Oral Surgery 2 (Midterms) PDF

DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina ORAL SURGERY 2 (MIDTERMS) Dr. Glaiza L. Sarmiento POST-OPERATIVE SURGICAL COMPLICATIONS FAT PAD PROLAPSE...

DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina ORAL SURGERY 2 (MIDTERMS) Dr. Glaiza L. Sarmiento POST-OPERATIVE SURGICAL COMPLICATIONS FAT PAD PROLAPSE Epulis Granulomatosa ❖ Incision extended beyond the MGJ then the fat on the cheeks go out ❖ just remove it by incision FRACTURED MAXILLARY TUBEROSITY ❖ when you apply excessive force on forceps adaptation or delivery of tooth SOFT TISSUE INJURIES ❖ Part of the maxilla is completely unattached No other choice but to remove it ❖ Tearing mucosal flap ❖ Part of the maxilla is still attached ❖ puncture wound of soft tissue just leave it ❖ stretch or abrasion injury PREVENTION OF SOFT TISSUE INJURIES ❖ Pay strict attention to soft tissue injuries Angular Cheilitis — common in 3rd molar surgeries ❖ Use adequate sized flap Heals from side to side not ❖ Use minimal force for retraction of soft tissue ❖ Use correct armamentarium COMPLICATIONS OF THE TOOTH BEING EXTRACTED ❖ Root fracture ❖ Root displacement ❖ Tooth lost into the oropharynx That's why Deliver Teeth buccally SURGICAL EMPHYSEMA ❖ Too much water or Air during splitting and PREVENTION OF ROOT FRACTURE & sectioning into the fascial spaces DISPLACEMENT ❖ Give antibiotics ❖ Always Plan for root fracture ❖ Prevention: Root tip picks Use 45 deg handpiece ❖ Use “open” technique if probability of fracture is ❖ Milk the flap high ❖ Avoid apical force on fractured root DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina Be aware kd nerve anatomy insurgical area Avoid making incisions or affecting the periosteum in the nerve area (ex. Mental foramen ❖ Injury To TMJ Support the mandible during extraction INJURIES TO ADJACENT TEETH Do not open mouth too wide Higher chance of mandible PREVENTION: dislocation ❖ Recognize potential to fracture large restoration If you can ask patient to ❖ Warn patient preoperatively close mouth just enough for So the patient will know that you the forceps to adapt to the know what you are doing tooth to be extracted ❖ Employ judicious use of elevators ❖ Ask assistant to warn surgeon of pressure on adjacent teeth ORO-ANTRAL COMMUNICATIONS ❖ Fracture of adjacent restorations ❖ Oro-antral perforation ❖ Luxation of adjacent teeth ❖ Oro-antral fistula Return the tooth to the socket, keep pdl Tooth may ankylose MANAGEMENT OF ORO-ANTRAL Remove the occlusal 3rd of the tooth = immobilization, do not use for function Use splints para di gumalaw Do RCT after bc wala nang blood supply l ❖ Accidental removal of crowns, bridges or ortho brackets on adjacent teeth ❖ If 2mm radiographic examination Primary closure ❖ NO excessive force Watertight closure ❖ Use “open” technique as needed to reduce Reduce bone for better coaptation force decongestants antibiotics post-op orders INJURIES TO ADJACENT STRUCTURES recall ❖ Injury or regional nerves DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina Notes: MAXILLARY SINUS DISORDERS AND MANAGEMENT Primary closure → gum to gum Secure clot → gel foam, gauze ❖ Sinus Decongestants → px will have colds; instruct px not to blow communication bet 2 body cavities his/her nose, just wipe the sipon only Dilatation in a vein Connected to the nasal cavity Maxilla is a pneumatic bone bc INTRA-OP / POST-OP BLEEDING contains air ❖ pressure ❖ Paranasal sinuses — 4 paired cavities around the ❖ gelfoam nasal cavities ❖ surgicel Maxillary ❖ topical thrombin Frontal ❖ collagen Ethmoidal ❖ clamping w/ hemostat Sphenoidal DELAYED HEALING / INFECTION MAXILLARY SINUS (ANTRUM OF HIGHMORE) ❖ Infection ❖ Tubular sacs in the embryo ❖ Wound dehiscence ❖ ↑air → ↑size ❖ Dry socket (Alveolar Osteitis) ❖ Maxilla → pneumatic bone → pneumatization Very foul smell, Dull pain ❖ Tubular— children Slow set zoe — put the mayo ❖ Pyramidal — adults consistency on the corner of the 4x4 ❖ Normal average volume of 15-20 ml (air) gauze then pack it inside the socket Slow promotion of Notes: epithelialization So mabagal socket preservation —- collagen, bone graft wound healing But wala max sinus have the same innervation as the teeth so often, when px has sinusitis they thought the pain is coming from the naffeel na pain teeth Have analgesic property Iodoform fast wound healing bcos it INNERVATION OF THE MAXILLARY SINUS promotes faster epithelialization but may ❖ Outer