Vasovagal Syncope - Due to needle anxiety. This is the most common syncope

Management: Trendelenburg

Blood pressure drops from standing up after a being in a supine position for a long time - this is the second most common cause of syncope.

3 Common types of Angina Pectoris:

• Stable

• Unstable - absence of stress

• Prinzmetal / Variant Angina - recurring

  Management: Vasodilators

Myocardial Infarction

- Surgery only AFTER 6 months since the infarction

Epinephrine content

• 0.2mg for normal patients, maximum of 7 carpules

• 0.04mg for patient who has experienced MI or any compromised patient. maximum of 4 carpules but much better if less than maximum amount allowed.

Asthma

Avoid NSAIDs, give acetaminophen instead

Late morning or afternoon scheduled appointments

Renal Failure

Avoid drugs that affect the kidney like NSAIDs

Schedule procedures (exo) after dialysis

Hypertension

Not a contraindication just a precaution

140/90 - mild to moderate blood pressure. Okay for surgery as long as maintaining medication

200/110 - severe blood pressure. Postpone surgery until bp lowers

Diabetes Mellitus

Type I - Since childhood. Underproduction of insulin due to problem with pancreas

Type II - Obtained because of lifestyle. Obesity, prone to infection.

Hypoglycemia is the most common concern for diabetes mellitus

Hyperthyroidism

Exophthalmos - bulging of the eye socket

Enophthalmos - sinking of the eye socket

Epinephrine will lead to thyroid storm

Pregnancy

The primary concern for pregnant women in oral surgery is the potential damage to the fetus

Best to do surgery during the 2nd trimester as anesthesia and medication are less likely to affect the fetus

Cephalexin - Medication for lactating mothers because only a small amount pass onto breast milk

Airway Obstruction

Management:

Chin tilt upward to extend the neck, if cervical fracture is present, perform jaw thrust instead

Seizures

Grand mal seizure

Absence seizure

Status Epilepticus - deadliest, lasts 5 minutes

Hyperventilation

Taking in too much O2, manage by using paper bag to take in more CO2

Air Emphysema

Air trapped in subcutaneous tissue

Must use surgical drills/handpiece as it vents air away from the operative site unlike the restorative drills

Adrenal Suppression

Normally, adrenal gland produces cortisol, the stress hormone

Px may be taking corticosteroids for maintenance, thus body stops producing cortisol on its own relying on medication.

Double dose of meds if maintaining, if not but has taken in the past year for more than 2 weeks, give 60mg

Cavernous Sinus Thrombosis

Blood clot forms in the cavernous sinuses; two hollow spaces located behind the eye socket

Caused by a tooth infection

Occurs in Opthalmic veins

Management: Antibiotics

Ludwig’s Angina

Bacterial infection, cellulitis involving the fascial spaces specifically the Submandibular, sublingual and submental

Management: ER

Bleeding or Hemorrhage

Primary hemorrhage - Occurs during surgery, unavoidable trauma during extraction

Intermediate/Reactionary hemorrhage - Occurs within 24 hours post op

Secondary hemorrhage - Occurs 7 - 14 days post op as a result of breakdown of clot due to infection

Management:

• Gauze and finger pressure

• Electrocautery but contraindicated for px with pacemaker

• Bone wax if the source of bleeding is the bone

• Suture

Root Displacement

Common in MX molars, specifically; first molars and apical third of palatal root

Assessment:

• 1 size of the root lost in the sinus

• 2 is the tooth infected or not

• 3 preoperative condition of the mx sinus

Management:

• if root and sinus are not infected, irrigate with sterile saline solution

• if root is big or infected do Caldwell-Luc Surgery - creating an opening in the mx sinus to allow for thorough cleaning and retrieval of displaced root

MN Molar roots are commonly displaced towards the submandibular space through thin coritcal plate

Surgical Complications

Soft Tissue Injuries:

Tear of mucosal flap - the most common soft tissue injury during tooth extraction

Prevention: Create adequately sized flap to prevent excessive tension

Management: Reposition flap and suture

Stretch or Abrasion Injury - caused by rotating shank of the bur or retraction of very dry mucosa

Prevention: moisturize surrounding mucosa

Management: Apply vaseline

Puncture Wound - Caused by slippage of instruments or uncontrolled force

Prevention: Controlled force and finger guard

Management: Prevent infection and allow healing to occur

Problems with a tooth being extracted

Root Fracture - most common problem associated with tooth extraction. common on teeth with long, curved divergent roots that lie in dense bone.

