Oral Surgery PDF

Fragiskos D. Fragiskos (Ed.) Oral Surgery Fragiskos D. Fragiskos (Ed.) Oral Surgery With 1307 Figures, mostly in Color and 11 Tables  Fragiskos D. Fragiskos, DDS, PhD Associate Professor, Oral and Maxillofacial Surgery School of Dentistry University of Athens Greece Originally published in...

Fragiskos D. Fragiskos (Ed.) Oral Surgery Fragiskos D. Fragiskos (Ed.) Oral Surgery With 1307 Figures, mostly in Color and 11 Tables  Fragiskos D. Fragiskos, DDS, PhD Associate Professor, Oral and Maxillofacial Surgery School of Dentistry University of Athens Greece Originally published in Greek by Professor Fragiskos Translated by Helena Tsitsogianis, DDS, MS Clinical Instructor, Oral and Maxillofacial Surgery, School of Dentistry, University of Athens, Greece ISBN-10 3-540-25184-7 Springer Berlin Heidelberg New York ISBN-13 978-3-540-25184-2 Springer Berlin Heidelberg New York Library of Congress Control Number: 2006939050 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9th, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. Springer is a part of Springer Science+Business Media Springer.com © Springer-Verlag Berlin Heidelberg 2007 The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Editor: Gabriele M. Schröder, Heidelberg, Germany Desk Editor: Martina Himberger, Heidelberg, Germany Production: LE-TeX Jelonek, Schmidt & Vöckler GbR, Leipzig, Germany Reproduction and typesetting: AM-productions GmbH, Wiesloch, Germany Cover design: Frido Steinen-Broo, EStudio, Calamar, Spain Printed on acid-free paper 24/3100/YL 543210  Preface It is my strong belief that writing a textbook consti- versity of Athens, Greece, for her contribution as a tutes an obligation for the academician towards his co-author of Chap. 16 “Prophylactic and Therapeu- students, as well as towards his colleagues who are in tic Use of Antibiotics in Dentistry.” search of continuing education. O Dr. C. Alexandridis, Professor and Chairman, De- Keeping this obligation in mind and given the partment of Oral and Maxillofacial Surgery, School developments in the field of oral and maxillofacial of Dentistry, University of Athens, Greece, for surgery and the recent impressive achievements in writing Chap. 12, “Surgical Treatment of Radicular technology that have been noted, the writing of Cysts” and his contribution as a co-author of this book, which was based on the many years of Chap. 15, “Osseointegrated Implants.” experience of the author and contributors as well as O Dr. E. Stefanou, Associate Professor, Department of the pertinent contemporary international bibliogra- Oral Diagnosis and Radiology, School of Dentistry, phy concerning oral surgery, was considered impera- University of Athens, Greece, for writing Chap. 2, tive. “Radiographic Examination in Oral Surgery.” This book aims to give the dental student and the O Dr. A. Pefanis, Consultant in Internal Medicine general practitioner practical guidance in the form of and Infectious Diseases, School of Medicine, Uni- an atlas, which includes surgical procedures that may versity of Athens, Greece, for his contribution as a be performed in the dental office. co-author of Chap. 16, “Prophylactic and Thera- The practical format of this book has obliged us to peutic Use of Antibiotics in Dentistry.” limit the extent of theory and detailed description of techniques. Instead, we opted for numerous figures I would also like to express my gratitude to Drs. and a detailed step-by-step analysis employing illus- P. Anastasiadis, E. Eleftheriadis, and G. Masoulas, trations of each surgical technique, keeping in mind Associate Professors at the Department of Oral and that, in this type of book, a picture is undoubtedly Maxillofacial Surgery, School of Dentistry, University more important than words. of Athens, Greece, and to Assistant Professor I. Zogra- The material is divided into 16 chapters which in- phos, as well as to clinical instructors N. Merenditis clude: medical history; radiographic examination in and I. Antonopoulou, for their valuable assistance. oral surgery; principles of surgery; equipment, instru- I would also like to express my thanks to: ments and materials; simple tooth extraction; surgical O Dr. P. Paizi, Assistant Professor, School of Medi- tooth extraction; surgical extraction of impacted teeth; cine, University of Athens, Greece, for her expertise perioperative and postoperative complications; odon- and advice in matters concerning her field of spe- togenic infections; preprosthetic surgery; biopsy and cialization. histopathological examination; surgical treatment of O Dr. G. Laskaris, MD, DDS, PhD, Associate Profes- radicular cysts; apicoectomy; surgical treatment of sor and Head of the Department of Oral Medicine, salivary gland lesions; osseointegrated implants; and School of Medicine, University of Athens, Greece, prophylactic and therapeutic use of antibiotics in den- A. Syngros Hospital, Athens, Greece, and Visiting tistry. Selective references are cited at the end of each Professor of University of London, UK, for his ami- chapter. cable assistance concerning the publishing of this Distinguished colleagues have contributed to the book in English. writing of certain chapters relevant to their field of O Dr. A. Omar Abubaker, Professor and Chairman, specialization. I would like to especially thank the Department of Oral and Maxillofacial Surgery, following for their valuable contribution: VCU School of Dentistry and VCU Medical Center O Dr. H. Giamarellou, Professor in Internal Medicine and Dr. C. Skouteris, Associate Professor, Depart- and Infectious Diseases, School of Medicine, Uni- ment of Oral and Maxillofacial Surgery, School of VI Preface Dentistry, University of Athens, Greece, for their in the Greek edition of this book, as well as for generosity and willingness to write the forewords the English translation for the international edition for the English edition. of this book. I feel deeply moved by and grateful for the contri- I am grateful to Dr. W. Wagner, Professor, Head of the butions of two distinguished colleagues who have Department of Oral and Maxillofacial Surgery, Uni- since passed away: versity of Mainz, and especially to Dr. B. Al-Nawas, for O Dr. E. Angelopoulou, Associate Professor, Oral Pa- their time and constructive suggestions and contribu- thology, School of Dentistry, University of Athens, tions concerning the book in English. Greece, who co-authored Chap. 11, “Biopsy and I would like to extend my sincere thanks to Sarah Histopathological Examination,” and Dr. G. Per- Price for copy-editing the English edition. dikaris, Consultant, Internal Medicine and Infec- I would also like to thank my dear friend Antonis tious Diseases, School of Medicine, University of Haikalis as well as Konstantinos Athanasoulis for Athens, Greece, for his contribution as a co-author their hard work in drawing all the figures and illus- of Chap. 16, “Prophylactic and Therapeutic Use of trations of the book, and Manuela Berki and Tasia Antibiotics in Dentistry.” Panagopoulou, for the artistic typesetting and editing of the Greek edition. Last but not least, I would like to thank my family, for I would like to express my sincere appreciation to their endless patience and understanding throughout Helena Tsitsogianis, clinical instructor, Department the entire effort. of Oral and Maxillofacial Surgery, School of Dentist- ry, University of Athens, Greece, for her invaluable aid Dr. F. D. Fragiskos  Foreword The past two decades have witnessed significant ad- enhanced the skills of both the general dental practi- vances in surgical techniques and instrumentation. tioner and specialist. Following the tradition of other However, the basic surgical principles upon which excellent oral surgical texts, Dr. Fragiskos has pro- these advances owe their successful implementation duced a well-written and amply illustrated text. Time- and outcome have remained unchanged. Oral and honored techniques and recent technical advances are maxillofacial surgery has its share of refinements and presented in a well-balanced and succinct manner. In a pivotal role in the contemporary management of its present format this book can serve the reader as many pathologic, functional, and esthetic problems both a quick reference and a more in-depth resource affecting the face and oral cavity. The majority of oral of information on minor oral surgical techniques and conditions that require surgical management fall related subjects. within the realm of minor oral surgery. Hence, oral surgery constitutes an integral part of dental practice at both the undergraduate and professional level. Omar Abubaker, DMD, PhD Over the years many oral surgery textbooks have Professor and Chairman, Department of Oral and served as recourses for useful information. This infor- Maxillofacial Surgery, VCU School of Dentistry and mation, when coupled with appropriate training, has VCU Medical Center, Richmond, Va., USA  Foreword Minor oral surgical procedures constitute a major part able addition to the dental literature. Dr. Fragiskos has of the practice of dentistry. The majority of patients made a commendable effort to produce a well-struc- are in need of minor oral surgical procedures (e.g., ex- tured, succinct, and superbly illustrated text. This tractions, implant placement, etc.) during the course book contains information on minor oral surgical of their dental management. Therefore, there is noth- procedures that is of great value to the dental student, ing “minor” about minor oral surgery. general dental practitioner, and specialist. Acquiring skills in oral surgical techniques is abso- lutely essential for today’s dental practitioner. In this Chris A. Skouteris, DMD, PhD context, textbooks that can help in laying the grounds Associate Professor of Oral and Maxillofacial Surgery for such skills to blossom and flourish are an invalu- School of Dentistry, University of Athens, Greece  Contents Chapter 1: Medical History Chapter 2: Radiographic Examination in Oral Surgery F. D. Fragiskos E. Stefanou 1.1 Congestive Heart Failure............. 