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    clinic manual clinic manual Document Transcript

    • Department of Oral and Maxillofacial Surgery Faculty and Staff DirectoryChairman of Oral MaxillofacialSurgery/Hospital Dentistry &Chair and Section Headof Oral Maxillofacial Surgery: Dr. J. HelmanAssociate Chair of Research: Dr. S. FeinbergAssociate Chair of Education: Dr. L.G. UptonClinic Director Dr. K. CottrellSection Head of Hospital Dentistry: Dr. S. ZwetchkenbaumDirector GPR ProgramOral Maxillofacial Surgery Dr. D. Aldrich Dr. D. Fear Dr J. Persico Part Time Faculty: Dr. N. Betts Dr. A. Grady Dr. K. Pullen Dr. R. Burke Dr. R. Hitchcock Dr C. Radecki Dr. G. Ebmeyer Dr. S. Mintz Dr. A. Weiss Dr. J. Faber Dr. T. OsbornMaxillofacial Resident Surgeons: Dr. S. Edwards, Chief Resident Dr. P. Brain, Chief Resident Dr. R. Pfeifle, Chief Resident Dr. J. Wasielewski Dr. S. Edlund Dr. M. Weideman Dr. J. Collins Dr. J. Campbell Dr. R. Chang Dr. T. Leyshon Dr. E. Leung Dr. E. SmithLecturer: Dr. B. DingmanReceptionists: 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 48109-1078Telephone: (734) 764-1568Fax: (734) 615-8399 2
    • D-3 Course SectionThe Oral & Maxillofacial Surgery course # 720 curriculum is mostly clinical in nature. The students are togain 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 selectedtopic presentations. The final grade will reflect the student’s clinical and didactic performance evaluations.Evaluations and grade assignmentsFinal Grade componentsDidactic performance will be based upon attendance (includes punctuality, appropriate dress.) Only excusedabsences 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 foryou to copy in the library loan section here at the Dental School Library. Clinical performance will contributethe remainder of the final grade and will be judged on the following criteria: Preoperative Patient Assessment:3-OutstandingPatient’s medical history was thorough and analyzed with clear interpretation of risks, complicating factorsand 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 therapyand demonstrated exceptional database of medical and surgical knowledge. All examination findings werenoted, including relative duration, size, location and appearance. The vitals and clinical findings wereaccurately assessed and interpreted and the students developed appropriate classifications of patients overallability to tolerate proposed procedures. The process has to be well structured and time efficient. There will bea limited number of these grades assigned, as it will denote a truly exceptional performance.2-SatisfactoryPatient’s medical history was complete but not all potential influences on the proposed treatment modalitywere pondered hence lacking treatment modifications required to limit morbidity and undue stress on thepatient. A complete list of medications was established but their mode of activity or some of the mostsignificant effects relative to the proposed oral surgical treatment were not fully identified. Vital signs wereappropriately recorded but the student may have failed to precisely interpret the values and classify thepatient’s ability to tolerate the procedure. Structure of the assessment was appropriate and accomplished in atimely manner. Most students are expected to attain this grade.1-MarginalPatient’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 proposedprocedure and or feel need to alter treatment to accommodate patients medical status. Vital signs and physicalexamination were lacking in depth and accuracy and student did not demonstrate adequate grasp of patientsoverall health status. The time spent on obtaining the assessment was excessive and unbalanced by lack offindings or depth of inquiries. Student failed to adhere to the desired format of presentation. Only a fewinstances of marginal performance will be expected to occur within the class and any pattern of recurrence inthe same individual will be monitored and require additional extra-curricular work from the individual toensure satisfactory performance. 3
    • 0-UnacceptablePatient’s medical assessment lacked depth in areas of patient’s health such that potential for iatrogenic injuryto the patient or clinic personnel occurred or was possible. The student failed to obtain vital signs prior topresenting the patient, commenced active treatment (pharmacological or surgical prior to obtaining a signedclearance from faculty), lacked organizational skills to complete work up in a reasonable period of time andpresented 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 theappointment. It is hoped that no student will show such lack of preparedness as to indicate the assignment ofthis grade. Infection control Asepsis3-OutstandingThe student demonstrated strict aseptic surgical skills and surgery protocols. A corresponding exceptionalknowledge of microbiology, sterilization techniques and principles as well as modified operating roomprotocols discussed at orientation was evident. It is hoped that each student will strive to achieve this grade inthe course of his/hers rotation as a result of practice and pursuit of excellence.2-SatisfactoryThe student showed consistent adherence to basic levels of infection control and the modified OMFS surgicalprotocols. Strong emphasis on operator, patient and assistant safety was evident. The surgery area wasproperly managed and the instruments and equipment were used in appropriate manor.1-MarginalThere were clear departures from the expected level of aseptic technique on the part of the operator or theassistant. Instruments were handled in negligent manner and the operatory was not maintained or organized toensure the maintenance of continuing asepsis from patient to patient. Personal grooming or attire inconsistentwith the professional standards will automatically denote a marginal performance.O- UnacceptableThe operator failed to demonstrate any understanding of the sterile protocols and the importance of theimplementation of stricter infection control protocols in surgical settings. The operatory and equipment weredamaged or abused secondary to operators misuse. Potential scenario of cross contamination or infectionbetween patients and or operator developed during the delivery of care. Sharps were not handled or disposedoff in a matter of strictest caution and care to prevent accidental percutaneous injury. Any occurrence of thisgrade will require the recipient to perform extra-curricular review of the topics and re-evaluation by facultybefore being allowed to participate in clinical activities. Surgical technique, clinical judgement and patient management3-OutstandingThe 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 surgicalor management problems of greater then average complexity. The operator must demonstrate both knowledgeof techniques, good clinical judgement, application of profound anesthesia and manual surgical skills along 4
    • with flawless patient management ability. The operator delivered complete post-operative managementincluding appropriate medications and instructions. It is expected that only a few of the students will be giventhis grade in the course of the year.2-SatisfactoryStudent was able to complete the planned procedure with minimal assistance from faculty and demonstratedgood patient management ability. Adequate anesthesia, proper use of instruments and knowledge of thesurgical 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 procedurecompleted.1-MarginalA good deal of faculty hands on assistance was required to complete the delivery of the patient. Lack ofappropriate judgement and or management skills was evident. The student lacked complete knowledge of theindications and appropriate application of instrumentation. Perioperative and actual in-surgery patientmanagement and or anesthesia have not been consistent with optimal stress-management strategies anddesired level of care. The postoperative management of the patient was deficient in depth of post-opinstructions and there was improper selection of postoperative medications. A repeated performance at thislevel from any student will require the student to complete extra-curricular review of relevant topics toenhance future delivery of care. It is hoped that the occurrences of this performance will be limited to the firstfew sessions of the clinical rotations as the clinical skill become fine tuned and expanded.O-UnacceptableThe student demonstrated a gross lack of clinical skills and understanding of the principles of surgery. Poorjudgment was evident and the welfare of the patient and other operatory staff was jeopardized. The studentfailed to follow explicit instructions of faculty. Student continued the attempts at the delivery of care in apoorly anesthetized patient or ina patient whose intraoperative condition changed to one incompatible with the delivery of elective oralsurgical care. Faulty technique, lack of control or untimely decision to seek faculty assistance has resulted inthe delivery of iatrogenic trauma to the patient. Patient did not receive post-operative instructions and thepharmacological management of pain or infections exposed the patient to potential complications orprogression of current disease process.D-4 Course SectionThe students participating in the Advanced Oral Surgery Course will be allowed to see elective patients forbasic dentoalveolar procedures in the clinic. The will be no grades assigned for clinical performance but it isexpected that the D-4 students will adhere to the protocols included in this manual. The final grades will beassigned based on the didactic evaluation of course materials.Clinic InformationThe Oral and Maxillofacial Surgery clinic is located in the University of Michigan School of Dentistry on thesecond floor. Access from the main floor is best through the main elevators and the hallways to the right ofthe second floor patient registration and information area. Follow the directions on the wall to KelloggBuilding and Surgery clinic. The facility consists of 9 individual operatories designed for the care of Oral & 5
    • Maxillofacial Surgery patients. A small waiting area is available to patients, as well as, a post anesthesiarecovery booth. An instrument processing area, and an adjoining instrument room, as well as, a publicrestroom 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 theUniversity of Michigan Medical Center’s department of Maxillofacial Surgery. These special arrangementswill ensure the highest level of accessibility of prompt and state of the art expert care to all patients treatedthrough the University of Michigan School of Dentistry Oral & Maxillofacial Surgery Clinic.Protocol of care delivery Guidelines for patient rapportWe want our patients to have a positive experience. It is therefore imperative that this is conveyed to thepatient by our demeanor, appearance and professional skills. The patients who present for oral andmaxillofacial surgery tend to be more anxious than any other group of dental patients. Hence they are much inneed of an operator’s positive attitude and good chairside manner. The clinicians must present their findingsand 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 wellas, the associated surgical risks the patient must be allowed to make their own decisions about the surgicaltreatment. In some cases the anxious patient needs to be made aware or reminded that the sole basis of all ouractions and protocols is to ensure his or her well being. At the same time we are dedicated to providingexpedient and timely service to all our patients. If any problems develop that are beyond the scope of yourability 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 yourhands. They are just like you and your family and deserve to be treated with outmost concern. Be caring andsupportive. Make the patient feel they are being cared for in the most humane and competent way. Appointment schedulingThe reception desk is a very busy area of our clinic. Please avoid entry into the reception area unless askedto do so. Students are required to schedule appointments for their patients with the Oral & MaxillofacialSurgery receptionist.Protocol & Procedure for Scheduled Patients1) 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. 6
    • 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 bedetrimental to the patients’ health. Prosthesis DeliveryAll instances where a prosthesis is to be delivered are required (per prosthodontics department guidelines) tohave the prosthesis and any surgical stents examined by a Prosthodontics faculty prior to the day of thesurgery. The site of the surgery itself must be inspected by both the Oral & Maxillofacial Surgery andProsthodontic faculty before the suture placement. In addition, the prosthodontic faculty must examine theinitial seating and post-adjustment seating of the prosthesis. The Oral & Maxillofacial Surgery faculty mustthen see the patient before discharge from surgical care. All arrangements with Prosthodontics faculty must bemade ahead of the day of the planned pre-prosthetic surgery. Any prosthesis delivered will require thearrangement of a prosthodontic follow-up in 24-hour time period. Unless otherwise indicated the patients willrequire Oral & Maxillofacial follow-up in seven to ten days post-operatively. If the desired date of surgerywould fall on a day where a 24-hour Prosthodontics follow-up is not available i.e. all Friday or the daypreceding any holiday or school closure an alternate date must be selected. 7
    •  Referral and Treatment PlanningBefore a patient can be scheduled for any procedure in the clinic they must have a complete referralform including the patient’s name, number, past medical history, medications, allergies, as well as, theprocedure required as well as properly dated. The procedures need to be listed with appropriate toothnumbers and the appropriate arch indicated. Specific denotation of the area for soft tissue or osseousprocedures must be marked clearly on the referral form. The form must bear a signature and a printed facultyname. Any unclear or unsigned referral forms will be considered invalid and no procedure will bescheduled. With any incomplete outside referrals the students are to contact the referring office and politelyask for confirmation to requested procedures. For comprehensive care patients the treatment plans must becompleted, 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 sixmonths of the planned date of surgery. Also any radiographic studies i.e. to confirm buccal or lingualorientation of structures must be available prior to consultation or treatment. After the completion of aconsultation, faculty and residents will perform the more complex procedures. Infection Control measuresSafety is everyone’s concern. In Oral & Maxillofacial surgery we practice the most invasive procedures indentistry 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 partof your clinical grade. By insisting on STRICT adherence to the outlined protocol below we want to developyour habits for the future.Please refer to your Clinic Procedure Reference (Yellow U of M handbook) for the basic OSHA concepts ofinfection 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. 8
    • 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 chair13. 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 equipment1. 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 9
    • 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. 10
