UNIVERSITY OF MICHIGAN SCHOOL OF DENTISTRY

ORAL & MAXILLOFACIAL SURGERY/HOSPITAL DENTISTRY

UNDERGRADUATE CLINICAL MANUAL

2003/2004

Department of Oral and Maxillofacial SurgeryFaculty and Staff Directory

Chairman of Oral MaxillofacialSurgery/Hospital Dentistry &Chair and Section Head of Oral Maxillofacial Surgery: Dr. J. Helman

Associate Chair of Research: Dr. S. Feinberg

Associate Chair of Education: Dr. L.G. Upton

Clinic Director Dr. K. Cottrell

Section Head of Hospital Dentistry: Dr. S. ZwetchkenbaumDirector GPR Program

Oral Maxillofacial Surgery Dr. D. Aldrich Dr. D. Fear Dr J. Persico

Part Time Faculty: Dr. N. Betts Dr. A. Grady Dr. K. PullenDr. R. Burke Dr. R. Hitchcock Dr C. RadeckiDr. G. Ebmeyer Dr. S. Mintz Dr. A. WeissDr. J. Faber Dr. T. Osborn

Maxillofacial Resident Surgeons: Dr. S. Edwards, Chief ResidentDr. P. Brain, Chief ResidentDr. R. Pfeifle, Chief Resident

Dr. J. Wasielewski Dr. S. Edlund Dr. M. Weideman

Dr. J. Collins Dr. J. Campbell Dr. R. Chang Dr. T. LeyshonDr. E. Leung Dr. E. Smith

Lecturer: Dr. B. Dingman Receptionists: Judy Boughton/

Surgical Care Staff: Malines Brookes C.D.A. Traci Cooper C.D.A.

Surgical Nurse: Darlene Slaughter R.N.

Address: Oral & Maxillofacial Surgery Clinic University of Michigan School of Dentistry 1011 N. University Drive Ann Arbor, MI 48109-1078

Telephone: (734) 764-1568Fax: (734) 615-8399

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D-3 Course Section

The Oral & Maxillofacial Surgery course # 720 curriculum is mostly clinical in nature. The students are to gain exposure to clinical procedures utilizing principles learned in the scope of the Introduction to Oral & Maxillofacial Surgery course # 613. The course will consist of clinical sessions and seminars for selected topic presentations. The final grade will reflect the student’s clinical and didactic performance evaluations.

Evaluations and grade assignments

Final Grade components

Didactic performance will be based upon attendance (includes punctuality, appropriate dress.) Only excused absences will be permitted, missed clinical sessions must be made up; attitude (includes professionalism, maturity, integrity); final examination and daily quiz material will either be given to you or made available for you to copy in the library loan section here at the Dental School Library. Clinical performance will contribute the remainder of the final grade and will be judged on the following criteria:

Preoperative Patient Assessment:

3-Outstanding

Patient’s medical history was thorough and analyzed with clear interpretation of risks, complicating factors and need for treatment modifications in provision of surgical care including need for medical consultations. The student was aware of all current medications, their effects on patient’s physiology and intended therapy and demonstrated exceptional database of medical and surgical knowledge. All examination findings were noted, including relative duration, size, location and appearance. The vitals and clinical findings were accurately assessed and interpreted and the students developed appropriate classifications of patients overall ability to tolerate proposed procedures. The process has to be well structured and time efficient. There will be a limited number of these grades assigned, as it will denote a truly exceptional performance.

2-Satisfactory

Patient’s medical history was complete but not all potential influences on the proposed treatment modality were pondered hence lacking treatment modifications required to limit morbidity and undue stress on the patient. A complete list of medications was established but their mode of activity or some of the most significant effects relative to the proposed oral surgical treatment were not fully identified. Vital signs were appropriately recorded but the student may have failed to precisely interpret the values and classify the patient’s ability to tolerate the procedure. Structure of the assessment was appropriate and accomplished in a timely manner. Most students are expected to attain this grade.

1-Marginal

Patient’s medical history was partially incomplete and failed to contain detail of past disease processes, current medication or the student did not relate significance of major health problems relative to proposed procedure and or feel need to alter treatment to accommodate patients medical status. Vital signs and physical examination were lacking in depth and accuracy and student did not demonstrate adequate grasp of patients overall health status. The time spent on obtaining the assessment was excessive and unbalanced by lack of findings or depth of inquiries. Student failed to adhere to the desired format of presentation. Only a few instances of marginal performance will be expected to occur within the class and any pattern of recurrence in the same individual will be monitored and require additional extra-curricular work from the individual to ensure satisfactory performance.

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0-Unacceptable

Patient’s medical assessment lacked depth in areas of patient’s health such that potential for iatrogenic injury to the patient or clinic personnel occurred or was possible. The student failed to obtain vital signs prior to presenting the patient, commenced active treatment (pharmacological or surgical prior to obtaining a signed clearance from faculty), lacked organizational skills to complete work up in a reasonable period of time and presented case with inadequate radiological surveys lack of proper records and prior consultation data. Student was late for scheduled appointment or did not arrange for assistant prior to the time of the appointment. It is hoped that no student will show such lack of preparedness as to indicate the assignment of this grade.

Infection control Asepsis

3-Outstanding

The student demonstrated strict aseptic surgical skills and surgery protocols. A corresponding exceptional knowledge of microbiology, sterilization techniques and principles as well as modified operating room protocols discussed at orientation was evident. It is hoped that each student will strive to achieve this grade in the course of his/hers rotation as a result of practice and pursuit of excellence.

2-Satisfactory

The student showed consistent adherence to basic levels of infection control and the modified OMFS surgical protocols. Strong emphasis on operator, patient and assistant safety was evident. The surgery area was properly managed and the instruments and equipment were used in appropriate manor.

1-Marginal

There were clear departures from the expected level of aseptic technique on the part of the operator or the assistant. Instruments were handled in negligent manner and the operatory was not maintained or organized to ensure the maintenance of continuing asepsis from patient to patient. Personal grooming or attire inconsistent with the professional standards will automatically denote a marginal performance.

O- Unacceptable

The operator failed to demonstrate any understanding of the sterile protocols and the importance of the implementation of stricter infection control protocols in surgical settings. The operatory and equipment were damaged or abused secondary to operators misuse. Potential scenario of cross contamination or infection between patients and or operator developed during the delivery of care. Sharps were not handled or disposed off in a matter of strictest caution and care to prevent accidental percutaneous injury. Any occurrence of this grade will require the recipient to perform extra-curricular review of the topics and re-evaluation by faculty before being allowed to participate in clinical activities.

Surgical technique, clinical judgement and patient management

3-Outstanding

The student performed at a level superior to his/her peers and to that expected of the level of his/her training. This grade can only be obtained during provision of surgical care to a patient presenting with either surgical or management problems of greater then average complexity. The operator must demonstrate both knowledge of techniques, good clinical judgement, application of profound anesthesia and manual surgical skills along

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with flawless patient management ability. The operator delivered complete post-operative management including appropriate medications and instructions. It is expected that only a few of the students will be given this grade in the course of the year.

2-Satisfactory

Student was able to complete the planned procedure with minimal assistance from faculty and demonstrated good patient management ability. Adequate anesthesia, proper use of instruments and knowledge of the surgical anatomy must be demonstrated. The delivery of care must be accomplished in a timely manor.Post-operative patient management was adequate for the level and severity of the surgical procedure completed.

1-Marginal

A good deal of faculty hands on assistance was required to complete the delivery of the patient. Lack of appropriate judgement and or management skills was evident. The student lacked complete knowledge of the indications and appropriate application of instrumentation. Perioperative and actual in-surgery patient management and or anesthesia have not been consistent with optimal stress-management strategies and desired level of care. The postoperative management of the patient was deficient in depth of post-op instructions and there was improper selection of postoperative medications. A repeated performance at this level from any student will require the student to complete extra-curricular review of relevant topics to enhance future delivery of care. It is hoped that the occurrences of this performance will be limited to the first few sessions of the clinical rotations as the clinical skill become fine tuned and expanded.

O-Unacceptable

The student demonstrated a gross lack of clinical skills and understanding of the principles of surgery. Poor judgment was evident and the welfare of the patient and other operatory staff was jeopardized. The student failed to follow explicit instructions of faculty. Student continued the attempts at the delivery of care in a poorly anesthetized patient or in a patient whose intraoperative condition changed to one incompatible with the delivery of elective oral surgical care. Faulty technique, lack of control or untimely decision to seek faculty assistance has resulted in the delivery of iatrogenic trauma to the patient. Patient did not receive post-operative instructions and the pharmacological management of pain or infections exposed the patient to potential complications or progression of current disease process.

D-4 Course Section

The students participating in the Advanced Oral Surgery Course will be allowed to see elective patients for basic dentoalveolar procedures in the clinic. The will be no grades assigned for clinical performance but it is expected that the D-4 students will adhere to the protocols included in this manual. The final grades will be assigned based on the didactic evaluation of course materials.

Clinic Information

The Oral and Maxillofacial Surgery clinic is located in the University of Michigan School of Dentistry on the second floor. Access from the main floor is best through the main elevators and the hallways to the right of the second floor patient registration and information area. Follow the directions on the wall to Kellogg Building and Surgery clinic. The facility consists of 9 individual operatories designed for the care of Oral &

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Maxillofacial Surgery patients. A small waiting area is available to patients, as well as, a post anesthesia recovery booth. An instrument processing area, and an adjoining instrument room, as well as, a public restroom are included in the clinic’s floor plan. A conference room is located adjacent to the treatment area #9.

The clinic provides opportunity for patients to be treated in all facets of basic Oral & Maxillofacial Surgery. Certain complex procedures, such as those requiring general anesthesias, can be delivered through the University of Michigan Medical Center’s department of Maxillofacial Surgery. These special arrangements will ensure the highest level of accessibility of prompt and state of the art expert care to all patients treated through the University of Michigan School of Dentistry Oral & Maxillofacial Surgery Clinic.

Protocol of care delivery

Guidelines for patient rapport

We want our patients to have a positive experience. It is therefore imperative that this is conveyed to the patient by our demeanor, appearance and professional skills. The patients who present for oral and maxillofacial surgery tend to be more anxious than any other group of dental patients. Hence they are much in need of an operator’s positive attitude and good chairside manner. The clinicians must present their findings and care recommendations as dictated by current standards of care and the body of professional knowledge. However, once the treatment options are explained to the patient including the benefits, indications, as well as, the associated surgical risks the patient must be allowed to make their own decisions about the surgical treatment. In some cases the anxious patient needs to be made aware or reminded that the sole basis of all our actions and protocols is to ensure his or her well being. At the same time we are dedicated to providing expedient and timely service to all our patients. If any problems develop that are beyond the scope of your ability to manage, politely excuse yourself from the patient and solicit the help of faculty.

Most important remember that you are treating another person who has elected to place his well being in your hands. They are just like you and your family and deserve to be treated with outmost concern. Be caring and supportive. Make the patient feel they are being cared for in the most humane and competent way.

Appointment scheduling

The reception desk is a very busy area of our clinic. Please avoid entry into the reception area unless asked to do so. Students are required to schedule appointments for their patients with the Oral & Maxillofacial Surgery receptionist.

Protocol & Procedure for Scheduled Patients

1) All patients MUST be scheduled in advance. If you have a patient that is having “new onset” pain, and you have not scheduled a room, you may bring them in as a “walk-in” and they will be treated by the first available D-3 on rotation, for immedidate** needs only. It is important that patients arrive early in the day. A referral is mandatory.

2) D-4 students and any D-3 students that have completed their Oral Surgery Rotation may schedule patients on Monday, Tuesday, Thursday, or Friday. D-4 students will be allowed to schedule on Wednesdays for treatment only, no consultations will be scheduled on this day.

3) Book one hour time for removal of 1-2 teeth. Book 1.5 hour for 3-6 teeth. Book one hour for a biopsy. Be advised that D-3 and D-4’s share the time on Monday, Tuesday, Thursday, and Friday. Only D-4’s have time available on Wednesday.

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4) Scheduled appointments will be made using a total of three chairs (Chair #5, 6, 7) on each day and will be scheduled by time needed to complete the approved procedure. All chairs will be reserved on 1st come, 1st serve basis. Only the following appointments are available:

a.m.: Monday, Tuesday, Thursday, Friday 9:00-10:00 a.m. or 10:00-11:30 a.m.p.m.: Monday, Tuesday, Thursday, Friday 2:00-3:00 p.m. or 3:00-4:00 p.m.

5) You must have an assistant during your treatment of any scheduled patient. The assistant must be a D-4 or D-3 student that has completed the OS rotation.

6) Patients requiring 3rd molar extractions, multiple extractions, tori, or those who have extensive medical histories must be SCHEDULED for a consultation and require the signature of OS faculty before scheduling a treatment appointment.

7) All students will be limited to 6 teeth or 1 quadrant at any 1 scheduled appointment. Any special requests must be authorized, in writing (on an Oral Surgery Referral) through Dr. Dingman or Dr. Cottrell.

8) Students are responsible for making proper arrangements with the department of prosthodontics for delivery of any immediate prosthesis (refer to the Oral and Maxillofacial Surgery Undergradulate Manual)

9) A room will be held for 15 minutes past appointed time, at which point the room may be forfeited (See Late Arrival Policy).

10) If a patient arrives and the student does not present on time, the treatment may be completed by a student on rotation at discretion of OS faculty/staff. The patient may be dismissed if there is no student/staff available.

11) All minors must have a legal guardian with them on the day of the appointment.

12) Any other questions concerning scheduled patients may be addressed by seeing the OS Lecturer or Clinical Assitant.

**Immediate needs are those that cause extreme pain with SWELLING AND/OR INFECTION that may be detrimental to the patients’ health.

Prosthesis Delivery

All instances where a prosthesis is to be delivered are required (per prosthodontics department guidelines) to have the prosthesis and any surgical stents examined by a Prosthodontics faculty prior to the day of the surgery. The site of the surgery itself must be inspected by both the Oral & Maxillofacial Surgery and Prosthodontic faculty before the suture placement. In addition, the prosthodontic faculty must examine the initial seating and post-adjustment seating of the prosthesis. The Oral & Maxillofacial Surgery faculty must then see the patient before discharge from surgical care. All arrangements with Prosthodontics faculty must be made ahead of the day of the planned pre-prosthetic surgery. Any prosthesis delivered will require the arrangement of a prosthodontic follow-up in 24-hour time period. Unless otherwise indicated the patients will require Oral & Maxillofacial follow-up in seven to ten days post-operatively. If the desired date of surgery would fall on a day where a 24-hour Prosthodontics follow-up is not available i.e. all Friday or the day preceding any holiday or school closure an alternate date must be selected.

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Referral and Treatment Planning

Before a patient can be scheduled for any procedure in the clinic they must have a complete referral form including the patient’s name, number, past medical history, medications, allergies, as well as, the procedure required as well as properly dated. The procedures need to be listed with appropriate tooth numbers and the appropriate arch indicated. Specific denotation of the area for soft tissue or osseous procedures must be marked clearly on the referral form. The form must bear a signature and a printed faculty name. Any unclear or unsigned referral forms will be considered invalid and no procedure will be scheduled. With any incomplete outside referrals the students are to contact the referring office and politely ask for confirmation to requested procedures. For comprehensive care patients the treatment plans must be completed, be signed and complete all surgical items required. Any exodontia of third molars, pre-prosthetic surgery or hard tissue biopsies require pre-operative panoramic radiograph taken within six months of the planned date of surgery. Also any radiographic studies i.e. to confirm buccal or lingual orientation of structures must be available prior to consultation or treatment. After the completion of a consultation, faculty and residents will perform the more complex procedures.

Infection Control measures

Safety is everyone’s concern. In Oral & Maxillofacial surgery we practice the most invasive procedures in dentistry and we must maintain strict measures to ensure asepsis. This involves all persons in the clinic: students, staff and faculty alike. As students the level of asepsis you will implement will be reflected by part of your clinical grade. By insisting on STRICT adherence to the outlined protocol below we want to develop your habits for the future.

Please refer to your Clinic Procedure Reference (Yellow U of M handbook) for the basic OSHA concepts of infection control.

The following guidelines are to be implemented while specifically practicing oral surgery:

1. Clean white, cuffed dental jackets must be always worn in the treatment areas. If soiled they are to be changed between patients.

2. Hair that is longer than collar length must be pinned back or a hat must be worn.3. Optimal personal hygiene must be maintained at all times.4. All rings and dangling earrings must be removed prior to treatment delivery.5. Do not contact patient without handwashing with anti-microbial soap then immediately drying hands and

putting on either the latex or vinyl gloves.6. When gloved, do not touch anything except instrument tray’s interior and the surgical instruments, the

drape’s sterile side (top), patient’s mouth, and foil covered light handles. Use utility pick-ups to gain access and acquire any local anesthesia supplies once gloved. Should you contaminate your gloves you should deglove, re-wash your hands and re-place new gloves.

7. Wear protective eyewear when performing any intraoral procedure.8. Masks must be worn at all times when examining or treating the patient if contact or proximity of less

than 3 ft. is anticipated. You do not have to wear them when you are simply conversing with the patient.9. Surgical packs are to be handled using aseptic technique. Open away from you. Keep gloved hands above

the waist. Do not place wrapped instruments, without taking the non-sterile cover sleeve off, on an opened sterile interior of the tray. Do not place the entire suture pack on the sterile field, rather open the pack and drop the suture carrier out onto the interior of the tray.

10. Upon completion of the procedure first locate and dispose of all sharps into a sharps container located in each operatory. Sharps include blades, needles, glass carpules, monoject irrigation syringes and used burs. Blood stained gauze and surgical suction hose is disposed of in the red biohazard bag located in the instrument processing area.

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11. Any and all tissue i.e. teeth, follicles, or bone removed from the patient will be disposed of in the sharps container except for the pathology specimen. If patients insist on keeping their extracted teeth they need to be informed of our strict adherence to the OSHA regulations pertaining to handling of human tissue waste. Issues of infectious disease spread can be related to the patient. With the issue of dispensing any deciduous teeth, please consult the supervising faculty regarding each individual case.

12. To turn around the operatory first check that all needles, glass cartridges, needles and scalpel blades have been removed from the tray, then take the dirty tray to the instrument preparation room and dispose of hose and any disposable materials. The operatory should be then wiped down with Micro-Quat (antiseptic) soaked towel, from the steel basin in the instrument process room, and left to air dry. Clean all areas starting in the clean part of the object and wipe towards the dirty or handled part of the object. Include the following areas:

(a) fold-out desk(b) Mayo stand(c) overhead light(d) dental chair

13. After the room has been wiped replace the headrest and blue patient bib. Ensure that all of the patient’s records are replaced into the chart including the radiographs on the view box.

14. Report all blood spills to the oral surgery staff, in order to ensure a prompt clean-up.15. Most of all, be careful and take your time. The surest way to reduce the risk of infection transmission,

percutaneous injury or equipment damage is to avoid haste and maintain solid protocols of action. In the event of an exposure or any suspected percutaneous injury notify the clinical instructor before the patient is discharged. The exposure control protocol must be followed

Use of operatories and equipment

1. Please leave personal belonging in your lockers. Bring only pertinent didactic and clinical material to the surgery clinic, as no storage area is available.

2. Sign in by listing your provider code and name daily. Keep a total of teeth extracted and patients seen.3. Check the undergraduate bin on the reception’s sidewall for patient’s charts labeled with your name on a

post-it note.4. Patients will be assigned to students by the clinic staff and/or faculty to ensure as even of exposure per

student as possible. The students with least performed procedures on record will be assigned the next incoming patient. Clearly call out the patient’s name and once the patient presents, politely introduce yourself.

5. Repeat clearly the patient’s name if no one answers the first time; if still no answer please inform the reception desk staff.

6. Escort the patient to the assigned operatory and introduce your assistant.7. Seat the patient in a safe and a comfortable position, adjust the headrest, secure the patient drape and ask

if there is anything we can do to make them more comfortable.8. Then explain to the patient the purpose of their visit to our clinic and reassure them that we will make

every effort to make their treatment and stay with us as comfortable as possible. 9. Explain the format of the appointment and step-wise manor in which they will be cared for:

(a) Vitals(b) Review of medical history(c) Necessary consultations(d) Case presentation to faculty(e) Any necessary pre-operative management per faculty(f) Delivery of surgical care(g) Post-operative evaluation with faculty(h) Post-operative instructions and discharge

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10. After compiling a detailed case work-up including but not limited to the chief complaint and its history, complete medical, therapeutic and surgical history, review of relevant past chart entries, any consultations and required radiographic studies the case will be discussed with the faculty. Be well organized and prepared! Know as much about your patient, his medical condition, medications and proposed plan of treatment as you can. Your patient investigative skills and future diagnostic routines will be developed mostly during this session. Upon review of data complied and any additional inquiries your plan of treatment must be initialed by faculty prior to delivery of any invasive surgical care: i.e. local anesthesia. Any student who fails to secure a written clearance will fail the session.

11. Explain the procedure to the patient including the indications, benefits and a complete list of possible complications. Allow the patient time to read over the written form and ask any questions. More detailed guidelines for attaining informed consent is located in the clinical syllabus section of this manual. In this time have your assistant set up the surgical tray suction and obtain any special equipment as per case discussion with the faculty.

12. Deliver all necessary anesthesia ONLY if you are familiar with the type, mode of action, maximal and therapeutic levels, onset and duration and complications associated with the use of this specific anesthetic, as well as, its components and additives. Remember you are delivering surgical care, anesthesia must be profound. Do not commence a procedure unless you have assessed for adequate level of pain control. If in doubt contact the faculty for further evaluation.

13. Monitor the patient for any signs of adverse effects of anesthetic. Continue this to the time of patient discharge. Most adverse reactions occur immediately following administration of local anesthesia and after the patient is attempting to leave your operatory following the completion of the procedure.

14. Begin the surgical procedure. Use throat packs at all times, bite blocks for mandibular extractions, retractors when indicated and controlled forces with the right instruments. Have your assistant evacuate fluids and monitor for any debris from exodontia/surgical site. GET THE RIGHT TOOTH. If in doubt recheck the case work up and referral forms. Have the assistant monitor for impingement or encroachment of adjacent tissues. If you judge the case to require faculty assistance ask for it early on as oppose to later. Your judgement is one of your greatest assets.

15. Following the conclusion of surgical therapy and dressing of the surgical site inform the patient of the need for post-operative evaluation by faculty prior to the final completion of the appointment. Do not dispose of any tissue prior to the faculty having an opportunity to evaluate it.

16. Apply all sutures and dressings and have the faculty evaluate prior to discharge. 17. Inform the patients of any complications if encountered, give post-operative instructions both written and

verbal; dispense the Rx and the gauze packs prior to discharge.18. Escort the patient to the front desk. Be sure that the charge ticket is properly completed. Make any

appropriate follow-up appointments. Leave the completed chart in steel basket on the rear counter of the reception area. Only complete paperwork will be returned to the reception. Have the faculty sign your record of treatment op/consultation notations, charge ticket, physician consultation forms as well as issue your grades. Remember that students delivering active care, or getting start checks will take priority over completion of your post-op paper work.

