Oral Surgery II Finals Lessons PDF

ORAL SURGERY II: FINALS LESSONS These facultative organisms can grow in the presence or absence LESSON 1: ODONTOGENIC INFECTION of oxygen. This can be the intitial process of spreading into deeper...

ORAL SURGERY II: FINALS LESSONS These facultative organisms can grow in the presence or absence LESSON 1: ODONTOGENIC INFECTION of oxygen. This can be the intitial process of spreading into deeper tissue ODONTOGENIC INFECTION Rarely found bacterias; Staphylococci, group of streptococcus Are generally caused by bacteria that have a propensity to caused organisms, neisseira spp. corynebacterium spp. and Haemophilus abscess formation. In addition the roots of the teeth provide pathway for infecting bacteria to enter the deep tissue of the THE PREDOMINANT ANAEROBIC BACTERIA IN periodontium and periapical region. Odontogenic infection cause ODONTOGENIC INFECTIONS deep seated abscesses and they always require some of surgical Anaerobic gram postive cocci are found on about 65% of the therapy. cases- Streptococcus and Peptostreptocossus Antibiotic therapy is an adjunctive treatment to the required The Prevotella and Porphyromonas spp. are found in about 75% surgery. Prophylactic antibiotic therapy may prevent distant Fusobacterium orgnanisms are present in more than 50% infection caused by bacteremias arising from oral-maxillofacial surgical procedure and such therapy may also prevent some post- ANAEROBIC BACTERIA WITH SEVERAL GRAM POSITIVE operative wound infection. COCCI Odontogenic Infection arise from teeth and have a characteristic (Ex. Anaerobic streptococcus and Peptrostreptococcus spp.) flora. Caries periodontal disease and pulpits are initiating Anerobic gram positive rods (Ex. Prevotella and Fusobacterium infections that can spread beyond teeth to the alveolar process and Spp.) to the deeper tissues of the face, oral cavity, head and neck. These The anaerobic gram negative cocci and the anaerobic gram infection my range from low grade , we localized infection that positive rods appear to have no role in odontogenic infections require only minimal treatment to severe, life-threatening deep instead they appear to be opportunistic infections. fascial space infection. MICROBIOLOGY OF ODONTOGENIC INFECTIONS MICROBIOLOGY OF ODONTOGENIC INFECTIONS The activity of these mixture of bacterias after initial inoculation( Bacteria that causes infection- most commonly part of the action of immunizing someone against a disease by introducing indigenous bacteria that normally lives in the host. infective material and microorganisms into the body) into deeper Bacteria that causes it are part of normal flora, that compromise tissue the facultative S. Milleri group will synthesize the bacteria of plaque that is found on the mucosal surface and the hyaluronidase which allows the infecting organisms to spread gingival sulcus. This is primarily aerobic gram- positive cocci and through connective tissue, initilaizing the Cellulitis stage of anaerobic gram- positive cocci, anaerobic gram- negative rods. infection. These are the cause of common diseases such as: Metabollic byproducts from the streptococci create an 1. Dental Caries environment for the growth of anaerobes, the release of essential 2. Gingivitis nutrients lowers the PH levels in the tissues and local oxygen 3. Periodontitis supplies the anaerobic bacteria then is able to grow as the local If these bacteria gain accers to deeper underlying tissues through oxidation reduction potential is lowered. The anaerobic bacteria dental pulp or deep perodontal pocket, they cam cause causes liquidification necrosis of tissue by synthesis of odontogenic infection. As the infection progresses more deeply collagenases. Collagen breakdown and the invasion of WBC, different members of the infecting flora can find better growth necrose, lyse and the formation of micro absses that may be condition and begin to outnumber the previously dominant clinically recognized as abcess. species of bacteria. The polymicrobial nature of these infections makes it vital for the clinician to understand the variety of bacteria that are most likely to cause infection By the laboratory examination Odontogenic infections are on average caused be 5 species of bacteria. New molecular methods which can identify the infecting species by thier genetic make-up allow scientists to identify greater numbers of a whole new range of species including unculturabe pathogens. In the future these methods may lead to a completely new undertsanding of the pathogens causing odontogenic infections Another important factor is the oxygen tolerance of the bacteria ABSCESS STAGE- anaerobic bacteria pre dominantly becomes that causes odontogenic infetion. Because the mouth flora is a the only organism found in culture combination of aerobic and anaerobic bacteria, the most common Early infection appearing initially as cellulitis characterized as bacteria found in odontogenic infections aerobic streptococcai infections and later chronic abcess Role of Anaerobic bacteria in odontogenic infection characterized as anaerobic infections o Anaerobic Only- 50% Clinical progression of the infecting flora from aerobic to o Mixed anaerobic and aerobic- 44% anaerobic is correlating with a type of swelling that can be found o Aerobic only- 6% in the infected region THE PREDOMINANT AEROBIC BACTERIA IN ODONTOGENIC INFECTIONS HAS 4 STAGES ODONTOGENIC 1. Swelling- Incubation stage, invading streptococci begins to INFECTIONS colonize when sensing heat. 1.) Steptococcus Milleri - almost 65% found in some cases. This 2. After 3-5 days the swelling becomes red and acutely tender consists of 4 groups of bacteria: as the infection triggers the intense inflammatory response o S. Viridans group of bacteria of the cellulitis stage o S. Anginosous 3. At 5-7 days after onset of swelling, anaerobic bacteria o S. Intermedius becomes predominant, causong a liquification of abscess in o S. Constellatus. the center of the swollen area- this is the Abscess stage ADORNA | ORAL SURGERYSII | DR. WENDY C. ZARATE 1  4. The final stage- abscess drains spontaneously through skin In mandible infection of incisors, canines and pre molar erodes or mucosa- Resolution stage, as the immune system destroys through the facial cortical plate, superior to the attachment of the the bacteria muscles of the lower lip. Resulting in vesticular abscesses most likely they erode at the lingual cortical bone more frequently in NATURAL HISTORY OF PROGRESSION OF the case of anterior teeth. ODONTOGENIC INFECTIONS o 1st molar infection drains buccally and lingually 2 MAJOR ORIGINS OF ODONTOGENIC INFECTIONS o 2nd molar can perforate buccally or lingually 1. Peri- apical- As a result of pulpal necrosis and bacteria o 3rs molar- always erode through the lingual cortial plate invasion into the peri-apical tissue The mylohyoid muscle determines whether the infection that 2. Periodontal- Deep peridontal pocket that allows incubation drained lingually superior to the muscle that makes its way into of bacteria into the underlying soft tissue the sublingual space or below into the submandibular space. Necrosis of the Dental Pulp- Is a deep carries which allow the The most common odontogenic deep faseral space infection is pathway for bacteria to enter the peri-apical tossues. Once vestibular space abscess This infection if not treated raptures incubation of bacteria starts in the tissue an active infection is spontaneously resulting in chronicity of the infection established and the spread of the infection begins in al direction, Sometimes the abscess establishes a chronic sinus tract that at the least restricted areas obstructs the oral cavity or the skin. As long as the sinus tract A contical plate forms because of the infection erodes through the continuous to drain, the patient experiences no pain, antibiotic bone and enters the surrounding soft tissue. Treatment of the administration usually stops the drainage of the infection necrotic pulp can be endodontic or extraction to resolve the temporarily but when the antibiotic course is over the drainage infection. recurrs. The necessary treatment is endodontic surgery or Antibiotics may arrest the bacteria but it won’t cure the infection extraction of the infected teeth because the infection will recurr when the antibiotic therapy has ended, without proper treatment of the dental cause. Once the PRINCIPLES OF THERAPY OF ODONTOGENIC infection erodes through the cortical plate of the alveolar process, INFECTION it spreads into the anatomic location, the infection of the teeth PRINCIPLE 1: DETERMINE SEVERITY OF INFECTION will be determined by 2 factors: - Mild odontogenic infection requre only minor surgical therapy. 