nerve loop ( buccal area) pain so pineprescribe ASAN painkillers MSAN no analgesic property PSAN have antibiotic property Curette yung taas lang na debris, tapos irrigate, pack yung gauze (maluwag), then palitan yung wound dressing if possible everyday Other way na di raw agree iba: Curette to promote bleeding FRACTURE OF THE JAW ❖ Due To excessive force when removing impacted lower 3rd molars ❖ Debridement ❖ Inner nerve loop (palatal area) ❖ Reduction Nasopalatine nerve ❖ Fixation Anterior palatine nerve (Greater palatine nerve) –------------------------------------------------------ Posterior palatine nerve (Lesser palatine nerve) - soft tissues DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina ❖ But if wala take a radiograph na diff angle PREVENTION OF ORO-ANTRAL COMMUNICATION FUNCTIONS OF THE MAXILLARY SINUS ❖ Pre operative eval of the tooth to be extracted ❖ Resonance to voice ❖ Avoid excessive apical force ❖ Warm and moisten the air before it enters the rest of the respiratory tract SIGNS OF OA PERFORATION ❖ Reduce the weight of the skull ❖ Protects the respiratory tract from harmful ❖ Unilateral epistaxis particles suspended in the inhaled hair (cilia) ❖ Increased bleeding Thru the socket ❖ Air passing freely thru oral cavity and nasal cavity SCHNEIDERIAN MEMBRANE ❖ Fluid passing freely through nasal and oral ❖ Consistency - malauhog na buko cavities ❖ No radiographic- di nakikita ❖ Malamig pag humihinga ❖ super thin ❖ Blood Clot if not collagen sponge to close ❖ inflamed = sinusitis ❖ Fistula formation may occur ❗️REMINDER ❗️ CLINICIAN PATIENT Dont probe Dont smoke Dont place any dressing Sont use straw to prevent possible Dont rinse vigorously pushing of the membrane Dont suck Dont irrigate Dont Play w the wound FACTORS W/C AFFECT THE HEALTH OF THE Dont create negative using the tongue MAXILLARY SINUS pressure inside the sinus Dont strain (lifting heavy given that you already objects) ❖ patency of the ,axillary ostium know about a perforation No strenuous activity ❖ Good Function of cilia ❖ Moderate secretion of mucus by goblet cells ❖ Effective control of mucus flow of mucus through ostium into the nasal vestibule PRIMARY CLOSURE OF AN ORO-ANTRAL ❖ No allergy PERFORATION ❖ No inflammatory diseases of the sinus ❖ no hyperplasia nor hypertrophy of the Schneiderian membrane ❖ no intro of infection from eustachian tube, nasolacrimal duct or from the oral cavity ODONTOGENIC SINUS INFECTION ❖ Pag may radiolucency, natutunaw yung bone bet sinus and yung tooth ❖ If may break yung line = perforation DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina ❖ U-shaped is not recommended bcos GPNs will BERGER'S TECHNIQUE not be included ❖ Pedicle = tongue shape ❖ Create an inverted letter U, twist it and cover the socket Include the blood supply of the flap, if hindi you'll just create necrotic tissue Para may blood supply, di ma damage si gpn ❖ flap deflecting beyond mucoperiosteum/MGJ to ❖ The exposed palatal bone can use dressing para be able to reposition the flap di exposed ❖ You have to create a flap extending to the ❖ Put periodontal dressing dun sa exposed bone mucogingival junction or the periosteum (same dressing na ginagamit for dry socket ❖ Flap deflection beyond the periosteum ❖ Usually a trapezoidal flap ❖ Deflect beyond the mucogingival junction = watertight closure Buccal to palatal ❖ Bone reduction, Have to remove bone So that ano daw wala na attachment ang alin ❖ Crush w bone rongeur, smoothen w bone file Kahit mag flat ridge, okay lang kesa sa ileave ng open ❖ horizontal mattress suturing technique is advised to achieve watertight closure MEMBRANE ASSISTED CLOSURE On the palatal Simple interrupted on the buccal ORO-ANTRAL FISTULA ❖ Non recognition or non closure of Oa perforation ❖ Epithelization of OA perf from gingiva and schneiderian membrane ❖ very foul smell PALATAL PEDICLE FLAP DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina ODONTOGENIC INFECTIONS ❖ Origin/location Dental Periodontal Dentoalveolar Soft Tissues Combination ❖ Clinical Course acute sub-acute chronic Ex. RF w/ fistulas MAJOR ORIGINS OF OROFACIAL INFECTIONS MANAGEMENT OF CHRONIC OA FISTULA 1. Emptying of necrotic contents of the antrum (curettage): caldwekk-luc or sinus lavage a. Content of max sinus: 15-20mL b. Lavage: Flush out the contents ❖ Cellulitis c. If lavage = may sasalo dapat sa water most severe among the three bcos u sa nose can't pinpoint the origin d. Sterile