19. Next walk the patient to the second floor cashier area to make payments and obtain parking validation. Politely thank them for choosing our clinic for their surgical care. Reinstate if they have any questions or concerns they should not hesitate to contact us, as delineated in the written instruction handout.

20. If you do not have an assigned patient or have completed your cases for the day, you are to observe and assist your classmates, faculty and residents, or do assigned work in the conference area. Do not block the hallways, make unnecessary commotion, or occupy faculty offices unless reviewing the cases or literature. Your behavior will reflect on the image of the entire department as seen by patients and the rest of the school.

21. Procedures performed are to be documented on bulletin board to assure equality of case assignment.

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The pre-surgical patient work up and case presentation

The depth of medical history, scope of the physical examination, extent of consultations and laboratory assays will be delineated for the purposes of the oral and maxillofacial surgery patient receiving basic outpatient oral and maxillofacial surgical care. This protocol is different than one utilized to work up a general dentistry patient, although it will cover similar areas the focus and depth will be different. The student is expected to work independently utilizing his basic medical science knowledge, materials presented in the course of the lectures and the references available in the resident’s room to compile all parts of the case presentation as outlined in the following section. The case work up should parallel the format of the case presentation. Use the pre-operative patient evaluation form to list and organize your findings.

Upon completion of the case work up the student cannot proceed with any aspect of the planned procedure without the review of the case and start check from the faculty. It is up to the student to approach one of the faculty members, introduce yourself and ask to have the case reviewed. Do not interrupt the faculty if they are simultaneously involved with another student or case. Make sure that you have all relevant records including the details of your work-up, radiographic surveys; study models, surgical stents, lab results and medical consultations are available for faculty review.

Chief Complaint Investigation

Begin by identifying your patient by age, sex and their current chief complaint. The chief complaint is in patient’s words reason for being at the clinic. Be brief i.e. “my back top tooth hurts” or “my gums are swollen behind my last bottom tooth”. Then after stating of the chief complaint be prepared to discuss the history and the specifics of the chief complaint. Include onset, duration, location, severity, quality or type of associated pain, details on onset and progression of any swelling, alleviating and worsening factors. Inquire into the past history of similar symptoms or problems in the similar anatomic location. For patients undergoing any current restorative, endodontic, orthodontic or prosthodontic treatment indicate pertinent area of their treatment plan to the proposed oral surgical procedure i.e. “ The patient is scheduled to have an immediate complete denture delivered upon complete edentulation of maxilla. Today posterior maxillary dentition is slated for clearance. Unless otherwise contraindicated, the remaining maxillary dentition is to be removed in six weeks with subsequent delivery of the prosthesis post-operatively.” Medical History Findings

Next be well prepared to discuss the patient’s medical history. Note the remarkable findings, the details of past and current medical conditions patient elicited through your probing. Clearly question the patients about any past or current cardiovascular diseases such as hypertension, myocardial infarctions, coronary artery disease, congestive heart failure, heart malformations, murmurs, prosthetic valves, history of endocarditis, rheumatic fever, episodes of arrhythmias or chest pain, etc. Inquire about respiratory pathology such as asthma, bronchitis, emphysema, COPD, lung cancer, episodes of pneumothorax, tuberculosis. Ask for any past history of liver and kidney dysfunction such as hepatitis, glomerulonephritis, cirrhosis, bouts of jaundice or alcoholism. Consider any neuropathy both central and peripheral including epilepsy, psychiatric diseases, motor dysfuctions, neuralgias and sensory deficits. Probe the status of the gastro-intestinal system by questioning about ulcers, diarrhea, Crohn’s or irritable bowel disease. Discuss any endocrine problems such as diabetes, hypo or hyper thyroidism, Cushing’s and Addison’s diseases. Any types of integumentary diseases including bleeding problems should be noted. Musculoskeletal system integrity and past history of trauma and disease, including prosthetic joints must be elicited. Incidence of any infectious pathology should be probed and include specific references to diseases impairing immune function or one’s which may be currently infections to the persons in the clinical setting i.e. active TB. Finally, all women between the ages of puberty and menopause should be questioned regarding any current pregnancy potential.

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Past history of surgeries

The medical history findings will be supplemented with the patients past surgical history. It is important to list the type of procedures, dates and any complication or drug reactions. Correlate the surgical history with the medical history you have just compiled. If you find any inconsistencies, you need to re-investigate the medical history issues. Assess the impact of past surgical management on your currently planned procedure. Consider any required pre-medications or treatment modifications.

Social History

Third area of the patient history is the social history. Specifically, the areas of tobacco, alcohol and street drug use should be probed. Find out the level of daily use, length of use, as well as last intake especially for drugs and alcohol. Quantify tobacco use in pack years e.g. 1 pack per day (ppd) for 40 years = 40pack years (py). Be prepared to discuss the impact of these substances on the patient’s current health and post-operative recovery.

Allergies and adverse drug reactions

Determine if the patient has ever had an allergic reaction to any medications or substances. List thee medications and their reactions. If yes, be able to qualify if true anaphylaxis type hypersensitivity is present or if the patient has had an adverse drug reaction. This will help to manage the patient better especially in terms of post-operative medication selection.

Physical Examination

After completion of a verbal examination, the patient should receive a physical examination. For the purposes of delivery of outpatient oral and maxillofacial surgery this will be mostly directed at exploring the structures of head and neck. To get a limited overview of the other systems and the patients current functional status one can use the four standard vital signs. The vital signs including blood pressure, heart rate, temperature and respiratory rate must be completed for each patient in the clinic. Values that fail to fall in the acceptable norms and ranges may need to be re-evaluated in 5 min to establish their true level and rule out outlier results secondary to recent ambulation or anxiety.

It is not the purpose of this course to teach the students oral diagnostic skills; however, a brief suggested approach tailored for the surgical patient is presented. Always start with general and narrow down to specific areas.

First note the patient’s overall appearance; level of anxiety, respiratory distress, level of alertness and responsiveness. Do they look old for their age? Younger? Do they look well or ill? Next, systematically examine the TMJ’s, salivary glands, oral cavity and oropharynx. Next, thoroughly evaluate the neck for masses and adenopathy and other stigmata of disease. In general, begin your exam away from the chief complaint/area of interest to avoid skipping other areas ending here only after examining everything else.

Radiological and laboratory assays

Systematically review all studies obtained. Consider the radiological surveys for any evidence of pathology; take note of the architecture of the surgical site to give you insight into potential level of complexity for the procedure. Any laboratory values and tests should be then presented and discussed in reference to the proposed procedure and patient’s health status.

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Diagnosis and Prognosis

Once all of the diagnostic information has been compiled, these should be presented as a diagnosis or list of diagnoses with the anticipated prognosis without and with possible treatment. Remember that statement such as “the tooth is not restorable” is not a diagnosis, but is an assessment of its potential for restorative therapy. Rather, one should specify that the tooth is grossly carious, with caries extending below the gingival margin or osseous crest.

Treatment plan

Finally, a plan for management of the patient should be put forth in an organized and logical sequence of steps. Include items such as: any necessary consults, modified treatment protocols i.e. stress reduction protocol, need for translator, guardian consent, etc., surgical procedure, type of anesthesia, and any post op considerations including medications, handling of biopsies and specific instructions.

When you are certain that you have covered all relevant topics and know your patient, as well as the principles of planned surgery, then go over your work up one more time and re-examine your radiographs. Next approach the faculty for case presentation. Follow the format outlined above and on the pre-operative work up section of the treatment form.

Supervision of care delivery

Students are required to have constant supervision by the faculty during the delivery of care. Unless a resident or staff surgeon is physically present in the surgery clinic patients are not to be seated in the operatories. All cases need to be presented and discussed with the faculty or the residents. The student is responsible for ensuring that the pre-operative form is signed off for start check by the faculty or resident before any procedure is commenced. The procedure forms are then completed post-operatively and presented to the faculty during debriefing for final signatures. Any time any questions or problems arise during a procedure the student is to immediately attempt to contact the faculty member who approved your case presentation and treatment plan. If they are unavailable, and the matter is urgent contact another resident or faculty. Otherwise it is required that one instructor oversees the case from start to finish and both start check and final signatures match. It will also be this instructor who will issue your grade for the session.

Emergency protocols

It is the responsibility of the Dentist and his/her staff to be able to recognize the variousemergencies that may be encountered, and as a result, provide the necessary basic treatment or supportive care to maintain life until further help arrives.

Specific attention to the medical history of the patient will help alleviate most serious problems before they are encountered.Use the following in management of all medical emergencies in a dental setting:1. Recognition of impending or occurring change in patients status2. Clinic/Office plan should be developed for each potential scenario - Don’t panic - Practice drills - Adequate training of office staff. Yearly CPR course with staff. - Supportive care - Emergency phone numbers

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3. Flow Chart a) Stop procedure b) Vital signs - BP, P, RR c) Oxygen - Is the patient responsive? d) Positional changes as necessary e) A - airway B - breathing C - circulation f) Necessary drugs g) CPR and/or call for help. Be aware of availability of a code team or a local physician.

Respiratory Emergencies

Physiology and Anatomy

Respiratory rate - 16 to 18 breaths per minute Cyanosis (greater than 5 grams of reduced hemoglobin) - Central - Peripheral Larynx - Trachea - Right and Left Bronchi - Bronchioles - Alveoli Smooth muscle - mucous - cilia

History

Smoker - ? packs per day and for how many years? Cough - sputum Exercise tolerance Chronic Obstructive Pulmonary Disease (C.O.P.D.) Asthma - medications - hospitalizations

Signs

Stridor (high obstruction - inspiration) Wheezing (low obstruction - expiration) Indrawing Cyanosis Panic Patient may clench neck area Respiratory efforts - gasping - absent Management

1) Stop the procedure - remove all hardware from mouth2) Airway - clear foreign bodies

a) Finger sweep / suctionb) Positional changes - head down position - back blow - abdominal thrust

3) Oxygen and check vitals 4) Airway adjuncts - oral or nasal airway tubes - endotracheal tube - laryngoscope - cricothyroidotomy

canula5) Emergency airway - cricothyroidotomy (cricothyroid membrane) 6) Medications - epinephrine (1:1,000 IM 0.3 - 0.5 mg.) - ventolin inhaler

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Airway obstruction

Level is important a) Trachea - emergent as total airway may obstruct b) Bronchi - not as emergent as still have one lung to ventilate - Right mainstem bronchus is the most common site

Treatment

As listed under management abovePossible need for a chest or abdominal radiographMedical consultationRemoval of foreign body - laryngoscope - Magill forceps - Bronchoscope

Emergency Airway

Cricothyroidotomy – canula inserted; best use a 14-gauge 1/2-inch long needle connected to 4.0 ETT connector and ambu bag.

Hyperventilation Syndrome

Anxiety - tachypnea - decreased PC02 and blood pHUsually don't lose consciousness

Signs

1. NeurologicDizzinessLightheadednessDisturbances of consciousness or vision

Numbness and tingling of the extremitiesTetany (rare)

2. Cardiovascular Palpitations Tachycardia Precordial pain

3. RespiratoryShortness of breathChest painDryness of mouth

4. GastrointestinalEpigastric pain

5. Musculoskeletal15

Muscle pains and crampsTremorsStiffnessTetany

6. PsychologicTensionAnxiety

Pathophysiology

Decreased PCO2 - vasoconstriction of cerebral vessels - cerebral ischemia- Increased coronary artery vascular resistance O2 more tightly bound to hemoglobin and therefore not easily released to tissues (ischemia)

- Decreased ionized calcium as pH increases

Treatment

1. Anxiety reduction - Stop procedure - Positional changes - Remove foreign material from mouth

- Calm patient 2. Correct respiratory alkalosis us. Directed, slowed inspiration/expiration - Re-breathing (bag, hands) - Drugs (valium) NOTE: oxygen not needed

Asthma

Basic pathology is hyper reactive airways with bronchospasm and increased mucous secretion.

Precipitant factors 1. Foods - cow's milk, eggs, fish, chocolate, shellfish, tomatoes 2. Drugs - penicillin, vaccines, aspirin 3. Exercise or stress 4. Viral respiratory tract infections 5. Environmental allergies

Prevention

1. Medical history2. Patient to bring inhaler with him - dose just before dental treatment in moderate to severe Asthmatics

Signs

Mild tightness in chestCoughing spellWheezing

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Dyspnea with increased respiratory rateAnxietyTacchycardia

Severe intense dyspneaCyanosisPerspirationUse of accessory respiratory muscles andIndrawingIncreased or decreased respiratory rate Decreased rate is a poor sign

Treatment

a) Stop procedureb) Positional changes - usually upright with slight forward tiltc) Administer bronchondilator – ventolin via MD1 or nebulizerd) Administer oxygene) If continues - epinephrine IM 1:1,000 0.3 - 0.5 mg. (adult) and call for help/EMSf) Additional medications – Solumediol but this is part of ER management

Cardiovascular Emergencies

Anatomy and physiology

Venous return R.A.R.VLUNGSL.A.L.V. arterial circulation (PRELOAD) (AFTERLOAD)

Cardiac work increases with demand - usually is a large functional capacity to adapt. With increasing age there is less cardiac reserve.

Cardiac ejection fraction - 50 - 80% normally - As little as 10 - 20% with failure

STARLINGS LAW - increased muscle length results in a more forceful muscle contraction.

The myocardium receives its blood supply during diastole via the right and left coronaryarteries. The length of diastole is decreased with tachycardia making pumping less efficient at rates.

Contributing factors include:

1. Increased afterload - Hypertension - Stenotic valves 2. Increased work - Regurgitation - Hyperdynamic circulation (e.g. anemia, hyperthyroidism) 3. Increased preload - Fluid overload in an already stressed heart 4. Cardiac diseases - Cardiomyopathies (e.g. viruses, drugs) - Coronary artery disease

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Considering all of the above, the primary goal of dental treatment in cardiac patients is to minimize stress to an absolute minimum. This can be done via:

1. Short appointments 2. Good local anesthetic 3. Friendly staff 4. Sedation

Evaluation

The medical history is the MOST important preventative measure. Extremely important – helps you determine if patient will tolerate stress of surgery. QUANTIFY ACTIVITY LEVEL e.g. patient can climb 1 flight of stairs without chest pain. Important aspects are: a) History of angina (stable or unstable), hypertension, previous heart attacks,

Congenital heart problems, rheumatic fever, cardiac arrhythmias. The cardinal signs of heart disease are chest pain; shortness of breath; palpitations.

b) Physical status of the patient - how much exercise can he/she tolerate (climb Stairs or walk on flat ground). Shortness of breathe on exertion or at rest. c) Any medications he/she is taking.

If there are any questions or patient is a poor historian contact the patient's physician.

Congestive heart failure

Fluid congestion of the pulmonary venous and/or systemic venous circulation. Fluid mechanics:

a) Osmotic pressure - tissue - Vessel b) Hydrostatic pressure - tissue - Vessel

The acute emergency is called Acute Pulmonary Edema. Signs and Symptoms are: - Shortness of breath (acute) - Possibly frothy sputum - Cyanosis

Treatment

1) Upright position2) Stop procedure3) Apply oxygen via mask and check vital signs (BP, P, and RR)4) Call for help5) Morphine, diuretics, CPR

Angina

Medical history again is the most important preventive measure.The patient may be on various medications such as nitroglycerin, isosorbide dinitrate, or calcium channel blocking agents (nifedipine). It is important to know if the patient's angina is stable or unstable. Unstable angina is:

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1) New onset chest pain2) Pain at rest3) Pain that has changed in character /frequency or amount of exertion that is required to bring it on.

It is a medical emergency – send them to ER. Coronary artery disease is the major cause. Atherosclerosis causes narrowing of the vessels and thus enough blood isn't allowed through to give adequate oxygen to the myocardium. Usually oxygenation of myocardium is adequate at rest but when cardiac work increases and thus oxygen demand; blood and oxygen supply are inadequate. This results in ischemia and pain, which, if not relieved, may progress to infarction and complete cardiovascular collapse. Stress is an important factor as epinephrine levels are high and thus an elevated level of cardiac work exists.Some modifications to treatment of cardiac patients must be applied. Local anesthetic with epinephrine 1:100,000 (0.01 mg./cc.) have 0.018 mg. per carpule.The maximum dose of epinephrine in a cardiac patient is 0.04 mg (i.e. 2 carpules of 1:100,000)CAUTION: Do not use epinephrine in patients with cardiac arrythmias and be aware of

the high concentration in epinephrine in some gingival retraction cords.

Risk factors for Coronary Artery Disease: 1) Smoking 2) Hypercholesterolemia (fatty diet) 3) Hypertension 4) No exercise 5) Diabetes 6) Obesity

Signs and Symptoms - Indigestion

- Pallor, Diaphoresis, Greyish skin colour - Crushing chest pain +/- radiation to left arm/jaw/neck

Treatment 1) Stop procedure 2) Apply oxygen and check vitals (BP, P, RR) 3) Nitroglycerin sublingually - 0.4 - 0.6 mg.-repeat dose q5min. x3If no relief after 3 doses then consider it a myocardial infarction and activate EMS. 4) Morphine 1-3 mg IV q5mins 5) Aspirin 325 mg. – have patient chew this

6) CPR and basic support as needed until help arrives

Chest pain can result from a number of non-cardiac problems such as: a) Chest wall - hyperventilation syndrome, muscle spasm, costochondritis b) GI - ulcers, esophagitis, esophageal spasm, reflux c) Pulmonary - pleuritis, embolism d) C.V. - pericarditis

For patients with recent Myocardial Infarctions they are at risk for a second M.I. if given a general anesthetic according to the following:

0 - 3 months post M.I. - 31% risk of re-infarction 3 - 6 months post M.I. - 15% risk of re-infarction Over 6 months post M.I. - 5% risk of re-infarction

* Defer elective care for at least 6 months post M.I.

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Cerebrovascular Accident

Pathology occurs due to destruction of brain substance secondary to: a) Intracranial hemorrhage (vessel rupture) b) Thrombosis c) Embolism

Risks: a) Hypertension b) Atherosclerosis c) Cardiac arrythmias e.g. atrial fibrillation d) Age

Signs and Symptoms

- Dizziness - Paresthesias and/or weakness or paralysis of one side of the body - Speech defect – dysarthric speech, word finding difficulties, nonsensical speech - Headache - Nausea and/or vomiting - Convulsions - Loss of consciousness - Visual field deficits

Treatment

1. Stop procedure 2. Apply oxygen and check vitals (BP, P, RR) 3. Call for help 4. Support airway as needed

Drug overdose reaction

Local AnestheticsThe overdose reaction is related to the blood level of local anesthetic.

Clinical manifestations:1. Rapid I.V. injection - signs and symptoms occur within seconds but the duration is usually short due to re-distribution and biotransformation. This is usually self-limiting.

2. Too large a dose - not as rapid an appearance. Usually after 3-5 minutes. Initial Excitement and then depression. Usually these are self limiting but last longer than an I.V. injection. 3. In patients with slow biotransformation or elimination, tend to see slower onset that may Take 15-25 minutes to manifest the adverse reaction.

Signs and symptomsa) Low to moderate overdose levels confusion headache talkativeness lightheadedness apprehension dizziness excitedness blurred vision slurred speech ringing in ears

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generalized stutter drowsiness muscular twitching and/or tremor disorientation nystagmus loss of consciousness increased blood pressure tachycardia tachypnea

b) Moderate to high blood levels generalized tonic clonic seizures followed by generalized CNS depression decreased blood pressure, heart rate, and respiratory rate

Treatment

a) Mild overdose (rapid onset) 1) Reassure patient 2) Administer oxygen 3) Vital signs 4) Recovery 5) Call for help if needed

b) Mild onset (slow onset) 1) Reassure patient 2) Administer oxygen 3) Vital signs 4) Call for help if needed

CAUTION: Use care if giving an anticonvulsant, as after the initial excitement phase as there is a generalized depression.

c) Severe overdose (rapid onset) 1) position patient (supine) 2) manage seizure (prevent injury, loosen clothing) 3) basic life support (assure airway, oxygen, vital signs) 4) anticonvulsant after 5 minutes if needed - Valium 5 mg/min 5) call for help

d) Severe overdose (slow onset) 1 ) basic life support 2) call for help

Epinephrine overdose

Optimal dilution is 1:250,000 and there is no rationale for 1:50,000 concentration solutions.Gingival cord - racemic epinephrine - 500 to 1000 micrograms of epinephrine per inch of cord.- Do not use epi soaked gingival refraction cord.

Dose Available Maximum

Epinephrine 1:50,000 (0.02 mg/cc) 0.2 mg (healthy adult) 1:100,000 (0.01 mg/cc) 0.04 mg (cardiac patient)

1:200,000 (0.005 mg/cc)Levonordefrin 1:20,000 (0.05 mg/cc) 1.0 mg (healthy adult)(neo-cobefrin) 0.2 mg (cardiac patient

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Levarterenol 1:30,000 (approx. 0.033 mg/cc) 0.34 mg (healthy adult)(levophed) 0.14 mg (cardiac patient)

Clinical Manifestations: fear elevated blood pressure anxiety tachycardia tenseness restlessness headache tremor perspiration weakness dizziness pallor respiratory difficulty palpitations

Treatment

1) stop procedure2) position patient – conscious patientcardiac position (seated with head elevated ~ 45)3) reassure patient4) vital signs, oxygen5) recovery time6) if needed call for help

Management of other drug overdoses

Sedative-Hypnotics 1 ) basic life support (airway, breathing, circulation) 2) vital signs and oxygen 3) call for help if needed Narcotic Analgesics 1) basic life support 2) vital signs and oxygen

3) Naloxone (narcan) 0.4 mg I.M. or I.V. 4) observe patient and call for help if needed

Allergy

A hypersensitivity state acquired through exposure to a particular allergen, re-exposure towhich produces a heightened capacity to react. Range from mild, delayed reactions occurring as long as 48 hours after exposure to immediate and life threatening reactions developing within seconds of exposure.