1. Thickness of the bone overlaying the apex of the tooth The initial goal is to asses the severity of infection Completed 2. Relationship of the site of the perforation of the bone to the History- The history of the patients infection is important for the muscles attachment of the maxilla and mandible pur[ose of intially finding out the patient’s “chief complaint” The infection perforates through the labial bone overlying the - Typical Chief complaints of a patient with an infection: apex of the tooth because its thin compared with the bone on the “ I have a toothache” palatal aspect, therefore the infection process spreads and goes “My jaw is swollen” into the labial soft tissues. “I have a gum boil in my mouth” In case of the tooth being severely proclined the palate bone - The complaint should be recorded in the patient’s own words become relatively thinner in this situation, the infection spreads History taking: to determine how long the infection has been through the soft tissue at the preatal abscess present. The onset of the infection, how long ago did the first Once the infection evolved through the bone, the location of the symptoms of pain, swelling or drainage are some of the factors in soft tissue infection is determined by the position of the asking when was the start of the infection perforation to the muscle attachments The course of the infection will be discussed if the symptoms of The infection eroded through the facial aspect of the alveolar infection is constant, if the patient’s condition steadily gets worse process and inferior to the attachment of the buccinator muscle take note when was the symptoms first appeared and the rate of resulting resulting to the infection appearing as a vestibular progression of the infection. Identify if the progress is is rapidly abscess. The palatial abscess are from the apex that severely accelerating over a few hours or gradually increased in severity incline lateral incision or the palatal area of maxillary 1st molar over several days or weeks or pre molar are incline The infection eroded through the bone superior to the attachment The severe inflammatory response of the infection will have signs of the buccinator muscle, this infection appears of the buccal as described in Latin terms: space because the buccinator muscle separates the buccal and 1. Pain (dolor) vesticular spaces, the adjacent fascisl space is involved 2. Swelling (tumor) Maxillary infection, teeth erode through the facial conical plate. 3. Warmth (Calor) These infection erode through the bone below the attachment of 4. Erythema redness (Rubor) the muscles that attach to the maxilla, this means that most 5. Loss of function (Functio laesa) maxillary dental abscesses are initially vestibular abscesses The most common complaint is pain and should be asked when Maxillary molar infection can causes erosion through the the pain started and how it spreads from there. insertion of the buccinator muscle resulting to the infection of the 1.) Swelling- Physical finding that is subtle and not to buccal space. In the maxillary canine the roots allows the obvious to the dentist but very evident to the patient. infection through the bone superior to the insertion of levator Ask the patient about the swelling and describe it anguli on the muscle causes infraorbital (canine) space infection 2.) Warmth- Ask the patient if he/she feels warmth when touching the infected area 3.) Redness- redness of the overlying area should be evaluated, ask if the patient notices change of color within the area of infection 4.) Loss of function- check the trismus (difficulty of opening the mouth widely) and any difficulty in chewing, swallowing, or breathing. Finally the general feeling of the patient should be addressed. If the patient feels fatigued, feverish, sick, and malaise which ADORNA | ORAL SURGERYSII | DR. WENDY C. ZARATE 2  usually indicates generalized reaction to a moderate to severe Duration of cellulitis is usually thought to be acute and most infection severe presentation of infection and also more painful than The dentist should also ask the patient about previous professional abscess resulting into acute onset tissue distention. treatment or history of self-treatment Abscess is a sign of increasing host resistance to infection Edema- hallmark of inoculation stage, typically diffuse a jelly- PHYSICAL EXAMINATION like substance with minimal tenderness to palpation, with the size Vital signs including temperature, blood pressure, pulse rate and of cellulitis is typically larger and more widespread that of an respiratory rate abscess or edema Patients who have systemic involvement of infection usually have Abscess- Has distinct and well defined borders, consistency to elevated temperature, patients with such infection have palpation, when palpated abscess feels fluctuant because it is a temperatures of 101 degrees Fahrenheit or higher (greater than 38 pus filled tissue cavity. Localized abscess is typically less degrees Celsius ) dangerous because it is more chronic and less aggressive Pulse rate increased up to 100 beats per minute, patients with Cellulitis- cellulitis is indistinct wit a diffuse border that makes it pulse rate greater than 100 beats per minute may have severe difficult to determine where the swelling begins and end. Always infection and should be treated more aggressively. described as indurated( boardlike) the severity increases as its Elevation of blood pressure should only happen when the patient firmness to palpation, an infection that appears innocuous in its has significant pain and anxiety. Elevation of systolic blood early stages, and extremely dangerous in its more advanced, pressure however is a sign of septic shock resulting in indurated rapidly spreading stages hypertension Edema- can be very soft or doughy and it represents the earliest Respiratory rate should also be observed in odontogenic infection, inoculation stage of infection when it is most easily treated. for there can be potential of partial or complete airway obstruction IN SUMMARY: Edema stages of infection is when it is most as a result of the deep fascial infection in the spaces of the neck. easily treated. Cellulitis is acute, painful with more swelling and Closely monitoring and carefully checking that the upper airway has diffuse boarders hard consistency on palpation and no visible is always clear and the patient is able to breathe without difficulty. pus and may rapidly lead to serious infection. Acute abscess is a Normal respiratory rates is 14 to 15 breathes per minute. Patients more mature infection with more localized pan, less swelling and who may have mild to moderate infection may have elevated well circumscribed boarders, fluctuant on palpation because it is respiratory rates of greater than 18 breathes per minute. a pus filled tissue, once it becomes chronic abscess it becomes Patients with normal vital signs with only a mild temperature slow growing and less serious than cellulitis once abscess has elevation usually have a mild infection that can be treated readily drained spontaneously to the external environment. Patients with abnormal vital sign with elevation of temperature, PRINCIPLE 2 : EVALUATION OF PATIENT HOST DEFENSE pulse rate and respiratory rate commonly have a serious infection MECHANISMS and require a more intensive therapy and evaluation by an oral- - Evaluation of patients medical history maxillofacial surgeon Patients who have worse than a minor localized infection have an MEDICAL CONDITIONS THAT COMPROMISE HOSY appearance of fatigue, feverish, and malaise as referred to a toxic DEFENSES: appearance Uncontrolled metabolic diseases Patients with severe odontogenic infection requiring o Poorly controlled diabetes hospitalization have found triscus in 73% , dysplaxia in 75% and o Alcoholism dyspnea in 14% of the cases. o Malnutrition Areas of swelling must be examined by palpation, the dentist o End stage renal disease should gently touch the area of swelling to check for tenderness, Immune system suppressing Diseases amount of local warmth, and consistency of the swelling o HIV (Human immunodeficiency virus)/ Acquired immuno Patients with severe odontogenic infection requiring deficiency syndrome (AIDS) hospitalization have found triscus in 73% , dysplaxia in 75% and o Lymphomas and Leukemias dyspnea in 14% of the cases. o Other malignancies Areas of swelling must be examined by palpation, the dentist o Congenital ad acquired immunologic diseases should gently touch the area of swelling to check for tenderness, Immuno Suppressive therapies amount of local warmth, and consistency of the swelling. The o Cancer Chemotherapy consistency of the swelling may vary from very soft and almost o Corticosteroids normal to a firmer, flushy swelling (doughy) to an even firmer or o Organ Transplantation hard swelling (indurated), to a tightened muscle, another is Uncontrolled Metabollic Diseases- These compromised the hosts’ fluctuance- a liquid feeling like a filled balloon indicating an defenses because it decreases function of leukocytes, chemotaxis, accumulation of liquid pus in the center of the infection. phagocytosis and bacterial killing The dentist should also check intra-oral examination to find the Immune system supressing diseases- It interfers the host defense specific cause of the infection. Severly cavious teeth, periodontal mechanisms, decrease white blood cell function and the antibody abscess, and severe periodontal disease or it can be a combination sythesis and production of both. Fracture of an infected teeth also may be cause of the Immuno suppressive therapies- Virus like HIV attacks T- infection lymphocytes affecting a persons resistance