-

,,
CHAPTER 3
I
,,
I

65
 ANATOMY
\ 'TRIGEMINAl NERVE (eN V) Ih S1 of Ihe 12 cranial nerves d pr\ncipal general sensory
ne~e to the head and lac ' "Ill a s so and motor root. The
001 enters the Iri emlnal (semilunar asseriall) an lion in the middle Cf31lla ~sa.

• Tngeminal neN arise he anglian a~ cranial cavity through

oramina m lhe sphenoid bO[le.J smaller moto asses under the ganglion and loins Ihe
mandibular division (V3) as 1\ exils Ihroug ORAMEN OVAL . andibular division (V3) innervates

•
-8museles.

eN v (trigeminal) contain NO parasympathetic com onent at its ori i

-

Somatic SENSORY bodies of the ganglion's sensory fibers enter ~thl<'-·---0=

I. Ophthalmic Djvision (V)) supplies general sensation to II ORBIT&S'Kirt f the lace above
Ihe eyes.
ry~. 2. Maliilary Division (V2) supplies eneral sensahon 10 nasal cavity, maxilla teeth alate &
.....- ]Bm pver the ma¥.liia. ' ,
. fl 3. Mandibular Division (VJ) supphe e era I sensation to the mandible, 1M], mandibular tee
.'Y\A...£Y Hoor ot mouth, tongue, and skin of mandible,

The axons pf the neurons enter the P H rough the senso r t and term mate In 1 01 3 nuclei pI the
ngeminal sensory nuclear complex,
1. mesencephalic nucieus-mediale~prtQCeptJpP,iI.e . 111 J cle spindle).
_ ~ 2. main sensory nucleus-mediates eneral sensa i . touch
;;;:> 3. spinal nucleus-medial (lIn and tram the ~d and Deck

~[99riQGe nljy e fi ber~ from. myscles & TM} are found only in trigeminal's mandjbular division (VJ).
'a" b~ gieul p~opno ce plrve 1st, orde~ neuronls Me found in the mesencephaHIi. nucleus, not the
tr'gemmal g~"L0n . rhe TMl (as With all Jomts), retelves no motor mnervatlon, however the muscles that
~ve the TMJ receIVe the motor inneNalion. ~

8ranchiomeric motor liber~le !em ppra~seter, m£1jial &J~ra\ p'el'i~

01 dlgastflc, mylohYOid, tensor tympan i, and tensor veil palat ine (palah)., ~

Mandibular Division (V3) .of Tri~eminal NefllC.pass~s throUgGRAM~H D~All),Ggptie$ ~

mnervatlon 10 tensor veil palatme l tensor tympani. muscleS.1lLmiiJlG3hpll.<temporalis mas t
lateral &medIal pterygOlds), anterior belly 01 digastric. & mylohyoid muscles. , se er,
• vijensorx InneOtiltion:
? ..!.,1ong.bucca! nerve u~m ory only) to Ihe cheek and mandibular buccal gingiva.
/" • Aurie,ulptemporal nerve (se!1sory onlyl 10 TMJ, altrlcle, and external auditory meatus.
/' • I iggU3! ner~e {sensory orli¥J 10 lloor of mouth. mandibular Imgual gingiva. and anlellor
2/3 at longue,
/" 10 mandibular teeth, chin skin, and lower lip .

.J ~ f2-- Masseteric Nerve (nerve to the masseter) branch at mandibular diVISIOn (V3) tliat~rie~:~'
~ ~nsory libers to the 'Mrs anterior portioG ~~f . f'v1 ~'W
J ~ Auriculotemporal Herve (V3) Ihat provides the. major SENSg RY
~ ~ation to the TMJ osterior ortio" Transmits pam in the 1MJ capsule and diSC penphery,

I.

66

zt
 Anterior Triangle Muscles

Muscle Nerve Innervation

~ (anterior beliy) eN Vi' Cpo§1eri.aLbelly)

posterior bellies) iju_ya
carried via hypgglossal oem (eN
eN VII
. (facial nerve)

NI i"Dern.cd by Ansa Cervicalis

(3 loop !Drllled by branohes 01 the
cervical plexus C1. C2, C3).

HYPOGLOSSALwhich is NERV1:~~i5~~~~~~i~i;i~
I and
i
I
I

II II and ohstrucl

• tjN 1I1Ilsryaljpn ~he ~to:n;'~lC~c~om~,~s~, ~o~m~I ~'~~o~to~ss~'~tn~'~rv~'~~~~~~!g~OiiY--

.CAROTID SHEATH - losat!p al
oro h3 II on eh side of the neck deep 10 "" .illM>Ul'":'""'!!-l'~!!L~!.!.U~!!i
rI and n t con,tai,lS "'!.liililllill.ilIIIiiiii~~
lymph nodes.

_~owever. the cervlca sympathetic runk' would remain In place when the carolld sheath is relracle<!
~ecause It is not within the sheath.

• Facial ~ein l!!!lli!Lwith the relromandibul~r vein below Ihe bnntm 01 the magdlbl1l31ulsmnVE mla
the main venous ~truclure plthe neck.poternal jugular VSIII). 1= -t --?:I
R J V
, .:J...TVo\S-V ,B'V
• ~t~~t~~~V~'~l!I~d~:~sc~:~ndtS~t~hrOUgh the neck within the carotid sheath and ;';';!igi~~~
, i
It 1-vvJ.- ] V -t J'Lob
(' I"'WIIIl/
::1. . J . V -+ .5uAx1 . ~ BX1t~ 0 w<iv
1) '( C{ th.,. "'\.ftfc).. = SMp -V'4uL- t.l>'-VaA- l > 13YiJv~ceph 61
"Y'W'-
JF

Maxillary 1st molar isgru;;;;t ed by the MSA &'PSA De~(middle su perior and QQsterior slIU..[[ior
alveolar nerves). To e~lracl the maxillary 1st molar, YQu ""9S1 numb bOth the PSA & MAS nerves, and the
greater (anterior) palatine nerve for palatal anesthesia (sofl tissue). =
• P$Anerve-innervates the DB rggt,91lhe 1st molar and dislallo it L2nd and 3rd molars).
• MSA nerye-innervates the MB tUpl pi the lsI molar and the two premolars.
• _ ASA nerye (anterior superior alveolar oerveHnnervates canines and incisors.

• -
the mandible, thus it ca n be mHllrated anywhere.
.

Ii

block, compa red

~GREATER (ANTERIOR) PALATINE NERVE - .~''€~~~~~~~~I!!!LI!!!!!deS

) soft tissue innervation to the ·

f~'fI.

" n

Cranial Nerve Function

8,tf/611~/~ v
V-
n n.
;
~~)6p
, ,
V-

V-
"
!2.. 7,<i /O
v
v
SOt! .,L~
V II

Parasympathetic Activity

*Craoial

-2, 7,Qr ('0

» --
 1t UU AX! A<.-c-w't
EXTERNAL CAROTID ARTERY supplies most of the head I. neck (except the brain, which gets ~ , C' ~
its blood supply from th~ internal carotid and vertebral arteries). External carotid passes through the
parotid salivary gland and terminates as the maxillary & 5uperiicial temporal arteries (terminal
branches). The superficial artery supplies the scalp.

Maxillary Arte~lies maxillary & mandibu larlM® muscles of mastication, palate, and almost the
entire nasal cavity.
• 1. Inferior alve!!lar artery-a z anch ol lbe maxillary artery thaI tYJijilles blood toJE.e>
rpandibUlar teeb
2. PSA artery-a maxillary artery branch thai supply blood to ttl OSTER lOR ali
3. ASA I. MSA arteries-maxillary arch branches that supply blood to h!(lNTERIOR maxillary tee1b.

~DU~ RE!ll!!yf both dental ,![ches is the\tlERYGDIO PLEXUS of yeiPS)

' GREATER (DESCENDING) P'LATINE-AATERY' -~~~~~~~
cp"nall0 the greater palatine foramen. II supplies Ih!
-1!3S a! wil!> - , =

. ®ndS a branch to anastomose with I I

,
-
Incisive foramen 10 supply !be mucosa of

LINGUAL ARTERY - supplies blood to th~hiCh also receives blood from th'~::::::::.!!.!
J,~!!l~h of the faCial apery & ascending pharyngeal artery).

• lingual Artery Branches:

3. suprahyoid artery:~:;~i~~i~~~;~~;~~~~~~ c:;

2. dorsal lingual artery:
1. deep lingual artery: 213
4. sublingual artery: ~

<:::W';rior al:eolar nerve & actel}' and lingual n~re found in th YGOMANDIBUlAR SPAC
.~.J.etween mC?i a! glerygpiWscle and ramus of the mandibl IA nerve passes lateral 10 I
__ sphenomandibular ligament. J

OPHTHALMIC ARTERY - supplies blood to the orbit and its contents.

Tongue Sensory Innervaton:

• Lingual nerve (branch of V3) Sl'~~:~::~
• Glossopharyngeal nerve (eN r "ill1=!Jii>1o..!~~~l!-~
v~allale

•
• ::~;'=~'; ~~~~ii
"
69
 bone,
NOTES FACIAL NERVE (CN
i
of the mandible through the foramen,
nUiScles

. from lJ

jr. ~il!!!-""m Ihe lacrimal gland an~

Bell's pa'sy~ajUnCljQOa! disorder of the facial nerve) caused by nerve irritation or

/ •
viral injection, thus is uS'uaUftemporall. . .

• the

~ ,} PAROTID GLA~D - the lallest saliyary gland and pu~~and supplied eoeral visee
~ (motor) nerve fib the lasso ha 0 e In . The parotids af I at ' . sl
'anrei=rOr'totheear,an are divided , odsu rlicialtobe ifil l lam dibularlunn I hich
eticloses the facial nerve) being the, div~ding line. Thus, a portioo 01 the parotid lies supedicial ~ the
mandibular ramllS and anotber portIOn hes deep.
~~
~ ~. ~and I
- dramed b STENSON'S DUe I
.-
Icrees the bUCCinator muscle a €SseiJfiP
~~ ~uSCle were It ooens IOta Ihe veshbule 01 the m~uth Opposite the maXilla..., 2n~ ~o'ar.

~ ......v~ '-... \<YQ; Ebner's g'~he only other adul! I These are

~ --..; , joc:a~t~ed~a~r~ou~n~d;Ci;rc;u;m;"~"!atiejP~ap~'t~,a~o~t~Ih~.~t~,"~.~ue~. Th~eir

fROM PAPilLA alter jt bas been lasted by the taste buds.

~ • . ~Otid gland receives it aras m a . ' . inllefVati~m

the glossOPb:;;)1
"erYe , otiC ganghon, and .auriculotemporaillerve (brallch of V3).
• External carotid a,':loe;n;;",,,,

•
(
iii~iiiiii~~~~~~!r.~;~~~~~~rnay muscles, ~lid, and upper and lower

• Wharton's c (Submandibular Ducll-emerges Irom the anterior eod 01 the d~p part QI 1M
s~ mandibular gland , and passes forward along the side of tb~ Inng ue, beneath the mucous
membrane of the moulh floor. It opens Inlo the mouth.Do the summjt Of a slIlal! papilla situated al
the side of the frenu lum of the ion ue. Clinically, the submandibutarduct and deep part 01 the gland
can e rea I y ga PJll~ ,Ihrough ~he mucous rnembr~~e oillie mouth floor alan
Saliva can usually be seen emergmg from I ductlinflce.

70

l
 l..-UDLI D L..
• During closely related

C.~ r0 ,,-,>-UJ<.
c.- ~'f>A-y:u;<.V-
~~- .
• lymphadenolWfiy is the most common cause of swelling of the submandibular triangle tissues
(riOt cysts or sialolilhs) .

SUBLINGUAL GLAND - the smallest salivary gland thai contains mostl~COU;AC~blingual

glands are in the IIQQr pi the wOlllh M'gw the longue close to the midline. M:t!obyoid mllsGle supPOrts cr- .
the individual sublingual glands inferiorly. Th!lY bave many small dutts IRjyji!O Ducts) that n onto - ~
the mouth floor. Most of its secretory units are mucous-secreting with serous demjlllnes
~
•
• fibers trom
. /-:J SuJo"-'4 .
t the
1r-<~.
,. I1mphaUc drainage from the sublingual & submandibular g;ands goes to the submandibular and'
deep Cerlicallymph nodes.
='
• ~melimes the numergus subljngllal dllGt$ iQiAj lQ"lgrm a siogie maio exlitflory dllc! (Bartholin's
DJl!jt) that usual& empties intQthe 'submandibular dllct
E •

~==~~%~::~~~~~i,~orm '
~ ~ h t

!?Ct.fdr01.~~-: I?<-t.....<-M
Regional Lymph Nodes:

1, Parotid Iy mph~~~~iii~~~~~ii~~~~~~~:, ~I('d.-<- K.J .-<. I", -e;.()

2.

and vestibu le, and gingiva , ~~U

• ~,ranasal Sinuses-a series of
enhance voice resonance.
3, Submental lymph
i i
-' .
~;~::""""'i"'. Efferen! Iympb yesseJs
':.lymph gpdCl..
II

ruXllLARy.,sI~U~ES - open into

---
th~US SEMILIINARiS:{gr.gove jn Ihe middl,e m,eatlls...D1 the
- late~al naS~1 cavity Iha.! conta ins openings of the 'wrlonasa! dpe! & anterjor gt bm?,d air cells). The
m enl tee lroll hout
ad~lt h~d . IOn ed b e maxilla jy;sion f the lri eminal nerve (eN V 2)" ~o
•
_wtllchmclu es ASA, PSA, MSA.& infraorbital nervesl. f1 ft ,- fVl /' P~-A";- ~- ~
~ Clinical signs of n I
i lJ II

7t
 NOTES • Antibioti eat sinus infections:
Ampicim realtsi;;;Silis due 1~,o2O;t",,,:,g;s;;;;;;;;:;;,,,,,~
• emci lin & Amoxicillin· reats on .og~~IC ~C .

Maxillary Sinus Communication: if a small communication is made with the maxillary sinus while
~ extracting a maxillary 2nd molar no additional sur ieal treatme . 51 t
to for vise Itt alieni to av id vi In uen! nose blowi" smoking, ~uc I
on a straw, and violent COLI hing or sneezin. ..
• Medications that can be prescribed for 1 week: antibiotics (penicillin or etythromydn), decongestant
nasal spray, and/or an Drat deto~o~,e~s~lal!tt---:~,..,...." , / =_ ___-"..
~ ' J. IIlhecomm""lcatiooop"lo,
tooth socket. mOO,,,leslzed (-6rnml, Ilgure-eight sulu is •placed "er the

~ II the comm""lcatl," 0"010, I oP"lo, I c osed with ~

'!J!..!!'9111 or large fragment is I it sinus, it s au e removed . If the
~he sOCk.et. it. I !lEiev'ed using a "Caldwell-lu)"
I to an OMS. thiS technique If you know Whit ;ou are doing. If not. refer the
~ T~einte ri " n sfloori .
'remaining maxillary molar due to possible ankylosis. vin removing a single

•
•
•
•

I I

LATERAL ~TERYGOJUS (RlGUl & LEfT) - actjn. !"ether "e th1rB!MARY PROJRACTORiJ,1Ihe
magdlbte. 10 add,l'Qo to ",,",ogaod Drotrudm" the! move the m,"dible 'rom S';;-;;ajl,ii,te
excurSIOns). ~or flghllateral eXCursive mOve!!!enls, the WJ lateral DlerygoiUS the primary mover (and
ra,

~
'ce versa). Thus, wbeo a patient attempts PROIRUSIOJ! the mandible . Dthe ri hi
c,ausing the buq:jnatQ,r t m (lra!i !ell lateral Ie go'l to contract. lowever, the right lateral
p erygoid cannot contract during protrusion.
71
 fracture.
01 the fractured condyle I

• = ==:..."01, hyperplasia

• lateral pterygoid muscles form the ROOF of the PTERYGOMANDIBULAR SeA.CE.

- $

; I
•
I I I. i I

..
•
; I
•

TEMPORO
art icu lation between

surface or

~acb condvJe i
I i
2.

~1iIlI1IIII.1IL!!l!.l~.!!el',smake up

3.

13
 . iZi~ l.<.&~ ~r
-=r~ArtICular msc !Meniscus~, BIDCQHCI!!i$b!QIIS "ddl...h'ped structuj;).:omposed wen~
~ ----- 't. ~ tibfOUS C.l. positioned between the condyle and lossa. The dIsc separatei the co~e ~n
9 -temooral bone. (d1V101ll the 1MJ I to Sli . spaces) . M'tJ'lscUSvanes_tO
s Ce~tral intermediate 20

~
~ 3.
<::---
cP-~ .,...~
.
.
JiUcklless
anterior and posterior bands) . .
-I 10 area at separates the thIcker portions called
:;::::=
• Posterior band oJ Articular dlsC@tkest b@:o attached wIth
lRetrodiscal ti~sues or bilaminar lone/posterior anachment).

