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Preoperative assesment in minor oral surgery
- 1. Preoperative Assessment in Minor Oral Surgery
- 2. Content What is impaction Indications for surgery Patient assessment Tooth assessment
- 3. Minor oral surgeries The term "Minor oral surgery" refers to smaller operations and include removing wisdom teeth, impacted teeth, and severely broken-down teeth, as well as apicectomies, biopsies and other procedures.
- 4. Impaction Impacted tooth is a tooth which is completely or partially unerupted and is positioned against another tooth, bone or soft tissue so that its further eruption is unlikely, described according to its anatomic position.
- 5. Indications for removal of impacted 3rd Molars Guidance • 1.1The practice of prophylactic removal of pathology-free impacted third molars should be discontinued in the NHS.
- 6. • 1.2The standard routine programme of dental care by dental practitioners and/or paraprofessional staff, need be no different, in general, for pathology free impacted third molars (those requiring no additional investigations or procedures).
- 7. • 1.3Surgical removal of impacted third molars should be limited to patients with evidence of pathology. Such pathology includes unrestorable caries, • non-treatable pulpal and/or periapical pathology, • cellulitis, abscess and osteomyelitis, • internal/external resorption of the tooth or adjacent teeth, • fracture of tooth, • disease of follicle including cyst/tumour, • tooth/teeth impeding surgery or reconstructive jaw surgery, and • when a tooth is involved in or within the field of tumour resection.
- 8. Evidence • 3.1There is no reliable research evidence to support a health benefit to patients from the prophylactic removal of pathology-free impacted third molar teeth.
- 9. • 3.2Every procedure for the removal of an impacted third molar carries risk for the patient, including temporary or permanent nerve damage, alveolar osteitis, infection and haemorrhage as well as temporary local swelling, pain and restricted mouth opening. There are also risks associated with the need for general anaesthesia in some of these procedures, including rare and unpredictable death. Such patients are therefore being exposed to the risk of undertaking a surgical procedure unnecessarily.
- 10. Evidence-based clinical data collected from prospective investigations show that an asymptomatic third molar does not necessarily reflect an absence of disease.
- 11. Practitioners typically should consider removing erupted and impacted third molars when they cause considerable pain, are infected, are associated with bone destroying pathology, are carious or adversely affect the health of adjacent teeth. In addition, practitioners should remove third molars that are expected to be problematic under dentures, are located at sites of planned osteotomies or interfere with planned orthodontic movements.
- 12. Current data are not sufficient to refute or support prophylactic removal of third molars versus active surveillance. Although third-molar management usually is straightforward, the evidence supporting extraction versus retention of asymptomatic, disease-free third molars is lacking. Active surveillance, a prescribed program of follow- up and reassessment at regular intervals are recommended for retained third molars rather than waiting for the onset of symptoms to initiate follow- up.
- 13. Why Preop. Assessment • Risk assessment • To minimize complications • For patient preparation • To determine type of anaesthesia • Costing For Planning the Surgery
- 15. General medical condition • Allergies • Bleeding problems and related diseases • CVS • Drugs • Endocrine disorders / DM • Fits • GI • Etc.…………………………...
- 16. • Previous history of Dental treatments • Past surgeries • Previous Hospitalizations • General build • Age
- 17. Bleeding Disorders • The use of variable “safe INR levels” for minor surgery continues to lack of full consensus . • The optimal INR value for minor oral surgery procedures is between 2.0 and 3.0. • Procedures may safely be done while maintaining an INR value level of 3.0 to 4.0 as long as local haemostatic measures are taken. • Surgery is contraindicated with an INR value of greater than 5.0.
- 18. Periprocedural recommendations Presumed bleeding risk of procedure SAPT/DAPT with ASA ± clopidogrel VKA DOACs Unlikely to cause bleeding Perform dental procedure without interruption Perform dental procedure without interruption. if INR is ≤3.5 24 hours before the intervention. Continue therapeutic anticoagulation, perform dental procedure at trough concentrations Low bleeding risk dental procedures Perform dental procedure without interruption Perform dental procedure without interruption if INR is ≤3.5 24 h before the intervention. Delay if INR >3.5 and adjust VKA dose until INR ≤3.5 Continue therapeutic anticoagulation, perform dental procedure at trough concentrations High bleeding risk dental procedures* Perform dental procedure without interruption Perform dental procedure without interruption if INR is ≤3.5 24 h before the intervention. Delay if INR >3.5 and adjust VKA dose until INR ≤3.5 Delay (rivaroxaban, edoxaban) or skip (apixaban, dabigatran) one dose on the morning of the dental intervention
- 19. Platelets 1) Dental extraction is safe in thrombocytopenic patients with greater than 50,000 platelets/µl. Bleeding complications are easily managed with local measures. 2) Because there is little evidence to support the safety of dental procedures for severely thrombocytopenic patients with less than 50,000 platelets/µl, physicians and their patients should consider platelet transfusions to reach 50,000 platelets/µl for dental extractions
- 20. Infective Endocarditis Prophylaxis Antibiotic prophylaxis with dental procedures is reasonable for patients with cardiac conditions associated with the highest risk of adverse outcomes from endocarditis, including: • Prosthetic cardiac valves, • Previous endocarditis • Congenital heart disease (CHD) only in the following categories:* –Unrepaired cyanotic CHD, including those with palliative shunts and conduits –Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or catheter intervention, during the first six months after the procedure† –Repaired CHD with residual shunts or valvular regurgitation at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) • Cardiac transplantation recipients with valve regurgitation due to a structurally abnormal valve *Except for the conditions listed above, antibiotic prophylaxis before dental procedures is no t recommended for any other form of CHD.
- 21. Local Assessment • Mouth opening • Cheeks and retractability of tissues • Tongue size • Oral Hygiene • Alveolar bone thickness • 2nd Molar condition • Restorations / Crowns etc...
- 23. Clinical • Complaint • Previous episodes of infections • Eruption status • Angulation • Local soft tissue condition ( infected/ inflamed) • Available space between 2nd molar to ramus • Caries
- 24. Radiological What type of x-ray IOPA OPG Lateral oblique Cone beam CT
- 25. Good IOPA Should show Full 3rd molar Full 2nd Molar ½ of 1st Molar Distal Bone cover ID nerve relationship
- 31. What else with IOPA Distal Bone cover and trabecular pattern Size of the follicle Other pathologies Root number, size, angulations Distance from roots of 2nd molar Status of 2nd molar tooth Relationship with ID canal
- 33. • Large follicle – easy removal
- 35. Caries of 2nd Molar
- 36. Root / Nerve relationships
- 37. Cone Beam CT
- 38. Coronectomy