NSS, thin tube, 20cc syringe Aerobic And anaerobic bacteria e. Thru the perforation, insert the tube not enough ang amox and flush out NSS prescribe clinda, co amox, 2. Maintaining patency of max ostium: intranasal Metronidazole Antrostomy; removal of polyps 3. Antibiotic therapy a. Address the infec PERIODONTAL b. Amox - broad spectrum (not suitable ❖ Gingival (Local/diffused) for chronic infec) ❖ Periodontitis (no bone loss) c. Metronidazole, clindamycin for ❖ Periodontitis (horizontal bone loss w/ pocket) chronic ❖ Periodontitis (vertical bone loss w/ pocket) 4. Culture and sensitivity test ❖ Mobility and Suppuration a. To know what bacterias are present sa suppuration — when u press the max sinus, then yung antibiotic tooth, the abscess comes out therapy, yun yung iaaddress na infection 5. Closure of oro antral fistula —------------------------------------------------------- DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina 2. Progression to mixed aerobic and anaerobic OROFACIAL INFECTIONS BASED IN infections ETIOLOGIC AGENT 3. Finally, infection ends mainly anaerobic 1. Bacterial — Antibiotics bacteria (fusobacterium) and bacteroides 2. Viral — Self limiting which leads to chronic abscess 3. Fungal - Fistula 4. Others - Orofacial sinuses MO PERCENTAGE SEQUENCE OF EVENTS Aerobic 6% 1. Pulpal or periodontal infec 2. Perforation of the cortical plate of the bone Anaerobic 44% 3. Cellulitis (induration)/ fascial space involvement Mixed 50% - Induration: Prev soft area is now hard **if mixed, kaya unang pineprescribe is amoxicillin kasi 4. Localization broad spectrum drug, u hope na whatever is causing the - Dating dispersed pamamaga, infection ay mawala magllocalize in one area and when u touch that area, fluctuated MO's CAUSING ODONTOGENIC INFECTIONS 5. Abscess formation (fluctuance) Larry Peterson - Pimpling?? May yellow sa gitna, thats when you’ll know that incision and AEROBIC (25%) ANAEROBIC (75%) drainage is needed - I&D is only done in this stage, pag Gr + Cocci 85% Gr + Cocci 30% matigas pa di pa dapat Strep spp. 90% Strep spp. 33% - Instruct px to do warm compress if u want to accelerate the stage from Strep grp D 2% Peptostrep 66% cellulitis to abscess formation Eikenella 2% Gr - Cocci 4% CELLULITIS (PHLEGMON) Gr-Neisseria 2% Gr + Rods 14% Gr + Rods 3% Gr - Rods 50% Gr - Rods 6% Bacteroides 75% Miscellaneous & 4% Miscellaneous & Undifferentiated Undifferentiated Note: There are 600+ types of bacteria living in the mouth MOST ODONTOGENIC INFECTIONS 5. From indigenous bacteria a. Found in the OC lang 6. Polymicrobial in nature a. no specific bacteria that causes the inf. (halo-halo na sha) SURGICAL MANAGEMENT OF CELLULITIS 7. Both aerobic (25%) and anaerobic (75%) MILD SEVERE PROGRESSION OF ODONTOGENIC INFECTIONS Remove cause Remove cause: I&D 1. usually start with highly virulent bacteria (strep) which leads to acute cellulitis Antistrep antibiotics Antistrep antibiotics DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina Resolution ? Resolution ? COMPLICATIONS OF DENTAL ABSCESS ❖ Cavernous sinus thrombosis (If not).... ❖ Ludwig's angina Incision and drainage (If di pa Additional Surgery ❖ Necrotizing fasciitis rin nagwork antibiotics) ❖ Orofacial sinus ❖ Osteomyelitis ❖ Septicemia ACUTE PERIAPICAL ABSCESS Immunocompromised patients that ❖ Not affected cortical area have poor oral hygiene ❖ Apical only ❖ Curettage SURGICAL MANAGEMENT OF DENTAL ABSCESS ❖ Remove cause, I&D ❖ Antistrep, antibiotic, anti anaerobic ❖ Resolution ❖ If not, additional surgery CELLULITIS VS. ABSCESS PROBING FISTULA CHARACTERISTIC CELLULITIS ABSCESS Duration Acute Chronic Pain Severe / Localized Generalized Size Large Small Location Diffuse border Well - circumscribed CUTANEOUS FISTULA Palpation Doughy to Flcutuant Indurated Suppuration No Yes Degree of Greater Less Seriousness Bacteria Aerobic Anaerobic DRAINAGE OF ABSCESS ❖ Low attachment of buccinator muscle FACTORS W/C DETERMINE SPREAD OF Pus will drain above the muscle ODONTOGENIC INFECTIONS Will go the the buccal space More prone to cellulitis ❖ thickness of bone around infected tooth ❖ High attachment of buccinator muscle Laterals usually drain on the palatal, Pus will drain below the muscle and CI on the buccal Will go to the vestibule ❖ position of muscle attachment in relation to root tip ❖ virulence of the bacteria Note: abscess will drain on the area w/ least resistance and ❖ patient’s host defense closer to the origin DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina FACTORS W/C DETERMINE ROUTE OF PUS Lower 2nd Buccal Below Oral DRAINAGE THROUGH THE CORTICAL PLATE M Vestibule Above Buccal Space ❖ Thickness of bone overlying the apex of the affected tooth/teeth Lingual Below Sublingual Space Level of the site of perforation of the bone relative to the muscle attachments of the Above Submandibul maxilla and mandible ar space Lower 3rd M Lingual Above Submandibul SITES OF LOCALIZATION OF ACUTE ar space Pterygoman DENTAL INFECTIONS dibular space INVOLVED USUAL EXIT RELATION OF SITE OF TEETH FROM BONE MUSCLE LOCALIZATI ATTACHMENT ON TO ROOT APICES FASCIAL SPACES ❖ The fascial spaces are potential spaces Upper CI Labial Above Oral Vestibule ❖ Healthy indiv manipis lang ❖ The fascial spaces are bounded by the fascia, Labial Above Submental Lower CI which may stretched or perforated by the Space Below Oral purulent exudate, facilitating the spread of Vestibule infection ❖ These spaces are absent in a healthy indiv Upper LI Labial Above Oral Vestibule Palatal Palate Lower LI Labial Above Submental Space Below Oral Vestibule Upper C Labial Above Oral Below Vestibule Palate Labial Below Oral Lower C Vestibule Upper Pm Buccal Above Oral Palatal Vestibule Palate Buccal Below Oral Lower Pm Vestibule Upper M Buccal Above Oral Palatal Below Vestibule Palate Buccal Space Lower 1st M Buccal Below Oral Lingual Vestibule Above Buccal Space Below Sublingual Space DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina INFRATEMPORAL SPACE MAXILLA MANDIBLE ❖ Superior extension of the pterygomandibular Pterygopalatine space Superficial sublingual space space Infratemporal space Deep sublingual space Canine space Submandibular space Lateral pharyngeal space Medial pharyngeal space Submasseteric space PRIMARY SPACES IN PRIMARY SPACES IN MAXILLA WHERE INFEC MANDIBLE WHERE INFEC COULD DRAIN COULD DRAIN Buccal space Sublingual space Infratemporal space Submental space Canine space Submandibular space Buccal space SUBMENTAL ABSCESS SECONDARY SPACES IN ❖ Superior: mylohyoid muscle MANDIBLE WHERE INFEC COULD DRAIN ❖ Lateral: anterior belly of the digastric muscle ❖ Inferior: superficial layer of the deep cervical Pterygomandibular space fascia above the hyoid bone; platysma m. and Retropharyngeal space overlying skin Submasseteric space SUBLINGUAL ABSCESS ❖ Superior: floor of the mouth ❖ Inferior: mylohyoid m. ❖ Anterior and lateral: inner surface of the body BUCCAL SPACE ABSCESS of the mandible ❖ Bet the buccinator and masseter muscles ❖ Posterior: hyoid bone ❖ Superior: pterygopalatine space ❖ Inferior: Pterygomandibular space SUBMASSETERIC ABSCESS ❖ cleft-shaped ❖ bet. the masseter m. and lateral surface of the ramus of the mandible ❖ Posterior: parotid gland DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina ❖ Anterior: mucosa of the retromolar area PRINCIPLES OF TREATING INFECTIONS 1. DETERMINE THE SEVERITY OF THE INFECTION ❖ complete history ❖ Evaluate clinical signs and symptoms ❖ Check for fever and general body malaise ❖ Determine meds Take and prev Tx ❖ Vital signs ❖ Check for swelling: hard, soft, warm, localized, diffuse, etc. SUBMANDIBULAR ABSCESS SEVERITY OF INFECTION ❖ Lateral: inferior border of the body of the ❖ Onset mandible ❖ Duration ❖ Medial: anterior belly of the digastric m. ❖ Rapidity and progress ❖ Posterior: posterior belly of the digastric m. ❖ S/s ❖ Superior: mylohyoid m. ❖ Vital signs ❖ Inferior: superficial layer of the deep cervical fascia 2. EVALUATE STATE OF PATIENT'S HOST DEFENSE MECHANISM ❖ Uncontrolled metabolic diseases uremia Alcoholism Malnutrition Severe diabetes m. ❖ Suppressing dses Leukemia Lymphoma Malignant tumors ❖ Suppressing drugs PTERYGOMANDIBULAR ABSCESS cancer suppressing drug ❖ Lateral: medial surface of the ramus of the Immunosuppressive drugs mandible ❖ Host’s defense mechanism ❖ Medial: medial pterygoid m. immunocompetent ❖ Superior: lateral pterygoid m. Immunocompromised ❖ Anterior: pterygomandibular raphe Immunosuppressed ❖ Posterior: parotid gland Px who received organ transplant- immunosupp drugs- until the body accepts the organ *pregnant women- not immunocompromised; just restrictions 3. DETERMINE WHETHER TO TREAT PATIENT OR REFER TO SPECIALIST/ER ❖ Criteria for referral Rapid progressive infection ———————————————————————————————— Dyspnea Dysphagia Fascial space involvement DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina Elevated body temperature - higher ❖ In treating infections, it is essential to remove than. 40 deg the source of infection surgically and to Severe jaw trismus (1 fing or less) establish drainage for pus as needed Extra oral swelling Toxic appearance Compromised host defenses ❖ When to go to the OR To establish airway security Moderate to high anatomic security Multiple space involvement Rapidly progressing infec Need for GA 4. TREAT THE INFECTION SURGICALLY ❖ For small acute abscesses Endodontic Tx to evacuate pulpal remnants and to establish limited drainage (consider prognosis) Endodontic tx w apicoectomy and periapical curettage blade faces up Tooth extraction- removal of cause why need for a drain — to prevent reinfection,, bc even if with drainage through the socket you prescribe the strongest antibiotic, it wont resolve on Incision and drainage as adjunct to its own. There is a need for surgical intervention endo or exo When u do i&d dapat yung MANAGEMENT OF ACUTE DENTAL ABSCESS blade upwards,, if downwards magccause ❖ Drainage — tooth exo or rct pressure inwards and ❖ Incision — intraoral or extraoral therefore cause ng pain sa ❖ Removal of source of infec px endo tx Why the need for a drain tooth exo to make sure that periradicular surg u remove all ❖ Supportive antibiotic therapy abscess within the severe spreading inf cavity systemic toxicity medically-compromised TREAT THE INFECTION SURGICALLY Abscesses should be drained to establish dependent drainage ❖ consider culture and sensitivity test prior to I & (from the most gravity dependent point) D ❖ C & S test a must when empirical antibiotic tx produces no improvement CULTURE AND SENSITIVITY TEST (CST) ❖ I & D best done when fluctuance is ❖ identifies MOs involved in the inf present. Why? ❖ suitable antibiotics to suppress the etiologic If diffused pa yung border ng lesion, if MOs pinoke walang pus na magddrain If fluctuant, may localization na yung pus kaya ma ddrain na lahat SWAB FOR CST If diffused pa, do hot compress to lead ❖ Aspiration yung pus in one area Ga 16 or 18 Kung saan mainit dun Small lumen of needle (if Ga 27, 30) = pupunta yung pus false negative, baka di pumasok yung abscess kasi masyadong maliit Cystic lesion- color urine DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina No need for antibiotics ❖ point of incision should be below the eye of the Abscess- yellowish, opaque, malapot abscess (most gravity dependent point) ❖ insert closed hemostat into initial incision and move within abscess cavity with forceps closed ❖ Move forceps laterally to puncture individual pus pockets ❖ Push on the surface to evacuate pus externally ❖ Collect pus for CST ❖ Insert and stabilize drain with sutures Sometimes dinedrain through tooth yung abscess. If so, cotton FLUCTUANCE lang nilalagay instead na tf para matakpan from food debris at the same time may lumalabas sa tooth. LANGER'S LINES ❖ different incisions per part of the body acc to the muscle direction to not cause scar formation ❖ Parang malaking pimple ❖ Incise not sa most fluctuant area (yung yellow spot sa gitna) ❖ Instead sunod nalang yung langer lines para di SPONTANEOUS DRAIN DUE TO HEAT magcause ng scar formation — not esthetically pleasing ❖ Apply Warm on the area, mabubutas siya INCISION & DRAINAGE ❖ (Nylon) Monofilament suture is recommended PROPER BLADE ANGULATION I & D ❖ Why is it needed? Won't resolve on its own, needs surgical intervention. ❖ Check for fluctuance ❖ If none, induce fluctuance How? Apply warm compress or warm rinse ❖ Swab with 10% povidone iodine starting At the ❖ Ilalim ng mata/ most fluctuant area point of puncture in a circular manner outwardly, never go back inwards toward point TYPES OF DRAINS of puncture ❖ Swab w alcohol starting at point of puncture outwardly again ❖ Use blade 11 for stab incision with cutting edge facing upward ❖ Prick with the tip of the blade going away from pus cavity to prevent pressure which will cause pain DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina IODOFORM GAUZE POINTS TO CONSIDER WHEN CHOOSING ANTIBIOTICS ❖ Use narrowest spectrum antibiotic ❖ Use the antibiotic with the lowest incidence of toxicity and side effects ❖ Use bacterial antibiotics, if possible (not Bacteriostatic) ❖ Consider patient compliance (shorter duration less frequency) 5. SUPPORT THE PATIENT MEDICALLY ❖ Consider drug cost relative to patient's ability to buy ❖ address symptoms accordingly (palliative care) ❖ alleviate pain w/ analgesics ❖ antipyretics for fever LOCAL INDICATIONS FOR ANTIBIOTICS ❖ rehydrate as needed (orally or IV) ❖ Rapidly progressing infections ❖ comfort measures ❖ Diffuse edema ❖ cold compress ❖ Compromised host defenses (diabetes cancer ❖ (Medicated) mouthwashes immunosuppressed px) 1% povidone iodine ❖ Involvement of fascial spaces Chlorhexidine ms nacu what is our ❖ Severe pericoronitis protocol ❖ Osteomyelitis of the Jaw ( inflammation of the ❖ adjust diet as tolerated bone) ❖ refer to/consult specialist for co-morbids If immunocompromised px ANTIBIOTICS NOT NEEDED IN THE FF LOCAL CONDITIONS 6. CHOOSE & PRESCRIBE APPROPRIATE ANTIBIOTIC ❖ Chronic, well localized abscess Maddrain sponti lang ❖ penicillin ❖ Minor vestibular abscess ❖ Amoxicillin ❖ Dry socket ❖ Clindamycin Prob is there is no blood clot ❖ Azithromycin We only give pain meds ❖ Clarithromycin Mabaho bc of food debris ❖ Metronidazole Only give pain Meds ❖ Mild pericoronitis BASIS OF EMPIRICAL ANTIBIOTIC THERAPY Sometimes pag finuaflush yung area narermove na pericoronitis ❖ More than 90% of odontogenic infections are caused by the ff: Aerobic streptococci INDICATIONS FOR PROPHYLACTIC ANTIBIOTICS Anaerobic streptococci ❖ Prosthetic cardiac valves Peptostreptococcus ❖ Hx of bacterial endocarditis Prevotella ❖ Congenital cardiac malformations (tetralogy of Fusobacterium fallot) ❖ Effective oral antibiotics against odontogenic ❖ Hypertrophic cardiomyopathy infections: ❖ Mitral valve prolapse w/ valvular regurgitation Penicillin backflow of blood (regurgitation) Erythromycin mixing of oxygenated & deoxygenated Clindamycin ❖ Rheumatic & other valvular dysfunctions Cefadroxil rheumatic Metronidazole problems w/ valves Tetracycline MOs that cause rheumatic not for preggers and fever/infections are the children Causes discoloration DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina same etiologic agents in the ❖ Placement of dental implants and heart reimplantation of avulsed teeth other valvular dse. ❖ Endodontic therapy or surgical procedures valvular stenosis (valve do performed beyond the apex not close) valvular regurgitation If u do prophylactic ab better to do rehab (multiple procedures that may have bleeding) If it will cause bleeding prophy antibiotics is needed No bleeding, no need antibiotic prophylaxis ANTIBIOTIC PROPHYLAXIS NOT RECOMMENDED Oral prophylaxis FOR THE FOLLOWING DENTAL PROCEDURES > Supragingival > Subgingival ❖ Placement of prosthetic dentures or > Give antibiotic prophylaxis orthodontic appliance ❖ Impression taking ❖ Fluoride treatment CONTRAINDICATIONS FOR PROPHYLACTIC ❖ Intraoral radiographs ANTIBIOTICS ❖ ❖ isolated atrial septal defect surgically repaired congenital malformations ‼️ REMEMBER ‼️ ❖ previous coronary artery bypass graft surgery ❖ Penicillin is still the drug of choice for oral ❖ mitral valve prolapse w/o valvular regurgitation infections. (bactericidal, narrow ❖ physiologic, functional/innocent heart spectrum,specific) murmurs ❖ Clarithromycin is now the drug of choice for ❖ cardiac pacemaker/implanted defibrillators oral infections if the patient is allergic to mostly are SA node → responsible for penicillin. cardiac rhythm ❖ Clindamycin, is sometimes toxic but useful in cannot use ultrasonic scaler, suspected cases of resistant anaerobes. (mixed) electrosurgery, and other tools that ❖ Cefadroxil and Cephalexin are both good uses electricity Cephalosporins but Cefadroxil is given it will disrupt the pacemaker b.i.d. while Cephalexin is given q.i.d. So...? Tetracycline (Doxycycline) is good for mild IMMUNOCOMPETENT HOST infections but it is not narrow. This is suggested ❖ Penicillin G: 1-4,000,000 IU, IV q4-6h for periodontal problems due to its broad ❖ Clindamycin: 600 mgs IV q6-8h spectrum. ❖ Cefoxitin: 1-2 g, IV 1-2g IV q6h Metronidazole (Flagyl/ Fasigyn) - useful as an ❖ Amoxicillin/Clavulanic Acid: 1-2g, IV q6-8h adjunct to other antibiotics when only ❖ Ampicillin/Sulbactam: 3g, IV q8h anaerobes are involved. ○ Fistula px then mata namamaga na din coamox and metronidazole ❖ IMMUNOCOMPROMISED HOST Piperacillin: 4g, IV q6h Azithromycin is expensive 🤑 ❖ Ticarcillin/Clavulanic Acid: 3.2-5.2g IV q6-8h ❖ Piperacillin/Tazobactum: 4.5g, IV q6-8h 7. ADMINISTER ANTIBIOTIC PROPERLY ❖ Imipenem: 0.5g, IV q6h ❖ Choose route (topical, mucosal, oral, parenteral) ❖ Meropenem: 1g IV, 6-8h If may ludwigs mahirap ang oral ❖ Choose dosage ANTIBIOTIC PROPHYLAXIS RECOMMENDED FOR ❖ Choose frequency THE FOLLOWING