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SCOPE of OMS
Major OMS:
Hospital procedureswhich include:
Rx Fractures
Pre-prosthetic: tuberosity reduction, implants,
vestibuloplasty (extending vestibule)
Re-constructive surgery: orthognatic, facialdeformities.
Administer general anesthesia
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GENERAL PRINCIPLES OF
SURGERY A. Wound Healing:
1. Primary: clean incision + sutured to get
good approximation.2. Secondary: not tightly sutured early
granulation tissuescar
3. Tertiary: wound excised extensively to
remove devitalized tissues and debrisgranulation tissuehealing (scar)
Depends on good nutrition (Vitamin C),
medical condition, blood supply.
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GENERAL PRINCIPLES OF
SURGERY B. Infection: control and isolation, culture &
sensitivity test to choose specific antibiotics.
C. Nutrition: very important, knowledge of thephysiology of nutrition, fluid balance , electrolytecontent (Na, K, Cl, CO3 )
D. Body fluid & electrolytes: physiology ofwater balance, urinary out put, shifting betweenvarious fluid and electrolyte compartments like
Cell &Tissues
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GENERAL PRINCIPLES OF
SURGERY E. Diagnostic Workup:
Cardiac function (Heart murmur, HBP)
Respiratory function (asthma, COPD)Hematology: Bleeding & Coagulation times
Medial History: diabetes, stomach ulcers,cirrhosis, kidney function
Drug history: coumadin (blood thinner)
Systemic disease: immunosupresson(steroid)
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EVALUATION OF PATIENT
A. General
1. History:
Reviewed verbally with patientDrug allergies (penicillin)
Chief complaint + History of Present Illness(symptoms & duration, what exacerbates pain,
history of similar episodes)
2. Extra & intra oral exam
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EVALUATION OF PATIENT
3. Diagnostic Aids:
X-rays Photos before/after
Sialographs Biopsy
Diagnostic nerve blocks
Transillumination (sinuses, nose)
Lab tests (CBC)Bacterial stains (Gram stain +/- )
KOH fungi Viral Ab studies
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EVALUATION OF PATIENT
4. Hospitalization:
Considerations:
Medically compromised: un-controlleddiabetes, hemophilia, HBP, MI, CVA)
Difficulty & Extent of Procedure
Special patients: emotionally disturbed,physically handicapped.
Cost: base room rate, OR fee, anesthesia,Lab tests, consultant fees
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EVALUATION OF PATIENT
Hospitalization (cont)
Dental Emergency
Infection: Increase temperature (> 101 F)
Increased sweating dehydration
Decreased BP, cold, pale IV therapy
Increased WBC count (.> 20,000)
Compromised airway
No response to oral antibiotics
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EVALUATION OF PATIENT
Hospitalization (cont)
Dental Emergency:
Bleeding: Uncontrolled (hemangioma,
hemophilia)
Monitor:
Pulse Blood pressure
Hematocrit (HCT)
Hemoglobin (Hb)
Patients orientation.
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Hospital Arrangements &
Orders A. Procedures for Admission
1. Tell patient what will occur; blood drawn,
I.V. started, probable length of hospital stay.
2. Give following info to hospital:
Patients name, address, age, insurance etc
Admitting diagnosis & procedure planned
Preferred date of admission
Need for special equipment (drills saws
Physical exam 48 prior to admission)
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ADMISSION ORDERS
1. General & Nursing Orders:
Diagnosis
Patients condition
Allergies
Diet
Activity (bed rest)Specific problems
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ADMISSIONS ORDERS
2. Laboratory Tests:
Hematocrit, Hemaglobin, CBC
Urine analysisChest x-ray (general anesthesia)
E. K. G. (Electro-cardio-gram)
Blood glucose level
Prothrombin Time (PT-liver function, clotting)
Partial Thromboplastin Time (PTT), plateletcount.
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ADMISSIONS ORDERS
Lab tests (con):
ESR (erythrocyte sedimentation rate-infection)
Vital signs: pulse, respiration rate, BP,Temperature
Chem-12 or S.M.A.-12: includes liver function
tests, albumin, total protein, calcium,phosphorous, alkaline phosphatase, serumcholesterol.
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Other Admission Procedures
Medications: dose and frequency
Informed Consent Form:
Discuss surgery & risks.Separate form for general anesthesia.
Prior to surgery:
Review record to ensure patient saw allappropriate consultants.
Evaluate lab results.
