clinic manual

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clinic manual

  1. 1. UNIVERSITY OF MICHIGAN SCHOOL OF DENTISTRYORAL & MAXILLOFACIAL SURGERY /HOSPITAL DENTISTRY UNDERGRADUATE CLINICAL MANUAL 2003/2004
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8.  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
  9. 9. 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. 10. 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
  11. 11. 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
  12. 12.  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
  13. 13.  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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25.  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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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

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