حصريا تحميل كتاب Fragiskos Oral Surgery مجاناً PDF اونلاين r nOriginally published in Greek by Professor nTranslated Helena Tsitsogianis, DDS, MS. scretch.info A Concise Textbook of Oral and Maxillofacial Surgery scretch.info scretch.info A Concise Textbook of Oral and . Oral scretch.info Ayko Nyush. Fragiskos D. Fragiskos (Ed.) Oral Surgery Fragiskos D. Fragiskos (Ed.) Oral Surgery With Figures, mostly in Color and
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PDF | Objective Intensive dental surgery course for GPs will go through a wide range of topics requires for a safe practice in routine dental clinic. PDF | On Feb 10, , P. A. Brennan and others published Minor oral surgery in dental practice. Indications for dental extractions. • Severe caries. • Pulpal necrosis. • Periodontal disease. • Orthodontic Rx. • Malposed teeth. • Cracked teeth. • Prosthodontic Rx.
Skip to main content. Log In Sign Up. Ayko Nyush. Vincent Road Kochi , Kerala, Phones: No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: This book has been published in good faith that the material provided by authors is original.
It is important in evaluating are normal or not, in a women. General Examination iv. History of allergies and reactions such as urticaria, hay fever, asthma, 1. A clinical diagnosis may be achieved untoward reactions to medication, food and from a look on the built of the patient, it is diagnostic procedures. This indicates the way the patient walks.
It is a bluish discolouration of the Abnormal gait occurs due to skin and mucous membrane due to increased a. Bone and joint abnormalities reduced hemoglobin more than 5 gm b. Muscle and neurologic disorder percent. Structural abnormality Types of cyanosis: Psychiatric disease. Central — caused due to defect in lung and Types of Gait: Wadding 2. Peripheral — caused due to block in circulation b. Equinus in tissue c. Scissor 3. Mixed — seen in congestive cardiac failure d. Hemiplegic 4.
Differential e. Steppage Difference in central and peripheral cyanosis: Shuffling g. Wobbly Central cyanosis Peripheral cyanosis h. Staggering a. Extremities are warm a. Extremities are cold i. Ataxic gaits. No change on b. Warming the extremities 3.
Affects the built of a person. It is the paleness of skin and mucous c. By giving oxygen central c. No change on cyanosis disappear giving oxygen membrane either as a result of diminished d. Seen in tip of nose d. Not seen in this region circulating red blood cells or diminished and tongue blood supply. Pallor is detected in the Examples: Peripheral vascular diseases.
Sites where anemia is detected: Edema is the collection of fluid in the interstitial spaces or serous cavities. It becomes evident only when litres of fluid have accumulated in the water depots. Nonpitting edema in myxedema and filariasis ii. Pitting edema in cardiac, liver, hypo- protenemia and renal disturbances. Ecchymosis and petechiae: These are hemorrhagic abnormalities of the skin.
Respiratory Rate: Blood pressure: Blood pressure is the lateral The normal temperature is pressure exerted by the contained column Tender, mobile, enlarged — Acute diastolic mm of Hg infection iii. Non-tender, mobile, enlarged — chronic diastolic mm of Hg infection.
Stage II hypertensive — systolic more than c. Fixed, enlarged — squamous cell IX. Rubbery, enlarged — lymphomas. Extraoral Examination 2. Temporomandibular joint: For temporo- 1. Lymph nodes: Lymph nodes are aggregation mandibular joint abnormalities we need to of lymphatic tissues present all over the body observe for deviation of mandible during which helps in drainage. Note the colour of the lip, texture, and any surface abnormalities, angular or vertical fissures, lip pits, cold sores, ulcers, scabs, nodules, sclerotic plaque and scars.
Labial mucosa: Orifice of minor salivary glands and granules. Buccal mucosa: Note any change in pigmentation and movability of mucosa, pronounced linea alba, leukoedema, intraoral swellings, ulcers, nodules, scars, other red and white patches and fordyces granules.
Maxillary and mandibular mucobuccal fold: Observe color, texture, any swelling, fistula, Fig. Location of the lymph nodes palpate for swelling and tenderness over the of head and neck region roots of teeth and tenderness of buccainator Types of lymph node inflammation: Non-significant — Where only 1 lymph node v.
Palate hard and sof t: Inspect for is involved, it is non tender and discrete. Significant — Where more than 1 cm size hyperplasia, tori, ulcers, hyperkeratinisation, increase is present and lymph node is tender asymmetry of structure, function and orifice and fixed. Floor of mouth: To confirm the diagnosis, a series of investi- vii.
Dorsum of the tongue should be gations are carried out. They are: Hematological investigations variations in colour, size and texture. Urine analysis viii. Observe for the colour, contour, 3. Biochemical investigations consistency, shape, size, surface texture, 4.
Radiological investigations position, bleeding on probing and exudation 5. Histopathological investigations on pressure. Microbiological investigations ix. Observe for the tonsils and pharynx and note for colour, size and 1.
Hematological Investigations surface abnormalities. Check for the quantity and quality Normal value of saliva.
Hard Tissue Examination gm percent males i. Teeth present ii. Teeth missing females iii. Mobility million males — grade I iii. Dental caries v. DLC Differential v. Retained teeth percent vii. Discoloured teeth Lymphocyte — viii. Occlusion Monocytes — x. Any other abnormalities. Post prandial blood produce similar lesion.
Prothrombin time vi. Partial thrombo- xiii. Urine Analysis xvi. Radiological Investigations iii. Intraoral radiographic techniques on standing, odour a. Occlusal radiographs to bacterial c. Bitewing radiographs decomposition ii. Extraoral radiographic techniques iv. Lateral skull projection v. Reverse towne projection vii. Submentovertex projection viii.
Urine ketone, f. Mandibular projection bile, bilirubin, iii. Orthopantamography OPG ix. Tomography x. Urine epithelial c. Ultrasonography cells, hyaline d. Stereoscopy f. Scanography 3. Biochemical Investigations g. Digital substraction radiography ii. Nuclear medicine iii. Serum alkaline j. Thermography iv. Serum acid l.
Sialography http: Screening of normal tissues from abnormal viewed or investigated or projection used tissues 1. Diagnosis of pathology 3. Mandibular fracture 2. Grading of tumor i. Determining neoplastic and non-neoplastic ii. Evaluation of recurrence iii. Determining the prognosis projection body iv. Hemorrhage v.