Write pre-operative notes in chart
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Other Admission Procedures
Pre-operative Notes:
Discuss patients condition
State abnormal findings in medical history &physical exam; plans to deal with them.
Record & evaluate lab tests
Stating plans for surgical procedures
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RADIOLOGIC AIDS for OMS
Panoramic Radiograph (Panorex)
Screeningfor pathologic lesions
Diagnosis & Rx Plan impacted third molars
Observe TMJ, Sinuses, Sialography
Waters view:View para-nasal sinuses, bones of mid face
Best for mid facial fractures
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RADIOLOGIC AIDS for OMS
Sub-mental vertex view:
Dx facture of base of skull
Dx fracture of zygomatic process, mandible
Townes view: Visualizing condyle
Lateral oblique view: Body & ramus
Mandibular occlusal view: symphysis area
Cervical spine series: neck fractures
TMJ views
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PRINCIPLES of OMS
A. TISSUE HANDLING:
1. Use of Flaps:
Access to & visibility of deep structuresBone removal
Prevent soft tissue damage
2. Types of Incisons:
Linearenvelope(no vertical component)
Releasing(vertical component)
Semi-lunar
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PRINCIPLES of OMS
4. Re-positioning of Flap:
Incision clean, sharp, perpendicular to
wound
Flap margins over solid bone
For dento-alveolar surgery releasing incison
should end in inter-proximal areas.
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PRINCIPLES of OMS
5. Principles in Working with Bone:
Use burs, chisels, rongeurs, files
Complicated by:
sharp edges
exposed bone (pain, delayed healing)Devitalzation of bone necrosis
Infection necrosis
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PRINCIPLES of OMS
B. Aseptic Technique:
Prevent pathogenic extra oral bacteria from
getting into wound
Sterilization of instruments
Thorough hand washing
Patients face washed and draped.
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PRINCIPLES of OMS
C. Wound Care:
Mechanically remove calculus & dead tissue
Irrigation to wash away bone chips & debrs
Elimination of dead space prevented by:
Closing wound inlayers
Pressure bandages
Draining hematomas
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SUTURE MATERIALS &
TECHNIQUES Needle Type: mostly curved, and triangular
(cutting)
Suture diameter: Intraoral 3-0or 4-0
Suture material:
Black silk: inexpensive, easy to see intraoral,
and removed in 7 daysGut:(sheep intestine) Resorbable, light tan
color
Nylon: not soft or pliable, mainly used onskin
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BIOPSY TECHNIQUE
INDICATIONS:
Confirm clinical diagnosis
Distinguish benign from malignant An ulcer that persists for more than 2
weeks in spite of removal of local irritantfactors MUST be examined histologically
Persistent white lesions biopsied anddiagnosed as Hyperkeratosis MUST befollowed closely and biopsied if changes
occur.
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BIOPSY TECHNIQUE
INDICATIONS (cont):
To establish type of treatment(in the hospitalall tissues remove teeth etc are sent for grossand histologic description)
Where or How to Biopsy:
Small (< I cm) benign appearing = ExcisionVesiculo-bulluous lesions= Incision (Michel
solution)
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BIOPSY TECHNIQUE
Where & How to Biopsy (cont):
Large ulcers or White lesions
Sample normal into abnormal areas Sample several areas if large lesion
Sample must extend into connective tissue
Pigmented lesions MUST ALL be excised
with wide margins
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BIOPSY TECHNIQUE
Where & How to Biopsy (cont):
Punch biopsy = skin (small & difficult to
orient for sectioning)
Tissue Handling & Instrumentation:
No tweezers or hemostats to grasp lesionAnesthesia = Do not inject into lesion
Fixative = 10% formalin immediately
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BIOPSY TECHNIQUE
Tissue Orientation:
The pathologist need to cut the lesionperpendicular to the surface to see progressionof the disease process. Thin biopsiesshould be
placed connective tissue side downon a pieceof thick paper before placing into fixative.
The pathologist need know margins(up, downfront, back etc); to see if lesion extends to theedge of what margin.
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FRACTURES
Classification (4 types)
1. Simple: (Closed)
Dividedbone into two parts, noexternal communication thru skin ormucosa
2. Compound: (Closed) (Mostly children)Incomplete, may extent thru cortical
plate.
