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Specialty recognized ADA Involves diagnosis & Rx of injuries,diseases & malformation of the mouth and jaws.
Minor oral surgery includes: Exodontia (extractions) Rx dental infection (incision & drainage) Biopsy of hard & soft tissue lesions Alveoloplasty (trimming of ridge, removal of tori)
SCOPE of OMS
Major OMS: Hospital procedures which include: Rx Fractures Pre-prosthetic: tuberosity reduction, implants, vestibuloplasty (extending vestibule) Re-constructive surgery: orthognatic, facial deformities. Administer general anesthesia
D. Body fluid & electrolytes: physiology of water balance, urinary out put, shifting between various fluid and electrolyte compartments like Cell &Tissues
EVALUATION OF PATIENT
A. General 1. History: Reviewed verbally with patient Drug allergies (penicillin) Chief complaint + History of Present Illness (symptoms & duration, what exacerbates pain, history of similar episodes)
2. Extra & intra oral exam
EVALUATION OF PATIENT
3. Diagnostic Aids: X-rays Photos before/after Sialographs Biopsy Diagnostic nerve blocks Transillumination (sinuses, nose) Lab tests (CBC) Bacterial stains (Gram stain +/- ) KOH fungi Viral Ab studies
EVALUATION OF PATIENT
4. Hospitalization: Considerations: Medically compromised: un-controlled diabetes, hemophilia, HBP, MI, CVA)
Difficulty & Extent of Procedure Special patients: emotionally disturbed, physically handicapped. Cost: base room rate, OR fee, anesthesia, Lab tests, consultant fees
EVALUATION OF PATIENT
Hospitalization (cont) Dental Emergency Infection: Increase temperature (> 101 F) Increased sweating dehydration Decreased BP, cold, pale IV therapy Increased WBC count (.> 20,000) Compromised airway No response to oral antibiotics
EVALUATION OF PATIENT
Hospitalization (cont) Dental Emergency: Bleeding: Uncontrolled (hemangioma,
hemophilia) Monitor: Pulse Blood pressure Hematocrit (HCT) Hemoglobin (Hb) Patients orientation.
ADMISSION ORDERS
1. General & Nursing Orders: Diagnosis Patients condition Allergies Diet Activity (bed rest) Specific problems
ADMISSIONS ORDERS
2. Laboratory Tests: Hematocrit, Hemaglobin, CBC Urine analysis Chest x-ray (general anesthesia) E. K. G. (Electro-cardio-gram) Blood glucose level Prothrombin Time (PT-liver function, clotting) Partial Thromboplastin Time (PTT), platelet count.
ADMISSIONS ORDERS
Lab tests (con): ESR (erythrocyte sedimentation rate-infection) Vital signs: pulse, respiration rate, BP, Temperature
Chem-12 or S.M.A.-12: includes liver function tests, albumin, total protein, calcium, phosphorous, alkaline phosphatase, serum cholesterol.
PRINCIPLES of OMS
A.
TISSUE HANDLING: 1. Use of Flaps: Access to & visibility of deep structures Bone removal Prevent soft tissue damage
2. Types of Incisons: Linearenvelope(no vertical component) Releasing (vertical component) Semi-lunar
PRINCIPLES of OMS
3. Flap Design:
Blood supply not compromised: wide base, no acute angles Size & thickness: big & mobile enough Full thickness mucoperiosteal flap for dentoalveolar surgery Soft tissue surgery: mucosal incision then dissection in layers identifying vital structures
PRINCIPLES of OMS
4. Re-positioning of Flap: Incision clean, sharp, perpendicular to wound
Flap margins over solid bone
PRINCIPLES of OMS
5. Principles in Working with Bone: Use burs, chisels, rongeurs, files Complicated by: sharp edges exposed bone (pain, delayed healing) Devitalzation of bone necrosis Infection necrosis
PRINCIPLES of OMS
B. Aseptic Technique: Prevent pathogenic extra oral bacteria from getting into wound
Sterilization of instruments Thorough hand washing Patients face washed and draped.
