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EasierEasier
Oral SurgeryOral Surgery
Extractions: Extractions: Avoiding ProblemsAvoiding Problems
1st Molar
MissingPremolars
51 year old woman.
Problem #1
Sinus
1. Recognize…2. Save the blood supply…3. Try to separate the tooth and remove it…4. Involve an oral surgeon to save the bone.
PreventPreventPreventSectionSection
Cryers
About 85% of these first molars need sectioning.
Leave some tooth.
Male, age 36.Extract 1,16.
3rd Molar
Maxillary Pre-molar Area
Bridge ??Implant ??
Problem #2
Easy
Bone Grafts
Calcigen Oral + BioGran
(3i Company)
Plaster
Calcigen Oral liquid
BioGran (bioactive glass bone graft)
Filling theempty syringe.
Surgical extraction of tooth # 3.
Problem #3
BuccalSide.
Smoker.Alvogyl placed at day 3 for dry sockets.
This picture: 7 days.
Chest
X-ray:
Standard of Care
Problem #4
Crown in rightmainstem bronchus.
Problem #5
80 y.o. lady.Appears healthy.
Taking Zometa (IV) and Actonel (oral).
Others: Aredia (IV), Fosamax (oral).
bisphosphonates
Problem #6
SymptomsSymptoms
• Exposed bone, pain, swelling and infection, loosening of teeth, poor healing of gums, numbness, draining with sequestration.
1. Avoid invasive dental procedures…2. Over 23 million Americans taking them…3. 90% are from the IV form.4. Preventive dentistry – best way to reduce risks.
Indispensible
Instruments
Luxators into the PDLLuxators into the PDL
301
3 mm luxator
(straight)
Reasons for Luxators.
Prevent Fear, Prevent Fear, Pain, and DeathPain, and Death
Prevent Fear, Prevent Fear, Pain, and DeathPain, and Death
Triazolam (Halcion): One Drug Oral Sedation
Cost: A few dollars.
Effect: A few hours.
Can work and drive: The next day.
Half lives of the most commonly used benzodiazepines:
Valium: 20-50 hrs.
Ativan: 10-20 hrs.
Halcion: 2-3 hrs.
Bottom Line with triazolam:• 0.25 mg or 0.50 mg one hour before the
procedure will decrease:
– anxiety,– the perception of pain, and– postoperative recall of discomfort
without significant adverse effects. Overdose symptoms develop with four times the maximum therapeutic dose (0.50 mg) or 2 mg.
0.25 mg.
Triazolam Equivalency:
• 0.50 mg triazolam given orally 60 minutes prior to the procedure is equivalent to 10-15 mg IV Valium for decreasing anxiety and producing amnesia.
Baughman, VL, et al. 1989
Rules with oral sedation:
• Current health history
• Written informed consent
• Check pulse, BP and oxygen saturation
• A reversal agent (Romazicon) is available
• Written postoperative instructions
• Accompanied by a responsible adult before and after the procedure
US$ 400 to US$ 2000 –
Oxygen, Pulse, Blood Pressure
Maximum dose I prescribe:
0.5 mg
Mistake: Took 1.0 mginstead of 0.5 mg.
Prevent Prevent Fear,Fear, PainPain, and Death, and Death
Septocaine(Septodont)
Articaine
From top ten “Can’t Live Without.” list:
#3 Septocaine (Articaine).
Why?• More profound• Faster onset• Good for “hot” teeth,
hard to numb patients• Infiltrate lower anterior
Recent SurveyHow many have had paresthesia over
last two years from Articaine?
• Out of 300: 30 (10%)– Up to 8 times as much as Lidocaine
• Lasted over two months: 5
• Numb tongue, lip, sloughing with PDL injection…
References:
Prevent Prevent Fear, Fear, Pain, and Pain, and DeathDeath
40 pounds2 mg/lb.
80 mg max dose
Injected over 200.About 6 cartridges.
Parentheses numbers are Dr. Stan Malamed’s recommendations.
Company Recommendatio
n.
More conservative
Recommendation.
Six cartridges were fatal.
90 lbs.
90 = 7.25 (4.5)
Female with persistent ulcer.Invasive squamous cell carcinoma.
52% will die within 5 years.
23 y.o. male chews tobacco.Not cancer yet.
5-17% chance of transforming to cancer.
Male with red/white lesion.Superficially cancer.Should be OK after surgery because caught early.
90% of these red lesions:DysplasiaCA-in-situInvasive CA
No 2X2s if four quadrants numb.
Much safer. Order 3X3s or 4X4s…
Following Dental TreatmentFollowing Dental Treatment
• Black eye• Swollen eyelid• Itching• Difficulty
breathing• Scared
Prevent Morbidity of AirPrevent Morbidity of Air
Forced into a Patient’s Forced into a Patient’s
Soft TissuesSoft Tissues
• Emphysema
• Crown preps: #19, #21.