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FRACTURES
Classification (cont)
Compound:
Communicate with outside of skin/mucosa Exposed fragments
Comminuted:Multiple fractures of a single bone
Simple or compound
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MAXILLARY FRACTURES
La Fort 1: Simplest Horizontal
Maxillary alveolus containing dentition
separated from upper face
Segment pushed backwards & downwards
X-ray show fracture thru maxillary sinus
Rx: closed reduction, immobilze 57 wks
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MAXILLARY FRACTURES
Le Fort type 1
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MAXILLARY FRACTURES
La Fort 11 Fracture (pyramidal fracture):
Alveolar fracture + across bridge of nose
Fracture near Lacrimal sac, alongInfraorbital ridge, exits around Infraorbitalforamen to wall of sinus and underneathZygomatic process, then to up Pterygoidplates.
Clinical: periorbital edema + ecchymosis,subconjuntival hemorrhage, epistaexis.
Rx: intermaxillary fixation
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MAXILLARY FRACTURE
La Fort 111
ThruZygomatic arch
Down lateral orbital wallTo Inferior orbital fissure
Along Medial wall of orbit
Over Bridge of nose
ThruPterygmaxillary fissure
Craniofacial disarticulation
Clinical: Epistaxis
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POST-OP COMPLICATIONS
HEMORRHAGE:
Mostly due to poor clot formation(use tea bag+ pressure)
Remove large exophytic jelly-like clots
Use local anesthesia with epinephrinetocontrol bleeding to facilitate exam
Sutureto control bleeding
If bleeding continuestake to EmergencyRoomfor Blood Tests
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POST-OP COMPLICATIONS
PAIN:
DRY SOCKET (most common)
Loss of clot + inflammation of bone3rdmandibular molar area most common
Pain radiated to ear on ipsilateral (sameside)
Goals of Rx:Clear out local irritants(food)
Apply topical analgesic
Prevent irritants from getting in socket
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POST-OP COMPLICATIONS
PAIN (cont)
Rx Dry Socket:
Do not currette out socketIrrigate socket with saline
Place sedative dressing in socket
Bacteriostatic agent: iodine, bacitracinAnalgesic: benzocaine, eugenol
Change dressing every 2448 hrs
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POST-OP COMPLICATIONS
PAIN (cont)
SEQUESTRUM:
Fragment of tooth or non-vital boneinwound.
Rx: X-rayand surgical removalwith LA
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POST-OP COMPLICATIONS
SWELLING: (due to infection)
Mild infection suppuration (no fever)
Infection
facial planes
cellulitis or pus Infectionbuccal, lateral pharyngeal,
pterygoid, peri-tonsllar,sublingual, submandibular
spaces Rx:
Drainage
Antibiotics (culture & sensitivity test),
systemic support fluids)
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POST-OP COMPLICATIONS
FEVER:
Infectious or non-infectious etiology
Mild temperature elevation= fluid lossoraltered metabolism
Post oral surgery mild elevation of
temperaturedue to transient bacteremia(1224 hrs)
High fever (> 99.8 F)for more than 48 hrs
need aggressive Rx.
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OMS & DIABETIC PATIENT
OUT PATIENT MANAGEMENT:
Early morningappointments
Short appointment timeHave patient take normal morning dose of
insulin or oral agent+ normal breakfast
Mid morning hypoglycemic (weak,trembling)
Have orange juice available
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Management of Emergencies in
the Dental Surgery A = Airway B = Breathing
C = Circulation
SYNCOPE (fainting):Cause:anxiety, nervousness, hypoglycemia
Made worseby lack of food, fever,infection,
lack of sleepPatient becomeanxious, sweaty, pale,
nauseous
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Management of Emergencies in
the Dental Surgery Syncope (cont)
Patient becomes unresponsive (drowsinesstounconscious)
Pulse isweak andslow
Management:
Supine positionincreased blood to headAirwayopen, tilt head backwards
Breathingoxygenby face mask
Circulation
check vital signs Pupils dilated
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Management of Emergencies in
the Dental Surgery Syncope (cont)
Management:
Apply cool wet towel to foreheadRemove tight bulky clothing
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Management of Emergencies in
the Dental Surgery RESPIRATORY OBSTRUCTION::
Patient trying to breathe but somethingblocking airwaystridor(high pitch) or
crowingnoise
Management:
Heimlich maneuver: quick forceful pressure
on abdomen, below rib cage, upwards Pull mandible forward, insert oropharyngeal
tube
Hemostat, kelly clamp or suction remove object
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Management of Emergencies in
the Dental Surgery Respiratory ObstructionManagement (cont)
If object can not be dislodged, place in supine
positionGive oxygen under pressure
Laryngoscopy intubationor tracheostomy
Chest x-ray ASAP
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Management of Emergencies in
the Dental Surgery RESPIRATORY ARREST:
Patient is making no effort to breathe,
although airway is clear. Management:
Check mouth for obstructive object
Oxygenvia breathing bagDial 119, continue to breathe for patient
every 3 to 4 seconds
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Management of Emergencies in
the Dental Surgery CARDIAC ARREST (Circulatory collapse):
Management: CPR
Dial 119Patient supine on flat hard surface
Start CPR
2 person = 1 breathe : 5 compressions 1 persons = 2 breaths : 15 compressions
Check pupils and pulse
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PAIN CONTROL
DIAGNOSIS & HISTORY:
Ask if painis:
Superficial or deepConstant or intermittent
What relieves and exacerbates pain
Is it sharp, dull, burningUnilateral or bilateral
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PAIN CONTROL
If patient describes pain in a bizarre manneritfeels like bugs are crawling up my face arm, thinkof psychogenic origin.