PRINCIPLES of OMS
C. Wound Care: Mechanically remove calculus & dead tissue Irrigation to wash away bone chips & debrs
Elimination of dead space prevented by: Closing wound inlayers Pressure bandages Draining hematomas
BIOPSY TECHNIQUE
INDICATIONS: Confirm clinical diagnosis Distinguish benign from malignant An ulcer that persists for more than 2 weeks in spite of removal of local irritant factors MUST be examined histologically
Persistent white lesions biopsied and diagnosed as Hyperkeratosis MUST be followed closely and biopsied if changes occur.
BIOPSY TECHNIQUE
INDICATIONS (cont): To establish type of treatment (in the hospital all tissues remove teeth etc are sent for gross and histologic description)
Where or How to Biopsy: Small (< I cm) benign appearing = Excision Vesiculo-bulluous lesions = Incision (Michel solution)
BIOPSY TECHNIQUE
Where & How to Biopsy (cont): Large ulcers or White lesions Sample normal into abnormal areas Sample several areas if large lesion Sample must extend into connective tissue Pigmented lesions MUST ALL be excised with wide margins
BIOPSY TECHNIQUE
Where & How to Biopsy (cont) Intra bony Lesions: If compressible, pulsate, blue or bruit heard BEWARE of vascular lesion. Biopsy in hospital.
Aspirate all radiolucent lesions first. Cystic lesions: biopsy benign areas also Encapsulated lesions = shelled (enucluated) out as a whole
BIOPSY TECHNIQUE
Where & How to Biopsy (cont): Punch biopsy = skin (small & difficult to orient for sectioning)
Tissue Handling & Instrumentation: No tweezers or hemostats to grasp lesion Anesthesia = Do not inject into lesion Fixative = 10% formalin immediately
BIOPSY TECHNIQUE
Tissue Orientation: The pathologist need to cut the lesion perpendicular to the surface to see progression of the disease process. Thin biopsies should be placed connective tissue side down on a piece of thick paper before placing into fixative. The pathologist need know margins (up, down front, back etc); to see if lesion extends to the edge of what margin.
BIOPSY TECHNIQUE
Pathology Request Form: Patients name, age, sex, ethnic background Lesions size, shape, color, location, duration, texture, symptoms Differential Diagnosis (Three)
FRACTURES
Classification (4 types) 1. Simple: (Closed) Divided bone into two parts, no external communication thru skin or mucosa
2. Compound: (Closed) (Mostly children) Incomplete, may extent thru cortical plate.
FRACTURES
Classification (cont) Compound: Communicate with outside of skin/mucosa Exposed fragments
Comminuted: Multiple fractures of a single bone Simple or compound
MAXILLARY FRACTURES
La Fort 1: Simplest Horizontal Maxillary alveolus containing dentition separated from upper face
Segment pushed backwards & downwards X-ray show fracture thru maxillary sinus Rx: closed reduction, immobilze 5 7 wks
MAXILLARY FRACTURES
Le Fort type 1
MAXILLARY FRACTURES
La Fort 11 Fracture (pyramidal fracture): Alveolar fracture + across bridge of nose Fracture near Lacrimal sac, along Infraorbital ridge, exits around Infraorbital foramen to wall of sinus and underneath Zygomatic process, then to up Pterygoid plates.