- Caused by inadequate luxation

Prevention: Luxate properly

Management: Raise a flap and removal of bone to retrieve fractured end

Tooth lost into the oropharynx - caused by slippage of tooth from instrument during delivery out of the socket.

Prevention: Place gauze anterior to soft palate to prevent loose tooth or instruments from falling into the oropharynx

Management: Position px in mouth-down position and encourage to cough out tooth into the floor.

Injuries of adjacent teeth

Fracture of adjacent restoration - Most common injury to adjacent teeth.

- caused by dentist not being cautious enough

Prevention: avoid application of force on the restoration

Management: Temporary restoration

Luxation of adjacent teeth - caused by inappropriate use of instruments

Prevention: careful when applying force with elevators and forceps

Management: Teeth repositioned and stabilized using silk sutures

Extraction of wrong teeth - Most common cause of lawsuits

Injuries to Osseous Structures

Fracture of Alveolar Process- caused by excessive force of forceps

Management: if bony process was totally removed, it should not be repositioned, if the bone remains attached to the periosteum, it should be separated from the tooth being extracted and repositioned and stabilized in place

Common areas for bony fractures:

• Buccal cortical plate over the maxillary molars

• Buccal cortical plate over the maxillary canine

• Portions of the floor of the mx sinus associated with mx molars

• Mx tuberosity

• Labial bone on MN incisors

Post Operative Bleeding

Prevention:

• Clean incisions

• Atraumatic surgery

• Gentle management of soft tissue

• Smoothen/Remove sharp bony spicules

• Curette granulation tissue

Management:

• Absorbable gelatin sponge - most commonly used and least expensive

• Topical thrombin

• Collagen

Hereditary Coagulopathies

Prolonged bleeding after tooth extraction is usually the first evidence of a bleeding disorder

ASPIRIN, WARFARIN & HEPARIN - common anticoagulants used

Normal Values:

Bleeding time - 7-8 mins

Clotting time - 6-17mins

Partial Thromboplastin time - 32-45secs

Prothrombin time - 11-16 secs

Tourniquet test - 10-20 petechiae

Bleeding time - time taken from initial injury to platelet plug formation

Clotting time - time taken for the formation of stable fibrin

Partial Thromboplastin time/ PTT - measures intrinsic pathway

Prothrombin time/PT - measures extrinsic pathway

INR/International Normalized Ratio - preferred laboratory test for assessing anticoagulant therapy in px taking warfarin

To promote PT test standardization, PT ratio expressed in INR

Management of Patients with Coagulopathies

Px receiving ASPIRIN - defer surgery until aspirin has been stopped for 5 days

Px receiving WARFARIN(Coumadin) - if PT less than 3.0 INR, proceed with surgery. If PT more than 3.0 INR, stop warfarin 2 days before surgery. Restart warfarin on the day of surgery

Px receiving HEPARIN - defer surgery at least 6 hours after heparin has been stopped or reversed with protamine.

Delayed healing and infection

Infection is the most common cause of delayed healing

Management: Decontamination and debridement - prescribe antibiotics

Wound Dehiscence - Partial or total separation of previously approximated wound edges, due to failure of proper wound healing. (previously healed wound reopens)

- caused by placement of flap over unhealthy bone and wound is under tension

Prevention: Leave projection alone or smoothen bone

Management: Close incision over intact bone and suture without tension

Evisceration - Extrusion of intestine through a surgical wound (internal organs protrude through an open wound following dehiscence)

Dry Socket or Alveolar osteonecrosis - delayed healing not associated with infection

• pain begins on 3rd or 4th day after tooth removal

• socket has a fetid odor and px complains of bad taste

Caused by increase in fibrinolytic activity in and around the socket

Prevention: Atraumatic surgery and irrigate with NSS

Management: Irrigate NSS then place a strip of gauze soaked in iodoform into the socket. Change gauze every other day for 3-6 days. No antibiotics needed

Contents of iodoform:

• eugenol

• topical anesthetic

• balsam of peru

Fracture of the Mandible - rare case. associated with extraction of impacted third molars

Management: reduction and stabilization done by an oral maxillofacial surgeon