to viruses and other The dentist should look and feel for areas of gingival swelling, intra cellular pathogens. HIV positive individuals are able to fluctuance and for local vestibular swelling or draining of the combat odontogenic infections, but people with AIDS where B- sinus tract. lymphocytes are severly impaired, the infection is usually more The next step is the radiographs examinations like peri-apical or intense. panoramic x-rays Immunosuppressive Therapies (Pharmaceuticals that The distinction between inoculation, cellulitis and abscess stages compromises host defenses)- Cancer chemotherapeutic agents are typically related to the duration, pain, size peripheral can decrease circulating white blood cells count to low levels, definition and consistency on palpation, presence of purulence, commonly less than 1000 cells per millimiter- patients are unable infecting bacteria. to defend themselves effectively against bacterial invasion ADORNA | ORAL SURGERYSII | DR. WENDY C. ZARATE 3  Patients under immuno suppressive therapy for organ cause of the infection most commonly the necrotic pulp or deep transplantation (autoimmune disease) the common drugs in these periodontal pocket categories are cyclosporine, corticosteroids, tacrolimus(prograt) - The second goal is to provide drainage of accumulated pus and and azathropine(imuran, these drugs decrease the function of T necrotic debris. and B lymphocytes and immunoglobulin production. Patients - Most odontogenic infection causes cavious teeth with a peri- taking these medications are more prone to serious infections apical radiolucency and small vestibular abscess. Surgical options In summary when evaluating a patient with chief complaints of are endodontic treatment or extraction with or without I&D maybe an infection, the patient’s medical history should be I&D procedure may be required if an infection is spreading carefully reviewed for the presence of diabetes, severe renal beyond the peri-apical region. Incision of te abscess or cellulitis disease, alcoholism, malnutrition, leukimias and lymphomas, allows removal of the accumulated pus and bacteria from the cancer, chemotherapy, immuno suppressive therapy of any kind. underlying tissue. This incision decreases the load of bacteria and All of these must be reviewed carefully with a patient that has an necrotic debris, it also reduces the hydrostatic pressure abd infection and must be treated much more vigorously because of decompressing tissues. It improves the blood supply and increases the infection being able to spread more rapidly. the host defenses in the infected area I&D procedure includes insertion of a drain to prevent pre mature PRINCIPLE 3: DETERMINE WHETER PATIENT SHOULD abscess of the mucosal incision which allows the abscess cavity BE TREATED BY GENERAL DENTIST OR ORAL to reform , it is important to remember that the surgical goal is to MAXILLOFACIAL SURGEON achieve adequate drainage Criteria for referral to an oral maxillofacial surgeon I&D of vestibular abscesses or cellulitis is a straight forward o Difficulty of Breathing technique. Intra oral incision is preferred directly on the site of o Difficulty of swallowing maximum swelling and inflammation. Avoid the area across the o Dehydration path of the oral nerve in the lower pre molar region. o Moderate to severe trismus I&D extra orally, it is more complex. Regional nerve block o Swelling beyond the alveolar process Elevated temperature anesthesia and it is preferred for a local infiltration of local o Several malaise and toxic appearances Compromised Anesthetic solution around the area to be drained defense of the host Need for general anesthetics Before the actual incision of the abscess is performed C&S or o Failed prior treatment culture and sensitivity testing must be considered. After the area Most odontogenic infection seen can be managed by minor is anesthetized. The surface mucosa is disinfected with solution surgical procedure and antibiotics, if the treatment is administered of povidon- iodine(betadine) and dried with sterile gauze, 18 rapidly. However some odontogenic infections can be life gauge large needle is used for collection of specimen. Small threatening and require aggressive surgical management. syringe of 3ml is adequate for collection of specimen. At least 1 The three main criteria in a patient needing immediate or 2ml of pus is aspirated. If the specimen may contain only tissue referral to a hospital emergency room is: fluid and blood instead of pus yet it commonly provides sufficient 1. Threat to the airway and rapidly progressing infection. In 1- bacteria for an accurate culture. The specimen is then inoculated 2 days this type of infection may cause swelling in deep directly into aerobic and anaerobic culturates. fascial spaces of the neck, which compress and deviate the airway INDICATIONS FOR CULTURE AND ANTIBIOTIC 2. The second criteria is the difficulty in breathing. The severe SENSITIVITY TESTING Infection spreading beyond the alveolar infection cusses severe swelling of the soft process 3. upper airway resulting to a difficulty in maintaining a Rapidly progressive infection patient’s airway. This situation may cause the patient to Previous antibiotic therapy refuse laying down, have distorted speech, and distressed Non responsive infection (after 48hrs) due to the difficulty in breathing. Recurring infection 4. The third is difficulty in swallowing due to the acutely Compromised host defenses progressive deep fascial space infection, difficulty Anaerobic bacteria as always said present in odontogenic swallowing their own saliva , drooling because the inability infections, the surgeon should request in writing a gram stain to control one’s secretion and the narrowing of the aerobic and anaerobic cultures and antibiotic sensitivity testing oropharynx. After obtaining the culture specimen, incision is made with a Another criteria for referral to an oral maxillo fascial surgeon is a scalpel no.II blade through the mucosa and sub mucosa into the patient with extra oral swelling sich as buccul space infection or abscess cavity submandibular space infections that may require extra oral Incision should be short no more than 1cm in length, once incision surgical incision and drainage. is completed a closed curved hemostat is inserted through the Trismus is also another criteria for referral, this is when muscle incision into the abscess cavity,. The hemostat is then opened in of mastification by the inflammatory process was involved. different directions to break up any small loculations(cavities of Mild Trismus- maximum of interincisal opening of 20-30mm pus) any pus or tissue fluid that drains out should be aspirated into Moderate Trismus- 10-20mm interincisal opening the suction not to the patients mouth. Severe Trismus- less than 10mm Once out the area of the abscess cavity have been opened and all The spread of infection in trismus is in the area of masticator pus has been removes, small drain is inserted to maintain the space and even worse both the lateral pharyngeal space abd retro opening. To drain intra oral abscess a quarter inch sterile penrose pharyngeal space surrounding drain or you can use a substitute small strip of sterilized rubber dam or surgical glove material. Being careful for any sensitivity PRINCIPLE 4: TREAT INFECTION SURGICALLY of the patient to the latex when selecting the dran material. Using - Surgical drainage to remove the cause of infection hemostat a small drain is inserted to the depths of abscess cavity. - Endodontic access opening and extirpation of the necrotic tooth The drain is sutured to one edge of the incision with a non- pulp to treatment as complex, wide incision of the soft tissue in absorbable suture the submandibular and neck regions for a severe infection. The The suture should be placed in viable tissue to prevent loss of the primary goal of surgical management of infection is to remove the drain because it might tear through viable and non-vital tissue. ADORNA | ORAL SURGERYSII | DR. WENDY C. ZARATE 4  The drain remains in place until all the drainage has stopped 4. Lymphadenopathy usually 2-5 days 5. Tempersature higher than 101 degrees farenheit Removal is done by simply cutting the suture and slipping the 6. Severe pericoronitis drain from the wound 7. Osteomyelitis The primary method for treating odontogenic infection is to Situations where use of antibiotics is not Necessary perform surgery to remove the source of infection and drain the 1. Patient demand- minor chronic and well localized abscess anatomic spaces affected by indursted cellulitis and abscess, even upon extraction, compute the removal peri-apical abscess if the teeth cannot be immediately extracted with an I&D being upon tooth extraction. Good host defense and no immune done compromising conditions. In summary the presence of potential or actual airway 2. Severe pain- but no facial swelling and well localized dento compromise, spread of infection beyond the alveolar process alveolar abscess medical or immune system compromise or signs of systemic 3. Dry Socket- This can be palliative treatment and it is not involvement, immediate referral to an oral maxillo facial surgeon related