobefrin)

1:20,000

Mepivocaine 2%

Norepinephrine (Levophed)

1:30,000

Procaine 2%

Agent

Remember: Vasoconst rictors act at alpha receptors to produce constriction of arterioles.

ORAL SURGERY/PAIN CONTROL

Anesth

After receiving an injection of a local anesthetic containing 2% lidocaine with 1:100,000


epinephrine, the patient loses consciousness. Which of the following is the most probable cause?

Acute toxicity
Allergic response
Syncope
Hypervent ilation syndrome

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DENTAL DECKS

Syncope
***Caused by transient cerebral hypoxia
Proper management of syncope:
Place patient in supine position with feet slightly elevated .
Establish airway (head tilt/chin lift)
- Administer 100% oxygen via face mask. O2 is indicated for treatment all types of
syncope except hyperventilation syndrome.
Monitor vital signs and support patient.
- Pupils may dilate from brain not getting oxygen.
Maintain your composure. Apply cool, wet towel to patient's forehead.
Follow-up treatment.
Determine factors causing unconsciousness.
Remember: Hyperventilation in an anxious dental patient leads to carpodedal spasm
(a spasm of the hand, thumbs, foot, or toes).

ORAL SURGERY/PAIN CONTROL


Local anesthetics depress small, nonmyelinated nerve fibers:

First
Last
At the same time as large, myelinated nerve fibers
After the large, myelinated nerve fibers

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DENTAL DECKS

Anesth

First

***Local anesthetics depress large, myelinated nerve fibers last.


Variations in susceptibility of nerve fibers to local anesthetics are dependent on the
diameter of the nerve and the distance between the nodes of Ranvier.
Clinically, the general order of loss of function is as follows:
Pain
Temperature (cold and warmth)
Touch/pressure
Proprioception
Skeletal muscle tone (motor)
Note: Nerves regain function in reverse order.

~-_.::......----------

ORAL SURGERY/PAIN CONTROL


Nitrous oxide works on the:
Peripheral Nervous System (PNS)
Central Nervous System (e NS)
Autonomic Nervous System (ANS)

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DENTAL DECKS

Anesth

Central Nervous System (eNS)


Nitrous oxide is the only inorganic gas used by the anesthesiologist. Room air contains 21% oxygen; you must make sure that the patient receives at least this much
oxygen. Maximal safe concentrations of nitrous oxide (70% nitrous / 30% oxygen)
produce intoxication, analgesia, and amnesia.
Nitrous oxide is carried in the bloodstream in physical solution. There is no metabolism or degradation of nitrous oxide in the body. It is excreted solely via the lungs,
unchanged. High blood levels of nitrous oxide can be achieved quite quickly. It is nontoxic to body tissues. The only toxicity with the use of nitrous oxide is the lack of oxygen that could result from the operator's error. The gag reflex is only slightly obtunded
with nitrous oxide analgesia. It is believed that nitrous oxide has its main effects on
the ~ i cy l a r activating system and the limbic system.
Remember:
The first symptom of nitrous oxide analgesia is tingling of the hands.
Nausea is the most common side effect of nitrous oxide analgesia.
The correct total liter flow of nitrous oxide/oxygen is determined by the amount
necessary to keep the reservoir bag 1/3 to 2/3 full.

ORAL SURGERY/PAIN CONTROL


What is usually the first clinical sign of mild lidocaine toxicity?

Itching
Nervousness
Vomiting
Sleepiness

Copyrig ht 2001 -

DENTAL DECKS

Anesth

Nervousness
Possible causes Include:
An intravascular injection
An unusually rapid absorption
Too large of a total dose of the local anesthetic
Clinical manifestations of a mild lidocaine toxicity:
Related to CNS excitation - Remember: Udocaine may skip this excitatory phase and go right
to depression (drowsiness).
Nervousness (increased anxiety)
Increased heart rate
Increased blood pressure
Talkativeness
Increased respiratory rate
Muscular twitching
Perioral numbness
II the clinical manifestations do not progress beyond these signs with retention of consciousness, no definitive therapy is necessary. The lidocaine will undergo redistribution and biotransformation, and the blood level will fall below the toxic level in a short time.
Treatment of a sustained convulsive reaction to a local anesthetic includes oxygen and
Diazepam IV. If proper equipment and adequately trained staff are not available, do not attempt
IV injections.
Some possible side effects of systemic absorption (not necessarily toxic levels) of lidocaine
include tonic-clonic convulsions, respiratory depression, and decreased cardiac output.

ORAL SURGERY/PAIN CONTROL


Local anesthetics are most effective in tissues that have what pH?

Below 7
Above 7
Below 4
Makes no difference what the pH of the tissue is

Copyright 2001 - DENTAL DECKS

Anesth

Above 7

Local anesthetics are alkaloid bases that are combined with acids to form water-soluble salts. Above pH 7 (alkaline) you get hydrolysis of the anesthetic salts. Remember:
The potential action of all local anesthetics depends on the ability of the anesthetic salt to liberate the free alkaloidal base (the non-ionic lipophilic molecule). The
potency of local anesthetics increases with increasing lipid solubility.
As pH of the solution (tissue) goes down and the hydrogen ion concentration is
increased, the cationic (water-soluble) form rises and free base form goes down.
Conversely, as the pH is increased and hydrogen ion concentration is decreased, the
free base (fat-soluble) form increases and the cationic form decreases. This free base
form readily penetrates the lipid rich nerve.
Remember: Inflammation and infection cause the tissues to be acidic. The cationic
(water-soluble) form of the anesthetic predominates (there is less free base available).
Therefore, the penetration of the membrane is lessened and the anesthetic has poor
effectiveness.

ORAL SURGERY/PAIN CONTROL

Anesth

Which of the following is that phase of anesthesia that begins with the administration
of anesthetic and continues until the desired level of patient unresponsiveness is
reached?