Psychotic pain mostly occurs in head & neck
Iatrogenic pain = cause by HCW
Be patient, interested Listen carefully
Look for simple causes first
Do meticulous Extra & intra oral exam
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PAIN CONTROL
SOMATIC PAIN:
Caused by noxious stimulus (exogenous,endogenous or spontaneous (no apparent cause)
Warning signof physical injury
Peripheral stimuli interpreted in subcortical
& cortical areasof brain.
Transmitted by pain conducting fibers whenheat, cold, proprioceptive fibers are
extremely stimulated.
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PAIN CONTROL
Methods of Controlling Somatic Pain:
Block conductionlocal anesthetic
Eliminate noxious stimuliAnalgesic drugs
Sedative & consciousness altering drugs
General anesthesiaHypnosis & Acupuncture
Beliefs (cultural, religious etc)
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PAIN CONTROL
PSYCHOGENIC (PSYCHOSOMATIC) PAIN:
Cortical & subcortical areas in the absence ofperipheral impulsesproduce the interpretation
of pain
Patient is calm, smiling, facial expression freeof distress.
Burning sensation& depression go together.Rx: Psychiatric consultation
Establish good relationship and treatdental needs.
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PHYSIOLOGY OF PAIN
Stimuli neural signals nervous system
Nervous system influenced by pastexperiences, culture, anxietyetc
These brain processes participate in theselection, abstraction & synthesis ofinformation of total sensory input.
Action potential begins in pain receptors
Free endings covered bySchwann cell sheath(no capsule) located in deep epithelium &
lamina propria
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PHYSIOLOGY OF PAIN
Distribution of Receptors:
Skin (MOST) Tendons
Mucous membrane FaciaPeriodontium Veins
Periosteum CT of muscle
Arteries (Least)Ligaments
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PHYSIOLOGY OF PAIN
Coded pattern of nerve impulsesAnterior-lateral Spinal cord
Thalamus (spinothalmic tracts)
Reticular formation (lower Brain)
Different speeds & frequencies
High threshold receptors = small diameterfibers (A-delta & C)
Low threshold receptors = large diameter
fibers (A-beta & C-fibers)
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PHYSIOLOGY OF PAIN
Means for Transmitting Signals
Spatial summation: stimulation of manyfibers in a nerve trunk simultaneously ratherthan of a single fiberintensified effect.
Temporal summation: # of impulses along a
single fiber (10, 30, 100). Stronger theimpulse the greater number of fibersinvolved & greater rate of impulsetransmissionby each fiber.
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Differential Diagnosis of Facial
Pain Most pain DHCW deal with = Odontogenic
Maxillary sinusitis Maxillary molars
Ear infection Mandibular molars
Most Common Causes of Facial Pain:
Caries
Acute or chronic pulpitis
Exposed dentin or cementum
Fractured tooth syndrome
Impacted tooth Gingivitis or periodontitis
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PERICORONITIS
Mostlyassociated with mandibular 3rdmolar.
