2023 ECD IV Exam III Study guide pt1.pdf

Non Complex Exodontia ● Procedure Challenges ○ ○ ○ ○ Access: limited mouth opening, gag reflex Anxiety: protective posturing by patient Infection/Pain: infection-> more acidic enviro-> hard to anesthetize (want to ensure absence of pus or cellulitis Lack of knowledge of anatomy, surgical technique...

Non Complex Exodontia ● Procedure Challenges ○ ○ ○ ○ Access: limited mouth opening, gag reflex Anxiety: protective posturing by patient Infection/Pain: infection-> more acidic enviro-> hard to anesthetize (want to ensure absence of pus or cellulitis Lack of knowledge of anatomy, surgical techniques, and/or meds Indications for tooth ext nonrestorable caries Irreversible pulpitis most common severe periodisease impaction medical crowding FEE gigationsurgery pre be therapy pre transplantsurgery Non Complex Exodontia ● Important aspects of Surgery ○ ○ ○ ○ ○ ○ ● Have a plan: know med hx, dental hx, past adverse experiences Know steps of procedure Know what to do if procedure doesn’t go well Emergency meds Know when to ask for help- refer Know how to give LA blocks and when to do infiltration, manndibular nerve block, long buccal block, gow-gates, akinosi, PDL, subperiosteal Codes ○ ○ Simple ext: D7140 Surgical ext: D7210 Non Complex Exodontia ● Precautions ○ ○ ○ ○ RBA with pt Risks benefits Alternatives ■ Risks: pain,bleeding, swelling, bruising, scarring, damage to adjacent teeth/structures, anesthesia (temp or permanent), paresthesia (temp or permanent), dysesthesia (temp or permanent), anesthetic complications (rash, anaphylaxis, death) Position pt supine with head elevated 20-30 degrees Good lighting Good suction Non Complex Exodontia ● LA ○ ● Lidocaine with epi: if pt is allergic to lido, use Benadryl or Demerol as alt (both short acting and not profound; max amount 5mg/kg Armamentarium ○ Minnesota cheek retractor, adult/child bite block, Weider tongue retractor (sweetheart), injection syringe (blue for maxillary, yellow for mandibular), 2% lido 1:100k epi (at least 2 carpules, more if needed), needle holder (gold handles), kelly hemostat, scalpel handle, #15 blade, suction tips, #9 periosteal elevator, #77R/#301/#190/#191 dental elevators, ext forceps (#150 or #151), Rongeur forceps, bone file, double ended spoon curette, 3-0 Chromic gut suture Non Complex Exodontia Non Complex Exodontia ● Technique ○ ○ ○ ○ 1. LA and confirm is working 2. Release gingival cuff around tooth (#9 periosteal elevator or Hirschfeld #2 elevator 3. Take bayonet elevator or 77R elevator and gently luxate tooth (turn into tooth being ext, do NOT elevate adjacent teeth as will damage enamel, fillings, crowns)- more gentle luxation, more comfortable patient is 4. Once you notice tooth mvmt with elevator, can attempt to seat ext forcep around tooth B-L (#150 for upper and #151 for mandibular)want to make figure 8 motion to widen socket with elevator and loosen tooth with good body position (can retract lips or stabilize alveolus to prevent rocking of pt head during this mvmt 2 3 3 4 Non Complex Exodontia ● Max Ext ○ Forceps move in figure 8 or unscrewing motion Non Complex Exodontia ● Mandibular Ext: ○ ○ ○ ○ Mandib incisors with #151 or #150 forceps or Ash forceps (bird beak) Apply apical pressure to seat forceps, use circular motion to remove Mandib premolars: #150 or #151 apical pressure then circular motion Fused roots: #151 forcep Bifurcated molar #23 cowhorn forceps seat into furcation and pump forceps up and down to engage working end of forceps deeper into furcation and lift tooth out of socket Non Complex Exodontia ● Suturing ○ ○ ○ ○ ● recommended to help pt after ext by ■ Min post-op bleeding ■ Min food impaction in socket ■ Dec dry socket risk May inc swelling 3-0 chromic gut suture used: will last 5-9 days and does NOT need removal 3-0 silk suture okay but needs removal at 1 week post op Place gauze at end of procedure and instruct pt to bite with light pressure ○ ○ ○ Promotes hemostasis and min risk swallowing blood (GI irritant -> nausea and vomiting) Remove after 30 min if stop or replace gauze at that time Non-herbal tea bags have tannic acid: pro-coagulant so if persistent oozing then have pt bite on Lipton tea bag for 30 min Non Complex Exodontia ● Post op prescriptions ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Most pain controlled with ibuprofen: 600mg q 6 hrs is gold standard Toradol: potent NSAID (ketorolac 10mg) Tylenol #3 (codeine 30mg/acetaminophen 300mg) Tylenol #4 (codeine 60mg/acetaminophen 300mg Norco5/325 (hydrocodone 5mg. Acetaminophen 325mg) Percocet 5/325 (oxycodone 5mg/acetaminophen 325mg) Ultram 50mg *tramadol): non-narcotic, non-NSAID Ketorolac 10mg #20 tabs, 1 tab q 6hr Norco: #20 tab 1 tab q 4hr Percocet: #20 tabs 1 tab q 4 hr (need triplicate form) Ultram: 50mg #20 tabs 1 tab q 4 hrs Peridex: .12% 1 bottle, 15cc swish 30sec then spit till gone Penicillin VK 500mg #24 tabs, 1tab qid till gone Amoxicillin 500mg #21 tabs 1 tab tid till gone Non Complex Exodontia ● Considerations ○ ○ ○ ○ ○ ○ ○ ○ ○ Call pts night and day after surgical procedure ■ Let them know you care ■ See if bleeding stopped, pain controlled, able to eat/drink sufficiently ■ Pt can ask questions ■ Prevent late night phone calls (hopefully) Quiet operating suite Clean room (no clutter) Know where instruments at at all times (careful not to pinch gingiva, hit lip, hit teeth…) Make sure pt has profound LA before starting Double check which tooth you are ext Have informed consent signed and