Infection vi. Poor wound healing projection ramus 4. Commonly used 5. It is a therapeutic as well as for the report. It is the study of tissue removed from Indication: Excisional and incisional biopsy Fig. It is a very useful Incisional biopsy: Rarely needed in oral cavity as most against breakdown during the staining process.
It is done in Before fixing the tissue they should be areas where lesion is small and inaccessible. The similar to that of incisional and excisional analgesic content maintains the tonicity and biopsy.
Brush biopsy: Exfoliative cytology: Microbiological Investigations procedure. Treatment Plan Limitations: Patient evaluation 2. Class I — Normal 1. Class II — Atypical presence of minor atypia 2. Mamm CV, Russell-R. Class III —Intermediate between cancer and 3. Peterson, Ellis, Hupp, Tucker — Contemporary no cancer- wide atypia suggests cancer but is oral and maxillofacial surgery, 4th ed Biopsy 4. Pathology, 5th ed. Class IV - Suggestive of cancer few malignant 5. Biopsy is 6.
Class V — Positive for cancer malignant cells 7. White and pharoah — Oral Radiology, Principles seen. Biopsy is mandatory. Hyperthyroidism 4. Diabetes Medical emergency is an unforeseen or an 5. Anxiety unexpected circumstances requiring immediate IV. Other conditions: Fortunately medical emergencies are 1. Renal insufficiency rare in dental practice but any clinician should 2. Hepatic insufficiency have a thorough knowledge of the medical 3.
Anticoagulant therapy emergencies to overcome them if any arise. Seizure disorder Preparation of the clinician to handle medical 5. Hypersensitivity emergencies are: Personal containing education in emergency 6. Hyperventilation recognition and management. Syncope 2. Auxiliary staff education in emergency 8.
Shock recognition and management. Tachyphalaxis 3. Establishment and periodic testing of a Local anesthesia toxicity system to readily access medical assistance Foreign body aspiration when an emergency occurs.
Hemorrhage 4. Equipping office with supplies necessary for Management of some common medical I. Features Confirming Cardiac Disorder I. Cardiac conditions: Congestive cardiac failure or at rest. Respiratory conditions: Hormonal conditions: Use an anxiety reduction protocol. Avoid rapid posture changes in patients taking drugs that cause vasodilatation. Consult patients physician 5.
Avoid administration of sodium- containing 2. Use anxiety reduction protocol. V solutions. Have nitroglycerin tablets or spray readily available use premedication if needed. Severe hypertension: Administer supplemental oxygen. Ensure profound local anesthesia before 1. Defer elective dental treatment until starting surgery hypertension is better controlled.
Consider use of nitrous oxide sedation 2. Consider referral to oral and maxillofacial 7. Monitor vital signs closely surgeon for emergency problems. Possible limitation of amount of adrenaline to 0.
Management of Patient with 1,00, adrenaline Myocardial Infarction 9. Maintain verbal contact with patient 1. Same as managing a patient with Angina. Defer surgery if possible for 6 months post MI attack. Management of Patient with 3. Administer oxygen. Congestive Cardiac Failure 4. Check if patient is taking anticogulants.
Defer treatment until heart function has been medically improved and physician believes II. Features confirming respiratory disorders: Recommend that the patient seeks the respiratory tract infection. Listen to chest with stethoscope to detect therapy of hypertension. Monitor the patients blood pressure at each procedures or sedation. Use anxiety reduction protocol, including adrenaline- containing local anesthesia nitrous oxide, but avoid use of respiratory surpasses 0.
Consult physician about possible use of Management of a Patient with preoperative cromolyn sodium. Chronic Obstructive Pulmonary 5. Defer treatment until lung function has insufficiency. Keep a bronchodilator — containing inhaler 2. Listen to chest bilaterally with stethoscope to easily accessible. Avoid use of nonsteroidal anti inflammatory 3. Afternoon or midday appointments are 4. If patient is on chronic oxygen supplemen- preferred.
If patient is not on supplement oxygen therapy, Management of Patient with Acute consult physician before administering Asthmatic Episode Occurring during oxygen. Dental Sugery 5. If patient chronically receives corticosteroid 1. Terminate all dental procedures therapy, manage patient for adrenal 2.
Position patient in fully sitting posture insufficiency. Administer bronchodilator by spray 6. Avoid placing patient in supine position until 4. Administer oxygen confident that patient can tolerate it. Keep a bronchodilator- containing inhaler accessible. Closely monitor respiratory and heart rates. Schedule afternoon appointments to allow for clearing of secretions. Terminate all dental treatment. Position patient in supine position, with legs Management of Patient Suffering raised above level of head.
Have someone summon medical assistance. Administer corticosteroid mg of 1. Terminate all dental treatment hydrocortisone or its equivalent I. V For Mild Hypoglycemia: Administer oxygen 2. Administer glucose source such as sugar or 6. Monitor vital signs. Start I. V line and drip of crystalloid solution. Start basic life support, if necessary.
Before further dental care, consult physician, 9. Transport to emergency care facility. Orally administer glucose source, such as 1. Defer surgery until thyroid dysfunction is well sugar or fruit juice controlled. Monitor pulse and blood pressure before, 4. If symptoms do not rapidly improve, during and after surgery.
Limit amount of epinephrine used. V or intramuscularly I. Management of Patient Suffering 5. Consult physician before further dental care. Insulin Dependent Diabetes 2. Administer 50 ml, 50 percent glucose IV or IM or 1mg glucagon. Defer surgery until diabetes is well 3. Have someone summon medical assistance controlled; consult physician. Monitor vital signs 2.
Schedule an early morning appointment; 5. Use anxiety reduction protocol, but avoid deep sedation techniques in outpatients. Features Confirming Acute 4. Monitor pulse, respiration and blood Adrenal Insufficiency pressure before, during and after surgery.
Pharmacologic means of anxiety control Watch for signs of hypoglycemia. Treat infections aggressively. Defer surgery until diabetes is well controlled. After surgery 2. If patient can eat before and after surgery, instruct patient to eat a normal breakfast and IV. Avoid the use of drugs that depend on renal metabolism or excretion. Modify the dose if Management of Patients with Anxiety such drugs are necessary.