1 2.1 Radiographic Assessment............. 22 1.2 Angina Pectoris.................... 1 2.2 Magnification Technique............. 23 1.3 Myocardial Infarction............... 2 2.3 Two Radiographs with Different 1.4 Rheumatic Heart Disease............. 3 Reference Planes.................... 23 1.5 Heart Murmur..................... 3 2.4 Tube Shift Principle................. 23 1.6 Congenital Heart Disease............. 3 2.5 Vertical Transversal Tomography 1.7 Cardiac Arrhythmia................. 3 of the Jaw......................... 23 1.8 Prosthetic Heart Valve............... 4 Bibliography.............................. 28 1.9 Surgically Corrected Heart Disease..... 4 1.10 Heart Pacemaker................... 4 Chapter 3: Principles of Surgery 1.11 Hypertension...................... 4 F. D. Fragiskos 1.12 Orthostatic Hypotension............. 5 3.1 Sterilization of Instruments........... 31 1.13 Cerebrovascular Accident............ 5 3.2 Preparation of Patient............... 32 1.14 Anemia and Other Blood Diseases...... 6 3.3 Preparation of Surgeon.............. 32 1.15 Leukemia......................... 6 3.4 Surgical Incisions and Flaps........... 33 1.16 Hemorrhagic Diatheses.............. 6 3.5 Types of Flaps...................... 34 1.17 Patients Receiving Anticoagulants...... 7 3.5.1 Trapezoidal Flap.................... 34 1.18 Hyperthyroidism................... 8 3.5.2 Triangular Flap..................... 35 1.19 Diabetes Mellitus................... 9 3.5.3 Envelope Flap...................... 35 1.20 Renal Disease...................... 10 3.5.4 Semilunar Flap..................... 36 1.20.1 Acute Glomerulonephritis............ 10 3.5.5 Other Types of Flaps................ 36 1.20.2 Chronic Glomerulonephritis.......... 10 3.5.6 Pedicle Flaps....................... 36 1.20.3 Chronic Renal Failure............... 10 3.6 Reflection of the Mucoperiosteum...... 38 1.21 Patients Receiving Corticosteroids..... 10 3.7 Suturing.......................... 38 1.22 Cushing’s Syndrome................. 11 3.7.1 Suturing Techniques................ 39 1.23 Asthma........................... 11 Bibliography.............................. 41 1.24 Tuberculosis....................... 11 1.25 Infectious Diseases Chapter 4: Equipment, Instruments, and Materials (Hepatitis B, C, and AIDS)............ 12 F. D. Fragiskos 1.26 Epilepsy.......................... 12 4.1 Surgical Unit and Handpiece.......... 43 1.27 Diseases of the Skeletal System........ 13 4.2 Bone Burs......................... 43 1.28 Radiotherapy Patients............... 13 4.3 Scalpel (Handle and Blade)........... 43 1.29 Allergy........................... 13 4.4 Periosteal Elevator.................. 45 1.29.1 Classification of Allergic Reactions..... 14 4.5 Hemostats........................ 45 1.29.2 Types of Allergic Reactions........... 14 4.6 Surgical – Anatomic Forceps.......... 46 1.30 Fainting.......................... 15 4.7 Rongeur Forceps.................... 46 1.31 Pregnancy......................... 15 4.8 Bone File.......................... 46 Bibliography.............................. 16 4.9 Chisel and Mallet................... 47 XII Contents 4.10 Needle Holders..................... 47 5.5.3 Extraction of Multi-Rooted Teeth 4.11 Scissors........................... 49 with Destroyed Crown.............. 88 4.12 Towel Clamps...................... 50 5.5.4 Extraction of Root Tips............. 90 4.13 Retractors......................... 51 5.6 Postextraction Care of Tooth Socket... 92 4.14 Bite Blocks and Mouth Props.......... 52 5.7 Postoperative Instructions........... 92 4.15 Surgical Suction.................... 53 Bibliography............................. 93 4.16 Irrigation Instruments............... 53 4.17 Electrosurgical Unit................. 54 Chapter 6: Surgical Tooth Extraction 4.18 Binocular Loupes with Light Source.... 54 F. D. Fragiskos 4.19 Extraction Forceps.................. 55 6.1 Indications....................... 95 4.20 Elevators.......................... 60 6.2 Contraindications................. 99 4.21 Other Types of Elevators............. 62 6.3 Steps of Surgical Extraction.......... 99 4.22 Special Instrument for Removal 6.4 Surgical Extraction of Teeth of Roots........................... 63 with Intact Crown................. 99 4.23 Periapical Curettes.................. 63 6.4.1 Extraction of Multi-Rooted Tooth..... 99 4.24 Desmotomes....................... 63 6.4.2 Extraction of an Intact Tooth 4.25 Sets of Necessary Instruments......... 64 with Hypercementosis of the Root Tip.. 99 4.26 Sutures........................... 66 6.4.3 Extraction of Deciduous Molar that 4.27 Needles........................... 67 Embraces Molar of Permanent Tooth... 102 4.28 Local Hemostatic Drugs.............. 67 6.4.4 Extraction of Ankylosed Tooth....... 103 4.29 Materials for Covering 6.5 Surgical Extraction of Roots.......... 104 or Filling a Surgical Wound........... 69 6.5.1 Root Extraction After Removal 4.30 Materials for Tissue Regeneration...... 70 of Part of the Buccal Bone........... 104 Bibliography.............................. 71 6.5.2 Extraction of Root after a Window is Created on Buccal Bone.. 109 Chapter 5: Simple Tooth Extraction 6.5.3 Creation of Groove on Surface F. D. Fragiskos of Root, after Removal of Small Amount 5.1 Patient Position..................... 73 of Buccal Bone.................... 113 5.1.1 Extraction......................... 74 6.5.4 Creation of a Groove Between Root 5.2 Separation of Tooth from Soft Tissues... 74 and Bone, Which Allows Positioning 5.2.1 Severing Soft Tissue Attachment....... 74 of the Elevator..................... 113 5.2.2 Reflecting Soft Tissues............... 75 6.6 Surgical Extraction of Root Tips...... 114 5.3 Extraction Technique Using 6.6.1 Surgical Technique................. 115 Tooth Forceps...................... 76 Bibliography............................. 118 5.3.1 Extraction of Maxillary Central Incisors 77 5.3.2 Extraction of Maxillary Lateral Incisors 77 Chapter 7: Surgical Extraction of Impacted Teeth 5.3.3 Extraction of Maxillary Canines....... 77 F. D. Fragiskos 5.3.4 Extraction of Maxillary Premolars...... 77 7.1 Medical History................... 121 5.3.5 Extraction of Maxillary First 7.2 Clinical Examination............... 121 and Second Molars.................. 80 7.3 Radiographic Examination.......... 121 5.3.6 Extraction of Maxillary Third Molar.... 80 7.4 Indications for Extraction........... 121 5.3.7 Extraction of Mandibular Anterior Teeth 80 7.5 Appropriate Timing for Removal 5.3.8 Extraction of Mandibular Premolars.... 81 of Impacted Teeth.................. 125 5.3.9 Extraction of Mandibular Molars...... 82 7.6 Steps of Surgical Procedure.......... 125 5.3.10 Extraction of Mandibular Third Molar.. 83 7.7 Extraction of Impacted 5.3.11 Extraction of Deciduous Teeth......... 83 Mandibular Teeth................. 126 5.4 Extraction Technique Using 7.7.1 Impacted Third Molar.............. 126 Root Tip Forceps................... 84 7.7.1.1 Removal of Bud of Impacted 5.5 Extraction Technique Using Elevator.... 84 Mandibular Third Molar............ 128 5.5.1 Extraction of Roots and Root Tips...... 84 7.7.1.2 Extraction of Impacted Third Molar 5.5.2 Extraction of Single-Rooted Teeth in Horizontal Position.............. 132 with Destroyed Crown............... 86 7.7.1.3 Extraction of Third Molar with Mesioangular Impaction........ 135  Contents XIII 7.7.1.4 Extraction of Third Molar 8.2.9 Disturbances in Postoperative with Distoangular Impaction......... 140 Wound Healing................... 200 7.7.1.5 Extraction of Impacted Third Molar Bibliography............................. 200 in Edentulous Patient............... 143 7.7.2 Impacted Premolar................. 145 Chapter 9: Odontogenic Infections 7.7.3 Impacted Canine.................. 149 F. D. Fragiskos 7.7.4 Premolar with Deep Impaction....... 152 9.1 Infections of the Orofacial Region..... 205 7.8 Extraction of Impacted Maxillary Teeth 155 9.1.1 Periodontal Abscess................ 206 7.8.1 Impacted Third Molar.............. 155 9.1.2 Acute Dentoalveolar Abscess......... 206 7.8.1.1 Extraction of Impacted Third Molar... 157 9.1.2.1 Local Symptoms................... 207 7.8.2 Impacted Canines................. 159 9.1.2.2 Systemic Symptoms................ 207 7.8.2.1 Extraction Using Labial Approach..... 160 9.1.2.3 Complications.................... 207 7.8.2.2 Extraction Using Palatal Approach.... 164 9.1.2.4 Diagnosis........................ 207 7.8.3 Impacted Premolar with Palatal Position 168 9.1.2.5 Spread of Pus Inside Tissues.......... 207 7.8.4 Ectopic Impacted Canine............ 172 9.1.3 Fundamental Principles of Treatment 7.9 Exposure of Impacted Teeth of Infection....................... 211 for Orthodontic Treatment.......... 