2.
~~~~~~~~;~i~~~t~hi,~e~'~r~~h~'
~ , runs 01tn~ sp enD
the styloid processlratemporal region
,'

3. Sphenomandibular ligament-an accessol'l'igament attached to the s ine 01the s henoid

on Ihe medial surface of the man Ie .

•
~ Su perficial temporal artery

TMJ Syndrome is Divided into 3 Categori _

.~ 1. Myofascial Pain Oysfunctio MPD) Syndr -th~t com~ cause of TM) pain . It is
a disease primarily involving the muscles of mastjJ:ation .
t MPD is believed to be a strc:;s,-rg!ated disgrder. An increase in stress produces iW in~
in mandibu lar mug !e tension and in combination with teeth clenching causes muscle spa slll ,
pain, and dyslunclioll. -
• MPD often

zg
1: 10 5'
C...€.u. f'!U'u:..-.c...q
OCt-\. 1U'1:.-<--l>'-">-

14
 occasional locking .
. These patients
affected

~~~'~~~~~i;~~~jl~;~~
(anterior displacemegt wjlhQut reduction). Ii
• In some patients,

I
downward pressure on the posterior teeth and
~X posterior displacement 01 Ihe enilre mandible .
• The most c m ause restricted mandibular movement i ISC INTERFERENC <"""'7"
DISORDERS. which change the relationship of the disc and condyle . ______
3. Degenerative Joint Disease (Osteoarthritis)~sapjc qeuprptjgn of the JMI'S artic!!!ar-§!I"!\!7=

1MJ Surgical Approaches:

i
I

Mas com M 2::::::7,

a e oqMJ agk yl gs!!. iSu.:;R::Al'U....
r eumatoid arthritJ .

~RACTURfS

i
• The highest incidence 01fractures """I>" usually from trauma
(i.e. car accidents), "::::::::.:;;:;=:::

GO ~uscle Groups Displace the Mandibular Condyles! . .

1. ",asset,r. medial pterygoid, & temporalis ELEVATE the mandible during mastlcallOn and cause
upward displacement of the proximal segment. .
2. DigastriC. mylohyoid, geniohYOid & lateral ptecyggjd D.f"PBfSS!hft maQdi~le and displace..
the distal fractured segment inferiorly and posteriorly.
3. ~ateraJ pterygoid i1.!.esponsible for forward displacement of the condylar head when the _
~dyte neck is fractured.

75
 ,
~nato ' 'stnbu ' n amlibular fractures:
NOlES Angle- e ost to it ofltactur :~i;UUtiDia
'3 D '; : impacted 31{\ molars at~}ocate In t IS region and turthew
"ThIS rea. n bl to the i3Wtll
Condylar nee tpresco's 25% of fracwr~' It is a salety,feat ure thai allows t e ow
:::J! S" \ 1 be dispersed at this point rather than dnvlng the condyle miD Ihe .
Iractures of

lained.
is usually where blows are sus.:.--

common Iractu~te .

. .. •,,',',,"" are most common

location and extent ot

signs and

, E;>cf'!.~u.~
?? &>p.-<.u:
, ". .:.. """""-
, OPEN REDUCllON - the reduction 01 a hact"! • bone b _ . alian alter incision int ki. n~
i1\uscle f . The most common site tor open reduction is at ttle an¢e 01 Ins mand1bl::::)
~ nee Ihejnsision is made, an intr30sseglls wire is placea through holes made on eitl}!!r side,oille
liadufe. Reduction is accomplished under direct Vision, and immpbilization is obtained by.\ight~h:
wires. This procedure is usually reseIVed lor Iractures that cannot be reduced and immobitlzed adequate
tiY"CiQsed methods. Best used to reduce i! fracture when teeth are missing in one or morl!....ot the
, a~~ ;? fractured segments. fI
LG.f:1U'l-.,/,---.3 -J.I.- (J ~ -, Indications tor !lAe» red"ction arGfjl!nllgd pross displacement 01 the bony segmelib and ~d
keoL"1t -bJ- unlavorable t[actu[~ that IS likely to cause turtber dIsplacement ol the lraclured se~ments ca.!!§.

~
by muscle pull. This \ e 0\ retiuc, . lor dIS lac n \ or bod fractures
~~ -:> C& ~ · Condylar neCk facture s are usually treated by closed reduction. eo-
-"t-ed' -n ~
ClOS£D 01 a lractured bone ~ , . .
skin. It is
, teeth .
•

, e!l!,osure ,

~ BILATERAL SA&ITIAL SPLIT OSTEOTOMY - the

orthognathic Q[Qcedu[l! to When performed
conec\ly, this technique allows tor .
disharmonies. The mandible is sold Sigjta!\y and
to
, retrognathial or set back the ma!!dible (Le . prognathia). I' is
~" p osUi2n oJ the [Qndyle is unchanged when correcting mandibular p.rognathism or re1ropathisrn .

nRTlCAl RAMUS OST£OTOMY used to correct mandibular TO na hi yvertically sectioning

Ihe ramus in line from the lower aspec 0 e mandibular notch vertically downward over lbe
~.!!'n ibular loramen, or just poslerlor 10 Ihe lower border 01 the mandible-at the angle.

16
 BODY OSTEOTOMY rocedure thai involves extracting mandibular teeth bilateral (usually
premolars), a piece of boge is remoyed from the mandible, and everything slides back. c.o rrects
mandibular prognathism 1£lass III maloccl lls i Q I I ) . · .
•
Ways to Immobilize a •
I. Ii

1. I i
II

~
II
Ii

4. . ~

:z;..L~
~~ M.cR."l
~~~~~I Iraclure Iha~dS onl, Ihrough Ihe cortical portion OL:> ~
§~~~~~I;is a closed fracture involving incomplete fraCluere:'.)WBil"hLA..A "'::"';;- ~,
=.:::-' ..:;=;;;;;;;;~ MM ~

Mandibular fractures are classified based on condition of e bone fragments at the fracture site, and ~
possible communication with the ed emal environment: ~-
1. i I I i I
(closed fractures ~ rS
2. Compound lraeluro-I
This may
I i I. ~.
" 10 , '1
3. coinminul~~mmon can be simple or compound. ~~ -"'f
\ . !he line of~[?"W.e determines if musples ~II
be able '9 displace the fractures! segments Irom their C
zz- V~
OrlErrlal OOSlt lPO _ .a ~ -t-l _
-~ unfavorable fracture-occurs if the fracture lin results in a muscle ull displacing the
( ;racture segment.5 '
- avora6ie Fracture-occurs if the fracture lin prevents displa cement of the fracture by
< mUSCle pull. ' )
~

MIDFACIAL FRACTURES - Iraclures ,fleeling Ih maxi!la, zygoma, & nasoorbital ethmoid comple~.
Types of midfacial frac tures;
I.

il

3. or

7J
 4, I bones

th.

-=- Paresthesia-the
. -Ai]JCll mostbecommon
m 15'Q" s) may CO']P~h~
filled with ca~t~io~n~,b~:U:~',~~;~~~~~~~
a hematoma . I II
~ ••Ocular muscle balance may be impajred because of
Zygomatic afCli fractures-are nlcelY-.®monslraled hi, '"dure
may not cause any problem olher than a Ii

!E!ill!Qilli!!!!Ui.>ini~i!M1 to treating
"" ""'""0 the flJ3xilia
, inlo proper
,

I i
these

Signs & Symptoms of a zy~o mati c fracture :

• @jnoculardiplopia (Can be secondary to mu scle enlrapmerll . neuromuscular injury, or
intramuscular hematoma). --
• Difficulty With mastica! i trismus due to masseter S 3sm bony impingement of the
coronoid process.
• Ip!lWeral epistaxis ~curs III some patients 10 iterated maxillary sinus mUCOsa .
-
Fracture of the infraorbital rim pres~nts. wllh the symptoms of ~umbness of the upper lip, c.!2;e& and
nose on the affected SIde. * W~e r's mw IS besllD evaluate orbital rim ar~s. ~

~ Water's view, PA skull view, & submental vertex view are radiographic views helpful to evaluate
. midfacial fractures.

Maxillary Iraclures have a greater ' e!ldeo~ to produce facial deformities than maodibular f l O
\0.the slope of the sp1leomooe
·d b .. til
compnSl1lg
..
. I I II
e crama
.vau . 'r'
lOOL blows to the maxilla Iveracthures. ue
e maKI'II a
backwards anllllownwards, resulting In a potential open bite or impingement of the airway.

S.gmental O steotomy ~ a maxillary procedure wllere the maxilla is sectioned into two or III .
OTe Pieces
Bone mayor may nol be removed . .

Fracture Healing:
• Endosteal Proliferation-occurs Ydthin a bone.
• Periosteal Prohlefalion-occurs within the C.LCllYenng aU paaes (periosteum).
• Primary (BOne-Io-Bone) Healing-Involves bolh endosteal and periosteal proliferaf
• Secondary Bone Healing-mvolves moslly endosteal proliferation into the voidl Ion. b '
pieces of bone). The space hils III With callus. _ Space elweeo 2

Healing 01 Bone o~cu rs jnl-overlapping phases:

I () 1/JoJ· Hemorrhage: occurs hrst and is associated.with ctOI organizaliQn & proliferation 01blood
v-y> vessels. ThiSnon-specIfic phase occurs dunng Ihe first 10 days of healing.
I ;_;'~Jil,~~~~~~~i::. a primary callus is formed in the Qut 10-20 days. A secondary callus forms
I v -}/c
/J3bl{),~ .~
I
II

JB
 4 Reasons Fractures 00 Not H ~I: ~ E
1. Ischemia:1i'tv'icular bone of the wrisl lemOlal~ and lowel thud the IIb.,e all poorly
vasculatized, thus are subject to ischemic necrosis..a a rae ure.
2. EKessjve M~ility: healing is prevented and pse 's or a pseudo-joint a occur.
3. Interposition of soft tissue: occurs between the fractured ends.
4. lli!!i£1i.!in. compQ.Un.dJraciures have ~ tlE,ndency to become intected.
dJAl:!mbolism is most often a se uela of fraclures.

1.

2.

caused •
reduction.
I

ANESTHESIA ,
G~Stages of General Anesthesia:
1. .JJan.l (Amnesia & Analiesia): , I

administration of anesthesia conscIOusness.

I
The best

-' " I (l-f-!

2. r<
i Ii I I .ho~
Pal lent " ,
"" )

\;~:~~; delirious II ~ l'p<~' I

and /' "1 I, <
" as possible.
smoothly
• I J .}, J/
\
3.
(
I i n 4>:
I I and
i
A j ~ I ,_
~
0
.> ., r j . '/ t' , (. ,
stow induction and

~
~~::;~~~r C£R..l,.~/,-
Side effects: senSitIZIng heart \0 the calecholamrllCS, l"{'(..t.('2.
. I h . Not a good analgeSIC, so used as an adjunct. l
hydrocarbons are associated with liver dama e if tOl ie doses are used. ~ I A. \ (JA ~,.. ~
,- Methoxyflurane: 1-3% ewes. slow Ulduclion and recovery, gOO(
~ the heart to catechp1arnincs, a respiratory dCp!essanl. and good analgeSIC.
sensitIZeS ~ ...AIV' r -1
a
vVt.Y
4. S~age (fPr~mortem.J)r MeAullary OegressioD)-sign3Is danger (characterized by maxima.!!y S.
dilated Ilu lis. and cold, ashen skin). BP is extremely low and often un-measurable. C~c ~
.ures IS ImmlDenl. 5 ale reall enl r when
functional (ir(utaljon to IllS bralQ bin Ij!opped Patient experiences ffillere respiratory
a!!,!! C~rdioyaSCular depression/paralysis Jequrring mechanical & pharmacologic suppo~

19
 American Society 01 Anesthesiologists (ASA) Classification of Patient Physical Status:
L....m.-I: a..runw.aJ. healthy young patitnl with an unremarkable mediB ' history and no
systemic disease. -
, k( 2. 1SA-II: pat iellt with mild systemic djsea;;e or signif icant health risk factor (smoki ng, excessive
alcohol use, obesity) ,
3. ASA-IIl: patient with severe disease that is nol incapaCitating.
4. ASA-IV: patient with ~evere systemic disease that is a constant threat to life.
5. ASA-V: a moribou'!.!!.palienl who IS nol expected to survive without the ope[atlon.
6. ASA-VI : pahenlls dedared "brain-dead" and their orgaflS afe being removed for donor purposes.

Elements of General Anesthesia: analgesia, relaxation, hyporeflexia, and narcosis

~ot hyperpyrexia = elevated body temperature).
• Medulla-the last area of the brain This
\irtal part of the brain and contains the ,
rJ) [he most reliable sign of il monitoring a patient during general anest hesia is
L I i may also ~e present. -
experienced du ring OUl plil i9H4eneral anesthesi a is

in oral

INDUCTION phase of anestheSia thai begins with the administration of anesthetic and continuing
.[ the desired level of patient unresponsiveness is reached. The depth ot genera l anesthes ia by
i I . of the anesthetic agent in the brain, and the rates
induction and on the rate of I
rate. The

'\,MAINTENANCE process of keepi llg a palient in surgica l anest hesia. r'

/ •
\. RECOVERY phase at anesthesia commencing when SU[gery is complete and delivery of t~e
anesthetic is termTnated, and ending when the anesthetic has been eliminated from the bOdy.

/ D1SS0CIATIVE ANESTHESIA a unique melhod of pain control thai reduces anxjety al!!!JlLQ.d.uces .
a trance-like state where the person is not asleep, but feels separated from their bOdy. Used in
( emergency situations (i.e. injury/trauma ) and ca n be ~sed t~r short, painful procedures (i.e. Changing
bandages) , This method is safe and lasts only a short tllne. Since the person does not Usually remem ber
the procedure. dissociative anest eSla I . LORE.N. A.person ~hO received diSSociative
/ anesthesia usually of's not remember the procedure, especially ~ I a ~edatlve was gIven WIth the pain
medlcatron. Most people feel normal Within a few hours. As the medication wears oft, an individual may
l have intense dreams or hallucinations.

b KETAMINE is the primary medication used in diSSOCiative anesthesia, but a sedative is otten given
IL I (~ before the Ketarnine to reduce anxiety. A single dose of kelaf11lne produces.a trancelike stale for 10-
.J .If 30 f11lnutes, and pain control for 30-45 minutes. The pallenl's eyes are open dUring the procedure,
- but he/she rs In a'Oaze and leels no patn. ,
- Ketamine secretions 01 salivary and b~nChial glands. BP, HR, and muscleJQJlr r -
~ - (not resplratrons). _ ' - c
~ [ • Si!!!.Qfects: hypertension, increased pulse, deli ri Ul~ c!
Local anesthetic s are MOST EffECTIVE in
I I . lorm
--
I,

80
 • As the pH of the tissue decreases and lH+! Increases,tlle cationic (waler-soluble) form rises and Ir~ / r"
base decreases. Conversely, ~ pH is iDcrea~ and IH+ 1is decreased, the free base (fat-soluble) form
increases and the cationic form decreases. This free base form readily penetrates the lipid-rich nerve.
• Inflammation and infection cause tissues to become acidic. The callOnlC (waler-soluble) form oj
the anesthetic predomi nates (there is less free base a~). Thus, the penetration ttlrough tile
membrane is decreased, giving the

in
II

1r are atteeted
"
cL_-
M~UM allowable dose o! 2% lidocaine with 1:100,000 EPI
' \ g = l.llbs.
• Ex: 101b patient x 3.2mg = 224m, (maximum allowable dosage) I J6mg (amount 01 lidocaine in 2%
carpule) _ 6.2 carpules (-6). ~'-"'.\:' . ~.l ; 1.. <"'p.
• FOI Carbocaille without [ PI, the maximum allowable dose is 3.Dmgllll...
• MaXimum allowable dose 01 [Pllhat can be administered to a cardiac-lIsk patient IS 0.04mg. In
SUMO
terms 01 local anesthetics, this is equivalent to either: - I . g--vvcb A-~'v
V I cartridge (I .Scc) with anesthelic concentration of 1:50,000. ~
· 2 ca rtridges (3.6cc) with anesthetic concentra tion of 1:100,000, bl. 'vt -= j ~I~<S
• >1 cartridges (7.2cc) with anest hetic concentration 011 :200,000.

-.::> O.OlBmg of EPI are in each cartridge/carpule (I .Bcc) of 2% lidocaine with 1:100,000 EPI. D.O ISmg
~ = 1.8cp .O lmg EPI.
• 1cc of 2% lidocaine with 1:100,000 EPI contains:
; 20m arne, O.Olmg [PI, 6mg NaCl, O.Sm sodium-metablsuifate (preservative
o stabilize i).
• Img 01 methylparaben (a preservallvel.and NaOH tostablhze the pH .

• I ,Bcc of 2% lidocaine (1 carpule) with EPII :100,000 contains:

• 36mg lidocaine (I .S';. 20mg), O.! Bmg [PI {l.S X.0 I mgl, I O.Smg NaCI (I ,S x6mg).
- • .90mg sodium-metabisu\1ate (1.8 X0.5), 1.8mg of methylparaben (1.8 x 1111&), and NaOH
t:.'>M ." t'<\~ ~\1 cl h COL<:>
t011abiHze Ihe pH. ,'''- -1':>.00.0 ~ u ""'-"-
~~'> '/JJ~\'lck1:LO
ESTERS potent local anesthetiCS slightly different mchemical structure from arnides AllergiC; reac tions
• ale much more common with esters. Allergic reactions to local anesthetics are usually caused by an lit--- Ll0'--!
a2 igen-antibOdi reac1ip~, ~

• i , Tetracaine/Pontocaine (mojlsrullm~dl. PropOX'tfa ulC

,Cocaine. *Pmcajoe was the protolype ester loca l aneStbetic used.

• Ester local anesthetics undergo rapid biotransformation in BLOOD PLASMA. The malor portIOn of
th is inactivation process occurs in the blood through hv,.4IolYsis to paraaminobenzoic aCid by the
~ enzyme "JlUludocholinesterase". Patients With ps~udocholil\esterase mactl'Jlty are unable to detOXify
~ster- type- agents al a normal rate, Thus, amide anesthetics <!,!:e recommended III these patients.

8\
 ~IDES - ~fe Y't\satjlElo,and effecllVf local anesthetjcs. If hypersensitivity to a drug in Ihi~p.pFeCludes
its use, one of Ibe ester-compound local anesthetics may provide analgesia wilhout adverse effect.

" ~de Local MsslMtics: P!!locame (CI!anesl), ~upivacaine (Marcaine), lid!!£ajneayJpcaine (I he

-
most common), Meplvacaltle (Carbocame). [lidocaine (Ouranest) .
.
ler ic reaction amide local anesthetics are rar ut may occur as a result of hypersens.illvily
o e ocal anesthelic a lor due 10 an allergy 10 methylparaben or olher preservatives used in mall'y
solu IOns. These reactions arc charac!,e1ized 6~ culaneous I~sions of delayed onset or urticaria, ede~a,
and other mallifestations of allerg"For patients r d amide local anesthetiCS,
~. DIPHENHYDRAMINE is a s Ie and effectiv lernative.

---::37 LlYER by microsomal enzymes, but

-
Amide local aoesthetics undergo biotragsformallon in Ibe I f!:
20% is excreted unchanged.

_
, local anesthesia works by reducing anxiety and sensitivity during the procedure. local anesthesia acts
~ by reducing sensitivity which thus reduces anxiety and stress related 10 treatment. Salivation is alSO
decrei'sed . ' & .'.

is,~~~~;;;;.~~.~~~'may ma~ilest its IOXiCi~IIY by initiaLde.~jSipn>-

it
~
theI bram
I Ifor localconvulSIOn). ~~~~~~i~~~~~-~~;~~
anesthetics usually stimulation, then de . H wever
tbat the excitat?ry phase of the r~aclion m~y e e~lreme y brief!..or may nol ~c~r (thi~
is tme especially with lidocame and mePlvaca~n~) causing patients to feel drowsiness. *Udocaille
& Mepivacajlle can a.lso S~Q~ Crg§§'@!!G\leDl~lty . .. . .
~ 'Usually, the FIRST clinical sign of mild Iidocam tOXICity IS NERVOUSNESS Mild toxicity can be
caused by an Intravascular Inlccllon, unusu.ally rapid absorption, or too I.ar ea i d e or the loca l
anesthetic. Clinical manifestat jons of a mild lidocaine toxicity related NS excitatio .
• Nervousness increased anxlet ). Ialkatlveness, mU5Cutartwllchlng, perioral numbness l'HR SP RR
1--e.
~ $iii Li ocaine can ski the exci alo hase and 0 strai hi to the de r . '", ine;s).' ~
=::q:::::s • t e clinical manifestations do not progress beyond these signs with retention of consciousness
no definitive is needed. The II i i '
I
• I anesthetic i Xv
i il I ,
n
I

Injections should
a systemiC reaction to the I
. I I'" presence of a
vasoconstrictor does not an In ravascu ar injection or systemic absorption.
, ,
then the
a psychogeniC reaction.
~ . 01 the loxic effects of the solution.

Reasons Vasoconstrictors (EPI) are placed in local Anesthetics:

~:~'liiiillil!!!li!!!!!!!!ii!Oi:!Ih!e!i'o~c'~I;'!n!eSl!hlei'!iCi(1m!OS~I;im: ;o:rt:':n:':re:':so:n:I', "

•
3. i
V-- 4 ,

"
Vasoconstrictgrs dnJWT r;!!uce the chance of dllVlllopiRQ an anergic reaction to the local anesthetic .

B1

. .
 Vasoconstrictors Used in local Anesthetics
Vasoconstricto Concentrations Available Anesthetics that contains this vasoconstrictor

uoo,ooo

\...uw.1

11
?o. \ ~
~"''V
~

lou cJ--
-
n~
~~~~~"":I'(- ~ '>">" I'--<-
2, ~~~~:~alld warmth).
3. i r ,-
4. eropfloceplion.
J~
( ll ·
--
5. skelelal muscle tooe (motor).