    • The pre-surgical patient work up and case presentationThe depth of medical history, scope of the physical examination, extent of consultations and laboratory assayswill be delineated for the purposes of the oral and maxillofacial surgery patient receiving basic outpatient oraland maxillofacial surgical care. This protocol is different than one utilized to work up a general dentistrypatient, although it will cover similar areas the focus and depth will be different. The student is expected towork independently utilizing his basic medical science knowledge, materials presented in the course of thelectures and the references available in the resident’s room to compile all parts of the case presentation asoutlined in the following section. The case work up should parallel the format of the case presentation. Usethe 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 procedurewithout the review of the case and start check from the faculty. It is up to the student to approach one of thefaculty members, introduce yourself and ask to have the case reviewed. Do not interrupt the faculty if they aresimultaneously involved with another student or case. Make sure that you have all relevant records includingthe details of your work-up, radiographic surveys; study models, surgical stents, lab results and medicalconsultations are available for faculty review. Chief Complaint InvestigationBegin by identifying your patient by age, sex and their current chief complaint. The chief complaint is inpatient’s words reason for being at the clinic. Be brief i.e. “my back top tooth hurts” or “my gums areswollen behind my last bottom tooth”. Then after stating of the chief complaint be prepared to discuss thehistory and the specifics of the chief complaint. Include onset, duration, location, severity, quality or type ofassociated pain, details on onset and progression of any swelling, alleviating and worsening factors. Inquireinto the past history of similar symptoms or problems in the similar anatomic location. For patientsundergoing any current restorative, endodontic, orthodontic or prosthodontic treatment indicate pertinent areaof their treatment plan to the proposed oral surgical procedure i.e. “ The patient is scheduled to have animmediate complete denture delivered upon complete edentulation of maxilla. Today posterior maxillarydentition is slated for clearance. Unless otherwise contraindicated, the remaining maxillary dentition is to beremoved in six weeks with subsequent delivery of the prosthesis post-operatively.” Medical History FindingsNext be well prepared to discuss the patient’s medical history. Note the remarkable findings, the details ofpast and current medical conditions patient elicited through your probing. Clearly question the patients aboutany past or current cardiovascular diseases such as hypertension, myocardial infarctions, coronary arterydisease, 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 asasthma, bronchitis, emphysema, COPD, lung cancer, episodes of pneumothorax, tuberculosis. Ask for anypast history of liver and kidney dysfunction such as hepatitis, glomerulonephritis, cirrhosis, bouts of jaundiceor 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 byquestioning about ulcers, diarrhea, Crohn’s or irritable bowel disease. Discuss any endocrine problems suchas diabetes, hypo or hyper thyroidism, Cushing’s and Addison’s diseases. Any types of integumentarydiseases including bleeding problems should be noted. Musculoskeletal system integrity and past history oftrauma and disease, including prosthetic joints must be elicited. Incidence of any infectious pathology shouldbe probed and include specific references to diseases impairing immune function or one’s which may becurrently infections to the persons in the clinical setting i.e. active TB. Finally, all women between the ages ofpuberty and menopause should be questioned regarding any current pregnancy potential. 11
    •  Past history of surgeriesThe medical history findings will be supplemented with the patients past surgical history. It is important to listthe type of procedures, dates and any complication or drug reactions. Correlate the surgical history with themedical history you have just compiled. If you find any inconsistencies, you need to re-investigate themedical history issues. Assess the impact of past surgical management on your currently planned procedure.Consider any required pre-medications or treatment modifications. Social HistoryThird area of the patient history is the social history. Specifically, the areas of tobacco, alcohol and street druguse should be probed. Find out the level of daily use, length of use, as well as last intake especially for drugsand 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-operativerecovery. Allergies and adverse drug reactionsDetermine if the patient has ever had an allergic reaction to any medications or substances. List theemedications and their reactions. If yes, be able to qualify if true anaphylaxis type hypersensitivity is presentor if the patient has had an adverse drug reaction. This will help to manage the patient better especially interms of post-operative medication selection. Physical ExaminationAfter completion of a verbal examination, the patient should receive a physical examination. For the purposesof delivery of outpatient oral and maxillofacial surgery this will be mostly directed at exploring the structuresof head and neck. To get a limited overview of the other systems and the patients current functional status onecan use the four standard vital signs. The vital signs including blood pressure, heart rate, temperature andrespiratory rate must be completed for each patient in the clinic. Values that fail to fall in the acceptablenorms and ranges may need to be re-evaluated in 5 min to establish their true level and rule out outlier resultssecondary to recent ambulation or anxiety.It is not the purpose of this course to teach the students oral diagnostic skills; however, a brief suggestedapproach tailored for the surgical patient is presented. Always start with general and narrow down to specificareas.First note the patient’s overall appearance; level of anxiety, respiratory distress, level of alertness andresponsiveness. Do they look old for their age? Younger? Do they look well or ill? Next, systematicallyexamine the TMJ’s, salivary glands, oral cavity and oropharynx. Next, thoroughly evaluate the neck formasses and adenopathy and other stigmata of disease. In general, begin your exam away from the chiefcomplaint/area of interest to avoid skipping other areas ending here only after examining everything else. Radiological and laboratory assaysSystematically 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 theprocedure. Any laboratory values and tests should be then presented and discussed in reference to theproposed procedure and patient’s health status. 12
    •  Diagnosis and PrognosisOnce all of the diagnostic information has been compiled, these should be presented as a diagnosis or list ofdiagnoses with the anticipated prognosis without and with possible treatment. Remember that statement suchas “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 marginor osseous crest. Treatment planFinally, a plan for management of the patient should be put forth in an organized and logical sequence ofsteps. Include items such as: any necessary consults, modified treatment protocols i.e. stress reductionprotocol, need for translator, guardian consent, etc., surgical procedure, type of anesthesia, and any post opconsiderations 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 theprinciples 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-operativework up section of the treatment form.Supervision of care deliveryStudents are required to have constant supervision by the faculty during the delivery of care. Unless a residentor staff surgeon is physically present in the surgery clinic patients are not to be seated in the operatories. Allcases need to be presented and discussed with the faculty or the residents. The student is responsible forensuring that the pre-operative form is signed off for start check by the faculty or resident before anyprocedure is commenced. The procedure forms are then completed post-operatively and presented to thefaculty during debriefing for final signatures. Any time any questions or problems arise during a procedurethe student is to immediately attempt to contact the faculty member who approved your case presentation andtreatment plan. If they are unavailable, and the matter is urgent contact another resident or faculty. Otherwiseit is required that one instructor oversees the case from start to finish and both start check and final signaturesmatch. It will also be this instructor who will issue your grade for the session.Emergency protocolsIt 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 supportivecare to maintain life until further help arrives.Specific attention to the medical history of the patient will help alleviate most serious problems before theyare 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 13
    • 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 mouth 2) Airway - clear foreign bodies a) Finger sweep / suction b) 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 canula 5) Emergency airway - cricothyroidotomy (cricothyroid membrane) 6) Medications - epinephrine (1:1,000 IM 0.3 - 0.5 mg.) - ventolin inhaler 14
    • Airway obstructionLevel 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 TreatmentAs listed under management abovePossible need for a chest or abdominal radiographMedical consultationRemoval of foreign body - laryngoscope - Magill forceps - Bronchoscope Emergency AirwayCricothyroidotomy – canula inserted; best use a 14-gauge 1/2-inch long needle connected to 4.0 ETTconnector and ambu bag.Hyperventilation SyndromeAnxiety - tachypnea - decreased PC02 and blood pHUsually dont lose consciousness Signs1. Neurologic Dizziness Lightheadedness Disturbances of consciousness or vision Numbness and tingling of the extremities Tetany (rare)2. Cardiovascular Palpitations Tachycardia Precordial pain3. Respiratory Shortness of breath Chest pain Dryness of mouth4. Gastrointestinal Epigastric pain5. Musculoskeletal 15
    • Muscle pains and cramps Tremors Stiffness Tetany6. Psychologic Tension Anxiety PathophysiologyDecreased 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 Treatment1. 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 neededAsthmaBasic pathology is hyper reactive airways with bronchospasm and increased mucous secretion. Precipitant factors 1. Foods - cows milk, eggs, fish, chocolate, shellfish, tomatoes 2. Drugs - penicillin, vaccines, aspirin 3. Exercise or stress 4. Viral respiratory tract infections 5. Environmental allergies Prevention1. Medical history2. Patient to bring inhaler with him - dose just before dental treatment in moderate to severe Asthmatics SignsMild tightness in chest Coughing spell Wheezing 16
    • Dyspnea with increased respiratory rate Anxiety TacchycardiaSevere intense dyspnea Cyanosis Perspiration Use of accessory respiratory muscles and Indrawing Increased or decreased respiratory rate Decreased rate is a poor sign Treatmenta) 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 managementCardiovascular Emergencies Anatomy and physiologyVenous return R.A.R.VLUNGSL.A.L.V. arterial circulation(PRELOAD) (AFTERLOAD)Cardiac work increases with demand - usually is a large functional capacity to adapt. With increasing agethere is less cardiac reserve.Cardiac ejection fraction - 50 - 80% normally - As little as 10 - 20% with failureSTARLINGS 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 17
    • Considering all of the above, the primary goal of dental treatment in cardiac patients is to minimize stress toan absolute minimum. This can be done via: 1. Short appointments 2. Good local anesthetic 3. Friendly staff 4. Sedation EvaluationThe medical history is the MOST important preventative measure. Extremely important – helps youdetermine if patient will tolerate stress of surgery. QUANTIFY ACTIVITY LEVEL e.g. patient can climb 1flight 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 patients physician.Congestive heart failureFluid congestion of the pulmonary venous and/or systemic venous circulation.Fluid mechanics: a) Osmotic pressure - tissue - Vessel b) Hydrostatic pressure - tissue - VesselThe acute emergency is called Acute Pulmonary Edema. Signs and Symptoms are: - Shortness of breath (acute) - Possibly frothy sputum - Cyanosis Treatment 1) Upright position 2) Stop procedure 3) Apply oxygen via mask and check vital signs (BP, P, and RR) 4) Call for help 5) Morphine, diuretics, CPRAnginaMedical history again is the most important preventive measure.The patient may be on various medications such as nitroglycerin, isosorbide dinitrate, or calcium channelblocking agents (nifedipine). It is important to know if the patients angina is stable or unstable. Unstableangina is: 18
    • 1) New onset chest pain 2) Pain at rest 3) 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. Atherosclerosiscauses narrowing of the vessels and thus enough blood isnt allowed through to give adequate oxygen to themyocardium. Usually oxygenation of myocardium is adequate at rest but when cardiac work increases andthus oxygen demand; blood and oxygen supply are inadequate. This results in ischemia and pain, which, if notrelieved, may progress to infarction and complete cardiovascular collapse. Stress is an important factor asepinephrine 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 6Chest 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. - pericarditisFor patients with recent Myocardial Infarctions they are at risk for a second M.I. if given a general anestheticaccording 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. 19
    • 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 neededDrug 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 symptoms a) Low to moderate overdose levels confusion headache talkativeness lightheadedness apprehension dizziness excitedness blurred vision slurred speech ringing in ears 20
    • 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 neededCAUTION: Use care if giving an anticonvulsant, as after the initial excitement phase as there is a generalizeddepression. 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 helpd) Severe overdose (slow onset) 1 ) basic life support 2) call for help Epinephrine overdoseOptimal 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 MaximumEpinephrine 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 21
    • 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 Treatment1) stop procedure2) position patient – conscious patientcardiac 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 neededNarcotic 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 neededAllergyA 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 48hours after exposure to immediate and life threatening reactions developing within seconds of exposure. ClassificationType1. 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 22
    • Urticaria Angioedema Hayfever2. 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. TreatmentSkin 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 useRespiratory reactions 1. Bronchial constriction a. Stop procedure b. upright position c. oxygen and vitals d. ventolin inhaler e. antihistamine and/or epinephrine 1:1,000 0.3-0.5 cc subcutaneous f. call for help if needed g. contact patients physician 23
    • 2. Laryngeal edema (partial obstruction) a. supine position b. 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, corticosteroidGeneral 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, corticosteroidGeneral anaphylaxis (no signs of allergy present) basic life support 1. supine position 2. monitor vital signs 3. immediate call for helpUnconsciousnessAny 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 beall that is required for proper patient management. There are however other causes that will require additionalsupport and possible need for assistance. Predisposing factorsVasodepressor syncope Most commonDrug administration/ingestion CommonOrthostatic hypotension Less commonEpilepsy Less commonHypoglycemic reaction Less commonAcute adrenal insufficiency RareAcute allergic reaction RareAcute myocardial infarction RareCerebral vascular accident RareHyperglycemic reaction RareHyperventilation syndrome RareMedical history is again the most important preventative measure. This will identify any medical problemsthat he/she is being treated for (ex. diabetes, Addisons disease, epilepsy).Stress is the most common precipitating factor in the dental office. 24
    •  Clinical ManifestationsAn unconscious patient will be incapable for responding to sensory stimulation and will have lost theprotective 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. Pathophysiology1) 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 syncopeOxygen DeprivationLoss of consciousness results in loss of muscle tone in the body. The tongue falls posterior and may occludethe airway. It is of utmost importance to maintain adequate oxygenation to the brain in the unconsciouspatient. The brain gets most of its energy from oxidation of glucose, therefore, it needs a continuous supply of 25
    • these. Without oxygen, glucose can still be metabolized to lactic acid with some energy provided but thissource 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 thevictim anoxic will lead to permanent brain damage within 4 to 6 minutes and to cardiac arrest within 5 to 10minutes. This implies the importance of early airway management and basic support to prevent permanentbrain 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 ObstructionSound heard Probable Cause ManagementSnoring Hypopharyngeal obstruction Clear upper airway with by the tongue finger sweep, pull tongue or mandible forwardGurgling Foreign matter (blood, water, Suction airway vomit) in airwayWheezing Bronchial obstruction Administer Ventolin by (asthma) inhaler or epinephrine I .M .Crowing Laryngospasm Suction airway, positive pressure oxygen, cricothyroidotomy neuromuscular blocking agentsVasodepressor Syncope 26