Amnesia
Induction
Maintenance
Recovery

Copyr ight 2001 -

DENTAL DECKS

Induction
The depth of general anesthesia (by inhalation) varies with the partial pressure (tension) of the anesthetic agent in the brain, and the rates of induction and recovery
depend upon the rate of change of tension in this tissue (also blood supply to the lungs,
pulmonary ventilation, and the concentration of the anesthetic influence the rate of
induction). The signs and stages of anesthesia are most likely to be seen with an anesthetic that has a slow rate of induction.
Notes :
1. Maintenance is the process of keeping a patient in surgical anesthesia
2. Recovery is the phase of anesthesia commencing when surgery is complete and
the delivery of the anesthetic is terminated and ending when the anesthetic has been
eliminated from the body.
3. The behavior of patients under general anesthesia suggests that the most resistant part of the eNS is the medulla oblongata (cardiac, vasomotor, and respiratory centers of the brain).
4. The most controllable route for administration of a general anesthetic is inhalation.

~ 'M IlS\ ["o lA.trotbb ~

ORAL SURGERY/PAIN CONTROL

Anesth

Which vein listed below is the optimum site for IV sedation for an outpatient?

Median basilic vein


Median cephalic vein
Median antebrachial vein
Angular vein

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DENTAL DECKS

Median cephalic vein


This vein lies in the lateral aspect of the antecubital fossa (anterior to the elbow). Avoid
entering the brachial artery. If the artery is entered, the following symptoms will
appear: immediate burning at the site of the injection, the arm will appear blotchy, and
the pulse in the arm will be weak compared to the other arm.
IV sedation:
Usually done with a 21 gauge needle
Popular drug is Valium (Diazepam)
The rate of injection of Valium is 1 ml/minute
- 1 ml of injectable Valium contains 5 mg of Valium
Injection is discontinued when the eyelids droop (ptosis)
Three common signs indicating when the correct level of sedation has been reached
when using Valium:
1. Blurring of vision
2. Slurring of speech
3. 50% ptosis of the eyelids (this is called Verrill's sign)
Remember: Valium is contraindicated for use in a patient with a history of narrow
angle glaucoma.

ORAL SURGERY/PAIN CONTROL


All of the following local anesthetics are amides except

Prilocaine
Bupivacaine
Lidocaine
Procaine

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DENTAL DECKS

Anesth

Procaine
PABA Esters

Procaine (Novocainl
Tetracaine (Pontocaine)
Propoxycaine (Ravocaine)
.enzocaine (Monocaine)
Cocaine

Nonester Group: Amides

Lidocaine (Xylocaine) - most commonly used


Prilocaine (Citanest)
Mepivacaine (Carbocaine)
Bupivacaine (Marcaine)
Etidocaine (Ouranest)

Amides are safe, versatile, and effective local anesthet ics. If hypersens itivity to a drug
in this group precludes its use, one of the ester -compound local anesthetics may provide anesthesia without adverse effect.
Esters are potent local anesthetics slightly different in chemical structure from the
amide group. Tetracaine is most commonly used. Allergic reactions are far more
common with esters.
Remember: The drug of choice in management of an acute allergic reaction involving
bronchospasm (an acute narrowing of the respiratory airway) and hypotension is epinephrine.
Note: Allergic reactions to local anesthetic are usually caused by an antigen-antibody
reaction.

ORAL SURGERY/PAIN CONTROL

Anesth

All of the following may prevent a patient from developing a vasovagal syncopal reaction after the use of a local anesthetic except:

Slowing injecting the anesthetic solution


Watching the patient's color change during the injection
Using a topical anesthetic prior to administration of the local anesthetic
Injecting the anesthetic solution as quickly as possible
Using a low concentration of vasoconstrictor
Premedicating extremely anxious patients
Sympathetic, but confident handling of the patient

Copyright 2001 - DENTAL DECKS

Injecting the anesthetic solution as quickly as possible


The most common cause of a transient loss of consciousness in the dental office is
vasovagal syncope. This generally is due to a series of cardiovascular events which
are triggered by the emotional stress brought on by the anticipation of or delivery of
dental care.
Prevention of vasovagal syncopal reactions involves proper patient preparation.
Remember: Any signs of an impending syncopal episode should be quickly treated by
placing the patient in a fully supine position or a position in which the legs are elevated above the level of the heart (Trendelenburg position) and by placing a cool, moist
towel on the forehead.
Important: The most common early sign of syncope is pallor (flushed).

ORAL SURGERY/PAIN CONTROL

Anesth

How will a larger than normal functional residual capacity affect nitrous oxide sedation?
Nitrous oxide sedation will happen much quicker
Nitrous oxide sedation will take longer
Functional residual capacity does not effect nitrous oxide sedation

Copyright @ 2001 -

DENTAL DECKS

Nitrous oxide sedation will take longer


The functional residual capacity is the amount of air remaining in the lungs at the end
of the normal expiration. Note: This air is used to provide air to the alveoli , which will
aerate the blood evenly between breaths .
Note: Pulmonary volumes and capac ity are about 20 to 25% less in females than in
males and are greater in large and athletic persons. Nitrous oxide sedation will vary
accordingly.

ORAL SURGERY/PAIN CONTROL

Anesth

How do local anesthetics effect the nerve membrane?


They increase potassium flux
They increase the membrane excitability by Increasing the membrane's permeability to sodium ions
They decrease the membrane's permeability to sodium ions and reduce the membrane excitability
They increase the calcium and chloride flux

Copyright @ 2001 -

DENTAL DECKS

They decrease the membrane's permeability to sodium ions and reduce the
membrane excitability
Most local anesthetics act directly on the activation gates of the sodium channels , making it much more difficult for these gates to open. This decreases sodium membrane
permeability, and therefore reduces membrane excitab ility. When the excitability has
been reduced below a critical level, a nerve impulse fails to pass through the anesthetized area (depolarization does not occur). Note: K+ FLUX remains unchanged .
Remember:
Na+-K+shift:
When Na+enters the nerve depolarization
When K+exits the nerve = repolarization

Important Points:
1. Local anesthetics reversibly block nerve impulse conduction and produce
reversible loss of sensation at their administration side .
2. The site of action of local anesthetics is at the lipoprotein sheath of the nerve.

ORAL SURGERY/PAIN CONTROL

Anat

When a patient attempts protrusion, the mandible deviates markedly to the left.
Which muscle listed below is unable to contract?