Classification

Type1. Anaphylactic (immediate, IgE Seconds to Anaphylaxis (drugs, insect venom, homocytotropic, antigen- 60 minutes antisera) induced, antibody- - most within Atopic Bronchial asthmas mediated.) 30 minutes Allergic Rhinitis

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Urticaria Angioedema Hayfever

2. Cytotoxic (antimembrane) IgG Transfusion reactions IgM Hemolytic anemia

Certain drug reactions3. Immune complex (serum IgG 6-8 hrs. Serum sickness sickness-like) Lupus nephritis

Acute viral hepatitis4. Cell mediated (delayed) 48 hrs. Allergic contact or tuberculin type response dermatitis Infectious granulomas(ex. tuberculosis)

Tissue graft rejection Chronic hepatitis

Clinical Manifestations

1) Onset This may be immediate or delayed. More intense reactions are immediate. 2) Skin reaction Most commonly see localized anaphylaxis, contact dermatitis, and drug eruption. (urticara). Pruritis tends to present early which can be followed by swellings of the lips, tongue and as the danger increases to the airway. (angioedema 3) Respiratory reactions usually follow skin reactions but precede cardiovascular reactions. Mainly evident is a bronchospasm with signs and symptoms of respiratory distress, perspiration, tachycardia, anxiety, and respiratory embarrassment. 4) Generalized anaphylaxis

It has a life threatening potential, with variable manifestations including skin reactions, smooth muscle spasm (G.I., G.U., and respiratory smooth muscle), respiratory difficulty, and cardiovascular collapse.

Treatment

Skin reactions (delayed) 1. Antihistamine (Benadryl 50 mg I.M./P.O.) 2. Refer to his physicianSkin reactions (immediate) 1. Epinephrine 0.3-0.5 ml 1:1,000 subcutaneous 2. Antihistamine I.M. 3. call for help if needed 4. Oral antihistamine for home use

Respiratory reactions1. Bronchial constriction

a. Stop procedureb. upright positionc. oxygen and vitalsd. ventolin inhalere. antihistamine and/or epinephrine 1:1,000 0.3-0.5 cc subcutaneousf. call for help if neededg. contact patient's physician

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2. Laryngeal edema (partial obstruction)

a. supine positionb. epinephrine 1:1,000 0.3-0.5 cc I.M.

c. airway maintenance d. call for help e. Additional therapy if needed - antihistamine, corticosteroids

3. Laryngeal edema (total obstruction) a. Supine position and remove hardware from mouth

b. epinephrine 1:1,000 0.3 - 0.5 cc I.M. c. cricothyroidotomy and oxygen d. call for help e. antihistamine, corticosteroid

General anaphylaxis (if allergy symptoms appear) 1. supine position 2. oxygen and check vitals, basic life support

3. epinephrine 4. call for help 5. additional drugs antihistamine, corticosteroid

General anaphylaxis (no signs of allergy present) basic life support1. supine position2. monitor vital signs3. immediate call for help

Unconsciousness

Any emergency left long enough may end in an unconscious patient.

In most cases the loss of consciousness will be only transient, and carrying out some basic maneuvers will be all that is required for proper patient management. There are however other causes that will require additional support and possible need for assistance.

Predisposing factors

Vasodepressor syncope Most commonDrug administration/ingestion CommonOrthostatic hypotension Less commonEpilepsy Less common Hypoglycemic reaction Less common Acute adrenal insufficiency Rare Acute allergic reaction RareAcute myocardial infarction RareCerebral vascular accident RareHyperglycemic reaction RareHyperventilation syndrome Rare

Medical history is again the most important preventative measure. This will identify any medical problems that he/she is being treated for (ex. diabetes, Addison's disease, epilepsy).Stress is the most common precipitating factor in the dental office.

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Clinical Manifestations

An unconscious patient will be incapable for responding to sensory stimulation and will have lost the protective reflexes (swallowing, coughing) with an attendant lack of ability to maintain a patient airway. Clinical signs and symptoms vary with the cause of unconsciousness.Fainting and Syncope are used interchangeably.

Pathophysiology

1) Inadequate cerebral circulation is most common mechanism for L.O.C. (loss of consciousness) Physiological disturbances that cause this are: a) vasodilatation b) failure of normal peripheral vasoconstriction c) sudden decrease of the cardiac output d) cerebral vasoconstriction due to hypocarbia (ex. hyperventilation) e) occlusion of the internal carotid f) ventricular asystole Management of these factors will be to increase the circulation to the brain. (Head down and feet up position - Trendelenburg position).2) General or local metabolic change as the result of changes in the quality of blood perfusing the brain. (Ex. hyperventilation, hyperglycemia, drugs, acute allergic reactions). Consciousness will be lost until abnormality is corrected.3) Actions on the central nervous system are via alterations within the brain itself or reflex effects on the CNS. (Ex. convulsions, cerebral vascular accident).4) Psychic mechanisms such as emotional disturbances. (Ex. hyperventilation syndrome, vasodepressor syncope).

MECHANISM EXAMPLE

Inadequate delivery of blood Acute adrenal insufficiency or oxygen to the brain Orthostatic hypotension

Vasodepressor syncope

Systemic or local Acute allergic reaction metabolic deficiencies Drugs

Hyperglycemia Hyperventilation

Hypoglycemia

Direct or reflex effects Cerebral vascular accident on the nervous system Convulsive episode

Psychic mechanisms Emotional disturbances Hyperventilation Vasodepressor syncope

Oxygen Deprivation

Loss of consciousness results in loss of muscle tone in the body. The tongue falls posterior and may occlude the airway. It is of utmost importance to maintain adequate oxygenation to the brain in the unconscious patient. The brain gets most of its energy from oxidation of glucose, therefore, it needs a continuous supply of

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these. Without oxygen, glucose can still be metabolized to lactic acid with some energy provided but this source only lasts a few seconds, rapidly leading to L.O.C. The brain utilizes 20% of the total oxygen and 65% of the glucose consumed. It only comprises 2% of the total body mass. Complete airway obstruction with the victim anoxic will lead to permanent brain damage within 4 to 6 minutes and to cardiac arrest within 5 to 10 minutes. This implies the importance of early airway management and basic support to prevent permanent brain damage. Management of the unconscious patient

1) Recognition of unconsciousness "Shake and shout" painful/ noxious stimuli 2) Position patient Supine position - recovery if vasodepressor syncope 3) Vital signs 4) Basic support airway patency - clear upper airway if needed breathing efforts hear and feel air from lungs look at chest and abdomen for movements 5) Call for help 6) Open airway position mandible forward pull tongue forward 7) Begin mouth to mouth ventilation if needed and CPR if needed Ambu bag with oxygen enrichment airways - nasal, oral 8) Wait for help to arrive while maintaining adequate CPR

Causes of Partial Airway Obstruction

Sound heard Probable Cause Management

Snoring Hypopharyngeal obstruction Clear upper airway with by the tongue finger sweep, pull tongue

or mandible forward

Gurgling Foreign matter (blood, water, Suction airway vomit) in airway

Wheezing Bronchial obstruction Administer Ventolin by (asthma) inhaler or epinephrine I .M .

Crowing Laryngospasm Suction airway, positive pressure oxygen,

cricothyroidotomy neuromuscular blocking agents

Vasodepressor Syncope

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Also known more commonly as a simple faint. It is a sudden transient loss of consciousness due to cerebral ischemia. Predisposing factors consist of psychogenic factors (fright, anxiety, stress), pain of a sudden or unexpected nature, and the sight of blood or surgical instruments. Nonpsychogenic factors are sitting upright (causing pooling of blood in the lower extremities) hunger (decreased blood glucose), exhaustion, poor physical condition, and a hot, humid crowded environment. Prevention is directed at eliminating the above factors.

Clinical Manifestations

Early feeling of warmth loss of color, pale or ashen gray bathed in sweat patient complains of feeling bad or faint nausea blood pressure approximately baseline tachycardia

Late pupillary dilation yawning hyperpnea coldness of hands and feet hypotension bradycardia visual disturbances dizziness loss of consciousness

Management

1 ) Supine position. Stop all procedures and removal all material from the patient's mouth.2) Airway management as needed3) Vital signs4) Follow up treatment if needed. Postpone dental appointment as needed.

Orthostatic hypotension

Certain medications may produce this, and thus it is important to know all medications thepatient is taking prior to any dental treatment (ex. guanethidine, chlorpromazine, doxepin alpha-adrenergic blockers, amitriptyline, meperidine, morphine, levadopa).Elderly patients may be more prone to this as hypovolemia is more common in this group.With long appointments this may occur at the end of the appointment when the patientreassumes the upright position. Caution with pregnant women in the supine position. The uterus can compress the inferior vena cava and thus decrease venous return to the heart with resultant syncope. Best to have the pregnant women lie more on the left side thus not allowing the uterus to compress the cava.Patients on steroids or with Addison’s disease requiring steroids need an increased dose to coverthe increased stress of a dental appointment. If this is not done complete vascular collapse may result. Prevention again is the most important preventative aspect.Have they fainted before at the dentist? What medications are they on?

With termination of long appointments, gradually upright the patient to help prevent anyorthostatic problems. This is especially true with elderly patients or those taking medications

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that have the side effect of orthostatic hypotension.

Pathophysiology

With changes in position the effect of gravity is intensified upon the cardiovascular system. Thesystolic blood pressure decreases 2 mm Hg for every inch above heart level and increases 2 mmHg for every inch below heart level. Mechanisms that maintain normal blood pressure when postural changes occur are: 1 ) arteriolar vasoconstriction - Baroreceptors 2 ) reflex increase in heart rate 3 ) reflex venoconstriction 4 ) increase in muscle tonus - venous pump (60% of the circulating blood volume is found in the venous system at any time) 5 ) reflex increase in respiration - increases venous return to the heart 6 ) release of various neuro-humoral substances. (epinephrine, ADH, renin,angiotensin) As a person stands, the systolic blood pressure drops slightly (5 - 10 mm Hg) and the pulse increases.

Management

1 ) Supine position and with pregnancy the left lateral position 2 ) Basic support airway breathing circulation 3 ) Vital signs and oxygen 4 ) Slowly upright position when patient recovers 5 ) Discharge patient

Acute adrenal insufficiency

Adrenal cortex secretes over 30 steroid hormones most of which lack any identifiable biologic activity of importance at present. Cortisol is considered one of the most important products of the adrenal cortex. It allows the body to adapt to stress.Addison's disease - lack of cortisol.Cushing's syndrome - excess of cortisol.Numerous diseases are treated with adrenocortical steroids at present. The adrenal cortex produces about 20 mg. of cortisol daily. In times of stress a much large dose of steroids are needed.

Equivalent does: mg. Cortisone 2 5 Hydrocortisone 2 0 Prednisolone 5 Methylprednisone 5 Methylprednisolone 4 Triamcinolone 4 Dexamethasone 0 . 7 5 Betamethasone 0 . 6

Patients should receive supportive therapy if;he/she has received as dose of 20 mg. or more of cortisone or its equivalent daily via the oral or parenteral route for a continuous period of 2 weeks or longer within 2 years of dental therapy.The patient's physician should be contacted to adjust the dose of steroids appropriately.

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Usually with minimal stress - double the daily dose *This is typical for an oral surgery appointment.moderate stress - 100 mg. hydrocortisone dailysevere stress - 200 mg. hydrocortisone daily

Clinical signs

mental confusionmuscle weaknessintense pain in the abdomen, lower back, legsextreme fatiguenausea and vomitinghypotensionsyncopal episodescoma

Again the medical history is most important in avoiding these problems.

With long regimens of exogenous steroids you get depression of the pituitary - adrenal axis. The patient thus cannot respond to stress by increasing the output of steroids.

Management

1 ) Stop procedure 2 ) Basic support and monitor vital signs 3 ) Oxygen 4 ) Call for help 5 ) Administer steroid (100 mg. hydrocortisone I.V.) 6 ) Transfer to hospital as needed

Diabetes Mellitus

Chronic systemic disease that affects most systems of the body, in particular neuropathy, microangiopathy and macroangiopathy.

Type I vs. Type II diabetes.

The following, which increase the body’s requirement for insulin, can precipitate hyperglycemia:

weight gainlack of exercisepregnancy (gestational diabetes)hyperthyroidism thyroid medication,epinephrine therapy, corticosteroid therapy acute infectionsfever

If untreated, hyperglycemia may lead to diabetic ketoacidosis in Type I diabetes or nonketotic hyperosmolar coma in Type II diabetics. Hypoglycemia can manifest itself very rapidly. Onset is slower with patientson oral hypoglycemics. Factors that decrease the requirements for insulin are: weight loss, increased exercise, termination of pregnancy, termination of other drug therapies (epinephrine, thyroid, corticosteroid), and

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recovery from an infection or fever. Most common cause is inadequate food intake. Prevention again is worth a thousand camels. Be sure to take a thorough and adequate medical history. Consult the patient's physician if any doubt exists.

Insulin dose needs to be adjusted if oral intake will be impaired after the procedure. Rarely, a patient will be admitted to the hospital for complicated extractions to have good control of the blood sugar levels. Transient periods of hyperglycemia tolerated better than periods of hypoglycemia. After extensive treatment, make sure the patient checks his glucometer readings at least 4 times a day and adjusts his insulin dose accordingly. Involvement of the patient's physician is a good idea before any problems develop.

Methods of testing blood glucose levels blood - dextrostix - glucometer

Clinical Manifestations

Hyperglycemia Hypoglycemia

polydipsia early stagepolyphagia diminished cerebral functionpolyuria changes in moodloss of weight decreased spontaneityfatigue hungerheadache nauseablurred vision more severe hypoglycemianausea and vomiting sweatingtachycardia tachycardiaflorid appearance piloerectionhot and dry skin increased anxietyKussmaul respiration bizarre behavior patternsmental stupor belligerenceloss of consciousness poor judgement

uncooperative

later severe stages unconsciousness seizures hypotension hypothermia

Management

1. Stop procedure2. Basic supportive care- airway, vital signs, oxygen3. Check blood sugar using glucometer4. Carbohydrate - oral, I.V. dextrose (50%), glucagon I.M. (1 mg)5. If recovers - implies hypoglycemic reaction - contact patient's physician and arrange appointment with him If doesn’t recover5 ) Continue supportive care and start CPR as needed.6 ) Call for help7 ) I.V. fluids and I.V. insulin drip

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8 ) Transfer to hospital

There will be other medical problems encountered in the dental office but these will hopefullybe identified before treatment commences by a thorough medical history questionnaire. One canthen proceed to reading the appropriate book to become familiar with the patient's disease aswell as consultation with the patient's physician. This will then prepare one for most problemsthat can or will be encountered.

Informed Consent

Upon completing the case presentation and receiving the green light to proceed, the student may not start any surgical care until the patient signs an informed consent form. The informed consent is an important part of a proper data base. It may be the only thing that keeps you from litigation. Note on your record the types of things you have discussed with your patient. Time and dated signatures of your patient, a witness, and yourself should appear in your records. Explain that they are about to have a small procedure performed but that it is a surgery hence there are some inherent risks and complications to each and every surgical procedure no matter how major or minor it is.

Initially discuss:

post operative pain, bleeding, swelling to the face occasional limitation of mouth opening.

Inform the patient to expect these for up to three days after the procedure and that normally these will decrease over the course of the forthcoming week. Then list the complications that tend to be less common in most cases, highlighting ones most relevant to the surgical site in question.

Temporary or even permanent numbness in the lower lip, gums, palate, teeth, cheek and the tongue following any surgery in the mandible

Oro-antral/Oro-nasal communications requiring additional procedure to correct them if they do not resolve with non-surgical therapy.

Displacement of a small part of a tooth, entire tooth or piece of bone into any sinus space or soft tissue space. These may or may not indicate additional corrective procedures.

Damage to adjacent oral structure including but not limited to teeth, fixed prosthodontics, gums, cheeks, tongue or lips.

Decision to leave a small piece of root in the bone when its removal would jeopardize any neurovascular structures

Postoperative infection requiring additional treatment Fracture of the jaw Adverse reaction to any of they medication administered and prescribed postoperatively. Development of TMJ problems and limitation in jaw movements Other complications relevant to individual cases

Give the patient time to read over the form and ask any questions. Be reassuring and explain that these are risks but that their incidence is limited and we do not anticipate encountering the majority of these during the procedure. However, your discussion with faculty should help to identify the cases where complications are more likely than in the “routine” case. These patients should be made explicitly aware of likelihood of the specific complications.

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A sample consent form for surgery and anesthesia is enclosed for your review. Please alter it to satisfy your practice style and your specific needs. It must again be emphasized that informed consents are absolutely necessary and must be part of any permanent record. Once the consent has been obtained verbally and in writing, proceed to the delivery of care. Remember, complications do occur and are inherent to oral surgery. Even the best skilled surgeons have cases that go less than smoothly. It is part of the game. So provide the patient with the most comprehensive consent and use good surgical technique. If you come up against any complications discuss these with the faculty for further management.

Radiological studies

Any visit to the oral and maxillofacial clinic should include review of pertinent radiographic surveys of the patient’s oral-facial structures. The most convenient survey for the purposes of basic oral surgery is the panoramic radiograph since it gives us an overview of all oral hard tissue structures, maxillary sinuses, mandible including the TM joint, as well as other perioral anatomy. Any third molar consultation or procedure require a panoramic radiographic to ensure adequate diagnosis and treatment planning. Also any alveloplasty, tori or exostosis removal and all bone biopsies will require a panoramic exposure of the jaws. Periapical films as well as occlusal films may be required to further aid in diagnosis and treatment planning. For single tooth extractions, excluding the third molars, periapical size 1 or 2 exposures will be acceptable if the entire tooth or structure is located on the film (including a 3-mm layer of supporting osseous structure). For cases where the tooth location has to be determined either an occlusal radiograph or two serial periapical views can be utilized. The radiograph must have been taken within last six months of the date if surgery in most cases. In more acute pathology or trauma cases new radiographs must be obtained. Radiographs older than six months will not be accepted except to compare with current radiographs in determining progression of disease over time. Any radiographs lacking or excessive in proper contrast, detail or density will not be acceptable and will require to be retaken. The oral surgery clinic is equipped with a portable X-ray unit and any periapical or occlusal films can be completed if required intra-operatively or post operatively. A developer is located on the clinic floor. No gloves, or contaminated materials are to enter the dark room. Remove the plastic covering from the film and hand it to your assistant for processing. However, panoramic surveys are to be taken in radiology on the first floor. Patients need to be escorted down to radiology, they are then signed in, and a radiology request must be completed. The patients can then bring the panoramic radiograph back to the clinic after it is developedFinally remember to use lead shields and use proper exposure settings.

Vital signs

Each patient seen at the clinic for any invasive surgical therapy requires their vitals checked. The vital signs include the blood pressures, heart rate, respirations and temperature. Commonly the stress and anxiety experienced by the patient perioperatively will have effects on their vital signs and these will need to be identified and treated differently from vital sign changes secondary to systemic pathology. Normal values for vital signs are listed below:

Blood Pressure: 120-140/70-90 Heart Rate: 60-80Temperature: 37 C Respirations: 12-18

Note: The entirety of your history and physical will be required for you to decide if the vitals are so aberrant to preclude treatment at that visit. Variations will be present in individuals secondary to age, fitness level and anxiety. Take those into consideration during analysis if the values fall outside above indicated ranges. Also

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do not relay on one set of measurements as there may be changes as the patient relaxes or becomes more agitated. Make sure your instruments are working properly and you are using appropriate technique i.e. right size of sphygmomanometer cuff for the girth of the upper extremity.

American Society of Anesthesiologists (ASA) classification

ASA I A normal healthy patientASA II A patient with mild systemic disease or significant health risk factors*ASA III A patient with severe systemic disease that is not incapacitatingASA IV A patient with severe systemic disease that is a constant threat to lifeASA V A moribund patient who is not expected to survive without the surgeryASA VI A declared brain dead patient whose organs are being harvested for donor purposes

Once the ASA classification of the patient is completed, it can be determined whether or not the patient can be treated on outpatient basis or what modifications to treatment protocol must be undertaken. For non-class I patients, it is necessary to chose one of three options: 1. Modification of treatment protocols** (i.e. anxiety reduction protocols, anxiolitic pre-meds, careful

monitoring intraoperatively) 2. Medical consultation3. Referral to OMFS specialist/ hospital based care

*Health risk factors: smoking, EtOH abuse, drug abuse, and obesity.**Usually that may be all needed in treatment of ASA II patient

Local anesthesia guidelines

Please be fully aware of all indications, actions, contraindications, adverse reactions and their management prior to using any medication. As dentists, the medications we use most often are local anesthetics. Along with antibiotics and analgesics these medications should be very well understood and utilized appropriately by the dental practitioner.This section will briefly consider the use of local anesthesia in the dental patient.Local anesthesia has been defined as a loss of sensation in a circumscribed area of the body caused by a depression in excitation in nerve endings or an inhibition of the conduction process in the peripheral nerves. The basic mode of action of local anesthetic has been greatly debated over the years. The current theory implies that anesthetics bind to receptors on sodium channel and interrupt the nerve conduction by decreasing the membrane’s permeability to sodium ions.The full discussion of pharmacology of local anesthetics is beyond the scope of the oral and maxillofacial surgery manual as it has been discussed in your pain control curriculum and pharmacology course, however we will reemphasize some areas with increased significance to oral surgery.

Local Anesthetic technique

Do not hesitate to use topical anesthesia prior to your injection, but use topical sparingly, since mucosal absorption can add to an overall toxic dose. Watch the benzocaine (ester) types, since these can precipitate an allergic response in those who are PABA sensitive (sunscreen sufferers). A note on local anesthesia: go for the major blocks and use a bit more local anesthetic than you think, the first time. A good suggestion is to use your lidocaine to deliver the initial punch, then extend its duration (comfort) with Marcaine. It has been found to be a good technique for prolonged comfort for my patients. Infiltration-type anesthesia can easily supplement your blocks (this hint may help you with your restorative procedures, since your procedures require much more profound anesthesia than surgical procedures) .

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A popular choice for a needle is the 1 1/2 inch 25 gauge with a plastic hub, providing for a better seal and the prolonging of the life of the hub of your aspirating syringe The most tragic sequelae to using a smaller needle, 27 and larger gauge, is breakage during injection. Please do not bury any needle to the hub; this could be a danger. The surgical procedure to retrieve this "foreign body" is horrible with a less than satisfactory success rate. Studies have also shown that muscle and soft tissue, particularly in the mandibular blocks may easily deflect small needles. This may account for unsuccessful blocks, so try a larger diameter needle . A bite block is used to stabilize your target area and landmarks, particularly with mandibular blocks. Many patients really like this technique because it gives them a "silver bullet" to bite on. Always when possible use the bite block to support the TMJs during surgery.

Overdose scenarios

Overdose reaction is related to the blood level of active local anesthetic.Factors that affect the rate at which the blood level is elevated and the time it remains elevated:

1. Patient factors These are the factors that alter the reaction of individuals to the same dose of drug a. Age Older and younger patients experience a higher incidence of adverse reactions. Absorption, metabolism, and excretion of drugs may be imperfectly developed or diminished. Higher levels occur because of an inability to properly clear the drugs. In patients 60 to 70 years old the half life of lidocaine was shown to increase by about 70% over a control group (22-26 years). b. Body Weight Generally the greater the weight, the larger the dose that can be tolerated. Related to the greater blood volume. Remember that the blood supply to fat is sparse. c. Presence of Pathology It may affect the ability to biotransform drugs. (ex. Liver dysfunction impairs breakdown of amide anesthetics). Renal dysfunction has little effect on local anesthetic toxicity. d. Genetics There are certain deficiencies that alter the response to drugs. (ex. Cholinesterase Deficiency – and ester local anesthetics) . e. Mental Attitude and Environment The local anesthetic seizure threshold is reduced in stressed patients. d. Sex

Importance only during pregnancy as renal function is decreased and this may impair excretion of certain drugs.