• Immediate air emphysema– Infraorbital area to anterior
neck (subcutaneous)– Also to mediastinum and
carotid sheath– Hard to breath
• Treatment– Steroids, oral antibiotics, pain
meds (no decompression)
Stanton, DC & Yepes, JF. Subcutaneous cervicofacial emphysema and pneumo-mediastinum: A rare complication after a crown preparation. Gen Dent. Mar/Apr, 2005.
Impact-Air 45
Sabra
Surgical Highspeeds: No blowing of air into the surgery site.
Aseptico AEU 17B with 2:1 increase Bien Air handpieces.
Both OK for surgery.
Prevent NervePrevent Nerve
DamageDamage
???
Painful tongue for the last four years.Pain that brings her to tears.
Dr. Karl KoernerDr. Karl Koerner
[email protected]@comcast.net
Bleeding Problems.Patient on anticoagulants, like Coumadin.
Coumadin Anticoagulant: Choices
• 1st choice: Don’t stop it before surgery.– One appointment, local measures– Two or more appointments, local measures
– Refer
• Stop it 3-4 days before surgery. Might die.– OK, if lower risk– Or use “bridging” therapy
LocalMeasures
Choices with Coumadin:
Don’t Stop Coumadin – use local measures.
-- talk to physician,
-- know the INR (1 to 4) Age 76
INR (1-4)International Normalized Ratio)
The new “Bleeding Time”.
Normal INR
No problems!
Gelfoam
$5.00 per piece
CollaTapeCollaPlug
$10.00 per piece
Hemostatic GauzePure oxidized cellulose: no additives. Resorbs to saline and glucose.
Surgicel
$16.00 per piece
Significantlydelayshealing.
Atlas of MinorOral Surgery..Dym & Ogle.Saunders, 2001.
Bone
Wax
Bone Wax
Choices with Coumadin:
Stop Coumadin – normal clotting. (But patient may be at risk.)
-- talk to physician, know INR
• DAILY HERALD/OBITUARIES.
• Lula B. Tallo • Lula B. Tallo passed away peacefully, with her children by her side
on Sunday morning, June 27, 2004 in the Mountain View Hospital.
She had suffered a stroke on Friday.
Age: 7914 extractionsStopped Coumadin 4 days before Massive strokeDental work Thursday, stroke Friday died Sunday.
Choices with Coumadin:
Stop oral Coumadin.
A few days later, start Lovenox every 12 hours. Patient gives herself a shot.
Stop Lovenox 12 hours before surgery.
Start Lovenox 6 hours after surgery.
Start oral Coumadin again.
On Coumadin orally
Stops 3-4 days before surgery
Starts on IM Lovenox bid (12 hr. duration) but not within 12 hrs. of surgery
If no bleeding problems, another Lovenox that night and/or the next morning.
Re-start Coumadin.
UnconventionUnconventionalal
Root CanalRoot Canal
InfectionInfection
Paresthesia of the Paresthesia of the liplip
PainPain
82% successful for at least 5 years if done quickly.
Within one week, the paresthesia resolved. The tooth lasted 15 years.
IntentionalReplantation
Super-EBA cement
Straight or surgical highspeed – it doesn’t matter.
Simple Step-By-Step Bone Graft Simple Step-By-Step Bone Graft Procedure for Single SocketProcedure for Single Socket
Simple Step-By-Step Bone Graft Simple Step-By-Step Bone Graft Procedure for Single SocketProcedure for Single Socket
• Mix plaster & liquid (Calcigen Oral) in dappen dish.• Discard half of plaster.• Quickly add syringe of synthetic bone graft material
(BioGran).• Wait one minute until putty-like.• Suction, then place in socket to 1 mm from the gingival
crest. (will set-up in 3-5 minutes)• Suture over socket to better approximate soft tissue.• Patient to rinse with Peridex twice a day for three weeks.• Wait three months for bridge, one year for implant.
3i: 800-342-5454
Notes:• Romazicon: 0.2mg (0.1mg/cc) initial dose ½
inch in tissue just off midline under tongue into venous plexus. 2nd dose in 2-3 min. Can have re-sedation.
• Sublingual: 80% effect within 20 minutes.
• Patient should always be able to wake up.
Portland, Kaiser/PermanenteInsurance Group
• 100 dentists• Lido: 1 paresthesia/40,000 blocks• Septo: 1 paresthesia/5,000 blocks
Their ruling:
Don’t use Septocaine for blocks!
Dr. Karl R. KoernerDr. Karl R. Koerner
[email protected]@comcast.net
I will send it in:MicroSoft PowerPoint