DENTAL PROCEDURES Occupation of px Compliance of px ❖ Dental extractions ❖ Choose duration ❖ Periodontal procedures including surgery, 3 days? 5 days? 7 days? scaling and root planing, probing, and recall Depends sa dentist maintenance ❖ Discourage inadvertent, habitual self medication with antibiotics for the slightest infection DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina ANTIBIOTIC FAILURE ❖ Patient non-compliance ❖ Drug not reaching site ❖ Drug dose too low ❖ Wrong bacterial diagnosis PRINCIPLES OF ANTIBIOTIC USE - Depends on sensitivity of pathogenic microbe to the Ab SELECTION - Empirical Approach - Scientific approach (CST) - If swab is taken,,, the most likely organisms cultured will be AEROBIC - Antibiotics cannot diffuse through thick-walled abscesses or CONTACT into poorly-vascularized areas, especially when necrotic areas are present - To increase the efficacy of the antibiotics, ,drain pus and remove necrotic tissues whenever possible 8. EVALUATE THE PATIENT FREQUENTLY Common reasons for failure of infections to heal: - To enhance the effectivity of the antibiotics, give them at regular ❖ Inadequate surgery CONCENTRATION intervals and prescribe in doses ❖ Depressed host defenses which are sufficient to maintain a ❖ Foreign body minimum blood concentration that is necessary to eliminate all ❖ follicular sac- kumot sa ngipin na unerupted the offending pathogens usually nakadikit sa distal ng tooth 7 > curette ng malala - Effective blood levels can be rapidly achieved through ❖ Bony spicules- di nag irrigate parenteral administration especially when infections are severe ACUTE PERICORONITIS - Acute dental infections require 5 to 7 days of antibiotic therapy TIME - Chronic low-grade infections (such as Actinomycosis) may require up to 6 weeks of antibiotic therapy ❖ Gingival overgrowth ❖ Extract opposing para di makagat yung gingiva Aalisin din naman kasi In Clinical Practice, although more accurate, CST creates undesirable delay in the commencement of antibiotic therapy. magssupraerupt sa future Therefore, empirical antibiotics are given first until the results of ❖ Anaerobes; Irrigate with the CST become available. nss: hydrogen peroxide mas better to introduce bubbles DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina PSEUDO LUDWIG'S ANGINA SEQUESTRUM ❖ Wala pa infection yung floor of the mouth ng px **Letter E sa pic** ❖ Fragment or fragments of dead bone separated from healthy bone in necrosis TRUE LUDWIG'S ANGINA ❖ Necrotic bone na kusang humiwalay sa sound bone ❖ Sequestrectomy: surgical removal of sequestra INVOLUCRUM ❖ Diretso sa ER ❖ Raised floor of the mouth (and tongue): hard for px to breathe **Letter C sa pic** LUDWIG'S ANGINA I & D ❖ Healthy bone covering sequestrum ❖ Drain bilaterally ❖ A layer of new bone growth outside the existing bone seen in pyogenic osteomyelitis ❖ Due to stripping off of the periosteum by the OSTEOMYELITIS accumulation of pus within the bone and new bone growing from the periosteum CLOACAE ❖ Inflammation in the bone beginning in the bone marrow extending to involve the periosteum ❖ After the pus in the medullary cavity and beneath the periosteum interrupts the blood supply **Letter D sa pic** ❖ Channels or openings in the involucrum of a necrotic bone DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina SAUCERIZATION CYST ❖ Pathologic cavity ❖ Lining: epithelium ❖ Contents Liquid Semi-solid Gas ❖ Loc ❖ Excision of margins of necrotic bone overlying a Bone pathology which allows visualization of soft tissue sequestra and excision of the affected bone or both ❖ Excavation of a tissue of a wound to form a shallow, saucer-like depression Note: Liquefaction causes cystic lesion if the cyst is not removed ❖ Used for the treatment of Osteomyelitis immediately ❖ To cut the surrounding skin and tissue to make the opening of a cavity ider, thus converting a deep cavity with a narrow opening into a more RADICULAR CYST superficial raw area with a broad opening ❖ From epitheliated granuloma DECORTICATION ❖ Fatty degeneration = cholesterol crystals ❖ Cholesteotoma → cysts mostly made up cholesterin ❖ Removal of chronically-infected lateral and inferior cortical plates of bone 1-2 mm beyond teeth ❖ Removal of portions of the cortical substance of a structure or organ –-------------------------------------------------------- Note: < 3cm : follicular sac > 3 cm : dentigerous cyst PATHOGENESIS DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina Note: Pseudo Cysts - Have no epithelial lining - Defects found within the bone FEATURES OF CYSTS OF THE JAWS TYPE SITE EPITHEL FREQUE RADIOG IAL NCY RAPHIC SOURCE APPEARA NCE RADICUL Any non Debris of Most Round or AR vital malassez common oval HISTOPATHOLOGY tooth of all radioluce ncy ❖ Thick fibrous capsule ❖ Cystic fluid DENTIGE Unerupte Reduced Relatively Radioluce ❖ Foam cells ROUS d teeth enamel common ncy epith. around ❖ Cholesterol slits the ❖ Inflammatory cells/granulation crown of Dentigerous cysts are similar under an the microscope but do not have it unerupte d tooth PERIODO Periodont Debris of Uncomm Round or NTAL al pocket malassez on oval radioluce ncy NASOLA Nasolabia Epith. Very rare Depressi BIAL l fold From on of nasolacri nasal mal duct lateral wall NASOPA Midline Epith. Uncomm Midline LATINE anterior nests at on palatal hard nasopalat radioluce CLASSIFICATION OF CYSTS BASED ON palate ine ncy, fissure lamina MODE OF FORMATION dura of centrals intact ODONTOGENIC NON-ODONTOGENIC (FOLLICULAR) (FISSURAL) STAFNE’ Lingual Not Very rare Small S BONE aspect of cystic but round Primordial Median Mandibular CAVITY mand. submand. shadow Dentigerous Median Palatal body Gland below Incisive Canal inclusion IAC Periapical Nasopalatine Residual ANEURY Usually Not rare Multilocu SMAL mandible cystic lar; MUCOUS RETENTION PSEUDO-CYSTS BONE Soa-bubb CYSTS CYST le Mucocele Solitary Bone Cyst KERATO Angle of Dental Ralitevely Multilocu Ranula Stafne’s Bone Cavity CYST the lamina common lar when Hemorrhagic Bone Cyst mand. large Traumatic Bone Cyst But Aneurysmal Bone Cyst anywhere possible DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina SOUTAR Mand. Not rare Scalloped Y BONE body epitheliu radioluce CYST m lined ncy Primordial Cyst around lower molar roots EFFECT ON PATHOLOGY SITE ❖ Bone types: central, lateral, Gradual, insidious resorption Dentigerous Cyst circumferential Tooth mobility, facial, disharmony, fracture ❖ Soft tissue Impinge on surrounding blood vessels, nerves, lymphatics and glands ❖ Infected Cysts If aspiration is done in an area not disinfected Only then need ng antibiotics from trauma On lip or habitual Not an inflammatory condition so you lip biting Mucocele will not observe pain, redness and inflammation CAVITATION Nasolabial Cyst THE TYPICAL CYST IN THE ORAL CAVITY IS STERILE!!! heart-shaped ❖ It is not usually caused by bacteria and so it Incisive Canal Cyst won’t respond to antibiotics ❖ It is not an inflammatory condition so you will not observe pain, redness and inflammation Cysts w/ Supernumerary Teeth before removing, inform px of Nasopalatine Cyst possible paresthesia due to damaged nasopalatine n. DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina REGARDLESS OF CLASSIFICATION, THERE ARE 4 SURGICAL TREATMENT MODALITIES ❖ Enucleation Complete removal of cystic sac and contents usually on vital tooth Lateral Periodontal Cyst ❖ Marsupialization (Deroofing) exteriorization granuloma can also become ❖ Initial Marsupialization followed by Complete residual cyst if not removed Residual Cyst Enucleation when sufficient bone has formed properly ❖ Surgical Enucleation Peripheral Ostectomy (SEPO) Where bone is removed by a bur 1 mm after enucleation (Carnoy’s solution) Ranula MARSUPIALIZATION ❖ Marsupialization, Decompression, Partsch’s Operation Traumatic Bone Cyst Creation of a surgical window in the wall of the cyst, evacuating the contents of the cyst, and maintaining the continuity between the cyst and the oral cavity DOS 5101 bahia.daquigan.escober.federizo.geroleo.laus.nacu.quiambao.sanquina ❖ The only part of the cyst that is removed is the roof or the part removed to produce the window. The remainder is left in situ. ❖ This procedure decreases intracystic pressure and promotes shrinkage of the cyst and bone fill ❖ Marsupialization may be used as the sole tx or in conjunction w/ enucleation later when the cystic cavity is smaller and there is less danger of damage to peripheral vital structures ❖ Use gauze dressing impregnated w/ antibiotic after marsupialization Iodoform resin “wound packing” put inside the marsupialization should be loosely packed only change weekly; if theres no more bleeding within the cystic lesion, stop changing the dressing have antiseptic property Acrylic Plug after Iodoform resin Px compliance is highly needed bcos they will change the plug by themselves irrigate w/ water or NSS when changing