Anxiety Protocol 2. Avoid the use of nephrotoxic drugs, such as non-steroidal anti inflammatory drugs. Before Appointment 3. Monitor blood pressure and heart rate.
Look for signs of secondary hyper- reception room time is minimized. Consider hepatitis B screening before dental 6. Take some extra measures during and after treatment. Take hepatitis precautions if surgery, to help promote clot formation and unable to screen for hepatitis.
Restart warfarin on the day of surgery. Attempt to learn the cause of the liver the safety of stopping heparin for the problem; if the cause is hepatitis B, take usual perioperative period. Defer surgery until at least 6 hours after the 2. Avoid drugs requiring hepatic metabolism or heparin is stopped or reverse heparin with excretion; if there use is necessary, modify protamine.
Restart heparin once a good clot has formed. Screen patients with severe liver disease for bleeding disorders with platelet count, Management of Patient with prothrombin time, partial thromboplastin a Seizure Disorder time and bleeding time 1.
Defer surgery until the seizures are well 4. Attempt to avoid situations in which the controlled patient might swallow large amount of blood. Consider having serum levels of anti seizure Management of Patient with medications measured if patient compliance Anticoagulant Therapy is questionable.
Patient receiving aspirin or other platelet 3. Avoid hypoglycemia and fatigue. Consult physician to determine the safety of Manifestation and Management of stopping the anticoagulant drug for several Hypersensitivity Allergic Reactions days. Defer surgery until the platelet inhibiting drugs Manifestations Management have been stopped for 5 days. Skin signs 3. Take extra measures during and after surgery a.
Delayed onset i. Stop administration of all skin signs: Benadryl 50 mg 4. Restart drug therapy on the day after surgery iii.
Benadryl 50 mg q6h 1. Immediate onset i. Obtain the baseline prothrombin time. IM or IV. Stop warfarin approximately 2 days before vi. Check the PT daily and proceed with surgery vii. Wheezing, mild dyspnea i. V access v. Stridorous breathing i. Anaphylaxis with or i.
Terminate all dental treatment and remove without skin signs: Position patient in chair in almost fully upright dyspnea, stridor, have someone summon position cyanosis, total assistance. Attempt to verbally calm patient airway obstruction, iii. Have patient breathe CO2 — enriched air, nausea, and vomiting, iv.
If symptoms persist or worsen, administer tachycardia, trained in use and if diazepam, 10 mg I. M or titrate slowly I. V until hypotension, laryngospasm is not quickly anxiety is relieved, or administer midazolam cardiac dysrythmias, relieved with epinephrine. V access. Monitor vital signs IV or IM 7.
Perform all further dental surgery using ix. Loosen tight clothing. Maintain airway Remove any obstruction in It is transient loss of consciousness due to cerebral path anoxia reduced cerebral perfusion thus inable 4. Inhalation of aromatic spirit of ammonia to maintain posture. Oxygen administration 6.
Maintain vital signs 1. Cardiac syncope 7. If unconsciousness for longer time than treat 2. Vasovagal syncope cause. Postural syncope 4. Drug induced syncope 5.
Cerebrovascular syncope Prodrome 1. Terminate all dental treatment Pathophysiology and Manifestation of 2. Position patient in supine position with legs Vasovagal Syncope raised above level of head. Attempt to calm patient 4. Monitor vital signs Syncopal Episode 1. Terminate all dental treatment 2. Position patient in supine position with legs raised 3. Management Shock 1. Maintain supine position with legs lifted above It is hemodynamic disturbance where there is head, therefore increased blood to brain.
Irreversible stage — — Decrease in blood pressure Type Cause Mechanism — Decrease in cardiac output 1. Hypovolaemic -Haemorrhage, -Decrease in blood — Tachypnea shock trauma volume — Decrease blood to vital organ and - fluid loss, specific features burns 2.
Cardiogenic - Myocardial -Decrease in — Can lead to death. Anaphylactic shock - Anaphylaxis -Peripheral vasodilatation and It can be easily prevented than treated: Supine position with head below the feet periphery should be positioned.
Oxygen inhalation 3. Maintain airway, and it may need tracheostomy. Monitor vital signs 5. Maintain body heat by covering with blanket and hot packs. Restore lost body fluid. Treat cause and symptomatic relief should be provided. Injection hydrocortisone and atropine sulphate, antibiotics, adrenaline. Tachyphylaxis It is the falling off in the effect produced by a drug during continuous use or constantly repeated administration.
Features It is mainly seen in drugs of nervous Three stages in shock are: Progressive stage: Mild toxicity: Moderate toxicity: V nystagmus, tremors, — Place in supine position — administer diazepam headache, dizziness, — Monitor all vital signs.
Severe toxicity: Seizure, cardiac — if seizure occurs, protect — Transport to emergency dysrhythmia or arrest patient from nearby care facility. Position patient in sitting posture. Bone wax on bone bleeding point. Postoperative Hemorrhage Causes Six reasons and difficulty to stop bleeding from extracted socket: In normal patients: The tissues of mouth and jaw are highly i.
Intraoperative vascular — Incision 2. Extraction leads a open wound in soft tissue — Damage caused while using various and bone hemostatic techniques 3.
Difficult to apply dressing material and proper ii. Postoperative pressure and sealing to the intraoral sites. Patient tends to play with the surgical area, — reactionary therefore dislodges clot.
Small negative pressure is created repeatedly 2. In diseased patients: Salivary enzymes lyse clot. This occurs generally due to infection varnish present in the area of surgery. Defer surgery after delivery if possible 2. Avoid dental radiographs unless information about tooth roots or bone is necessary for proper dental care. If radiographs must be taken, use proper shielding. Avoid the use of drugs with teratogenic potential. Use local anesthetics when anesthesia is necessary.
Use at least 50 percent oxygen if nitrous oxide sedation is used Fig. Hemorrhage management 6. Avoid keeping the patient in the supine on applying pressure position for long periods, to prevent vena cava compression 7. Allow the patient to take frequent trips to the rest room. CPR can be administered outside hospital or in hospital. If it is done outside hospital, then cardio- pulmonary resuscitation is providing basic life support, but if it is done in hospital, then basic life support BLS as well as advanced care life support ACLS is also given.
Objectives The ABCs of life is maintained. Mouth to mouth breathing They are: Place the patient is supine position with head higher than the legs.