174 9.1.4 Treatment of Infection in Cellular Stage 213 7.9.1 Impacted Canine with Palatal Position 174 9.1.4.1 Intraalveolar Abscess............... 213 7.9.2 Impacted Mandibular Canine 9.1.4.2 Subperiosteal Abscess............... 214 with Labial Position................ 176 9.1.4.3 Submucosal Abscess................ 214 Bibliography............................. 177 9.1.4.4 Subcutaneous Abscess.............. 218 9.1.5 Fascial Space Infections............. 218 Chapter 8: Perioperative and Postoperative Complications 9.1.5.1 Abscess of Base of Upper Lip......... 220 F. D. Fragiskos 9.1.5.2 Canine Fossa Abscess............... 220 8.1 Perioperative Complications......... 181 9.1.5.3 Buccal Space Abscess............... 222 8.1.1 Fracture of Crown or Luxation 9.1.5.4 Infratemporal Abscess.............. 224 of Adjacent Tooth.................. 181 9.1.5.5 Temporal Abscess.................. 224 8.1.2 Soft Tissue Injuries................. 181 9.1.5.6 Mental Abscess.................... 225 8.1.3 Fracture of Alveolar Process.......... 183 9.1.5.7 Submental Abscess................. 225 8.1.4 Fracture of Maxillary Tuberosity...... 183 9.1.5.8 Sublingual Abscess................. 227 8.1.5 Fracture of Mandible............... 184 9.1.5.9 Submandibular Abscess............. 229 8.1.6 Broken Instrument in Tissues........ 185 9.1.5.10 Submasseteric Abscess.............. 230 8.1.7 Dislocation of Temporo- 9.1.5.11 Pterygomandibular Abscess.......... 231 mandibular Joint.................. 185 9.1.5.12 Lateral Pharyngeal Abscess.......... 232 8.1.8 Subcutaneous or Submucosal 9.1.5.13 Retropharyngeal Abscess............ 232 Emphysema...................... 186 9.1.5.14 Parotid Space Abscess.............. 232 8.1.9 Hemorrhage...................... 186 9.1.5.15 Cellulitis (Phlegmon)............... 234 8.1.10 Displacement of Root or Root Tip 9.1.5.16 Ludwig’s Angina................... 235 into Soft Tissues................... 188 9.1.6 Chronic Dentoalveolar Abscess....... 237 8.1.11 Displacement of Impacted Tooth, Root, Bibliography............................. 239 or Root Tip into Maxillary Sinus...... 189 8.1.12 Oroantral Communication.......... 190 Chapter 10: Preprosthetic Surgery 8.1.13 Nerve Injury...................... 191 F. D. Fragiskos 8.2 Postoperative Complications......... 195 10.1 Hard Tissue Lesions or Abnormalities.. 243 8.2.1 Trismus.......................... 195 10.1.1 Alveoloplasty..................... 243 8.2.2 Hematoma....................... 195 10.1.2 Exostoses........................ 253 8.2.3 Ecchymosis....................... 196 10.1.2.1 Torus Palatinus.................... 253 8.2.4 Edema.......................... 196 10.1.2.2 Torus Mandibularis................ 256 8.2.5 Postextraction Granuloma........... 197 10.1.2.3 Multiple Exostoses................. 259 8.2.6 Painful Postextraction Socket........ 197 10.1.2.4 Localized Mandibular 8.2.7 Fibrinolytic Alveolitis (Dry Socket).... 199 Buccal Exostosis................... 259 8.2.8 Infection of Wound................ 199 XIV Contents 10.2 Soft Tissue Lesions or Abnormalities... 261 Chapter 14: Surgical Treatment of Salivary Gland Lesions 10.2.1 Frenectomy....................... 261 F. D. Fragiskos 10.2.1.1 Maxillary Labial Frenectomy......... 262 14.1 Removal of Sialolith from Duct 10.2.1.2 Lingual Frenectomy................ 265 of Submandibular Gland............ 327 10.2.2 Denture-Induced Fibrous Hyperplasia.. 268 14.2 Removal of Mucus Cysts............ 330 10.2.3 Fibrous Hyperplastic 14.2.1 Mucocele........................ 330 Retromolar Tuberosity.............. 272 14.2.2 Ranula.......................... 334 10.2.4 Papillary Hyperplasia of the Palate.... 275 Bibliography............................. 335 10.2.5 Gingival Fibromatosis.............. 277 Bibliography............................. 278 Chapter 15: Osseointegrated Implants F. D. Fragiskos, C. Alexandridis Chapter 11: Biopsy and Histopathological Examination 15.1 Indications....................... 337 E. Angelopoulou, F. D. Fragiskos 15.2 Contraindications................. 337 11.1 Principles for Successful Outcome 15.3 Instruments...................... 337 of Biopsy......................... 281 15.4 Surgical Procedure................. 337 11.2 Instruments and Materials........... 281 15.5 Complications.................... 346 11.3 Excisional Biopsy.................. 281 15.6 Bone Augmentation Procedures....... 346 11.3.1 Traumatic Fibroma................. 283 Bibliography............................. 346 11.3.2 Peripheral Giant Cell Granuloma..... 286 11.3.3 Hemangioma..................... 286 Chapter 16: Prophylactic and Therapeutic Use 11.3.4 Peripheral Fibroma of Gingiva........ 291 of Antibiotics in Dentistry 11.3.5 Leukoplakia...................... 294 G. Perdikaris, A. Pefanis, E. Giamarellou 11.4 Incisional Biopsy................... 295 16.1 Treatment of Odontogenic Infections.. 349 11.5 Aspiration Biopsy.................. 297 16.1.1 Oral Flora of Odontogenic Infections.. 349 11.6 Specimen Care.................... 298 16.1.2 Principles of Treatment 11.7 Exfoliative Cytology................ 298 of Odontogenic Infections........... 351 11.8 Tolouidine Blue Staining............ 298 16.1.2.1 Penicillins........................ 351 Bibliography............................. 298 16.1.2.2 Cephalosporins.................... 352 16.1.2.3 Macrolides....................... 352 Chapter 12: Surgical Treatment of Radicular Cysts 16.1.2.4 Clindamycin...................... 353 C. Alexandridis 16.1.2.5 Tetracyclines...................... 353 12.1 Clinical Presentation............... 301 16.1.2.6 Nitroimidazoles................... 353 12.2 Radiographic Examination.......... 301 16.2 Prophylactic Use of Antibiotics....... 355 12.3 Aspiration of Contents of Cystic Sac... 301 16.2.1 Prophylaxis of Bacterial Endocarditis.. 355 12.4 Surgical Technique................. 301 16.2.2 Prophylaxis of Wound Infections Bibliography............................. 308 (Perioperative Chemoprophylaxis)..... 358 16.3 Osteomyelitis..................... 360 Chapter 13: Apicoectomy 16.3.1 Sclerosing Osteomyelitis............ 361 F. D. Fragiskos 16.3.2 Proliferative Periostitis.............. 362 13.1 Indications....................... 309 16.3.3 Osteoradionecrosis................. 362 13.2 Contraindications................. 309 16.4 Actinomycosis.................... 362 13.3 Armamentarium.................. 309 Bibliography............................. 362 13.4 Surgical Technique................. 312 13.5 Complications.................... 322 Subject Index.............................. 365 Bibliography............................. 323  Contributors F. D. Fragiskos, DDS, PhD A. Pefanis, MD, PhD Associate Professor, Oral and Maxillofacial Surgery, Consultant, Internal Medicine and Infectious School of Dentistry, University of Athens, Greece Diseases, 3rd Dept. of Medicine, School of Medicine, University of Athens, Greece; Sotiria General C. Alexandridis, DDS, MS, PhD Hospital, Athens, Greece Professor and Chairman, Oral and Maxillofacial Surgery, School of Dentistry, University of Athens, G. Perdikaris, MD, PhD (deceased) Greece Consultant, Internal Medicine and Infectious Diseases, 3rd Dept. of Medicine, School of Medicine, E. Angelopoulou, DDS, PhD (deceased) University of Athens, Greece Associate Professor, Oral Pathology, School of Dentistry, University of Athens, Greece E. Stefanou, DDS, MS, PhD Associate Professor, Oral Diagnosis and Radiology, H. Giamarellou, MD, PhD School of Dentistry, University of Athens, Greece Professor, Internal Medicine and Infectious Diseases, 4th Dept. of Medicine, School of Medicine, University of Athens, Greece; Attikon General Hospital, Athens, Greece  Chapter 1 Medical History 1 F. D. Fragiskos The medical history and clinical examination of the ious and might feel like he or she is choking and as if patient are deemed necessary in order to ensure the death is imminent. successful outcome of a surgical procedure, as well as The preventive measures that are deemed necessary a favorable postoperative healing process. before the surgical procedure for a patient presenting Investigation of the medical history is carried out with congestive heart failure are the following: with numerous questions pertaining to the presence of O Written consent from the patient’s cardiologist and pathological conditions that may adversely influence consultation is desirable the surgical procedure and endanger the patient’s O Oral premedication, e.g., 5–10 mg diazepam (Vali- life. um) or 1.5–3 mg bromazepam (Lexotanil), 1 h be- There are various types of questionnaires that may fore the surgical procedure may be helpful be used by the dentist for gathering information about O Small amounts of vasoconstrictors in local anes- the general health of the patient. Table 1.1 presents the thetic with particular importance of aspiration one that we feel fulfills the needs of the dental office. O Short appointments, as painless as possible Patients with underlying diseases should be given particular attention and all necessary preventive mea- sures should be taken, in cooperation with the physi- 1.2 cian treating the patients, in order to avoid potential Angina Pectoris complications during and after the surgical procedure. This chapter refers to diseases and conditions that are Angina pectoris is considered a clinical syndrome that included in the aforementioned medical history and is characterized by temporary ischemia in part of or which may cause