Acute infection around crown of tooth withsuppuration around pericoronal flap(operculum)
Rx:
Irrrigate under flap
Rx antibiotics (Penicillin or Clindamycin)Operculectomy
If not treatedinfection can spread thru facialplanes of face & necktrismus, pain,
elevated temperature
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Facial Spaces & Spread of
Infection LATERAL PHARYGEAL:
Rapid spread of infection
Lies medial to ramusInfection canextent to base of skull & chest
Trismus of Medial Pterygoid Muscle
PERITONSILLAR:
Most commonly involve tonsillar infections
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Routes of Spread of Infections
Hematogenous
Lymphogenous
Facial spaces
Direct extension
All sinuses are in direct communicationwitheach other
Maxillary canine infectionCavenous SinusThrombosis
Mandibular molar infectionsLudwigsangina
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ANESTHESIA
MAXILLARY:
Ant, Mid, Post SAN All Teeth + Bu gingiva
Post SAN DB roots 1st, 2nd, 3rdMolars
Mid SAN M-B root 1stmolar + PMs
Ant SAN Incisors + Canine
Nasopalatine N soft tissue palatal toincisor + canine
Greater Palatine N soft tissue palatal &distal to canine
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LOCAL ANESTHETICS
ESTERS OF BENZOIC ACID:
Procaine (Novocaine)
AMIDES:
Xylocaine (Lidocaine) 2% + Epinephine1:100,000
Carbocaine (Mepivicaine) 3% (NOepinephrine)
Topical Anesthesia: 2% xylocaine ointment
Ethyl chloride (cold spray)
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CHARACTERISTICS OF LA
Highest Concentration Needed for:
Motor nerves fibers
Pain fibers
Autonomic fibers
LA Results in Order of Loss of Function:
Pain (unmylinated) Proprioception
Temperature Muscle tone(myelinated)
Touch
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MODE OF ACTION OF LA
LOCAL ANESTHETICS:
Lipid soluble + weak organic bases
Converted to water soluble acid saltsDissolved in water for injection
Non-ionized free base penetrates nerve
membrane
Cationic form required for anesthetic
activity within cell
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Mode of Action of LA
Potency increaseswith increased lipid solubility
Cationic formavailable ininjection capsule
Cationic formchanges to free baseoninjection into alkaline buffers in tissue
Free baseenters cellreconverted to cationicformblocks Na channel
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MODE OF ACTION OF LA
Tissue pH should be slightly alkaline tohydrolyze free base from water soluble salt
form
Acidc pH (infection) ionic form pooranesthesia
LA stabilize nerve membrane elevatedmembrane threshold no depolarization
Na channels do not open, Na will not enter
axon
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EXCRETION &
ABSORPTION OF LA PROCAINE:
Hydrolyzedby plasma esterase paraaminobenzoic acid (PABA) diethylaminoethanol
(80% excreted in urine) (3% in urine)
XYLOCAINE (LIDOCAINE):
80%metabolized inLiver by microsomalenzymes
2% Xylocaine: 1cc=20 mgs.
Max adult (70 kg) dose = 300 mg or 15cc
(8 carpules)
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ACTION OF LA
Concentration of LA= 6x greater than thatneeded to affect CNS
Smallest amount necessary should be used
Aspiration extremely important
Toxicity of LAresults in respiratory arrestbefore cardiac arrest
i f
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Action of vasopressors
(epinephrine) in LA Increase depth & length of anesthesia
Retains LA solution in the area injected bydiminishing blood(vasoconstriction) prolong
anesthesia
Reduces bleedingbetter visibilityof field
Reduces the toxicity of LA by decreasing rapidabsorption into blood
Most common vasopressor used = epinephrine
1:50,000 1:100,000 1:200,000
C f 1 8 l l f
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Contents of 1.8 ml carpule of
2% Xylocaine with epinephrine 36 mg Lidocaine
0.018 mg Epinephrine
NaCl
Na-metabisulfate (preservativetostabilizeepinephrine)
Methylparaben (preservative, cause of allergy)
NaOH(stabilize pH)
T i i & Ad R i
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Toxicity & Adverse Reactions
to LA Majority of toxic reactionsdue to overdose
Urticaria (local edema) + bronchospasm (rare)
Rx Benadryl 10 mg/1 cc + epinephrine1:100,000
Intravascular injection cardiac arrhythmias
Tissue irritation if injected into muscle CNS stimulation then depression & peripheral
cardiovascular depression
Increased salivation
T i i & Ad R i
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Toxicity & Adverse Reactions
to LA Tremors
Convulsions
Coma Hypertension
Tachycardia
Hypotension Paralysis of orbital nerves
Blindness (wrong injection technique)
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Pre-op Medication
Tranquillizer(Valium)
Psycho-sedative(Librium)
Both produce no hang over(barbiturates do)