to an infection, although bacterial pathogens may in life threatening cases. play a role in the etiology of a dry socket 4. Multiple dental extractions in a patient who is not immune compromised 5. Mild pericoronitis (inflammation of the operculum) 6. Drained alveolar abcess Sometimes irrigation with hydrogen peroxide or chlorhexadine for mild perocoronitis and gingival edema or mild pain, antibiotic is not ncessary for their infection Use of Emperical Therapy routinely Emperical therapy for odontohenic infection is commonly used because the bacteria involved are well known and their antibiotic sensitivity testing is not necessary Common pathogens of the bacteria responsible for odontogenic infections are primarily fucultative oral streptococci and anserobic streptoccocci and other bacteria like prevotella and fusobacterium spp. these bacteria are often opportunistic in nature Effective Antibiotics against these infections are: 1. Penicillin 2. Amoxicillin PRINCIPLE 5: SUPPORT PATIENT MEDICALL 3. Clindamycin - Emphasizes the importance of considering the patients overall 4. Metronidazole medical condition when planning and executing treatment for 5. Moxifloxacin odontogenic infections. It highlights the need for holisitc The antibiotic’s efficacy systemic reviews indicate that newer approach that incorporates the patients medical history, risk antibiotics do not significantly improve clinical cure rates sompared to fsctors and coordination with other health care providers to ensure amoxcillin or penicillin when appropriate dental surgery is performed safe and effective management of the infection. A patients Penicillin allergies- For patients allergic to penicillin , systemic resistance must be considered in three areas; clindamycin and azithromycin are suitable alternatives while 1. Immune system compromise metronidazole are only effective against anaerobic bacteria and 2. Control of systemic diseases should be used in cases where only anaerobic bacteria are 3. Physilogic reserves identified or in combination with an antibiotic that has anti- aerobic activity such as penicillin PRINCIPLE 6: CHOOSE AND PRESCRIBE APPROPRIATE Patient Adherence- Patients often fail to take medication as ANTIBIOTIC prescribed with a historical reference to Socrates in 400 BC - Appropriate antibiotic for treating odontogenic infections must be cautioning physicians to be aware that patients might lie about chosen carefully there are situations where a broad spectrum or taking their prescribed medications even combination of antibiotic therapy may be indicated Patient Compliance- Decreases as the number of daily doses Determine the need for antibiotic administration increases for instance: 1. The seriousness of infection when the patient comes to the Compliance is approximately 80% when the medication is taken once dentist. If the infection has caused swelling and has daily. It decreases to 69% for twice a day and drops to 35% for 4 times progressed rapidly or diffuse cellulitis the use of antibiotics a day regiments. This highlights the importance of prescribing is needed in addition to surgical therapy medications that can be taken less frequently to improve compliance. 2. Second considerstion is wheter adequate surgical treatment Examples given include: can be achieved. In many situations extractions of the Amoxicillin and Clindamycin- typically taken 3 times daily but if offending teeth may result in rapid resolutions of the amoxicillin is combined with clavulanic acid it may be taken only infection 2 times daily. Azithromycin taken only once daily due to its long 3. Considered the state of the patients host defenses. Young lasting life. When choosing between antibiotics, factors such as healthy patients may be able to mobilize host defenses and anti-bacterial effectiveness, side effects, interactions and cost may not need antibiotics for resolution of a minor infection. should be considered. If 2 antibiotics are equally effective the one However those medically compromised patients may require requiring fewer doses is preferred vigorous antibiotics even for minor infections Routine C&S testing is not considered to be cost-effective for Indicators for therapeutic use of antibiotics most odontogenic infection, however the test lists specific 1. Swelling extending beyond the alveolar process (accute situations where C&S testing may be warranted including: onset infection) 1. Severe infection or rapid spread 2. Cellulitis 2. Infections that do not resolve as expected 3. Trismus 3. Recurrent infections ADORNA | ORAL SURGERYSII | DR. WENDY C. ZARATE 5  4. Patients with compromised immune systems who may Cost Considerations Cost is another important factor in antibiotic harbor unusual pathogens selection. Newer-generation antibiotics tend to be more Future C&S testing advances i molecular methods such as PCR expensive, while older, generic antibiotics are more affordable. (Polymerase chain reaction) and the use of RNA/DNA analysis When efficacy and safety profiles are comparable, the less may replace conventional C&S testing. These methods can expensive option should be chosen to reduce the financial burden identify bacteria that are difficult to culture and can detect on patients. antibiotic resistance agents directly Antibiotic Spectrum and Sensitivity Patterns When an antibiotic PRINCIPLE 7: ADMINISTER ANTIBIOTIC PROPERLY is administered, it typically targets the bacteria causing the Once the decision is made to prescribe an antibiotic to the patient, infection. However, the scope of its effect can vary widely. the drug should be administered in the proper dose and at the Narrow-spectrum antibiotics are designed to kill a specific range proper dose interval. The manufacturer usually recommends the of bacteria. For example, *penicillin* is effective against proper dosage and administration. Provision of plasma levels that streptococci and oral anaerobic bacteria but has little effect on are sufficiently high to kill the bacteria that are sensitive to the other bacteria like staphylococci or those in the gastrointestinal antibiotic but are not so high as to cause toxicity is adequate. The (GI) tract. This specificity minimizes disruption to the body's peak plasma level of the drug should usually be at least four or normal flora and reduces the likelihood of developing antibiotic- five times the minimal inhibitory concentration for the bacteria resistant bacteria. In contrast, *broad-spectrum antibiotics*, such involved in the infection. as *amoxicillin-clavulanate (Augmentin)*, target a wider array of Clearly, some patients stop taking their antibiotics after acute bacteria, including those in the skin and GI tract. While effective symptoms have subsided and rarely take their drugs as prescribed against a broader range of pathogens, they also pose a greater risk after 4 or 5 days. Therefore, the antibiotic that would have the of disrupting normal flora and promoting resistance, especially in highest compliance would be the drug that could be given once a immunocompromised patients. day for not more than 4 or 5 days. Studies have shown that for The ADA Guidelines on Antibiotic Use The American Dental odontogenic infections a 3- or 4-day course of a penicillin, Association (ADA) advises that dentists should prefer narrow- combined with appropriate surgery, has been as effective as a 7- spectrum antibiotics for treating simple infections. Simple day course of the antibiotic. odontogenic infections are typically confined to the alveolar At the clinical follow-up examination, additional prescription of process or oral vestibule, and the patient is generally antibiotics may be necessary in the case of infections that do not immunocompetent. The common narrow-spectrum resolve rapidly. The clinician must make it clear to the patient that antibiotics include: the entire prescription must be taken. If for some reason the o Penicillin patient is advised to stop taking the antibiotic early, all remaining o Amoxicillin pills or capsules should be discarded. Patients should be strongly o Clindamycin discouraged from keeping small amounts of unused antibiotics to o Metronidazole self-treat a sore throat next winter. Casual self-administration of On the other hand, broad-spectrum antibiotics are reserved antibiotics is not only useless, but also may be hazardous to the for more complex infections, where the infection may have health of the individual as well as that of the community. spread beyond the alveolar process or in cases where the patient is immunocompromised. Examples include: PRINCIPLE 8: EVALUATE PATIENT FREQUENTLY o Amoxicillin with clavulanic acid (used for sinus infections) 1. Post-Treatment Monitoring (2-3 Days After Therapy): o Azithromycin Assess response: check pain, swelling, temperature, trismus, o Tetracycline and patient’s feelings of improvement. o Moxifloxacin Inspect incision & drainage (I&D) site for potential drain The Importance of Choosing the Right Antibiotic When removal. selecting an antibiotic, it is crucial to consider not only the 2. Common Reasons for Treatment Failure: effectiveness against the target bacteria but also the potential Inadequate Surgery: Missed areas of infection or insufficient