Patency of the airway is checked iii. Any obstruction in the airway by any foreign body is removed. Patients airway is opened by a head tilt-chin lift position. Administer mouth to mouth breathing Fig. Mouth to nose breathing or mouth to airway breathing, can also be given if mouth is seriously Fig.
Chest compression injured or cannot be opened. External cardiac compressions are given to restore blood circulation. Antibiotics These are substances produced by micro Compression Method organisms that either retard the growth of or 1. In case of 1 operator, 15 compressions with kill other micro-organisms at high dilution. If the pulse is absent, then CPR These are similar to antibiotics, except that they should be resumed Fig. In case of 2 operators, 5 compressions with 1 ventilation is administered.
Drugs inhibiting cell wall synthesis: The improvement of the patient during administ- — Penicillin ration of basic life support is evaluated by the — Cephalosporins colour of the skin and mucosa, chest size, pulse — Vancomycin rate, respiratory movements, and pupil of the — Cyclosporine eyes.
Drugs inhibiting protein synthesis: Extended spectrum penicillin — Drug binds to 30s ribosomal subunit: Drugs affecting cell permeability — Salbactam — Aminoglycoside — Tazobactum 4. Drugs affecting DNA Gyrase: Cephalosporin 5. Drugs interfering with DNA function: First generation against gram positive cocci — Rifampicin and gram negative aerobes — E.
Coli, proteus — Metronidazole i. Oral 6. Drugs interfering with DNA synthesis: Drugs interfering with intermediate ii. Parenteral metabolism: Second generation against first generation — Pyrimethamine organism and H. Parenteral — cefuroxime A. Penicillin — cefatetan 1. Natural penicillin — cefoxitin i. Benzyl penicillin 3. Third generation Neisseria, E. Sodium penicillin H. Depot penicillin procaine pen i. Oral 2.
Semisynthetic penicillin — cefixine i. Acid resistant penicillin — cefprodoxine — phenoxy ethyl penicillin ii. Parenteral — phenoxy methyl penicillin — ceftriaxone ii. Fourth generation gram positive, gram — cloxacillin negative, Pseudomonos iii. Broad spectrum penicillin Parenteral — Amoxycillin — cefipime — Ampicillin — cefpirome http: Short acting and thus preventing cell wall formation of i.
Thus are bacteriocidal. Intermediate acting succeptible than gram negative. Thus inhibits are: Use of Opoid analgesic 3. Acupuncture patients. Morphine ii. Hydroxodone 3. Naltrexone iii. Sodium salicylate http: Ibuprofen ii. Ketoprofen Contraindications 4. Phenylbutazone ii. Oxicams i. Piroxicam Classification ii. Meloxicam 1. Short acting Natural 8. Fenamate i. Hydrocortisone i. Mefanamic acid ii.
Cortisone 9. Furanones 2. Intermediate acting Synthetic i. Rofecoxib i. Prednisolone ii. Celecoxib ii. Methylprednisolone Sulfoanilide 3. Long acting Synthetic i. Nimesulide i. Beclamethasone Acetic acid ii. Betamethasone i. Diclofenac iii. Dexamethasone Alkanone 4. Inhaled i. Nabumetone i. Benzoxazocine ii. Budesonide i. Nefopan iii. Fluticasone 5. Topical Mechanism of Action i. Betamethasone iv. Fluticasone Effects v. Pharmacological therapy Adverse Reactions i. Mineralocorticosteroid ii.
Collagen disorder i. Sodium and water retention — Systemic lupus erythromatosis SLE ii. Edema — Discoid lupus erythromatosis DLE iii. Hypokalemic alkalosis — Nephritis syndrome iv. Progressive rise in blood pressure iii. Allergic disorders 2. Hyperglycemia — Angioneuretic edema iii.
Muscles weakness — Serum sickness iv. Susceptibility to infection iv. Autoimmune disorders v. Delayed wound healing — Pemphigus vi. Osteoporosis — Hepatitis vii. Peptic ulceration v. Bronchial asthma viii.
Psychiatric disturbance vi. Pulmonary edema ix. Growth retardation vii. Skin disease x. Suspension of hypothalamopitiutary axis. Shock and septicemia. Apthous ulcer ii. Desquamative gingivitis iv. Oral lichen planus Classification v. Oral pemphigus 1. Centrally acting vi. Postextraction edema. Pulp capping 2. Peripherally acting viii. Pulpotomy i. Competitive blockers. TMJ arthritis a. Intracanal medicament — Pancuronium. Some of this can be learned from books.
If the proposed diagnosis is not excluded. Diagnosis for the expert is often a combination of: It would still be necessary to examine lymph nodes and the oral mucosa as routine screening. What is not so clear is how. Patients should also be advised as to the likelihood of incidence. The process of diagnosis.
The process is complete. Consent may be withdrawn at any time. Diagnosis is a process of measuring. The latter have been shown markedly to improve the diagnostic accuracy of junior surgeons dealing with acute abdominal pain.
This means that you should take some note of the likelihood of particular diagnoses before deciding what is wrong with your patient. Toothache as pain referred from myocardial ischaemia is exceptionally unusual. Clinical guidelines on treatment planning. But remember: In this process you aim to link together knowledge of anatomy. Disease processes may be listed as: These may take the form of written texts or computerbased.
It is merely a tool to help you think about the range of possible diagnoses. At present. Answers on page It has been growing slowly for 12 months and over 2 months has occasionally been traumatized when eating.
Consent key documents. If you are struggling with a diagnosis. What clinical features of this lump will you seek at clinical examination? A patient attends with a history of a lump on the partially edentulous. This chapter therefore attempts to summarize important points of surgical relevance. We would not wish pain and anxiety control to appear separate from surgical treatment planning: Select a means of anxiety control 3.
Nonetheless there are several issues of direct relevance to the practice of oral and maxillofacial surgery. Select a means of pain control suited to a particular patient 2. There are. Prepare a patient for the use of sedation or general anaesthesia 4. General anaesthetics have been used in the past to overcome problems of potential pain or anxiety.
Patients have a right to expect adequate and appropriate control of pain and anxiety. Bodily movement. This is probably one of the commonest reasons for failure of local anaesthesia in such patients. Noises ranging from grunts to screams can be illustrative—and may require immediate action.
