3. Classification of the physical status of the medically
compromised patients according to American Society
Of Anesthesiologists(ASA)
◦ ASA I – a patient without systemic disease- a normal healthy patient.
◦ ASA II- a patient with mild systemic disease.
◦ ASA III- a patient with severe systemic disease – that limits activity but incapacitating .
◦ ASA IV- a patient with severe incapacitating systemic disease – that is constant threat to life.
◦ ASA V- a moribund patient not expected to survive more than 24 hours.
◦ ASA E – Emergency procedure of any kind, E precedes the ASA number , indicating the patient’s
physical status.
4. Detection by clinical signs and history of
bleeding
◦ Screening tests normal value
◦ Prothrombin Time (PT/INR) 10-13/1.0 sec
◦ Partial Thromboplastin Time 25-35 sec
◦ Bleeding Time (BT) 3-9 minutes
◦ Platelet Count 150,000- 450,000/ml
◦ PT/INR if INR =2-2.5 – most treatment are
safe
if INR >3 – consider alteration of
coumadin (anticoagulant therapy)
INR –International normalized ratio
5. Normal factor –VIII levels in the blood
◦ IU/mL IU/dL
◦ SEVERE <0.01 IU/ml (<1% OF NORMAL) <1 IU/dL
◦ MODERATE 01-0.05 IU/Ml moderate 1 to 5 IU/Dl
◦ MILD >0.05-<0.40 IU/m greater than 5 IU/dL but
below the normal range
6. Instrument mechanism
Principle Elevator Mechanical
advantage
◦ 1. Lever (most straight elevators(Coupland) 3(Effort arm is
of them are apex elevator greater resistance
class1and few cryer arm
are class II levers ) pick type- warwick james
2. Wedge ,cryer extraction forceps 2.5
3. Wheel and cross bar elevator
axle (Winters elevator) 4.6
and cryers elevator
7. Blades and uses
◦ Periosteal elevator most commonly used in oral surgery – no.9 molt periosteal elevator.
◦ The hemostat most commonly used in oral surgery – curved hemostat.
◦ The instrument commonly used for removing bone is – Ranguer forceps
◦ The needle commonly used in closing mucosal incisions- small ½ circle or 3/8 circle suture needle
with a reverse cutting edge.
◦ The size of suture commonly used in suturing oral mucosa is – 3-0 black silk.
◦ The most commonly used suture for oral cavity- 3-0
◦ Retractor most commonly used in oral surgery – langenback’s retractor.
◦ The two commonly used cheek retractors – Austin retractor
◦ The most commonly used elevator to luxate teeth – Straight or gauge type.
◦ Most commonly used scalpel blade for intraoral surgery – no-15.
◦ The blade used primarily for making small stab incisions , such as for incising an abscess –no 11
◦ Blade commonly used for skin incisions- no 10 blade
◦ The hooked blade commonly used for mucogingival procedures – no. 12 blade
◦ The blades commonly used in gingivectomy – no 11 and 12
◦ The blade used for incising periodontal abscess – no 12.
8. Sutures
Natural absorbable
◦ Surgical cat gut-plain or chromic –collagen derived from the intestine or sheep and bovine .
◦ Collagen – pure collagen fibrils from the flexor tendons or beef
Synthetic absorbable
◦ Coated vicryl (polygalactin 910)- copolymer of lactide and glycolide coated with polygalactin 370 and
calcium sterate.
◦ Polydiaxonone – polyster polymer.
Natural non absorbable
◦ Surgical silk – from silkworm linen
◦ Linen – staple flax fibres.
◦ Cotton- Egyptian cotton fibres
◦ Steel – alloy of nickel and chromium
Synthetic non absorbable suture
◦ Polypropelene – polymer of propelene
◦ Nylon - polyamide polymer.
9. Sutures and absorption rate
Suture Absorption rate
◦ Surgical chromic gut 70 days
◦ Chromic 90 days
◦ Dexon 90-120 days
◦ Vicryl 60-90 days
◦ Polyglyconate 180 days
◦ Glycomer 631 90-110 days
◦ Polydiaxone –PDS 210 days
◦ Polyglycotone 6211 variable
◦ Surgical silk not applicable
◦ Nylon degrades at a rate of 15-20% per year.
10. Cardiac conditions associated with endocarditis
Prophylaxis recommended Prophylaxis recommended Prophylaxis not recommended
High risk category Moderate risk category Negligible risk category
Prosthetic cardiac valves Most other congenital cardiac
malformations
Isolated secundum atrial septa
Previous bacterial endocarditis Acquired valvular dysfunction, e.g.
rheumatic heart disease
Surgical repair of atria septal defect
or patent ductus arteriosus PDA
Complex cyanotic congenital heart
disease(CHD)
Hypertrophic cardiomyopathy Previous coronary bypass graft
surgery
Surgically constructed systemic
pulmonary shunts or conduits
Mitral valve prolapse Mitral valve prolapse without
regurgitation
Physiological , functional or
heart murmurs
Previous Kawasaki disease
Previous rheumatic fever
Cardiac pacemakers
Implanted defibrillators
11. Dental procedures and endocarditis
prophylaxis
Endocarditis prophylaxis recommended for:-
◦ Dental extractions, periodontal procedures including surgery , scaling and root planning,
probing and recall maintenance.
◦ Dental implant placement and reimplantation of avulsed teeth.
◦ Endodontic (root canal) instrumentation or surgery only beyond apex.
◦ Subgingival placement of antibiotic fibres or strips, initial placement of orthodontic bands but
not brackets
◦ Intraligamentary local anesthetic injections
◦ Prophylactic cleaning of teeth or implants where bleeding is anticipated.
◦ Restortive dentistry (extensive fillings ad crown and bridge) with /without retraction cord.
12. Endocarditis prophylaxis not recommended for:-
◦ Restorative dentistry (operative and prosthodontics) with or without retraction cord.
◦ Local anesthetic injections (nonintraligamentary)
◦ Intracanal endodontic treatment , postplacement and buildup.
◦ Placement of rubber dams.
◦ Postoperative suture removal
◦ Placement of removable prosthodontics or orthodontic appliances
◦ Taking of oral impressions.
◦ Fluoride treatments
◦ Taking of oral radiographs
◦ Orthodontic appliance adjustment
◦ Shedding of primary teeth.