tts:ves regain their function in the:everse order. ~

{..

EPINEPHRlNE drug of choice for In . an acute a nvolving bronchospasm

4acute narrowing of Ih~ resplra ory airway) and "h ote . n.

i
i~~~~i-jthieii ;~!~~~Wji!thit~he;fiAiSiST
TI ONSET action.Iis a of
1 ,
i\l(" ooe ~
11
,f..{; - ~ fr6 = 0 err
' ~
GOi', IV(J -+ CIOJ,

01

,
1

which is

83
 •

!VA C' Aaf

f)M/
Ihe
'£etWc..,{.rV7.,
: ~~S~~~land~;
.. is the
=-
~~ n but not under

lieu(oleplic + Narcotic analgesic + N2.0 Neurolept Anesthesia (~ slale 01 :!!:_urol~l!:t anesthesia &
unconsciousness prodUced by comb!!led admnllslrallQQ pI a narcotiC analgeSIC and neuroleQ"c agent
With Inhalation 01N20 & oxygen).
~. The induction 01 anesthesia is slow, but consciousness returns quickly after nitrous oxide inhalation
IS st8bbM · c::z _

--.ff?
is
~ 0 ~tI .G~ -<:au.uP
~ ~dl'tu-a,,- 2, in
and

II ~
I
III

~. but is_not used to

.t;tu... patients hold IheT;-

~ ..
. ttssue is a measure of I
I PleSSUIe 01 "Iension " in Ihe iOh,'ed ijjr or in blood or
. Since the standard pressure of the total inhaled mjKl;ure
is atmos hefle ressure (760mm H at sea level the art!al r ur e ex ressed as
50 1J';2.0 -::=- Pf' 380
"""
~ [ rJ.J"L0 ~..::) yo ptJ :!;r • ' SP
.........
, %. Thus, 50% N20 III lite IIlhaled air WOUld, have a partial pressure 0
L' l on in oe', tlce :
Omm Hg.

1. as solubility (the primary factor). The more soluble the gas in blood, the slower rate 01 induction .
........... 2. Inspired ~as uartjal pressur.a...
........... 3. Y'infilatjM ute.
" ~. Pulmonary blood flow_
"'" 5. Arteriovegous concentration gradienL

84
 ",,' A mi islr .. · n of an inhala~ion anestl!etic (except H20) is !ISually r . ed by IV or intramuscuj" '- TE
a mimstration 01 a s rt-actin edallve hypnotic drug (often arb!turale . he pfOcedure almost b- ...;,.
always require ndotracheal in ion . . - - . .

.!II Barbitl",'e~
choice for
minutes to lhr), and
I
l~~~~~:~~:::n,~
~ Ih
i more
on dose. The
onset f
barbilural.;e~
i is short -30
suffiCient for 1I10si denial procedures
......
'" •
-:- Barbiturates t I .-'Q~
• Drugs to aVOid In patients laking
an . . These dru s enhance the eNS
~henolhlal!Oes ~lcohQI <1WlhlStam!~s . &
~
'1Z- -+.y-,y,
• fler IV administration of a ultra-short actin barbilu11ie (i.e. ~ revi l a\ Of Penlothal), the last tissue
• ~OC~~~~I~i~ as a result 01 redistributiOn! FAT (bet;au~ It iSJlot as vascular as lIVer,
\ I

• In low
• In higher
ellects may
remove

J~
• , coma, even

•
I
~ i.Jlft,-;-..<A..
General Anesthetics most commonly used al"". .,,11 +
0:>.. -f N;;.,.. \
l!.AYk,
. Also. all II ~~
• e i due to overdose of ~ 4Jv. . '~_ Y' ~
•

, S.c J?A. f -tc<- c.( ~

.\I ,BREVITAL
~au lV barbiturate preScribed I
=t .p '-'U1..~ ~ r P.Q-5
if. Med l ~ ~
lo"Other anestheti
LV
I'f\ I~ n
v-< - 0 ~
U.
,-q < "'-
• Brevltat is etabolized in he liv creted by the kidney. 0 ..., Ij
• euerat anest esia i du reeove usi Brevita is ra ifl e..(. ~ { L-a..(?
• )liccoughs is the most common side effect due to ra id injectiou 01 8revital. C; lj G::::t. lL Ut?
• A prinlary ~dva ntage of IV s~s!..alion is the ability to titrate individua liC (osages. ~ ,q.< <"C-""-' L~

MALIGNANT HYPERTHERMIA--- alGitqsgmal domiganl iuij;iter! condi tion and li fe-threatening)

acute pharmacogenetic disorder occurring 10 patients undere:Qjng general anesthesia ClaSSIC Mil
usually manilesls in Ihe operaling room, but can also occur WllhlO tbe fllst lew hours 01recovery from
a!leslh~a . Characterized by a sudden, rapid rise in body temperature asso c ia~ed. with signs of
increased muscle metabolism (i.e. taFhycardia, tachypnea l sweating. and cyanosIs, Iflcreased C0 2
p,roducjlon, and muscle rigidity).
• Usually occurs in apparentl¥, healthy children and rounp dults a\ an average age ot 21 years (equally
III males & females). .," ,__ 4

When Mfl is diagnosed early and Ireated promplly. the mortalit rale should be near zero. Whellever
anesthesia is administered, Dantrolene be rea il aval a e an Ie protocol lor M!!,
management (I Ires an correct in acidosis and' h erkale .
trolene is currentl the onl known dru that treats MH b impairing calcium-dependent
muscle contraction '
• People with MH.are informed of their condition and advised thai 50% ollhelf Ilrsl-degree relallves
... a~e likely to have Ihe trait.

85
 appreliensive or

j the
I I
""" ,,,. (arm appears blotchy,
i
, ,
usually done with a
IS i I I
discontinued I
• 3_common signs !hat jndicate the correct level of sedation has been reached with Valiult!
b~rrlng 01 ViSIOrI, slurring of speech,and ~ O % ptosis of the eyelids (Verrill's sign).

-
~

~
~
presence , ,,
"
~
~ seen aller IV
-
~
~

~
< in J

~ --t
~,~
-
.Clinical Ob~ervations of Phlebitis:

•
Vessels feel hard thready or cord-like
IllS extrem;fy sellsitJve to pressure
_
•
_

_
• The surrounding area lIlay be erythematous and warm to touch

J; u
~,
~.

~
flev..e~
~* .
"
/ '- - SCOPOLAMINE
• The enllre 11mb
,
I
miaib~eiPa~,ie'iCiO'~d.~a~n~d~SW~O~II~en~~~~~~~~~~~~~~~
of
dry

6a~ :~~;,~~~~;';£;~5~~
-- --- 0 ~ Scopolamine is very
~ , common chOical use.
, anesthesia and as an and

• (~·~ra~g~ita~'~'o~n~(,~,e~'d~e~lir~'"~m~,~~~~~~~~~~~
melf tion with Sco olamioe roloo s certain effects imifar
like amnesia, psychic sedation, and deoeased salivatioo
16dicalionJXi~'
~

,. Reduction 01 secretions occurs com etitive block e f ac t Icholine and other ch " ,
, " '"I . . omerglc
stimuli al chohner 'Ie rece or SI I glands. Antagonism of acet , , "
d '" b d " d' ' (d· . Yc 10 Ine
011 the sp lIncter an Cll ar)' ~=y~"I~,,~e~ye~c~a~u~se~s~m~Y~r~"~SI~s;,'a;'~IO~n~o,:p:u:p':'s:':::__ -
ANTICHOLINERGIC DRUGS:- interfere with IOding of acetylcholine at its reee The mosl
. ·d . - Common
mel hod for categorizing afJjl-chohngrglc drugs IS.tO I entl y e IOnlzahon state of nitrogen I 1 '
,
or Quaternary) because this ,,!I£tIS! Ie drug 'Sab"'l
II yt il
0 pene ra e Ihe eNS. -.. -' e. ertlal}'
-

, TriheXYPhenidYI:r~ comp~

J.?t ~i,
"'-. Gycopynolale, IpratropmJll, &Probanttllne are quaternary compounds that cannot penetrate the eNS
. ~

• Prmclpal therapeutic uses of ~ ntl -c hohnergIC drugs in dent!stry

86
C . glands durillg
saliva flow during denial procedures (anli-sialogu.) and Ih. sec"lion lrom
' . .
"spiralo~
these purposes. II

Air Volumes:

V
1.
Residual
J. Tidal vo'~m:;'~~~~~~~~~~~~~~~~i.iq~Ui~etib~re~a~'~bi~"~·~~H~
Expiratory Reserve
· 4. Inspiratory Reserve Volume
!
I
I
II
;1

5. Vital Capacity {VC)-Iotallung

:~ Functional Residual Capacity a
normal expiration. This
Dieaihs. Alar er than normal fu 10
13 e longer. ERe = ERV + RY,

i Pulmo[lary volumes and capacity are 20-25% less in lemalps tltilR !Rales. aA~ afe greater in laQIP 3m!
I a~ N20 sedation varies accordingly.
LARYNGOSPASM suddenee spasm 01 the vocal cords and epiglottl}:lhal cal<ffiS'Ui, in alrWaV
occlUSion and death. Apatient under general anesthesia loses the lartTlgeal reflex. I~ d saliva coUett
,;ear the yocal cords, this st~mulales the palienllo go join spasm (laryngospasm) and the vocal cords close.
When Ihis happens. air cannot pass thrp@h. The two most impgrtant steos in j~itial mao32ement Of a - 7
' fa n as a mare a I in under oSltive ressure and adminis rin succin Icholine (a skclclal \
muscle relaxant u when pe arming endotracheal intubation an ndoscopies). __

UN;VERSAL Sign O~ngeal

o:struction i~
(crowing sounds Stridor high-pilch, nOISY
respnahon, like blowmg 01the wind. II is a si n I res irat obstruction, es la Iy in the ea Of larynx.
• . Because total airwa obslructlo Isuall occurs during inspirahor, here is usually adequate oxygen
lell In the cereblal blood I It up to 2 minutes 01 cansciousne It the obstruction is not
reco nized mana ed ar 0 en IS not de rvere a e VIC 1m s un s blood and brain (manen
neurolo ic dama t.b5Jninutes.
• Non-invasive Procedures for Obstructed Airway: back blows, manual thrusts, He&nltch maneuver
chest thrust. and linger...s.weep.
II! Invasive Procedures tor Obstructed Airway: these procedures afC onty perlormed by people trarned
in these techniques and With the proper eQlIIpmen\:

-;-\
,-l"" •• Tracheotomy-used mor~;:I\:o~r~~~~~~~~~~
Cricothyrotomy-a procedure

,>...
~... unsuitable or impossible. 1~~~~I!i~;~·
~
.·
~ c:'
(, <-r <;: !r>.
.
• m
I r.
~~~~~~~~
a patient shows signs 01 I I
shows

\ ~ ~.~ epinephrine and oxygen is administered .

t -
~ • If a patient loses consciousness and is unable to breathe, an emergency crlcolhyrolOOlY
may be reqUired to bypass the laryngeal pbslruchon__ .

.... Durrng an inferior alveolar nerve block injection, the needle passes through the mucous membrane &·1
. buccinator muscle, and lies lateral to the MEDIAL PTERYGOID MUSCLE.· ~
• If the needle aCCidentally passes posterior at the level 01 the mandibular f ramen, It penetrates Ihe
parotid gland causing the patient's cheek to leel..!l...um patient may develop paralysis 01 muscles
\ of facial expression eN VII),
• II the needle tiP IS restmg well below the mandibular loramen. il penetrates the medial plerye:ojd
muscle.
• Trismus is most likely caused by irritation of the medial pterygoid muscle during an in!erior
31veolar nerve block.

87
 ,
·
•

'\ Post-operative Hypotension may De l!L!e to tile ellect ollransfusion reactions, fat embolism, anesthetic
\.- or analgesics on the myocardium (the mgst common callsel liver failure, or anaphylaxiS. Treatment:
Narean (narcotic antagonist) jt hYQolepswo is due tQ narcotics Ilse Atropine (anti-chol ioergic) if
bradycardIa is presenL

Post-a eraU,e Hypertension -most often due to gOS1;,DgeraUye gain , s~lth narcot ics and
se alives. It is also caused by hypercarbia (> normal C02 amounts in the blood), or administ ration of
a vasopressor or catecholamine ageots._ . •

PSYCHOGENIC REACTION - cause<}

Signs: ,II
•
,
psycho!,:enic
, .
Actions that may prevent "'patient Irol]1 developing a vasovagal syncopal [ea,.clion after a
local anesthetic:
.......... Slowly injecting the anesthetiC sOlution.
..... Watc/llng the pallenl"S color change during the IIljection.
'), Usmg a topical anesthetiC flor to administration of the local anesthetic.
......... Using a low concen riclor.
::::. Premedicating extremely anxIOus pallents.
.. ~ympathetic, bul conflden! ,handling of the Qalmu! _
""". Proper patient preparalwn .

. The most common cause of transient 10 S~ of oosciousn~ss in the deWal office is vasovaf at sym;;'~e
due to a series 0 car lovascula tn gered by emotional stress brought on by the an IClpation of
. or delivery 0 enta are. Any signs of an impending syncopal episode should be Quick ly trea ted by
placing the patient in a FI,WJ SUPINE Po,slILON, or a position where the legs are eleyated above the
~ level of the heart (TRENDELENBURG POSITION), and by placing a cool,"moist towel on the forehea~ .
rhe most common early sign 01 syncope IS PALLOR (oaleness).

TRENDELENBURG'S POSITION a position where I h~ patient is 00 an elevated arrd inClined plane

(_(5") with the head down and legs and fee over the edge of the table. It is used in abdominal
opera tions 10 puSti abdominal organs toward the chest, and is usually used to treat shock (j.e.
anaphylaxis reactions). However, if there is an associated head injury, the head should not be kept lower
than the trunk. ' -

~s that wbe n admigistered 1 lijjijDrjOI to the dental apQojntment are sa1e and effective ways to
,allay fears 01 all apprehensi.JADULT dental patient and avoid a psychogenic reactiolLin the denta l
chair include:
~ . Diaze am Vati
~ . Pr ner a ·25m orall / p"'"'- ~
~. , Penlo . mbulal or Secoba (1). O- IOOmg oraJly (PO).
a.d-.P~ (~

• These drugs are NOT recpmmended unless the delltlst has e erie wi h them and can handle any
complica tions ,lOrn their use. For a den!ls 0 use "'lin!era ! sedilljAll" (use of a pharmacologica
mwhod thai produces a minimally-depressed level 01 consciousness), some stales require speCial
training alld reglstratioll with tile state.
"
88
The most common emergency seen I»S,ocope oH"
occurs when upright, .!l!!!lL'!!',m . The
patient may complam of
• The mltial event in a amounts
of and sweating.
•

After receiVing injecting a local anesthetic contaln~i~l~~id~oc~a~ln~

e[W~ith~L~IOO~.O~Oo~[p~~e~,~a~~~O~I'~Dses
Co~ys!less. Th~ost probable cause IS ~PE cau ed tr
Management of SlijIoope:
- , . Place thepalienl ill Ihe supine position with their teet slightly elevated.
2. Establish airway lliead till/chin hit) and administer 100% oxygen via a lace mask !G2js
indicated tor treating ali1¥oes 01 syncope EXCEPT hypeNentila\!O!l syndrome),
3. Momtor vila I signs and support the patiell! Pupils may dilate tram lii~ pi iiIIIgiln to the brain.
4. ~ntam your comOOSlJre Apply, cool. wet towel 00 the patient's foreh ead . <=;:.
5. FoJ1pw-up treatment. Determine factors causing the unconsciQUSness. <--
~ryenl!lal~n a anxious denial allen leads I CARPOOEOAl SPASM pasm 01 hand, thumbs,
loot, or toes).

-
SOMAJOGENIC REACTION - the development 01a reaction from a organic pathophysiologic cause.
.
Shock Symptoms: dness slee ine c Ilfusion. Skin is col
~k & rapid. and P drogs. Reduces cardiac output (CO) is the MAIN factor in all types of
shock. Stages of Shock: ~ •
1. compensatorx stage-th~here cOl1JJ?ensatory mechamsmsWIR ~nd periphefaI)
resistance] mamtain vllal or ans.
2. pro ressive -met hc aCI urs and compensatory me<:hallisms are no ~
longer adequate. .
3. irreversible/refractory stae:e-orgUJ1aIDage occurs and ~alls nnposslb\0
. .
ShllCk -m"sl commonl .·Shock consists 01 a
sel 01 h mod namic chan es tha diminish II W lat prOVides adequate-
oxygen lor the etabolic n 1r nd tissues. Shock is circulato colla se resuUm /Jh:..pvr1e!//IC- I-
from rop failure of the LEFT VENTRICL st often caused by a assive myocardial infarction
2. Hypovo emlc ShOCk-produced by reduction in blood volu due to severe hemorrhage. ,?lkrx.h,n, "
3.
dehydration vDIDiling, diarr r fluid loss Irom burns.
Septic ShOCk-due I severe inlectio aused by endotoxin from gram (.) bactelia.
/1'111-</1''11'1 XI L
4. Neurogenic Shock-results Irom severe injury or trauma 10 the CNS,=
5. ~aphyta ctic ShOCk-occurs trom a severe allergic reaction.

Whot~,;, ~~~~~~~!'!l ~~~~~~~~;II;~

subsequently developed a
seizures. When
A patient
~
Tch§e~,~sYC~h,~al~"~C~dr~"~g~m~OS~I~i~~r~es~,~or~lS~ible
tor MAO
and Ihls untoward
inhibitors

• I relievrnderate-tg-seyere pWU
and as probably the Illgs, widely used narcotic in U.S. hospitals.
j' tor narcotic ana lgesics). Mepe~ine is the mosl
89
 "I', ( oY
----~-.-M::-Orllhine-thGtind;rd dru~hiCh all analgesic d[U~~~auses euphoria .
5"- ~alge Sia . dr~$ in eSs, miosis, and respiratory depression. -

.-Complete Blood ~un CDC rinal si re two tests that shou~one before using a genera I

I - anesthetic for surgical procedures. If a eeding problem is suspecl~artial thromboplastin l ime)

IS also evaluated. A cac
lest Includes:
I. Hematocrit: the volume % of ROC in whole
(40·45%). Hematocrit IS the
. normal female

2. normal
3.
4. I women (4.3 -5.5) x I06/m
, m3.

:ormal
•
vaIU~S~f~D~r~~~~~i~~ ICDm~.r~'",ro' ).
• acti~~e<3~trJ)mpared 10 normal con trol).
•
.. '
Urine Values: pH 6 (4.7-8.0); specifi~ gravity (1.005.-1.025).
•

, EXOOONTlA _

General Conc erns of Surgery: patlenrs nutritional status, body fluids and electrolytes pre ,.
. . -- , -opera Ive
and post-operative IIIformallOlI, wound healing (primary and secondary), and most impOrtant infection
*The dilferen.ce betw~en acceptable and an exceJleol surgical outcome depends on how the surgeO~
handles the h5~e, '. -

Discipline of oral surgery IS "the diagnosis and surgical treatment of injuries, disease, and malformation
of the mouth and laws". - - ---=-
Major Oral Surgical Procedures:
.. "

-;- ltea1JIW1l ofJllBillary and m~Ddibular fractures

• ~e - Qroslhetic surgery {luberostlYJ.e9uctions and ves~i b u l oplastU.
• Reconstructive surgery (ortll,lu:,nathlc_surf!gey and faCial deformities).
• Traumatology (treatment oj wounds, in~ alld re~lIl!jng djsabili~s).
• .l!wI.QD.lia (including ro,llti!!,e. multjole & surgical extractions) is N.DT a major oral
, surgery proc edure -
... -
Minor Oral Surgical Procedures:
• Exodontia (routine extractions, multiple extracflOns, surgical extractions)
• ffeiiliient of dental Infect lOllS (periapical. periodontal, pericornitis, facial in fections ( II r . )
• Treatmen t of hard tissue (alveoplasly) alld soillissile (bjopst. benign lesions) p Ih , c~ U IllS.
- ' _ a o ogles.

Local Contraindication} 10 Tooth Extra C l ion s~'

• ANUG, irradiated laws, anC! malignant dIseaSe.
• Ac~n With uncontrolled cellulitis.
• Acute infectiOUs 5tomalillS.

90
Systemic Contraindications to Tooth Extractions:
• Uncontrolled diabetes mellitys
• Uncontrolled Cardiac disease and d'JiJ¥tllmias.
• Uncontrolled leukemias and Iymghomas.
• Debilitating dlseases.
• Sev+ere bleeding disorders.
• PatientSlaking certain medications (Le. immunosuppressives, corticosteroids, & cancer
chemolhera peuticagents).

An acute dentoalveolar altscess shpyld N9I be a contraindicatigg to extractign heCilllse inlections ~

.However. it may b~ dllficylt to extract the
C=L::;:t:=~lde
can resolve very quickly when tlte a It I ' . _
tooth eilher because the patient enoul(.h, or because adequate local
anesthesia can not be obtained. ..

_Colldjtions that require Antibiotic Prophylaxis prior to oral surgery:

1 Prosthetic heart valve . r
2: "Rheumatic valve dise!se .....--
3. Most congenital heart malillrrnations-

Pat ients with ca r~ia c p a cema ~ rs do not re_qui(e antjbiotic Qroghy!axis since tlle£ndocardium IS sot
~d. • .

II antibiotic prophylaxIs is necessary, these medications & dosages are recommended by the American
Heart Association:

Situation Medication Dosage

Standard prophylaxis Amoxicillin Adults: 2, ~
Children: SOmg/kg orally Ihr prior

Unable to take oral AmpiCillin Adults: 2g 1M or IV

• medications Children: SOmg/kg 1M or IV JOmm prior

Penicillin Allergy
(90-0
?fl"
Clindamycin
~
Adults: 600mg
Children : 20mg/kg orally lhr prior " -
Cephat~n or Cefadroxit Adults: 2,
~ ""4 Children, SOmg/kg ora lly t hr prior

C"'-'>
\ ('~
Azithromycin or Adults: SOOmg \.. .---
Clarithromycin Children: JSmg/kg orally lllr prlOI

Penicillin Allergy &

cannot take oral
Clindamycin Adults: 600mg
-----
Children: 20mg/kg IV JOmUl pflOf
medications
~
Cefazolin Adults: I,
Children: 2Smg/kg 1M or IV JOmm prior

~
The most frequently IMPACTED teeth are MANDIBULAR 3rd MOLARS (!ollowed by maxillary 3rd molars
and maXIllary canines). One system describes the angulation of the long axis o!..!.he Impacted 3rd molar '
wlrlt the 2nd molar's tong aXIS:
• Mesioangutar _ 43% of all impacted teelh. ----
• Vertical = 38% of all impacled teeth.
• Distoangufar = 6% of all Impacted teeth.
• HoriZontal = 3% 01 all impacted teeth.

ndihutar 31d molars are an led--

91
 ~re also classified based on their relationshi to bone and tissue
• Soft tissue impaction = tooth is impacted only by t tissu
• Partial bony impaction = crown , ..,ered bone.

.~
-
• Full bony impaction =tooth is e e ycovered b bo

The ideal lime 10 ~e impacted 3rd ~ when the r 01 is approximately 2/3 .forme . The
~ ~ .
patient is around 17-21 years old. Allhis lime, bone is more flexible an
enough to have deVeloped ~!Iryes and rarely fracl!l[e durjng extraction.
-
e rools are not formed well
--
~

• When the roolls fully formed, the pOSsib"ilitY increases lor abnormal rool morphology and fracture of

~~~~~~~~!~~~~~~~~~
the tooth is more difficult to remove b!:C3use it

.. preventing eilsy elevation.

i i ~::'~~~~ili:';;;~;;'~:;. Older
usuallY
responds more slowly to the entire process (anesthesia n
• Complications most often seen after extraction of an isolated residual maxillary erupted molar
are fracture of the tube!.osity or ~o r. ~ Warning; be~f the lone mo!!tr. •

During edr,action 01 a maxillary 3rd molar, it you realize the tuberoSity has also been extracted, the proper
,- treatment is to smooth sharp edges DUhe remaining bon~ and suture the remaining soH tissue. A
_;-' fracture of the maxillary tuberosity most commonly results from extraction of an erupted maxillary 3rd
lnalar (or 2nd molar II il is Ihe laslloolh in the arch). If the tuberOSItY IS fractured but Intact it should
be manually repositioned and stabilized with sutures. \ •

CAVERNOUS SINUS THROMBOSIS (CST) usually caused by a late complication of an infection

~(Sta phylococcus Aureus) of the central face or paranasal sinuses, CST is an unusual occurrence that is
.-? rare~ the result 01 an in~ecled tooth. It is usually a fu~ant prOC!!Ss with high rates 01 morbidity and mortality.
• CST inCidence has decreased greally with the advent ot e!lectlve antibiotics Most cases are due to
an acule inlet: i . an . i .. I. However, most patient s with chronic Sin usitiS

------
or dla etes melhtus may be at a slightly higher risk.

in the

• csr is not usually caused bv a bacteremia trauma, or ear infectious .

;c---

GDWli i ANGJHi=>mosl commonly encountered neck space infection that inVOlves sublingual.
sul!.mandibular, & submental spaces. 9 . _
SUBMANDIBULAR SPACE -.a potential space of .the neCk. bound by the oral mucosa and tongue
.alllenorly and medl@¥. supe.!JIClal layer of deep cefVlcalla .s~la lateraJIy.....and Ilyojd bone inferiorly. It
tomprlses two spaces (sublingual & submaXillary spaces). diVided by the mylQhWoid mUitie.

(. SUbm::ibUIa[ sga~e luall~ drains infections from

apices lie BELOW tile mylohYOid muscle attachment.
m~ndibula[ Premolars & molars since their

• :J!:!I..!D!Q!i!r..il.YJl Unotice I distal root tip is missin it is most likely

prevent this, avoid all apical pressures when
u I '!!

92
SUBLINGUAL SPACE superior art ol lhe subm n a illS the sublin al land t<;
& loose C.l surrounding the tongue.

SUBMENTAL SPACE medial part 01 the subma)(illary space lal contams submental lymjlh nodes
that drain the median parts 01 the lOwer lip. tip of tongue, an mouth !Joor. II usually drains infections
from mandibular incisors and canines because their apices lie ABOVE the mylohyoid muscle attachment.

MOST COMMON SITE for a s~ernume[ary tooth is the MAXILLARY INCISOR AREA. When it occu rs here,
it is called a ~SIQDENS (these teeth are usually STall, peg-shaped, and do not resemble the teeth
normal to the site). Treatment 01 mesiodens is by surgical removal.

" " ' Ion

The main reason to use water Irrlga " when ('..!"'"'ng;oAe
b IS 7 <:) heat generated by the drill
l-\because
affects bone vitality (you do not want to burn tbe bOne) Irri.&!tine the Sllrglcal wound during and after
the procedure is crititaCCopious amounts of ~oolant spray are crucial In mlDlQllzmg QSSenllS necroSIS
caused by heat generated from the bur l[liBation also cleans the c!),pt and areas beneath the !lap of Dony
debris, tooth fragments, and blood.

ale ( luxation forc es J

be used I
I n transmiHed

extracted.

W Scalpal is UNIVERSALLY used for ora! surgical procedu~ incisions are used in oral surgery:
• Linear incjsjon-a straight line incision used for Apicoectomies.
• R,eleNi"g illcision -~sed to ad aver Ica e to a horizontal cr )(tractions,
~ugme ntati.gns . The correct osition for endin a vertical releasin incision is al the TOOTH UNE
ANGLE (not over the too s buccal surface). If the inCISion ends over a buccal suriace, the edges are
dii'iku"1t to"aOQ[oximate, which can cause ne;iodontal problems. ' _
• Semi-lunar incision-a curved IOclsion used mostly lor Apicoectomies.

FLAP a section 01 solt tissue thatl;> outlined by a surgical mCISion, callies lIs own blood supply, allows
surgical access to underlying tissues, call be replaced in the original pOSition, and maintained wllh
sulures and is expected to heal.
• nap design should ensure adequate blOod supply (flap base is always larger than the flap apex).
• Flap rellection should adeguately eXPQse the ooeratjye field .
• Flap design should permit atraumalic closurul ,Ihe wQ..und.