    • Also known more commonly as a simple faint. It is a sudden transient loss of consciousness due to cerebralischemia. Predisposing factors consist of psychogenic factors (fright, anxiety, stress), pain of a sudden orunexpected 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, poorphysical condition, and a hot, humid crowded environment. Prevention is directed at eliminating the abovefactors. Clinical ManifestationsEarly 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 tachycardiaLate pupillary dilation yawning hyperpnea coldness of hands and feet hypotension bradycardia visual disturbances dizziness loss of consciousness Management1 ) Supine position. Stop all procedures and removal all material from the patients mouth.2) Airway management as needed3) Vital signs4) Follow up treatment if needed. Postpone dental appointment as needed.Orthostatic hypotensionCertain 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-adrenergicblockers, 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 compressthe inferior vena cava and thus decrease venous return to the heart with resultant syncope. Best to have thepregnant 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 27
    • that have the side effect of orthostatic hypotension. PathophysiologyWith 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 changesoccur 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. Management1 ) Supine position and with pregnancy the left lateral position2 ) Basic support airway breathing circulation3 ) Vital signs and oxygen4 ) Slowly upright position when patient recovers5 ) Discharge patientAcute adrenal insufficiencyAdrenal cortex secretes over 30 steroid hormones most of which lack any identifiable biologic activity ofimportance at present. Cortisol is considered one of the most important products of the adrenal cortex. Itallows the body to adapt to stress.Addisons disease - lack of cortisol.Cushings syndrome - excess of cortisol.Numerous diseases are treated with adrenocortical steroids at present. The adrenal cortex produces about 20mg. of cortisol daily. In times of stress a much large dose of steroids are needed.Equivalent does: mg. Cortisone 25 Hydrocortisone 20 Prednisolone 5 Methylprednisone 5 Methylprednisolone 4 Triamcinolone 4 Dexamethasone 0.75 Betamethasone 0.6Patients 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 parenteralroute for a continuous period of 2 weeks or longer within 2 years of dental therapy.The patients physician should be contacted to adjust the dose of steroids appropriately. 28
    • 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 signsmental confusionmuscle weaknessintense pain in the abdomen, lower back, legsextreme fatiguenausea and vomitinghypotensionsyncopal episodescomaAgain 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 thuscannot 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 neededDiabetes MellitusChronic systemic disease that affects most systems of the body, in particular neuropathy, microangiopathyand 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)hyperthyroidismthyroid medication,epinephrine therapy,corticosteroid therapyacute infectionsfeverIf untreated, hyperglycemia may lead to diabetic ketoacidosis in Type I diabetes or nonketotic hyperosmolarcoma 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 29
    • recovery from an infection or fever. Most common cause is inadequate food intake. Prevention again is wortha thousand camels. Be sure to take a thorough and adequate medical history. Consult the patients physician ifany doubt exists.Insulin dose needs to be adjusted if oral intake will be impaired after the procedure. Rarely, a patient will beadmitted to the hospital for complicated extractions to have good control of the blood sugar levels. Transientperiods of hyperglycemia tolerated better than periods of hypoglycemia. After extensive treatment, make surethe patient checks his glucometer readings at least 4 times a day and adjusts his insulin dose accordingly.Involvement of the patients physician is a good idea before any problems develop.Methods of testing blood glucose levels blood - dextrostix - glucometer Clinical ManifestationsHyperglycemia Hypoglycemiapolydipsia 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 Management1. 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 patients physician and arrange appointment with himIf doesn’t recover5 ) Continue supportive care and start CPR as needed.6 ) Call for help7 ) I.V. fluids and I.V. insulin drip 30
    • 8 ) Transfer to hospitalThere 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 patients disease aswell as consultation with the patients physician. This will then prepare one for most problemsthat can or will be encountered.Informed ConsentUpon completing the case presentation and receiving the green light to proceed, the student may not start anysurgical care until the patient signs an informed consent form. The informed consent is an important part of aproper data base. It may be the only thing that keeps you from litigation. Note on your record the types ofthings you have discussed with your patient. Time and dated signatures of your patient, a witness, andyourself should appear in your records. Explain that they are about to have a small procedure performed butthat it is a surgery hence there are some inherent risks and complications to each and every surgical procedureno 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 willdecrease over the course of the forthcoming week. Then list the complications that tend to be less common inmost 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 casesGive the patient time to read over the form and ask any questions. Be reassuring and explain that these arerisks but that their incidence is limited and we do not anticipate encountering the majority of these during theprocedure. However, your discussion with faculty should help to identify the cases where complications aremore likely than in the “routine” case. These patients should be made explicitly aware of likelihood of thespecific complications. 31
    • A sample consent form for surgery and anesthesia is enclosed for your review. Please alter it to satisfy yourpractice style and your specific needs. It must again be emphasized that informed consents are absolutelynecessary 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 lessthan smoothly. It is part of the game. So provide the patient with the most comprehensive consent and usegood surgical technique. If you come up against any complications discuss these with the faculty for furthermanagement.Radiological studiesAny visit to the oral and maxillofacial clinic should include review of pertinent radiographic surveys of thepatient’s oral-facial structures. The most convenient survey for the purposes of basic oral surgery is thepanoramic 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 orprocedure require a panoramic radiographic to ensure adequate diagnosis and treatment planning. Also anyalveloplasty, 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 ifthe 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 periapicalviews can be utilized. The radiograph must have been taken within last six months of the date if surgery inmost cases. In more acute pathology or trauma cases new radiographs must be obtained. Radiographs olderthan six months will not be accepted except to compare with current radiographs in determining progressionof disease over time. Any radiographs lacking or excessive in proper contrast, detail or density will not beacceptable and will require to be retaken. The oral surgery clinic is equipped with a portable X-ray unit andany periapical or occlusal films can be completed if required intra-operatively or post operatively. Adeveloper 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, panoramicsurveys are to be taken in radiology on the first floor. Patients need to be escorted down to radiology, they arethen signed in, and a radiology request must be completed. The patients can then bring the panoramicradiograph back to the clinic after it is developedFinally remember to use lead shields and use proper exposure settings.Vital signsEach patient seen at the clinic for any invasive surgical therapy requires their vitals checked. The vital signsinclude the blood pressures, heart rate, respirations and temperature. Commonly the stress and anxietyexperienced by the patient perioperatively will have effects on their vital signs and these will need to beidentified and treated differently from vital sign changes secondary to systemic pathology. Normal values forvital signs are listed below:Blood Pressure: 120-140/70-90Heart Rate: 60-80Temperature: 37 CRespirations: 12-18Note: The entirety of your history and physical will be required for you to decide if the vitals are so aberrantto preclude treatment at that visit. Variations will be present in individuals secondary to age, fitness level andanxiety. Take those into consideration during analysis if the values fall outside above indicated ranges. Also 32
    • do not relay on one set of measurements as there may be changes as the patient relaxes or becomes moreagitated. Make sure your instruments are working properly and you are using appropriate technique i.e. rightsize of sphygmomanometer cuff for the girth of the upper extremity.American Society of Anesthesiologists (ASA) classificationASA 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 purposesOnce the ASA classification of the patient is completed, it can be determined whether or not the patient canbe treated on outpatient basis or what modifications to treatment protocol must be undertaken. For non-class Ipatients, 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 patientLocal anesthesia guidelinesPlease be fully aware of all indications, actions, contraindications, adverse reactions and their managementprior to using any medication. As dentists, the medications we use most often are local anesthetics. Alongwith antibiotics and analgesics these medications should be very well understood and utilized appropriatelyby 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 adepression 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 theoryimplies that anesthetics bind to receptors on sodium channel and interrupt the nerve conduction by decreasingthe membrane’s permeability to sodium ions.The full discussion of pharmacology of local anesthetics is beyond the scope of the oral and maxillofacialsurgery manual as it has been discussed in your pain control curriculum and pharmacology course, howeverwe will reemphasize some areas with increased significance to oral surgery. Local Anesthetic techniqueDo not hesitate to use topical anesthesia prior to your injection, but use topical sparingly, since mucosalabsorption can add to an overall toxic dose. Watch the benzocaine (ester) types, since these can precipitate anallergic 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 firsttime. 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) . 33
    • A popular choice for a needle is the 1 1/2 inch 25 gauge with a plastic hub, providing for a better seal and theprolonging 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 adanger. The surgical procedure to retrieve this "foreign body" is horrible with a less than satisfactory successrate.Studies have also shown that muscle and soft tissue, particularly in the mandibular blocks may easily deflectsmall 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. Manypatients really like this technique because it gives them a "silver bullet" to bite on. Always when possible usethe bite block to support the TMJs during surgery. Overdose scenariosOverdose 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 % Amide Mepivacaine 2 % Amide (with vasoconstrictor) Mepivacaine 3 % Amide (without vasoconstrictor) 34
    • Prilocaine 4 % Amide Bupivacaine 0.5 Amide Etidocaine 1.5% Amide b. Route of Administration Local 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 Injection Faster 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. MetabolismESTERS are metabolized by pseudocholinesterase in blood then further in the liverAMIDES are metabolized in the liver by the microsomal enzymesIn 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 serummore 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 InjectionEspecially 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 aspiratebefore injecting (Harpoon syringes vs. self aspirating). Also consider the orientation of the bevel of needle: ifit is lying against the wall of the vessel you will often see no aspiration even though the needle is in thevessel. With rapid injection tend to obtain higher and faster blood levels of injectables. 35
    • N20 sedationNitrous oxide sedation can function as a great adjunct to standard pain and anxiety control. Patients tend tofeel more relaxed, and the analgesic properties of N2O may aid in administration of local anesthetics. Objectives of N20 application1. Sedation2. Analgesia3. Maintenance of all reflexes Side Effects1. Nausea2. Perspiration3. Tinnitus4. Disinhibitions5. Exaggerated sounds6. Dysphoria Contraindications1. Pregnancy2. Nasal obstruction (relatively, since the gas is inhaled via a nasal hood)3. Potentiating medicaments4. Dead space such as bullous emphysema Administration1. 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 N2OIV sedationThe use of Intravenous Sedation is common place in the delivery of outpatient oral and maxillofacial surgeryby certified specialists and general practitioners with advanced training in this area. Some exposure to IVsedation will be available during the clinical rotations in oral and maxillofacial surgery clinic. Please taketime to familiarize yourself with armamentum, monitoring and medications used to deliver this therapyadjunct to the patient.Review of anatomy and physiology of the oral cavityThe oral cavity, the initial portion of the digestive system, plays a functional role in both the ingestion anddigestion of food. Through the act of mastication, food is mixed with saliva and broken down into smallerparticles, which are subsequently transported to the stomach by the peristaltic muscle contractions of the 36
    • 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 andcheeks and internally by the alveolar process, gingiva, and teeth. Frenula join the upper and lower lips as wellas the cheeks to the gingiva. The oral cavity proper is the more central region of the mouth and is bounded bythe hard and soft palate superiorly; the tongue, lower jaw and mucosa of the floor of the mouth inferiorly; andthe oral pharynx posteriorly. Lips and cheeksThe lips and cheeks form the orifice of the mouth and are composed of four distinct tissue layers: an outercutaneous, a deeper muscular, a submucosal glandular, and an inner-mucosal layer. Functionally, the lips andcheeks play an important role in mastication, assisting the tongue in the transfer of food between the vestibuleand the oral cavity.Lip anatomyThe most prominent external feature of the lips is the vermilion mucosa, which merges with the outer skin toform 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, anda curving region of the vermilion border called the Cupids bow. The Cupids bow unites with its oppositecounterpart in the midline to form the vermillion tubercle. Internally, the vermillion mucosa merges with theoral mucosa forming the so-called "wet-dry" line. The submucosa of the lips contains the labial minor salivaryglands.Cheek anatomyThe cheeks are structurally similar to the lips. They form the lateral borders of the mouth. The external skinand internal mucosal linings enclose the buccal fat pad and the principle muscle of the cheek, the buccinator.The parotid duct (Stensons duct) pierces the mouth at the level of the upper second molar tooth. Buccalsalivary glands are contained within the submucosal tissue.Muscles of the lips, cheeks, and perioral regionThe oral musculature includes muscles of the aperture and muscles of the lips and cheeks. The predominantmuscle within the lips is the Orbicularis Oris, which encircles the oral aperture. Functionally, this musclecloses and protrudes the lips. Supplementary muscles of the face work in concert with the Orbicularis Oris tomove the lips and the mouth. Five facial muscles converge at the angle region of the oral aperture. Thesemuscles include the Levator Anguli Oris, Zygomaticus Major, Risorius, Platysma, and the Depressor AnguliOris. Their fibers merge and interlace with fibers of the Orbicularis Oris. The Levator Anguli Oris arises fromthe canine fossa of the maxilla and inserts into the superior aspect of the angle of the mouth. Its function is toelevate 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. Originatingfrom the lateral facial fascia and joining together with the posterior fibers of the Platysma is the Risoriusmuscle. This muscle functions primarily during laughter. The Depressor Anguli Oris takes its origin from theanterior mandible and attaches to the inferior aspect of the angle region of mouth. Functionally, this muscledepresses the corner of the mouth.Additional muscles of the upper lip include the Levator Labii Superioris Alaeque Nasi, the Levator LabiiSuperioris, and the Zygomaticus Minor, all of which have their origin from the orbital margin and attach tothe more central fibers of the Orbicularis Oris. These muscles function to elevate the upper lip. Two othermuscles 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 37
