Abdullah Khasawneh Dr- fadi jarab

11/7/2013

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Oral Surgery Lecture 3: A review

The oral surgery exam will consist of 30-40 questions. This lecture is a review of the last one, and is the last lecture before the mid exam. The subjects covered here are only those that the doctor thought are extremely important. Anything that has been emphasized by the doctor should be given extra attention.

Complications of tooth extraction

Root fracture
The tooth that is most susceptible to root fracture is the upper first premolar. The dentist's response to a fractured root depends on the length of the fractured part of the root. If it's more than 1/3 the root's length(, or more than 4-5mm long); then surgical extraction is performed: a flap is opened, bone is removed, and the fractured part of the root is removed from the socket. If there was an infection, a fractured root fragment should always be removed; because the infection will not resolve. If it's less than 1/3 the root's length(, or less than 4-5mm long); then it's left in the socket, and the patient is followed up later. Most importantly, the patient should always be informed that a fragment of the root remained in his mouth, even if complications are very unlikely. Even if the fragment was a small one, the presence of infection necessitates removing it surgically.

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What happens to the root tip when left in the socket? One of the following scenarios: It resorbs, and is replaced by bone. It is ejected through the alveolar ridge, and the patient is aware two years or so later that a root tip came out into the ridge. It stays in its place, without causing any problems. This is the least likely scenario. If an implant is to be applied in place of the extracted tooth, any tooth fragments should be removed. For orthodontic patients, fragments should also always be removed. For example, if the space created by extracting the tooth is to be closed. Cases in which fractured root tips should always be removed: It's more than 4-5mm in length.

There's an infection.
An implant is to be put. Orthodontic considerations.

Root displacement into maxillary sinus

The root that is most likely to be displaced into the maxillary sinus is the palatal root of the maxillary first molar. Roots of teeth 4, 5, 7, 8 may also undergo this displacement, but it's not as likely in those teeth as it is in tooth 6. What should be done once a root is displaced into the maxillary sinus? First of all, the patient is asked to lean forward, so that the root doesnt move posteriorly.
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Secondly, X-rays are taken in two angulations: anterior-posterior, and lateral. Thirdly, after it's been made sure that the root is within the sinus, an opening is made in the labial sulcus into the canine fossa. This fossa will give direct access to the sinus. A hole is made, the sinus is accessed, and the root is removed. The canine fossa is the fossa distal to the canine eminence. So it's the area between the teeth 3 and 4. This procedure is performed in the case of an acute displacement; if the root was displaced during an extraction procedure, the dentist should immediately remove it as described above. However, if a patient tells you that the root tip was displaced two years earlier, and no complications have arisen, there is no need to remove it. If complications arose after two years of an extraction, the root tip should be removed, even though this is not an acute case.

Bleeding
If bleeding occurs after extraction, we have to recheck the patient's medical history; since some patients have some conditions (like hemophilia) that cause bleeding. If no such conditions are present, the dentist will have to remove the blood by aspiration (suction) to locate the source of the bleeding. Most importantly, pressure should be applied to the source of the bleeding. If the socket is bleeding, there are materials that can be applied to its inside to stop the bleeding (e.g., bone wax, Surgicel). For soft tissue bleeding, suturing should be performed. After the treatment of bleeding, the patient should be monitored. Do not let the patient go home immediately.
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One of the components of local anesthesia is epinephrine (a vasoconstrictor). By the vasocontrictive effect of epinephrine, the bleeding that is being treated stops. And so after suturing, the operator should wait until this effect wears off (fades) to make sure that the bleeding has stopped permanently and ensure that the suturing is successful.

Dry socket
It is the most common painful complication following tooth extraction. The tooth most commonly affected is the lower third molar. It is a form of abnormal (delayed) healing. Anaerobic bacteria do play a role in this complication, but this doesn't mean that we have to administer systemic antibiotics to the patient: delayed healing means that less blood goes to the extraction site, so giving antibiotics will not benefit the dry socket patient. The symptoms of the dry socket begin to manifest themselves after 2-3 days of the extraction procedure. The patient feels deep-seated severe throbbing pain. To treat a dry socket the operator should work to accelerate healing. This does not mean performing aggressive curettage to induce bleeding inside the socket. Soft curettage should be done; which means only removing the debris and foreign bodies, frequent irrigation, and placement of a sedative material inside the socket to relieve the pain.

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Medical emergencies in the dental chair

Fainting
It is the most common cause of loss of consciousness in the dental clinic. It might be caused by phobia, stress, or anxiety. A dental procedure is a stress-inducing What happens is that sympathetic activity will start, and then the parasympathetic system (the vagus nerve) will make a compensatory attempt; the parasympathetic response predominates causing in hypotension which results in loss of consciousness. The patient recovers immediately after being put in the supine position with slightly elevated legs.

Collapse in a patient with a history of corticosteroid therapy Corticosteroids are stress hormones that are secreted from the adrenal glands. They are secreted in response to stress, and they raise blood pressure and blood glucose levels; and so when a patient is taking corticosteroids from an external source, his/her adrenal glands will be suppressed, and they will not be able to produce more hormones in response to stress. The dental procedure is stressful event. In a normal patient, the adrenal glands will secrete more corticosteroids during a dental procedure. A patient receiving corticosteroid therapy (and suppressed adrenal glands) should take supplements before starting the procedure to avoid shortage of these hormones. Otherwise, this patient will be hypotensive and hypoglycemic.