side effects and toxicity. For instance, while drainage. o Penicillin is generally safe with minimal side effects, some Depressed Host Defenses: Immunocompromised, patients may experience severe allergic reactions. dehydration, malnutrition. o Clindamycin can be effective, but it carries a risk of Foreign Body: Implants or other objects may harbor bacteria. antibiotic-associated colitis due to the overgrowth of 3. Antibiotic-Related Issues: Clostridium difficile. Patient noncompliance (e.g., not filling prescription). o Azithromycin is favored for its low toxicity and minimal Drug not reaching infection site (poor blood supply, drug interactions inadequate surgery). o Moxifloxacin despite being effective, is associated with Incorrect dose or wrong antibiotic. serious side effects like muscle weakness, mental clouding, Increasing bacterial resistance (e.g., Prevotella resistance to and potential drug interactions. Therefore, moxifloxacin penicillin). should be reserved for severe, recalcitrant infections where 4. Additional Considerations: no other effective treatment options are available. Monitor for toxicity (e.g., diarrhea, nausea). Bactericidal vs. Bacteriostatic Antibiotics can be categorized Watch for secondary infections (e.g., oral/vaginal based on their mechanism of action: candidiasis). o Bactericidal antibiotics kill bacteria directly by interfering Prevent recurrence through complete therapy and careful with cell wall production, making them especially useful in patients with compromised immune systems. Examples post-resolution monitoring. include penicillin and amoxicillin. o Bacteriostatic antibiotics inhibit the growth of bacteria, allowing the host's immune system to clear the infection. These are typically used in patients with intact immune systems but should be avoided in those with compromised defenses, such as patients undergoing chemotherapy. ADORNA | ORAL SURGERYSII | DR. WENDY C. ZARATE 6 LESSON 2: POST OPERATIVE MANAGEMENT FOR PATIENT IN ORAL SURGERY STITCHES AND FOLLOW-UP CARE IMMEDIATE CARE Dissolvable Stitches: If dissolvable stitches are used, they Bleeding Control: After surgery, the patient may experience some typically disappear within 7-10 days. bleeding. Instruct the patient to bite gently on a gauze pad placed over the surgical site for at least 30-60 minutes. Change the gauze Non-Dissolvable Stitches: If non-dissolvable stitches were used, as needed. Excessive bleeding should be reported. schedule a follow-up appointment to have them removed. Blood Clot Preservation: Inform the patient not to disturb the Follow-up Appointment: A post-operative check-up should be surgical area. Avoid rinsing, spitting, or using a straw for at least scheduled to ensure proper healing. 24 hours as these actions can dislodge the blood clot, leading to dry socket SMOKING AND ALCOHOL Advise against smoking for at least 72 hours post-surgery as it can PAIN MANAGEMENT delay healing and increase the risk of complications such as dry Medications: Prescribe analgesics such as acetaminophen or socket. ibuprofen for pain relief. Stronger medications like opioids may be given for more intense pain but should be used cautiously and Alcohol should be avoided while taking prescribed medications only as needed. and for at least 24 hours after surgery. Cold Compresses: Apply cold packs to the outside of the face near PATIENT EDUCATION the surgical area for the first 24-48 hours to minimize swelling Emergency Instructions: Educate the patient on what to and discomfort. Alternate 20 minutes on and 20 minutes off. expect during recovery and provide emergency contact information if complications arise. SWELLING AND BRUISING MANAGEMENT Swelling often peaks 48-72 hours after surgery. Cold compresses Written Instructions: Give the patient written post-operative help initially, but after the first two days, warm compresses may care instructions to take home, covering all aspects of care be used to reduce swelling and promote healing. including medication schedules, dietary commendations, and activity restrictions. Bruising around the surgical site is normal and should subside within a week. CONTROL POST OPERATIVE HEMORRHAGE - Post-operative hemorrhage is a potential complication following DIETARY RECOMMENDATIONS oral surgery. Effective control of bleeding is crucial for patient Soft Diet: Advise the patient to consume soft, cool foods for the safety and comfort. Here’s a guide to managing post-operative first few days. Avoid hard, chewy, spicy, or hot foods that can hemorrhage in oral surgery irritate the surgical site. INITIAL ASSESSMENT Hydration: Encourage the patient to stay hydrated but avoid using Identify Source: Assess whether the bleeding is from the surgical straws. Drinking directly from a glass or bottle is recommended. site (e.g., tooth socket or incision) or from surrounding tissues like the gums. ORAL HYGIENE Distinguish Normal Bleeding: Differentiate between normal Gentle Cleaning: Patients should be advised to maintain oral oozing (which can be expected) and significant, active bleeding hygiene by gently brushing their teeth, avoiding the surgical area (which requires intervention). for the first 24 hours. After 24 hours, the patient can begin gentle rinsing with a saltwater solution (½ teaspoon of salt in 8 ounces IMMEDIATE CONTROL MEASURES of warm water) several times a day, especially after meals. Direct Pressure: The most effective way to stop post-operative bleeding is applying direct pressure. Instruct the patient to bite Avoid Mouthwashes: Refrain from using commercial firmly on a folded gauze pad placed over the bleeding site for 30- mouthwashes for at least a week unless specifically instructed by 60 minutes. This encourages clot formation. the surgeon. Reposition Gauze: If bleeding continues after the initial period, replace the gauze with a fresh, tightly folded piece and repeat the ACTIVITY RESTRICTION process. Rest: Encourage rest for the first 24-48 hours after surgery. Tea Bag Method: If bleeding persists, using a moistened black tea Physical exertion should be avoided as it may increase bleeding bag (which contains tannic acid, a natural vasoconstrictor) and swelling. wrapped in gauze can help promote clotting. The patient should bite down on it for 30 minutes. Gradual Return to Normal Activity: The patient can gradually return to normal activities as comfort allows, but heavy lifting or PHARMACOLOGIC HEMOSTATIS strenuous exercise should be avoided for at least a few days. Local Hemostatic Agents: Consider using local hemostatic agents such as: MONITORING FOR COMPLICATIONS Gelfoam (Gelatin sponge) : Placed into the socket or wound to aid Infection: Signs of infection include increased pain, swelling, in clot formation. fever, and foul-smelling discharge. The patient should be Surgical (Oxidized cellulose) : Acts as a scaffold to support informed to report these symptoms immediately. clotting. Topical Thrombin: Promotes clotting by converting fibrinogen to Dry Socket: If the blood clot dislodges prematurely, the patient fibrin. may develop a dry socket, which is characterized by severe pain. Collagen Plugs: Used in tooth sockets to help stabilize the clot Immediate contact with the surgeon is necessary for management. and promote hemostasis. ADORNA | ORAL SURGERYSII | DR. WENDY C. ZARATE 7  - Control of postoperative pain and discomfort is critical in SUTURING ensuring patient comfort, promoting healing, and preventing Re-suturing the Site: If the bleeding is from a wound that has not complications after oral surgery. Here’s a detailed guide for properly closed, re- suturing the area may be necessary to secure managing these postoperative sequelae the blood vessels and tissues. Figure-8 Suture for Extractions: For extraction sites, a figure-8 PAIN CONTROL suture can help compress the socket and stabilize the clot. Pharmacologic Management: Non-Opioid Analgesics: Non-steroidal anti-inflammatory drugs SYSTEMIC MEASURES (NSAIDs), such as ibuprofen, are commonly prescribed for mild Tranexamic Acid: In cases of persistent bleeding, tranexamic acid to moderate pain. Ibuprofen (400-800 mg every 6-8 hours) helps can be used as a mouth rinse or administered systemically. It control both pain and inflammation. Acetaminophen (500-1000 works by inhibiting fibrinolysis (the breakdown of clots). mg every 4-6 hours) can also be used alone or in combination with Vasoconstrictors: If the patient is not hypertensive, NSAIDs. vasoconstrictors (such as epinephrine) can be used locally to Opioid Analgesics: For more severe pain, short-term use of opioid reduce blood flow and encourage clot formation. analgesics like hydrocodone or oxycodone may be necessary. These should be prescribed with caution due to the potential for MANAGEMENT OF UNDERLYING CONDITIONS dependence and side effects such as nausea, drowsiness, and Address Coagulopathies: If the patient has a known bleeding constipation. Usually, they are combined with acetaminophen disorder (e.g., hemophilia, Von Willebrand disease) or is taking (e.g., Percocet or Vicodin). anticoagulants/antiplatelet drugs (e.g., warfarin, aspirin), Combination Therapy: NSAIDs and acetaminophen can be management should be coordinated with their