    • paired Mentalis muscles are situated between the left and right Depressor Labii lnferioris. Contraction of theMentalis 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 thepharynx through its posterior connection with this muscle, forming the pterygomandibular raphe. Superiorlyand inferiorly, the Buccinator attaches to the alveolar processes of the maxilla and mandible, usually belowthe apices of the teeth. The attachment of this muscle apical to the roots of the teeth is important clinically inthat it serves as an anatomic barrier limiting the spread of odontogenic infection into the soft tissues of theface. The Buccinator merges with Orbicularis Oris of the upper and lower lips anteriorly. Contraction of thismuscle produces cheek compression against the teeth, assisting the tongue in the positioning and movementof food during mastication. In addition, it has a functional role during blowing and sucking.Nerve supply to the lips and cheeksThe facial nerve (cranial nerve VII) supplies motor innervation to the musculature of the lips and perioralregion. It splits within the parotid gland into two major divisions, the temporofacial and cervicofacial. Thetemporofacial division terminates as the temporal and zygomatic branches. The cervicofacial division dividesinto the buccal, mandibular, and cervical branches. The zygomatic and buccal branches supply the upper lipand 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). Theinfraorbital 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) hasseveral divisions: lingual, mental, buccal, and auriculotemporal. The mental nerve innervates the skin andmucous 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 lingualgingiva.Arterial supply to the lips and cheeksThe facial artery, which arises from the external carotid, enters the face at the anterior border of the Massetermuscle. It then courses anteriorly and superiorly, crossing over the Buccinator and Levator Anguli Orismuscles. At the level of the angle of the mouth, the superior and inferior labial arteries originate. Thesevessels supply the upper and lower lips through an anastomosing vascular system, which encircles the oralaperture. A buccal branch from the facial artery as well as a buccal branch from the maxillary artery suppliesthe cheeks. GingivaThe masticatory oral mucosa that covers the alveolar processes of the maxilla and mandible is called thegingiva. 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 tothe underlying bone. The gingiva extends from the dentogingival junction to the alveolar mucosa and can bedivided into the free gingiva, the attached gingiva, and the interdental papilla. The free gingival grooveseparates the attached from the free gingiva. The mucogingival junction is the line of separation between theattached gingiva and the alveolar mucosa. Alveolar processThat portion of the maxilla and mandible, which forms the osseous supporting structure for the dentition iscalled the alveolar process. The alveolar process is developed during tooth eruption and is maintained by thepresence of functioning teeth. Resorption occurs upon the loss of the teeth. The alveolar processes arecomposed of two distinct regions, the alveolar bone proper and the supporting alveolar bone. The alveolarbone proper is that area that encompasses the tooth root and provides attachment for the suspensory fibers of 38
    • the periodontal ligament. The periodontal ligament is composed of fibrous connective tissue, which serves toconnect the cementum of the tooth to the alveolar process. The supporting alveolar bone is that component ofthe alveolar process that serves as a structural foundation sustaining the alveolar bone proper. DentitionThe human dentition is made up of two sets of teeth, deciduous and permanent. In each jaw, the teeth arearranged 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 eightmolars. The permanent dentition gradually replaces the deciduous dentition beginning approximately at theage of six. The permanent dentition consists of 32 teeth: eight incisors, four canines, eight premolars, and 12molars.The predominant function of the teeth is to masticate food; however, they also play a minor role in speecharticulation. The incisors (central and lateral) are shearing or cutting teeth. The canines are positioned distal tothe lateral incisors. They also have an incising action but, because of their single cusp, are also able to piercefood and hold it in position. The premolars and molars are positioned posterior to the canines. As a result oftheir size and position within the jaws, they are the most efficient teeth for breaking down food into smallparticles suitable for swallowing.Each tooth can be divided into a crown and a root portion. The transitional zone between the crown and theroot is called the neck or cervix. Internally, each tooth contains a pulp chamber, which continues down eachroot as a pulp canal. The pulp, or soft tissue component of the tooth, is composed of a connective tissuematrix supporting neural and vascular elements. It communicates with the periodontal ligament through anapical 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 bycementum.Nerve supply to the gingiva, alveolar process and teethThe trigeminal nerve (cranial nerve V), via its maxillary and mandibular branches, provides sensoryinnervation 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 foramenrotundum. Within this fossa, several branches are given off. The zygomatic nerve is the first branch. It entersinto the orbit through the inferior orbital fissure. Ganglionic branches to the sphenopalatine ganglion aregiven off next. One or two posterior superior alveolar nerves are usually present distal to the ganglionicbranches. They are the last of the nerve branches within the pterygopalatine fossa and enter the maxilla viathe posterior alveolar foramina. The maxillary division continues anteriorly to enter the inferior orbital fissureand, from this point on, is referred to as the infraorbital nerve. The middle and anterior superior alveolarnerves 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 inferioralveolar nerves. The inferior alveolar nerve enters the mandible via the mandibular foramen. Its terminalbranch, the mental nerve, emerges from the mental foramen.In the maxilla, the molars, their supporting alveolar bone, and the labial gingiva opposite the molars, areinnervated by the posterior superior alveolar nerve. The middle superior alveolar nerve supplies the premolarsand adjacent labial gingiva and alveolar process. In the anterior maxilla, general sensation to the canine andincisor teeth, as well as the labial gingiva and alveolar process opposite these teeth, is provided by the anteriorsuperior alveolar nerve. The greater palatine nerve innervates the palatal gingiva and alveolar processopposite the maxillary molars and premolars. The nasopalatine nerve supplies the anterior palatal mucosa andalveolus from the canines to the central incisors.In the mandible, the inferior alveolar nerve innervates all of the teeth. The buccal nerve supplies the buccalgingiva, mucosa of the vestibule and the lateral aspect of the alveolar process in the posterior region of the 39
    • 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 lingualnerve supplies the alveolar process, gingiva, and mucosa on the lingual aspect of the mandible as well as themucosa of the floor of the mouth.Arterial supply to the gingiva, alveolar process and the teethThe maxillary artery provides the vascular supply to the mandible and maxilla including the gingiva, alveolarprocesses, and teeth. Originating from the external carotid artery within the parotid gland, the maxillary arterypasses deep and medial to the subcondylar region of the mandible, and then enters into the infratemporalfossa. Within this fossa, the external pterygoid muscle serves as landmark, which can be used to divide themaxillary artery into three specific regions. The first part of the artery lies anterior to the muscle while thesecond part traverses across its surface. The third part of the artery is the terminal portion of the vessel thatenters 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 themaxillary artery supplies the muscles of mastication as well as the buccinator. Vessels within this division arethe masseteric, deep temporal, pterygoid, and buccal arteries. The terminal branches of the maxillary arteryarise 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 ofthe 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 arteriesprovide vascularity to the gingiva, alveolar processes, and teeth of the maxilla. The posterior superior alveolarartery supplies the maxillary molars, supporting alveolar bone, and gingiva. The posterior maxillary labialgingiva and mucosa receive additional blood flow from the buccal artery. The blood supply to the premolarsand anterior teeth, as well as their supporting alveolar bone and gingiva, is derived from the middle andanterior superior alveolar arteries. The anterior labial gingiva and mucosa also obtain a portion of their bloodsupply 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 derivedfrom the inferior alveolar artery. Perforating blood vessels arising from the muscles that attach to its corticalsurface provides additional vascularity to the mandible. The inferior alveolar artery enters the mandiblethrough the mandibular foramen. It continues anteriorly within the mandibular canal giving off dental andseptal 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 palateThe palate forms the superior boundary of the oral cavity. It is divided into two distinct regions, the hardpalate 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 palatineaponeurosis. The hard palate is lined with a keratinized stratified squamous epithelium. Based upon the natureof the submucosal tissues, the hard palate can be divided into an anterior fatty and a posterior glandularregion. Surface anatomic landmarks of the hard palate include the incisive papilla, anterior folds of mucosacalled rugae, midline palatal raphe, and gingiva. The osseous portion of the hard palate is composed of thepalatine processes of the maxilla anteriorly and the horizontal plates of the palatine a midline bonesposteriorly. Palatal to the third molar two osseous foramina can be identified. The larger anterior opening iscalled the greater palatine foramen. The greater palatine vessels and nerves exit at this point. The smallerposterior opening is referred to as the lesser palatine foramen, in which the lesser palatine vessels and nervesemerge. The anterior palate also has an osseous opening, which is known as the incisive foremen. It is locatedin the midline just posterior to the maxillary incisors. The nasopalatine nerve and vessels traverse through thisorifice. 40
    • 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 softpalate is called the uvula. Overlying the muscular layer of the soft palate is a surface layer of mucosacomposed of non keratinized epithelium. Deep to the mucosa, a glandular submucosal tissue layer is present.Muscles of the soft palateThe soft palate is composed of the confluence of five pairs of muscles; the Tensor Veli Palatini, Levator VeliPalatini, Palatoglossus, Palatopharyngeus, and Musculus Uvulae.The Tensor Veli Palatini originates from the scaphoid fossa, the spine of the sphenoid bone, and the lateralsides of the auditory tube. Its tendon wraps around the hamulus of the pterygoid joining in the midline with itscounterpart from the opposite side to form the palatal aponeurosis. Its function is to tense the soft palate andopen the auditory tube during deglutition.The Levator Veli Palatini has its origin from the petrous portion of the temporal bone and medial side of theauditory tube. Its fibers join in the midline with those of the opposite side. Contraction results in elevation ofthe soft palate.The Palatoglossus and the Palatopharyngeus muscles form the tonsilar pillars. The Palatoglossus, or anteriortonsilar pillar, arises from the anterior surface of the soft palate and inserts into the dorsum and lateral aspectof the tongue. Contraction of this muscle produces a decrease in the anterior opening of the fauces as well asan elevation of the tongue posteriorly. The Palatopharyngeus, or posterior tonsilar pillar, originates from thesoft palate. It inserts on the posterior border of the thyroid cartilage and aponeurosis of the pharynx. Itsfunction 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 posteriornasal spine and palatine aponeurosis. They insert into the mucosa of the uvula. Functionally, these muscleselevate the uvula.Nerve supply to the palateThe sensory nerve supply to the hard palate is derived from the nasopalatine nerve (anterior 1/3) and thegreater palatine nerve (posterior 2/3). The greater palatine nerve arises from the pterygo (spheno)palatineganglion within the pterygopalatine fossa. It descends within the greater palatine canal to reach the hardpalate through the greater palatine foramen. The nasopalatine nerve, a branch of the maxillary nerve, departsthrough the sphenopalatine foramen, traverses across the roof of the nasal septum, and travels along thevomer within the mucoperiosteum. It exits through the incisive foremen to supply the anterior portion of thehard palate.The soft palate receives its sensory nerve innervation from two sources: the lesser palatine andglossopharyngeal (cranial nerve IX) nerves. The lesser palatine nerve, a branch of the maxillary nerve, ariseswithin the pterygopalatine fossa from the pterygo(spheno)palatine ganglion, and exits through the lesserpalatine 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 thepharyngeal 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 ofthe mandibular division of the trigeminal nerve (V3 ).Arterial supply to the palateThe blood supply to the palate is derived from the greater palatine artery, the lesser palatine artery, thenasopalatine artery, and the ascending palatine branch of the facial artery. The greater and lesser palatinearteries 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 vascularizesthe bone, mucosa, glands, and gingiva of the posterior 2/3 of the hard palate. The nasopalatine artery, a 41