have answered all questions before starting Do not elevate from L aspect, always B Throat pack made of 4x4 gauze can be placed at post aspect of palate and tongue on operating side donotuse 2 2 Surgical Armamentarium Incising Tissue: - Begin w incision (scalpel: reusable handle & disposable sterile sharp blade; OR single-use w plastic handle & fixed blade) Hold in pen grasp for max control - - - Most commons handle for OS: #3 handle Most common scalpel blade for intraoral surgery: #15 (others use: #10, #11, #12) Incising tissue: #11 (small stab incisions (abscess)) #12 (mucogingival procedures (incisions on post of teeth or in max tuberosity) Used blade discarded in red sharps containers (if dull blade, DISCARD). Avoid needle stick injuries. After blade used, mucoperiosteum is elevated. Incision thru periosteum made, periosteum be reflected from underlying cortical bone in single layer w/ periosteal elevator - Most commonly used in OS: #9 Molt periosteal elevator (pointed end for periosteal reflection & reflect dental papillae from bw teet, broad rounded end for continue elevation of periosteum for bone) Good access & vision = essential for excellent surgery Soft Tissue Retraction: - Use right-angle Austin retractor or broad offset Minnesota retractor Weider tongue retractor (sweetheart): broad, heart-shaped retractor that is serrated on one side so firmly engages tongue & retract it medially & anteriorly - Common setup: - Weider retractor hold tongue away from surgical field - Austin/Minnesota to retract cheek Grasping Soft Tissue: Avoid putting fingers in pt’s mouth to avoid lacerations to fingers. Tissue forceps most commonly used are Adson forceps. When removing larger tissue amounts or doing biopsies, forceps w/ locking handles & teeth that grip tissue needed (Allis tissue forceps) Allis beaks Adson Controlling Hemorrhages - Usually pressure on wound is sufficient Pt bite on 2x2 gauze for excessive bleeding Hemostat used when pressure doesn’t stop bleeding Removing bone - Rongeur forceps: bone-cutting that have spring-loaded handles Surgical Handpiece + surgical bone = remove bone for surgical removal of teeth High-speed, high-torque handpieces w sharp carbide burs (703 fissure bur) → remove cortical bone - - Handpiece must not exhaust air into operativing field Regular handpiece not used bc air exhausted into wound may be forced into depper tissue planes → tissue emphysema Final smoothing of bone before suturing mucoperiosteal flap into position is done w small bone file (effective only in pull stroke) After bone removed & bone contouring done, remove soft tissue from bone cavities using periapical curette (double-ended spoon shaped) Rongeurs --> Armamentarium for Suturing & XB Surgery is done, mucoperiosteal flap returned to OG position & held in place by sutures. Needle holder: places sutures; has a locking handle & short blunt beak - 6in (15cm needle holder) recommended Face of needle holder crosshatched to permit positive grasp of suture needle Hemostat has parallel grooves on face, decreasing control over needle & suture Needle holder held by using thumb & ring finger in rings & 1st & 2nd finger control instrument Closing mucosal incisions → half-circle or ⅜ths circle suture needle - needle curved to pass thru limited spaces that straight needles can’t reach. Passage done w/ twist of wrist - Needle’s tip used to suture mucoperiosteium is triangular in x-section to make it a cutting needle - Need holder grapes curved needle ¾ distance from tip - Scissors (Dean scissors most common), held same as needle holder Armamentarium for Suturing & Ext ● Suture material ○ ● When ext of mand teeth, support jaw w bite block ○ ● classified by diameter, resorbability, monofilament/polyfilament ■ nonresorbable: silk, PTFE nylon, vinyl, stainless steel ■ resorbable: gut/catgut (gut really from serosal surface of sheep intestines treated by tanning solution, lasts 7-10 days) ■ size of suture relates to diameter & designated by series of zeros ● BIGGER THE SUTURE NUMBER, THE THINNER THE SUTURE ● 3-0 sutures ((000) (Most common for oral mucosa)) large enough to withstand tension placed intraorally & strong enough for knot tying w needle holder compared w/ small-diameter sutures side-action mouth prop or Molt mouth prop used to open mouth wider (too wide = TMJ damage) Suctioning & irrigation of blood, saliva, irrigating solutions ○ ○ ○ for adequate visualization Many openings so soft tissue not aspirated Need irrigating solution with removal of bone to cool bur and prevent bone damage Armamentarium for Suturing & Ext ● Ext ○ Elevator: luxate teeth from surrounding bone to loosen before using forceps ■ Large handle to apply large but controlled force ■ blade= working tip that transmits force ■ 3 types: ● straight type: most common to luxate, blade with concave surface placed towards tooth ● triangle or pennat- shaped type: second most common , has right and left ● the pick type: delicate, used to tease out root tips Armamentarium for Suturing & Ext Triangle Straight Pick Armamentarium for Suturing & Ext ● Ext Forceps: remove tooth from alveolar bone ○ ○ ○ Max teeth: hold with palm underneath forceps so that beaks pointed up Mandib: palm on top so that beak pointed down Beak designed to adapt to root structure of tooth (not crown) with different beaks for different amount of roots Armamentarium for Suturing & Ext ● ● Max forceps: No. 150 Molar forceps: No. 53 R and L (can fit around palatal beak and buccal bifurcation Molar Max