problems at the dental office. The all of the myocardium, resulting in diminished oxy- preventive measures that must be taken before and gen supply. after the surgical procedure are also emphasized. An episode of angina pectoris presents as brief par- oxysmal pain posterior to the sternum, may be pre- cipitated by fatigue, extreme stress, or a rich meal, and 1.1 subsides within 2–5 min after rest and the use of vaso- Congestive Heart Failure dilators. The patient may describe the episode as pain- ful discomfort in the chest, with a burning sensation, Congestive heart failure is defined as the inability of pressure, or tightness. Pain may be present in the car- the myocardium to pump enough blood to satisfy the diac area, radiating to the left shoulder, neck, left arm needs of the body, so that the lungs and/or the system- (with a numb sensation as well as tingling), sometimes ic circulatory system are congested. The dentist treat- down the chin and teeth of the mandible (usually the ing patients with congestive heart failure must be es- left side), or it may even be felt at the epigastrium, pecially careful, because any surgical procedure at the causing confusion in diagnosis. dental office may cause undue stress, resulting in car- Perspiration, extreme anxiety, and a feeling of im- diac dysfunction (workload increase of the heart, minent death often accompany these painful symp- which surpasses the functional ability of the heart) toms. Patients with a history of coronary heart disease followed by potential acute pulmonary edema. have a greater chance of exhibiting angina pectoris Patients with this condition present with extreme during a dental appointment, due to the anxiety and dyspnea, hyperventilation, cough, hemoptysis (thin stress of the upcoming procedure. pinkish foamy expectoration), great difficulty in The preventive measures suggested in this case are: breathing, murmurs due to cardiac asthma, and cya- O Written consent by the patient’s cardiologist is de- nosis. The patient prefers the sitting position, is anx- sirable 2 F. D. Fragiskos Table 1.1. Medical history Name Age Sex Occupation Address Telephone Name of physician Questions pertaining to general condition of patient’s health: : 1. Have you had any health problems during the last 5 years, so that you had to visit a physician or a hospital? : 2. Have you taken any medication for whatever reason during the last 2 years? : 3. Are you allergic to any substance or medication (e.g., antibiotics, local anesthetics, aspirin, etc.)? : 4. Have you taken any antibiotics during the last month? : 5. Did you ever have any prolonged bleeding that needed special treatment? : 6. Have you ever received radiotherapy in the neck or facial region for therapeutic purposes? : 7. Did you ever have, or do you have, a problem related to the following diseases or conditions? : :hCongestive heart failure :hProsthetic heart valve :hAngina pectoris :hSurgically corrected cardiac disease :hMyocardial infarction :hHeart pacemaker :hRheumatic fever :hHypertension :hHeart murmur :hOrthostatic hypotension :hCongenital heart disease :hCerebrovascular accident h :hCardiac arrhythmia 8. Have you ever been troubled by any other health problems other than the above? Notes (Date) (Signature) O Appropriate premedication, usually 5–10 mg diaz- A myocardial infarction has a sudden onset with epam (Valium) or 1.5–3 mg bromazepam (Lexot- severe pain posterior to the sternum, which increases anil) orally, 1 h before the surgical procedure may in severity rapidly and is characterized by a burning be helpful sensation, pressure, and extreme tightness. The pain is O Dental surgery in hospital, when the patient refers more severe compared to that of angina pectoris, last- many episodes of angina pectoris ing longer than 15 min and does not subside with rest O Small amounts of vasoconstrictors in local anes- or use of nitrates sublingually. Pain usually radiates thetic with particular importance of aspiration (as in angina pectoris) to the left shoulder or towards O Short appointments, as painless as possible the ulnar surface of the arm. It may also radiate to- wards the neck region, the mandible, teeth, midback region, epigastrium, and the right arm. The pain may 1.3 also be associated with nausea, vomiting, perspiration, Myocardial Infarction and dyspnea. It is not always possible to treat patients in the den- Myocardial infarction refers to the ischemic ne- tal office if they have suffered a myocardial infarction. crosis of an area of the heart, usually due to complete It is considered prudent to avoid any routine dental blocking of some of the branches of the coronary surgery on patients with recent infarctions (within the arteries. last 6 months). In cases where treatment is deemed  3 Evolution of the Face 3 absolutely necessary (acute infection, pain, etc.), man- Murmurs are described as: agement should take place in a hospital. Six months a. Systolic murmurs: following the myocardial infarction, patients may also 1. Flow rate murmurs or outflow murmurs be treated in the dental office, as long as the dentist 2. Cardiac insufficiency murmurs follows the same recommendations as those that were b. Diastolic murmurs: described in the case of angina pectoris. 1. Cardiac insufficiency murmurs 2. Congestive murmurs (via the mitral valve or tri- cuspid valve) 1.4 c. Continuous murmurs Rheumatic Heart Disease Besides the murmurs mentioned above, which are due Patients with a history of rheumatic fever may have to organic cardiac defects, other murmurs are charac- damage of the mitral and aortic valves, which may be terized as innocent or functional, which have a good described as stenosis, or insufficiency, or both. prognosis. Because patients with such a disease may develop From a dental point of view, when a patient reports clinical manifestations in the cardiovascular system a history of heart murmur, the dentist must establish years later, they must be evaluated very carefully be- whether the murmur is functional or pathologic. An fore the surgical procedure is performed in order to antibiotic prophylaxis should be considered (see determine if they can actually handle the stress in- Chap. 16). volved. It is also extremely important for the dentist to real- ize that transient bacteremia, which in healthy patients 1.6 is nonthreatening and which may develop after inva- Congenital Heart Disease sive surgical procedures, is considered especially dan- gerous for patients belonging to this category. In this Some congenital heart diseases (patent ductus arterio- case, the endocardium generally presents great sensi- sus, atrial septal defects, ventricular septal defects, tivity to bacterial infection, and, as a result, any inva- idiopathic pulmonary stenosis, tetralogy of Fallot, sive procedure in the oral cavity without the use of cyanotic heart disease, stenosis of pulmonary or aortic antibiotics results in greater risk of bacterial endocar- valve) are considered grave conditions, which must be ditis. evaluated carefully before the surgical procedure. The preventive measures that are recommended The preventive measures recommended in these are: cases are: O Premedication before the surgical procedure can be O Consultation with the physician treating the pa- helpful tient O Avoidance of vasoconstrictors (or maximum con- O Premedication 1 h before the surgical procedure centration 1:100,000) might be helpful O Small amounts of vasoconstrictors in local anes- O If recommended by the cardiologist: administra- thetic with particular importance of aspiration (see tion of antibiotic prophylaxis, according to the reg- Chap. 16 for administration of antibiotic prophy- imen for rheumatic heart diseases involving valve laxis) damage (see Chap. 16) O Use of vasoconstrictors at the smallest possible con- centration 1.5 O Short appointments, as painless as possible Heart Murmur Heart murmurs are pathologic sounds (of longer dura- 1.7 tion and greater frequency than heartbeats) which are Cardiac Arrhythmia the result of vibrations caused by turbulence in the cir- culation through the vessels or chambers of the heart. Arrhythmia is any periodic variation in the normal Most heart murmurs are caused by valve defects, re- rhythm of the heart, caused by disturbances of the sulting from rheumatic disease and more rarely due to excitability of the ventricles by the sinoatrial node. septic endocarditis, syphilis, or other diseases. They may also be due to congenital heart conditions. 