Clinical: periorbital edema + ecchymosis, subconjuntival hemorrhage, epistaexis. Rx: intermaxillary fixation
MAXILLARY FRACTURES
Le Fort type 11
MAXILLARY FRACTURE
La Fort 111 Thru Zygomatic arch Down lateral orbital wall To Inferior orbital fissure Along Medial wall of orbit Over Bridge of nose Thru Pterygmaxillary fissure Craniofacial disarticulation Clinical: Epistaxis
MAXILLARY FRACTURE
POST-OP COMPLICATIONS
HEMORRHAGE: Mostly due to poor clot formation (use tea bag + pressure) Remove large exophytic jelly-like clots Use local anesthesia with epinephrine to control bleeding to facilitate exam
Suture to control bleeding If bleeding continues take to Emergency Room for Blood Tests
POST-OP COMPLICATIONS
PAIN: DRY SOCKET (most common) Loss of clot + inflammation of bone 3rd mandibular molar area most common Pain radiated to ear on ipsilateral (same side) Goals of Rx: Clear out local irritants(food) Apply topical analgesic Prevent irritants from getting in socket
POST-OP COMPLICATIONS
PAIN (cont) Rx Dry Socket: Do not currette out socket Irrigate socket with saline Place sedative dressing in socket Bacteriostatic agent: iodine, bacitracin Analgesic: benzocaine, eugenol Change dressing every 24 48 hrs
POST-OP COMPLICATIONS
PAIN (cont)
SEQUESTRUM: Fragment of tooth or non-vital bone in wound. Rx: X-ray and surgical removal with LA
POST-OP COMPLICATIONS
SWELLING: (due to infection) Mild infection suppuration (no fever) Infection facial planes cellulitis or pus Infection buccal, lateral pharyngeal, pterygoid, peri-tonsllar, sublingual, submandibular spaces Rx: Drainage Antibiotics (culture & sensitivity test), systemic support fluids)
POST-OP COMPLICATIONS
FEVER: Infectious or non-infectious etiology Mild temperature elevation = fluid loss or altered metabolism
Post oral surgery mild elevation of temperature due to transient bacteremia (12 24 hrs) High fever (> 99.8 F) for more than 48 hrs need aggressive Rx.
PAIN CONTROL
DIAGNOSIS & HISTORY: Ask if pain is: Superficial or deep Constant or intermittent What relieves and exacerbates pain Is it sharp, dull, burning Unilateral or bilateral
PAIN CONTROL
If patient describes pain in a bizarre manner it feels like bugs are crawling up my face arm, think of psychogenic origin.
Psychotic pain mostly occurs in head & neck Iatrogenic pain = cause by HCW Be patient, interested Listen carefully Look for simple causes first Do meticulous Extra & intra oral exam
PAIN CONTROL
SOMATIC PAIN: Caused by noxious stimulus (exogenous, endogenous or spontaneous (no apparent cause) Warning sign of physical injury
Peripheral stimuli interpreted in subcortical & cortical areas of brain. Transmitted by pain conducting fibers when heat, cold, proprioceptive fibers are extremely stimulated.
PAIN CONTROL
Methods of Controlling Somatic Pain: Block conduction local anesthetic Eliminate noxious stimuli Analgesic drugs Sedative & consciousness altering drugs General anesthesia Hypnosis & Acupuncture Beliefs (cultural, religious etc)
PAIN CONTROL
PSYCHOGENIC (PSYCHOSOMATIC) PAIN: Cortical & subcortical areas in the absence of peripheral impulses produce the interpretation of pain Patient is calm, smiling, facial expression free of distress. Burning sensation & depression go together. Rx: Psychiatric consultation Establish good relationship and treat dental needs.
PHYSIOLOGY OF PAIN
Stimuli neural signals nervous system Nervous system influenced by past experiences, culture, anxiety etc These brain processes participate in the selection, abstraction & synthesis of information of total sensory input. Action potential begins in pain receptors
Free endings covered by Schwann cell sheath (no capsule) located in deep epithelium & lamina propria
PHYSIOLOGY OF PAIN
Distribution of Receptors: Skin (MOST) Mucous membrane Periodontium Periosteum Arteries Ligaments
Tendons Facia Veins CT of muscle (Least)
PHYSIOLOGY OF PAIN
Coded pattern of nerve impulses Anterior-lateral Spinal cord Thalamus (spinothalmic tracts) Reticular formation (lower Brain)
Different speeds & frequencies High threshold receptors = small diameter fibers (A-delta & C) Low threshold receptors = large diameter fibers (A-beta & C-fibers)
PHYSIOLOGY OF PAIN
Means for Transmitting Signals Spatial summation: stimulation of many fibers in a nerve trunk simultaneously rather than of a single fiber intensified effect.
Temporal summation: # of impulses along a single fiber (10, 30, 100). Stronger the impulse the greater number of fibers involved & greater rate of impulse transmission by each fiber.