Buccinator muscle
Temporalis muscle
Right lateral pterygoid muscle
Left lateral pterygoid muscle

Copyright 2001 -

DENTAL DECKS

Left lateral pterygoid muscle


"'With lateral pterygoid injury, the mandible will deviate toward the side of injury.
The mandible will also deviate.!9ward the side of injury with:
Aoky losis of the condyl ~ t **The most common cause of TMJ ankylosis is trauma)
A unilateral condylar fracture

--

The mandible will deviate away from the affected side with:
Condylar hyperplasia (**'Malocclusion is also a common occurrence with this
injury)
Remember: The lateral pterygoids (right and left) acting together are the prime protractors of the mandible.
Important: In addition to opening and protruding, the lateral pterygoids move the
mandible from side to side. For right lateral excursive movements, the left lateral
pterygoid muscle is the prime mover and vice versa.

ORAL SURGERY/PAIN CONTROL

Anat

Which artery listed below supplies the mucosa of the hard palate posterior to the maxillary canine?

Sphenopalatine artery
Greater palatine artery
Posterior superior alveolar artery
Nasopalatine artery

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DENTAL DECKS

Greater palatine artery


The descending palatine artery gives rise to the greater and lesser palatine arteries, which
pass through the greater and lesser palatine foramina , respectively, and supply the hard and
soft palates . In addition to the soft palate, the lesser palatine artery also helps supply the tonsils (along with the tonsillar artery, a branch of the facial artery). Note : The greater palatine
artery sends a branch to anastomose with the nasopalatine branch of the sphenopalatine
artery in the incisive foramen to supply the mucosa of the hard palate anterior to the maxillary
canine.
<,

Innervation of the soft tissue of the posterior two-thirds of the hard palate is derived from the
greater (anterior) palatine nerve. It emerges into the hard palate by way of the greater palatine
foramen and passes forward approximately halfway between the alveolar crest and the midline.
It supplies the soft tissues of the palate as far anteriorly as the canine tooth where it overlaps with
branches from the nasopalatine nerve. It is necessary to anesthetize the greater palatine nerve
if extractions or surgical procedures are contemplated in this area of the palate.
To anesthetize the greater (anterior) palatine nerve, you need to deposit local anesthetic at the
greater palatine foramen. The greater palatine foramen is situated between the second and
third maxillary molars about 1 cm from the palatal gingival margin toward the midline.
Note: The greater palatine nerve is a branch of the maxillary (e N V-2) nerve.

ORAL SURGERY/PAIN CONTROL

Anat

Which nerve listed below innervates the facial muscles with motor fibers, the lacrimal
gland and salivary glands with parasympathetic fibers, and the anterior tongue with
sensory fibers?

Trigeminal (CN V)
Vagus (CN X)
Facial (CN VII)
Glossopharyngeal (CN IX)

Copyright 2001 -

DENTAL DECKS

Facial (eN VII)


The facial nerve originates in the pons, travers es the facial canal of the tempora l bone, and exits
the cranium through the stylomasto id fora men. Not e: If you cut the facial nerve just after its exit
from the foramen, it would cause a loss of innervation to the muscles of facial express ion.
FUNCTIONS:
Motor Innerv ati on - muscles of facial expression, posteri or belly of digastric mu ~, the
stylohyoid muscle, and stapedius muscle within the middle ear. Note: Lower motor neuron
lesions of the facial nerve will cause an ipsilateral (same side) flaccid paralysis of the facial
musculature.
Sensory - proprioception innervation. Fro m the same muscles li sted for motor innerv ati on.
o
Motor - parasympathetic innervation. Secretion of tears from the lacrimal gland and salivation from the Sl,bljngyal and submandibylar glands
o Sensory - taste impulses (sweet sensation) from the taste buds on the anterior two-thirds of
the tongue, the floor of the mouth and the palate.
Cli nical inf orm ation:
1. Bell 's palsy - Facial paralysis, a functional disorder of the facial nerve, caused by nerve irritation or viral infection and is, therefore, usually temporary.
2. Faci al trauma - Trauma to the facial nerve destroys the ability to contract the facial muscles
on the affected side of the face and distorts taste perception. The affected side of the face
tends to sag since muscle tonus is lost.

ORAL SURGERY/PAIN CONTROL

Anat

All of the following statements conce rning the articular eminence are true except.

It is also called the articular tubercle


It is convex
It is a ridge that extends med iolaterally just in front of the mand ibular fossa
It is considered to be the non-funct ioning portion of the temporomandibular joint
It is lined with a thick layer of fibrous connective tissue (fibrocartilage)

Copyright 2001 -

DENTAL DECKS

It is considered to be the non-functioning portion of the temporomandibular


joint

---This is false ; it is considered to be the functional portion of the temporomandibular joint


Components of the TMJ:
1. Mandibular condyle (sometimes called the condyloid process of the mandible) : the
articulating surface or functioning part of the condyle is located on the superior and
anterior surfaces of the head of the condyle. Important: This surface is covered with
a vascular layer of fibrous connective tissue. hnt Pl~~'~
2. Articular fossa (also called the glenoid fossa): this fossa is actually the anterior 3/4
of the larger mandibular fossa, which is a depression in the temporal bone just
anterior to the auditory canal. Important: This part of the mandibular fossa is considered to be the non-functioning portion of the joint.
Articular eminence (also called the articular tubercle): is a ridge that extends
mediolaterally just in front of the mandibular fossa. Important: It is considered to
ith fibrocartila e.
be the functioning portion of the TMJ and is lin
3. Articular disc (also called the meniscus): is a biconcave fibrous. saddle-shaped
structure that separates the mandibular condyle from the temporal bone.

ORAL SURGERY/PAIN CONTROL


The internal jugular vein descends through the neck within the:

Arachnoid sheath
Carotid sheath
Spiral sheath
Dural sheath

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DENTAL DECKS

Anat

Carotid sheath
The facial vein unites with the retromandibular vein below the border of the mandible
and empties into the main venous structure of the neck, the internal jugular vein.
The internal [uqular vein descends through the neck within the carotid sheath and
unites behind the sternoclavicular joint with the subclavian vein to form the brachiocephalic vein. The brachiocephalic veins (right and left) unit in the superior mediastinum to form the superior vena cava , which returns blood to the right atrium of the
heart.
The carotid sheath is located at the lateral boundary of the retropharyngeal space at
the level of the oropharynx on each side of the neck deep to the sternocleidomastoid
muscle. It extends from the base of the skull to the first rib and sternum.
Remember: The carotid sheath encloses the carotid arteries, the internal jugular vein,
and the vagus nerve.