2. Drug Factors a.. Nature of the Drug Lipid solubility, protein binding, and vascular activity are important. More lipid soluble and protein bound anesthetics(ex. etidocaine, bupivacaine) are retained by fat and tissues at the injection site and thus result in slower systemic absorption than lidocaine or mepivacaine. Bupivacaine and etidocaine produce less vasodilatation than lidocaine or

mepivacaine.Lidocaine 2 % AmideMepivacaine 2 % Amide (with vasoconstrictor)Mepivacaine 3 % Amide (without vasoconstrictor)

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Prilocaine 4 % Amide Bupivacaine 0.5 Amide

Etidocaine 1.5% Amide

b. Route of AdministrationLocal anesthethics produce their clinical actions at the site and it is not necessary to get systemic absorption. Intravascular injection produces high blood levels in a short period of time thus a potential overdose reaction.

c. Rate of InjectionFaster rates of injection increase systemic blood levels.

3. Vascularity of the Injection Site. The greater the vascularity the more rapid the absorption. The oral structures are highly vascular along with the vasodilating properties of the agents suggests the need for a vasoconstrictor along with the local.

Metabolism

ESTERS are metabolized by pseudocholinesterase in blood then further in the liver AMIDES are metabolized in the liver by the microsomal enzymes

In patients with a history of liver failure, you may consider decreasing your doses of amide local anesthetics. important to use decreased doses of amide types.

1. Excessive Total DoseEven in a patient with a normal liver function, a large dose of local anesthetic may be absorbed into the serum more rapidly than the liver can remove it.

Recommended maximal local anesthetic dosages (Manufacture maximal dose is typically higher) Amides: LIDOCAINE – 4.4 mg/kg up to a max of 300 mg. (2% plain) - 7 mg/kg up to a max of 300 mg. (2% with constrictor) MEPIVACAINE – 4.4 mg/kg up to a max of 300 mg. (3% plain) - 6.6 mg/kg up to a max of 300 mg. (2% with constrictor) PRILOCAINE- 8mg/kg up to max dose of 400mg (4% with/without constrictor)

BUPIVACAINE- 1.3mg/kg up to max of 90mg (0.5% with constrictor) ETIDOCAINE- 8mg/kg up to max of 400mg (1.5% with constrictor)

Esters: PROCAINE –6mg/kg up to a max of 400 mg (2% multi dose vial only)

2. Rapid Absorption of Drug into Circulation Vasoconstrictor agents limit this factor. 4. Intravascular Injection

Especially important at the following sites: inferior alveolar-mental-PSA-ASA-BuccalRoute of entry is via retrograde flow and into the internal carotid system. Great care must be taken to aspirate before injecting (Harpoon syringes vs. self aspirating). Also consider the orientation of the bevel of needle: if it is lying against the wall of the vessel you will often see no aspiration even though the needle is in the vessel. With rapid injection tend to obtain higher and faster blood levels of injectables.

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N20 sedation

Nitrous oxide sedation can function as a great adjunct to standard pain and anxiety control. Patients tend to feel more relaxed, and the analgesic properties of N2O may aid in administration of local anesthetics.

Objectives of N20 application

1. Sedation2. Analgesia3. Maintenance of all reflexes

Side Effects

1. Nausea2. Perspiration3. Tinnitus4. Disinhibitions5. Exaggerated sounds6. Dysphoria

Contraindications

1. Pregnancy2. Nasal obstruction (relatively, since the gas is inhaled via a nasal hood)3. Potentiating medicaments4. Dead space such as bullous emphysema

Administration

1. Explain the process of sedation and its delivery to the patient2. Start with O2 at 8L/min3. After adjusting the tidal volume of the breathing bag start @ 20% N204. Adjust with 5% increments every 30 seconds5. Do not exceed 70% - some patients will not like the sensation of N20 at high levels and you will decrease

their anxiety by backing off on the conciliation6. When comfortable level is achieved administer local anesthesia7. When the procedure is complete leave O2 @ 100% for minimum of four minutes8. Scavenge exhaled N2O

IV sedation

The use of Intravenous Sedation is common place in the delivery of outpatient oral and maxillofacial surgery by certified specialists and general practitioners with advanced training in this area. Some exposure to IV sedation will be available during the clinical rotations in oral and maxillofacial surgery clinic. Please take time to familiarize yourself with armamentum, monitoring and medications used to deliver this therapy adjunct to the patient.

Review of anatomy and physiology of the oral cavity

The oral cavity, the initial portion of the digestive system, plays a functional role in both the ingestion and digestion of food. Through the act of mastication, food is mixed with saliva and broken down into smaller particles, which are subsequently transported to the stomach by the peristaltic muscle contractions of the

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esophagus. The oral cavity, an integral portion of the stomatognathic system, also functions in deglutition, speech articulation, and respiration. The oral cavity proper and the vestibule form the mouth. The vestibule is bounded externally by the lips and cheeks and internally by the alveolar process, gingiva, and teeth. Frenula join the upper and lower lips as well as the cheeks to the gingiva. The oral cavity proper is the more central region of the mouth and is bounded by the hard and soft palate superiorly; the tongue, lower jaw and mucosa of the floor of the mouth inferiorly; and the oral pharynx posteriorly.

Lips and cheeks

The lips and cheeks form the orifice of the mouth and are composed of four distinct tissue layers: an outer cutaneous, a deeper muscular, a submucosal glandular, and an inner-mucosal layer. Functionally, the lips and cheeks play an important role in mastication, assisting the tongue in the transfer of food between the vestibule and the oral cavity. Lip anatomy

The most prominent external feature of the lips is the vermilion mucosa, which merges with the outer skin to form a transitional region termed the vermilion border. Anatomic landmarks of theupper lip includes: a central philtrum depression, which is bordered by a left and a right philtrum column, and a curving region of the vermilion border called the Cupid's bow. The Cupid's bow unites with its opposite counterpart in the midline to form the vermillion tubercle. Internally, the vermillion mucosa merges with the oral mucosa forming the so-called "wet-dry" line. The submucosa of the lips contains the labial minor salivary glands. Cheek anatomy

The cheeks are structurally similar to the lips. They form the lateral borders of the mouth. The external skin and internal mucosal linings enclose the buccal fat pad and the principle muscle of the cheek, the buccinator. The parotid duct (Stenson's duct) pierces the mouth at the level of the upper second molar tooth. Buccal salivary glands are contained within the submucosal tissue.

Muscles of the lips, cheeks, and perioral region

The oral musculature includes muscles of the aperture and muscles of the lips and cheeks. The predominant muscle within the lips is the Orbicularis Oris, which encircles the oral aperture. Functionally, this muscle closes and protrudes the lips. Supplementary muscles of the face work in concert with the Orbicularis Oris to move the lips and the mouth. Five facial muscles converge at the angle region of the oral aperture. These muscles include the Levator Anguli Oris, Zygomaticus Major, Risorius, Platysma, and the Depressor Anguli Oris. Their fibers merge and interlace with fibers of the Orbicularis Oris. The Levator Anguli Oris arises from the canine fossa of the maxilla and inserts into the superior aspect of the angle of the mouth. Its function is to elevate the angle of the mouth. The Zygomaticus Major which joins the Orbicularis Oris on its lateral aspect, has its origin at the zygoma. It is the predominant muscle functioning during the act of smiling. Originating from the lateral facial fascia and joining together with the posterior fibers of the Platysma is the Risorius muscle. This muscle functions primarily during laughter. The Depressor Anguli Oris takes its origin from the anterior mandible and attaches to the inferior aspect of the angle region of mouth. Functionally, this muscle depresses the corner of the mouth. Additional muscles of the upper lip include the Levator Labii Superioris Alaeque Nasi, the Levator Labii Superioris, and the Zygomaticus Minor, all of which have their origin from the orbital margin and attach to the more central fibers of the Orbicularis Oris. These muscles function to elevate the upper lip. Two other muscles are contained within the lower lip. They are the Depressor Labii Inferioris and the Mentalis muscles. The Depressor Labii Inferioris arises from the anterior mandible and functions to depress the lower lip. The

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paired Mentalis muscles are situated between the left and right Depressor Labii lnferioris. Contraction of the Mentalis muscles produces puckering of the skin over the chin and protrusion of the lower lip. The principle muscle of the cheek is the Buccinator. It is continuous with the Superior Constrictor of the pharynx through its posterior connection with this muscle, forming the pterygomandibular raphe. Superiorly and inferiorly, the Buccinator attaches to the alveolar processes of the maxilla and mandible, usually below the apices of the teeth. The attachment of this muscle apical to the roots of the teeth is important clinically in that it serves as an anatomic barrier limiting the spread of odontogenic infection into the soft tissues of the face. The Buccinator merges with Orbicularis Oris of the upper and lower lips anteriorly. Contraction of this muscle produces cheek compression against the teeth, assisting the tongue in the positioning and movement of food during mastication. In addition, it has a functional role during blowing and sucking.

Nerve supply to the lips and cheeks

The facial nerve (cranial nerve VII) supplies motor innervation to the musculature of the lips and perioral region. It splits within the parotid gland into two major divisions, the temporofacial and cervicofacial. The temporofacial division terminates as the temporal and zygomatic branches. The cervicofacial division divides into the buccal, mandibular, and cervical branches. The zygomatic and buccal branches supply the upper lip and cheek musculature. The mandibular branch supplies the muscles of the angle of the mouth and lower lip. Sensory innervation to the lips and cheeks is derived from the trigeminal nerve (cranial nerve V). The infraorbital nerve, a branch of the maxillary division of the trigeminal nerve (V2), supplies the upper lip, mucous membrane of the cheek and the maxillary anterior labial gingiva. The mandibular nerve (V3) has several divisions: lingual, mental, buccal, and auriculotemporal. The mental nerve innervates the skin and mucous membrane of the lower lip and chin. The buccal nerve supplies the mucosa and skin of the cheek. Auriculotemporaal nerve supplies the TMJ and scalp. The lingual nerve supplies the tongue and lingual gingiva.

Arterial supply to the lips and cheeks

The facial artery, which arises from the external carotid, enters the face at the anterior border of the Masseter muscle. It then courses anteriorly and superiorly, crossing over the Buccinator and Levator Anguli Oris muscles. At the level of the angle of the mouth, the superior and inferior labial arteries originate. These vessels supply the upper and lower lips through an anastomosing vascular system, which encircles the oral aperture. A buccal branch from the facial artery as well as a buccal branch from the maxillary artery supplies the cheeks.

Gingiva

The masticatory oral mucosa that covers the alveolar processes of the maxilla and mandible is called the gingiva. It is composed of a stratified squamous epithelial lining, which overlies a dense lamina propria. Within the lamina propria, collagen fibers insert into the alveolar process and serve to attach the gingiva to the underlying bone. The gingiva extends from the dentogingival junction to the alveolar mucosa and can be divided into the free gingiva, the attached gingiva, and the interdental papilla. The free gingival groove separates the attached from the free gingiva. The mucogingival junction is the line of separation between the attached gingiva and the alveolar mucosa.

Alveolar process

That portion of the maxilla and mandible, which forms the osseous supporting structure for the dentition is called the alveolar process. The alveolar process is developed during tooth eruption and is maintained by the presence of functioning teeth. Resorption occurs upon the loss of the teeth. The alveolar processes are composed of two distinct regions, the alveolar bone proper and the supporting alveolar bone. The alveolar bone proper is that area that encompasses the tooth root and provides attachment for the suspensory fibers of

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the periodontal ligament. The periodontal ligament is composed of fibrous connective tissue, which serves to connect the cementum of the tooth to the alveolar process. The supporting alveolar bone is that component of the alveolar process that serves as a structural foundation sustaining the alveolar bone proper.

Dentition

The human dentition is made up of two sets of teeth, deciduous and permanent. In each jaw, the teeth are arranged in an arch form composed of a sequence of continuous occlusal surfaces. The deciduous dentition, which is usually complete by the age of two, consists of twenty teeth: eight incisors, four canines, and eight molars. The permanent dentition gradually replaces the deciduous dentition beginning approximately at the age of six. The permanent dentition consists of 32 teeth: eight incisors, four canines, eight premolars, and 12 molars. The predominant function of the teeth is to masticate food; however, they also play a minor role in speech articulation. The incisors (central and lateral) are shearing or cutting teeth. The canines are positioned distal to the lateral incisors. They also have an incising action but, because of their single cusp, are also able to pierce food and hold it in position. The premolars and molars are positioned posterior to the canines. As a result of their size and position within the jaws, they are the most efficient teeth for breaking down food into small particles suitable for swallowing. Each tooth can be divided into a crown and a root portion. The transitional zone between the crown and the root is called the neck or cervix. Internally, each tooth contains a pulp chamber, which continues down each root as a pulp canal. The pulp, or soft tissue component of the tooth, is composed of a connective tissue matrix supporting neural and vascular elements. It communicates with the periodontal ligament through an apical foramen. Surrounding the pulp chamber and canal as well as forming the bulk of the tooth is the dentin. The dentin is covered externally in the crown portion of the tooth by enamel and in the root portion by cementum.

Nerve supply to the gingiva, alveolar process and teeth The trigeminal nerve (cranial nerve V), via its maxillary and mandibular branches, provides sensory innervation to the teeth, gingiva, and alveolar processes of the maxilla and mandible. The maxillary division of the trigeminal nerve enters the pterygopalatine fossa after exiting from the foramen rotundum. Within this fossa, several branches are given off. The zygomatic nerve is the first branch. It enters into the orbit through the inferior orbital fissure. Ganglionic branches to the sphenopalatine ganglion are given off next. One or two posterior superior alveolar nerves are usually present distal to the ganglionic branches. They are the last of the nerve branches within the pterygopalatine fossa and enter the maxilla via the posterior alveolar foramina. The maxillary division continues anteriorly to enter the inferior orbital fissure and, from this point on, is referred to as the infraorbital nerve. The middle and anterior superior alveolar nerves originate within the inferior orbital fissure. The mandibular division of the trigeminal nerve emerges at the base of the skull from the foramen ovale, splitting into an anterior and posterior division. The posterior division divides to form the lingual and inferior alveolar nerves. The inferior alveolar nerve enters the mandible via the mandibular foramen. Its terminal branch, the mental nerve, emerges from the mental foramen. In the maxilla, the molars, their supporting alveolar bone, and the labial gingiva opposite the molars, are innervated by the posterior superior alveolar nerve. The middle superior alveolar nerve supplies the premolars and adjacent labial gingiva and alveolar process. In the anterior maxilla, general sensation to the canine and incisor teeth, as well as the labial gingiva and alveolar process opposite these teeth, is provided by the anterior superior alveolar nerve. The greater palatine nerve innervates the palatal gingiva and alveolar process opposite the maxillary molars and premolars. The nasopalatine nerve supplies the anterior palatal mucosa and alveolus from the canines to the central incisors. In the mandible, the inferior alveolar nerve innervates all of the teeth. The buccal nerve supplies the buccal gingiva, mucosa of the vestibule and the lateral aspect of the alveolar process in the posterior region of the

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mandible opposite the molars and premolars. Anteriorly, the mental nerve innervates the labial gingiva, mucosa of the anterior vestibule, and the alveolus adjacent to the canine and central incisors. The lingual nerve supplies the alveolar process, gingiva, and mucosa on the lingual aspect of the mandible as well as the mucosa of the floor of the mouth.

Arterial supply to the gingiva, alveolar process and the teeth

The maxillary artery provides the vascular supply to the mandible and maxilla including the gingiva, alveolar processes, and teeth. Originating from the external carotid artery within the parotid gland, the maxillary artery passes deep and medial to the subcondylar region of the mandible, and then enters into the infratemporal fossa. Within this fossa, the external pterygoid muscle serves as landmark, which can be used to divide the maxillary artery into three specific regions. The first part of the artery lies anterior to the muscle while the second part traverses across its surface. The third part of the artery is the terminal portion of the vessel that enters the pterygopalatine fossa. Branches of the first part of the maxillary artery include the deep auricular, tympanic, middle meningeal, accessory meningeal, and inferior alveolar arteries. The second part of the maxillary artery supplies the muscles of mastication as well as the buccinator. Vessels within this division are the masseteric, deep temporal, pterygoid, and buccal arteries. The terminal branches of the maxillary artery arise within the pterygopalatine fossa and include the posterior and middle superior alveolar, pterygoid, infraorbital, descending palatine, and sphenopalatine arteries. These vessels are accompanied by branches of the maxillary nerve and exit the fossa through foramina in the posterior maxilla. The greater palatine artery supplies the mucosa, glands, and gingiva of the posterior 2/3 of the hard palate. The nasopalatine artery nourishes the mucosa and gingiva of the anterior palate. The superior alveolar arteries provide vascularity to the gingiva, alveolar processes, and teeth of the maxilla. The posterior superior alveolar artery supplies the maxillary molars, supporting alveolar bone, and gingiva. The posterior maxillary labial gingiva and mucosa receive additional blood flow from the buccal artery. The blood supply to the premolars and anterior teeth, as well as their supporting alveolar bone and gingiva, is derived from the middle and anterior superior alveolar arteries. The anterior labial gingiva and mucosa also obtain a portion of their blood supply from the superior labial artery, a branch of the facial artery. The predominant blood supply to the mandible, including the teeth, gingiva, and alveolar processes, is derived from the inferior alveolar artery. Perforating blood vessels arising from the muscles that attach to its cortical surface provides additional vascularity to the mandible. The inferior alveolar artery enters the mandible through the mandibular foramen. It continues anteriorly within the mandibular canal giving off dental and septal branches that supply the molar and premolar teeth as well as the supporting alveolar bone and gingiva. Terminal branches of the inferior alveolar artery include the mental and incisive arteries. The incisive artery, through its dental and septal branches, supplies the anterior mandibular teeth, supporting bone, and gingiva.

The palate

The palate forms the superior boundary of the oral cavity. It is divided into two distinct regions, the hard palate and the soft palate. The hard palate forms the anterior two thirds of the palate and is bony in character. The posterior third of the palate is called the soft palate and is composed of muscles and the palatine aponeurosis. The hard palate is lined with a keratinized stratified squamous epithelium. Based upon the nature of the submucosal tissues, the hard palate can be divided into an anterior fatty and a posterior glandular region. Surface anatomic landmarks of the hard palate include the incisive papilla, anterior folds of mucosa called rugae, midline palatal raphe, and gingiva. The osseous portion of the hard palate is composed of the palatine processes of the maxilla anteriorly and the horizontal plates of the palatine a midline bones posteriorly. Palatal to the third molar two osseous foramina can be identified. The larger anterior opening is called the greater palatine foramen. The greater palatine vessels and nerves exit at this point. The smaller posterior opening is referred to as the lesser palatine foramen, in which the lesser palatine vessels and nerves emerge. The anterior palate also has an osseous opening, which is known as the incisive foremen. It is located in the midline just posterior to the maxillary incisors. The nasopalatine nerve and vessels traverse through this orifice.

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The soft palate, a pliable posterior extension of the hard palate, is confluent with the pharynx laterally. Posteriorly, it terminates as a free margin. The central pendulant portion of the posterior margin of the soft palate is called the uvula. Overlying the muscular layer of the soft palate is a surface layer of mucosa composed of non keratinized epithelium. Deep to the mucosa, a glandular submucosal tissue layer is present.

Muscles of the soft palate

The soft palate is composed of the confluence of five pairs of muscles; the Tensor Veli Palatini, Levator Veli Palatini, Palatoglossus, Palatopharyngeus, and Musculus Uvulae. The Tensor Veli Palatini originates from the scaphoid fossa, the spine of the sphenoid bone, and the lateral sides of the auditory tube. Its tendon wraps around the hamulus of the pterygoid joining in the midline with its counterpart from the opposite side to form the palatal aponeurosis. Its function is to tense the soft palate and open the auditory tube during deglutition. The Levator Veli Palatini has its origin from the petrous portion of the temporal bone and medial side of the auditory tube. Its fibers join in the midline with those of the opposite side. Contraction results in elevation of the soft palate. The Palatoglossus and the Palatopharyngeus muscles form the tonsilar pillars. The Palatoglossus, or anterior tonsilar pillar, arises from the anterior surface of the soft palate and inserts into the dorsum and lateral aspect of the tongue. Contraction of this muscle produces a decrease in the anterior opening of the fauces as well as an elevation of the tongue posteriorly. The Palatopharyngeus, or posterior tonsilar pillar, originates from the soft palate. It inserts on the posterior border of the thyroid cartilage and aponeurosis of the pharynx. Its function is to narrow the oro pharyngeal isthmus and elevate the larynx during swallowing. The final pair of muscles forming the soft palate is the Uvular muscles. Their origin is from the posterior nasal spine and palatine aponeurosis. They insert into the mucosa of the uvula. Functionally, these muscles elevate the uvula.

Nerve supply to the palate

The sensory nerve supply to the hard palate is derived from the nasopalatine nerve (anterior 1/3) and the greater palatine nerve (posterior 2/3). The greater palatine nerve arises from the pterygo (spheno)palatine ganglion within the pterygopalatine fossa. It descends within the greater palatine canal to reach the hard palate through the greater palatine foramen. The nasopalatine nerve, a branch of the maxillary nerve, departs through the sphenopalatine foramen, traverses across the roof of the nasal septum, and travels along the vomer within the mucoperiosteum. It exits through the incisive foremen to supply the anterior portion of the hard palate. The soft palate receives its sensory nerve innervation from two sources: the lesser palatine and glossopharyngeal (cranial nerve IX) nerves. The lesser palatine nerve, a branch of the maxillary nerve, arises within the pterygopalatine fossa from the pterygo(spheno)palatine ganglion, and exits through the lesser palatine foramen. It supplies general sensation to the soft palate.The glossopharyngeal nerve, via its tonsilar branch, provides additional sensory innervation to the soft palate. The motor innervation to all of the muscles of the soft palate, except the Tensor Veli Palatini, is from the pharyngeal plexus. The pharyngeal plexus is composed of contributions from the sympathetic, glossopharyngeal, vagus, and spinal accessory nerves. The Tensor Veli Palatini is supplied by motor fibers of the mandibular division of the trigeminal nerve (V3 ).