~tu(es ;
• tllterru ted Suture Pattern/Method-offers strength and flexibilit because each suture IS
III ependent 10 one another.]his is advalrtageou ause il one su ure I lost or loosens, the integrity
Onhe.Ler~allling sutu;s is nol cornpromise~. The"malor disadvantage 01 this pattern 01 sut uring IS
the extra time reQuired tor placement.
• n, n
I I II I' , and a r
• Sutures should apart, placed from
mobile tissue into I
• Suture

are
ThjS~~~~~ II i.. 000 and
h suture malefl3l.
• Because suture material is foreign to the body, I diameter suture sufficient to keep the
wound closed property snould be used . Most OMS procedures reCUHre 3-0 or 4-0 sutures. 9-0 suture
size has the least
, strength"and smallest diameter.
93
 The most evere tissue r~ ccurs witt@ CATGUT SUT~aterial. Resorbable sutures ello~e
an intense in lammatory reaction (thus, plain and chromic gut are nol used to suture the surlace of a S.kl~
wound).

Properties of "Resorbable " Suture Materials

Name Tissue Reactivity Knot Security Handling
fair
Plain Catgut Severe P"" GOO<!
Chronic Catgut Moderate Good
Polyglactin !II II Minimal Fair Good
Polyglycolic Acid Minimal Fair Good

~( Ir~p intestiflUusceptible 10 rapid digestion by proteolytic..enzymes.

Retains strength IqU·7 da~C

~Chromic Gut-"c~~"~m~it~iZ~""~'B't~"~P~"~d",~e~m~"~,,~,~e~Si~SJ~an~c~e:J,,~:,,:,,lerlt:~'""-~.;"~~l!I~me~s.
Retains slrength lor 9·14 days.
· POlygIYColic.Jcid.{loes Dol enzvmalically bleak dowydergoeGClw h:;dfD~
less slit! tha~ gut sutures (easier 10 tie) , and more expensive.

~-
"" it

Stainless Steel Wire None hceHent

Polyethylene Minimal POOl

""-. iii

:~:y"ted I ~:~ ~,~?, : ,,,,"00' ~:1'lw>:i\nlru'ml from wh ich

into the II ' it should be removed using a
procedure an i j made into '11 i
above the levelClf the premolar roots. . "An ~ sUfReon to whom
palient should be leler~ should perform i

Strong apical pressure with a small straight elev~to~ may displace root tips of mnillary premolars
•
& molars into the MAXILLARY SINUS 11 the root tIP IS small (2·3mml, non-Infected, and cannot be
r movedthrou mall 0 enin . i~thes~keta . e~ n .. Isur ical rocedureisperformed
Ihmugh the socket, andlhe 1001tIP Ii tillt 1111~1I 'i'OUS, II the root tip IS left in the SinUS, measures
should be taken similar to those taken when leaving any rgot tip in place. The patient must be
ifllorrned 01the decision aod giveo flIooer follow_Up illstlllctions. S

~ Maxillary lrd molars can also be displaced into the infratemporal space during elevation of the tooth,
'the elevator may torce the tooth ,~ le[iQ[!Y throllgh the peripsteum into the infratemporal foss;a. If
access and light are good, the tooth may be retrieved with a hemos~l.1f the tooth is not retrieved after
a short amount at lime, the area should be closed, and the patient intmmed that the tooth was displaced
an~ wiltpe removed by an o(al surgeon who will use a spetjla l tecbuiqIJ8 III remove it.

94
 ~ Cc~ ,~ 'YtWA' . oj- h tiJ fP-l vt,~
DISTOANGUlAR IMPACTION - t maxi\! 3rd molar i paction most likely displaced into the G
antrum (maxillary sinus) and in!ratem 0 ace if correct extraction techniques are nol used.
MlIndibular 3rd molars with II distoangular impaction are the ~st di~i~Ult i~pactio~ to remove. __...--~

MESIOANGULAR IMPACTION - the most common and LEAST diffIcult ImpactIOn to remove , -
comprisinB-43% of al l impacted teeth.

• For impacted mandibular 3rd molars, ~sioangular impactions are the least d~" remove, )~
followed by horizontal "arid v~rtical impactions, then the mo t difficult to remove which is the 01 S. t- eM:
. disloaDglIl~r impaction . (P ~ @ V~ @)~n' ce,.J..,o
• For impacted maKillary 3Td molars, mesioan rim actions are the most difficult to remove ,
wh.ile verti actio are the easiest to remove.
'YCu:.ko L.s '>V!.<> , r J
Once sufficient amounts of bone are removed from around the impacted toot h, the.tooth is usually ~ ' ~ " DIC {- " ~( -
sectioned to ~l1ow portion~ 01 the tooth to be removed.separately with elevators through the opening
provided by bone removal Bone is rarely, if ever, removed on the lingual as ect ot tile mandible because
of the likelihood of damaging the lingual nerve ~~ ~~ A.....N~ _t-l.I..-~ -~"<"'- """-
• Reasons to Section Teeth : allows for minimal bone removal, minimal force to remove the tooth. and .lL--u. ~....Q. ~-...J ...
shortens the entire surgical proceifiire. Tooth sectioning is performed with a bur or chisel, but the
~~s used by most surgeons. - ,>

___ Dead space in a il ~~~ with a high infection

potential. Dead -"7-"C"". after ~ Iosjng the wound.
(D~d I tissue
I I

Dead space is eliminated by closing the wound in layers to minimize the postgperative void, applying
pressure dressings, using drains to remove any bleeding that accumulates, and placing pac.!.ing into
the void !lntil bleeding stops.

The recommended
t easily
with a bur. I I
removal. A the roots, then ins~rting an elevator

surgeon should begin a surgical removal il

i I """-
• Teeth i , are not resistant to shea rlliUs, place the lorcep beaks opposite
to §ach other at the same level On the tooth. ForceD 6eaks are apptied in a tine parallel with the
long axis of the tooth.
• _When luxating a tooth with forceps, the movements should be firm and deliberate, orimaril~ to the
fac.iaLwith secondary movements to the lingual.
• Maxillary 1st premolar is the least likely to be removed by rotational forces due tQlts roo! structure
(r!!£!ars are obvio!lsly NOT removed usrng rotation).
I" (t<.-t'ecw
PALATAL is the p~imary direction of luxatiOg for ed9cting.m3lillarfPilary/rlecidllou~t¥s, while
the BUCCAL i ~ the primary direction for adult maxillary molars. This is because primary QWlars are more otvI.< U{o-vv j 0/;.<--<-
p~ latally posi.llolled, and the p~§!&.mot is strong and less prone to fracture. ~/) ""-'" I (;(CG( ot«'l2.-tg
• In general, remov i~ not difficult. It is facilitated by the I I bone and
resorption of root structure. 00 n ~0
G, Mv.-- cul ccC r
• 'Vv\<vN _ W"..e(1JW·
I ill!
• a child after a mandibular given. always advise
the chil.!l!'0t to bite his/her lip while he/she is numb . Also inform the parents to watch 1he child to
prevent this. -.: ,

95
 When extracti~he patient's maxilla is~as the dentist'S
shoulders. Stand .l!!....!!ID11of and 10 the si~ of the patierll foUnarinI ity an_d leverage.

For n((n'iiIbiilar extractions:Matient is positioned so the occlusal lane of the mandibular arch is
PARALLEL to the FLOOR~hen themoulh IS opeoed. and the ch should be as low as possible. tand
direc!Ty to the side or behind the patient.

Fingers on the left hand (for a right-handed dentist) serle to;

• Retract salt tissue. provide the operator with sensory stimlili to delect expansion of the alveolar plate
and '[(lSIl movemen~Re plate. .
• Help guide the forceps jnto place pn Ihe·looth, pr~tect leeth ·in the opposile jaw from accidel!!.al
contact with the back of the forceps, and support the mand ible while performing malldibular
extractlDDs.
~~~~~~
, - V e.-. GENIAL TUBERCLES -1",led on Ihe I. ofthe
& inferior borders. There .
are I I i

each may be

, I
Ihe
• When

MAXILLARY TORUS gORUS PALATINUS)

-most "egucnlly localed '" Ihe 01
MIDLINE 1~eJla[d
palate. They usually appear before age 30. an~ affect females more oflenthan males. Maxillary tori
-present few problems whellthe lTI,axlliary dentition is present and only occasionally interferes with speech
or become ulcerated flOJIllrequent trauma to the palate.

• Indications for Removel; a large, lobulated torus with a thin mucoperjgsteal coyer extending
posteriorly 10 the vibrating line 91the palalr that prevents seating ol .a derlture and formation of a
posterior seal at the fovea palatine. Chronic irritation. jntedercocc With speech, rapid growth and
patients willl a;!ncer-phobia are ~tso indicatiOnS. _ '

• Removal Technique ; it should nol be excis{td en masse to prevent en trlto the IlOse (t~ I r
bone Will come out with the torus). ,Subdivide the tor mto se menl.S jth a bur nd re~~:: ;~:
--?? segments with an osteotome . An roluberances are smoothed out Wit a bone file. The flap is then
~ loosely sutured and place a palatal splint 10 prev~ hematoma ormahon and 10 sUpport the flap.

Normal Post-Extraction Procedure;

- .
1. AU loose bone spiclltcs,Aod portions of Ihe toolh. restoration, or c~lt;lIl!ls are
WTQ"pd ham the
sOckel and from the,gueeelatttlllMgNiil gI'UQ'£ and IOP81'1I '
~2. ;Ocke! IPns! be cowpressedJly the Ilug!rs to reestablish the ~ormal width presenl before the
buccal plate was surgically expanded. The nalural reconlonrUlg ol-the residual ridge occurs
primarily by resorption 01 the labJal-bucca[ cortical bone.
/ "_ ~ ... 3. Sutures ar~ usually Dot olaced unless the papillae have been excised. When there is severe
~ bleed 109 trom the gingiva, or jllhe glOglVal rill! is lorn or lose ooly theD would you place a
C. . of sl'lure over a single extraction socket
> 4. Socket is covered with a gpn{G spope r folded pUd mOistened slightly at its cenler with cold wa~r.
5. Patient IS inSlructed to bl.te down gn the pressure dressing (or 30 60 minlll~s.
6. Prmted Iflslrucllon sheet 's G'ven 10 the pallcnt *The m,ost common cause of p ost -extra ~tion
bleeding is failu re of the patient to follow post-extraClion instructiqns. ~ .

If bl:C:=::'~~ ::: ::':;::~I;:,I~: ';::::,:::;,::;'::':Ihe p,I;,,! ;0 1i;le'" , lea baE/

~ the tea bag helps promote hemostasis.

96
DRY SOCKET (POST-EXTRACTION ALVEOllTiS OR LOCALIZED ALVEOLAR OSTEITIS) ~ mDSt E
common complication after surgical removal of a mandibular molar resuiling lrom a pathologic process
combining the loss 01 a healing blOOd clot wlth a localized jnllammatjon. Most common after extracting
MANDIBULAR MqLARS. ~

• A patient with~eveloPs severe,~pain<k4 a dalS AfTWa tooth

extraction . The !lain is often excruciatin g, may ~ar, and is not relieved by oral
analgesics. There may be an associated 10111 (ldor and taste, and the extract jon site is I jlled with
neCrOtIi:-tissue, which is delayed wound healing ,.

•
minimallrauma

• Treatment enll flush out debris with saline solution and lace a sedative dressin n the socket
(eugenol is the active component in most sedative dressings). Gauze prOVides an attachment for the
obtundent paste so it stays in the socket. Prescribe analgesics if needed .
r

PERICORONITIS - ~flammahon 01 tlle sot! tjssues associated with the crown of a PARTIAllY erue,ted
tooth seefl most commonly in relation 10 Ihe ~ANDIBULAR ltd h\D.I..A& Maxillary 3rd molar is the most
frequent contributing factor to pericoronal infections found arounilmalUlibular 3rd molars, so always
examine the maxillary 3rd molar because it may he superernplNl or malaligned.

• Signs & Symptom : pain, bad taste inflammation, expressible Irorn beneath, and the ricoronal
tissues are aggrava e y trauma from the OpOOSiRg toolh. ellCoronl\rS i~! criteria by the NIH
(Natlonallnstitule of Health) lor removing 3rd molars.

• Unless the cause is [emov ericoronitis may present as a recurrent cOllditi I r IIIring multiple
treat ments. tn severe episodes an acute cricorOlla\ abscess rna whi h rna remai n localized
or sprea6 to invo ve one Qr more 01 the adjacept deep surgical spaces. and may be assocjated with
systel)1~ local signs and symptoms.

• Treatment: 'lllI:!.ll~;'!!!~i.'
instruct the n Ii

5 Phases of Healing of an ExtractiQP Site:

" " Hemorrhage and blood clot !prmatiga.
2. ~ by granulation tissue. *GlucocprtiCDjds haVe the greatest eNact
.
by retarding healing.
3. " i and epithelialization ollhe slte._
4. of C.T. by fibrillar hoor
5. ~~~~~ the alveglar booe and hone matllratjgg

The jiame s\~~ge~s~t~ha~t;~~i~~~~I~I

& remodeling) also occur i I 111 r~~~~~~~I~n;~~ij~ilili~~
involved 10 91

•
 Stages of Wound Healing: r?
1. Inflammatory stal!:e-conSlsls of a vascular and cellular phase whet.e..@utrophilS)
and lymphocytes predominate. The macrophage is I ~e most important inflammatory cell for
wound healing.
2. Proliferative Siage (fibroblastic Siagel-ihis stage is~ated by fibr~ which
form collagen and new blood vessels.
l. Maturation Siage (Remodeling Slagel-foreign material, necrotic tissue, ischemia. and tellsion.

~s the agent 01 choice to bnde intraoral wound

""" Bone & Soft Tissue HEAL by Primary Dr Secondary intention:

""'-.J Primary Intentioo (Primary Closure or fjrst Intention): lie repai ].at- s both endosteal
& periosteal proliferation. Primary mlenlion occur en bone is either '"com lelely frae , or
a surgeon closely reapproximates the fractured ends of a bone ittle fibrous tissue is prodUCed
with minimal callus formation ' primary intention occurs when wound margins are nicely apposed.
Hea ting IS more rapid with a 10 , "th less scar formation, and less tissue loss than
wounds Ihat heal by secondary intentioo. Examples of primary intention (well-repaired and weu _
reduced bone fractures).

• Secondary Inlention (Secondary .Closure or Second IntenliQD): OCcurs when a wound is large and
exudative. This side fills in wilh granulation tissue. Healing is slower and produces more scar tiSSue.
Bone repair Ihal involvet-mostly endosteal proliferation. If fractured bones remain more than I mm
apart. this type of repair occurs. lots 01 1brous tissue is formed and a callus is formed (whiCh
eventually OSSifies). Examples (extraction sockets, poorty reduced fractures. and large ulcers).

.. Factors that DELAY the healing proceS$ of..alUltractjon site: patient wilh protein deficiency or On
gl",ocort,co,d Ihera", older pall"ls, aod local Inleclloos, \

GRAFTS
IDEAL GRAFT is replaced by the hosl "bone, Withstands mechanical forces. prodUces flO immunological
res . . n, and aclively assists osteoeenlc {60ne-formmg! Processes of the basI. The greatest
enic otenti ccurs with an,jutogenous.cancellolls graft and hemoPo.ietic mar'row
• ones lates b· h . ins, !i!aniu and inlrao au wires e used to fil at bo ·
ra s.
Suture; are not genera II y use d.
• Costochondrial .Bib.Grafl-may b.e lIsed wj t~ the ca.rtilagin.ous portiOl~imul~ting Ole TMJ and cond Ie
When used for ridge augmenlal loll . ext~nslve shnnkage IS noted. Y.
.. :
ALLOGENEIC GRAFTS (ALLOGRAFTS
.
OR
.
HOMOGRAFISl - composed 011155'eaenrom
I k I a
donor of th!.,SAME SPECIES who IS.n~t .genetlcally rel'ated t~ the recipient (usually cadaver bone).

• The mos( commonl used all .. . ' s FREEl - lEO. These graft s consist of f~e-dried
bone an reeze-dried decalCified bone from anolher Source (human cadaver bonel .
• • > =
•

• Host MUST..orodySe AU. of Ille essenhal elemenls 10 the grqft'.bed for an allogeniei: bone graft to
become resorbed and replaced _ _ .

• .allogeneic Advantages· does not require another site of preparation in the lIoSI. and a Slm ~ ar bone
or bone of similar shape to the bone bemg replaced can be obtained.

98
AUTOGENOUS GRAFTS (AUIDGMFI~ 1 composed 01 tiS,"sG''" I<om the SAME tNOfV~ TE
Most often used in oral surgery. Autogenous grafts, while often present surgical & 'ethnical problems,
do nol usually irlVOlvf: rejection or i[nmunological complicatIOns. .. • •
~
• OPTIMAL bone grafting material should be of autogenous origio. Autogenous bone is from the same
person (lrom one part of the body to another). Autogenous grafts are usually uW' 19 restgre large
.areas pI los! mandibl!lar hgneSafter oncological surgery or trauma. OJ all fa Cial bones resected
· in O n~ IOgiCa' surgery, the mandible is the most frelluently removed. ~

• jlo"e marrow for ~ftmg defect; in the mandible & maxilla IS usually obtained from th~
(C~ES!?AISO used for ridge allgm~Dlation. ~ ~
ISDSENIC GRAFTS (ISQliRAfTS OR SYNGENESIOPLASTIC GRAFTS1 - composed 01 I"Stles

- ..
laken from an indivfOual of the SAME SPECIES wllo is GENETICAllY RELATED to the recipient.
.
XENOGENIC .IMPLANTS (XENOGRAHS OR HETEROGRAFTS1 - composed 01 IlSsue taken "pm
a donor of ANOTHER SPECIES (i.e. ~imal bone grafted to man). Rarely used in oral surgery..

Rejection of
"a graft is MOST common when Allografts or Xenografts of bone and carlilage are used 11\

oral surgery. ,/? ~ *' ~ -

Alloplastic Grafts - inerl, man-made synthetic materials. Allpplasllc materials used lor
genioplasty tend to MIGRATE from the position i ....
a~
problems often eKperienced when using alloplastic materials for genioplasty are:
~rgSiQlQllhe chin prominence contiguous with the implant. .
2. Unpleasant sensation in th.e implant region when exposed 10 cold temperatures,

obtained from
I I
II and chemically to bone.

•
.
• ~ ~~~~~~~~~~~~~
~
u office procedure.'
HA granules:
bone graft material.
non-resorb able .

Instruments that Remoye Bone:

. - Rovgepr Forcgos are the most cgmmgoly used instrumenlto remQVe bOIl!! A chisel & mallet. and
bone fIIe.can also be lIsed. However, the techniglle most oral surgeo"s use to remove bone IS the bur
& handpie..c.e. ...
• M t hi tIWS eed turbine drill rative dentist ar TALLY UNACCEPTABLE
for oral surgery. Air exhausted from these drills goes into lbe wouod afld may orce eeper 11110
t!SSU; P I:~;~r~uces \iss!!e emphysema ,! potentially qangerous Situation . An acute inlected
C
tl~SU_ e__ yWJi)ls usually caused by indiscreet use of:
1. ir- ressure syringes: III dl)'ing out a root canal With a compressed air synnce, ~
rna ena can e orced through the apicallgramen into iiie cancellous pori Ion 01 the alveolar
process,
and ultimately ouithiiiugh the nut rient ioramlll<l into adjacent soflllssues, resulting
III formation gf a septic cellulitis & tissue emphysema .

99
..... ---
2. ~~~~iiii~~~~;~;~~~a:g:s:;m~~da!!',~c:~ond't'on can be
i
II is
I I in the retromolar bY
region).
induced
or drying root 'carlals since
to

FRENUM - a membranous fold of skin or mucous membrane thai sworts or restricts movement
of a pari or orga fl li'ke the small band of tissue thai connects the underside of the tongue to the fl~or of
the mouth. When a frenum is maJposilioned and interferes with the normal alignment of teeth, or results
m pullmg away gingiva from the tooth surface causing recession, it is olien removed via~.
3 surgicaileChniques are used for a Frenectomy: • •.
I. ·Simple excision and Z - plas~ are elfeclive when the mucosal and fibrous tissue band.!.S
relatively narrow. The"SeTeChmques re1illihe pull ollhe frenum. ~::
-? 2. V-V pJasty (localized vestibulo last )ooften preferred when the frenal attachment has a 'de
@. fhls lechnlQu oDd for len thenin tissue and usually results in less Scar

Local aneslhehc mill ' n IS uSlially slllhcleni fro sllrglcal trealment 01 Irenal altac.!!.[tenls. Ca re is
la eo to avoid excessive infiltration directly in the frenum area Decallse il may obscure view 01 the
anatomy dUnog the excision.

GINGIVOPLASTY - a sllfgical procedure tc(§iape the g~ to create a normal, flloclional form,

OPERCULECTOMY removal of the o,~p~".':.,"~I~",,,,""!I!.2lJ!l""'~""!'.!!~~l!!d or partially

erupted toolh).

~STY - a
tor genioplasty
~~~ ~~~~~:: T
hemost eo,;moo; techn;qU~S
I I . The best way to
I~ anteriorly