ORAL SURGERY/PAIN CONTROL

Anat

The pterygopalatine fossa communicates laterall y with the infratemporal fossa by


way of:

The sphenopalatine foramen


The pterygoid canal
The foramen rotundum
The petrotympanic fissure
The pterygomaxillary fissure

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DENTAL DECKS

The pterygomaxillary fissure The pterygopalatine fossa communicates medially with the nasal cavity through the
sphenopalatine foramen , posteriorly with the foramen lacerum through the pterygoid canal, superiorly with the skull through the foramen rotundum, and anteriorly
with the orbit through the inferior orbital fissure.
The pterygopalatine fossa is a small space behind and below the orbital cavity. It lies
between the pterygoid plates of the sphenoid and palatine bone below the apex of the
orbit.
Openings into the fossa: Pterygomaxillary fissure, inferior orbital fissure, sphenopalatine foramen, pterygoid canal, pharyngeal canal, and foramen rotundum.

lhe pte rygopalatine ganglion lies in the pterygopalatine fossa

jllS! belew the mmmlary nerve (Y-?) It receives preganglionic parasympathetic fibers from the facial
nerve by way of the reater petrosal nerve. It sends postganglionic parasympathetic fibers to the cnmal Ian n g an s In the palate and the nose.

Note: The maxillary nerve (V-2) and the maxillary artery pass through the pterygopalatine fossa.

ORAL SURGERY/PAIN CONTROL


In the head and neck, all the lymph ultimately drains into the:

Submental lymph nodes


Submandibular lymph nodes
Deep cervical lymph nodes
Retropharyngeal lymph nodes

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DENTAL DECKS

Anat

Deep cervical lymph nodes


The deep cerv ical lymph nodes form a chain along the course of the internal jugular vein, from
the skull to the root of the neck. These nodes receive lymph from neighboring structures and from
all the other regional lymph nodes in the head and neck. The efferent lymRh vessels join to form
the jugular lymph trunk. This vessel drains into either the thoracic duct or the right lymphatic

dUct.
Some regional groups of lymph nodes:
Parotid lymph nodes - receive lymph from a strip of scalp above the parotid salivary gland,
from the anterior wall of the external auditory meatus, and from the lateral parts of the eyelids
and middle ear. The efferent lymph vessels drain into the deep cervical lymph nodes.
Submandibular lymph nodes - receive lymph from the front of the scalp , the nose and adjacent cheek; the upper lip and lower lip (except the center part); the paranasal sinuses; the
maxillary and mandibular teeth (except the mandibular incisors); the anterior two-thirds of
the tongue (except the tip); the floor of the mouth and vestibule; and the gingiva. The efferent lymph vessels drain Into the deep cervical lymph nodes.
Submental lymph nodes - receive lymph from the tip of the tongue, the floor of the mouth
beneath the tip of the tongue, the mandibular incisor teeth and associated gingiva, the
center part of the lower lip, and the skin over the chin. The efferent lymph vessels drain into
the submandibular and deep cervical lymph nodes.

ORAL SURGERY/PAIN CONTROL

Anat

Which division of the trigeminal nerve listed below passes through the foramen ovale
and supplies motor innervation to the tensor veli palatini, tensor tympani, muscles
of mastication (temporalis, massete r, lateral and medial pterygoids), and the anterior
belly of digastric and mylohyoid muscles?

Ophthalmic division (V- 1)


Maxillary division (V-2)
Mandibular division (V-3)
None of the above

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DENTAL DECKS

Mandibular division (V-3)


The trigeminal nerve contains no parasympathetic component at its origin.
Sensory innervation of V-3:

Cheek
Mandibular buccal gingiva

} long buccal nerve (sensory only)

Jaw joint (TMJ)


Auricle
External auditory meatus

} auriculotemporal nerve (sensory only).

Floor of mouth
}
Mandibular lingual gingiva
lingual nerve (sensory only)
Anterior two-thirds of tongue
Mandibular teeth
Skin of chin and lower lip

} inferior alveolar nerve (mixed sensory and motor)

ORAL SURGERY/PAIN CONTROL

Anat

The facial nerve, the retromandibular vein, and the external carotid artery lie within which salivary gland listed below?
Submandibular gland
Parotid gland
Sublingual gland

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DENTAL DECKS

Parotid gland

~Iand.

The parotid gland is the largest of the salivary glands and is


The
parotids are located below and just anterior to the ear. They are diilieiritOdeep and superficiallobe s with the stylomandibular tunnel (which encloses the facial nerve) being the dividing
line. Therefore, a portion of the parotid lies superficial to the mandibular ramus, and another portion lies deep.
The parotid gland is drained by Stenson's duc t.. which pierces the buccinator muscle and
crosses the masseter muscle where it opens into the vestibule of the mouth opposite the maxIllary second molar.

The parotid gland receives it parasympathetic secretomotor innervation from the 91~SOPha
ryngeal nerve by way of the lesser petrosal nerve , the otic ganglion, and the auriculotemporal nerve (branch of V-3).

The external carotid artery and its terminal branches within the gland, namely the superficial
temporal and the maxillary arteries, supply the parotid gland. The Ivmphatic drainage of the
parotid gland is through the parotid nodes to the deep cervical lymph nodes.
Notes:
1. Mumps is a viral disease of the parotid gland. Parotitis is the inflammation of the parotid
gland.
2. Von Ebner 's glands are the only other adult salivary glands which are purely serous.