Arterial supply to the palate

The blood supply to the palate is derived from the greater palatine artery, the lesser palatine artery, the nasopalatine artery, and the ascending palatine branch of the facial artery. The greater and lesser palatine arteries originate from the maxillary artery within the pterygoidfossa. They descend within their own canals, emerging from the greater and lesser palatine foramina respectively. The greater palatine artery vascularizes the bone, mucosa, glands, and gingiva of the posterior 2/3 of the hard palate. The nasopalatine artery, a

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branch of the sphenopalatine artery, supplies the anterior third of the hard palate. The soft palate receives its blood supply from two sources, the lesser palatine artery and the ascending branch of the facial artery. After emerging from the lesser palatine foramen, the lesser palatine artery courses posteriorly to nourish the soft palate. The lesser palatine artery supplements the ascending branch of the facial artery, which provides the predominant blood supply to the soft palate.

Floor of the mouth

The floor of the mouth and tongue form the inferior boundary of the oral cavity proper. Inferior to the mucosa of the floor of the mouth is the sublingual space. This U-shaped region is bounded laterally by the body of the mandible, inferiorly by the Mylohyoid muscle, medially by the Geniohyoid, Genioglossus, and Hyoglossus muscles, and superiorly by the mucosa of the floor of the mouth. The primary contents of the sublingual space include: the sublingual gland, the sublingual artery and vein, the lingual nerve, hypoglossal nerve, the deep portion of the submandibular gland, and the duct of the submandibular gland (Wharton's duct). The sublingual space, which is, in reality, a potential space, is filled with a loose connective tissue matrix. It only becomes a true space when the loose connective tissue is broken down by an invading infectious process, such as occurs in Ludwig's angina, a cellulitis of the floor of the mouth usually arising from a carious lower molar. Anatomical landmarks of the mucosa of the floor of the mouth include: the lingual frenum, a fold of mucosa extending from the tongue to the floor of the mouth; two sublingual papilla, which are located just anterior to and on each side of the lingual frenum; the ducts of the submandibular glands, which open on each papilla; and the plica sublingualis, which is formed by the superior aspect of the sublingual gland. The plica sublingualis is actually a ridge of tissue extending posteriorly from the sublingual papilla. It contains between six and eight sublingual gland ducts that open along its crest. The sublingual space is bounded laterally by the lingual aspect of the body of the mandible. In order to understand the anatomic relationships of the sublingual space, it is important to review the medial surface anatomy of the mandible. Medial surface landmarks include: the inferior and superior genial tubercles, digastric fossa, mylohyoid line, sublingual gland fossa, submandibular gland fossa, lingula and mandibular foramen, mylohyoid groove, coronoid process, mandibular notch, mandibular condyle, and the areas of attachment for the pterygomandibular raphe and medial pterygoid muscle.

Muscles of the floor of the mouth

The muscles of the floor of the mouth form the medial and inferior borders of the sublingual space. The paired Mylohyoid muscles limit the inferior extension of the sublingual space and form the actual floor of the mouth. Originating from the mylohyoid line on each side of the mandible, they insert into the body of the hyoid bone as well as the midline raphe. The raphe extends from the hyoid bone to its attachment in the midline on the medial side of the anterior mandible. Functionally, the mylohyoids elevate the hyoid bone, the base of the tongue, and the floor of the mouth. The Geniohyoid, Genioglossus, and Hyoglossus muscles contribute to the medial border of the sublingual space. The Geniohyoid muscle, a paired muscle, takes its origin from the inferior genial tubercle and inserts into the anterior surface of the body of the hyoid bone. Contraction of this muscle elevates the tongue and hyoid bone. Originating from the superior genial tubercle is one of the paired Genioglossus muscles, one of the extrinsic tongue muscles. It has a dual insertion into the body of the hyoid bone and into the base of the tongue. Functionally, its posterior fibers protrude the tongue while the anterior fibers produce tongue retraction and depression. The Hyoglossus, also paired extrinsic muscle of the tongue, takes its origin from the body of the greater cornu of the hyoid bone. It inserts into the side of the tongue. Contraction of this muscle produces tongue depression.

Nerve supply to the floor of the mouth

The lingual nerve, a branch of mandibular division of the trigeminal nerve, provides general sensory innervation to the floor of the mouth, the anterior two thirds of the tongue, and the lingual gingiva of the mandible. After emerging from the anterior fibers of the medial pterygoid muscle in the posterior region of

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the mandible, it enters the floor of the mouth inferior to the Superior constrictor and superior to the Mylohyoid. In its course anteriorly, it crosses over the submandibular duct, traveling with the duct for a short distance on its lateral side. It then passes underneath and crosses the duct medially to enter the anterior portion of the tongue and sublingual region. The motor supply to the muscles of the floor of the mouth is derived from three different nerves. The mylohyoid nerve, a branch of the mandibular division of the trigeminal nerve, supplies the Mylohyoid muscle. The Genioglossus and Hyoglossus muscles are innervated by cranial nerve XII, the hypoglossal nerve. Cervical fibers from Cl, which join with the hypoglossal nerve, supply the Geniohyoid.

Arterial blood supply to the floor of the mouth

The arterial supply to the floor of the mouth, sublingual region, and sublingual gland is derived from the sublingual artery. The sublingual artery is one of the terminal branches of the lingual artery.

The tongue

The tongue, which is predominantly a muscular structure, functions in mastication, taste, speech articulation, and deglutition. The tongue is composed of an anterior portion called the body, or anterior two thirds of the tongue. It is separated from the posterior third, or root, of the tongue by a V-shaped line termed the terminal sulcus. Located at the angle of the terminal sulcus is the foramen cecum, which is a remnant of the thyroglossal duct. Developmentally, the anterior and posterior portions of the tongue are derived from different embryological structures. The body, or anterior two-thirds of the tongue, is formed from the floor of the developing pharynx and is predominantly of first branchial arch origin. The posterior third of the tongue has its origin from the third branchial arch, and is formed from the anterior wall of the developing pharynx. This dissimilarity in developmental origin explains the structural, topographical, and functional differences between the anterior two-thirds and posterior third of the tongue. The mucosa of the anterior two-thirds of the tongue differs widely in structure and is made up of four different types of papilla. The filiform papillae, which are epithelially lined connective tissue projections, give the tongue its characteristic appearance. Located on the dorsal surface of the oral portion of the tongue, they are slender thread-shaped structures devoid of any taste buds. Interspersed between the filiform papilla are red mushroom-shaped structures called fungiform papillae. They are red because their core is composed predominantly of vascular elements. They are only found on the dorsal surface of the tongue and usually contain between one to three taste buds. The vallate papillae are found in a V-shaped configuration in front of the terminal sulcus. They are circular structures, which contain many taste buds within the epithelium of their lateral surface. Located along the lateral border of the tongue are the foliate papillae. They are narrow vertical folds of mucous membrane and are not well developed in man. Taste buds, however, are contained within the epithelium of the foliate papillae. The mucosa of the posterior third of the tongue is devoid of papillae. The surface of the tongue in this area is composed of oval irregularly shaped structures, the lingual follicles. These follicles contain lymphoid tissue and are surrounded by a crypt. Mucous glands deposit their secretions into these crypts. Collectively, the lingual follicles form the lingual tonsil. The ventral tongue mucosa is smooth and papillae are absent. The lingual vein can be identified on each side of the under surface of the tongue.

Muscles of the tongue

The musculature of the tongue is composed of 3 paired extrinsic muscles and 3 paired intrinsic muscles. Separating these paired muscles and located in the midline is the septum of the tongue. The extrinsic muscles have their origin outside the body of the tongue. Therefore, contraction of these muscles can change the shape of the tongue as well move it bodily. In contrast, the intrinsic muscles originate and insert entirely within the confines of the tongue. The resultant contraction of these muscles can, therefore, only produce a change in tongue shape.

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The extrinsic tongue muscles are the Genioglossus, Hyoglossus, Palatoglossus, and Styloglossus. The Genioglossus muscle has a dual insertion into the body of the hyoid bone and the base of the tongue. Functionally, its posterior fibers protrude the tongue while the anterior fibers produce tongue retraction and depression. The Hyoglossus takes its origin from the body of the greater cornu of the hyoid bone. It inserts into the side of the tongue. Contraction of this muscle results in tongue depression. The Palatoglossus, the muscular component of the anterior tonsilar pillar, arises from the anterior surface of the soft palate and inserts into the dorsum and lateral aspect of the tongue. Functionally, this muscle decreases the anterior opening of the fauces and elevates the tongue posteriorly. The Styloglossus originates from the anterior border of the styloid process and inserts into the side of the tongue. Its function is to retract and elevate the tongue. The intrinsic tongue muscles are the Longitudinal, Transverse, and Vertical. The Longitudinal muscle is divided into a superior and an inferior division. The superior division arises from the submucous region of the posterior portion of the tongue. The inferior division originates from the inferior aspect of the tongue between the Genioglossus and Hyoglossus muscles. Both divisions insert into the tip of the tongue. Contraction of this muscle produces tongue shortening and the turning up of the tip. The Transversus has its origin from the median fibrous septum. It inserts into the dorsal and lateral portions of the tongue. Functionally, this muscle narrows and elongates the tongue. The Verticalis originates from the mucous membrane on the dorsum of the anterior tongue. It inserts into the under surface of the tongue. Contraction of this muscle flattens and broadens the tongue.

Nerve supply to the tongue

The sensory nerve supply to the tongue can be explained on the basis of the developmental differences that exist between the anterior two-thirds and posterior one-third of the tongue. Recall that the anterior two-thirds of the tongue are derived from structures of the first and second branchial arches (the mandibular division of the trigeminal and facial nerves, respectively). The posterior third is formed from structures derived from the third and fourth branchial arches ( the glossopharyngeal and vagus nerves, respectively) . Therefore, the third division of the trigeminal nerve, specifically the lingual nerve, supplies general sensation to the anterior two-thirds of the tongue. In addition, taste to the anterior two-thirds of the tongue is supplied from the chorda tympani (cranial nerve VII), via the lingual nerve. Both general sensation and taste to the posterior third of tongue are derived from the glossopharyngeal nerve. The internal laryngeal nerve, a branch of cranial nerve X, innervates the mucosa of the valleculae.The motor innervation to the musculature of the tongue both intrinsic and extrinsic, except the Palatoglossus, is provided by the hypoglossal nerve. The pharyngeal plexus innervates the Palataglossus.

Arterial supply to the tongue

The arterial supply to the tongue is obtained chiefly from the lingual artery. Arising from the external carotid artery at the level of the greater horn of the hyoid bone, the lingual artery passes deep to the Hyoglossus to enter into the tongue. Two dorsal lingual arteries originate posteriorly to supply the root of the tongue as well as the palatine tonsil. The lingual artery continues anteriorly, bisecting into two terminal branches, the deep lingual artery and the sublingual artery. The deep lingual artery vascularizes the anterior two-thirds of the tongue. The sublingual artery supplies the floor of the mouth.

ORAL WOUND REPAIR

The oral cavity serves as an entry portal into the body. It is therefore often traumatized by foreign materials as well as its own components of the masticatory system; namely the dentition. Understanding of the healing process will allow the practitioner to ensure optimal healing and reduce amount of complications associated with less then optimal healing conditions.

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Classification of wounds:

Oral wounds are classified based on etiology, mechanism of repair and the tissue injured.

Etiology of injury

Wounds will stem from either trauma or pathologic processes. The former injury will be caused from disruptive action of a physical or chemical agent. The physically induced injuries will stem from either surgical incisions, blunt masticatory trauma, radiation and temperature extremes or sharp masticatory trauma. Chemical agents capable of extensive soft tissue include commonly ingested substances such as aspirin or alcohol. The pathological processes such as neoplasias, bacterial or viral invasions as well as various systemic conditions (e.g. pemphigus vulgaris, benign mucous membrane pemphigoid, erythema multiforme, and aphtous stomatitis) will also be capable of inducing oral wounds.

Types of repairs

Wounds will heal by either primary or secondary intention. Primary intention can be accomplished readily in injuries where no tissue loss occurred (non-avulsive injuries). In these cases wound margins can be directly reapproximated and allow for rapid healing and minimal structural or functional deficits as well as limited scarring. In secondary intention healing, there has been a loss of tissue via excision, avulsion or other form of destructive processes. In these cases the wound margin may not be always re-approximated and the tissue will heal by growth of new subcutaneous and epithelial tissues.

Type of tissue involved in injury

The tissue types are divided into two main categories: hard and soft.In dealing with the oral structures the most important tissues are mucosa, skin, muscle, nerve and organ parenchyma(soft) and bone, enamel, dentin and cementum(hard). For the purposes of this discussion we will consider the healing of skin, bone and mucosa.

1. Soft tissue repair

The basis of mucosal or dermal healing is connective tissue restitution and the reepitheliazation of the tissue bed. The connective tissue upon exposure by injury will induce conversion of blood protein fibrinogen to fibrin and will initiate formation of net like matrix allowing for blood constituents to form a clot. This matrix will then allow for fibroblasts to lay down connective tissue scaffold, which when latter infiltrated by capillary endings will become granulation tissue.The area will undergo significant changes over the next several hours. Initial population of neurtrophils and lymphocytes becomes replaced by fibroblasts migrating from adjacent tissues. The fibroblasts will produce Glycosaminoglycans(though to act as mediators of cell function) and collagen ( responsible for integrity of the connective tissue bed). The collagen will replace damaged collagen, which is simultaneously being broken down by the cellular components namely fibroblasts and macrophages. This is known as the wound remodeling and often results in scarring. Within 48 hours the wound becomes infiltrated with blood vessels necessary for supply of nutrients. Patients who are anemic and have low hematocrits will tend to heal slower. The wounds will then undergo contracture and a net decrease in the size of the wound will occur. Specialized type of fibroblasts named myofibroblasts has been postulated to be responsible for the mechanical movement of the wound margins. The rate and extent of contracture will be related to two factors: formation of granulation tissue and mobility of wound margins. This process can be both favorable and unfavorable depending on the site of injury.

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2. Reepithelialization

The process involving the proliferation of epithelium adjacent to the wound margin starts within 24-hours of the injury. The epithelium will be initially cuboidal and as it thickens into layers it will produce the more classical stratified squamous appearance. The growth continues until apposition of epithelium occurs finalizing the initial repair process. Normally further remodeling will ensue with predominantly changes in the dermal layer.

3. Osseous healing

Most common mode of injury to osseous structures of the oral cavity is extractions. Also pathological lesions, fractures and other surgical care can induce trauma to the bones around the oral cavity. For our purposes we will concentrate on the model for extraction socket healing. Initially a clot is formed by extravasated blood and then subsequently replaced by granulation tissue. Leukocytic migration, fibroblastic activity and capillary budding are responsible for early repair within the first few days. The oral portion of the fibrin matrix has been found to have a higher content of PMN’s and plasma cell than the apex of the wound. The epithelialization commences within 24-hours in a manor similar to that of soft tissue healing. Further organization of the clot continues over the following few days. In the first week after injury there is bone production not in the socket itself but in the marrow spaces immediately surrounding it. At two weeks post injury there will be little evidence of new bone formation radiologically but histological survey will show some appositional bone deposition at the walls and the fundus of the socket. At three weeks a characteristic axial trabecular pattern will be seen. The inflammatory cells will continue to be present but slowly decrease in numbers. The subepithelial union will allow for connection of collagen fibers spanning the cemental structure of adjacent teeth. Some resorption will usually be seen at the alveolar crest. After four weeks bone will tend to occupy majority of the site although the lamina dura may still be visible on radiographs. Further bone deposition and resorption will continue in the socket as well as the buccal plate will be resorbed to expose the new bone. The lingual cortex is usually less affected. After 2 months the lamina dura will be completely lost and the bone will appear uniform. The epithelialization will also result in normal appearance of the mucosa. Abnormal wound healing

Two reasons for abnormal healing are failure to heal and excessive repair. These stem from systemic or local influences such as: infection, foreign bodies, poor nutrition, hypoxia, temperature extremes, drugs or pathological conditions.

Infections

Contamination of the site with microorganisms is common. However when the site becomes overcome with microorganisms the site becomes infected. Factors such as necrotic tissue, foreign bodies, and compromised host defenses are deleterious to healing and facilitate wound infection. Most important in prevention of wound infections are meticulous surgical technique, including debridement, adequate hemostasis and elimination of dead space. Prophylactic antibiotics in immunocompetent patients for most extractions do little to prevent infections.

Nutrition

Proteins and vitamin C are of primary importance. The patients who are malnourished will tend to have decreased fibroplasia and hence less collagen formation resulting in decreased wound tensile strength. Vitamin C is also important to collagen synthesis and degradation. The effect of ascorbic acid can also be important in maintaining the integrity of the healed site after the completion of reepthelialization.

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Oxygenation

Tissue oxygen levels are required for normal cellular respiration and also for cellular migration, protein synthesis, and collagen hydroxylation. Initially low oxygen levels are thought to stimulate collagen production.

Temperature

Hypothermia will result in ischemia and decreased tissue healing, conversely raising of temperature above 30 C will increase rate of tissue healing.

Other chemical agents and modulators of healing

1. Zinc- numerous enzymes are Zn dependent. Low levels decrease epithelialization and fibroblast proliferation. However high Zn levels will result in macrophage inhibition and decrease collagen cross-linking.

2. Hormones (a) Adrenocorticoids can suppress all phases of wound healing.(b) Hyperglycemia has generally been related to delayed wound healing. In well-controlled diabetic patients

there are fewer impairments in oral healing.

3. Anti-inflammatory agents have little effect on oral healing at the dosages used for post op analgesia.

4. Ionizing energy significantly impairs wound healing by destroying progenitor cells and decreasing the reproduction of normal reparative cells as well as neoplastic cells targeted. Vascular supply to these areas is often compromised especially in mandible. Hypobaric oxygen dives may aid in increasing healing potential by increasing post-radiation vascularity of the site. Special care must be taken in delivery of surgical care to the radiated sites.

5. Cytotoxic drugs impair cellular proliferation and metabolic functioning. It is believed that the delayed healing in these patients may also be secondary to a general state of debilitation.

6. Localized oral pathology – most relevant is neoplasms where persistent ulceration will persist as the tissues are not able to undergo normal healing process secondary to disturbance in cellular metabolism and regeneration patterns.

7. Localized traumatic influences must be removed to prevent chronic reinjury. Such can involve dentures, deleterious patient habits or fractured dentition.

Excessive wound repair

Hypertrophic scaring and keloid formation when the scar extends beyond the margins of the wound. Although less common then faulty healing processes the excessive healing can produce scaring beyond the margins of the wound. This is associated with excessive dermal collagen deposition and distortion in the architecture of the collagen matrix. Exact pathogenesis is still being investigated. There is a definite genetic predisposition as these are seen more often in patients of African and Asian lineage.

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Management of intraoral wounds

1. Make sharp, perpendicular to surface incisions long enough to provide adequate access with minimal tension and tearing of the tissues.

2. Attempt primary closure where possible. Tissues may need to be undermined to allow for primary closure.

3. Debride and cleanse the wound by curettage and copious irrigation.4. Prevent hematoma formation. 5. Close the wounds in layers where applicable.6. Use appropriate sutures and suturing technique.7. Place appropriate dressings8. Treat any complications that arise only if your intervention will increase the rate of healing.9. Remove any exogenous sources of irritation or delayed healing.

Exodontia

Estimation of Difficulty

The relative difficulty to be anticipated when performing exodontia is assessed through a thorough clinical and radiographic examination of the patient. By estimating the expected difficulty prior to surgery, the practitioner may plan for routine forceps/elevator extraction or complex exodontia. Surgery is always made easier if the appropriate equipment and support staff is present prior to the start of the procedure. Clinical assessment (clinical and radiographic examination) should include an evaluation of the following prior to surgery: 1. The crown—extent of coronal destruction, and type of restoration present are important determinants of difficulty. Generally, a large crown means a large root. If significant portions of the crown are missing, this will compromise the purchase point and necessitate more advanced techniques of extraction. Large alloy, composite, or full crown restorations also complicate the extraction procedure. 2. The supporting structures—the root size, shape, number, and presence of RCT are important determinants of difficulty. In addition, the supporting bone density, quantity and quality, as well as the amount of PDL space will influence difficulty. The presence of large divergent roots, multiple roots, invested in thick dense bone with a narrow PDL space, will increase the difficulty of the extraction procedure. 3. Adjacent structures—restorations or teeth that are malpositioned complicate forceps application and extraction. 4. Access—appropriate access to the dentition must be present for the proper application of forceps and elevators. Limitation in access secondary to prior trauma, burns, surgery, and pathologic conditions will complicate the extraction procedure. In addition, marked masticatory muscle trismus,

TMJ disorders, and the presence of a large protuberant tongue increase the surgical difficulty. A final assessment of difficulty is based upon the following:1. Access2. Clinical and radiographic evaluation3. Assessment of possible complications

Principles of exodontia

The safe and efficient use of forceps and elevators is achieved through controlled force. Controlled force implies no unnecessary injury to the adjacent teeth or supporting structures.

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The purpose of controlled force is to achieve adequate alveolar expansion, rupture of the PDL, and separation of the gingival attachment.

The use of controlled force when performing routine forceps extraction involves: 1. Appropriate forceps selection.2. Proper forceps application.3. The use of suitable forces for extraction.

The forces for extraction include the following: 1. Closing force—initiates forceps adaptation2. Apical force—continues forceps adaptation3. Lateral force—results in alveolar expansion4. Rotational force—separates the PDL

The use of elevators supplement forceps extraction. They are usually available in two basic designs: straight and offset. Their proper application involves both parallel and perpendicular application. Elevators can be used to test anesthesia, separate the epithelial attachment, and initiate expansion of the alveolus. Following extraction, the following post extraction procedures are recommended: 1. Examination of the alveolus2. Complete removal of all debris and pathology3. Smooth all bony surfaces4. Alveolar compression5. Patient postoperative instructions

Complex exodontia When the preoperative evaluation discloses inadequate crown structure, the presence of impacted teeth, abnormal root morphology, dense bony support, ankylotic teeth, or an impaired path of exit, more advanced surgical techniques successfully perform the extraction. Advanced techniques include the development of a surgical flap, osseous removal, and tooth sectioning.

Principles of surgical flap design include the following: 1. Maintaining adequate blood supply to the flap.2. The flap must be full thickness (mucoperiosteal).3. Flap size must be sufficient for proper access.4. The flap margins must be supported by bone.

In those clinical situations where the path of exit is impaired or when unusual crown, root, or supporting structure anatomy is present, osseous removal and tooth sectioning will be required to safely accomplish the extraction.

Complications Potential complications associated with routine and complex exodontia are known to occur. The following are the most common complications anticipated following exodontia:

1. Hemorrhage2. Infection3. "Dry socket"4. Osseous fracture5. Antral perforation

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6. Nerve damage7. Dislodgment into the soft tissues8. Subcutaneous air emphysema

Hemorrhage may occur during the extraction procedure or in the postoperative period. Local causes (osseous or vessel injury) and systemic conditions (liver or hematologic disorders) are the most common causes of excessive hemorrhage encountered during surgery and in the postoperative period.