9 ALVEOLOPLASl! - surgical ~ ~Iocedu~e

used
preparation of a complete .or partial denture. It IS ~
tOl~~~~~~~~~~:~in
U 111
• ObjectIves of ~...!ill1fC01ltolUmg should provl~e the best po~sib re tissue contour for prosthesis support,
whire m3111talfllllg as much bone and salt tissue as POSSible. • • -

U;;;dreduct~~ing the space between a fractured bon without cutting through soil liss ear
iurroundulg bone. ' .

~ystem~ications 10 EI~~tixt Surge!;:) •

~ • Blood d~crasl3s (i.e. hemophlha, leukemla)
• 'UJlCOhlrOiied diaijies mellitus (controlled diabetes is NOT II conlraindication to elective surgery).
• Addison's Oisease.,Dr any sterOid defiCiency
• ~ver 01 unexQlajneg origin
• )g,nhrjtJ¢
• iriV debilitating djsease
• Carurac diseasr,lj e. coron~ry artel)' disease, uncontrolled hypertension. and cardiac decompensation)
. O"sua.IlY a posHnfarction pa~jent is not Subjected to oral surgery within
. However, e~rgency procedures can be performed, if the patient's
I i !I

~ P.alients with these systemic cooditions can be treated bllt you need to cnnslllt with their physician
before tre~t. In most cases, these patients are best treated in the hospital by an oral surgeon.

100
AUTOGENOUS TOOTH TRANSPLANTATION - a tooth .!!:om the same..mdilUdual is. move 10 allOllleL
socket 10 the mQuth. The MOST common indication for toolh transplantation is SEVER OECAY of a lst
MOt..AR (the sl motar is atrau malica lly removed, and the jrd molar is placed mto Ihe socket).

• s uc,~s is most are 1/3-1/2

, absence of
areaiSii' i

• The most likely cause of transplantation failure is a chronic , progressive EXTERNAL ROOT
RESORPTION. ""
c
~
• Universal sequelae of an allogeneic tooth transplant is ANKYLOSIS & PROGRESSIVE ROOT r
V

,-••
RESORPTION. Allogeneic tooth transplant is when a tooth from one patient is placed into the soc~et C

of~atienC

• The change in continuity of the occlusal plane observed alter ankylosIs ot a toQ1h..iu;.aused by lhe
continued eru ption ot the other Illl~losed teelh and growth of the alVeolar process.

IMPLANTS
Any toothless area can be considered lor dental implants. Factors thaI determine wbethedmplanU
are an !!ption and the type of implants to use jnclude· ~tieul's requirements and expectations, amount
01 additional work needed (i.e. bone grafting), denlisl"s skill level, and long-term prognosis. •
F =
tmplant Indications:
• A prollounced gag reflex may be an indication lor implant placement because tile patient may not
be able to tolerate the placement of a removable prosthesis.
• Alveolar ridge resorotjon of lother anatomic consjderations thaI do not allow adequate retention of
a conventional removable prostheses.
• Patient is physiologically unable to tolerate a removable prosthesi;.
• Medical conditio2 where a rei:i'ovable prostheses may create a risk 11.e. selZllTe disorder).
• loss ot posterior teeth, particularly unilaterally- -

koolrajndjcations to Implant Placement:

• Inadequate bone space.
' . E~stillg b~e thai d~s not meet implant criteria.
• Jli,aheles. pituitary and ad rerlal insuffiCiency, and hyeothyroidislD which may cause consldcra~le
healing probtljJ)s. r

• !liability to figh t inlectioDS

• Diseases like tubercllloSis and sarCOidOSIS.
• History of unc;nlrQlled bleedlr,].l -
= -
Implants placed in the MAXILLARY ANTERIOR region have the HIGHEST FAILURE RATE . Implant mobility
is the most common sign of implant failure . - -
 2 Ways Implants can be Placed:
1. submerged-requires a second surgical procedure (two-stage) 10 uncover thelWure.
• 2. ,non-submerged-does nol require a second surgical procedure (~me-slage).

3 Main Groups of Implants: ~

~. Endosseous Implants-Ihe most frequently used implants today that are sUfiiCaUl..i~serted
- into the jawbone. They are further subdivided into root-form implants and blade-form unplantS.
... • root-form implants: are cx1jndrjcal In sha~e, can be thfCaded or n~ed (pres
sfill
depending on the exterior surtace. They come ;n various widths (3.2mm-7m.m.l and len~hS
(lOmm- 18mm), and are tYP,ically made 01 titanium . Treatment with root -form implants IS
divided into 3 phases (surgical, healing, I{ pumb.etic). *root-form endosseous implants
--....?""=-are the most ruul.ular. -
• blade-form implants {plate-form imolants}: are flatter IQ appearance, and ar~ where
there is insuffiCient bone Width, but adequate bone depth. Available in slQgle and two~ge
forms. Typically made of titanium. -
--.=;,:;::>. 80% of all current imolants are ENDOSSEOIIS (into bone). .
2. SubPeriosteaf Implants-frameworks s .. all f bricated to fit 011 to 01supporting areas In
the mandible or maxilla under the mucoperiosleum. They are placed e ow e periosteum,
but above the bone.
3. Tran·sosseo us Implants-similar 10 endosseous implants because they are sl!.!lically insped
into the jawbone. However, these actually ~nelrate fbi eRlire jfITI so they emerge oppos~e t~
~Ihe entry site, usually at the bottom of the chin . *Their primary indication is ,nille very a!!]phlc
~ mandible where root f.2fm implants may further compromise the strength!f the jaw.

Olher types of impt~nIS.: lransosleal : IhrQ!!gh the bone. In~ramuscosal : within mucosa.

!
•
•
,~":~'~n~;~m~'~"~n:t ~O;be~Sinc!c~e~S ~fn~'~,yo~n~n~e ~d~'~d~e~qn~'~te~tr~'n:S~ie~r~o~I~'o~r~c~e~'~nd~b;~OC~D~mpatib_ili_ty_. ~JE~
S I !
__
and an intac<Ji9D-infiamed
nqjiscolllfgrt during
and the implant must be

BI.llfSY
~ OPs ie s:
1. tncisional Biopsy-removes ~n of !h.e lesion . . often used for ora l lesions A (_
~3 CA-l. iilcisional biopsy report of . I. h .SI!S ICI~U~ oralleslOl~ su . , 10 S s eeden
~ - is necessary in view 01 the clllllcal Impres.Slons. The key I I , U •
<::::." 3 ~ .. fxcjsjonal Bjopsy·removes .the entire leSion. Most often used lor oral lesions. n
3. Needle Bi!IDsy-asp!.@'lon brOpSY.
4. 'Exfoliative CytoIOgy- pa,~'

Method of tissue removal varies depending on t.he type of bi~ps~:

. needle (percutaneous)
. biopsy, the tissue sample IS Simply obtained by_ ns IIlg a synnge . A
1 In
' is passed mlo the tissue to be bloj},}.led, and the cells are removed through til
needle .
.- . ' ·s ,de in ckm the 0 e needle.
2. Irl an ' open
::sa bioPJY
- _' an IncIsion
, I ; rn - '-%1' rgan IS exposed,and
u a tiss
e sample
is taken.
3. II~ bio s IOvolves IIch smaller ' nc~s jon an an open biopsy. The small incision is
made to allow IIlsertion 01 a vlsuahzalIOn deVice that can guide the p YSlcian tJ;"ihe appropriate
area to'lake the sample.

_..?1 0% Formalin-the fjMljve 91 choice used lor a [ouline bigpsy specimen. Aller removal, the tissue is
~ iillllledialeiy maced III 10% lorlllahn solutIOn {4% lorma.ldeh del that is ~fleast 20x the volume 01 the
surgical specirn~ . The Issue must be tota.1I Immersed rn the solution, and care is taken to ensure the
tissue h~ not become lodged on th~ contamer wall above Ihe leve 0 the formalin .

102
• with no basis.
• I
• I
•
•
a local irritant}.
• A persistent swellin, (vi~ble or palpablel below relatively normal tissue.

Biopsy
-- & Surgical
• I . 11 nol, intillLatilmJnay be

•
•
•
•
.i
I ( S'~1 9' ''' ~
. obtain sOme rlinl JssW:MaceUte leSion IS possible.
.. .
• use a (raeha" suture IhrougllJhe specimen, nol tissue
~ . to~eps to avoid
I
• Specimen Care: alter removal, the tissue should be immediately placed in 10% formalin solution that
is alieasl20x the volume 01 the ;Ulgical specimen. *No other solution is acceptable ...
=
.i I. h show a small

or Follicular Cysts)-cysts associated

h
"
I more commonly '""""_'"-" I any looth. "
treatment is indlcaled,,~a~~1.J!l

Whether a bone cysl or other cysts are CQlmotetely enucleated or treated by marsupializatIOn depends on
the SIZE & LOCATION to vital structures.
( EnuclealiQn -process by which Ihe TOTAL REMOVAL of a cystic lesion is achieved. Enucleation
isthe treatment 01 choice whenever possible lor congenital Cysts, mucoceles, and most
.odontogenic..cyst§.
2. Mar,supialization, Oecompression, & Partsch OperatioQall cre ate a "~urgical window" in the
wa ll of the cyst. Theclst is uncovered or "demgted" and the cystic liOing IS millie contmuous
with the oral cavill or surroundmg structures. The cyst sac is opened and emptied; ~

M~r s~za l~ is the treahnent of choice for ran tor a r!!Current ranula, treatment.,also involves
excISion of tile ~ ublingual gland). Also mr when a c st i lar e and close 10 vital
slructures .