ORAL SURGERY/PAIN CONTROL


The nerve to the mylohyoid muscle is a branch of the:

Ophthalmic nerve (CN V-1)


Maxillary nerve (CN V-2)
Mandibular nerve (CN V-3)
Facial nerve (CN V/I)

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DENTAL DECKS

Anat

Mandibular nerve (eN V-3)


Function of mylohyoid - elevates hyoid bone, base of tongue, and floor of mouth. The sublingual
gland is located superior to the mylohyoid muscle.
MUSCLES OF THE ANTERIOR TRIANGLE
Muscle
Suprahyoid muscles (origin above hyoid bone)
Digastric muscle
Anterior belly
Posterior belly
Mylohyoid muscle
Geniohyoid muscle
Stylohyoid muscle
Infrahyoid musc les (origin below hyoid bone)
Omohyoid muscle
Stemohyoid muscle
Stemothyroid muscle
Thyrohyoid muscle

Nerve Innervation

CNV-3
CN VII
CN V3
Fibers of Cl carried via the hypoglossal nerve (e N XII)
CN VII

All are innervated by the ansa cervics tte, which


is a loop formed by branches from the
cerv ical plexus (C1 , C2. and C3)

Notes:
1. When plac ing the film for a periapica l view of the mandibular molars, it is the mylohyoid muscle
that gets in the way if it is not relaxed .
2. The sublingual gland is located superior to the mylohyoid muscle . When the floor of the mouth is
lowered surgically, the mylohyoid and genioglossus muscles are detached.

ORAL SURGERYIPAIN CONTROL


Wharton 's duct is associated with the:

Parotid gland
Subma ndibular gland
Sublingual gland
Von Ebner's glands

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DENTAL DECKS

Anal

Submandibular gland
The submandibular glands (sometimes called submaxillary glands) are located in the space (submandibular triangle) bounded by the two bellies of the digastric muscle and the angle of the mandible.
The submandibular duct (Wharton 's duct) passes forward along the side of the tongue, beneath the
mucousmembrane of the floor of the mouth. It is crossed by the lingual nerve and then lies between
the sublingual gland and the genioglossus muscle. It opens at the base of the frenulum of the
tongue.
Note: These large salivary glands are composed of a mixtyre of serous and mucous acini.
The submandibular glands are innervated by parasympathetic secretomotor fibers from the facial
M nerve, which run in the chorda tympani and in the lingual nerve (branch of V-3) and synapse in the
Of)' submandibular ganglion. Note: This Is the same as the sublingual glands. The blood supply
comes from the fac ial artery, which is a branch of the external carotid artery.
Important: During its course, Wharton's duct is closely related to the lingual nerve which eventually
crosses over it. This is important because if you incise the mucous membranes of the floor of the
mouth, depending on where you cut, you may expose the lingual nerve, Wharton's duct, and the sublingual gland.
Notes:
1. To expose the duct intraorally, only mucous membrane needs to be cut through.
2. The best technique for palpation of this gland is bimanual, simultaneous intraoral and extraoral
palpation.
3. Lymphadenopathy Is the most common cause of swelling of the tissues in the submandibular
triangle (not cysts , sialoliths , etc.).

ORAL SURGERYIPAIN CONTROL

Anat

Branches of which artery listed below supply the maxillary and mandibular teeth?

Vertebra l
Occipital
Maxillary
Subclavian

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DENTAL DECKS

Maxillary
Branches of the maxillary artery supply both dental arches. The maxillary teeth
are supplied by branches of Part 3 (Pterygopalatine part) as follows:
Posterior teeth (molars and premolars) from posterior and superior alveolar arteries.
Anterior teeth (canines and incisors) from anterior and middle superior alveolar
arteries.
The mandibular teeth are supplied by the inferior alveolar artery, which is a branch of
Part 1 (Mandibular part).
Note: The maxillary artery supplies the muscles of mastication, the maxillary and
mandibular teeth, the palate , and almost the entire nasal cavity.
Remember: The venous return of both dental arches is the pterygoid plexus of
veins.
The external carotid artery supplies most of the head and neck. except for the brain
(the brain gets its blood supply from the internal carotid and the vertebral arteries). The
external carotid passes through the parotid salivary gland and terminates as the maxillary and superficial temporal arteries. The superficial temporal artery supplies the
scalp ~1'Mr.

ORAL SURGERYIPAIN CONTROL

Anat

Which of the following arteries does not accompany the corresponding nerve throughout its course?

Infraorbital artery
Inferior alveolar artery
Lingual artery
Posterior superior alveolar artery

Copyright 2001 - DENTAL DECKS

Lingual artery
The lingual artery arises from the external carotid at the level of the greater horn of
the hyoid bone and passes deep to the hyoglossus muscle to supply the tongue.
Branches include:
Suprahyoid artery - supplies suprahyoid region
Dorsal lingual artery - remember dorsum of the tongue is the top part that can be
seen easily
Sublingual artery - supplies the floor of the mouth and sublingual gland
Deep lingual artery - supplies the anterior two-thirds of the tongue
The lingual artery supplies blood to the tongue, floor of the mouth, suprahyoid region,
sublingual gland, and palatine tonsils.
Important: The inferior alveolar nerve and artery along with the lingual nerve are
found in the pterygomandibular space between the medial pterygoid muscle and the
ramus of the mandible. The inferior alveolar nerve passes lateral to the sphenomandibular ligament.
Note: The lateral pterygoid muscle forms the roof of the pterygomandibular space.

ORAL SURGERY/PAIN CONTROL

Anat

Which nerve listed below is the largest of the 12 cranial nerves and is the principal
general sensory nerve to the head, particularly the face?

Vagus (CN X)
Glossopharyngeal (CN IX)
Facial (CN VII)
Trigeminal (CN V)

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DENTAL DECKS

Tri gem inal (e N V)


The trigeminal nerve originates from the brainstem at the inferior surface of the pons. It has two
roots (small motor and large sensory). The large sensory root expands to form the trigem inal
ganglion (also called the semilunar ganglion) that occupies the trigeminal impression on the
petrous portion of the temporal bone. It is from this ganglion that the three divisions (ophthalmic,
maxillary and mandibular) arise. These three divisions exit the skull through openings in the
sphenoid bone.
Note: The motor portion of the trigeminal nerve only travels with the mandibular division.
The cell bodies of the sensory neurons are found in the trigeminal ganglion.
There are different nuclei (mass of nerve cells) associated with the trigeminal nerve:
Mesencephalic - a nucleus from which fibers run laterally with the mandibular nerve to innervate the muscles of mastication. Cell bodies of proprioceptive fibers are located here.
Spinal - a nucleus that receives fibers which mediate pain and temperature for the head
and neck.
Note: If the trigeminal nerve is cut or damaged. there would be a complete loss of sensation
in the facial area on the same side ("ipsilateral"). There would also be difficulty in chewing and
speaking.

