2nd and 3rd os topic prelim

• Management of Patients with Compromising Medical Conditions:

  • Patient with Adrenal Suppression:
  • Instructions for patients currently taking corticosteroids and those who have received at least 20 mg of hydrocortisone
  • Patient with Hepatic Insufficiency:
  • Precautions and screening for bleeding disorders
  • Patient with Diabetes Mellitus:
  • Instructions for insulin-dependent and non-insulin-dependent diabetes patients before and after surgery
  • Patient with Hyperthyroidism:
  • Signs of hyperthyroidism and caution with local anesthetics containing vasoconstrictor
  • Patient with Coagulopathy:
  • Steps to take before, during, and after surgery for patients prone to bleeding
  • Patient taking Anticoagulant:
  • Steps to follow for patients receiving aspirin or other platelet-inhibiting drugs and patients receiving Warfarin (Coumadin)
• Anticoagulants are medicines given to people at high risk of blood clots to prevent conditions like strokes and heart attacks
• Examples of anticoagulants include:

  • Aspirin
  • Warfarin
• Patients using anticoagulants are prone to bleeding, so precautionary measures include:

  a. Referring back to the physician about planned procedures and medications

  b. Indicating when to stop and resume anticoagulant intake
• For patients receiving heparin:

  1. Consult the patient’s physician to determine the safety of stopping heparin for the perioperative period

  2. Defer surgery until at least 6 hours after stopping heparin or reverse heparin with protamine

  3. Restart heparin once a good clot has formed
• Management of a patient who is pregnant includes:

  1. Deferring elective surgery until after delivery if possible

  2. Consulting the patient’s obstetrician if surgery cannot be delayed

  3. Avoiding dental radiographs unless necessary for proper care, using proper lead shielding if needed

  4. Avoiding drugs with teratogenic potential and using local anesthetics when anesthesia is necessary
• Dental medications to avoid in pregnant patients include:

  • Aspirin and other nonsteroidal anti-inflammatory drugs
  • Diazepam and other benzodiazepines
  • Tetracyclines
  • Nitrous oxide if exposure is high
• Drug classifications for pregnant patients:

  • Category A: No fetal risk demonstrated
  • Category B: No fetal risk in animal studies or confirmed in controlled studies
  • Category C: Adverse fetal effects in animals, should be given if no safer alternatives
  • Category D: Positive evidence of human fetal risk, benefits may outweigh risks
  • Category X: Fetal abnormalities demonstrated, contraindicated in pregnant women
• Principles of surgery for oral surgery include:

  • Adequate visibility
  • Assistance

  
• Adequate visibility factors for oral surgery:

  • Good chair lighting with white light instead of yellow light
  • Provision of natural light
  • Indirect vision with a mouth mirror
  • Ergonomics for proper positioning of both the dentist and the patient
• Assistance in oral surgery:

  • A properly trained and focused assistant provides invaluable help during oral surgery
  • The assistant should be familiar with the procedures being performed to anticipate the surgeon’s needs
• Principles of incision in oral surgery:

  • Sharp blade of the proper size and shape should be used
  • Firm continuous stroke
  • Carefully avoid accidentally cutting important structures
  • Blade held perpendicular to the epithelial surface
  • Properly placed incisions through attached gingiva over healthy bone, avoiding prominences and the gingival sulcus
• Prevention of flap necrosis in oral surgery:

  • Flap design principles include the height of a flap should never be greater than the base, unless a major artery is present in the base
  • Generally, the height of a flap should be no more than twice the width of the base
  • An axial blood supply should be included in the base of the flap
  • The base of flaps should not be excessively twisted, stretched, or grasped with anything that might damage vessels
• Prevention of flap dehiscence in oral surgery:

  • Flap margin dehiscence is prevented by approximating the edges of the flap over healthy bone, gently handling the edges of the flap, and not placing the edges of the flap under tension
• Tissue handling in oral surgery:

  • Tissue can be easily damaged through excessive pulling or crushing, extremes of temperature, desiccation, and use of unphysiologic chemicals
  • Proper tissue handling includes delicate use of tissue forceps, avoiding over-aggressive tissue retraction, using copious irrigation when cutting bone, and protecting soft tissue from frictional heat or direct trauma
• Hemostasis in oral surgery:

  • Prevention of excessive blood loss during surgery is important for preserving a patient's oxygen-carrying capacity
  • Meticulous hemostasis during surgery is necessary for other important reasons
• Hemostasis is crucial during surgery to prevent excessive blood loss and maintain meticulous hemostasis for reasons like decreased visibility and prevention of hematoma formation

  
• Promoting wound hemostasis can be achieved in 4 ways:

  1. Assisting natural hemostatic mechanisms

  2. Using heat for the end of cut vessels to fuse (thermal coagulation)

  3. Ligation

  4. Placing vasoconstrictive substances
• When using heat for thermal coagulation, the patient must be grounded, the cautery tip and any metal instrument it contacts cannot touch the patient other than at the bleeding vessel site, and any accumulated blood or fluid around the vessel must be removed
• Suture ligation involves grasping each end of a severed sizable vessel with a hemostat and tying a non-resorbable suture around the vessel
• Vasoconstrictive substances like epinephrine can be placed in the wound to promote hemostasis
• Dead space management after wound closure can be done by suturing tissue planes together, placing a pressure dressing, using packing until bleeding stops, or employing drains
• To prevent dry socket after extraction/surgical procedures, avoid frequent gargling, spitting, playing with the open wound using the tongue, and negative pressure like smoking or sipping
• Decontamination and debridement of open wounds involve irrigation, wound closure, and wound debridement to decrease bacterial count and prevent wound infection
• Inflammation control post-surgery can be managed by minimizing tissue damage during surgery, using ice to decrease vascularity and edema, patient positioning to keep the head elevated, and short-term, high-dose systemic corticosteroids to lessen inflammation and transudation
• Proper wound healing depends on a patient's ability to resist infection, provide essential nutrients, and carry out reparative cellular processes