    • branch of the sphenopalatine artery, supplies the anterior third of the hard palate. The soft palate receives itsbloodsupply from two sources, the lesser palatine artery and the ascending branch of the facial artery. Afteremerging from the lesser palatine foramen, the lesser palatine artery courses posteriorly to nourish the softpalate. The lesser palatine artery supplements the ascending branch of the facial artery, which provides thepredominant blood supply to the soft palate. Floor of the mouthThe floor of the mouth and tongue form the inferior boundary of the oral cavity proper. Inferior to the mucosaof the floor of the mouth is the sublingual space. This U-shaped region is bounded laterally by the body of themandible, inferiorly by the Mylohyoid muscle, medially by the Geniohyoid, Genioglossus, and Hyoglossusmuscles, and superiorly by the mucosa of the floor of the mouth. The primary contents of the sublingual spaceinclude: the sublingual gland, the sublingual artery and vein, the lingual nerve, hypoglossal nerve, the deepportion of the submandibular gland, and the duct of the submandibular gland (Whartons duct). The sublingualspace, which is, in reality, a potential space, is filled with a loose connective tissue matrix. It only becomes atrue space when the loose connective tissue is broken down by an invading infectious process, such as occursin Ludwigs 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 mucosaextending from the tongue to the floor of the mouth; two sublingual papilla, which are located just anterior toand 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 plicasublingualis is actually a ridge of tissue extending posteriorly from the sublingual papilla. It contains betweensix and eight sublingual gland ducts that open along its crest. The sublingual space is bounded laterally by thelingual aspect of the body of the mandible. In order to understand the anatomic relationships of the sublingualspace, it is important to review the medial surface anatomy of the mandible. Medial surface landmarksinclude: 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 andmedial pterygoid muscle.Muscles of the floor of the mouthThe muscles of the floor of the mouth form the medial and inferior borders of the sublingual space. Thepaired Mylohyoid muscles limit the inferior extension of the sublingual space and form the actual floor of themouth. Originating from the mylohyoid line on each side of the mandible, they insert into the body of thehyoid bone as well as the midline raphe. The raphe extends from the hyoid bone to its attachment in themidline on the medial side of the anterior mandible. Functionally, the mylohyoids elevate the hyoid bone, thebase of the tongue, and the floor of the mouth. The Geniohyoid, Genioglossus, and Hyoglossus musclescontribute to the medial border of the sublingual space. The Geniohyoid muscle, a paired muscle, takes itsorigin 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 tubercleis one of the paired Genioglossus muscles, one of the extrinsic tongue muscles. It has a dual insertion into thebody of the hyoid bone and into the base of the tongue. Functionally, its posterior fibers protrude the tonguewhile the anterior fibers produce tongue retraction and depression. The Hyoglossus, also paired extrinsicmuscle of the tongue, takes its origin from the body of the greater cornu of the hyoid bone. It inserts into theside of the tongue. Contraction of this muscle produces tongue depression.Nerve supply to the floor of the mouthThe lingual nerve, a branch of mandibular division of the trigeminal nerve, provides general sensoryinnervation to the floor of the mouth, the anterior two thirds of the tongue, and the lingual gingiva of themandible. After emerging from the anterior fibers of the medial pterygoid muscle in the posterior region of 42
    • the mandible, it enters the floor of the mouth inferior to the Superior constrictor and superior to theMylohyoid. In its course anteriorly, it crosses over the submandibular duct, traveling with the duct for a shortdistance on its lateral side. It then passes underneath and crosses the duct medially to enter the anteriorportion of the tongue and sublingual region.The motor supply to the muscles of the floor of the mouth is derived from three different nerves. Themylohyoid nerve, a branch of the mandibular division of the trigeminal nerve, supplies the Mylohyoidmuscle. The Genioglossus and Hyoglossus muscles are innervated by cranial nerve XII, the hypoglossalnerve. Cervical fibers from Cl, which join with the hypoglossal nerve, supply the Geniohyoid.Arterial blood supply to the floor of the mouthThe arterial supply to the floor of the mouth, sublingual region, and sublingual gland is derived from thesublingual artery. The sublingual artery is one of the terminal branches of the lingual artery. The tongueThe 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 thetongue. It is separated from the posterior third, or root, of the tongue by a V-shaped line termed the terminalsulcus. Located at the angle of the terminal sulcus is the foramen cecum, which is a remnant of thethyroglossal duct.Developmentally, the anterior and posterior portions of the tongue are derived from different embryologicalstructures. The body, or anterior two-thirds of the tongue, is formed from the floor of the developing pharynxand is predominantly of first branchial arch origin. The posterior third of the tongue has its origin from thethird branchial arch, and is formed from the anterior wall of the developing pharynx. This dissimilarity indevelopmental origin explains the structural, topographical, and functional differences between the anteriortwo-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 fourdifferent types of papilla. The filiform papillae, which are epithelially lined connective tissue projections, givethe tongue its characteristic appearance. Located on the dorsal surface of the oral portion of the tongue, theyare slender thread-shaped structures devoid of any taste buds. Interspersed between the filiform papilla are redmushroom-shaped structures called fungiform papillae. They are red because their core is composedpredominantly of vascular elements. They are only found on the dorsal surface of the tongue and usuallycontain between one to three taste buds. The vallate papillae are found in a V-shaped configuration in front ofthe terminal sulcus. They are circular structures, which contain many taste buds within the epithelium of theirlateral surface. Located along the lateral border of the tongue are the foliate papillae. They are narrow verticalfolds of mucous membrane and are not well developed in man. Taste buds, however, are contained within theepithelium 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 iscomposed of oval irregularly shaped structures, the lingual follicles. These follicles contain lymphoid tissueand are surrounded by a crypt. Mucous glands deposit their secretions into these crypts. Collectively, thelingual follicles form the lingual tonsil.The ventral tongue mucosa is smooth and papillae are absent. The lingual vein can be identified on each sideof the under surface of the tongue.Muscles of the tongueThe 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 muscleshave their origin outside the body of the tongue. Therefore, contraction of these muscles can change the shapeof the tongue as well move it bodily. In contrast, the intrinsic muscles originate and insert entirely within theconfines of the tongue. The resultant contraction of these muscles can, therefore, only produce a change intongue shape. 43
    • The extrinsic tongue muscles are the Genioglossus, Hyoglossus, Palatoglossus, and Styloglossus. TheGenioglossus 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 anddepression. The Hyoglossus takes its origin from the body of the greater cornu of the hyoid bone. It insertsinto the side of the tongue. Contraction of this muscle results in tongue depression. The Palatoglossus, themuscular component of the anterior tonsilar pillar, arises from the anterior surface of the soft palate andinserts into the dorsum and lateral aspect of the tongue. Functionally, this muscle decreases the anterioropening of the fauces and elevates the tongue posteriorly. The Styloglossus originates from the anteriorborder of the styloid process and inserts into the side of the tongue. Its function is to retract and elevate thetongue. The intrinsic tongue muscles are the Longitudinal, Transverse, and Vertical. The Longitudinalmuscle is divided into a superior and an inferior division. The superior division arises from the submucousregion of the posterior portion of the tongue. The inferior division originates from the inferior aspect of thetongue 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 itsorigin 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 mucousmembrane on the dorsum of the anterior tongue. It inserts into the under surface of the tongue. Contraction ofthis muscle flattens and broadens the tongue.Nerve supply to the tongueThe sensory nerve supply to the tongue can be explained on the basis of the developmental differences thatexist between the anterior two-thirds and posterior one-third of the tongue. Recall that the anterior two-thirdsof the tongue are derived from structures of the first and second branchial arches (the mandibular division ofthe trigeminal and facial nerves, respectively). The posterior third is formed from structures derived from thethird and fourth branchial arches ( the glossopharyngeal and vagus nerves, respectively) . Therefore, the thirddivision 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 chordatympani (cranial nerve VII), via the lingual nerve. Both general sensation and taste to the posterior third oftongue are derived from the glossopharyngeal nerve. The internal laryngeal nerve, a branch of cranial nerveX, 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 tongueThe arterial supply to the tongue is obtained chiefly from the lingual artery. Arising from the external carotidartery at the level of the greater horn of the hyoid bone, the lingual artery passes deep to the Hyoglossus toenter into the tongue. Two dorsal lingual arteries originate posteriorly to supply the root of the tongue as wellas the palatine tonsil. The lingual artery continues anteriorly, bisecting into two terminal branches, the deeplingual artery and the sublingual artery. The deep lingual artery vascularizes the anterior two-thirds of thetongue. The sublingual artery supplies the floor of the mouth.ORAL WOUND REPAIRThe oral cavity serves as an entry portal into the body. It is therefore often traumatized by foreign materials aswell as its own components of the masticatory system; namely the dentition. Understanding of the healingprocess will allow the practitioner to ensure optimal healing and reduce amount of complications associatedwith less then optimal healing conditions. 44
    •  Classification of wounds:Oral wounds are classified based on etiology, mechanism of repair and the tissue injured.Etiology of injuryWounds will stem from either trauma or pathologic processes. The former injury will be caused fromdisruptive action of a physical or chemical agent. The physically induced injuries will stem from eithersurgical 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 oralcohol. The pathological processes such as neoplasias, bacterial or viral invasions as well as various systemicconditions (e.g. pemphigus vulgaris, benign mucous membrane pemphigoid, erythema multiforme, andaphtous stomatitis) will also be capable of inducing oral wounds.Types of repairsWounds will heal by either primary or secondary intention. Primary intention can be accomplished readily ininjuries where no tissue loss occurred (non-avulsive injuries). In these cases wound margins can be directlyreapproximated and allow for rapid healing and minimal structural or functional deficits as well as limitedscarring. In secondary intention healing, there has been a loss of tissue via excision, avulsion or other form ofdestructive processes. In these cases the wound margin may not be always re-approximated and the tissue willheal by growth of new subcutaneous and epithelial tissues.Type of tissue involved in injuryThe 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 organparenchyma(soft) and bone, enamel, dentin and cementum(hard). For the purposes of this discussion we willconsider the healing of skin, bone and mucosa.1. Soft tissue repairThe basis of mucosal or dermal healing is connective tissue restitution and the reepitheliazation of the tissuebed. The connective tissue upon exposure by injury will induce conversion of blood protein fibrinogen tofibrin and will initiate formation of net like matrix allowing for blood constituents to form a clot. This matrixwill then allow for fibroblasts to lay down connective tissue scaffold, which when latter infiltrated bycapillary endings will become granulation tissue.The area will undergo significant changes over the next several hours. Initial population of neurtrophils andlymphocytes becomes replaced by fibroblasts migrating from adjacent tissues. The fibroblasts will produceGlycosaminoglycans(though to act as mediators of cell function) and collagen ( responsible for integrity ofthe connective tissue bed). The collagen will replace damaged collagen, which is simultaneously being brokendown by the cellular components namely fibroblasts and macrophages. This is known as the woundremodeling and often results in scarring. Within 48 hours the wound becomes infiltrated with blood vesselsnecessary 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. Specializedtype of fibroblasts named myofibroblasts has been postulated to be responsible for the mechanical movementof the wound margins. The rate and extent of contracture will be related to two factors: formation ofgranulation tissue and mobility of wound margins. This process can be both favorable and unfavorabledepending on the site of injury. 45
    • 2. ReepithelializationThe process involving the proliferation of epithelium adjacent to the wound margin starts within 24-hours ofthe injury. The epithelium will be initially cuboidal and as it thickens into layers it will produce the moreclassical stratified squamous appearance. The growth continues until apposition of epithelium occursfinalizing the initial repair process. Normally further remodeling will ensue with predominantly changes inthe dermal layer.3. Osseous healingMost 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 wewill concentrate on the model for extraction socket healing. Initially a clot is formed by extravasated bloodand then subsequently replaced by granulation tissue. Leukocytic migration, fibroblastic activity andcapillary budding are responsible for early repair within the first few days. The oral portion of the fibrinmatrix has been found to have a higher content of PMN’s and plasma cell than the apex of the wound. Theepithelialization commences within 24-hours in a manor similar to that of soft tissue healing. Furtherorganization of the clot continues over the following few days. In the first week after injury there is boneproduction not in the socket itself but in the marrow spaces immediately surrounding it. At two weeks postinjury there will be little evidence of new bone formation radiologically but histological survey will showsome appositional bone deposition at the walls and the fundus of the socket. At three weeks a characteristicaxial trabecular pattern will be seen. The inflammatory cells will continue to be present but slowly decrease innumbers. The subepithelial union will allow for connection of collagen fibers spanning the cemental structureof adjacent teeth. Some resorption will usually be seen at the alveolar crest. After four weeks bone will tendto occupy majority of the site although the lamina dura may still be visible on radiographs. Further bonedeposition and resorption will continue in the socket as well as the buccal plate will be resorbed to expose thenew bone. The lingual cortex is usually less affected. After 2 months the lamina dura will be completely lostand the bone will appear uniform. The epithelialization will also result in normal appearance of the mucosa. Abnormal wound healingTwo reasons for abnormal healing are failure to heal and excessive repair. These stem from systemic or localinfluences such as: infection, foreign bodies, poor nutrition, hypoxia, temperature extremes, drugs orpathological conditions.InfectionsContamination of the site with microorganisms is common. However when the site becomes overcome withmicroorganisms the site becomes infected. Factors such as necrotic tissue, foreign bodies, and compromisedhost defenses are deleterious to healing and facilitate wound infection. Most important in prevention ofwound infections are meticulous surgical technique, including debridement, adequate hemostasis andelimination of dead space. Prophylactic antibiotics in immunocompetent patients for most extractions do littleto prevent infections.NutritionProteins and vitamin C are of primary importance. The patients who are malnourished will tend to havedecreased 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 beimportant in maintaining the integrity of the healed site after the completion of reepthelialization. 46
    • OxygenationTissue oxygen levels are required for normal cellular respiration and also for cellular migration, proteinsynthesis, and collagen hydroxylation. Initially low oxygen levels are thought to stimulate collagenproduction.TemperatureHypothermia will result in ischemia and decreased tissue healing, conversely raising of temperature above 30C will increase rate of tissue healing.Other chemical agents and modulators of healing1. 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 repairHypertrophic 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 themargins of the wound. This is associated with excessive dermal collagen deposition and distortion in thearchitecture of the collagen matrix. Exact pathogenesis is still being investigated. There is a definite geneticpredisposition as these are seen more often in patients of African and Asian lineage. 47