Although we have said that pain is a defence reaction. Colicky abdominal pain. Some anxiety may even be frankly damaging. This chapter is concerned with pain associated fairly closely with surgery. Like pain. This includes the pain that would be associated with the surgery if no measures such as local anaesthesia were taken to prevent it and the pain so often experienced after surgery.
It must be unpleasant to be effective. Pain tends to elicit certain reactions. It is wise to remember also that pain requires consciousness to be experienced. PAIN How to recognize pain What pain is Pain is a defence reaction that tends to be associated with actual or perceived injury.
A key feature of pain is that it conditions avoidance. Almost any tissue excluding dental enamel may be the source. But anxiety associated with dental treatment is often unhelpful because it not only causes great suffering but also creates barriers to dental care. Not all pain. It is also of considerable therapeutic advantage because the latter responds well to analgesics. This can precipitate angina or worse. Some anxiety or fear is clearly advantageous. Anxiety is the anticipation of an unpleasant event that conditions avoidance.
The distinction between the sharp pain of a needle prick and the ache of overworked muscles is all too obvious and the separation of these two examples into fast. Where fear of a particular thing. Therefore when a patient says that they have pain. Pain may result from a range of stimuli: This can also have a major impact on the anticipation of pain in those particularly frightened by injections.
By spreading widely around the mouth they can induce numbness in a much wider area than would otherwise be necessary. For this reason it is important that you actively look for and assess the level of anxiety. The mortality rate associated with dental treatment that does not involve general anaesthesia is about one case per annum and even amongst such cases local anaesthesia is rarely regarded as causative of the death.
Rapid penetration of the mucosa by the needle results in far less discomfort than that experienced on slow pressure. It should be left on the skin for at least one hour before the procedure. In almost all dental applications it is possible to completely abolish pain during the procedure and. Local anaesthetics have become the most widely used form of pain relief in dentistry.
How to recognize anxiety: Anxiety consists of a range of responses. How to recognize pain: Pain of injection can also be reduced by injecting slowly. Few drug systems in medicine have such a good safety record. EMLA cream does penetrate deeply enough to be effective. This is made easier in lax tissues by tensing the mucosa before needle penetration. Overt signs of sympathetic nervous system activity such as pallor and sweating may be diagnostic.
Reducing pain on administration The application of lidocaine or benzocaine in the form of a paste. The drugs are safe to use. For procedures involving the skin topical lidocaine is of no value. Tens of millions of cartridges of local anaesthetics are administered by dentists in the UK each year.
The distinction between what is a somewhat exaggerated concern about dental treatment and what is a true phobia is rather blurred. If you need more evidence. Amethocaine gel can also be effective on skin.
The use of topical local anaesthetics does have disadvantages. Behaviour such as failing to attend or cancelling appointments. The drugs are effective. Both interfere with surgical treatment and may be damaging. This can abolish the pain of needle penetration and. Clues can be found in body language: There is therefore an underreporting of anxiety and considerable variation in the weight that individuals place on their own fear.
Failure is more common with regional block anaesthesia. The depth that can be achieved is dependent upon the patient. There may also be a relationship between failure and severe anxiety. Distraction by conversation. Openness and honesty are very important. Flexibility in your approach—for instance. For a new and nervous patient it is better to start treatment with less frightening procedures. Long periods of silence are worrying.
You do not need to describe unpleasant things in graphic detail. Seen from the opposite perspective. Where surgery is to involve more than one quadrant you should consider exactly how much local anaesthetic will be required. The attitude of the whole dental team to the patient can make a major contribution to the comfort of the patient.
They might be asked to imagine that they are on the beach in the sun. Hypnosis is thought of as a more formal psychological technique. It may be helpful to talk through a pleasant scenario for the patient during treatment.
If you experience repeated failures in regional block anaesthesia you should revise the anatomical guidance in textbooks and consider the accuracy with which you are following recommendations. Although anatomical landmarks provide a guide. Timing can also be important. Meechan et al. With purposedesigned relative analgesia machines the risks due to oversedation can be brought close to zero. Oral sedation can be very successful in the individual who requires relatively little support and in those for whom mask and injections may be unacceptable.
Inhalational sedation Inhalational sedation commonly uses a mixture of nitrous oxide and oxygen. Sedation may be achieved with drugs given by mouth. For that reason it is usually necessary to tailor the technique chosen to the patient.
Intravenous sedation Intravenous sedation is of rapid onset up to 2 minutes after injection of the drug. The depth of sedation is controllable. It may also be that the maximum depth of sedation achievable without the patient becoming disorientated is still not as great as can be achieved by intravenous sedation.
The disadvantages are few. The latter might include the potential for problems with the cardiovascular or respiratory systems. The level of sedation achievable whilst maintaining cooperation and verbal contact is somewhat deeper than can be achieved with inhalational sedation.
There are great advantages to nitrous oxide sedation. Girdler and Hill For that reason a local anaesthetic is also required. The aim must be to exercise maximum control over the perceived problem often anxiety in terms of onset. Oral sedation Oral sedation with a drug such as temazepam has the advantages of being safe.
Some risk is believed to be associated with high concentration of nitrous oxide in the surgery. This also means that within 15 minutes of the end of sedation almost all of the sedative effect is gone.
Therefore the dose required is unpredictable and. There is no mask. For this reason some operators place a pack over the back of the tongue for extraction work. The procedure should be delayed in the presence of acute medical conditions. In addition. Patient selection and preparation must still be thorough.
Local anaesthesia is still required. Advantages Conscious sedation offers a lower mortality risk than GA. General anaesthesia has been used widely for the control of pain in dentistry since the end of the nineteenth century.
Airway protection The airway can still be at risk during sedation. During recovery the patient must be accompanied and monitored. Sedation does not require the presence of an anaesthetist and therefore makes the dental treatment more convenient to arrange. By eliminating pain. Morbidity and mortality are lower than with general anaesthesia. All advice to the patient. An appropriately trained dentist and dental nurse may administer sedation without an anaesthetist.
There should be a responsible. Regurgitation of gastric contents seems to be particularly rare with moderate sedation and the risk of aspiration must be seen as very small. In almost all other respects preparation is as for GA. The patient is able to cooperate in the treatment. It is wise to avoid large quantities of water for irrigation and maintain suction throughout the procedure. Sedation may be oral.