Both are muscle relaxants + anti-convulant
Both no analgesicproperty
Both show little depression of respiration or heart
Amnesia = IV Valium (not in 1sttrimester) Barbiturates relieve anxiety
Demerol (narcotic) drowsiness + euphoria +elevated painthreshold (Lorfan, Nalline antagonist)
PRINCIPLES OF MINOR
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PRINCIPLES OF MINOR
EXODONTIA A. Reasons for Exodontia:
Pulpalpathology: endodontics not feasible
Peridontalpathology: peridontics not feasble
Trauma: fractured or displaced teeth beyondrepair
Impacted teeth
Orthodonticindications: create spaceProsthodonticindications: path of insertion
Estheticindcations: micro or macrodont
PRINCIPLES OF MINOR
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PRINCIPLES OF MINOR
EXODONTIA B. Contra-indications for Exodontia:
Acuteperiapical infection
Acute periodontal infection ANUG
Osteo-radionecrosis
Uncontrolled Systemic conditions
PRINCIPLES OF MINOR
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PRINCIPLES OF MINOR
EXODONTIA C. Factors re Difficulty Level of Exodontia:
Number of roots
Length of roots
Hypercementosis
Periodontal disease
Density of bone (condensing ostitis)
Vitality of tooth (tooth brittle) Degree of caries
Relation to sinus, mandibular canal etc
PRINCIPLES OF MINOR
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PRINCIPLES OF MINOR
EXODONTIA D. Mechanics of Tooth Extraction
1. Forceps
Luxation forces perpendicular to long axis oftooth (not pulling along long axis)
Fulcrum close to apex of tooth
High ratio of lever to action arm
Beaks short & concave to adapt to root Place beaks opposite each other at same
level
Beaks parallel to long axis of tooth
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MECHANISM OF
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MECHANISM OF
EXTRACTION 3. Types of Elevators
Straight: most commonly used
Crane pic: off set blade placed in purchasepoint & furcation and used as a lever.
Root elevators(right & left): blades off set
to reach into back of socket.
Cryer elevators(EastWest): (right & left):triangular pointed blades, used primarily on
lower molar roots.
MECHANISM OF
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MECHANISM OF
EXTRACTION 4. Procedures in Minor Exodontia
A. Use opposite hand to:
1. Retract soft tissues for visibility &protection
2. Help guide beaks of forceps into
position
3. Stabilize jaws & apply counterpressure to take stress of neck &
jaw muscles
PROCEDURES IN MINOR
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PROCEDURES IN MINOR
EXODONTIA B. Test for anesthesia& reflect periodontal
attachment.
Use elevator to facilitates placement of beaks
& prevents tearing marginal gingival
C. Place beaks sub-gingivally on cementum.
Handles held in hammer-type grip forapplying forces
PROCEDURES IN MINOR
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PROCEDURES IN MINOR
EXODONTIA D. Extraction forces Initial force directed apically (places
fulcrum point near apex + minimize root
fracture)
Next forcesether buccal-lingual luxationorrotation(incisors + canines)
No pullinguntil tooth is loose
PROCEDURES IN MINOR
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PROCEDURES IN MINOR
EXODONTIA E. WOUND CARE:
Compress buccal plate with finger
Use curette to remove periapical pathology
Pressure applied by patient biting on gauze
Suture only if severe bleeding or marginal
gingiva is torn or loose
PROCEDURES IN MINOR
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PROCEDURES IN MINOR
EXODONTIA F. EXODONTIA FOR DECIDUOUS TEETH Molarshave flared spindly rootswhich
increase risk of root fracture
For maxillary molars the primarydirection of luxation is palatal (buccal inadults). Deciduous molars more palatally
positioned & palatal root is strong.
Caution not to disturb permanent tooth
bud
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EXTRACTION FORCES
MAXILLA LUXATION
Anteriors Labail + Palatal +Rotation
1stPM Buccal + Palatal(no rotation)
2nd
PM Buccal + Palatal +Rotation
Molars Buccal + Palatal(N.B. Palatal delivery fordeciduous molars)
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EXTRACTION FORCES
MANDIBLE LUXATION
Incisors Labial+ Lingual +Rotation
Cuspid Labial+Lingual +Rotation
Premolars Buccal + Lingual +Rotation
Molars Buccal + Lingual
POST EXTRACTION
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POST EXTRACTION
PATIENT INSTRUCTIONS A. Mouth rinses: No rinses for 24 hrs (preventsloosing clotdry socket
B. Pressure dressings: 2x2 gauze over site +
patient bite down. Tea bag (Tannic acid). C. Avoid spitting vigorously
D. Application of Ice: first 24 hrson out side offace (reduces edema)
Application of Heat: after 24 hrs if there is lotsof swelling. Causes increased blood supply.
Di t id ti ll h t ld f d
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