Os Clincon - MedEmergencies & SurgComplications
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
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