4 F. D. Fragiskos Patients presenting arrhythmia, especially persis- tent arrhythmia despite antiarrhythmic management, 1.11 require the following preventive measures: Hypertension O Consultation with treating physician O In severe cases avoidance of local anesthetics con- Arterial pressure in healthy adult patients over 20 years taining vasoconstrictors or postponing of dental of age is considered normal when diastolic blood pres- procedures sure is under 90 mmHg and systolic blood pressure is O Premedication before the surgical procedure can be under 140 mmHg. of help Hypertension is the abnormal elevation of arterial O Short appointments and pain control pressure above the aforementioned values. Arterial hypertension of unknown etiology exists in 95% of cases and is recognized as essential hyper- 1.8 tension, whereas in 5% of cases the cause is known and Prosthetic Heart Valve is called secondary hypertension. Measurement of blood pressure before any dental Patients who have undergone corrective surgery for procedure is necessary in order to avoid many unde- various cardiac disorders with placement of prosthetic sirable circulatory problems. Patients with blood pres- heart valves require antibiotic prophylaxis before the sure values ranging 140–160/90–95 mmHg may un- surgical procedure, because the endocardium associ- dergo dental surgery safely, whereas patients with ated with the artificial valve is particularly susceptible blood pressure values ranging 160–190/95–110 mmHg to microbial infection. The regimen recommended is will have to be given premedication half an hour to an the same as that for valve disease of rheumatic origin. hour before the surgical procedure, especially patients under stress. If the blood pressure values remain high even after premedication (e.g., over 180/110 mmHg) 1.9 the dental session is postponed and the patient is re- Surgically Corrected Heart Disease ferred to his/her physician for further treatment. Pa- tients with blood pressure values over 190/110 mmHg Patients who have undergone surgery for heart disease are not allowed regular dental treatment. The patient’s in the past should be evaluated, with consultation with treating physician is consulted immediately and if the treating physician, depending on the surgical pro- there is an acute dental problem, the patient must be cedure, the degree of cardiac or vascular defect, and treated in a hospital, to prevent a possible sudden in- the need for antibiotic prophylaxis (see Chap. 16). crease in arterial pressure, which is considered by many, erroneously, as a hypertensive crisis. Most pa- tients considered to be suffering from a hypertensive 1.10 crisis present intermittent elevation of arterial pres- Heart Pacemaker sure, which is usually due to inadequate antihyperten- sive medication. Pacemakers are mainly used for the control of symp- If no acute signs and symptoms of the target organs toms due to disturbances of the cardiac rhythm. Most of hypertension (e.g., acute pulmonary edema, hyper- modern types of pacemaker are able to maintain a tensive encephalopathy) accompany the “peaks” of hy- relatively normal cardiac rhythm only when the need pertension, no emergency therapeutic intervention is arises. The dentist must be aware of the following con- required. The patient must be referred to a physician cerning pacemakers: for effective control of blood pressure. The sublingual O The use of certain dental instruments increases the administration of nifedipine (Adalat) may result in risk of abnormal activity of the pacemaker (mono- myocardial infarction or cerebrovascular accident, polar electrosurgery, ultrasonic scalers, electronic and so is not recommended. When acute signs and dental anesthesia, etc.) symptoms of the target organs accompany the “peaks” O Local anesthetics with vasoconstrictors may be of hypertension, then the hypertension is termed ma- used safely lignant. This is characterized by severe hypertension O Antibiotic prophylaxis is not deemed necessary (diastolic blood pressure >140 mmHg), along with papilloedema and/or retinal hemorrhage. The most serious complication is hypertensive encephalopathy,  Chapter 1 Medical History 5 the symptoms of which include severe headache, nau- signs in the case of orthostatic hypotension, as there sea, vomiting, confusion, convulsions, and coma. would be in the case of fainting (pallor, nausea, dizzi- Immediate management of hypertension is required ness, and perspiration). That is why, based on the med- very rarely, with intravenous administration of anti- ical history, if the dentist deems that the patient is at hypertensive medication, targeting at a drop in blood risk for orthostatic hypotension, then he or she must pressure within a matter of minutes (e.g., hypertensive support the patient as they get out of the dental chair, encephalopathy, acute weakening of left ventricle, en- to protect them from a sudden fall, which may lead to cephalic hemorrhage, etc.), and should be carried out serious injury. in a hospital. In actual practice, a dentist is not meant To avoid an episode of orthostatic hypotension, the to administer emergency antihypertensive agents, ex- following preventive measures must be taken: cept in cases of repeated acute pulmonary edema O Careful evaluation of medical history, especially (rarely), whereupon the intravenous administration of concerning antihypertensive agents; also, fainting furosemide (Lasix) is indicated. episodes, convulsions, etc. To avoid uncontrollable blood pressure in hyper- O Blood pressure should be monitored in an upright tensive patients, certain preventive measures are nec- and sitting position essary: O Administration of premedication for patients with O Premedication before surgery often is helpful severe psychological distress and physical exertion O Blood pressure should be monitored before anes- O Avoidance of sudden changes in chair position dur- thesia and during the surgical procedure ing dental treatment, from the horizontal to the up- O Preliminary aspiration to avoid intravascular ad- right position (slow return), and not letting the pa- ministration, especially when the local anesthetic tient get out of the chair suddenly, especially if he or contains a vasoconstrictor she uses psychiatric drugs and antihypertensive O Avoiding noradrenaline in patients receiving anti- agents or if the patient has a history of orthostatic hypertensive agents hypotension O Short appointments, as painless as possible 1.13 1.12 Cerebrovascular Accident Orthostatic Hypotension A cerebrovascular accident (stroke) is an acute neuro- Orthostatic hypotension is a sudden drop in blood logic disability secondary to deficit of a specific area of pressure, which is noted as the patient is quickly re- the brain. This deficit is due to focal necrosis of brain turned to an upright position in the dental chair. This tissue, because of intracranial hemorrhage, cerebral condition is due to disturbances of the autonomic ner- embolism, or thrombosis. vous system, and is the second most frequently ob- The warning signs and symptoms include dizzi- served cause of transient loss of consciousness in the ness, vertigo, severe headache, perspiration, pallor, etc. dental patient, after fainting. These signs and symptoms may appear suddenly or The etiology of orthostatic hypotension is not en- gradually, while the patient may also present with loss tirely known, but there are predisposing factors. These of consciousness (apoplexy), upon which he or she factors include: diabetic neuropathy, antihypertensive rarely has time to mention anything at all. Other signs agents or combinations of these, phenothiazines, seda- and symptoms include slow breathing, rapid pulse tives, prolonged supine position, pregnancy, extreme rate, partial or complete paralysis of one or both limbs fatigue, sympathectomy (due to the accumulation of of one side of the body, difficulty in swallowing, loss of large amounts of blood in the lower limbs), occasion- expression or inability to move facial muscles, loss of ally general infections, and severe psychological and tendon reflexes and an inability to rotate the head and physical exertion. eyes towards the side of cerebral damage (which is the In the dental office, patients of any age may present opposite side of that which presents paresis) with dila- with orthostatic hypotension if they are predisposed, tion of the pupils, which do not react to light. or if they are hypotensive. As soon as these patients get Patients with a history of a cerebrovascular accident out of the dental chair, their blood pressure drops sud- must avoid surgical dental care for 6 months after the denly, which is accompanied by dizziness, weakness, stroke. After this time, they may be treated, following headache, loss of balance, sense of fainting, and finally consultation with their physician, after taking certain loss of consciousness. There are usually no prodromal preventive measures: 6 F. D. Fragiskos O Blood pressure should be monitored before and during the surgical procedure (blood pressure must 1.15 be controlled) Leukemia O Premedication 1 h before the surgical procedure can be helpful Leukemia is a pathologic condition of neoplastic na- O Adequate duration of local anesthesia and profound ture, characterized by quantitative and qualitative anesthesia defects of circulating white cells. Depending on the O Short appointment, as painless as possible, with duration of the disease, it is classified as acute or gentle manipulations chronic, and, according to the leukopoietic tissue that is involved, as myelogenous or lymphocytic. If dental care is necessary within 6 months of the Patients with leukemia must be treated with special stroke, then it should be provided in a hospital. Pa- care and always under consultation with the patient’s tients who have suffered a cerebrovascular accident hematologist, because these patients are susceptible to may be administered vasoconstrictors, in as low a dose severe infection and postoperative hemorrhage. The as possible. preventive measures deemed necessary are: O Avoidance of nerve block (only if anesthesia of the area is possible with local infiltration) because, due 1.14 to the blood cell disorder, extensive hematoma may Anemia and Other Blood Diseases result. O Surgical procedures (e.g., tooth extraction) may be Patients with a history of anemia must be evaluated performed in a hospital, except in the case of chron- carefully, because severe hemorrhage due to a tooth ic leukemia in a state of remission, upon which extraction or other surgical procedure in the oral management may take place in the dental office cavity results in aggravation of the anemia, possibly with administration of large doses of a broad-spec- endangering the patient’s life. trum antibiotic. The patient must be handled with Anemias that are of interest to the dentist include care, without abrupt movements, and with meticu- aplastic anemia, Biermer’s megaloblastic anemia (a lous measures for the control of bleeding. type of pernicious anemia), hypochromic anemias O Antibiotic prophylaxis should be administered. (iron deficiency anemia, thalassemia), and sickle cell anemia. Dentists should also be aware of patients with methemoglobinemia. 