medical provider. alternated or combined (e.g., ibuprofen and acetaminophen taken Pre-operative optimization and post-operative adjustments in together have shown synergistic effects) to provide more effective medication may be required. pain control while minimizing the need for opioids. Check for Hypertension: Uncontrolled hypertension can Topical Anesthetics- In some cases, topical anesthetic gels or contribute to post-operative bleeding. Blood pressure should be sprays (e.g., lidocaine) can be applied to the surgical area to checked, and medical management may be necessary. provide localized pain relief. Non-Pharmacologic Management- Cold Therapy: Applying ice PATIENTS INSTRUCTION FOR HOME CARE packs to the affected area (20 minutes on, 20 minutes off) during Activity Restriction: Advise the patient to rest and avoid physical the first 24-48 hours can reduce pain by minimizing inflammation exertion, bending, or heavy lifting, as these can increase blood and numbing the area. It is particularly effective for controlling pressure and cause re-bleeding. pain associated with swelling. Avoid Dislodging the Clot: Instruct the patient to avoid spitting, Elevation: Keeping the head elevated with pillows, especially rinsing vigorously, using straws, or smoking for at least 24-48 during sleep, can help reduce swelling and pressure in the affected hours, as these can dislodge the clot. area, indirectly reducing discomfort. Dietary Advice: Recommend a soft diet, avoiding hot foods and drinks, as these can stimulate bleeding. DISCOMFORT MANAGEMENT Swelling and Inflammation- Cold Compresses: Apply ice or cold REFERAL TO SPECIALIST packs on the face near the surgical site in the first 48 hours. After Severe or Persistent Bleeding: If conservative measures fail, or this period, switch to warm compresses to encourage circulation the bleeding is severe, refer the patient to an oral and maxillofacial and reduce residual swelling. Steroids: In some cases, oral surgeon or the emergency room for further intervention. corticosteroids like dexamethasone may be prescribed to reduce Hospital Admission: In rare cases where bleeding is life- postoperative inflammation and swelling. This is typically threatening or uncontrollable, hospital admission may be considered for more extensive surgical procedures. necessary for IV fluids, blood transfusion, or surgical Jaw Stiffness- Warm Compresses: After 48 hours, warm intervention. compresses applied to the jaw can help relieve stiffness and promote circulation. Jaw Exercises: Gentle jaw-opening exercises MONOTORING AND FOLLOW-UP (e.g., slow opening and closing) may be recommended to improve Close Monitoring: After initial hemorrhage control, monitor the mobility and reduce stiffness after the initial healing phase. patient closely for recurrence of bleeding. Re-evaluate the clot Anxiety and Stress Reduction- Patient Education: Ensuring the formation and the condition of the surgical site. patient is well-informed about the normal healing process, Scheduled Follow-Up: Ensure the patient returns for follow-up including expected pain and discomfort, can alleviate anxiety. within 24-48 hours to check for re-bleeding, infection, or other Patients who understand the nature of their symptoms often cope complications. better with discomfort. Sedation Options: If anxiety is anticipated, sedation options such as oral sedatives or nitrous oxide may be SCHEDULED FOLLOW-UP offered during the procedure, and appropriate medications (e.g., Ensure the patient returns for follow-up within 24-48 hours to benzodiazepines) may be provided for post-surgery anxiety check for re-bleeding, infection, or other complications. management. ▪ Hydration and Diet- Soft Foods: Encourage a soft or liquid diet CONCLUSION during the recovery period. Foods such as smoothies, yogurt, soups, Effective management of post-operative hemorrhage involves and mashed potatoes help prevent irritation to the surgical site and applying direct pressure, using local hemostatic agents, and reduce discomfort from chewing. Hydration: Encourage the patient to addressing any underlying medical conditions that may contribute stay well- hydrated, but advise against drinking. to bleeding. Timely intervention and clear instructions for home care are essential for successful outcomes. ORAL HYGIENE - Postoperative oral hygiene plays a critical role in preventing CONTROL OF POST OPERATIVE SQUELAE infections, promoting healing, and reducing discomfort after oral surgery. Here's how to manage oral hygiene after surgery: ADORNA | ORAL SURGERYSII | DR. WENDY C. ZARATE 8 IMMEDIATE POSTOPERATIVE CARE (FIRST 24 HOURS) smelling discharge. Prompt oral hygiene can help prevent Avoid Rinsing: Instruct the patient not to rinse their mouth for the infection, but any concerning symptoms should be reported to the first 24 hours after surgery to avoid disturbing the surgical site surgeon. and disrupting the blood clot formation, which could lead to Dry Socket Prevention: Dry socket is a painful complication that complications like dry socket. can occur after extractions, especially if the blood clot is No Brushing Near the Surgical Area: Patients should avoid dislodged. Proper oral hygiene, combined with avoiding vigorous brushing the teeth immediately adjacent to the surgical site for the rinsing, spitting, and sucking motions (e.g., straws), can help first 24 hours. However, they should still brush the other teeth prevent this. gently to maintain overall oral hygiene. FOLLOW-UP CARE ORAL HYGIENE AFTER 24 HOURS Regular Check-ups: Patients should attend their follow-up Gentle Rinsing: After the first 24 hours, the patient can start appointments to ensure proper healing of the surgical site. Any rinsing their mouth gently with a warm saltwater solution (1⁄2 concerns regarding oral hygiene or complications can be teaspoon of salt in 8 ounces of warm water). This should be done addressed at these visits. 3-4 times a day, especially after meals. Saltwater helps cleanse the area, reduce bacteria, and promote healing without being too CONCLUSION abrasive. Postoperative oral hygiene management requires a balance Avoid Commercial Mouthwash: Patients should avoid using between maintaining cleanliness and protecting the healing commercial mouthwashes containing alcohol for at least a week, tissues. Gentle brushing, saltwater rinses, and avoiding irritants as these can irritate the surgical site and delay healing. Alcohol- like alcohol and tobacco will promote healing and minimize the free mouthwashes may be allowed if recommended by the risk of complications. surgeon. EDEMA BRUSHING AND FLOSSING - Postoperative edema (swelling) is a common occurrence after oral Gentle Brushing: Patients can resume gentle brushing near the surgery and can cause discomfort, delayed healing, and surgical site after 24-48 hours, using a soft-bristled toothbrush to sometimes complications. Proper management of edema is avoid disrupting the healing tissues. Brushing the other teeth as essential for a smoother recovery. Here's how to control and normal is encouraged to maintain overall oral hygiene. manage postoperative edema: Avoiding Direct Contact with Surgical Site: Care should be taken to avoid direct brushing of the surgical area (e.g., extraction IMMEDIATE POSTOPERATIVE MANAGEMENT socket or incision site) for the first few days. Instead, patients Cold Compresses (First 24-48 Hours): - Application: Encourage should brush the surrounding teeth while avoiding contact with the patient to apply a cold compress or ice pack to the affected sutures or the healing tissue. area on the face near the surgical site. This should be done Flossing: Normal flossing can usually resume after 24-48 hours, intermittently—20 minutes on, 20 minutes off. except around the surgical site, where patients should be cautious Effectiveness: Cold therapy constricts blood vessels, reducing to prevent irritation. blood flow to the area and helping to minimize swelling. It also numbs the area, providing pain relief. USING ORAL IRRIGATION DEVICES Head Elevation:- Positioning: Keeping the head elevated (e.g., Oral Irrigators (Water Flossers): If an oral irrigator (e.g., with pillows) while resting or sleeping helps reduce swelling by Waterpik) is part of the patient's routine, they should avoid using preventing fluid accumulation in the surgical area. it around the surgical site for at least a week to prevent dislodging Importance: Lying flat can increase blood flow to the head, the blood clot or damaging the healing tissue. When they resume worsening swelling. Elevating the head encourages proper use, it should be on the lowest setting and away from the surgical drainage and minimizes edema. area. AFTER THE FIRST 48 HOURS MANAGING SUTURES Warm Compresses (After 48 Hours) - Application: After the Self-Dissolving Stitches: If dissolvable stitches were placed, initial 48 hours, switch to warm compresses applied to the area. remind the patient that these will typically dissolve on their own Use a warm, damp cloth or heating pad (on a low setting) for 20- within 7-10 days. The patient should be instructed to avoid poking minute intervals. or pulling at the sutures to prevent premature loss. Purpose: Heat therapy