    •  Management of intraoral wounds1. 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 DifficultyThe relative difficulty to be anticipated when performing exodontia is assessed through a thorough clinicaland radiographic examination of the patient. By estimating the expected difficulty prior to surgery, thepractitioner may plan for routine forceps/elevator extraction or complex exodontia. Surgery is always madeeasier 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 followingprior to surgery:1. The crown—extent of coronal destruction, and type of restoration present are important determinants ofdifficulty. Generally, a large crown means a large root. If significant portions of the crown are missing, thiswill 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 determinantsof difficulty. In addition, the supporting bone density, quantity and quality, as well as the amount of PDLspace will influence difficulty. The presence of large divergent roots, multiple roots, invested in thick densebone 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 andextraction.4. Access—appropriate access to the dentition must be present for the proper application of forceps andelevators. Limitation in access secondary to prior trauma, burns, surgery, and pathologic conditions willcomplicate 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 exodontiaThe safe and efficient use of forceps and elevators is achieved through controlled force. Controlled forceimplies no unnecessary injury to the adjacent teeth or supporting structures. 48
    • The purpose of controlled force is to achieve adequate alveolar expansion, rupture of the PDL, and separationof 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 PDLThe use of elevators supplement forceps extraction. They are usually available in two basic designs: straightand offset. Their proper application involves both parallel and perpendicular application. Elevators can beused 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 exodontiaWhen 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 advancedsurgical techniques successfully perform the extraction. Advanced techniques include the development of asurgical 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 supportingstructure anatomy is present, osseous removal and tooth sectioning will be required to safely accomplish theextraction. ComplicationsPotential complications associated with routine and complex exodontia are known to occur. The following arethe most common complications anticipated following exodontia:1. Hemorrhage2. Infection3. "Dry socket"4. Osseous fracture5. Antral perforation 49
    • 6. Nerve damage7. Dislodgment into the soft tissues8. Subcutaneous air emphysemaHemorrhage may occur during the extraction procedure or in the postoperative period. Local causes (osseousor vessel injury) and systemic conditions (liver or hematologic disorders) are the most common causes ofexcessive 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. electrocautery c. 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 disordersDry socket, or localized osteitis, is a commonly encountered postoperative complication. Appropriatediagnosis is based upon clinical signs and symptoms. Most commonly, dry socket is diagnosed on clinicalgrounds alone when the following symptomatology is present: 1. Severe pain—usually beginning 2-4 dayspost-extraction. 2. Loss of blood clot—examination of the extraction site will usually disclose the absence ofan 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 ahigher 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 levelof incidence is associated with the extraction of mandibular third molars.Treatment is mostly empiric. Preventative measures such as atraumatic surgery, maintaining good oralhygiene, and the use of topical antibiotics decrease the incidence of dry socket. Supportive care aimed atdecreasing pain, consisting of saline irrigation of the extraction site, proper drying, and the use of analgesicdressings (iodoform gauze/benzocaine-eugenol mixture) daily or on alternate days, is indicated.Antral perforations are most commonly encountered when extracting maxillary bicuspids or molars. Accuratepreoperative diagnosis and the use of controlled force will help prevent this particular complication. Ifentrance into the maxillary sinus is suspected, direct examination or the use of the nose-blowing test may helpconfirm 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) 50
    • 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 closureSubcutaneous air emphysema, although an uncommon complication, is important for the general practitionerto recognize, since its etiology is related to the use of air turbine handpieces. Clinically, the usual findings area rapid swelling, which, if palpated, is crepitant, most commonly following third molar extractions.Differential diagnosis includes hematoma formation, infection, and allergic reactions. Treatment may consistof antibiotics, airway observation, adequate hydration, and ruling out chest involvement via a chest x-ray.Corrective surgical proceduresA number of oral surgical procedures have been advocated for the purpose of creating an ideal ridge formprior to prosthetic rehabilitation or to eliminate abnormal muscle position. Some of the more commonsurgical procedures utilized today by the Oral and Maxillofacial Surgeon are frenectomy, vestibuloplastyprocedures, with and without skin grafting, and tori removal. FrenectomyThis 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 adequatemuscle resection and/or lowering of the attachment. Tori and exostosis removalTori are bony exostoses, which most commonly occur centrally on the hard palate or on the lingual cortex ofthe 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 anddegree of lobulization determine the incision for maxillary tori. In the majority of cases, a midline incisionover the torus is adequate. An alternative incision design, located in the anterior palate allowing a fullthickness flap over the torus, may be used. In the majority of cases, the torus must be either divided, orsectioned at its base.Mandibular tori are approached most commonly through a crestal or lingual sulcular incision. A full thicknessmucoperiosteal flap is raised, and the tori are sectioned and the lingual cortex appropriately contoured. Theseare more difficult to remove in the dentate mandible. 51
    •  VestibuloplastyVestibuloplasty is a ridge extension procedure aimed at uncovering existing alveolar bone and repositioningthe muscle attachments to a more superior position in the maxilla or inferior position in the mandible. The useof 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 forcepsMaxillary 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 componentsSurgical TechniqueEstablish a methodical technique. Double and triple check the tooth to be extracted with your charting (yourstaff should be part of this valuable review). Liability insurance carriers have noted that this is still one of themost frequent causes of litigation, based upon the sheer number of cases. 52
    • After your administration of profound anesthesia and appropriate placement of a bite block, use yourperiosteal elevator to expose the junction between the tooth and the bone. Trying to extract a broken-downtooth that is not fully visible damages much more soft tissue. Simple flaps are much easier to close and healmuch more quickly than macerated tissue. It is preferred to start generally with a conservative mucoperiosteal 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 thechance for greater bony plate damage later in the procedure. When removing bone, try to remember theoverall 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 a77R. By using proper elevation technique, many teeth can be removed without the use of forceps. It isimportant to remember that the elevator must be used for good and not evil. That is to say one can onlyelevate a tooth using the alveolar bone as your fulcrum, not the adjacent teeth. Try driving the tooth towardsan EMPTY space (unless you are doing a complete edentulation, you will want to elevate only one tooth at atime. 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 beselected so that adjacent and opposing teeth will not be injured. The primary hazard in using full-size forcepson 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. Itis strongly encouraged that you to refer your patient sooner than much, much later (swallow that ego andmake a logical decision on behalf of your patient). According to a study in journal of AAOMS theAVERAGE time that a patient has undergone some sort of surgery before he/she is referred to a specialist’soffice is 3 hours. This is abusive. Proper referral procedures should include a description of the procedureattempted, 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 thesurgical expenses in order to maintain your rapport with your patient. Surgical blade selection and their useThe most commonly used scalpel blade is the #15 blade, since it is easy to control and possesses less of athreat to adjacent structures. The small, curved cutting surface allows you to see the full extent of the tissuecontact area.. It is advised that you do not lose sight of the blade at any time and use a minimum amount ofpressure to accomplish the incision.The longer blade handle is of help since you will not obscure the field with your own hand. Always attach orremove surgical blades with a hemostat or needle holder. You may choose to purchase assembled blade andhandle units, but these are a bit expensive. Osteotome (Chisel) usageChisels are valuable assets to your surgical tray. You can remove a small amount of bone using them like anenamel chisel (make sure they are sharp enough) or, with minimal and judicious malleting, a larger amount ofbone can be removed. Be aware of the adjacent structures: a chisel can inadvertently "drive" a tooth into thesinus or below the mylohyoid muscle. One can split or section a multirooted tooth, as well as, fracture theangle of the mandible or a maxillary tuberosity. Make sure you have a "stop" planned for your chisel and tryto be the one wielding the mallet. One can make a chisel for small osteotomies out of an endo or #24 cementspatula or a commercial variety can be purchased. The use of chisel and mallet should be only attempted byexperienced clinicians and usually to treat sedated patients. 53
    •  Surgical burs and their useages:Some clinicians prefer using round burs of various configurations and sizes, but most surgeons believe onecan 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 overallvisibility. It is suggested that a high-torque straight handpiece of some sort be used (Hall and Stryker are mostpopular), 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 materialsThe selection of suture material is up to your own personal style. The suture materials are available as eitherresorbable or non-resorbable/monofilament or multifilamentous form. Resorbable sutures are reactive andcan 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 tohandle. 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 afterplacement.Dexon 3-0 and Vicryl 3-0 are absorbable sutures that tie as easily as silk. They have displayed a variable (2-3weeks) absorptive pattern in the mouth.Non-resorbable suture includes silk, polypropylene and nylon. Silk is available only in a multifilamentousform, polypropylene in monofilimentous form and nylon is available in both forms. Multifilamentous formallows for increased suture strength but is more likely to collect debris and increase risk of infection. Of thenon-resorbable sutures, silk evokes the most intense inflammatory response and should not be used for faciallacerations. 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 edgesof two flaps, as in 3 rd molars. Smaller needles can be used where space is at a premium, as in the palate. Thetwo most popular styles of needles are the so called "atraumatic" and the cutting. The atraumatics are round tooval in cross-section and tend to be a bit more difficult to pass through the tissues. The cutting varieties comein the standard and the reverse type. These needles are triangular in cross-section the apex of which is on theouter part of the curve in the reverse cutting style (this design is supposed to reduce the tendency for thesuture 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 needleholder is worthy of consideration since it may help you get into those "hard-to-reach" areas. To allow forgood control over the needle use needle holders and not hemostats. A good suggestion for suture scissors iseither 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 controldiscrete areas (inter-dental suturing and simple mucosal closures). Over a long closure, variable flap tension isa valuable feature of multiple interrupted sutures. 54
    • In the closure of a palatal flap (used for exposure of impacted supernumerary teeth), use multiple interruptedsutures that begin deep in the palate and which are tied off in the facial interproximal areas. This createsrather 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 mucosalclosure over implants, antral openings, etc.The continuous-locking (continuous-horizontal mattress) or the e blanket stitch suture is useful in closing along 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 thistheme 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 aboutwound-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 discussingpost-operative instructions will save your sanity. Each patient who has received surgical care must receivepost-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 weeksIf a follow-up visit is required, make sure that the patient books the visit with the receptionist prior to leavingthe clinic. Ask the patients if they have any further questions or concerns. Before discharging the patientmake 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 wellas a clear set of instructions as to their use. An adequate amount of sterilized sponges should be given to thepatient 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 tothe patient that they may start at the lower end of the analgesic spectrum with an OTC medication if thecompleted procedure was quick, simple and limited tissue was disturbed. Thank the patient for choosing ourclinic for delivery of his care and remind them to call the numbers, listed on the written post-operativeinstruction 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 latersection on analgesic and antibiotic therapy guidelines.Post-operative complications InfectionsThe 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). 55
    • If an infection is suspected, give a loading dose of antibiotic, usually penicillin. Begin with a dose of 1 gramwith 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 thepenicillin 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 newgeneration cephalosporins and combination agents are very expensive and not worth the difference in price intreatment of oral infections.For further discussion of antibiotics consult the section on guidelines of antibiotic therapy. BleedingBleeding is a frightening thing for the patient and their families, so try to treat it as such. The first level ofinvolvement is to check if the patient has actually used the surgical gauze properly. Usually, the patientchecks the gauze for bleeding every 5-10 minutes and not allowing the pressure and normal hemostasis totake 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 canbegin with an evaluation of the area using good light and suction. A local anesthetic with a vasoconstrictorwill 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 helpcontain 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 disordersManagement of the surgical patient who has bleeding disorders requires the understanding of the normalhomeostatic process and the patient’s specific coagulation system. Need for appropriate preoperativereplacement therapy exists as well as choice of conservative therapy options along with local hemostaticmeasures.Procedures that are likely to induce bleeding are:Flap surgeryNerve blocks (IAN, PSA)ExtractionsThe hemostatic systemA series of complex reactions between plasma, platelets and endothelial lining of blood vessels preventsblood loss through fibrin clot formation. Initially smooth muscle contracts to yield vascular constriction anddecreased 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 onarachidonic acid, enables platelet to release ADP and serotonin aiding in further aggregation of platelets andvasoconstriction respectively.Following the initial aggregation platelet membranes expose receptor sites and activate the coagulationsystem. 56