Model instructions to patients Figure 3. It also has the distinct advantage. If you do not follow them your treatment will not be performed at this appointment. GA should be prescribed only when absolutely essential. You must: Lovett and Jentell Dental Practice 2. Patients need to be assessed on an individual basis.
Please contact the practice if you are uncertain about any of the above. You must NOT: GA deprives the patient of the ability to cooperate and prevents consultation during the procedure.
Some disorders require a degree of preparation before the GA. Additional procedures may also be required to prevent other injury during anaesthesia. Such risks can usually be avoided by deferring the planned procedure. Age is not of itself a contraindication to GA. Dental treatment on people in classes IV and V is rarely appropriate and would almost never justify general anaesthesia. Fitness The risk associated with GA is dependent on a number of factors. A range of temporary disorders.
The referring practitioner has an obligation to discuss alternative methods of control of pain and anxiety with a patient and assure themselves that the patient requires.
An additional point. The loss of muscle tone means that action must be taken to keep the mouth open. Morbid obesity is a special problem with GA. Thus an expert anaesthetist is needed to deliver the anaesthesia. It can result in hypertension. Pregnancy is a contraindication to GA because of risks to the fetus and. Elderly people are not only prone to diseases that contraindicate GA but may not tolerate the rigours of GA well.
An individual who is currently undergoing medical investigation. Indications There are no absolute indications for the use of general anaesthesia. Severe systemic disturbance or disease from whatever cause. Solid material could also obstruct part of the airway. IV Severe systemic disorders that are already life threatening. III Limitation of lifestyle. Testing for sickle disease is routine for those whose families derived from areas such as Africa. Investigation may also be advised in the case of people with no known ailment but who may be in an at-risk group.
The risk of aspiration is believed to increase with increased volume of stomach contents. For any patient or situation where the best course of action is uncertain the practitioner should discuss the patient with the anaesthetist who would perform the anaesthetic. It is therefore normal practice to require a patient to refrain from eating or drinking for a period before. Most of these patients require operation as a resuscitative measure with little.
II Mild to moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiological processes. On occasion. The pathological process for which surgery is to be performed is localized and does not entail a systemic disturbance. Gastric contents are extremely damaging to the lining of the respiratory tract and can cause a bronchiolitis. The examples given here are in no way a complete list of potential investigations.
For a patient with chronic obstructive pulmonary disease it would be wise not only to examine the chest carefully but also to order a PA radiograph of the chest and to arrange tests of lung function. V The moribund patient who has little chance of survival but is submitted to operation in desperation. Once such a test has been performed and the patient knows the result. Orotracheal intubation may give better access to the anterior maxilla. The placement of a naso-endotracheal tube and having the patient supine gives good access and ample operating time.
Escort After an outpatient procedure under GA the patient may be permitted to go home when they are steady on their feet and thinking clearly. Written consent is required. In all other circumstances.
That period may be shortened for a small. The emptying of the stomach is greatly delayed by fatty foods. Inpatient or outpatient day stay? For GA where the patient is expected to return home the same day: It is also worth remembering that patients may put greater emphasis on their own comfort than on following what they consider to be arbitrary rules given them by doctors or dentists.
Consent Consent must be obtained before any procedure. The tube enters the patient through the mouth. They should refrain from driving for 24 hours. Importance of the mode of anaesthesia to the surgery The mode of administration and maintenance of anaesthesia is determined by the anaesthetist in consultation with the surgeon.
There are some situations in which control of the airway must be managed via nasal intubation. Adequate recovery facilities must be available and the patient should be appropriately protected. For hospital inpatients it is possible to control these variables. In order to ensure their safety. Rarely the decision will be made that the risks associated with treatment.
Corticosteroids also reduce pain and some surgeons routinely give a drug such as dexamethasone for surgical patients. British Dental Journal The drugs reduce swelling simultaneously.
Analgesic drugs. Standard local anaesthetics such as lidocaine with epinephrine will give pain relief for several hours. There are several approaches to postsurgical pain. Whittington I. Cannell H. In those circumstances that particular treatment should not be offered: Longer-acting local anaesthetics such as bupivacaine with epinephrine may be used for pain relief after surgical procedures and may give relief for 8 hours or more.
Anesthesiology However this drug should be avoided in those who have: Cawson R. There is little evidence of damage caused by use of steroids in this way. Coplans M. It is right in this situation to attempt to balance the risks and potential suffering for each option. Curson I. Risk of morbidity and mortality makes it necessary to select and prepare patients carefully.
Probably more important than details of precisely which drug to choose is that one does actually prescribe or recommend an analgesic! It is also rational to give the analgesic drug early. An anaesthetist must administer the anaesthetic. Meechan J. What can be done to reduce the risk to the airway during the procedure?
Seymour R. Report of an expert group on sedation for dentistry. Oxford University Press. The patient is 5 ft 2 in. What activities should you advise a patient not to undertake after intravenous sedation? When should that advice be given? A patient is to have a tooth removed and requests general anaesthesia. What forms of anxiety control might you suggest for a routine extraction?
Hill C. What advice should you give her? What analgesic is suitable for a patient to take when she has had a lower third molar surgically removed under local anaesthesia? A lower third molar is to be removed using local anaesthesia and intravenous sedation.
Why is general anaesthesia on a day-stay basis not ideal for the insulin-dependent diabetic? Robb N.. Extraction is irreversible and occasionally associated with complications. Pedlar Removal of a tooth is a surgical procedure. It should be employed only when all alternatives have been excluded.
List and justify postoperative instructions to be given after tooth extraction 5. Position yourself and the patient for extraction and use your supporting hand effectively for a given extraction 3.
Describe the directions of displacement of teeth during extraction 4. If you think that you are not well equipped in these areas. It is important to attempt to evaluate.
Teeth may be taken out for a number of reasons: The loss of bone due to periodontal disease. Radiographs may show extensive caries. Increasing age is associated with more dense. It is not possible for a patient to consent to a procedure unless they know what is being proposed and its likely implications. But radiographs are indicated in the following circumstances: Some medical factors indicate risks of local problems e. Incompletely erupted teeth require a transalveolar approach.