PERICORONITIS
Mostly associated with mandibular 3rd molar. Acute infection around crown of tooth with suppuration around pericoronal flap (operculum) Rx: Irrrigate under flap Rx antibiotics (Penicillin or Clindamycin) Operculectomy If not treated infection can spread thru facial planes of face & neck trismus, pain, elevated temperature
ANESTHESIA
MAXILLARY: Ant, Mid, Post SAN All Teeth + Bu gingiva Post SAN D B roots 1st, 2nd, 3rd Molars Mid SAN M-B root 1st molar + PMs Ant SAN Incisors + Canine
Nasopalatine N soft tissue palatal to incisor + canine Greater Palatine N soft tissue palatal & distal to canine
ANESTHESIA
MANDIBULAR: Inf Alveolar N pulp of all teeth + Bu gingiva & periosteum anterior to 1st molar
Long Buccal N 1st, 2nd, 3rd Molar + Bu gingiva & periosteum Lingual N gingiva + muco-periosteum lingual of mandibular teeth
LOCAL ANESTHETICS
ESTERS OF BENZOIC ACID: Procaine (Novocaine) AMIDES: Xylocaine (Lidocaine) 2% + Epinephine 1:100,000 Carbocaine (Mepivicaine) 3% (NO epinephrine)
Topical Anesthesia: 2% xylocaine ointment Ethyl chloride (cold spray)
CHARACTERISTICS OF LA
Highest Concentration Needed for: Motor nerves fibers Pain fibers Autonomic fibers
LA Results in Order of Loss of Function: Pain (unmylinated) Proprioception Temperature Muscle tone (myelinated) Touch
MODE OF ACTION OF LA
LOCAL ANESTHETICS: Lipid soluble + weak organic bases Converted to water soluble acid salts Dissolved in water for injection Non-ionized free base penetrates nerve membrane Cationic form required for anesthetic activity within cell
Mode of Action of LA
Potency increases with increased lipid solubility
Cationic form available in injection capsule Cationic form changes to free base on injection into alkaline buffers in tissue Free base enters cell reconverted to cationic form blocks Na channel
MODE OF ACTION OF LA
Tissue pH should be slightly alkaline to hydrolyze free base from water soluble salt form Acidc pH (infection) ionic form poor anesthesia
LA stabilize nerve membrane elevated membrane threshold no depolarization Na channels do not open, Na will not enter
axon
ACTION OF LA
Depress action of nerves, smooth, cardiac & skeletal muscles
Initial effect on Brain stimulation (then depression) Factors that Decrease effectiveness of LA: Too high/low tissue pH (infection) Excessive dilution by blood (hematoma) Too rapid absorption in tissue fluid
ACTION OF LA
Concentration of LA = 6x greater than that needed to affect CNS
Smallest amount necessary should be used Aspiration extremely important Toxicity of LA results in respiratory arrest before cardiac arrest
Pre-op Medication
Tranquillizer(Valium) Psycho-sedative(Librium) Both produce no hang over (barbiturates do) Both are muscle relaxants + anti-convulant Both no analgesic property Both show little depression of respiration or heart Amnesia = IV Valium (not in 1st trimester) Barbiturates relieve anxiety Demerol (narcotic) drowsiness + euphoria + elevated pain threshold (Lorfan, Nalline antagonist)
MECHANISM OF EXTRACTION
3. Types of Elevators Straight: most commonly used Crane pic: off set blade placed in purchase point & furcation and used as a lever.
Root elevators (right & left): blades off set to reach into back of socket. Cryer elevators (EastWest): (right & left): triangular pointed blades, used primarily on lower molar roots.
MECHANISM OF EXTRACTION
4. Procedures in Minor Exodontia A. Use opposite hand to: 1. Retract soft tissues for visibility & protection
2. Help guide beaks of forceps into position 3. Stabilize jaws & apply counter pressure to take stress of neck & jaw muscles
EXTRACTION FORCES
MAXILLA Anteriors
1st PM
2nd PM
Buccal + Palatal + Rotation Molars Buccal + Palatal (N.B. Palatal delivery for deciduous molars)
EXTRACTION FORCES
MANDIBLE Incisors LUXATION Labial + Lingual + Rotation
Labial +Lingual + Rotation Buccal + Lingual + Rotation Buccal + Lingual
Cuspid
Premolars Molars