    • CoagulationVia 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 tissuethromboplastin acts with factors VII, X, V, and Ca++ to convert prothrombin to thrombin. Quantitatively it isthe smaller of the two pathways but it aids in the aggregation of platelets and enhances the outcome of theintrinsic pathway.The slower intrinsic pathway generates majority of thrombin required to convert fibrinogen to fibrin. Thecascade is stimulated by factor XII (Hageman’s) which circulates and becomes activated by contact with aforeign surface antigen or collagen, activated platelets, phospholipids, or vascular basement membrane. Theprocess 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 extrinsicpathways. 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 isbroken down as a part of remodeling response by factors XII, XI, proteolytic plasminogen and activators fromendothelial cells through synthesis of plasmin from plasminogen.Bleeding DisordersSpecific and detailed history must be obtained to elicit any past history of bleeding episodes, which haveoccurred secondary to injury, dental therapy, surgical therapy, epistaxis, or menorrhagia. In addition, a list ofall 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 commoncauses of the acquired disorders are pharmacological agents, kidney, liver or other systemic diseases.Effects of pharmacological agentsWarfrin (Coumadin) is often used in prophylaxis of pulmonary embolism and venous thrombosis, atrialfibrillation and embolization as well as in some post-operative scenarios. Its action is to inhibit the vitamin Kdependant production of clotting factors II, VII, IX, X. In adults the dosages are tittered to achieve an INR of2.0-3.0 for most cases. In prosthetic heart valves the INR is desired to be at 2.5-3.5. Overcoumadization canresult in spontaneous bleeding at values of INR greater than 5.0. The onset is action is 8 to 12 hours withmaximum 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, atrialfibrillation, 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. Clinicaleffectiveness I usually achieved at 1.5-2 times the control.NSAIDS-inhibit cyclo-oxygenase pathway and production of thromboxane A2 essential for plateletaggregation. The effects can be prevalent to dosage as small as 300-600 mg and last for the lifespan of theplatelets (9-12 days). Normally normal platelet count will be seen with prolonged bleeding time. Similar labfindings are seen in Von Willebrand’s disease (factor VIII).Diagnosis of drug induced thrombocytopenia can be made on the basis on correlating onset of thethrombocytopenia and the drug administration. Treatment will involve discontinuation of the agent and theplatelets will normally return to baseline levels in 7-14 days 57
    • 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 specificIgG. Treatment of these cases involves glucocorticoids, and if not responsive may require splenectomy andother immunosuppressive agent to be administered.Pregnancy-associated thrombocytopenia usually seen in 5 –10 % of pregnancies but these are rarely of greatpost-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 byproductssuch as succinic and phenolic acids and render the binding sites non-functional. Additionally due to proteindepletion the clotting factors may be decreased in quantity.HIV-positive patients are potentially likely to develop thrombocytopenias similar to ITP. AZT and lower thanITP corticosteroid doses are often applied in treatment.Autoimmune diseases, chronic lymphocytic leukemia, lymphomas, infectious mononucleosis as well as someviral infections can also precipitate thrombocytopenia.Vitamin K deficiencyLiver disease or vitamin K deficiency will affect the production and levels of all coagulation factors with theexception of VIII. The vitamin K is necessary for the synthesis of factors II, VII, IX, and X. Hence if factorV is not deficient compared to the other factors the cause is related to Vitamin K deficiency, however if allfactors are deficient liver disease can be implicated. These patients are difficult to treat and if required willneed 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: biliaryobstruction, malabsorbtion, antibiotics, nutritional deficiencies, and warfarin ingestion. This can occur inhospital 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 DisordersDeficiencies of factors VIII (Hemophilia A) and IX (Hemophilia B) are X-linked disorders which tend tohave similar clinical presentation. Spontaneous bleeding will occur in the hemophiliac patient whose factorlevels are less than 1% of control values (severe hemophilia). Patients with mild form (1-4% of normal factorlevels) will tend to have less spontaneous bleeds and tend to have problems with trauma or surgical wounds ifnot managed appropriately. Mild hemophiliacs quite often will go undetected and will rarely have anybleeding problems. The typical laboratory values will be inclusive of an elevated PTT, normal INR, PT andbleeding time. Treatment of these patients should be delivered in conjunction with a hematologist and involvefactor replacement.To calculate replacement dose for factor VIII use the following formula:Dose (units)= (desired % activity – initial % activity)X (weight in kg)/2For 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 totreat Hemophilia A & B, but factor IX concentrate is better for B variety therapy. Factor IX may not betreated with viral inactivators. 58
    • 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 containssmall amounts of vWF and is treated with viral inactivators . Recombiant VIII is also available but has beenassociated with greater incidence of immune reactions.Factor IX concentrates- are highly purified, viral inactivated and have lower rates of DIC in hemophilia Bpatients 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 afour fold increase of factor VII.Epsilon-aminocaproic acid (EACA) an inhibitor of fibrinolysis can be used on the day of the surgery atdosage 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 higherdoses 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, decreasedlevels of ristocetin cofactor activity and variable deficiency of factor VIII. Typically PTT will be prolongedand the patient may experience hematomas and hemarthrosis. The treatment involves desmopressin acetate(DDAVP) (vWD type I and IIa only) or cryoprecipitate.Other inherited coagulopathies90 % of all inherited coagulopathies involve the above mentioned forms. The occurrence of other factordeficiencies may be considered in cases where factors VIII, IX, and vWF are normal and bleeding is notexplained otherwise. Treatment with FFP is usually effective.Laboratory work-upLaboratory tests that are useful to determine a patient’s coagulability status are the INR, PT, PTT, plateletcount, bleeding time, thrombin clotting time, and clot stability testing.INR-International Normalized Ratio gives a standardized value for PT and measures the integrity of theextrinsic 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 theINR.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. Normalvalues 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 5molarurea or 1% monochloracetic acid. 59
    • 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 at10-20 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 ofnormal 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 vigorouscurettage) irrigate the socket, and place a topical anesthetic type packing (use a magic mixture of your choiceplaced on iodoform gauze or a gelfoam). Remember, these patients are not eating properly and should beencouraged 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 familiesof the analgesics; that is, that Vicodin is very similar in nature to Tylenol and codeine, though some patientsmay tolerate it better. You may use Vicodin and Vicodin ES in some patients who have used these drugssuccessfully and who request these agents. An alternate drug for those who have problems with codeine andcodeine-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. Thismay eliminate the pain cycle .Infections of odontogenic origin Principles of diagnosisAcute infections of odontogenic origin may be primarily related to dental or periodontal disease or, they mayoccur secondarily following exodontia or surgery. Regardless of the specific etiology, essential aspects ofdiagnosis and treatment must be implemented to assure proper treatment. Accurate diagnosis involves thefollowing:1. An appropriate history: eliciting the onset, character, and location of pain and swelling, the presence oftrismus, 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 filmradiography, computerized tomography, radionucleotide imaging, magnetic resonance imaging4. Laboratory studies: are essential in the diagnosis and treatment of odontogenic infections. Numerouslaboratory tests are available to the clinician such as: Gram stain, quantitative tissue smears, culture andsensitivity testing, wet preparations, immunologic techniques, blood cultures5. Transport of specimens: accurate diagnosis is dependent upon proper transportation of specimens collectedduring surgery. The most precise method would be collections of aspirated material for study. However, mostcommonly, specimens are obtained utilizing swaps and transporting the specimen in a transport media. It isimportant that the clinician have the appropriate collection materials available at the time of surgery. 60
    • 6. Assessing antimicrobial activity: empiric therapy is begun, based upon the knowledge of the organisms thatare most commonly associated with such infections. Definitive antibiotic selection is based upon in vitrosusceptibility testing.Final diagnosis and treatment planning is based upon proper interpretation of the data developed during thehistory, physical examination, radiographic, and laboratory. Clinically, infection is manifested by thepresence 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 isdependent upon the anatomic position of the roots relative to muscle attachments. From an infected pulp, theinfection process can invade the periapical region and subsequently spread into the surrounding soft tissues ofthe head and neck region. Fistula, cellulitis, intraoral soft tissue abscess, bacteremia, deep facial spaceinfection and osteomyelitis may develop. Treatment of odontogenic infectionsThe management of infections of odontogenic origin will usually require medical, surgical, and dentaltherapy. Once it is ascertained that the infectious process is of odontogenic origin, definitive dental treatmentmust be instituted. Endodontic, periodontal, or exodontic therapy must be performed as indicated. In severeinfections, it is recommended that the offending tooth be extracted. Surgical drainage of purulence is ofcritical importance in the management of odontogenic infections. Dentoalveolar abscesses are easily drainedby a sharp incision through the mucosa down to bone. Drainage of deep fascial spaces requires a thoroughknowledge of head and neck anatomy. The incision should be positioned, aesthetically as possible, to the siteof maximum fluctuance. Blunt dissection through the deeper tissues is recommended to localize areas ofpurulence and explore all aspects of the abscess cavity. An adequate drain should then be placed within theabscess 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 ofinfections of odontogenic origin. Antibiotic therapy doesn’t need to be applied in all cases. For furtherdiscussion of this topic please refer to the section on guidelines to the antimicrobial therapy included in thismanual. Patients with systemic signs and symptoms, fever, trismus, or who are medically compromised, mayrequire hospitalization and the use of intravenous antibiotics. Supportive care in the form of analgesics, fluidresuscitation, oral hygiene, and maintaining nutritional intake should also be instituted.Fascial Space Infections Fascial vestibule of the mandibleAnatomical 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 mandibleAnatomical 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 61
    •  Mentalis spaceAnatomical 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 spaceAnatomical 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 spaceAnatomical 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 spaceAnatomical 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 AnginaAnatomical 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 maxillaAnatomical boundaries• Medial to the buccinator muscle, inferior to the insertion of this muscle below the zygomatic process of the maxilla 62
    • • 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 spaceAnatomical 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 spaceAnatomical 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 spacesAnatomical 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 spaceAnatomical 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 spaceAnatomical 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 63
    • • 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 spaceAnatomical 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 spacesAnatomical 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” areaAnatomical 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 areaAnatomical 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 veinAntimicrobial therapy guidelinesThe current standards of practice demand of the practitioner the use of appropriate antibiotics and targetingthe specific microorganisms causative to the particular infection. Proper antibiotic selection is important inthe management of infections of odontogenic origin. 64
    • Once the decision to use antibiotics has been made, the following should guide the clinician in selecting themost 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 bedetermined. Dosage is based upon the minimum inhibitory concentration (MIC) of an antibiotic for a specificorganism and the peak serum concentration of that antibiotic. In general, peak serum concentrations 3 to 4times the MIC are required. Therefore, the dosage prescribed must be capable of producing concentrations 3to 4 times the MIC. Additionally important is the frequency of dosing. The correct time interval betweendoses should be established. Determination of the frequency of antibiotic administration is based upon theplasma half life (T 1/2) of the drug. The most commonly utilized dosing interval for antibiotics is 4 times theT 1/2. Once the appropriate dose as well as the interval of dosing has been established, the clinician must thendetermine the most effective route of administration. The severity of the infectious process and the serumlevel required will influence the route of administration. Medically compromised patients, the presence ofsystemic signs and symptoms, bacteremia, and severe infections or those caused by unusually virulentorganisms, will usually require intravenous antibiotic administration.For oral and more specifically odontogenic infections the causative bacteria tend to be indigenous to the oralcavity. Most of these infections are the result of a mixed flora, both aerobes and anaerobes. The mostcommonly 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 periodontaldefects 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 useThe 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 65
    • Cases where antibiotics may not be indicated1. Chronic well-localized abscess2. Minor vestibular/gingival abscess3. Dry socket4. Root canal sterilization5. Mild pericoronitis6. Intraoral spontaneously draining fistula Culture and sensitivity studiesThe 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 odontogenicinfections. 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 antibioticEffective orally administered antibiotics useful for oral microflora & odontogenic infections1. 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. 66
    • 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 300mgDisp: 28 (twenty-eight) tabs Disp: 28 (XXVIII) tabsSig: one tab QID till all finished Sig: I tab qid x 7 daysChlorhexidine 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 bidLast important note: be aware of the relationship of antibiotics and oral contraceptives and beprepared to discuss these with the patients.Analgesic therapy guidelinesMost patients are likely to experience some discomfort following oral surgical procedures. There are someconsiderations, which will help you to determine the appropriate choice of post-operative anelgesic. 67