ORAL SURGERY/PAIN CONTROL

Anat

Which of the following teeth could be removed without pain after administration of an
inferior alveolar and lingual nerve block?

All anterior teeth on the side of the injection


Canine and first premolar on the side of the injection
All teeth in that quadrant on the side of the injection
Both premolars and first molar on the side of the injection

Copyright

2001 -

DENTAL DECKS

Canine and first premolar on the side of the injection

You need to give a long buccal injection in order to extract the molars and second
bicuspid. For operative procedures, a long buccal injection may not be needed for
these teeth.
Incisors may need local infiltration for extractions.
Note: An injection into the parotid gland (capsule) when attempting to administer an
inferior nerve block may cause a Bell's palsy facial expression (paralysis of the forehead muscles, the eyelid and of the upper and lower lips on the same side of the face
that the injection was given).
Remember: The bone of the maxilla is more porous than that of the mandible, therefore, it can be infiltrated anywhere. The onl y place where the mandible is porous is at
the incisive fossa.

ORAL SURGERY/PAIN CONTROL

Anat

The stylomandibular ligament of the TMJ is a band of cervical fascia that runs from
the styloid process of the spheno id bone to the:

Mandibu lar condyle


Ramus of the mandible
Angle of the mandible
Lingula of the mandible

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DENTAL DECKS

Angle of the mandible


of the mandible

*** Posterior border

There are 3 ligaments associated with the TMJ . These ligaments support and reinforce
the TMJ and are involved in complex jaw movements.
One
or ligame . The temporomandibular ligament (also called the lateralligament or cramomandibular ligament) runs from the articular eminence to the
mandibular condyle. It provides direct support to the capsule. This ligament prevents posterior and inferior displacement of the condyle.
Two accessory ligaments:
The stylomandibular ligament separates the infratemporal region anteriorly from
the parotid region behind. It runs from the styloid process of the sphenoid bone to
the angle of the mandible
The sphenomandibular ligament is attached to the spine of the sphenoid bone
and lingula on medial surface of the mandible .
The TMJ is protected by:
the muscles of mastication
synovial fluid

ligament suspens ion


durability of the fibrocartilage

ORAL SURGERY/PAIN CONTROL

Anat

Which salivary gland listed below is the smallest and contains both serous and
mucous acini?
Submandibular gland
Parotid gland
Sublingual gland

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DENTAL DECKS

Sublingual gland
The sublingual glands are located in the floor of the mouth beneath the tongue, close to the
midline. The mylohyoid muscle supports the individual sublingual glands inferiorly. They have
numerous small ducts (Rivian ducts) that open onto the floor of the mouth. Most of the secretory units are mucous secreting with serous demllunes.
~
The .Ubllngual gland is innervated by parasympathetic secretomotor fibers from the facial
nerve, which run in the...ctlo.rda tympaw and !Q. the lingual nerue (branch o f 11- 3,1 and synapse in
the submandibular ganglion. The blood supply comes from the sublingual artery, which is
a branch of the lingual artery (which is a branch of the external carotid).
Important:
Lymphatic drainage from both the sublingual and submandibular glands goes to the submandibular and the deep cervical lymph nodes.
Bartholin's ducts are two larger ducts associated with the sublingual gland that actually join
the submandibular duct.
Note:
1. Von Ebner 's glands are located around the circumvallate papilla of the tongue. Their main
function is to rinse the food away from the papilla after it has been tasted by the taste buds.
They are purely serous.
2. All of the major salivary glands are classified as compound tubuloalveolar glands. They
deliver their salivary secretions into the mouth by way of large excretory ducts.

ORAL SURGERY/PAIN CONTROL


Which two arteries listed below supply blood to the TMJ?

Facial artery
Lingual artery
Superficial temporal artery
Deep auricular artery

Copyright @ 2001 -

DENTAL DECKS

Anat

Superficial temporal artery


Deep auricular artery
"""The deep auricular artery is a branch of the maxillary artery.
""Both the superficial temporal artery and the maxillary artery are terminal branches of the external carotid artery.

I/J

The auriculotemporal nerve. which is a branch of the mandibular division of the


trigeminal nerve, provides the major sensory innervation to the posterior port ion of
the TMJ. Note: Pain is transmitted in the capsule and the periphery of the disc by the
auriculotemporal nerve.

1,/3

The nerve to the masseter (called the masseteric nerve), also a branch of the
mandibulardivision of the trigeminal nerve,carries a few sensory fibers to the anterior portion of the TMJ.
--

Remember: Muscles acting on the joint:


Masseter
Pterygoids (medial and lateral)
Temporalis
Digastric

ORAL SURGERYIPAIN CONTROL


Which artery listed below supplies the tongue?

Palatine artery
Inferior alveolar artery
Lingual artery
Vertebral artery

Copyright 2001 -

DENTAL DECKS

Anat

Lingual Artery
***'t also receives blood from the tonsillar branch of the facial artery and the -sscending pha~ngea l

artert:

The lingual artery arises from the external carotid artery at the level of the tip of the greater
horn of the hyoid bone in the carotid triangle. Branches include dorsal lingual artery, suprahyoid
artery, and sublingual artery (which supp lies sublingual gland). It terminates as the deep lingual
artery, which ascends between the genioglossus and inferior longitudinal muscles. Note: The
floor of the mouth also receives its blood supply from the lingual artery.
Remember (very important information about the tongue):
Motor innervation is from the hypoglossal nerve (eN XII).
Sensory Innervat ion - lingual (branch of trigeminal eN V-3) supplies the anterior two-thirds,
glossopharyngeal (CN IX) supplies the posterior one-third (including vallate pap illae), vagus
(CN X) through the internal laryngeal nerve supplies the area near the epiglottis. Note :
Besides the posterior 1/3 of the tongue the glossopharyngeal nerve also supplies sensory
innervation to the tonsil, nasopharynx and pharynx areas.
Taste - facial (CN VII) via chorda tympani supplies the anterior two-thirds; glossopharyngeal (CN IX) supplies the posterior one-third.