1.16 The following preventive measures are necessary Hemorrhagic Diatheses for patients with a history of anemia and who need to have a tooth extracted: These are pathologic conditions with hemorrhage, O Hematocrit and hemoglobin levels must be as near which may be spontaneous or the result of trauma. normal as possible and consultation with the pa- Bleeding disorders are classified into three groups, tient’s hematologist is often necessary. according to their pathogenic mechanism: O Patients with sickle cell anemia in particular must a. Vascular disorders, which are due to alterations of avoid: the vascular wall, especially of the capillaries. These – Pain and severe stress, otherwise a sickle cell cri- include hereditary hemorrhagic telangiectasia or sis might result. Premedication and pain control Rendu–Osler disease, Ehlers–Danlos disease, von with anesthetics that cause profound anesthesia Willebrand disease (vascular hemophilia), and con- are recommended. genital bleeding diseases, scurvy, and purpura due – Abrupt awkward manipulations during the ex- to allergy. traction; due to osteoporosis caused by the dis- b. Thrombocytic disorders, which are due to either ease, there is increased risk of fracture of the decreased numbers of platelets (thrombocyto- mandible. penia), or to congenital functional abnormality of O As far as local anesthetics are concerned, there are the platelets. These include primary or idiopathic no contraindications for patients with anemia. thrombocytopenia, Glanzmann’s disease, and However, methemoglobinemia, whether congenital thrombocytosis or thrombocythemia. or idiopathic, is a relative contraindication for the c. Hemorrhagic diatheses because of disorders of co- administration of two types of amide local anes- agulation, either due to deficiency of certain coagu- thetics, articaine and prilocaine. lation factors or the presence of anticoagulants in  Chapter 1 Medical History 7 the blood, which often occurs when the patient a tendency to bleeding. Acetaminophen, other- takes anticoagulant medication for years for thera- wise known as paracetamol, and ibuprofen are peutic or preventive purposes. These include inher- considered safer analgesics where bleeding is a ited disorders of coagulation (hemophilias and de- problem. ficiency of other factors) and acquired disorders of – Consumption of cold foods and liquids for the the prothrombin complex (vitamin K deficiency), first few days and avoiding chewing hard foods severe liver disease, and excessive use of various for about a week. coagulation factors. Patients with this type of disease are usually aware of 1.17 their problem and always inform their dentist. The Patients Receiving Anticoagulants dentist should take the necessary precautionary mea- sures before any surgical procedure, due to the risk of Patients who use anticoagulants should be treated uncontrollable bleeding. The treating physician should after consultation with their treating physician. What be consulted, and, if deemed necessary, the surgical basically concerns the dentist is the type of anticoagu- procedure must be carried out in a hospital with lant and the condition for which it is administered. screening laboratory tests and medical management. Usually, anticoagulants are administered for long pe- The preventive measures recommended for patients riods for various cardiovascular conditions (after acute with hemorrhagic diathesis are the following: myocardial infarction, vascular grafts, etc.), for cer- O Designation of the time and place for the surgical tain types of cerebrovascular accidents, and for condi- procedure. tions involving veins (pulmonary embolism, venous O Administration of medication by the treating he- thrombosis). They are given as special treatment for matologist, depending on the nature of the disease. thrombo-embolic manifestations, as well as the pre- O Scheduling of surgical procedure for morning vention of recurrences. hours, so that there is ample time to control possible The most commonly used anticoagulant drugs are postoperative hemorrhage during the day. coumarin drugs and heparin drugs, as well as antico- O Limiting appointments that require therapy with agulant derivatives of acetylsalicylic acid (aspirin). replacement factors to as few as possible. Remove as many teeth needing extraction as possible at each Coumarin Drugs. These drugs are administered in session. doses sufficient to increase the prothrombin time to O Administration of both nerve block anesthesia and 2–2.5 times above the normal level (normal range: 11– local infiltration anesthesia concurrently is thought 12 s), thus delaying or preventing the intravascular to better control hemorrhage in the area with vaso- coagulation of blood. This increase poses a major constrictors. Some people suggest that nerve block problem for blood coagulation, because of decreased anesthesia should be avoided, especially in hemo- plasma levels of factors II, VII, IX, and X. Therefore, if philic patients, due to the risk of extensive hemato- a surgical procedure is performed, there is an increased ma resulting from injury to a large vessel if the pa- risk of prolonged postoperative bleeding, which is of- tient has not taken the necessary medication. ten difficult to control. For extensive surgical proce- O Local control of bleeding, which includes: dures there should be consultation with the hematolo- – Smoothing of bone edges, so that the flap edges gist so that the dose of the anticoagulant is reduced or are as close as possible during suturing. even discontinued entirely before surgery, until the – Packing the postoperative extraction alveolus prothrombin time reaches the desired range (1.5 times with absorbable gelatin sponge or oxidized cel- the normal level, maximum). More specifically, the lulose, and suturing of the wound. prothrombin time must be within a range of 17–19 s – Biting gauze at the extraction site for approxi- on the day of surgery, with gradual reduction of the mately an hour. therapeutic dosage at least 2 days beforehand. O Following postoperative recommendations, namely: After surgery, the prothrombin time is restored to – Continuation of administration of medication at the previous therapeutic levels with a gradual increase the dose and time schedule as instructed by the over a period of 2 days. hematologist. Today, the correct measurement of anticoagulation – Avoidance of administration of acetylsalicylic is based on the INR (International Normalized Ratio), acid (aspirin) and other nonsteroidal anti-in- which must be between 2 and 3 if the anticoagulation flammatory drugs (indometacin), which produce therapy is indicated for prophylaxis of venous throm- 8 F. D. Fragiskos bosis or atrial fibrillation, and range 2.5–3.5 if it is in- abscess) in a patient with heart disease who takes anti- dicated for patients with prosthetic heart valves. Un- coagulants and it is not possible to measure the pro- complicated dental extractions or minor osteotomies thrombin time, the dental procedure must be per- can often be performed at an INR of 2.0–3.5. For ex- formed in a hospital with meticulous local measures to tensive surgical procedures the INR should be 1.6–1.9, control bleeding. so that the risk of bleeding is reduced. A reduction of It has been suggested that reduction or discontinu- the oral anticoagulant should be weighed up against ation of the anticoagulant is not necessary for minor the risk of general complications together with the surgical procedures, if care is taken to control the treating physician. The dentist must never reduce the bleeding and inhibitors of fibrinolysis are used oral anticoagulant without close consultation of the (tranexamic acid), for at least 2 days postoperatively. treating physician. Heparin Drugs. Unfractionated heparin is usually 1.18 only administered to hospitalized patients, because Hyperthyroidism it is given parenterally. Its effect lasts approximately 4–8 h, but it may be prolonged for up to 24 h. Hyperthyroidism is a condition that refers to an excess Heparin may be discontinued at least 4 h before the of thyroid hormones, due to hyperfunction of the thy- scheduled dental procedure. Postoperatively, if there is roid gland. no profuse bleeding, heparin may be administered Thyrotoxic patients present with anxiety, irritabili- again the very same day, in dosages that have been ty, hyperactivity, profuse sweating, tremor of the adjusted accordingly. hands, insomnia, weight loss because of increased