improves blood circulation to the area, Non-Dissolvable Stitches: If non-dissolvable sutures are present, promoting the resolution of the swelling and enhancing tissue instruct the patient to be particularly careful around the area. They healing. should return to the clinic for suture removal at the scheduled follow-up. PHARMACOLOGIC MANAGEMENT Anti-inflammatory Medications - NSAIDs: Non-steroidal anti- AVOIDING IRRITANTS inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, Tobacco Use: Smoking and other forms of tobacco use should be are effective at reducing both pain and inflammation. These avoided for at least 72 hours post-surgery, as smoking can delay medications can help decrease postoperative swelling when taken healing, increase the risk of infection, and cause dry socket by as prescribed. disrupting the blood clot. Steroids: In more severe cases of anticipated edema, oral Alcohol: Patients should avoid alcohol for at least 24-48 hours corticosteroids like dexamethasone may be prescribed by the after surgery, as it can interfere with healing and interact surgeon. Steroids are particularly useful in reducing inflammation negatively with prescribed medications. and swelling following extensive surgeries (e.g., impacted wisdom tooth extractions or jaw surgeries). MONOTORING FOR COMPLICATIONS Signs of Infection: Instruct the patient to watch for signs of HYDRATION AND DIET infection, including increased swelling, pain, fever, or foul- ADORNA | ORAL SURGERYSII | DR. WENDY C. ZARATE 9  Adequate Hydration: Encourage patients to stay well-hydrated, as Surgical Trauma: The use of instruments during surgery, dehydration can worsen inflammation and swelling. Proper especially near the jaw or TMJ, can contribute to trismus. hydration helps promote circulation and the removal of excess Inflammation: Postoperative swelling, particularly in the muscles fluids from swollen tissues. and surrounding tissues, can contribute to limited mouth opening. Soft, Cool Foods: Advise the patient to consume soft, cool foods Infection: In rare cases, infection can result in muscle spasms during the recovery period. Cold foods such as yogurt, smoothies, leading to trismus. and ice cream may soothe the area and help reduce swelling. Avoid hot foods and beverages during the initial recovery period IMMEDIATE POSTOPERATIVE MANAGEMENT as heat can exacerbate swelling. Pain and Swelling Reduction: Cold Compresses (First 24-48 Hours): Applying cold packs to the ACTIVITY RESTRICTIONS outside of the face near the surgical site can reduce inflammation Rest and Avoidance of Strenuous Activity -Rest is essential and help prevent or minimize the onset of trismus. during the first few days after surgery to prevent further swelling. NSAIDs: Non-steroidal anti-inflammatory drugs such as Patients should avoid heavy lifting, vigorous exercise, or any ibuprofen are effective in reducing both pain and inflammation, physical activity that may increase blood pressure and exacerbate which can contribute to the development of trismus. edema. Steroids: In some cases, corticosteroids such as dexamethasone Gradual Return to Activity: Patients should be advised to may be prescribed to reduce swelling and inflammation, gradually resume normal activities as the swelling subsides. especially in patients with a high risk of developing trismus (e.g., wisdom tooth extractions near the TMJ). MONITORING AND PATIENT EDUCATION Normal Course of Edema - Explain to patients that swelling AFTER 48 HOURS: WARM COMPRESS AND JAW typically peaks 48-72 hours after surgery and then begins to EXERCISES subside. It is a normal part of the healing process. Warm Compresses: After the first 48 hours, switch to warm Swelling may last up to a week or more, depending on the extent compresses. Applying heat to the affected area can help relax the of the surgery. muscles and improve blood flow, promoting healing and reducing Signs of Complications: Educate patients on recognizing stiffness. abnormal swelling that could indicate a complication such as Jaw Exercises- Passive Stretching: Gentle jaw-opening exercises infection or hematoma. Signs to watch for include sudden should be encouraged to prevent stiffness. Patients can practice increases in swelling after initial improvement, increasing pain, slowly opening and closing their mouth as wide as comfortably fever, redness, or pus discharge. possible, holding the open position for a few seconds before Instruct patients to contact their surgeon if they notice any of these closing. signs. Active Resistance Exercises: These can be introduced as tolerated. For example, the patient can apply gentle resistance LYMPHATIC DRAINAGE TECHNIQUES under the chin while trying to open the mouth. This helps stretch Massage: In some cases, gentle massage techniques may be used the muscles and improve range of motion. to promote lymphatic drainage and help resolve edema. However, Consistency: Exercises should be performed several times a day patients should be instructed to avoid directly massaging the to gradually improve jaw mobility and reduce trismus. However, surgical site and to do so only if recommended by their healthcare they should be done gently to avoid causing pain or further injury. provider. PHARMALOGIC MANAGEMENT FOLLOW-UP AND LONG-TERM CARE Muscle Relaxants: If muscle spasms are contributing to trismus, Scheduled Follow-ups: Postoperative follow-up appointments are muscle relaxants such as diazepam or cyclobenzaprine may be important for monitoring the progression of swelling and ensuring prescribed on a short-term basis to alleviate muscle tension. proper healing. The surgeon can assess if the edema is resolving Analgesics: Pain relief is critical in managing trismus. Along with as expected or if further intervention is needed. NSAIDs, acetaminophen or prescription pain medications can be used as needed. CONCLUSION Effective management of postoperative edema involves a MOIST HEAT AND MASSAGE combination of cold therapy, elevation, anti-inflammatory Moist Heat Application: Applying moist heat (e.g., a warm towel medications, and rest. Educating the patient on the normal soaked in hot water) to the jaw muscles can be more effective than progression of swelling and signs of complications is crucial to dry heat. This helps to relax tight muscles and improve flexibility. promoting a smooth recovery. Massage: Gentle massaging of the affected jaw muscles can help relieve tension and improve blood circulation. It should be TRISMUS performed with care to avoid irritation of the surgical site. - Trismus, or the restricted ability to open the mouth, is a common postoperative complication in oral surgery, particularly after DIETARY MANAGEMENTS procedures involving the wisdom teeth, jaw, or Soft Diet: A soft diet should be recommended during the recovery temporomandibular joint (TMJ). Trismus can result from period to avoid putting excessive strain on the jaw muscles. Soft inflammation, muscle spasms, trauma to the jaw muscles, or the foods such as mashed potatoes, soups, smoothies, yogurt, and proximity of surgery to the TMJ. Managing trismus effectively is scrambled eggs are appropriate. Chewing hard or tough foods important to restore normal function and minimize discomfort. should be avoided until trismus resolves. Here’s how to manage and prevent trismus ▪ Adequate Nutrition: Ensure that the patient maintains adequate nutrition and hydration despite the difficulty in opening the mouth. CAUSE OF POSTOPERATIVE TRISMUS Liquid nutritional supplements can be helpful if chewing remains Muscle Trauma: Damage to or inflammation of the muscles of difficult. mastication (e.g., masseter, temporalis) can result in restricted movement. MONOTORING AND FOLLOW-UP ADORNA | ORAL SURGERYSII | DR. WENDY C. ZARATE 10  Gradual Improvement: Reassure the patient that trismus typically Pre-Surgical Counseling: Patients should be informed of the improves over time as inflammation subsides and the muscles possibility of bruising, especially in surgeries that involve heal. Improvement usually begins within a few days to a week, significant tissue manipulation. depending on the extent of the surgery and severity of the trismus. Signs of Complications: Patients should be advised to report if POSTOPERATIVE MEASURES trismus worsens after initial improvement or if it is accompanied Cold Compresses (First 24-48 Hours)- Application: Applying ice by symptoms such as fever, increased pain, or signs of infection. packs or cold compresses to the affected area on the face near the In such cases, further evaluation may be required. surgical site can reduce the risk of bruising by constricting blood vessels and minimizing bleeding. This should be done PREVENTION STRATEGIES intermittently—20 minutes on, 20 minutes off—during the first Preoperative Counseling: Educate the patient about the risk of 24-48 hours after surgery. trismus before surgery, especially for procedures near the TMJ or Effectiveness: Cold therapy helps control both swelling and involving impacted wisdom teeth. Preventive measures like cold bleeding, limiting the extent of ecchymosis. therapy and NSAIDs should be discussed. Jaw Exercises: Encourage patients to gently open and close their MANAGEMENT OF