ORAL SURGERY/PAIN CONTROL

Anat

Which of the following statements concerning the hypoglossal nerve (eN XII) are
t rue?
It is a mot or nerve supplying all of the intri nsic and extrins ic muscles of the
tongue, except the palatoglossus, which is supplied by the vagus nerve
It leaves the skull through the hypoglossal canal medial to the carotid canal and
jugular foramen
It passes above the hyoid bone on the lateral surface of the hyoglossus muscle
deep to the mylohyoid muscle
It loops around the occipital artery and passes between the external carotid artery
and internal jugular vein
In the upper part of its course, it is joined by C1 fibers from the cervical plexus
All of the above statements are true concerning the hypoglossal nerve

Copyright 2001 -

DENTAL DECKS

All of the above statements are true concerning the hypoglossal nerve
Lesions of the hypoglossal nerve:
Unilateral lesions of the hypoglossal nerve result in the deviation of the protruded
tongue towards the affected side. This is due to the lack of function of the
genioglossus muscle on the diseased side.
Injury of the hypoglossal nerve eventually produces paralysis and atrophy of the
tongue on the affected side with the tongue deviated to the affected side.
Dysarthria (inability to articulate) may also be found.
Important: If the genioglossus muscle is paralyzed, the tongue has a tendency to
fall back and obstruct the oropharyngeal airway with risk of suffocation.

ORAL SURGERY/PAIN CONTROL


Whic h paranasal sinuses are the largest?

Frontal
Ethmoidal
Maxillary
Spheno idal

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DENTAL DECKS

Anat

Maxillary
Located within the frontal, ethmoid, maxillary, and sphenoid bones are a series of
mucous membrane-lined air spaces called the paranasal sinuses. The sinuses lighten the skull and enhance the resonance of the voice.
Clinical signs of acute maxillary sinusitis:
Severe pain . constant and localized
Tenderness to percussion of the maxillary posterior teeth
A mucopurulent exudate
Any unusual motion or jarring accentuates the pain
Tenderness over the anterior sinus wall
Antibiotics used to treat sinus infections:
8mp jci!!l!J - for sinusitis due to upper respiratory infections
Penicillin - for sinusitis caused by odontogenic foci
Amoxicillin - for sinusitis caused by odontogenic foci
Note: The maxillary sinus is innervated by the maxillary division of the trigeminal nerve
(eN V-2).

ORAL SURGERY/PAIN CONTROL

Anat

The TMJ is the articulation between the condyle of the mandible and the squamous
portion of the:

Spheno id bone
Temporal bone
Ethmoid bone
Zygomatic bone

Copyright 2001 :- DENTA L DECKS

Temporal bone
Each condyle is elliptically shaped (they are not symmetrical nor identical) with their
long axis oriented mediolaterally. The articular surface of the temporal bone is composed of the concave articular fossa (also called the glenoid fossa or mandibular
fossa) and the convex articular eminence (or tubercle). Note: This area is the functional and articular portion of the TMJ and is covered by fibrocartilage.
The articular disc (or meniscus) is a fibrous. saddle shaped structure that separates
the condyle and the temporal bone. The disc varies in thickness: the thinner, central
intermediate zone separates thicker portions called the anterior band and posterior
band. Posteriorly, the disc is contiguous with the posterior attachment tissues called
the bilaminar zone. The bilaminar zone is a vascular. innervated tissue that plays an
important role in allowing the condyle to move forward.
The disc and its attachments divide the TMJ into superior and inferior spaces.

ORAL SURGERY/PAIN CONTROL

Anat

Which nerve below supplies motor function to the buccinator muscle?

Trigem inal nerve (CN V)


Facial nerve (CN VII) .
Vagus nerve (CN X)
Glossopharyngeal nerve (CN IX)

Copyright 2001 -

DENTAL DECKS

Facial nerve (e N VII)


Buccinator muscle - originates from three areas:
1. Pterygomandibular raphe is a thin, fibrous brand or tendon running from the hamulus of the medial pterygoid plate down to the mandible. It lies between the buccinator and superior constrictor muscles.
2. Maxillary alveolar process
3. Mandibular alveolar process
***The buccinator muscle inserts at orbicularis oris and skin at the angle of mouth.
Notes:
1. The facial and maxillary arteries supply blood to the buccinator muscle.
2. The action of the buccinator muscle is to compress the cheeks against molar
teeth; sucking and blowing.
3. When draining purulent exudate from an abscess of the pterygomandibular
space from an intraoral approach, the buccinator muscle is most likely to be
incised.

ORAL SURGERY/PAIN CONTROL

Anat

A posterior superior alveolar nerve block (tuberosity injection) will provide anesthesia
for:

The
The
The
The

second and third molars along with the mucoperiosteum of the palate
first and second molars along with the mucoperiosteum of the palate
first, second, and third molars but not the mucoperiosteum of the palate
first, second, and third molars along with the mucoperiosteum of the palate

Copyright 2001 -

DENTAL DECKS

The first, second, and third molars but not the mucoperiosteum of the palate
***For extraction of any or all of the three molar teeth, a greater palatine injection
should be given to anesthetize the mucoperiosteum of the palate
The PSA injection (tuberosity injection) does not always anesthetize all of the roots
of the maxillary first molar tooth. Therefore, if anesthesia of this tooth for either
restorative dentistry or extraction is required, an infiltration injection also should be performed over the second premolar tooth.
Note: Patients experience few subjective signs of anesthesia after receiving a posterior superior alveolar nerve block, as compared to an inferior alveolar nerve block
(numb lip).
Important: If a patient's face becomes distended and swollen after a posterior superior alveolar nerve block, the following treatment is recommended:
Place cold packs and pressure on the affected side
Explain to the patient that he/she may become black and blue on that side
***This is caused by an intravascular injection.

ORAL SURGERY/PAIN CONTROL


The maxillary first molar is innervated by the:

Anterior superior alveolar and middle superior alveolar nerves


Middle superior alveolar and posterior supe rior alveola r nerves
Posterior superior alveolar and inferior alveolar nerves
Midd le superior alveolar and palatine nerves

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DENTAL DECKS

Anat

Middle superior alveolar and posterior superior alveolar nerves


The PSA innervates the distobuccal root of the first molar and distal to it (second
molar and third molar).
The MSA innervates the mesiobuccal root of the first molar and the two bicuspids.
The ASA (anterior superior alveolar nerve) innervates the canine and incisors.
Remember: In order to extract the maxillary first molar, you must numb both the PSA
and MSA nerves as well as the greater (anterior) palatine nerve for palatal anesthesia
(soft tissue).