Cervical abrasion cavities. Extensive caries. A clear diagnosis must be made. For this reason careful assessment. Check that the extraction is appropriate The consent of the patient must be obtained before any procedure. This maximizes the chance of things going according to plan. Should you take a radiograph for every tooth to be extracted? Valvular heart disease and anticoagulation therapy require special precautions. Forceps for use in the upper jaw further back than the canine have a curve in the beak Fig.
Teeth should not be extracted unless. There are many designs. The blades are applied to the buccal and lingual aspects of the root. In principle. The handles are straight and 12—14 cm long. These forceps can be applied to the long axis of anterior teeth. The beaks are both concave on their inner aspect Fig. Forceps for upper teeth Forceps for extracting upper anterior teeth are of a simple design Fig. All forceps consist of two blades and handles joined at a hinge. Look for clinical and radiographic features suggesting an increased risk of tooth fracture.
The handles are contoured on their outer surface to allow a good grip. The design of forceps has remained remarkably constant over many years: These forceps could be used to extract posterior teeth. The beaks are applied labially and palatally.
Note the curve in the beak. Because of this distinction between buccal and palatal beaks. This inevitably means that such forceps must have separate designs for right. Full molar forceps have a point and two adjacent concave facets on both buccal and lingual beaks Fig. A further variation involves a step in the beaks of the forceps Fig. In the UK it is usual to overcome the problem by using forceps with a right-angled bend in them.
Just as with the forceps for upper teeth. The beaks of these simple forceps are similar to those used on upper anteriors. Such forceps can be used effectively on all lower teeth. Forceps for lower premolars and incisors no. Compare the handle shape with that in Fig. The potential risk associated with the use of these instruments makes them unsuitable for beginners: Practitioners in the USA use forceps.
In order to maintain that position. The thumb should not be placed between the handles as this also misaligns the instrument and tooth breakage during extraction risks injury to the thumb. Forceps for use in the lower jaw have blades at a right angle to the handles. Upper posterior forceps have a bend in the beak and handle to avoid the lower lip. This results in a very different extraction movement.
Smaller versions of forceps are available for use on deciduous teeth. Forceps used in the upper jaw are variants of the straight design. The thumb is braced on the handle but not placed around it—that could produce too great a compressive force and tends to misalign the instrument in the hand. Forceps with a curved end to the handle are therefore either right. For mandibular extraction the position of the forceps is very similar Fig.
For maxillary teeth this is achieved by pushing on the Fig. There is little advantage in spreading the legs widely. Extraction of mandibular teeth For teeth in the lower left quadrant. It is perfectly possible to extract teeth low-seated. The left leg should be forward and slightly bent.
It also holds soft tissue out of the way to permit good vision. The back should be kept straight. For teeth in the lower right quadrant the operator stands behind the patient Fig.
The description assumes a right-handed operator. This will be helped if the patient turns slightly toward the operator. Extraction of maxillary teeth The positioning is determined by the need to push in the long axis of the tooth. For maxillary teeth. This usually requires the elbow to be up in the air. The operator stands in front and to the right of the patient Fig. It is important in all these manoeuvres to ensure that no soft tissues are trapped against the teeth.
For these teeth apply the forceps as described above. Lower incisors are very close together. For mandibular extractions: These teeth should be treated similarly to lower incisors. A tooth is held in place by the periodontal ligament. Some teeth generally have conical or near-conical roots. Maxillary central incisor The action to remove a maxillary central incisor is to push in the long axis of the tooth.
Do not pull on teeth. Then tip it lingually to the same degree. At this point the tooth can be gently delivered down through the socket. The approach can be extended to mandibular or maxillary third molars if they have conical roots and often also to mandibular second molars.
Still pushing toward the apex. For these teeth. Some such teeth are removed readily towards the labial side. Summary of positioning For maxillary extractions: The tooth is turned in the opposite direction again until the blades almost touch the adjacent tooth. It is likely that some teeth will break if you do—and even if you are successful in removing the tooth.
Maxillary molars Maxillary molars are often best displaced buccally again whilst pushing hard in the long axis of the tooth. Displacing this tooth buccally tends to allow the palatal beak to slip into the carious cavity. An example of this would be a maxillary molar with extensive palatal caries.
Fractured buccal roots of the maxillary molar are more accessible than palatal ones. Bodily displacement of a tooth commonly results in outward bending or fracturing of alveolar bone. Mandibular molars Mandibular molars can also be displaced directly to the buccal side. Modifying techniques No two extractions are the same any more than any two people are.
This feeling is better picked up if the tooth displacement movements are slow and deliberate. It is usual to place a rolled-up gauze swab over the extraction socket for a few minutes.
Bleeding should have stopped in 10 minutes. Post-operative instructions should include the advice listed in the following. In theory this movement must include a component of mesiodistal rocking of the tooth. With any multi-rooted tooth. The bone on the buccal side is also thinner and more malleable than that on the palatal side.
In general. A fractured surface is sharp edged. This may be noted from the crack heard at the time or because part is evidently missing on removal. It is essential to check that bleeding has stopped before the patient leaves. If you have bleeding or pain that you cannot control with these measures please contact us at these numbers: Hot salt-water mouthwashes a teaspoon of salt in a mug full of hot water — but not hot enough to burn every few hours may ease some of the discomfort and help to keep the mouth clean.
Each dental hospital tends to have its own guidance. The gauze should be removed from the mouth and the wound examined under a good light. A trace of blood in the mouth is likely for at least a few hours. Because you have judged that it is appropriate to take the tooth out. If there is any doubt as to how much of the tooth has fractured. If satisfactory access for an elevator is not available it may be made via the mucosa a transalveolar approach.
Eat and drink normally. By choice. Some discomfort is likely. If that is not possible. Please take the time to look through these notes and keep them for reference It is not uncommon for a tooth to fracture during extraction. It is often better to take pain killers early. You may take any pain killers that you can download over the counter in the chemist according to the directions on the packet. There are two main classes Fig. For an elevator 15 cm in length.
The force applied at the tip of the elevator is dependent on the force torque applied by the hand holding it and the ratio of the diameters of the handle and tip. It is essential to maintain sound support for an elevator throughout its use.
The instrument is held in the palm of the hand. Without such a rest. This makes it readily possible to apply excessive force to the jaws. Principles Because an elevator is used as a lever. They cannot grasp the tooth and frequently can only move the tooth in one direction away from the point of application. Elevators should be used only by rotation around their long axis.