•
•

~~~IU~I~e!ov~,~a~va~s~cu~':.ar;,,~e~SI~on. Il a lesjon seems E2.fTlpresslble,

I..! beware of a vascular lesion and biopsy only

'OJ
 DISORDERS & CONDITIONS
DYSPNEA the unpleasant sensation of dilficulty breathing .
."
APNEA transient cessation or absence 01 breathing.
<

HYPERCAPNEA - e~cess C02 in arterial blood.

jHYPOCAPNEA below normal C02 in arterial blood.

,
!HYPERAPNEA abnormallydeeD and rapid breathing.

RESPIRATORY ARREST - permanent cessallQg.oLbfeathiAA (unles's corrceled).

HYPERVENTILATION _ increased QylmQ; arx ventilation in excess 'of metaboliC reQu!remenIS.
Hyperventilation results in loss of C02 from the blood (hypoca~nea), thus causing a~rease '!!..BPand
spmetnnes fainting.

HYPOVENTiLATION - underyenlilaljqq j~ relaligo to metabolic ;equirement s. Hypovenlilalion results

in an Increased lewl 01C02 in the blood (hyperc.apnea).

DEHYDRATION - loss of water and important blood salts like potaSSium (K+) & sodium (Na+). Vital
organs (i.e. kidneys. bFain, and heart cannot function without a certain minimum Of water and salt). Causes
ulclude decreased intake (lack of wa ndlor increased ou\ "\ (vomitin . e
trom burns, diabetes mellj1u"s, diuretic use. or a lack of ADH ("nli diuretic hormone) owing to diabeteS
b~
-
insipidus (kidneys are umesoonsiye 10 ADH. or AOH is no! being produced Ihe posterior pituitaryr.-

• Initially. a pal lent suffering from deh drat ion will clinicalI demOIl d ness of the skin and
mucOUS Olein ranes. However, a dehydration progresses, the turgor (fullness) of the skID IS lost. U
dehydration perSists, oliguria (.J..urine output) occurs to compensate for the flUid loss. More severe
degrees of Iluid loss ale accom tint -tl a sldl 0' water from the inlr ar-spaceJo the
exlracellul ar soace (a process Ihat causes severe cell yshlilc 19/1. esnecially in the brain). Systemic
BP falls wllh contif'iuous dehydration, and decliningllerfusion eventually leads to death,
• fluids in several form s shollid be continually urged on the patient. lu..severely dehydrated ' d'"d Is
Ih"1
""~121O",:"h~e;h~,~sp~'I~'~'~im~m~e~dlateIY.
"" musl V. ' m 0 ,IVI
IV fluid s quickly reverse dehydration ' , "od IS u~1
ten h e-'
savlllg in young children and Inlanls.

• Symptoms
_ 01 Dehydration: .J;BP,
_ weight loss, tHE. C.O, body temperature, and sunken
~s. e b

CHRONIC OBSTRUCTIVE. PULMONARY DISEASE (COPDI - a grn~ d;S"d"s ch aractenzed .

-=
~ by airflow obstruct ill dUring
emplW
..
. . reS~Lratlon.
COPD · h '"
b.IS a c roOic
I· airway obstruction resu ,.tlng- from
. chronic bronchltLS, ast rna, or any com lOatlon 0 Ihese diseases. In most cas b ..
sema " S nd p' 0 h rt . . es, ronchltls
and emphysema occur toge ler. eco ary u m nary ype enSlOn IS most often caUsed b C
1' Bronchial. Asthma-disorder
" malked by DYSPNEA & WHEEZING expiration
_ caused byeplsodlc
y ~PD.
narrowlOg of the airways. -
2. Emphysema-often coexists wilh chronic bronchilis. laoor~ breathing and Increased
',sllsceoljbilily \0 IIIlection. r

3. Bron c hiectasis -.s~p!Ous p".rulenl §!ll!tum: hemoptYSis, and recurffiut pulmpnary illtection.
4. Chronic BronchitiS a condltll)l1 ?f excessive bronchial mucus and a productive cough that
produces sput!!!J1 (hypersecretIOn of mucus) for 3 months or more in at least 2 consecutive
years without any other disease I I . A productive cough,
often without wheezing, is the

10,
 • ..chronic bronchItis is a very common, debilitating respIratory disease, characterized by E~
increased '. It has a strong

of the hearl's fight ~

the bronchial tree.

• Patients with 1 i {or

these patients depend on maintaining an I
Many of ~c::zt~
experience difficulty breathing if placed in an almost supine position or if placed on high-
flow nasal oxygen .
~ ,
ATELECTASIS - Ih."-'!O!!!ll!l'!l!setm.~UI.~~'.!!lu!!ln~~~1 e aIr passages (bronchus or
bronchioles}, or by very shallow breathing. Atelectasis nesthetic complication '::::::::;::: '
occurring within the first 24hrs after surgery under r I esia m ms include: diminished C_
!!"eath sounds, fever, iflCreasin dyspnea. Prolon ed ateleclasi n lead to PNEUMON

PNEUMOTHORAX the presence 01 air in the leural 11 can occur as a post-operative

• Naysea;s the most common pos-operative complication of out.P.atient general anesthesia.

ASTHMA a syndrome consisting 01 dyspnea, cough, and wheezine caused by bronchospasm, which
resulls trom a hyperirritability of the tracheobronchial tree. Two tyoes of asthma eXIst (allergiCasthma)
the mosl common, and idiosYflcratic asthQ"la .

patient IS lakiflg
• Avoid

• ~~~~~~~~di S especially I~dicatl!d lor paILenls whose

n thell phYSIcian for the possible
I

need lor ............. ~ \. t-; (

\ r
• Inhalation 01 a selective betal-agouis(("(erbutaline, AibuterolJ is the oreferred treatment for an
acute asthmatic attack.'- 1 -
~ Jr'/", ..)'c.'t6u <k.(lt<...'
• I I I hospltalizalion that
does not respond managed properly, chronic
partiatair.wiY I by hypoxemia t
hyjfercapnea).

Man~ ement of n ute AsthmatiC Episode during oral surgery:

• Ter 1 r nd sit ion the patient in an erect or semi-erect poSition.
• Pallenl should admlDlster t~elr own bronchodilator using an I!lhaler. In most severe asthma allacks
or when the !Iatle.nl's bronchoai'lator is inefleclive, [PI 10.3ml of a 1,000 dilutio& ~n btilllected
1:
1M or SC,
• Adnunister oxygen and monitor vital Signs.

105
 DISORDERS & CONDITIONS
DYSPNEA - the unpleasant sensation of diUlcul!x breathing .
.'
APNEA - transient cessation or absence of breathing.
<

HYPERCAPNEA excess
- C02 in• arterial blood .

IHYPOCAPNEA - below normal C02 10 arterial blood ,

!HYPERAPNEA abnormally deeD and rapid breathing.

RESPIRATORY ARREST - permanent cessatjon 91 breatbing (unless corrected) .•

.
HYPERVENTILATION - .increased pulmOoary ventilation il] excess 01 metabolic requirements.
Hyperventilationresuits in loss of C021rom the blood (hYPOC3,£neal, thus causing a~crease i,!!..BP and
sometimes faint mg. • . .

HYPOVENTILATION - undervenlilatjoo in relatign 10 metabolic requirements. Hypoventilation results

in an increased level of C02 in the blood (hypercapnea).

important blood salts like potassium (K+J & sodium (Ha+l. Vital
organs I without a cerlain minimum 01 w"3ier and salt). Causes
I ( I ~
hormone) owing 10 diabetes
the posterior plluilaryr.-

• r the skin and

";~~~ I progresses, the turgor . If
dl perSists, oliguria {""urine output} occurs to compensate for the fluid loss. More severe
degrees of fluid loss I to the
. Systemic
I I

• fluids in several forms should be continually urged on the palienl.!n.severely dehydrated individuals
they must ~et to the hospital immediately. IV fluids Quickly reverse dehydratiofl:aiidTs often life~
saving in young children and infanls.

• S~toms of Dehydration: ""Br, weighlloss, :!WL C~O, body temperature, and sU~s.
CHRONIC OBSTRUCTIVE PULMONARY OISEASE (COPD) aWo~ disorders chacaclerized
~ by airflow obstructin during resl!:iration. COPD is a chronic airway obstruction resulting from
F

emphysema, chroniC bronchitiS. asttima. or any combinatIOn of these diseases. In most cases, bronchitis
and emphysema occur togetller. "Secondary pulmonary hypertension is most often caused by COPD.
1. Bronchial Asthma-disorder marked by DYSPNEA & WHEEZING expiration caused by episodic
narrowing of fhe airways.

; 1~~~~~~~~i;'iC~h~";m:C~;';~l~a~bo~rtd~breathjng
3.
4. Chronic I .
and increased
recurrent p"lmppary infection.
'and a productive cough that
produces soutu91 or more in at least 2 consecutive
years without any other disease that could account fo m. A productive cough,
often without wheezing. is the unrversaJ actor 0 chronic ronc ilis.
 • Chronic bronclulJs IS a very common, debilitating respiratory disease, characterized by
increased production of mUCI)U$ by the glands olthe tracbe.a &..bronchi II bas a strong
association with ClGARRETTE SMOKING.
• Common resulls of Chronic Bronchitis. or ulmonale IIlargemenl of the heart's nght
ventricle}, airway narrowing an 0 s ruction, & squamous metaplasia of the bronchial tree.
Pahent's with chroniC b DchiliS may be qred jsposed to Illog cancer (bronchogenic carcinoma). <:;" ~ff;c,yJU~
• Patients with chronic bronchitis (or any COPD). c~n have difliculty during oral surgery. MallY 01 ~ rrlLl.-- ~ __
these patients depend on maintaining an upright posture 10 breathe adequately. They often .
experience difficulty breathing if placed in an almost supine position or if placed on high- ~ ,
flow nasal oxygen.

ATELECTASIS - th olla se 0 a lun b e air passages (bronchus or

bronchioles), or by very sha llow brealhing. Atelectasis the MOST Resthetic complication ~.
occurring within the first 24hrs after sur e und r I esia m t I}1S include ' diminiShed . ~
..!!eath sounds. fever. increasin dyspnea. Prolon ed alelectasi n lead to PNEUMON

PNEUMOTHORAX the presence of air in the leur' 11 can occ ur as a posl -operalive
complication of aspiration 0 IQujd ypmjtus into the trachea and bronchj . Onset of pneumothorax is
accompanied by a sudden. shar che F It fa id breath! " ssation 01 normal
chest movements on t e affected side, tachycardia , weak ulse h resis and elevated
temperature. pallor. diZZIness, an anxle l

•t p~~lammati~ lun~re the two most common causes of lever

in a patient who has hat! general anesthesia?
7

• Jlli&a is the most common pos-operative complication of.outl!atient general anesthesia.

ASTHMA a syndrome consisting of dyspnea. cough, and wheezing caused by bronchospasm . which
results from a h~rirfitability of the tracheobronchial tree. Two types 01 asthma exist (allergic asthma)
the most cornman. and idiosyncratic aSlb [fla.

patient IS laking

• . ~~~~~~~~( is especially indicated lor patients whose

~~~!!.l:'~"'" their physician lor the possible
need lor
'"• ~:f L (
• Inhalation of a selective beta2-aggpjst (Ierbutaline, Albuterol) ;s the oreferred treatment for an
acute asthmatic attack. ' , ,,~ -
.~ -") f<,y ,J'c/"t U\ d((l"\.<"
• Status Asthmaticus-Ihe most severe GliQic~1 form 01 aslhma,.usually reqlJl ring hospltahzatlonlhal
does not respond adequately to ordinary therapeutic n at managed properly. chronic

=
partiatai[Wjy obstruction may lead to death from espiratory acidos! (produced by hypoxemia &
~'j)ercapnea).

:la~~~~~~~~As~th~matiCfu~~~~t~he~p~a~\lelll
•
•
or
Episode during oral surgery:
I
in an erect or semi-erecl position.
I most severe asthma a!tacks

IMorSe.
I 11
"
• Administer OKYgel1 and monitor vital Signs.
=

105
p

HEMOPHILIA a hereditary BLEEDING DISORDER that moslly affects MALES, where illakes a ~rne
f~r blood to clot and abnormal bleeding occur£ A true hemophiliac has rolanged partial thrombop';lstiIl
Prl" _ time (pm. bul lIorma'rprothromtiin time (PT) and bleeding time (BT)
~ /::>.,/1/1,1 0
• Hemophilia A & B are inherited ass .a:,~:~i~~~~~'gt:r:ajt where males are affected '/Jd
a\ e&" females are carriers. Most people a Ii and it presents unde~ 3ge

-----
:>,7,'6
25yrs. Signs, symptoms, 311d clinical
hematomas, and hemarthroses.
[i ,epjta~is.

• HemoPhi.lii A: repre;..enls most people with hemophilia . The classic type caused by a deficien~~ of
coagulation Faclor<"Vlll janti-hemophilic lactor).
' tt

• Hemophm{8'rchristmas Disease): caused by a deficiency of Factor;!i)Plasma Ihrombopl~slin

componenl). ............-

• HemophififC
a .i I

'lIlN WlllEBRAND'S_DJSE!\Sk.i"heriled as '" !UTOSOMAL DOMINANT BLEEDING DISORDER Ih"

occurs equally in males and females. Due 10 a defiCIency jn ihe von -Wniebrand faclQL !a"'Thrgt"
glycoprotein with brndmg s.ies fo r VIII and facilitates platelet adhesion to colla en (importrnt-
fo eeu ).

,
per microliter
~,~~
. the person is "thrombocytopenic".
I , . common in pe<>ple with Idiopathic thrombocytopenic purpur@here an
t ve!1'ow platelet counts. Abnormal reductions in the number of
are abnormalities occur in any ot 3 processes: ...-
I J productIOn by !Jone marrow.
2. 'J<lfapplflg 01 ptafelets by the spleen.
3. taSler than normal destruction of platelets.