EXISTING ECCHYMOSIS mouths during the early stages of recovery, once any acute Warm Compresses (After 48 Hours)- Application: After the discomfort has subsided, to prevent muscle stiffness from initial 48-hour period of using cold therapy, switch to warm developing. compresses. Apply a warm, moist towel to the area for 20- minute intervals. LONG -TERM CARE FOR PERSISTENT TRISMUS Purpose: Heat promotes blood flow and helps the body reabsorb Physical Therapy: For persistent or severe cases of trismus, the blood that has accumulated under the skin, which accelerates referral to a physical therapist specializing in TMJ disorders may the resolution of bruising. be warranted. They can provide tailored exercises and therapeutic Massage- Gentle Massage: Once ecchymosis has formed and is modalities to improve jaw function. no longer acutely painful, gentle massage around the bruised area Dental Appliances: In cases related to TMJ disorders, dental may help to disperse the pooled blood. It should be done with appliances such as bite splints may be recommended to reduce caution to avoid irritating the surgical site. tension in the jaw muscles. Surgical Revision: In rare cases where trismus persists due to scar ARNICA AND BROMELAIN tissue formation or other complications, surgical intervention may Arnica: Arnica montana, a natural remedy, is sometimes used to be required to restore normal mouth opening. reduce bruising and swelling. It is available in topical forms (gels and creams) or oral supplements. Patients should consult with CONCLUSION their healthcare provider before using herbal remedies. Trismus can be effectively managed with a combination of early Bromelain: Found in pineapple, bromelain is an enzyme that may intervention, exercises, medication, and supportive care. help reduce bruising and swelling. It can be taken as a supplement Educating patients about the importance of jaw mobility exercises or consumed naturally through pineapple. and monitoring for signs of complications will ensure a smoother Analgesics: If the ecchymosis is causing discomfort, mild pain recovery and help prevent long-term dysfunction. relievers such as acetaminophen (Tylenol) can be used. Avoid NSAIDs like aspirin or ibuprofen within the first 48 hours after ECCHYMOSIS surgery, as they can thin the blood and potentially worsen - Postoperative ecchymosis, or bruising, is common after oral bruising. surgery, especially in procedures that involve significant manipulation of soft tissues, such as extractions or jaw surgeries. MONITORING AND PATIENT EDUCATION Ecchymosis results from bleeding under the skin and can cause Normal Progression: Educate patients that bruising is normal after discoloration and mild discomfort. Managing ecchymosis surgery and typically changes color as it heals—from red or effectively involves understanding its causes and employing purple to blue, green, yellow, and eventually fading away over the strategies to minimize and treat it. course of 7-14 days. Reassure them that ecchymosis will resolve on its own with time. CAUSES OF POSTOPERATIVE ECCHYMOSIS When to Be Concerned: Instruct patients to monitor the bruised Trauma to Blood Vessels: During surgery, small blood vessels in area for any signs of worsening (e.g., increasing pain, swelling, or the soft tissues may be damaged, leading to minor bleeding under the appearance of a firm lump) or signs of infection, such as the skin, which manifests as bruising. redness, warmth, or discharge. If any of these occur, they should Aging: Older patients are more prone to bruising due to thinner seek medical attention. skin and more fragile blood vessels. Medications: Patients taking anticoagulants, antiplatelet drugs DIET AND HYDRATION (e.g., aspirin, warfarin), or corticosteroids may be more prone to Hydration: Adequate hydration can help the body reabsorb the ecchymosis because these medications affect blood clotting. blood pooled under the skin and assist in the healing process. Extent of Surgery: Procedures involving extensive dissection of Diet Rich in Vitamins: Encourage patients to eat a diet rich in tissues, such as impacted tooth extractions or facial bone vitamin C and K, which are essential for tissue repair and blood surgeries, carry a higher risk of postoperative bruising. clotting. Foods such as leafy greens, berries, and citrus fruits may aid in faster recovery. PREVENTION AND MINIMIZATION OF ECCHYMOSIS Preoperative Measures- Medication Management: If safe and ACTIVITY MODIFICATION appropriate, certain medications that increase the risk of bruising, Limiting Physical Activity: Patients should avoid strenuous such as anticoagulants or aspirin, may be paused prior to surgery physical activities and exercise for at least the first few days after (under the guidance of the patient’s physician). surgery, as increased blood pressure and physical exertion can exacerbate bruising and swelling. ADORNA | ORAL SURGERYSII | DR. WENDY C. ZARATE 11  Elevation: Keeping the head elevated, especially during sleep, can help minimize bruising and swelling by reducing blood flow to the head and face. CAMOUFLAGE FOR COSMETIC CONCERNS Makeup: For patients who are concerned about the appearance of facial bruising, cosmetic camouflage can be used. Concealers with a greenish tint can neutralize the purple tones of bruises, while regular concealers can be applied over them. CONCLUSION Ecchymosis after oral surgery is a common and typically benign condition that resolves on its own with time. Cold therapy, followed by warm compresses, along with gentle massage, proper diet, and activity modifications, can help reduce the severity and duration of bruising. Educating the patient on what to expect and how to manage ecchymosis effectively will help ensure a smoother recovery and minimize cosmetic concerns. ADORNA | ORAL SURGERYSII | DR. WENDY C. ZARATE 12 LESSON 3: PRINCIPLE OF ENDODONTIC SURGERY often evaluated radiographically over several months to ensure - Endodontic surgery, often referred to as apical surgery or proper bone healing and the absence of infection. periradicular surgery, is performed when conventional root canal - Prognosis depends on factors such as the accuracy of the root-end treatment fails, and retreatment is either not possible or filling, the presence of untreated canals, and the patient's systemic unsuccessful. The primary goal of endodontic surgery is to health. Success rates are generally high when performed under preserve the natural tooth by addressing issues that lie beyond the appropriate conditions. reach of non-surgical treatment. Here are the core principles: CONCLUSION DIAGNOSIS AND CASE SELECTION Endodontic surgery should be considered a secondary treatment - A thorough diagnosis must be established to determine the need option after conventional methods have been exhausted. It is a for surgery. Factors include persistent infection, unhealed lesions, specialized procedure that requires precision and a thorough procedural complications (such as blocked canals or broken understanding of both endodontic and surgical principles to instruments), and inaccessible canals. achieve the desired outcome—preservation of the natural tooth. - Only cases where surgery offers a predictable outcome and retreatment is not feasible should be considered for endodontic CATEGORIES OF ENDODONTIC SURGERY surgery. Abscess drainage Periapical surgery ASEPTIC TECHNIQUE Hemisection or root amputation - As with all dental procedures, maintaining sterility is critical. This Intentional replantation minimizes the risk of infection and maximizes the chance of Corrective surgery healing. A. DRAINAGE OF AN ABSCESS ACCESS TO THE ROOT TIP - Drainage releases purulent or hemorrhagic transudates and - The surgical approach typically involves lifting the gum tissue to exudates from focus of liquefaction of necrosis( expose the bone and root tip of the tooth. abscess).Draining of the abscess relieves pain increases - The diseased tissue surrounding the apex of the root is carefully circulation and removes potent irritant. The abscess may be removed, and often the tip of the root itself is resected. confined to bone or may have eroded true bone and the periosteum to invade soft tissue, managing this intraoral or extra ROOT-END RESECTION (APICOECTOMY) oral swelling by incision or drainage - A small portion (usually 3 mm) of the root tip is removed to eliminate infected or damaged tissue. - An abscess is bone resulting from an infected tooth may be - It is essential to ensure that the cut is perpendicular to the long drained by two methods axis of the root to preserve the maximum surface area for healing. 1. Openings into the offending tooth coronally to obtain ROOT-END PREPARATION AND FILLING drainage through pulp, chamber and canal - After resecting the root tip, the canal system is cleaned and shaped at the apex. 2. Incision and drainage with or without placement of drain - A biocompatible material, such as mineral trioxide aggregate incision and drainage (I &D) Is indicated if they spread if the (MTA), is placed in the root end to seal the canal and prevent infection is rapid reinfection. - Endodontic infection do not required culture and sensitivity in MANAGEMENT OF PERIAPIC