Whenever excessive hemorrhage is encountered, the following plan of management is suggested:

1. The patient must be properly anesthetized.2. Appropriate lighting and instrumentation must be available. 3. All blood clots must be removed.4. The bleeding source must be correctly identified (capillary, venous, arterial, osseous, or soft tissue). 5. Definitive control of hemorrhage may include the use of:

a. pressure b. electrocauteryc. hemostatic agents

d. occlusive dressings (bone wax) e. production of an artificial clot (oxycel, surgicel, gelfoam) f. use of vasoconstrictor agents g. appropriate systemic evaluation and treatment of bleeding disorders

Dry socket, or localized osteitis, is a commonly encountered postoperative complication. Appropriate diagnosis is based upon clinical signs and symptoms. Most commonly, dry socket is diagnosed on clinical grounds alone when the following symptomatology is present: 1. Severe pain—usually beginning 2-4 days post-extraction. 2. Loss of blood clot—examination of the extraction site will usually disclose the absence of an appropriate blood clot and exposed osseous tissue is evident. 3. No signs of infection must be present, i.e.: fever, unusual swelling, or purulence. The etiology is essentially unknown, but is thought to be multifactorial. Factors known to contribute to a higher rate of incidence include: increased patient age, pathologic bacteria introduced at the time of surgery, difficult surgery, and the use of birth control pills. The incidence of dry socket has been reported, in the literature to range from 2.6% to 37.5%. The high level of incidence is associated with the extraction of mandibular third molars. Treatment is mostly empiric. Preventative measures such as atraumatic surgery, maintaining good oral hygiene, and the use of topical antibiotics decrease the incidence of dry socket. Supportive care aimed at decreasing pain, consisting of saline irrigation of the extraction site, proper drying, and the use of analgesic dressings (iodoform gauze/benzocaine-eugenol mixture) daily or on alternate days, is indicated.

Antral perforations are most commonly encountered when extracting maxillary bicuspids or molars. Accurate preoperative diagnosis and the use of controlled force will help prevent this particular complication. If entrance into the maxillary sinus is suspected, direct examination or the use of the nose-blowing test may help confirm the diagnosis. Treatment is based upon the size of the communication. The following is recommended: Communications less than 2.0 mm:

1. Assure quality clot formation (suturing, gelfoam)2. Institute sinus precautions (avoid pressure changes, nose blowing, smoking, sneezing, and the use

of wind musical instruments)

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Communications 2.0 to 5.0 mm:1. Assure quality clot formation

2. Institute sinus precautions 3. Medical management (decongestants, antibiotics, antihistamines)

Communications greater than 5.0 mm: 1. All of the above

2. Immediate vs. delayed closure

Subcutaneous air emphysema, although an uncommon complication, is important for the general practitioner to recognize, since its etiology is related to the use of air turbine handpieces. Clinically, the usual findings are a rapid swelling, which, if palpated, is crepitant, most commonly following third molar extractions. Differential diagnosis includes hematoma formation, infection, and allergic reactions. Treatment may consist of antibiotics, airway observation, adequate hydration, and ruling out chest involvement via a chest x-ray.

Corrective surgical procedures

A number of oral surgical procedures have been advocated for the purpose of creating an ideal ridge form prior to prosthetic rehabilitation or to eliminate abnormal muscle position. Some of the more common surgical procedures utilized today by the Oral and Maxillofacial Surgeon are frenectomy, vestibuloplasty procedures, with and without skin grafting, and tori removal.

Frenectomy

This preprosthetic procedure is indicated in the following clinical situations: 1. Denture impingement.2. Interdental diastema.3. Interference with speech.4. Restricted tongue movement.5. Retraction of the gingiva.

Surgical techniques generally utilize a wedge resection approach to frenectomy. This requires adequate muscle resection and/or lowering of the attachment.

Tori and exostosis removal

Tori are bony exostoses, which most commonly occur centrally on the hard palate or on the lingual cortex of the mandible adjacent to the bicuspid region.

Indications for removal include: 1. Interference with prosthetic treatment.2. Interference with speech.3. Chronic mucosal ulceration.

Maxillary tori should be radiographed prior to surgery to rule out the presence of pneumatization. Size and degree of lobulization determine the incision for maxillary tori. In the majority of cases, a midline incision over the torus is adequate. An alternative incision design, located in the anterior palate allowing a full thickness flap over the torus, may be used. In the majority of cases, the torus must be either divided, or sectioned at its base. Mandibular tori are approached most commonly through a crestal or lingual sulcular incision. A full thickness mucoperiosteal flap is raised, and the tori are sectioned and the lingual cortex appropriately contoured. These are more difficult to remove in the dentate mandible.

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Vestibuloplasty

Vestibuloplasty is a ridge extension procedure aimed at uncovering existing alveolar bone and repositioning the muscle attachments to a more superior position in the maxilla or inferior position in the mandible. The use of skin or mucosal grafts may or may not be necessary. Indications for vestibuloplasty procedures include the following:1. The presence of an atrophic ridge.2. When high muscle attachments are present resulting in attached gingiva retraction or interference with denture flange extension.3. In those cases in which there is inadequate vestibular depth.

Surgical Armamentarium

Extraction forceps

Maxillary forceps Elevators and Picks Centrals and laterals Periosteals #l CLASSIC ANTERIOR FORCEPS #9 ELEVATOR * #32 UNIVERSAL BAYONET BENNETT ELEVATOR #62 UNIVERSAL FORCEPS #150 BICUSPID FORCEPS Alveolar and dental Bicuspids #77R ELEVATOR * #150 BICUSPID FORCEPS STRAIGHT #301 ELEVATOR * Molars STRAIGHT #302 ELEVATOR * #62 UNIVERSAL FORCEPS CRYER/EAST & WEST ELEVATORS #32 UNIVERSAL BAYONET COGSWELL ELEVATOR #62 UNIVERSAL FORCEPS POTTS ELEVATOR #151 BICUSPID FORCEPS #8 CRANE ELEVATOR #lOS CLASSICAL UNIVERSAL #1 ELEVATOR #53R UPPER ANATOMIC RIGHT #1A ELEVATOR #53L UPPER ANATOMIC LEFT Other instrumentsMandibular forceps HEMOSTATS Centrals and laterals NEEDLE DRIVER * #145 SPECIAL ANTERIOR FORCEPS SUTURE SCISSORS * #151 BICUSPID FORCEPS TISSUE PICKUPS * ASH FORCEPS SUCTION TIP * Bicuspids RUSSIAN FORCEPS #151 BICUSPID FORCEPS MINNESSOTA RETRACTOR Molars IRRIGATION BASIN * #23 CLASSIC "COWHORN" FORCEPS SCALPEL HANDLE * #62 UNIVERSAL FORCEPS WEIDER RETRACTOR #222 3RD MOLAR UNIVERSAL MIRROR * #151 UNIVERSAL FORCEPS #17 MOLAR FORCEP* denotes student tray components

Surgical Technique Establish a methodical technique. Double and triple check the tooth to be extracted with your charting (your staff should be part of this valuable review). Liability insurance carriers have noted that this is still one of the most frequent causes of litigation, based upon the sheer number of cases.

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After your administration of profound anesthesia and appropriate placement of a bite block, use your periosteal elevator to expose the junction between the tooth and the bone. Trying to extract a broken-down tooth that is not fully visible damages much more soft tissue. Simple flaps are much easier to close and heal much more quickly than macerated tissue. It is preferred to start generally with a conservative muco periosteal flap that is elevated around the necks of the teeth.

Minimal bone removal or section of the offending tooth may be prudent at this point. This may reduce the chance for greater bony plate damage later in the procedure. When removing bone, try to remember the overall goal of treatment and the area where bone conservation is critical.

In many clinicians’ estimation, the dental elevator is THE utilitarian instrument. Most commonly, you’ll use a 77R. By using proper elevation technique, many teeth can be removed without the use of forceps. It is important to remember that the elevator must be used for good and not evil. That is to say one can only elevate a tooth using the alveolar bone as your fulcrum, not the adjacent teeth. Try driving the tooth towards an EMPTY space (unless you are doing a complete edentulation, you will want to elevate only one tooth at a time. Anyone can generate sufficient force to fracture a jaw. Forceps that are well adapted to the tooth and will be fully visible by you and your assistant should be selected so that adjacent and opposing teeth will not be injured. The primary hazard in using full-size forceps on children is the injury to the unerupted permanent tooth bud below the deciduous tooth being removed but, by taking reasonable care, this should not be a problem.

Know your own limitations. Set and stand by an absolute time limit for your surgical/extraction procedures. It is strongly encouraged that you to refer your patient sooner than much, much later (swallow that ego and make a logical decision on behalf of your patient). According to a study in journal of AAOMS the AVERAGE time that a patient has undergone some sort of surgery before he/she is referred to a specialist’s office is 3 hours. This is abusive. Proper referral procedures should include a description of the procedure attempted, pre-operative radiographs, and perhaps even the fragments of tooth that you were able to remove. If the procedure has been particularly traumatic for the patient, it is prudent for you to offer to cover the surgical expenses in order to maintain your rapport with your patient.

Surgical blade selection and their use

The most commonly used scalpel blade is the #15 blade, since it is easy to control and possesses less of a threat to adjacent structures. The small, curved cutting surface allows you to see the full extent of the tissue contact area.. It is advised that you do not lose sight of the blade at any time and use a minimum amount of pressure to accomplish the incision.

The longer blade handle is of help since you will not obscure the field with your own hand. Always attach or remove surgical blades with a hemostat or needle holder. You may choose to purchase assembled blade and handle units, but these are a bit expensive.

Osteotome (Chisel) usage

Chisels are valuable assets to your surgical tray. You can remove a small amount of bone using them like an enamel chisel (make sure they are sharp enough) or, with minimal and judicious malleting, a larger amount of bone can be removed. Be aware of the adjacent structures: a chisel can inadvertently "drive" a tooth into the sinus or below the mylohyoid muscle. One can split or section a multirooted tooth, as well as, fracture the angle of the mandible or a maxillary tuberosity. Make sure you have a "stop" planned for your chisel and try to be the one wielding the mallet. One can make a chisel for small osteotomies out of an endo or #24 cement spatula or a commercial variety can be purchased. The use of chisel and mallet should be only attempted by experienced clinicians and usually to treat sedated patients.

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Surgical burs and their useages:

Some clinicians prefer using round burs of various configurations and sizes, but most surgeons believe one can do a better job by troughing and sectioning with a straight fissure bur (usually a #301, #302, #556 or #560 carbide). Try using this bur for yourself and you will note more efficient cutting with better overall visibility. It is suggested that a high-torque straight handpiece of some sort be used (Hall and Stryker are most popular), with plenty of irrigation (saline is preferable). Post-surgical irrigation is mandatory prior to suturing, etc., since this will remove all fragments of enamel and bone, which appear to be an irritant to the soft tissues.

Suture materials

The selection of suture material is up to your own personal style. The suture materials are available as either resorbable or non-resorbable/monofilament or multifilamentous form. Resorbable sutures are reactive and can evoke inflammatory reactions, thus they are generally not used to close the skin wound.

Gut and chromic gut materials are good absorbable materials. Some clinicians find them a bit difficult to handle. Gut is a good material in patients you would rather not have to challenge with a suture removal visit, e.g., children. You can be assured that the material will not be present after the first week to 10 days after placement.

Dexon 3-0 and Vicryl 3-0 are absorbable sutures that tie as easily as silk. They have displayed a variable (2-3 weeks) absorptive pattern in the mouth.

Non-resorbable suture includes silk, polypropylene and nylon. Silk is available only in a multifilamentous form, polypropylene in monofilimentous form and nylon is available in both forms. Multifilamentous form allows for increased suture strength but is more likely to collect debris and increase risk of infection. Of the non-resorbable sutures, silk evokes the most intense inflammatory response and should not be used for facial lacerations. Nylon or polypropylene as the suture materials of choice for skin.

As far as needle size is concerned, choose the larger half-circle when spanning the distance between the edges of two flaps, as in 3 rd molars. Smaller needles can be used where space is at a premium, as in the palate. The two most popular styles of needles are the so called "atraumatic" and the cutting. The atraumatics are round to oval in cross-section and tend to be a bit more difficult to pass through the tissues. The cutting varieties come in the standard and the reverse type. These needles are triangular in cross-section the apex of which is on the outer part of the curve in the reverse cutting style (this design is supposed to reduce the tendency for the suture to tear through the flap).

Sutures may be purchased either as a unit or as free needles and spooled thread, depending upon your need. Your usage pattern and pocketbook will determine which you choose.

Suturing techniques:

As a general rule place a suture if you have ANY question as to whether it is needed or not. A curved needle holder is worthy of consideration since it may help you get into those "hard-to-reach" areas. To allow for good control over the needle use needle holders and not hemostats. A good suggestion for suture scissors is either a curved or an angled pair of tissue scissors, since it can be of multiple use.

The single or interrupted is the most useful type of intra-oral suture. This allows the clinician to control discrete areas (inter-dental suturing and simple mucosal closures). Over a long closure, variable flap tension is a valuable feature of multiple interrupted sutures.

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In the closure of a palatal flap (used for exposure of impacted supernumerary teeth), use multiple interrupted sutures that begin deep in the palate and which are tied off in the facial interproximal areas. This creates rather long sutures that will help reduce hematoma formation.

The horizontal mattress suture is useful in everting the wound edges. This suture is used to insure mucosal closure over implants, antral openings, etc.

The continuous-locking (continuous-horizontal mattress) or the e blanket stitch suture is useful in closing a long area of mucosa over the edentulous ridge (immediate dentures, multiple extractions, etc.). This self-adjusting suture allows the tissues to distribute the edema over the length of the incision. A variation on this theme is the sling suture. This type of suture is useful in periodontal surgery.

The continuous-running suture is useful if you need to close a long span and are not too concerned about wound-edge closure.

Post op management

Post-operative instructions:

If you value your sleep and privacy, a few extra moments spent with the patient and his/her family discussing post-operative instructions will save your sanity. Each patient who has received surgical care must receive post-operative instructions both written and verbal, gauze packs for pressure hemostasis. The standard written instruction sheet is included in the form index of this manual.

Be sure to inform the patient that they will experience the following four routinely expected squelae:

Pain up to one week Minor bleeding over the next 24 hrs. Swelling up to one week Limitation in the opening of the mouth up to several weeks

If a follow-up visit is required, make sure that the patient books the visit with the receptionist prior to leaving the clinic. Ask the patients if they have any further questions or concerns. Before discharging the patient make certain that the faculty has signed the final check on the procedure sheet and ensure that all pre-scriptions are correctly completed and signed. Exodontia sponges should be provided to your patients as well as a clear set of instructions as to their use. An adequate amount of sterilized sponges should be given to the patient for post operative bleeding control, based upon estimated bleeding potential. Analgesics are a must but a prescription should not be given to everyone who has had surgery. Do suggest to the patient that they may start at the lower end of the analgesic spectrum with an OTC medication if the completed procedure was quick, simple and limited tissue was disturbed. Thank the patient for choosing our clinic for delivery of his care and remind them to call the numbers, listed on the written post-operative instruction handout, if they should have any further questions or problems.For further discussion of pharmacological management of post operative pain and infections refer to the later section on analgesic and antibiotic therapy guidelines.

Post-operative complications

Infections

The major problems that is encountered with clinicians and antibiotic administration are the following: ( 1 ) inadequate dosage, (2) the changing of antibiotics, and (3) the limiting of coverage (fixed therapeutic time).

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If an infection is suspected, give a loading dose of antibiotic, usually penicillin. Begin with a dose of 1 gram with an average divided daily dose of 2 grams (500 mg q.i.d.). A 7 day course is typically required. Follow-up with the patient in 24-48 hours. Another good choice is Clindamycin, 300mg qid, especially for the penicillin allergic patient. Again, give a good loading dose and give enough to be therapeutically significant. Do not be seduced by the drug company representatives, take their gifts and use what works. The new generation cephalosporins and combination agents are very expensive and not worth the difference in price in treatment of oral infections. For further discussion of antibiotics consult the section on guidelines of antibiotic therapy.

Bleeding

Bleeding is a frightening thing for the patient and their families, so try to treat it as such. The first level of involvement is to check if the patient has actually used the surgical gauze properly. Usually, the patient checks the gauze for bleeding every 5-10 minutes and not allowing the pressure and normal hemostasis to take effect. Advise the patient to place the gauze over the bleeding area with pressure for 45 minutes non-stop. If this does not help, see the patient in your office.

In most cases, by the time the patient arrives at your office, the bleeding will have ceased. If not, one can begin with an evaluation of the area using good light and suction. A local anesthetic with a vasoconstrictor will go a long way toward control. If you have generalized socket bleeding, pack the socket using Gelfoam (use a very firm packing technique; do not allow the material to float out). Suturing at this time may help contain the packing. The patient should be encouraged to limit their diet to mechanically soft foods and, if bleeding is persistent, only liquids for the 24-48 hours.

Management of oral surgical patients with bleeding disorders

Management of the surgical patient who has bleeding disorders requires the understanding of the normal homeostatic process and the patient’s specific coagulation system. Need for appropriate preoperative replacement therapy exists as well as choice of conservative therapy options along with local hemostatic measures.

Procedures that are likely to induce bleeding are:Flap surgeryNerve blocks (IAN, PSA)Extractions

The hemostatic system

A series of complex reactions between plasma, platelets and endothelial lining of blood vessels prevents blood loss through fibrin clot formation. Initially smooth muscle contracts to yield vascular constriction and decreased local circulation. Secondarily platelets aggregate and adhere to exposed collagen at site of injury.Their contact with collagen results in release of arachidonic acid to direct synthesis of prosthoglandins, endoperoxidases and thromboxanes. Thromboxane A2, produced through the action of cyclo-oxygenase on arachidonic acid, enables platelet to release ADP and serotonin aiding in further aggregation of platelets and vasoconstriction respectively.Following the initial aggregation platelet membranes expose receptor sites and activate the coagulation system.

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Coagulation

Via either the intrinsic or extrinsic pathway the conversion of fibrinogen to fibrin results in coagulation.

The extrinsic pathway is triggered by a substance elaborated at he injured site. Essentially tissue thromboplastin acts with factors VII, X, V, and Ca++ to convert prothrombin to thrombin. Quantitatively it is the smaller of the two pathways but it aids in the aggregation of platelets and enhances the outcome of the intrinsic pathway.

The slower intrinsic pathway generates majority of thrombin required to convert fibrinogen to fibrin. The cascade is stimulated by factor XII (Hageman’s) which circulates and becomes activated by contact with a foreign surface antigen or collagen, activated platelets, phospholipids, or vascular basement membrane. The process ultimately yields fibrin. Factors involved in the intrinsic pathway are XII, XI, IX, and VII.

The common pathway is the part of the clotting cascade that is shared for both the intrinsic and extrinsic pathways. It involves factors X, V, I, XIII.

Fibrin monomers are stabilized to maintain a fibrin clot by factor XIII. In subsequent healing the fibrin clot is broken down as a part of remodeling response by factors XII, XI, proteolytic plasminogen and activators from endothelial cells through synthesis of plasmin from plasminogen.

Bleeding Disorders

Specific and detailed history must be obtained to elicit any past history of bleeding episodes, which have occurred secondary to injury, dental therapy, surgical therapy, epistaxis, or menorrhagia. In addition, a list of all current medications including over the counter medications must be compiled.Hemostatic disorders can be inherited or acquired with the acquired being more prevalent. The most common causes of the acquired disorders are pharmacological agents, kidney, liver or other systemic diseases.

Effects of pharmacological agents

Warfrin (Coumadin) is often used in prophylaxis of pulmonary embolism and venous thrombosis, atrial fibrillation and embolization as well as in some post-operative scenarios. Its action is to inhibit the vitamin K dependant production of clotting factors II, VII, IX, X. In adults the dosages are tittered to achieve an INR of 2.0-3.0 for most cases. In prosthetic heart valves the INR is desired to be at 2.5-3.5. Overcoumadization can result in spontaneous bleeding at values of INR greater than 5.0. The onset is action is 8 to 12 hours with maximum effect at 36 hours. The effects of therapy will persist for up to 72 hours after drug is stopped.

Heparin is a commonly used treatment and prevention of venous thrombosis, pulmonary embolism, atrial fibrillation, with emboli formation and acute arterial occlusion. It inactivates thrombin and thromboplastin. Because it mostly affects the extrinsic pathway you should evaluate PTT or activated clotting time. Clinical effectiveness I usually achieved at 1.5-2 times the control.

NSAIDS-inhibit cyclo-oxygenase pathway and production of thromboxane A2 essential for platelet aggregation. The effects can be prevalent to dosage as small as 300-600 mg and last for the lifespan of the platelets (9-12 days). Normally normal platelet count will be seen with prolonged bleeding time. Similar lab findings are seen in Von Willebrand’s disease (factor VIII).

Diagnosis of drug induced thrombocytopenia can be made on the basis on correlating onset of the thrombocytopenia and the drug administration. Treatment will involve discontinuation of the agent and the platelets will normally return to baseline levels in 7-14 days

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Auto-immune thrombocytopenias result from accelerated platelet destruction mediated by platelet antibodies. Most are patients will suffer from the Idopathic Thrombosytopenia Purpura, characterized by platelet specific IgG. Treatment of these cases involves glucocorticoids, and if not responsive may require splenectomy and other immunosuppressive agent to be administered.

Pregnancy-associated thrombocytopenia usually seen in 5 –10 % of pregnancies but these are rarely of great post-natal significance. Mothers with past history of ITP may benefit from glucocorticoids.

Kidney disease such as chronic renal failure can cause the coating of the platelets with metabolic byproducts such as succinic and phenolic acids and render the binding sites non-functional. Additionally due to protein depletion the clotting factors may be decreased in quantity. HIV-positive patients are potentially likely to develop thrombocytopenias similar to ITP. AZT and lower than ITP corticosteroid doses are often applied in treatment.

Autoimmune diseases, chronic lymphocytic leukemia, lymphomas, infectious mononucleosis as well as some viral infections can also precipitate thrombocytopenia.

Vitamin K deficiency

Liver disease or vitamin K deficiency will affect the production and levels of all coagulation factors with the exception of VIII. The vitamin K is necessary for the synthesis of factors II, VII, IX, and X. Hence if factor V is not deficient compared to the other factors the cause is related to Vitamin K deficiency, however if all factors are deficient liver disease can be implicated. These patients are difficult to treat and if required will need vitamin K and FFP or platelet transfusion if the former two do not resolve the crisis.Vitamin K is necessary cofactor in hepatic gamma-carboxylation of glutamate residues of factors II, VIII, IX, and X. Normally PT will be prolonged. Conditions associated with Vitamin K deficiencies include: biliary obstruction, malabsorbtion, antibiotics, nutritional deficiencies, and warfarin ingestion. This can occur in hospital patients who are malnourished and are on antibiotics in as little as two weeks.