    •  Complexity and duration of surgeryThe amount of tissue disturbance, periosteum elevated and osseous removal will tend to be reflected byincreased inflammation and pain. Simple extractions of periodontaly involved teeth with no associated acuteinfections will tend to be followed by limited discomfort easily managed by over the counter non-steroidalanti-inflammatory agents. These include Advil, Naproxen or ASA. Also another peripherally acting analgesicof choice is acetominophen. It tends to be useful in patients who claim allergic reactions or complain of GIupset with the use of NSAIDs. In cases where a significant amount of surgical trauma occurred to tissues suchas large muco-periosteal flap elevation, osteotomies or long duration of procedure, narcotic analgesiccombinations can be employed. Presence of pre-operative infectionPatients with moderate to severe soft tissue swelling may experience more severe pain secondary to the largerinvolvement of oro-facial tissues and space expanding cellulitis or purulence. Along with the need for incisionand drainage of the infected soft tissues the patients tend to require more advanced pain management. Ifseveral analgesic and narcotic combinations are available it may be wise to avoid anti-inflammatorymedications in cases where their effect will hinder the body’s activity in fighting infection throughinflammatory response. Patient factorsIn addition to the pathology and surgical procedure it is wise to consider the patient’s past history of allergicreactions, history of past prescribed or illicit narcotic intake, potential for placebo effect and economicfactors. As a general rule it is important to avoid narcotic use in patients with a higher abuse and addictionpotential. All recovering drug addicts should be managed with appropriate combinations of non-narcoticanalgesics.One of the red-flag raisers is the patient who begins the consultation by asking for the analgesics by name anddosage, 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 majorityof oral surgical patients). Remember, the elderly patients need far less analgesic medications, so begin withvery low dosages. In children, it may be helpful to prescribe liquid dosage forms, but do not dismissprescription of tablets to the pediatric patients since they can be crushed and mixed with something the childwill actually enjoy (milkshakes, etc.). Sample Analgesic Prescriptions: Tylenol#3 Vicodin (5/500) Disp: 20 (twenty)tabs Disp: 20 (twenty)tabs Sig: one to two tabs Q4-6H prn pain Sig: 1-2 tab Q6h prn pain Ibuprofen 600mg Naproxen Na 550mg Disp: 20(twenty)tabs Disp:10(ten)tabs Sig: one tab Q5H prn pain Sig: I tab bid prn pain Tylenol with Codeine Elixir (120mg+12mg/5cc) Disp: 300cc Sig: 10cc Q4-6H prn pain 68
    • Pathology & biopsies Oral PathologyThe most common pathological conditions of the oral-facial region requiring surgical treatment include cysticlesions, neoplasms, and salivary gland disorders.Odontogenic cysts are pathological epithelial lined cavities of odontogenic origin containing fluid orsemisolid material. Diagnosis is based upon the patients history, physical findings, as well as a thoroughradiographic and histopathological evaluation. Common clinical findings range from no signs or symptoms tothe presence of pain and/or expansion or swelling.Once the diagnosis has been established, treatment of cysts of odontogenic origin usually will consist of eitherenucleation or marsupialization. In general, enucleation whereby all excised tissue may be submitted forevaluation, 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 growthexceeds and is uncoordinated with that of normal tissues. In the head and neck region, neoplasms may beclassified as follows: 1. Odontogenic. 2. Nonodontogenic 3. Benign 4. 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-facialregion. Specific surgical management may include local excision, en block resection, or partial or totalresection of the jaw. Salivary gland diseasesSalivary gland disorders commonly result in patients seeking dental evaluation. The presence of pain andswelling caused by a pathologic process involving the salivary glands is often mistaken to be of odontogenicorigin. It is only through a combination of physical findings, history, as well as radiographic and specialstudies evaluation that the exact diagnosis can be established.Once the clinician identifies the pathological process to be of salivary gland origin, definitive diagnosis isbased upon the following:1. History—of the duration of the swelling, nature of onset, and rapidity of swelling. Pain and swelling thatintensifies 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 sialadenitis3. Sialoangiectasis.4. Neoplasia.Most commonly, the surgical modality required to treat the majority of salivary gland disorders will involveeither transoral sialolithotomy or gland removal (intraoral or extraoral), since most disorders of the salivarygland system involve obstruction of the duct system. Exceptions include mucoceles or ranulas. Medicaltreatment of salivary gland disorders may include the use of antibiotics, hydration, gland massage, and the useof salivary stimulants 69
    •  BiopsiesThe best rule of thumb for assessing the need for a biopsy is to have a high index of suspicion (failure todiagnose is negligence and malpractice).Any pathological specimen removed from the patient must besubmitted to an oral pathologist for an evaluation and histological diagnosis. The specimen should besubmitted in a fixative containing specimen container labeled with the patient’s name, date of biopsy and thename 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 tendto crush the specimen and distort organization of tissue layers making interpretation of tissue more difficultand sometimes impossible. Most pathologists will want as large of tissue sample as possible. Identifypatient’s data, doctor’s information, date of the biopsy, clinical history, lesion location, clinical diagnosis (listat least three differentials) in the oral pathology laboratory report. Include radiograph as much as possibleespecially in hard tissue lesions. Make sure you provide the pathologist with the largest piece of the lesionthat you can possibly deliver. It is not necessary to skew your sample by providing normal tissue, unless yourdifferential diagnosis includes the vessiculo-bullous diseases; most pathologists know what normal tissuelooks like. Perhaps one of the most neglected aspects of the biopsy is the inclusion of a good history of thelesion. 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 beplaced 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 smallspecimen 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 willcause distortion/destruction of your sample). Establish a working relationship with a reputable oral pathologylaboratory, usually those affiliated with either a teaching center or university. These labs will provide youwith 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 biopsyprocess and are booked for follow-up and biopsy results when these are available.Management of trauma to dentition and supporting structuresStructuresDental injuries are common in todays society, affecting between 5.0% to 29% of the population. Males aretwice as likely as females to sustain dentoalveolar injury. The majority of injuries involve the maxillary andmandibular anterior dentition. The most common etiologies resulting in injury to the dentition includeinterpersonal violence, MVA, and athletic injuries. The most common dental injuries usually requiring theexpertise of the oral and maxillofacial surgeon include luxation injuries, avulsion injuries, and fractures of thealveolar 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 spaceand/or widening of the periodontal ligament space. The reduction and fixation of the luxated teeth treat theseinjuries. Following accurate repositioning, the displaced teeth will require some form of stabilization. 70
    • 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 pulpalnecrosis 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 inwhich the tooth has been stored, are important aspects to be discovered by the clinician. Clinically, it isimportant to determine the condition of the avulsed tooth and supporting structures. Prognosis is improved ifthe 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 alveolusshould be examined for extensive injury and foreign bodies. The avulsed tooth is then replaced within thealveolus and stabilized. Endodontic therapy should be performed within two weeks of the injury. Recentstudies have shown that complications such as internal and external resorption are increased by long periodsof fixation. It is now recommended that the fixation period not exceed 3 to 4 weeks.Physiology of occlusion and masticationOcclusion is defined as the contact of teeth in the mandibular arch with those of the maxillary arch in anyfunctional relationship. Mastication of food is dependent upon the functional movement of the mandible andthe occlusion of the teeth in centric, lateral, and protrusive positions (within dentistry, original concepts ofocclusion related to the anatomic alignment of the teeth when the jaws were closed together). It has been anaccepted concept that, when the teeth are positioned properly within the alveolar supporting bone and alignedcorrectly with the teeth in the opposing arch, they are functionally more efficient. Also, correct alignment ofthe teeth is conducive to the maintenance of a healthy oral environment through inter-and intra-archstabilization.Current philosophies regarding occlusion consider not only the static relationship of the maxillary andmandibular teeth when occluded, but also the functional movements of the mandible. The concept of afunctional dynamic occlusion emphasizes both muscle physiology as well as temporomandibular jointfunction and their role in "occlusion." Factors controlling occlusion in this concept are the static position ofthe teeth when in occlusal contact, condylar position, and the functional anatomy of the temporomandibularjoint.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, andpresence of dental restorations. In addition, the amount of overbite and overjet of the anterior teeth control themagnitude of disocclusion of the posterior teeth during mandibular function. The overbite and overjet of theanterior 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. Asa result of this relationship, the condylar position becomes an important factor influencing the occlusion ofthe 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. Thischaracteristic pattern of mandibular movement, which is unique to each individual, governs both the occlusalmorphology and the functional efficiency of the dentition. 71
    • An important concept that must be clarified in any discussion of occlusion is the distinction between normaland optimal occlusion. Normal occlusion implies acceptable conditions in the absence of pathology andstresses function and adaptability within the masticatory system. In contrast, optimal occlusion encompassesesthetic, physiological, and anatomical ideals.A malocclusion is defined as any abnormal relationship between the maxillary and mandibular teeth when incontact. The most widely used classification system to describe malocclusion is that proposed by Angle. Hisclassification system is based upon the assumption that the first molar is the "key" to occlusion. His systemdescribes the anteroposterior relationship of the maxillary and mandibular arches. Angle classifiedmalocclusion into three categories based upon the relationship of the upper to the lower first molars. Class INeutrocclusion, is present when the mesiobuccal cusp of the upper first molar occludes in the mesiobuccalgroove of the lower first molar. Class IIDistocclusion, is characterized by the lower dentition being positioned in a distal or posterior relationshiprelative to the upper dentition. The mesiobuccal cusp of the upper first molar is positioned anterior to themesiobuccal groove of the lower first molar. Angle further classified Class II malocclusions into twodivisions, I and II. Class II Division I malocclusion is characterized by distocclusion as well as otherassociated features such as hypereruption of the lower anterior teeth, a V-shaped maxillary arch, andprotrusion of the maxillary central incisors. Class II Division II malocclusion is also characterized bydistoclusion. In addition, other features are usually present such as a wide maxillary arch, excessive lingualinclination of the maxillary central incisors, excessive labial inclination of the maxillary lateral incisors, and adeep overbite. Class IIIMesiocclusion, is present when the lower first molar is anterior or medial to the upper first molar. Usually, theentire lower dentition is anteriorly positioned and the lower incisors are in crossbite.Physician consultationIf during the case work up any details of the patient’s past medical history, current medical condition or vitalsigns suggest a questionable ability to tolerate a procedure or require a more comprehensive medical work upprior to commencement of surgical therapy a consultation must be obtained from a physician. The sampleform is included in the form index section of this manual. The form must be returned with a written statementfrom the physician, explicitly stating that a patient is cleared for an oral surgical therapy from medicalstandpoint prior to booking the date of the surgery. To facilitate the process stamped return envelopes areavailable from the reception desk. All forms must be reviewed and signed by the faculty or a resident prior tobeing given to the patient. 72
    • MEDICAL CONSULT GUIDELINESAs dentists we are responsible for diagnosis and therapy of oral pathology. Our training is entrenched inprinciples of medicine and basic medical sciences. However, most dental schools do not adequately train theirgraduates in the full scope of medical therapy. Moreover, most dentists with time lose their basic medicalknowledge 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 medicallycompromised patient. You should be able to establish some basis of the patient’s physical status using yourbasic science background and then consult the medical colleagues about specific issues of concern in theproposed delivery of care. Below is a summary of obtaining a medical consultation to ensure propermanagement 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 sharedwith a physician. However, you are not fully qualified to make medical diagnosis and deliver medical careand therefore a physician must be involved in provision of care to some patients. 73
    • Dental office basic emergency kit suggestions Drugs1. Drugs for acute allergic reaction epinephrine 1:1,000 (1 mg./cc.) IM 1:10,000 (1 mg./10 cc.) I.V.2. Anticonvulsants diazepam3. Antihistamines diphenhydramine (benadryl)4. Analgesics demerol, morphine5. Vasopressors6. Corticosteroids hydrocortisone (solu-cortef)7. Antihypoglycemics 50% dextrose glucagon 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 stuffReference sectionContemporary 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 74
    • 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 75
    • CONTENT INDEX:Mission Statement and Departmental Objectives 1Faculty 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 74THE UNIVERSITY OF MICHIGAN NAME:___________________________ 76
    • 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 DISEASESDETAILS: __________________________________________________________________________________________________PULMONARY DISEASESDETAILS: __________________________________________________________________________________________________HEPATOGASTROINTESTINAL DISEASESDETAILS: __________________________________________________________________________________________________ENDOCRINE DISORDERSDETAILS: __________________________________________________________________________________________________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_____________________________________________________________ 77
    • UNIVERSITY OF MICHIGAN PATIENT:__________________________ORAL & MAXILLOFACIAL SURGERY REG. No.: __________________________ PROCEDURE NOTECONSENT OBTAINED O MEDICAL HX REVIEWED O PROPER REFERAL OAge: _____ 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 PLAINN2O 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 17COMPLICATIONS: _____________________________________________________________FINDINGS: ____________________________________________________________________DRAINS PLACED: _____________________________________________________________SUTURES:______________________________ DRESSINGS: __________________________Rx: _________________________________________________________________________________________________________________________________________________________POST OPERATIVE INSTRUCTIONS VERBAL O WRITTEN OSPECIAL PRECAUTIONS: _______________________________________________________FOLLOW UP: PRN O REVISIT ON _____________________________________________STUDENT”S NAME __________________________ STUDENT’S SIGNATURE : ___________________________FACULTY FINAL CHECK _____________________________________ 78