j which may vary in size frorTI

h n even massive hematomas. Patients alto

•
•

~~~~~~~~~~atter
l' bleedin~. Patients with
alcoholic liver disease,
ii
t, i and hypertension).
time (i.e. non-

~ • Excessive bleeding causes formation of hematomas which increase the chance of infection .
(], ,( ,:::. q
J _'1~'"
z,o, , 0
5 Ways to Obtain Wound Hemostasis:
///t_ - ,. ASSisting natural hemostatic mechanisms: usually by p)a6ng a cotlon sponge with pressure
.on Ihe blecdrnR vessels or using a hemostat directly Dille vessel.
2. Heat on the cui vessels lIhermaJ coagulation!.
3. Suture ligation of Ihe vessel.
4. rtacmg a pressUI:.e_dr.essing.over th,!! wound (most bleeding from ora l surgeI)' can be
controlled rh is way).
106 5:'yasoconstrictive substances like EeUnlo.caLanesthelics.
Tests to Measure Clotting Mechanisms: the most important considerahon to rule out hemorrhagic
disorders is history. ~
1. ,Normal Prothrombin Ti"lOO < II sec (+ 2 sec . PI s t best test to determine if oral
surgery can be safely pertorme on a palien akin OUMADI r any oral anti-coaRulant).
To be a good candidate for surgeryj'T time should be withi n 5·7 seconds of the cont rol sample.
2. Partial Thromboplastin Time (PIT : detects coa ulalion defects 01th! intrinsic system. The
basic test for hemophilia ormal value is econds.
3. !Ieeding Time (Ivy Method): normal value it < 9 minutes.
4. ry.telel Coull1§:: n~lue 150,000-450,000 per mm3 of bl~. Minimal platelet countlOf
oral surgeI)' is 50,000.

Tests routinely performed in the pre-operative workup for a patient being admitted to the hospital
for
1. an evaluation

r.

Factors .to Consider when deciding to hospitalize.;. alieni fO~iye Procedure:

• I compromising trealme labetes. hemophiha. '
• I u.
• I i
• I r

•
• I
"lY' "..G,pped lor 5 d ¢' £ V V 'v Y \ J
the salety 01stopping tile anti-coagulant
< 'I)
I surgery jf the patient is taking anti-

•
•

an
III ,.
,,

t is placed withll1 lhe socket.

iI !!I I and avoid mouth rinses
I

PQg-OPERATlVE ECCHYMOSIS a result ollr.. um .. 10 underlying btood yes

esc.. sf the vascular tree and accumulates 10 the tissues. I common ~"er extractions in I.) 13 {
elderly patl nts . e 10 the !ra~itity 0.' Ihe vessel watts. AU p tients sho ur a er
e~ rac Ions. Sometimes the pallent wilt com )lall1 01 a dittuse nOI1- n 01 he
skin. Moist heal often speeds the resoluhon 0 postoperative ecchymOSIS.
- - IOJ
 OSTEORADIONECROSIS (ORN) tnek SERIOUSpotential complic~n a.fter.e..~t~actions frorn
areas previously irradiated , ORN is a condition of non-vital bone in» ll£j)lradlatloo 1~11Ir.y , thai. ca."
be sponlaneous, but most often results lrom tissue in' absence of reserve reparative capacity IS
a lesult ollne prior ra la Ion mlury.

OSTEOMYELITIS !!!r~~.""Ii"n after

IOfmalion of new bone. caused by

steom eliti _rna be chronic or acute. commonly r~sults from.a,co~binalion of loca l trau ma
usually trivial. but causmg a hematoma) and all ~C\~te lofcellOIl ofl glllatmg elsewhere ill the body
~ chHdrcn, lon, bopes ate uSMa!ly affected, whitt m ajlJJ,ru. the vertebrae and pelvis are most
commollly affe<:Ied. -

• Pus is Dloduced in bone which may causeG}"o:e

'~
abs~hich deprives Ihe Impe pi il<:"_ loOd h.
; ?" supply. --

ost blood Sll pply.

the maxilla b.e.c ause the bl

" ODd
" ,
h

~ F~ when Indiallng CPR l£!iIah!;Sh IlPmpnpsi¥eo!!!,s by shakjng thu atie"?-- d h . ..

~ you OK",.then use Ihe ·'ASes": :.. _cw.-aTl s ou~

l~y: open the airway With the h.ead till -chin hit; This is the easiest le1:hnique ill 010 t
medical emergenCies. s
2. B~ng; look, listen. and feet.
3. CircuJalian; check the carotid pulse.

Cardiopulmonary Resuscitation (CPR):

• A = Airway:
• Place thmtim flat 011 hislher back ill a ba rq tisslle J
• Shake victim at the shoulders and S~I~ "~1'~ ~'"
• If no response~ call EMs f!}lll.1hcn. h t o hGiiilt (open the victi ' .
. . back with .O~lC hand while lift u1eJ!P their chin with your other 11;n~:.lrway by till in g

• h, toward the victim's I

,, ~
" II
_ = the

it is

011 the Side of the victim's necr!JI

>UU\ ~.e sg ue b[eathiD~.a1!me of 1 breath
ISno pulse begin ChPStCompressions

.-- • Place heal of one hand on the lower part ol lhe Victim's stern um. With your other hand
I J (]~ ~ directly on top 01 the lust hand, depress the sternum 1.5-2.0 inches.
~r-v:r Z ~ • Perform 1 ~ compressions f~r eve~ 2 breaths (rate: ~O- 100 per minute). Check lor pulse
{} ~eturn every minute and contmue uninterrupted until advanced lile support (ALS) is available.

108
 ..
Only discontinue cea under these conditions:
,. Another trained person lakes over the CPR for you.
• EMS persqollel arrive and lake over care 01 the victim.
• You are exhausted and cannot continue or the scene becomes unsate.

Rescue Breathing I breath every 1 breath every

(victim has a pulse 5 seconds 3 seconds
but is not breathing) (12 breaths per minute) (!5 breaths per minute) {W-pcr mjolltrJ..

Follpw the ribs into the followthe ribs into the ODe 'jngerwidth below
notch with one finger notch with one finger I h ~ nipple line -
landmark) on the sternum on the sternum

Compressions 2...hands stacked (heal .1\831 01 1 hand the

performed with of one on the sternum) on sternum

Rate 01compression 80-100 80-100 At least 100

per minute = =

Compression depth

Ralio of compressions:
breaths
1 rescuer
2 rescuers

Most COMMON ERROR in recording liP is applying the blood pressure cuff 'WP ! PPH'Y , This gives
falsely eleMted readings. ~si n G the WCQnp rllll size can result in erroneous readings. ~
"" c:;;.
~
. , Anormal adull BP cull plased on an obese oatjenl's arm produces falsely elevated readings. TillS
same cuff {lpplied to a~ thin arm of a child will pro~llcr: lat sely lowreadings .
• The compression cuff's width should be 20% greater than the extremity diameter olll'ih~h the BP
is bejnp recowed. tl Yl!u need to take additiona l readings, wait at,!easl15 seconds belore re inflatlnf
jJle BP cull.

~NGESTIVE HEART FAllUR~leart failure resullil~$ frorn<R!OgreSSive diseases that :::>

weakens the heart irect lyor cause an increased demand on the hea1.Q!Loccurs most commonly. In
association wit alheroscler art disease. v~lvular deformities, and hypertensive
carQjQQathy. *Usually th eft ventricle fails f ollow soon aller by right -sided failure.
• Common CHF Signs:
- :' ExertlOnal dYspnea ---
~ • ~roxysmal nocturnal ~yspnea (patient wakes up gasping for air). Earliest &most commonsign. ~
• Peripheral edema (swollen ankles). .- ~
• Cyanosis.: Orthopnea Jsilling or standing to breathe com fortably) , and high venous pressure,_

• Treatment & DenIal Management:

., Digitalis causes patient 10 be
r

• Patients '
i ~
are prone to orthostatic hypotension, also

~:::;."" having chest uiscomlort or possible

t09
 Calcium levels ar e ulated by PARATHYROID HORMONE creased hormone causes bone resorption)
which then Illcreas a tlUrn leve . a clUrn is also regulated to some extent b~idne lubul~s a~d
GI mucosa (lowering pB causes increased calcium absorption Low se rum calcium eve result I.,
hyperirritability of nerves and ~uscles.

Serum calcium (Ca2+1 is increased in these conditions:

• Hyperparathyroidism ---
• Chronic Glomerulonephntis r--
• Hypervitaminosis 0 f"""""
• Malignant diseases of Ihe skeleton (Le. multiple myelomal_

*Serum calCIUm is decreased in Diabetes Melli U .

•/ Phosphorus concentration is also regulated by PARATHYROID HORMONE. InQeased hormone causes thliJ
kidneys to increase llie rate of phosphate excretion, which cau~es a decrease ill plasma phosphat~
concelltralion . '

V Il!.good health, the ratio of calcium to phosphorus in the blood is 10:4. II a glandular imbalance exists
(espetially with the parathyroid glands), then· this ratio is maintained at a different level, causing long~
term health deteriorallOn. A high ratio 01 phosphOlus to calcnJ,.m sensitizes the body and increases.
mflammatory tendencies. >

G LOOD CLUCD$) concentration is regulatedI

glucose). Glucose normally does not appear in ·~
~~i~~iliFd
in the prOXimal convoluted tubule ollhe kidney.
~ m ~'!'!:'!r"i'bet,",",oIelJ""u,""ual.l!!!'~'~,'"" growth hormone, and
Tv a; ~

Normal serum concen;:tloll 01 glucose i ' -120mgld0

Normal laboratory Values Blood Chemistry

Arterial Blood Gjlses:
- osmolality. = 280-300 mOsQl/L
HC03 = 21-28 mEqll
pC02 = 35-45 mmHg Pho~ phatase :Acid =0.2-1.8
pH = 7.35-7.44 mtemalional units
p02 =83· 108 mmHg Alkaline =21-91 international units

Calcium =9-1iJng/dl Phosphorus == 3-4.5 mg/dl, 1,-1.5 mEq/l

CO2 21-30m Eqll PotaSSium 3.5-5.0 mEQll
Chloride 98-106 mEq/l Protein - 5.5-8.0 gldl
Cholesterol: Total 180-240 mg/dl Sodium 132-142 mEq/l
Esters = 100-180 md/dl
Creatinine _ 1-2 mg/dl Urea nitrogen - 10-20 mgldl
Glucose 70-120 mgldl Urine: pH == 6.0 (4.7-8.0)
Spe c ili~ gravity = 1.005-1.025

~ Adrenal cortex secretes 2..O..m.g of hydrocortisone dallv) gurini stress, the corlG~ ,an increase its
hydmcorllsone output t!t200mg da!D •

Patient s laklfll! steroids or peopte with !!,isease 01 the adrenats have a decreased ability to Dfoduce more
glucocqrtlcolds (hydrocortisone) during stress Ii e extr aClion 5). This is because glucocorti;oid secretion
is stimulated bACT ·ch is produced in the anterior pituitary to r.csponse 10 stress by Increasing
AC tout ut II . ncreases. A relative lack of glucocorlicoids also increases
IICHt output. fin over~bundance 01 CIf II ill'S stemlC steroids in I I S P iOIl. Patients on
large steroid doses repr ess ACTH production, causing atrophy of the a rena cortex.
110 <"
G[s2-year old women reQ llests extraction of a painful mandibular 2nd maja!) She tells y(lu stle has not
rested for two days and nights because of the pam. Her medical history is umema rkable, eJcept that she
lakes 20mg 01Prednisone daily lor Erythema Mulli lorme, Tn treat this patient. you would give steroid
supplementation and remove !be looth with lacal anesthesia and sedation. ~
• • The lear here is Ihal the patient may nol have sullicienl adrenal cortex secretion (adrenal
insufliciency) 10 wilhstand the stress of an extraction without taking additional steroids (this hold
true for any patient Ire~d for any disease wilb steroid therapy!.

• <&Ythema MUltifOIlll
~ypersensitivity syndrome chilracterizgtJ b~ polymorphous eru ption and mucous
membranes. Macules, papules, nodules, vesicles, or bullae and beget ("bulls-eye-shaped") lesions
are seen. A severe form at this condition is "Stevens-Jo!msoo SYAdrome". These pallents may be
receiving moderate doses 01 syslemic corticosteroids. thus may be unable 10 Withstand the slress of an
exlraction. Consn"a';oo witb tbelr physician is absolutely necessary before treating these e.atients.

'ijOSHING'S SYNDRQptVPERCORTISOllSM) - a rela!ively rare hormonal disorder caused by

prolonged exposure of the body's tissues to high levels of CORTISOl HORlIJONE. Most commonly a/lecrs
adull"s ages 20-50yrs. 10- 15 out of every 1 million people are affected each year. Most common cause
of Cushing's Syndrome is pituitary adenomas,
• Cushing's Syndrome Symptoms;
• Upper body obesity, rounded fa ce, increased fa t around the neck, thinning arms and legs.
• Children tend to be obese with slowed growth rates.
• skin beComes thin and fragile, and brUises easily and heals poorly.
• purplish pink streich marks may appear on the abdomen, thighs, buttocks, arms, and breasts.
• Bones are weakened, and routine activities like bending. lilling, or riSing a chair may cause
backaches, rib and spinal column fractures. ..
• Most people have severe fatigue, weak muscles, h}gh BP and high btood glucose levels.
• 1((Ilability, anxiety, and depreSSIOn are common.
• Women usually have excess hair glOwth on their face, neCk, chest, abdomen . and thi ghs.
Their menstru ai lleriods lIIay bctoille irregular or stop.
• Men have decreased lerti lit with diminished or absent desire tor sex.
• A Cushing yll rome patient's cardiovascular status MUST be eva mlted and treated
If necessary prior to surgery, -

A person who has been 0 SU PRESSIVE DOSES OF STEROIDS will take u to 1 year to r 11
adrenal cortical fun ction. GUidelines to help determme If a patlenl"s adrenallunclion ISsuppressed (If
any doubt exists, cO,JJsul! wilb the patlellt:s.p.l~
• People on small doses..lSmg of Predlllso!lrJda~) will haw slippressioll if they have been on the regimen
for a monlh.
• People laking an equiva lence 01 1 0111 Cortisol er d y (20-30mg of Prednisone/day) will have
abnormal cortical function in a eek.
• Short -term IherlPY (1 -3 days) of even 11Igh dose steroids does NOT alter adrenal cortlcalluncllOn.
• Aperson on suppressive slelOld doses will take as mych as I year to regam full adrenal cOll.ical funcIIOI).
• Stress or taligue can £ause an adrenal crisis in a palient With suppressed adrenalluncllon.
. ' .

1. MeTabolic Alkalosis-a condition where I It has too lIIuch base.ol

"'aD little acid (high level
1Il ' ~
major effect on the body i I t a caus
(tonic spasm).
• Major Causes: diuretics i mgestlo" of alkaline drugs,
vomiting gastric i I as In Cushing's Syndrome 01
LIse 01 corticosterioids).
• Respiratory Alkalosis-a condition In whlC~ood is alkaline Ix:i:a"se rapid or d~
r alhing result In a low blood C02 level. Major Causes: hyperveni llatilln from armely. pam,
li,ver elrr osis, low levels of oxygen i~ the blood (high aUiludltS'l. & asplnn overdase.. ~Much
LESS COMMONthan r es~ci~ A0 R 0" . ~
• Treatment: ingeslioll r(!MMONW~ ~ ~-~ ~ ,.. \. . o...~
111
- 2. Metabolic Acidosis-a condition in which Ihe<liI!od has too much acid or too I~I(' ofle;tte
causing a detrease i ood H ore acidic blood). When blood pH lalls below norma 73),
eNS becomes epressed the arson first experiences Jsoncnlaho hen is comat05ed. "The
norm r onate-carbonic acid r 10:1 ratio indicates UflCOm . nsa
acidosis. Seyere aCidosis always occurs urrng CPR . Metabolic acidosis is e~ blood
a~jdity characterized by all inappropriate level of bicarbonate in the blood. Major CaUses:
chroniC, renal fail.ure,.diabetic .ketDacidosi~, ,lactic acidosis, poisons, and d~arrhea . to
• Respiratory ACldOSIHxcesslve blood aCidity caused by a buildup of C02 III Ihe blOOd due
, poor lung function or slow breathing (decreased respiratory rate) . Major Causes:
"' yCilygoyerlilliiJ;Dn::emphysema, chronic bronchitis, :evere pneum~nia. ~ma,
and asthma .
• Trea1imiilt: ingestion 01 ~M BICARBbNi , 9

~
01 insulin's action 111
~~~;~]
~ by

& polyphagia.

Type 1 vs. Type 2 Diabetes Mellitus

Characteristic Type 1 OM Type 2 OM
Level 01 Insulin secretion None or little insulin is produced May be normal or exceed normal
Typical age 01 onset ~
Diagnosed in Child hood Ad ulthood
% 01 Diabetics -... 10·20% (less common) 8090%
Basic Defect Oestruclion of Bcells
"- -- Reduced sensitivity of insulin's
larget cells
ASSOCiated wilh.olles!!Y No Usually
Speed 01development of::: Rapid Slow
~melgID ~ -
Development 01 Ketosis ~mmon it untreated Rare
Treatment daily insulin injections and dietary Dieta ry control and weight
"- managemenllo sustain lite
reduction; occaSionally oral
hypoglycemic drugs

~f Diabetes Mellilus:<WCOSUna pol~u[ia polydipsia hyperglycemia, weakness. weigh!j;?

C~ lI d vascular abnonnalltles. ' . . •
• people with well-controlled diabetes a(~~or.e susceotlhle 10 lofectlons tha~
'tJ!hOlrt diabetes. ilowever. they have more d,Hlcul1Y containing infections.~ltered
leukocyte.1JJnc..tjon.
,../"'". p!!!.enls who take insulin daily and c~ec.k their urine regularly for sugar & ketones (controlled
diabetics). can usually be treated m Ih~ no,rmal manner without additional drugs or diet
alterations. If any doubt exists as to the pallenl s medical status, consult with their physician and
do not ass lime any{hing! ~
/ " . !rea n of choice for hypoglycemia in ~~abetiG'Y injection of 50% dextrose )
In wat r.
/ " • Treatment oj choice ~hypoglycemia in a COHS"Ciii'iIDdiabetic is adm~ral

.-- -
carbohydrate (orange juice. cola heve(~ candy bars) ,

. Another form

112
END-STAGE RENAL DISEASE (ESRD) a condilion in which there is ~anent a~~
complete loss of kidney functi on. The kidney functions al < 10% of its normal caoaclty In ESRD loxms
sloWl'y build up in tile body.
th rough urine.
No~'m~al:k:::id=n:,,:s:':'m:o:':':th:':S':'~O~'i",
"0
ns (i.~. urea and creatinine) Irom the body <:::: f O J. 0, r-
• Patients with ESRD are ften on steroid thera [GO re suscep,ible to post-operative)
infections. and have an increased tendeRcy to ee
• When o[al surgery Qlocedures are oerformed on tbese gallents, meticulous attention to good surgical
lechqi9ue is n~essary 10 reduce the risks 01excessive bleeding and Infection, -

When WliWatients with Renal Insufficiency and patients on Hemodialysis:

• Aij,id "Sing df!l~s metabolized or excreted by the kidneys.
• DQ not use N$AlDi U they are nephrotoxiC.
• Perlo!.m oral surgery the day after dialysis.
• con~lhe patient's physician lor possible prophylactic antlbiotiq.

RHEUMATIC FEVER (RHO)

particular involvement of i lollows an uPller
beta-hemolytic streptgcoccus. Although rheumatic lever may follow !!
! n~n. but an inflammatory reaction to an infectiDn.

•
""'-
Rheumatic lever is most common in children ages 5-15yrs. The onset is sydden and olten occurs_
\-5 sym~tom free weeks after recovery Irom a sore throat or tmm
scarlet fever. Mild cases may last
3-4 wee s, while severe cases may last 2-3 months, Irealme!lt· Penicitlin & Rest.

• Clinicat diagnosis or rheumatic lever is made wilen two major (or one ma jor and one millor) CJllena
(the "Jones Criteria") are met. ¥ajD[ IOPPS ~rit8ria: carditis arthriti h rea e hema mar Inatulll.
& subcutaneous nod"l!::s ..MinQr criteria inchlde: lever arthralglas hislmy pi rhellma tlc lever,
changes, and ~s. • -

. (~~~~~i~(~ca~ro~i~liS~)~d~i~~p~~~a~"~'~rn~d~,,~a~,"~~~~~~~~~~~~~~~~
I III I

narrow (mitral valve stenosis), or both.

• A history of rheumatIC leVer should I

pre~f rheumatic heart dlse~se. 1f
the risk of subacute bacterial

General Considerations en Checking Vital Signs:

• Ie patient should not have had alcphpl tobacco. catleine. 01 pellormcd Vigorous exercise wlthrn
30min 01 the exam.
• Ideally the patient should be 5;lI io g wllb Ibull IMt on the lIoqr and their back supported. The
examination room should be quiet and the patient comlortable.
• Ihs1Qry 01hypertenslPQ slo», or rapi1 pulse, and current medications should al,:",ays be obtained
• Abnormalitics 01 vital . lucs to dise es nd an al1cratlon of vrtals can be used to
ev'llYale a pa1Jeul:s.g.r0PQos js, In complicated cases do not heSitate 10 con ac a Ila ICIl s physician
or previous dentist for a consultation.
,

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 Routine Vilal Signs:
). 1. BP (normal120f801
'-. 2.-rulse Rate (normal 72)
" 3. Temj[ratu re can be measured several ways: OFor 37"C) .
• Oral wllh a glass. pi cr, or electroniC Ihermorne
. • Axilla- und m) willi a glass, or e eelronic Ihermoille n (lOa "or 36.3"C).
L _ 51 accurate.
V. \) , 11'1 ---::::;7 ~ecta[ or "core" with a glass or electrgotc thermometer (normal 99.6°For 37.r ' C).
~
V ....--s _MOST(e~ilh
accura e.
_ ura an electromc thermometer (oormal 99 6"F Of 37 lX).

5 Major Areas Oiscussed when taking Patient Medical History:

1. Chief complaint .,...-
2. Histo[Y of present illness /
3. Spec!!IC drug allergies .r-
4. Review of systems (heart, ~ kidney, brain) -----
5. Nal.llfe of systems ~

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