ORAL SURGERY/PAIN CONTROL

Anat

Which cran ial nerve listed below prov ides motor innervation that allows for movement
of the mandible?

Trigeminal (CN V)
Olfactory (CN I)
Facial (CN VII)
Vagus (CN X)

Copyright @ 2001 -

DENTAL DECKS

Trigeminal
SUMMARY OF CRANIAL NERVES
Nerve
I Olfactory nerve
II Optic nerve
III Oculomotor nerve
IV Trochlear nerve
V Trigeminal nerve
VI Abducens nerve
VII Facial nerve
VIII Vestibulocochlear nerve
IX Glossopharyngeal nerve
X Vagus nerve
XI Accessory nerve
XI I Hypoglossal nerve

Type: Function
Sensory: smell
Sensory: sight
Motor: movement of eyeball, focusing. and change in pupil size
Motor: movement of eyeball
Motor movement of jaw
Sensory: sensations from face, teeth , and tongue
Motor: movement of eyeball
Motor: movement of facial muscles. secretion of saliva and tears
Sensory: taste
Sensory: hearing , balance, and posture
Motor: swallowing and secretion of saliva
Motor: visceral muscle movement
Sensory: visceral sensations
Motor: swallowing and head and neck movements
Motor: speechand swallowing

Important: Cranial nerves III tocutomoton, VII (fa cia~ , IX (glossopharyngea~ . and X (vagus) all
have parasympathetic activity.

ORAL SURGERY/PAIN CONTROL

Adren Cart

Which of the following is a metabolic disorder caused by a chronic excess of glucocortlcolds?

Cushing's syndrome
Addison 's disease
Cretinism
Grave's disease

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DENTAL DECKS

Cushing's Syndrome
Four Causes:
1. Iatrogenic - caused by chronic therapeutic use of steroids in high doses.
2. Abnormal production of ACTH by the pituitary 2..
3. Abnorma l production of cortisol by the adrenals,' usually caused by an adrenal
tumor (this is the most common cause of Cushing 's Syndrome).
4. Certain non-pituitary neoplasms can produce ACTH (cortisol is normally produced
in response to ACTH, therefore excess cortisol is produced).
Characteristics of the patient with Cushing 's Syndrome:
Decreased glucose tolerance
Supraclavicular fat pads or " Buff alo hump"
Central obesity or "truncal obesity "
Round "moon" face
Muscular atrophy
Poor wound healing; minor infections may become systemic and long-lasting
The skin may be abnormally pigmented and fragile
Important: The patient's cardiovascular status must be evaluated and treated if necessary prior to surgery.

ORAL SURGERY/PAIN CONTROL

Adren Cort

A 52-year-old woman requests removal of a painful mandibular second molar. She tells
you that she has not rested for two days and nights because of the pain. Her medical
history is unremarkable, except that she takes 20 mg of Prednisone daily for erythema multiforme. How do you treat this patient?
Have patient discontinue the Prednisone for two days prior to the extraction
Give steroid supplementation and remove the tooth with local anesthesia and
sedation
Instruct the patient to take 3 grams of amoxicillin one hour prior to extraction
No special treatment is necessary prior to extraction

Copyright 2001 -

DENTAL DECKS

Give steroid supplementation and remove the tooth with local anesthesia and
sedation
Note: The fear here is that the patient may not have sufficient adrenal cortex secretion
(adrenal insufficiency) to withstand the stress of an extraction without taking additional
steroids. (This holds true for any patient who has been treated for any disease with
steroid therapy.)
Prednisone is a glucocorticoid prescribed as an anti-inflammatory agent.
Remember: Erythema multiforme is a hypersensitivity syndrome characterized by
polymorphous eruption of skin and mucous membranes. Macules, papules , nodules,
vesicles, or bullae and target ("bull's-eye-shaped'? lesions are seen. A severe form of
this condition is known as Stevens-Johnson syndrome. These patients may be
receiving moderate doses of systemic corticosteroids and therefore may be unable to
withstand the stress of an extraction. Consultation with their physician is absolutely
necessary before treating these patients.

Adren Cort

ORAL SURGERY/PAIN CONTROL


A person who has been on suppressive doses of steroids will:

Never regain full adrenal cortical tunctlon .


Take as much as a year to regain full adrenal cortical function
Take as little as a week to regain full adrenal cortical function
Take usually a couple of days to regain full adrenal cortical function

CopyrIght 2001 -

DENTAL DECKS

Take as much as a year to regain full adrenal cortical function


The following guidelines may help determine if a patient's adrenal function is suppressed , however , if any doubt exists, consult the patient's physician before performing surgery.
People on small doses (5 rng Predisone/day) will have suppress ion when they have
been on the regimen for a month.
People taking equivalence of 100 mg cortisol/day (20-30 rna Predn;son e/dCij() will
have abnormal cortical function in a ~
Short-term therapy (1-3 days) of even high dose steroids will not alter adrenal cortical function.
A person who has been on su
ssive doses of steroids will take as much as a
year to regain full adrenal cortical function.

Remember: Stress or fatigue may cause an adrenal crisis in a patient that has suppressed adrenal function.

ORAL SURGERYIPAIN CONTROL


How much hydrocortisone is secreted by the adrenal cortex da ily?

About
About
About
About

1 mg
100 mg
20 mg
200 mg

Copyright

2001 -

DENTAL DECKS

Adren Cort

About 20 mg
During stress the cortex can increase the output to 200 mg daily.
Remember: Patients taking steroids or people with disease of the adrenals will have
decreased abjlit to produce more glucocorticoids (hydrocortisone) in times of stress
(extractions). The reason for this is as follows: Secretion of glucocort icoids is stimulated by ACTH, a hormone produced in the anterior pituitary. The pituitary responds to
stress by increasing ACTH output and therefore glucocort icoid production increases.
A relative lack of glucocorticoids will also increase output of ACTH. An overabundance
of circulating systemic steroids will inhibit production of ACTH. Patients on large doses
of steroids repress ACTH production which leads to atrophy of adrenal cortex.

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