Fits (epileptic seizures)

Fits are induced by starvation, light, or certain drugs. They might be preceded by auras (e.g., seeing zigzag lighting). The patient experiences
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loss of consciousness with a rigid extended appearance and generalized jerking movements. During a fit, patients are frequently incontinent of urine and might bight their tongues. The recovery is slow, with the patient feeling sleepy. Most patients recover from a fit spontaneously. But until they do, the dentist should stay away from the patient, and keep anything that might harm the patient away as well. The patient should be put in the recovery position: patient should be laid on his/her side, with patent airways. The most important thing to do when a patient undergoes a fit is to make sure the patient does not hurt himself/herself or anyone in the vicinity.

Once the dentist senses the patient is about to have a fit, it is recommended that the dentist put some gauze inside the patient's mouth to prevent tongue biting. After that the dentist is to move away from the patient. If after recovering from one fit, the patient undergoes another one, he/she has entered status epilepticus. This occurrence causes severe spasms in all muscles (including respiratory muscles), and it is therefore fatal. In the case of status epilepticus, the dentist should call for an ambulance. If the dentist has any muscle relaxant (e.g., lorazepam, diazepam) it should be administered to the patient intravenously.

Acute asthma
An asthmatic attack is an incidence of bronchospasm in response to exposure to an allergen, infection, cold, exercise, or anxiety. The characteristic symptoms are tightness of chest and breathlessness.

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An asthma patient should inform the dentist of his/her condition. The dentist then should keep in mind (1) any allergens that might cause an asthmatic attack, and (2) that the patient is probably on steroids, which might lead to adrenal insufficiency. In the management of an asthmatic attack, the patient should be kept upright. Salbutamol (a 2 agonist, a bronchodilator) inhaler should be administered to the patient. Also, O2 and steroids should be given to the patient. Any patient with a cardiac or pulmonary problem should never be put in a supine position; as that will increase the load, and harm the patient. At the hospital, the patient is nursed upright, and given 5 mg of nebulized salbutamol with O2, 0.5 mg of nebulized ipratropium with O2, and up to 200 mg of IV hydrocortisone.

Inhaled foreign bodies

In the case of an inhaled foreign body (most likely a tooth), it usually goes to the right lung because the path to the right lung is straight (the angle between the bronchus of the right lung and the trachea is larger than that between the bronchus of the left lung and the trachea). A foreign body inhaled into the upper airways will stimulate the cough response, but that is not always the case: the lack of cough does not mean the patient has not inhaled a foreign body; it might have reached the lungs. The cough response might be sufficient to clear the airways. If the obstruction is complete, or if there are signs of cyanosis, and the patient is conscious and can stand up, the patient is given 5 blows to the back. If that doesn't work, the Heimlich maneuver is applied.

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The Heimlich maneuver Patient is approached from behind, both hands are placed just below the diaphragm, and the diaphragm is pushed in a posterior-inward direction. Sometimes, a combination of 5 back blows and 5 abdomen pushes are needed. In the case of an unconscious patient, finger sweep is done (fingers are used to locate the foreign body in the upper airways), and abdominal thrusts are performed with the patient supine (basically, the same principle as the Heimlich maneuver: hands are placed just below the diaphragm and push in an upward-backward direction. If all attempts to clear upper airways fail, cricothyrotomy is performed. The cricothyroid membrane (between the cricoid cartilage and the thyroid cartilage) is opened with a blade into the airways. It's a simple and bloodless procedure. Cricothyrotomy might only preserve life if the obstruction lies above the level of the cricothyroid membrane.

The ABCDE approach In any case of emergency or trauma, ABCDE should be kept in mind. A: Airway B: Breathing C: Circulation D: Disability (AVPU) E: Exposure They should be considered in that particular order! (Airway>>Breathing>>Circulation>>Disability>>Exposure).
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Disability refers to the patient's responsiveness: A: Alert

V: response to Verbal stimuli

P: response to painful stimuli U: Unresponsive

Exposure means that patients should be exposed (stripped out of their clothes) to check for hidden injuries that cannot be seen otherwise. In trauma cases in particular, the patient is exposed, the body is inspected, and then a cover is placed on the patient.

Cardiorespiratory arrest The most common cause of cardiorespiratory arrest is ventricular fibrillation. In the case of a cardiorespiratory arrest, adult basic life support should be followed: Responsiveness is checked. It is ensured that the airway is patent (head tilt/chin lift or jaw thrust, and manually clearing the oropharynx).

Breathing is assessed: look (chest movement is observed), listen (breathing sounds at the mouth and nose), and feel (air is moving out of the mouth and nose). If the patient is breathing, this means that the circulation is OK. He/she should be put in the recovery position. Otherwise, the dentist should get
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help, and give two effective breaths (up to 5 attempts), then move on to the circulation. Circulation is assessed: carotid pulse is checked (by feeling) for 10 seconds. If pulse is present, we make a return to breathing: ventilation is continued, and pulse is checked every minute. If there was neither pulse nor breathing, chest compressions are applied (100 chest compressions/minute; 15 compressions/2 breaths; 12-13 breaths/minute). Chest compressions are performed until help arrives, or until the dentist is absolutely exhausted and no response is elicited from the patient.

FINIS

Special thanks go to my dear friend Saif Sharyri for his unfailing derision.

Done by : Abdullah Khasawneh

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