Treatment with vitamin K and FFP in cases of severe hemorrhage are indicated.

Inherited Bleeding Disorders

Deficiencies of factors VIII (Hemophilia A) and IX (Hemophilia B) are X-linked disorders which tend to have similar clinical presentation. Spontaneous bleeding will occur in the hemophiliac patient whose factor levels are less than 1% of control values (severe hemophilia). Patients with mild form (1-4% of normal factor levels) will tend to have less spontaneous bleeds and tend to have problems with trauma or surgical wounds if not managed appropriately. Mild hemophiliacs quite often will go undetected and will rarely have any bleeding problems. The typical laboratory values will be inclusive of an elevated PTT, normal INR, PT and bleeding time. Treatment of these patients should be delivered in conjunction with a hematologist and involve factor replacement.

To calculate replacement dose for factor VIII use the following formula:

Dose (units)= (desired % activity – initial % activity)X (weight in kg)/2

For factor IX the value is to be doubled since it has a greater extravascular distribution.

Fresh Frozen Plasma- contains all coagulation factors in approximately normal concentration. Can be used to treat Hemophilia A & B, but factor IX concentrate is better for B variety therapy. Factor IX may not be treated with viral inactivators.

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Cryoprecipitate- contains factor VIII, vWF and fibrinogen. One bag has approximately 100 units.

Factor VIII is the preferred choice of factor replacement for severe A type hemophiliacs. It also contains small amounts of vWF and is treated with viral inactivators . Recombiant VIII is also available but has been associated with greater incidence of immune reactions.

Factor IX concentrates- are highly purified, viral inactivated and have lower rates of DIC in hemophilia B patients making them a preferred choice for these patients.

In addition to factor replacement the use of desmopressin acetate in mild Hemophilia A patients has netted a four fold increase of factor VII.Epsilon-aminocaproic acid (EACA) an inhibitor of fibrinolysis can be used on the day of the surgery at dosage 50-100mg/kg PO or IV q6h for 3-5 days (maximal daily dose 24g)

For Hemophilia B patients minor bleeds can be treated with FFP but the more severe problems require higher doses of factor IX.The main concern in transfusing these patients is viral contamination hence single donor samples and specific, purified and viral inactivated agents are preferred.

Von Willebrand Disease is an inherited autosomal disease characterized by prolonged bleeding, decreased levels of ristocetin cofactor activity and variable deficiency of factor VIII. Typically PTT will be prolonged and the patient may experience hematomas and hemarthrosis. The treatment involves desmopressin acetate (DDAVP) (vWD type I and IIa only) or cryoprecipitate.

Other inherited coagulopathies 90 % of all inherited coagulopathies involve the above mentioned forms. The occurrence of other factor deficiencies may be considered in cases where factors VIII, IX, and vWF are normal and bleeding is not explained otherwise. Treatment with FFP is usually effective.

Laboratory work-up

Laboratory tests that are useful to determine a patient’s coagulability status are the INR, PT, PTT, platelet count, bleeding time, thrombin clotting time, and clot stability testing.

INR-International Normalized Ratio gives a standardized value for PT and measures the integrity of the extrinsic system factors V, VII, X and the common pathway factors V, II, I. Normal value: 1-2.

PT- prothrombin time may vary from lab to lab and day to day secondary to the source of reagents.Normal values vary but tend to be 12-14 avoid treating patient with values greater than 18. Always check the INR.

PTT or APTT- partial thromboplastin time gives insight into the integrity of the intrinsic pathway (Factors XII, XI, IX, VIII, X) Values should be less than 45sec.

Thrombin clotting time- measures the rate of fibrin formation when thrombin is added to plasma. Normal values are 15-18. Patients with values of 30 or higher may fail to clot post op.

Clot stability determines the activity of factor XIII. Normal clots will remain stable when subjected to 5molar urea or 1% monochloracetic acid.

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Platelet count- gives the severity of thrombocytopenia. Be aware of qualitative vs. quantitative differences. Normal values are expressed in 1000’s hence they range from 200-400. Thrombocytopenias are severe at 10-20 or mild at 60-100. Do not treat patients with counts less than 50.

Specific factor assays- measure the ability of patient’s plasma to coagulate. Values are in % of activity of normal samples and range 60-160%.

Parting thoughts:

All bleeding eventually stops.

Pain and incidence of “dry sockets”

The so-called "dry socket" or alveolar osteitis is a very painful condition. It may be beneficial (no vigorous curettage) irrigate the socket, and place a topical anesthetic type packing (use a magic mixture of your choice placed on iodoform gauze or a gelfoam). Remember, these patients are not eating properly and should be encouraged to maintain a high level of nutrition and fluid intake. Antibiotics are not necessary.

The surgical management of alveolar osteitis should be in conjunction with effective use of analgesics. Agents such as Tylenol#3 should be considered as first line agents. Remember, the pharmacological families of the analgesics; that is, that Vicodin is very similar in nature to Tylenol and codeine, though some patients may tolerate it better. You may use Vicodin and Vicodin ES in some patients who have used these drugs successfully and who request these agents. An alternate drug for those who have problems with codeine and codeine-like derivatives is Talwin(only one dosage form).

Do not forget that you are always able to give an appropriate local anesthetic to block the painful area. This may eliminate the pain cycle .

Infections of odontogenic origin

Principles of diagnosis

Acute infections of odontogenic origin may be primarily related to dental or periodontal disease or, they may occur secondarily following exodontia or surgery. Regardless of the specific etiology, essential aspects of diagnosis and treatment must be implemented to assure proper treatment. Accurate diagnosis involves the following: 1. An appropriate history: eliciting the onset, character, and location of pain and swelling, the presence of trismus, chills, fever, or airway compromise. 2. Physical examination:

a. Inspection—for swellings, fistula; examination of the dentition and periodontium. b. Palpation—evaluating areas of tenderness, size of swellings, detection of lymph nodes, salivary

glands and their ducts, and detecting the presence of fluctuance.c. Percussion—evaluate the presence of dental hypersensitivity.

3. Radiographic and diagnostic imaging: various studies available for diagnosis include: —Plain film radiography, computerized tomography, radionucleotide imaging, magnetic resonance imaging 4. Laboratory studies: are essential in the diagnosis and treatment of odontogenic infections. Numerous laboratory tests are available to the clinician such as: Gram stain, quantitative tissue smears, culture and sensitivity testing, wet preparations, immunologic techniques, blood cultures 5. Transport of specimens: accurate diagnosis is dependent upon proper transportation of specimens collected during surgery. The most precise method would be collections of aspirated material for study. However, most commonly, specimens are obtained utilizing swaps and transporting the specimen in a transport media. It is important that the clinician have the appropriate collection materials available at the time of surgery.

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6. Assessing antimicrobial activity: empiric therapy is begun, based upon the knowledge of the organisms that are most commonly associated with such infections. Definitive antibiotic selection is based upon in vitro susceptibility testing.

Final diagnosis and treatment planning is based upon proper interpretation of the data developed during the history, physical examination, radiographic, and laboratory. Clinically, infection is manifested by the presence of swelling, pain, heat, loss of function, fever, and lymphadenopathy. Pathways of dental infection follow the path of least resistance. Localization of a dentoalveolar abscess is dependent upon the anatomic position of the roots relative to muscle attachments. From an infected pulp, the infection process can invade the periapical region and subsequently spread into the surrounding soft tissues of the head and neck region. Fistula, cellulitis, intraoral soft tissue abscess, bacteremia, deep facial space infection and osteomyelitis may develop.

Treatment of odontogenic infections

The management of infections of odontogenic origin will usually require medical, surgical, and dental therapy. Once it is ascertained that the infectious process is of odontogenic origin, definitive dental treatment must be instituted. Endodontic, periodontal, or exodontic therapy must be performed as indicated. In severe infections, it is recommended that the offending tooth be extracted. Surgical drainage of purulence is of critical importance in the management of odontogenic infections. Dentoalveolar abscesses are easily drained by a sharp incision through the mucosa down to bone. Drainage of deep fascial spaces requires a thorough knowledge of head and neck anatomy. The incision should be positioned, aesthetically as possible, to the site of maximum fluctuance. Blunt dissection through the deeper tissues is recommended to localize areas of purulence and explore all aspects of the abscess cavity. An adequate drain should then be placed within the abscess cavity and stabilized with sutures. Irrigation and advancement of drains should be performed daily. Drains should be removed as early as possible. Medical treatment consisting of supportive and antibiotic therapy, should be used in the management of infections of odontogenic origin. Antibiotic therapy doesn’t need to be applied in all cases. For further discussion of this topic please refer to the section on guidelines to the antimicrobial therapy included in this manual. Patients with systemic signs and symptoms, fever, trismus, or who are medically compromised, may require hospitalization and the use of intravenous antibiotics. Supportive care in the form of analgesics, fluid resuscitation, oral hygiene, and maintaining nutritional intake should also be instituted.

Fascial Space Infections

Fascial vestibule of the mandible

Anatomical boundaries:• Between the buccinator muscle and the oral mucosa• Inferiorly bounded by the intersection of the buccinator into the mandible• Swelling over the buccal and labial mandibular alveolus• May spread into the buccal space

Space of the body of the mandible

Anatomical boundaries• Between the body of the mandible and its periosteum and extends from the symphysis to the anterior border of the masseter and medial pterygoid• Swelling adjacent to the mandibular body• May spread into the sublingual, submental, buccal, mentalis, facial vestibule, or submandibular spaces

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Mentalis space

Anatomical boundaries• Between the anterior surface of the mandible, on either side of the mandibular symphysis, and below the mentalis and inferior labialis muscle and superior to the platysma• Slight bulging of the mandibular labial vestibule or the swelling of soft tissues of the chin prominence• May spread to the submental and submandibular spaces

Submental space

Anatomical boundaries• Between the mylohyoid and platysma superioinferiorly and between the diverging anterior bellies of the digastric muscles laterally • Swelling beneath the chin in the middle third of the mandible • Contains the submental lymph nodes • May spread to the submandibular space and then to the parapharyngeal space, inferiorly to fascial planes of the neck, and superiorly to the sublingual space

Sublingual space

Anatomical boundaries• V-Shaped trough which lies above the mylohyoid muscle and below the mucosa of the floor of the mouth, bounded by the lingual surface of the mandible both laterally and anteriorly • Usually no external swelling, but discomfort on swallowing and elevation of the tongue • Contents are the sublingual salivary glands, the submandibular ducts, and the lingual and hypoglossal nerves. • May spread posterio-inferiorly into the submandibular space, posterio-laterally into the parapharyngeal spaces or to the pterygomandibular space (rare)

Submandibular space

Anatomical boundaries• Inferior to the mylohyoid muscle, medial to the body of the mandible, mylohyoid and hypoglossus muscles which comprise its medial boundary, platysma and the body of the mandible forms its lateral boundary. • Generally very hard swellings of the submandibular region with limited mouth opening • Contains the submaxillary salivary gland, and submaxillary nodes, and the facial artery and vein • May spread to the sublingual space, parapharyngeal space, inferiorly to fascial planes of the neck

Ludwig’s Angina

Anatomical boundaries• Massive bilateral swelling involving the submandibular, sublingual and submental spaces • Tongue is displaced upwards and backward, and edema of the glottis is noted • May spread to the neck and then the mediastinum via fascial planes in the neck

Buccal vestibule of the maxilla

Anatomical boundaries• Medial to the buccinator muscle, inferior to the insertion of this muscle below the zygomatic process of the maxilla

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• Swelling in the buccal vestibule • May spread superiorly into the buccal space or infraorbital space, to the cavernous sinus via the facial vein, angular vein, and ophthalmic vein

Buccal space

Anatomical boundaries• Bounded anteromedially by the buccinator muscle, posteromedially by the masseter, anterior border of the ramus and covered laterally by the skin and subcutaneous tissue, together with an extension of fascia from the parotid capsule • Swelling of the cheek, generally with no trismus • Contains the buccal fat pad • May spread posteriorly to the pterygomandibular space or submasseteric space, superiorly and medially to the deep temporal space, superiorly and laterally to the superficial temporal space, and posteriorly to the lateral pharyngeal space

Submasseteric space

Anatomical boundaries• Located between the masseter muscle and the lateral surface of the mandibular ramus • Most striking sign is severe trismus and a deep-seated throbbing pain • May spread superiorly to involve the superficial temporal spaces, anteriorly and laterally, to involve the buccal space

Superficial and deep temporal spaces

Anatomical boundaries• The superficial is between the temporal fascia and the temporalis muscle, with the inferior boundary being the zygomatic arch • The deep temporalis space is between the temporalis muscle and the underlying bony skull and is contiguous inferiorly with the pterygomandibular space • Swelling over the temporal region above the zygomatic arch and pain which will cause trismus • May spread inferiorly to the pterygomandibular and submasseteric spaces, posterioinferiorly to the parapharyngeal spaces

Infratemporal space

Anatomical boundaries• The upper extremity of the pterygomandibular space, bounded laterally by the medial surface of the mandible and temporalis muscle and tendon, medially by the medial and lateral pterygoid muscle • Contents include the maxillary artery and pterygoid plexus of veins • Severe trismus, and bulging of the temporalis muscle • May spread superiorly to involve the deep temporal space, inferiorly to involve the pterygomandibular space, intracranially via the pterygoid plexus to involve the cavernous sinus and can produce a septic thrombosis of the cavernous sinus

Parotid space

Anatomical boundaries• Space occupied by the parotid gland and enclosed by the fibrous capsule of the parotid gland • Rarely develops from an odontogenic source• Usually from a retrograde flow of oral flora along the parotid duct

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• Swelling in parotid area suppuration from the parotid duct; inflamed parotid duct papilla • May spread medially to involve the parapharyngeal spaces, superiorly to involve the deep temporal space

Pterygomandibular space

Anatomical boundaries• Between the medial surface of the ramus and the 1ateral surface of the medial pterygoid muscle, limited superiorly by the lateral pterygoid muscle • Contents are inferior alveolar neurovascular bundle and the lingual nerve and the chorda tympani • Moderate to severe trismus • May spread superiorly to involve the temporal spaces, anteromedially, then posteriorly to involve the parapharyngeal spaces, anteriorly and laterally to involve the buccal and submasseteric spaces, anteriorly and inferiorly to involve the e submandibular space

Parapharyngeal spaces

Anatomical boundaries• Lateral pharyngeal space (right or left) is located between the medial pterygoid muscle laterally and superior constrictor muscle and expends inferiorly to the hyoid bone • Retropharyngeal space is located posterior to the superior constrictor and is anterior to the carotid sheath and pre vertebral fascia • High fever and significant malaise, dysphagia, and trismus • May spread inferiorly via carotid sheath and fascial planes of the neck to the mediastinum and pericardium, superiorly to the temporal spaces, the base of the skull and foramen ovale, and the brain – danger space.

Infarorbital “Danger” area

Anatomical boundaries• Bounded superiorly by levator muscles, anteriorly by the orbicularis oris, and posteriorly by the buccinator muscle • Edema of the upper lip and lower eyelid, flaring of the ala • May spread to cavernous sinus via facial vein, angular vein and ophthalmic vein, superiorly to the periorbital area

Periorbital area

Anatomical boundaries• Under the orbicularis oculi • Swelling of the upper and lower eyelids • May spread to the cavernous sinus via the facial vein, angular vein, and ophthalmic vein

Antimicrobial therapy guidelines

The current standards of practice demand of the practitioner the use of appropriate antibiotics and targeting the specific microorganisms causative to the particular infection. Proper antibiotic selection is important in the management of infections of odontogenic origin.

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Once the decision to use antibiotics has been made, the following should guide the clinician in selecting the most appropriate antibiotic:

1. Proper identification of the causative organism.2. Determination of antibiotic sensitivity.3. The use of the most narrow spectrum agent.4. The use of the least toxic agent.5. The use of bactericidal over bacteriostatic agents.6. The use of the least-costly agent.

Following the selection of the appropriate antibiotic, the proper dose and route of administration should be determined. Dosage is based upon the minimum inhibitory concentration (MIC) of an antibiotic for a specific organism and the peak serum concentration of that antibiotic. In general, peak serum concentrations 3 to 4 times the MIC are required. Therefore, the dosage prescribed must be capable of producing concentrations 3 to 4 times the MIC. Additionally important is the frequency of dosing. The correct time interval between doses should be established. Determination of the frequency of antibiotic administration is based upon the plasma half life (T 1/2) of the drug. The most commonly utilized dosing interval for antibiotics is 4 times the T 1/2. Once the appropriate dose as well as the interval of dosing has been established, the clinician must then determine the most effective route of administration. The severity of the infectious process and the serum level required will influence the route of administration. Medically compromised patients, the presence of systemic signs and symptoms, bacteremia, and severe infections or those caused by unusually virulent organisms, will usually require intravenous antibiotic administration.

For oral and more specifically odontogenic infections the causative bacteria tend to be indigenous to the oral cavity. Most of these infections are the result of a mixed flora, both aerobes and anaerobes. The most commonly isolated organisms include: aerobic streptococci (alpha, beta, and gamma), anaerobic streptococci (peptostreptococcus), Bacteroides (B. melaninogenicus, B. fragilis, and B. oralis), and staphylococci (S. aureus, S. epidermidis). Primarily these include aerobic gram-positive cocci, anaerobic gram-positive cocci and gram-negative rods. When these organisms tend to enter the deeper structures through necrotic pulp space or deep periodontal defects they tend to develop into odontogenic infections.

Not all infections need to be treated with antibiotics. Consider the following factors in decision making:1. Extent of the infectious process and its rate of progress2. Ability to provide with surgical treatment of the source of infection3. Patient’s ability to respond with cellular and humoral responses to fight off the infection

Indications for antibiotic use

The following instances necessitate antibiotic employment with or prior to surgical treatment:

1. Acute onset infections2. Diffuse swelling3. Immunocompromised host4. Facial space spread5. Severe productive pericoronitis6. Osteomyelitis7. Lymphadenopathy, fever, and malaise in conjunction with dental pathology

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Cases where antibiotics may not be indicated

1. Chronic well-localized abscess2. Minor vestibular/gingival abscess3. Dry socket4. Root canal sterilization5. Mild pericoronitis6. Intraoral spontaneously draining fistula

Culture and sensitivity studies

The antibiotic sensitivity of oral infection causative agents is well known and tends to be highly consitient. Hence it is not usually necessary to apply culture and sensitivity studies for the routine odontogenic infections. There are however some situations were the culture and sensitivity studies are indicated:

1. Rapidly progressing and spreading infections2. Non responsive infections3. Recurrent infections4. Post operative infections5. Osteomyelitis6. Immunocompromised patient7. Suspicion of actinimycosis

Choosing the antibiotic

Effective orally administered antibiotics useful for oral microflora & odontogenic infections

1. Penicillins

Penicillin V- the drug of choice for routine odontogenic infections, it is to be used as a first-line agent. It is effective against gram positive cocci (except staph) and oral anaerobes. The penicillin is reasonably priced compared to other antibiotics. It does however, cause an allergic response in approximately 3% of patients. There are other medications that are members of the penicillin family most notably in dentistry- Amoxicillin. It is more effective against gram-negative rods and tends to be well absorbed from the GI tract. The American Heart Association has chosen Amoxicillin for oral prophylaxis agent against subacute bacterial endocarditis. It is also indicated in management of infections associated with the maxillary sinus microflora. It does have a higher price tag and it is unnecessary to use amoxicillin as the first line agent for oral/odontogenic infections. Other broader spectrum penicillins are available such as oxacillin, carbenicilin, as well as, penicillin family/ clavulonic acid or sulbactam combinations augmentin(amoxicillin clavulanate) and only IV available unasyn (ampicilin sulbactam).

2. Clindamycin

The second line agent of choice or a first line agent in patients with penicillin hypersensitivity is clindamycin. It has replaced erythromycin are the alternate choice for penicillin due to the relatively high incidence of gastrointestinal irritation. Although less frequent than with erythromycin clindamycin does however have some notable adverse drug reactions associated with it. The most notable is the incidence of diarrhea and in a small percentage of the population, pseudomembranous colitis has been precipitated by clindamycin.

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3. Erythromycin

Although this antibiotic has a greater affinity for staphylococci than penicillin its major drawback besides the high incidence of GI side effects is the bacteriostatic mode of action. It should be avoided in serious infections. However if patients are sensitive to penicillin and cannot tolerate clindamycin it can be chosen to treat odontogenic infections. To improve the gastric tolerance the enteric coating has been added such as in PCE 333 formulation of Erythromycin.

4. Cephalosporins

Offer little over Penicillin in the treatment of otodontogenic infections. Often these may be useful in treatment of compound facial fractures involving skin, sinuses and oral structures.

5. Metronidazole

The spectrum of activity of this drug is essentially for anaerobic bacteria hence, by itself it will not be effective in treatment of odontogenic infections. However in some of the cases where penicillins are not effective on their own it can be added to the regimen. Periodontists have used metronidazole in the therapy of periodontal disease.

6. Tetracyclines

Once commonly used are now mostly used for treatment of acne today. Due to years of overuse they have a greater incidence of bacterial resistance. Also any use should be avoided in patients less than six years of age or pregnant and lactating women due to the staining of developing enamel..

7. Antifungals

Most oral candidiasis can be treated with topical application of nystatin or clotrimazole.These medications are available in ointments, lozenges and rinses. Two week therapy is minimal to ensure eradication of condition. In patients with partial or complete dentures the application of the ointment to the denture base is optimal along with lozenges or rinses.

Sample Antibiotic Prescriptions:

Penicillin 500mg Clindamycin 300mg Disp: 28 (twenty-eight) tabs Disp: 28 (XXVIII) tabsSig: one tab QID till all finished Sig: I tab qid x 7 days

Chlorhexidine 0.12% Nystatin Ointment 100,000uDisp: 600cc 1bottle Disp: 250ccSig: Take 1 cap full by mouth Sig: Apply to denture base tidRinse for 2 mins. then expectorate bid

Last important note: be aware of the relationship of antibiotics and oral contraceptives and be prepared to discuss these with the patients.

Analgesic therapy guidelines

Most patients are likely to experience some discomfort following oral surgical procedures. There are some considerations, which will help you to determine the appropriate choice of post-operative anelgesic.

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Complexity and duration of surgery

The amount of tissue disturbance, periosteum elevated and osseous removal will tend to be reflected by increased inflammation and pain. Simple extractions of periodontaly involved teeth with no associated acute infections will tend to be followed by limited discomfort easily managed by over the counter non-steroidal anti-inflammatory agents. These include Advil, Naproxen or ASA. Also another peripherally acting analgesic of choice is acetominophen. It tends to be useful in patients who claim allergic reactions or complain of GI upset with the use of NSAIDs. In cases where a significant amount of surgical trauma occurred to tissues such as large muco-periosteal flap elevation, osteotomies or long duration of procedure, narcotic analgesic combinations can be employed.