me- Recently, heparin with low molecular weight (e.g., tabolism, tachycardia, arrhythmia, increased blood Clexane, Fraxiparine, etc.) has been widely used for pressure, weakness, and exophthalmos (71%). the prevention of deep vein thrombosis. Patients un- In certain circumstances, thyrotoxic patients may der this type of medication do not need to adjust their develop thyrotoxic crisis, that is, acute worsening of dosages before any surgical procedure, nor do they re- the thyroid symptoms mentioned above. Patients with quire screening laboratory tests. this condition have fever, marked tachycardia, ar- rhythmia, abdominal pain, profuse sweating, nausea, Aspirin-Containing Compounds (Aspirin). Patients congestive heart failure, pulmonary edema and per- who take aspirin for anticoagulant treatment for long haps coma, which in a large number of patients results periods must discontinue its use at least 2–5 days be- in death. Precipitating factors of a thyrotoxic crisis in- fore the surgical procedure and may continue it 24 h clude severe stress, various infections, surgical proce- later. dures, trauma, pregnancy, diabetic ketoacidosis, drugs The aforementioned cases of discontinuing the an- containing iodine, etc. Local anesthesia or surgical ticoagulant treatment require the following screening procedures may precipitate a thyrotoxic crisis, because laboratory tests on the morning of the scheduled sur- of the stress they cause. Therefore, the administration gical procedure: of a sedative is deemed necessary to decrease the stress a. Prothrombin time, for patients receiving coumarin and fear a patient may have. drugs Consultation with a physician is important in the b. Partial thromboplastin time, for patients receiving case of hyperthyroidism, because these patients usu- heparin (except for low molecular weight heparin) ally suffer from cardiovascular disease, which must be c. Bleeding time and prothrombin time, for patients taken into consideration by the dentist so that the receiving salicylates for a prolonged period treatment plan is altered accordingly. Surgical dental management should be postponed until function of Patients receiving anticoagulants because of artificial the thyroid has been normalized by appropriate medi- heart valves, severe venous thrombosis or vascular cal management. grafts who discontinued the therapy in order to have a These patients also present adverse interactions tooth extracted must resume the anticoagulant drug with catecholamines, therefore there is increased risk as soon as possible, because of the increased risk of of having a severe reaction to vasoconstrictors, es- embolism due to thrombi. Tooth extractions in these pecially adrenaline and noradrenaline. Thus, if these patients must be performed in as few sessions as pos- patients, whose cardiovascular system is already sible, so that the period without anticoagulant therapy stimulated by the hyperthyroidism, are given vaso- is limited. If an emergency arises (acute dentoalveolar constrictors, e.g., adrenaline (which is a drug that  Chapter 1 Medical History 9 stimulates the heart), then acute arrhythmia, ventric- according to the regimen in Chap. 16, with incision ular fibrillation or even thyrotoxic crisis may result. and drainage procedures following. Vasoconstrictors must be administered in the low- est concentration possible and definitely after prelimi- Administration of Local Anesthetics. Local anes- nary aspiration. Felypressin is considered the safest thetics must be administered with great care, because vasoconstrictor. of the vasoconstrictor, whose concentration must be minimal. Adrenaline, which is one of the most com- monly used vasoconstrictors, causes glycogenolysis, 1.19 thus interacting with insulin. Noradrenaline has less Diabetes Mellitus of a glycogenolytic effect compared to adrenaline, and so is preferred in diabetics. Generally, though, the Diabetes mellitus is a syndrome characterized by al- amount of vasoconstrictor in an ampoule is very small teration of the metabolism of carbohydrates, proteins, (the greatest concentration being 1:50,000) and so the and lipids and is caused by abnormalities of the secre- risk is considered minor. tion mechanism and effect of insulin. The dentist must be extremely careful about per- Administration of Other Drugs. Mild analgesics and forming surgery on a diabetic patient, as far as the fol- sedatives containing acetaminophen (Tylenol) are lowing are concerned. used. Corticosteroids must be avoided because of their glycogenolytic action, as should salicylates (aspirin), Screening Tests. A recent blood glucose test is due to potentiation of the hypoglycemic action of the important. This test may be performed in the dental antidiabetic tablets. The administration of an anxio- office before surgery using a glucometer, a portable lytic is recommended the previous afternoon and the piece of equipment that is battery operated. A drop of morning before the surgical procedure. capillary blood from the fingertip is placed on the test strip after pricking with a special lancing device, Wound Healing. Surgical procedures in the oral cav- and within 1 min a numerical value appears on the ity must be performed with gentle manipulations for screen. optimal wound healing. Bone edges must be smoothed in order to avoid irritation of the gingiva. Suturing Scheduled Time of Surgery. In order to avoid the may be helpful. risk of a hypoglycemic reaction (insulin shock), it is best if surgery is performed in the morning, 1–1.5 h Blood Glucose Level at the Time of Surgery. Gener- after breakfast (insulin’s peak action is noted in the af- ally, there is no specific blood glucose level that is pro- ternoon). This way, the patient comes to the dental of- hibitive for emergency dental procedures. If surgery is fice rested and without stress. not imperative, then it is better if it is postponed and the patient’s blood glucose level is controlled. Diet. The diabetic’s diet must not be altered before or after the surgical procedure. Before surgery, and par- Dental Office Supplies. For treatment of an emer- ticularly afterwards, the patient often neglects to eat gency situation such as hyperglycemia or hypoglyce- their meal or cannot because of the pain and bleeding, mia, insulin, sugar or glucose solution, saline solution, with hypoglycemia resulting. glucose, etc. should be available at the dental office. Diabetic hypoglycemia is most important, present- Postoperative Recommendations. Patients with ing when the blood glucose level is below 55 mg/100 ml. controlled diabetes do not require preoperative or It appears rapidly and is characterized by hunger, postoperative antibiotic prophylaxis. These people distress, fatigue, sweating, vertigo, trembling, pallor, should be treated in the same way as nondiabetic den- feelings of anxiety, headache, mental confusion, par- tal patients. esthesia, diplopia and blurred or decreased vision, convulsions and neurological disorders. In more se- Presence of Infection Before Surgery. All infections vere cases, excessive perspiration, muscle hyperten- – especially those with fever and suppuration, by stim- sion, localized or generalized convulsions, and finally, ulating the release of catecholamines and glucagon – loss of consciousness, coma, and death are observed. are considered risk factors for hyperglycemia and must Diabetic hyperglycemia develops slowly, is observed be treated as quickly as possible. Antibiotics are ad- more rarely and is less dangerous than hypoglycemia. ministered in the case of acute dentoalveolar abscess, It is characterized by weakness, headache, nausea, 10 F. D. Fragiskos vomiting, diarrhea, xerostomia, dehydration, dyspnea, rhagic diatheses (thrombocytopenia in 50% of cases), and, finally, lethargy resulting in a coma. as well as other metabolic disturbances. The most common causes of the disease are glome- rulonephritis, hypertensive nephrosclerosis, diabetes 1.20 mellitus, and nephrotoxins. Renal Disease When a surgical procedure is to be performed on the patient, the following preventive measures are nec- The renal diseases that are of particular interest to the essary: dentist are acute glomerulonephritis, chronic glomer- O Consultation with the patient’s treating nephrolo- ulonephritis, and renal failure. gist O In cases of severe anemia, the hematocrit must be at acceptable levels 1.20.1 O Preventive measures to avoid extensive hemorrhage Acute Glomerulonephritis due to hemorrhagic diatheses O Local measures to control bleeding by placing gela- This disease is characterized by acute, diffused in- tin sponge in the socket, as well as sutures for opti- flammation of the glomeruli. It is more common in mal healing of the wound young people and it is caused by group A β-hemolytic O Use of minimal amounts of vasoconstrictors, be- Streptococcus, especially after upper respiratory infec- cause hypertension is usually observed in chronic tion (tonsillitis, otitis, pharyngitis). This is a severe renal failure condition and no surgical procedure is allowed in the O Use of minimal amounts of local anesthetics in oral cavity without consultation with the patient’s order to avoid toxicity treating physician. If deemed absolutely necessary, O Avoidance of any dental procedure on the day of the surgical procedure must be performed in the hos- hemodialysis pital. 