If that fulcrum is another tooth that tooth could be dislodged. The elevator must rest only on the tooth to be removed. From left to right: It is important not to place the elevator too far down Fig. The root then lifts up as the elevator is rotated. Rotation Rotation Point of application Groove in root Fig. Many surgeons like to start all maxillary extractions by separating the buccal plate of bone from the tooth Placement of elevator Bone removal Fig.
The curved Warwick James is. This markedly reduces the risk of displacing the unerupted tooth. For removal of retained roots of upper or lower molar teeth. If the root is still not accessible it is possible to remove about 0. The curved Warwick James was designed for the purpose but it tends to move the tooth directly backwards.
Bone has been removed mesially. It must not rest against the adjacent tooth. Rotation Point of application against bone for elevation of the third molar Fig. When a root of a lower premolar has fractured.
The point is placed between the roots retained and over the crown of its successor. This would breach principle 4 as the incision would run dangerously close to the mental nerve. Be designed to maintain a good blood supply 3. They have not been widely adopted. A second relieving incision may be placed posteriorly Fig.
The above list is only a selection of many possible uses. This reduces pain and the time taken for healing. The intended use is to incise the periodontal ligament.
If mucoperiosteum were separated away from the bone on a convex surface the attached gingiva would tear. Most surgical removal of roots is performed from the buccal aspect of the ridge as this is more accessible. Such a root is better approached surgically. See also comment on the Periotome. Be amenable to repair with its margin on sound bone 4.
In this case the relieving incision would extend down from the interspace between the two premolar teeth. Not risk damage to adjacent structures. Mental foramen Fig. For instance. This can be a good way of developing the skill of handling elevators and reduces extraction forces. The principles may be seen well in relation to one of the most common procedures: Give adequate access to the site of interest 2. Surgical procedure The scalpel is held in a pen grip.
The gingival margin incision is made holding the scalpel in the long axis of the tooth. This is extended backwards. Incisions are made full thickness through mucosa and periosteum to bone and extended by cutting with the bow of the blade. This should be extended to about the level of the apices of the teeth. A suitable list of instruments is given in Appendix A. Bone removal must gain access to the roots for their removal as in Fig. During drilling it is important that the bone is cooled with running saline.
The sharp edge of the scalpel must be kept immediately against the tooth surface to prevent inadvertent laceration of the gingiva. Start by turning out the interdental papillae using an instrument such as a curved Warwick James elevator. It is wise to use the root surface to guide the bone removal.
Sometimes it is not necessary to run the bur all the way through to the lingual side which risks some damage to lingual mucosa. This also permits division of the tooth. Avoid excessive pressure and blunt burs. Also beware overheating of the drill due to worn bearings. Removal of bone to reach the roots is most commonly performed with a bur a round tungsten carbidetipped surgical bur is suitable.
In this situation remove bone buccally to see the roots and the bifurcation. Equally it. Divide the tooth. Space must be made to place an elevator next to the root and into which to displace the root. The mucosa on the other side of the wound is then turned out and the needle is passed out through it.
That may also permit the turning out of one root towards the buccal side and occlusally. Having removed the roots. Black silk is still a useful material when it is essential that sutures remain in place for a week or more such as closure of an oroantral communication or where precise tensioning is important such as for control of postextraction haemorrhage.
The loose end of the suture is held in the needle holders and the loops are slid off the needle holders over it. Sutures are placed both in the relieving incision and interdentally. The needle is then grasped on the other side of the mucosa and turned around its curvature to pull it through. The needle holders still holding the free end of the suture are The needle is held at the end of the needle holders Fig. The needle is held in the left hand and two loops are made around the needle holders held in the right.
Rapidly resorbing synthetic sutures. Beware not to rest the suture on the lip as the suture is pulled: The pain is often resistant to common analgesics. The surrounding mucosa and the whole alveolus may be red.
In Table 4. Now a further single loop. It includes adverse events occurring locally. It is recognized by pain at the site of extraction. Dry socket Dry socket alveolar osteitis. The ends are now cut. It is not necessary to review the patient unless problems are anticipated.
What should you do when something does go wrong? The range of potential complications is vast. Greyish remnants of clot may be present. Examination reveals a socket partly or totally devoid of blood clot with exposed.
There is considerable variation in the degree to which complications are predictable or preventable. There is obviously a bacterial component to this condition. Some patients are particularly prone to dry socket.
A radiograph is valuable. Be aware that misdiagnosis can occur. The condition is most prevalent in patients in their fourth decade. Its incidence may be reduced by the prophylactic administration of metronidazole.
The mouth smells and tastes foul a smell of anaerobic bacterial activity or rotting meat. A variety of antiseptic dressings is available to cover the exposed bone. Treatment of the condition is primarily symptomatic.
It is probable that the condition represents the outcome of a mixture of disease processes in which trauma. It should be noted. Zinc oxide and eugenol cements are not recommended as they tend to adhere strongly to the bone. It can be left in situ and is usually shed spontaneously from the socket over a few days. If relief is not achieved in a reasonable time. A proprietary. There may be a local lymphadenitis. The socket should be irrigated with warm saline to remove the debris.
Investigation need not be extensive. Occasionally a patient will believe that the wrong tooth has been extracted because of the pain in the adjacent tooth. Similar pain is experienced whenever an area of bone is left exposed in the mouth and usually settles when the exposed and non-vital bone is either eventually covered by granulation tissue or is separated from the underlying bone and sequestrated.
If no treatment were provided the condition would eventually resolve spontaneously. A few untreated cases of dry socket may progress to infection that spreads through the bone marrow osteomyelitis. Dry socket is more likely to occur after extractions under local anaesthesia than under general anaesthesia and is less frequent after multiple extractions.
There are similarities to acute ulcerative gingivitis in the high spring and autumn prevalence. Pain relief is usually very effective within hours. Usually a bleeding socket responds to these measures.
Such bleeds are often best dealt with by pushing a small quantity of bone wax a malleable wax commercially available for this purpose into the bleeding point. Postextraction haemorrhage After a routine extraction it is expected that bleeding will cease after no more than 10 minutes. If bleeding continues. A suture taking bites of tissue from all four corners of the socket.
Because of its consistency the dressing can be compressed into the socket and secured readily with sutures.