Presence of pre-operative infection

Patients with moderate to severe soft tissue swelling may experience more severe pain secondary to the larger involvement of oro-facial tissues and space expanding cellulitis or purulence. Along with the need for incision and drainage of the infected soft tissues the patients tend to require more advanced pain management. If several analgesic and narcotic combinations are available it may be wise to avoid anti-inflammatory medications in cases where their effect will hinder the body’s activity in fighting infection through inflammatory response.

Patient factors

In addition to the pathology and surgical procedure it is wise to consider the patient’s past history of allergic reactions, history of past prescribed or illicit narcotic intake, potential for placebo effect and economic factors. As a general rule it is important to avoid narcotic use in patients with a higher abuse and addiction potential. All recovering drug addicts should be managed with appropriate combinations of non-narcotic analgesics.One of the red-flag raisers is the patient who begins the consultation by asking for the analgesics by name and dosage, particularly such drugs as Percodan. Though you may elect to have a triplicate blank in your office, do NOT prescribe the more heavy-duty drugs unless absolutely necessary (most likely not the case in majority of oral surgical patients). Remember, the elderly patients need far less analgesic medications, so begin with very low dosages. In children, it may be helpful to prescribe liquid dosage forms, but do not dismiss prescription of tablets to the pediatric patients since they can be crushed and mixed with something the child will actually enjoy (milkshakes, etc.).

Sample Analgesic Prescriptions:

Tylenol#3 Vicodin (5/500)Disp: 20 (twenty)tabs Disp: 20 (twenty)tabsSig: one to two tabs Q4-6H prn pain Sig: 1-2 tab Q6h prn pain

Ibuprofen 600mg Naproxen Na 550mgDisp: 20(twenty)tabs Disp:10(ten)tabsSig: one tab Q5H prn pain Sig: I tab bid prn pain

Tylenol with Codeine Elixir (120mg+12mg/5cc) Disp: 300ccSig: 10cc Q4-6H prn pain

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Pathology & biopsies

Oral Pathology

The most common pathological conditions of the oral-facial region requiring surgical treatment include cystic lesions, neoplasms, and salivary gland disorders. Odontogenic cysts are pathological epithelial lined cavities of odontogenic origin containing fluid or semisolid material. Diagnosis is based upon the patient's history, physical findings, as well as a thorough radiographic and histopathological evaluation. Common clinical findings range from no signs or symptoms to the presence of pain and/or expansion or swelling. Once the diagnosis has been established, treatment of cysts of odontogenic origin usually will consist of either enucleation or marsupialization. In general, enucleation whereby all excised tissue may be submitted for evaluation, is preferred over marsupialization. Exceptions may include large soft tissue cysts. Neoplasms are new growths of abnormal tissue. They are abnormal masses of tissue in which their growth exceeds and is uncoordinated with that of normal tissues. In the head and neck region, neoplasms may be classified as follows:

1. Odontogenic.2. Nonodontogenic3. Benign4. Malignant.

Common clinical findings include expansion or swelling, pain, or neurologic dysfunction. The type, size, and location of the neoplastic process determine treatment of neoplasms in the oral-facial region. Specific surgical management may include local excision, en block resection, or partial or total resection of the jaw.

Salivary gland diseases

Salivary gland disorders commonly result in patients seeking dental evaluation. The presence of pain and swelling caused by a pathologic process involving the salivary glands is often mistaken to be of odontogenic origin. It is only through a combination of physical findings, history, as well as radiographic and special studies evaluation that the exact diagnosis can be established.

Once the clinician identifies the pathological process to be of salivary gland origin, definitive diagnosis is based upon the following: 1. History—of the duration of the swelling, nature of onset, and rapidity of swelling. Pain and swelling that intensifies just prior to eating is suggestive of an obstructive disorder of a salivary gland duct.2. Physical examination—inspection, bimanual palpation of the gland and duct. Examination of saliva (flow, color, quantity).3. Radiographic evaluation—panorex, occlusal x-rays, C.T. scanning, sialogram. Salivary gland disorders most amenable to surgical treatment include:

1. Sialolithiasis. 2. Chronic sialadenitis 3. Sialoangiectasis.4. Neoplasia.

Most commonly, the surgical modality required to treat the majority of salivary gland disorders will involve either transoral sialolithotomy or gland removal (intraoral or extraoral), since most disorders of the salivary gland system involve obstruction of the duct system. Exceptions include mucoceles or ranulas. Medical treatment of salivary gland disorders may include the use of antibiotics, hydration, gland massage, and the use of salivary stimulants

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Biopsies

The best rule of thumb for assessing the need for a biopsy is to have a high index of suspicion (failure to diagnose is negligence and malpractice).Any pathological specimen removed from the patient must be submitted to an oral pathologist for an evaluation and histological diagnosis. The specimen should be submitted in a fixative containing specimen container labeled with the patient’s name, date of biopsy and the name of the dentist. Be careful and delicate when handling the specimen. Use sutures or tissue forceps( non-locking to pick up specimen) avoid using hemostats of needle drivers to handle the specimen. These will tend to crush the specimen and distort organization of tissue layers making interpretation of tissue more difficult and sometimes impossible. Most pathologists will want as large of tissue sample as possible. Identify patient’s data, doctor’s information, date of the biopsy, clinical history, lesion location, clinical diagnosis (list at least three differentials) in the oral pathology laboratory report. Include radiograph as much as possible especially in hard tissue lesions. Make sure you provide the pathologist with the largest piece of the lesion that you can possibly deliver. It is not necessary to skew your sample by providing normal tissue, unless your differential diagnosis includes the vessiculo-bullous diseases; most pathologists know what normal tissue looks like. Perhaps one of the most neglected aspects of the biopsy is the inclusion of a good history of the lesion. Remember, it is not a guessing game played with the pathologist, but a collaborative diagnostic effort. There is no law against sampling multiple areas, but "tag" them so the areas can be documented. Tags can be placed in a large specimen to orient the sample (provide this "map" to the pathologist).

Electro-cautery, "hot-knives," and lasers are not recommended in biopsy techniques, particularly in small specimen areas. For small specimens, these will untowardly distort the margins.

Do not store tissue samples in tap water; saline is acceptable for a short period of time (such storage will cause distortion/destruction of your sample). Establish a working relationship with a reputable oral pathology laboratory, usually those affiliated with either a teaching center or university. These labs will provide you with biopsy report forms as well as various holding and preservative agents for your specimens.

Most biopsy results are available in one week. Make sure that patient’s are counseled about the biopsy process and are booked for follow-up and biopsy results when these are available.

Management of trauma to dentition and supporting structures

Structures

Dental injuries are common in today's society, affecting between 5.0% to 29% of the population. Males are twice as likely as females to sustain dentoalveolar injury. The majority of injuries involve the maxillary and mandibular anterior dentition. The most common etiologies resulting in injury to the dentition include interpersonal violence, MVA, and athletic injuries. The most common dental injuries usually requiring the expertise of the oral and maxillofacial surgeon include luxation injuries, avulsion injuries, and fractures of the alveolar processes.

Luxation injuries are classified as follows:

1. Concussion—injury to a dental unit without loosening or displacement.2. Subluxation—abnormal loosening without displacement.3. Intruded luxation—tooth is displaced apically into the alveolar bone.4. Extruded luxation—partial displacement from the alveolus.

Radiographic findings suggestive of a luxation injury include increased apical periodontal ligament space and/or widening of the periodontal ligament space. The reduction and fixation of the luxated teeth treat these injuries. Following accurate repositioning, the displaced teeth will require some form of stabilization.

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Methods of fixation include the use of interdental wiring, arch bar, or acrylic splint techniques. Immobilization usually from 3 to 6 weeks. Root canal treatment is indicated in all cases in which pulpal necrosis occurs.

Avulsion injuries include all cases in which the tooth has been completely displaced from the alveolar socket. The prognosis is dependent on the extraoral time period. This amount of time, as well as the environment in which the tooth has been stored, are important aspects to be discovered by the clinician. Clinically, it is important to determine the condition of the avulsed tooth and supporting structures. Prognosis is improved if the intraoral time period is under two hours and there has been minimal injury to the tooth and alveolus. Reimplantation may be possible under ideal circumstances.

The following are the basic requirements for reimplantation procedures:

1. The avulsed tooth should be without extensive injury, decay, or periodontal disease.2. The alveolar socket should be intact.3. The extraoral time period should be under 2 hours.

The injured tooth should be cleansed with saline. The PDL remnants should not be removed. The alveolus should be examined for extensive injury and foreign bodies. The avulsed tooth is then replaced within the alveolus and stabilized. Endodontic therapy should be performed within two weeks of the injury. Recent studies have shown that complications such as internal and external resorption are increased by long periods of fixation. It is now recommended that the fixation period not exceed 3 to 4 weeks.

Physiology of occlusion and mastication

Occlusion is defined as the contact of teeth in the mandibular arch with those of the maxillary arch in any functional relationship. Mastication of food is dependent upon the functional movement of the mandible and the occlusion of the teeth in centric, lateral, and protrusive positions (within dentistry, original concepts of occlusion related to the anatomic alignment of the teeth when the jaws were closed together). It has been an accepted concept that, when the teeth are positioned properly within the alveolar supporting bone and aligned correctly with the teeth in the opposing arch, they are functionally more efficient. Also, correct alignment of the teeth is conducive to the maintenance of a healthy oral environment through inter-and intra-arch stabilization. Current philosophies regarding occlusion consider not only the static relationship of the maxillary and mandibular teeth when occluded, but also the functional movements of the mandible. The concept of a functional dynamic occlusion emphasizes both muscle physiology as well as temporomandibular joint function and their role in "occlusion." Factors controlling occlusion in this concept are the static position of the teeth when in occlusal contact, condylar position, and the functional anatomy of the temporomandibular joint. The static position of the teeth when in occlusal contact influences the functional efficiency of the dentition. Modifying factors include the individual tooth position, tooth inclination, size and shape of the teeth, and presence of dental restorations. In addition, the amount of overbite and overjet of the anterior teeth control the magnitude of disocclusion of the posterior teeth during mandibular function. The overbite and overjet of the anterior teeth are referred to as the anterior determinants of occlusion. The condylar position, within the glenoid fossa, which is controlled by meniscal position, meniscal anatomy, and the muscles and ligaments of the jaws, determines the position of the mandible relative to the maxilla. As a result of this relationship, the condylar position becomes an important factor influencing the occlusion of the teeth. The functional anatomy of the temporomandibular joint, referred to as the posterior determinant of occlusion, determines the morphology of mandibular movement in the horizontal, sagittal, and frontal planes. This characteristic pattern of mandibular movement, which is unique to each individual, governs both the occlusal morphology and the functional efficiency of the dentition.

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An important concept that must be clarified in any discussion of occlusion is the distinction between normal and optimal occlusion. Normal occlusion implies acceptable conditions in the absence of pathology and stresses function and adaptability within the masticatory system. In contrast, optimal occlusion encompasses esthetic, physiological, and anatomical ideals.

A malocclusion is defined as any abnormal relationship between the maxillary and mandibular teeth when in contact. The most widely used classification system to describe malocclusion is that proposed by Angle. His classification system is based upon the assumption that the first molar is the "key" to occlusion. His system describes the anteroposterior relationship of the maxillary and mandibular arches. Angle classified malocclusion into three categories based upon the relationship of the upper to the lower first molars.

Class I

Neutrocclusion, is present when the mesiobuccal cusp of the upper first molar occludes in the mesiobuccal groove of the lower first molar. Class II

Distocclusion, is characterized by the lower dentition being positioned in a distal or posterior relationship relative to the upper dentition. The mesiobuccal cusp of the upper first molar is positioned anterior to the mesiobuccal groove of the lower first molar. Angle further classified Class II malocclusions into two divisions, I and II. Class II Division I malocclusion is characterized by distocclusion as well as other associated features such as hypereruption of the lower anterior teeth, a V-shaped maxillary arch, and protrusion of the maxillary central incisors. Class II Division II malocclusion is also characterized by distoclusion. In addition, other features are usually present such as a wide maxillary arch, excessive lingual inclination of the maxillary central incisors, excessive labial inclination of the maxillary lateral incisors, and a deep overbite.

Class III

Mesiocclusion, is present when the lower first molar is anterior or medial to the upper first molar. Usually, the entire lower dentition is anteriorly positioned and the lower incisors are in crossbite.

Physician consultation

If during the case work up any details of the patient’s past medical history, current medical condition or vital signs suggest a questionable ability to tolerate a procedure or require a more comprehensive medical work up prior to commencement of surgical therapy a consultation must be obtained from a physician. The sample form is included in the form index section of this manual. The form must be returned with a written statement from the physician, explicitly stating that a patient is cleared for an oral surgical therapy from medical standpoint prior to booking the date of the surgery. To facilitate the process stamped return envelopes are available from the reception desk. All forms must be reviewed and signed by the faculty or a resident prior to being given to the patient.

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MEDICAL CONSULT GUIDELINES

As dentists we are responsible for diagnosis and therapy of oral pathology. Our training is entrenched in principles of medicine and basic medical sciences. However, most dental schools do not adequately train their graduates in the full scope of medical therapy. Moreover, most dentists with time lose their basic medical knowledge since they do not dedicate significant portions of their CE towards those topics as per ADA stats. It is therefore imperative to relay on the judgment and advice of physicians to properly manage medically compromised patient. You should be able to establish some basis of the patient’s physical status using your basic science background and then consult the medical colleagues about specific issues of concern in the proposed delivery of care. Below is a summary of obtaining a medical consultation to ensure proper management of the patient.

Take a complete medical and dental historyPerform a clinical exam, especially that of head and neck structuresMake initial evaluation of patient’s health status and treatment needs.Consult the patient’s physician either by phone or via written form.It is preferred from medico-legal standpoint to have written documentation of your communications.

Completing the form:

State the patient’s name and age. Discuss briefly his chief complaint. Describe the patient’s general condition and list your significant findings from your medical history and

physical exam List the medications that you are aware of. Be prepared to discuss the proposed plan of dental therapy including the procedure, anesthesia (w

vasoconstrictor or without), sedation, and potential for blood loss and infection. Ask the physician to assess the patients systems (CVS, Resp, Neuro, etc) and indicate weather the patient

is able to undergo the planned procedure on outpatient basis or whether treatment modifications are required.

Inquire into need for any specific pre-medication such as SBE prophylaxis requirements. In-patients with suspected coagulopathies secondary to disease or medications ask for appropriate lab

values to be taken the AM of the appointment. Also ask the physician to indicate if patient can be taken off anticoagulants for several days prior to the procedure or if supplemental doses of steroids, anti-anxiety meds are needed for patients who are regularly on these medications.

Thank the physician for their assistance. Be courteous and professional.

If there are areas that are unclear reconsult the MD, look it up in references or consult OMFS specialist.

Remember that ultimately you are fully responsible for delivery of care to the patient. This cannot be shared with a physician. However, you are not fully qualified to make medical diagnosis and deliver medical care and therefore a physician must be involved in provision of care to some patients.

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Dental office basic emergency kit suggestions

Drugs1. Drugs for acute allergic reaction

epinephrine 1:1,000 (1 mg./cc.) IM1:10,000 (1 mg./10 cc.) I.V.

2. Anticonvulsantsdiazepam

3. Antihistaminesdiphenhydramine (benadryl)

4. Analgesicsdemerol, morphine

5. Vasopressors6. Corticosteroids

hydrocortisone (solu-cortef)7. Antihypoglycemics

50% dextroseglucagon

Non-injectables8. Oxygen9. Bronchodilators ventolin (patient will usually have their own supply) epinephrine10. Vasodilators nitroglycerin

Equipment11. Positive pressure oxygen delivery system ambubag12. Tonsil suction13. Tourniquets14. Scalpel or cricothyroidotomy needle15. Other unnecessary stuff

Reference section

Contemporary Oral & Maxillofacial Surgery, 2nd edition, Peterson, Ellis, Hupp, TuckerMosby, St.Louis. 1993Surgical Correction of Dentofacial Deformities. Bell, Proffit, WhiteW.B. Saunders, Philadelphia 1980Handbook of Medical Emergencies in the Dental Office, 2nd edition, Malamed, SheppardMosby, St.Louis 1992Handbook of Local Anesthesia, 3rd edition, Malamed, QuinnMosby, St.Louis 1990Oral Pathology Clinical Pathological Correlations, 2nd edition, Regazi,SciubbaW.B. Saunders, Philadelphia 1993

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Form index

OMFS Consultation OMFS Procedure note (Resident & Student) Referral form Medical Consultation Form Consent Form Oral Pathology Laboratory Report Sedation Instruction Handout Home Care Instruction Handout Medicaid Signature Form

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CONTENT INDEX:Mission Statement and Departmental Objectives 1 Faculty and Staff Directory 2D-3 Course Section 3Evaluations and grade assignments 3Clinic Information 5Protocol of Care Delivery 6The pre-surgical patient work-up and case presentation 10Supervision of care delivery 12Emergency Protocols 12Respiratory Emergencies 13Airway Obstruction 14Hyperventilation Syndrome 14Asthma 15Cardiovascular Emergencies 16Congestive Heart Failure 17Angina 17Cerebrovascular Accident 19Drug Overdose Reaction 19Allergy 21Unconsciousness 23Oxygen Deprivation 24Vasodepressor Syncope 25Orthostatic Hypotension 26Acute Adrenal Insufficiency 27Diabetes Mellitus 28Informed Consent 30Radiological Studies 31Vital Signs 32American Society of Anesthesiologists (ASA) Classification 32Local Anesthesia Guidelines 32N2O Sedation 35IV Sedation 35Review of Anatomy and Physiology of the Oral Cavity 35Exodontia 47Corrective Surgical Procedures 50Surgical Armamentarium 51Surgical Technique 52Post-Op Management 54Post-Operative Complications 54Infections of Odontogenic Origin 59Fascial Space Infections 60Antimicrobial Therapy Guidelines 63Analgesic Therapy Guidelines 66Pathology and Biopsies 68Management of Trauma to Dentition and Supporting Structures 69Physiology of Occlusion and Mastication 70Physician Consultation 71Dental Office Basic Emergency Kit Suggestions 73Reference Section 73Form Index 74

THE UNIVERSITY OF MICHIGAN NAME:___________________________

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ORAL & MAXILLOFACIAL SURGERY REG.No:_____________________________

OMFS PRE-OPERATIVE ASSESSMENT FORMCC:____________________________________________________________________

HPI: DURATION:___________________________________ LOCATION: R L ____________________________________ONSET FACTORS____________________ RELIEF FACTORS ____________________ SEVERITY: 0 1 2 3 4 5 6 7 8 9 10THERAPY TO DATE:_________________________________________________________________________________________

PMHx: UNDER M.D.’S CARE CURRENTLY NAME: DR.___________________________ PH.( )_____________CARDIOVASCULAR DISEASES DETAILS: __________________________________________________________________________________________________PULMONARY DISEASES DETAILS: __________________________________________________________________________________________________HEPATOGASTROINTESTINAL DISEASESDETAILS: __________________________________________________________________________________________________ENDOCRINE DISORDERS DETAILS: __________________________________________________________________________________________________RENAL DISEASESDETAILS: __________________________________________________________________________________________________ MUSCULOSKELETAL DISORDERS:DETAILS: __________________________________________________________________________________________________BLEEDING AND INTEGUMENTARY DISORDERS: DETAILS: __________________________________________________________________________________________________

OB/GYN: PREGNANT TRIMESTER _____________, BREAST FEEDING OTHERS:________________________________

PSHx: PATIENT DENIES ANY PAST SURGERY, HOSPITALIZATIONS OR ANY OTHER PAST MEDICAL THERAPY PROCEDURE DATE COMPLICATIONS CURRENT F/U__________________________________________ ________________ _______________________________ ___________________________________________________________ ________________ _______________________________ _________________CURRENT MEDICATIONS: PATIENT DENIES CURRENTLY TAKING ANY FORMS OF MEDICATION MEDICATION DOSAGE MEDICATION DOSAGE MEDICATION DOSAGE____________________ _______________ ____________________ ______________ ____________________ __________________________________ _______________ ____________________ ______________ ____________________ ______________

ALLERGIES: NKDA ANAPHYLAXIS TO:_____________________ ADVERSE RXN TO:______________________

SOCIAL Hx: TOB: ______PPD x _____YRS. ETOH: _________oz .QD DA: CR METH MJ HER IV LAST________

PHYSICAL EXAMINATION: VITAL SIGNS BP___________HR_________RESP_______TEMP__________

GENERAL: ________________________________________________________________________________________________

EXTRAORAL EXAM: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

INTRAORAL FINDINGS: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________RADIOLOGICALAND LABORATORY FINDINGS: ____________________________________________________________

ASSESSMENT: ______________________________________________________________________________________

PLAN: _________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FACULTY APPROVAL FOR PLANNED THERAPY_____________________________________________________________

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UNIVERSITY OF MICHIGAN PATIENT:__________________________ORAL & MAXILLOFACIAL SURGERY REG. No.: __________________________ PROCEDURE NOTE

CONSENT OBTAINED O MEDICAL HX REVIEWED O PROPER REFERAL O

Age: _____ Sex: M F Time: __________BP ________ HR _____ TEMP_____ RESP______ Time: __________BP ________ HR _____ TEMP_____ RESP______DIAGNOSIS: ________________________________________________________________________________________________________________________________________________PROCEDURE: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SURGEON: __________________________ ASSISSTANT: ____________________________LOCAL ANESTHESIA: _____mg 2% XYLOCAINE _____mg 1:100,000 EPINEPHRINE _____mg 0.5% MARCAINE _____mg 1:200,000 EPINEPHRINE _____mg 2% POLOCAINE _____mg 1:20,000 LEVONORDEFRIN _____mg 4% CITANEST FORTE _____mg 1:200,000 EPINEPHRINE _____mg 3% POLOCAINE PLAIN _____mg 4% CITANEST PLAIN

N2O SEDATION: Duration of sedation ______min Flow Rate______L/min N2O%_______IV SEDATION ___________________________________________________________

Circle all treated teeth (O) Mark osseous surgery(***) and sutures placed(XXX)

1 2 3 4 5 6 7 8 | 9 10 11 12 13 14 15 16------------------------------------------------------------------------ ------------------|------------------ 32 31 30 29 28 27 26 25 | 24 23 22 21 20 19 18 17

COMPLICATIONS: _____________________________________________________________FINDINGS: ____________________________________________________________________DRAINS PLACED: _____________________________________________________________

SUTURES:______________________________ DRESSINGS: __________________________

Rx: _________________________________________________________________________________________________________________________________________________________

POST OPERATIVE INSTRUCTIONS VERBAL O WRITTEN O SPECIAL PRECAUTIONS: _______________________________________________________

FOLLOW UP: PRN O REVISIT ON _____________________________________________

STUDENT”S NAME __________________________ STUDENT’S SIGNATURE : ___________________________

FACULTY FINAL CHECK _____________________________________

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