1.21 1.20.2 Patients Receiving Corticosteroids Chronic Glomerulonephritis Patients who are to have oral surgery and who take This disease presents without symptoms in the initial corticosteroids must be managed in such a way to avert stages, the findings being proteinuria and the presence the possibility of acute adrenocortical insufficiency of hemorrhagic casts in the urine. Hypertension, head- due to stress because of the imminent surgical proce- ache, anemia, and polyuria are also observed. This dure. There are, however, various opinions as to the disease develops slowly and eventually the renal pa- criteria that determine which patients are at risk of renchyma of both kidneys is destroyed, leading to developing acute adrenocortical insufficiency and renal retraction. which are not. Patients with this disease may undergo surgery According to Glick’s recommendations: without prophylactic antibiotics. The following, how- a. Patients who have received glucocorticoids during ever, are considered necessary: the last 30 days should be considered immunocom- O Consultation with the patient’s treating physician promised, and, as such, should be administered O Constant monitoring of blood pressure before and supplementation. during the surgical procedure, because these pa- b. Patients who have received glucocorticoids in the tients are usually hypertensive past, but not during the last 30 days, are considered able to respond to stress and therefore do not need supplementation. 1.20.3 c. Patients who receive glucocorticoids on a long-term Chronic Renal Failure basis, using an alternate-day regimen, should have the surgery performed on the day they are not hav- This is a clinical syndrome characterized by perma- ing therapy. These patients do not require an in- nent kidney damage, resulting in impaired glomerular crease of their dosage of glucocorticoids. and tubular function. Patients with chronic renal fail- d. Patients who receive glucocorticoids on a regular ure develop anemia, and, in advanced cases, hemor- basis (daily), in doses greater than 10 mg predni-  Chapter 1 Medical History 11 sone (10 mg of Prezolon or 8 mg of Medrol), should may provoke paroxysmal attacks of asthma. The attack be considered immunocompromised and do need presents with expiratory dyspnea, which is accompa- supplementation. nied by exertional nonproductive cough with wheez- ing. The patient’s expression is anxious, their face is Supplementation involves the administration of pale and cyanotic, and the patient has cold limbs and 100 mg hydrocortisone (Solu-Cortef) intramuscularly perspires. or intravenously, before surgery. If the surgical proce- An acute asthmatic attack is one of the most com- dure proves to be particularly painful or prolonged, mon respiratory problems encountered in the dental then the supplementary administration of 50–100 mg office. Immediate treatment is required, so that fur- hydrocortisone is recommended 6 h later. It is recom- ther deterioration of the patient’s condition is avoided, mended that the total dose administered does not which may otherwise lead to a condition called status exceed 250 mg. asthmaticus. This condition is a severe form of parox- Despite the aforementioned recommendations and ysmal asthma, and is refractory to the usual therapy adhering to the recommendations of the patient’s phy- for asthma. sician, the dentist must be prepared to face the possi- As for patients with a history of asthma who are bility of a crisis of acute adrenal insufficiency. Com- about to undergo surgery, the dentist must take all mon findings of this condition include weakness, the appropriate precautions to prevent an attack nausea, vomiting, hypotension, confusion, sleepiness, during the dental procedure, as well as be prepared to headache, dehydration and hyperpyrexia, and, if it is deal with an asthma attack, should it occur for any not treated rapidly, it may lead to coma and death of reason. the patient. The preventive measures that are recommended are the following: O Take a detailed medical history of the patient, to de- 1.22 termine the severity of the condition (frequency Cushing’s Syndrome and duration of attacks) O Administration of sedative medication for stress Apart from the cases of insufficient corticosteroid se- management, which is a precipitating factor in an cretion, the patient may present with a pathologic con- asthmatic attack dition characterized by hypersecretion of hormones O Control of pain (to avoid stress), with sufficient du- from the adrenal cortex. Cushing’s disease or hyper- ration and depth of local anesthesia adrenalism causes this condition. O Short appointments, with gentle manipulations The preventive measures that are recommended for during surgical procedure patients of this category who are to have dental sur- gery are the following: O The surgical procedure should be performed in a 1.24 hospital with the cooperation of the patient’s physi- Tuberculosis cian O Sedative medication must be administered Tuberculosis is an infectious disease that is caused O In the case of a tooth extraction, manipulations by Mycobacterium tuberculosis, otherwise known as must be performed carefully, because there is risk Koch’s bacillus, and may affect all organs, though the of fracture due to severe osteoporosis of the jaw lung is the most common site. Unfortunately, recently there has been an increase in the number of infected persons internationally, generating fear of an even 1.23 greater spread. Asthma Clinical signs and symptoms include persistent cough, which becomes productive with sputum that is This chronic condition, characterized by paroxysmal nonpurulent and may contain blood. Fever, anorexia, dyspnea with coughing, presents with stenosis of the weight loss, and lassitude are also noted. duct of small bronchi and bronchioles, due to bron- People as well as animals suffering from tuberculo- choconstriction, edema of the mucosa, and viscous sis transmit disease. The mycobacterium enters the mucous production. Asthma affects children and body by way of the respiratory system and more rarely adults, while 50% of the cases are due to allergy. Stress, via ingestion. allergy, and temperature changes, among other things, 12 F. D. Fragiskos In the dental office, transmission of the disease may O Programming the surgical procedure as the last ap- occur by way of droplets containing mycobacteria pointment of the day. (mainly when the patient coughs during various den- O Using two pairs of disposable gloves. Gloves protect tal procedures). the patient as well as the dentist and should be dis- The following necessary precautionary measures to carded immediately after use. prevent spread of the disease must be taken in the den- O Special protective glasses and disposable surgical tal office: mask. O Patients presenting with symptoms that suggest O Special protective surgical gown and cap covering clinically active tuberculosis must be referred for scalp hair. a physical examination, to verify the current sta- O Disposable needles. Great care should be taken dur- tus. ing their use, in order to avoid accidental puncture. O Dental treatment of patients with clinically active Also, the plastic cover of the needle should be re- tuberculosis of the lungs or larynx should be post- placed with the special resheathing device only. poned until it is confirmed that there is no danger This should be a standard technique for all pa- of transmitting the disease. tients. O If emergency dental treatment is deemed necessary O Discarding of surgical blades and disposable nee- in a patient with active tuberculosis or if the patient dles in a rigid sharps container, which is sealed has signs and symptoms suggestive of tuberculosis when full and is removed from the dental office of the lungs or larynx, then the treatment should be should also be a standard. rendered in a hospital. The dentist and staff who O Collecting all garbage (saliva ejectors, plastic cups, come into contact with these patients should take gloves, masks, gauze, etc.) in a tough nylon bag. additional protection measures (e.g., surgical mask, O After the surgical procedure, disinfection of certain disposable gown, etc.). objects with a virus-active disinfectant according to the local hygiene guidelines (exposed parts of the dental chair, the dentist’s stool, spittoon, etc.). 1.25 O Sterilization of all instruments that were used in an Infectious Diseases autoclave, after they are cleaned and disinfected (Hepatitis B, C, and AIDS) manually or preferably by an automat. AIDS and hepatitis B and C are infectious diseases that are worldwide health problems and are found in 1.26 all social classes. Therefore, both the dentist and the Epilepsy patient need to be protected against transmission. The medical history of the patient is significant and Epilepsy is the clinical manifestation of abnormal precautionary measures must be taken especially electrical activity of the brain, which leads to motor where high-risk groups are involved; namely, patients activity and altered states of consciousness. who undergo hemodialysis, drug-users, homosexuals, Epileptic patients are administered specific drug patients who have blood transfusions on a regular ba- therapy and may present with epileptic seizures under sis, and people who come from countries where the certain circumstances. The main factors that precipi- incidence and prevalence of these infectious diseases tate such seizures include severe stress, alcoh