easier oral surgery

EasierEasier

Oral SurgeryOral Surgery

Extractions: Extractions: Avoiding ProblemsAvoiding Problems

1st Molar

MissingPremolars

51 year old woman.

Problem #1

Sinus

1. Recognize…2. Save the blood supply…3. Try to separate the tooth and remove it…4. Involve an oral surgeon to save the bone.

PreventPreventPreventSectionSection

Cryers

About 85% of these first molars need sectioning.

Leave some tooth.

Male, age 36.Extract 1,16.

3rd Molar

Maxillary Pre-molar Area

Bridge ??Implant ??

Problem #2

Easy

Bone Grafts

Calcigen Oral + BioGran

(3i Company)

Plaster

Calcigen Oral liquid

BioGran (bioactive glass bone graft)

Filling theempty syringe.

Surgical extraction of tooth # 3.

Problem #3

BuccalSide.

Smoker.Alvogyl placed at day 3 for dry sockets.

This picture: 7 days.

Chest

X-ray:

Standard of Care

Problem #4

Crown in rightmainstem bronchus.

Problem #5

80 y.o. lady.Appears healthy.

Taking Zometa (IV) and Actonel (oral).

Others: Aredia (IV), Fosamax (oral).

bisphosphonates

Problem #6

SymptomsSymptoms

• Exposed bone, pain, swelling and infection, loosening of teeth, poor healing of gums, numbness, draining with sequestration.

1. Avoid invasive dental procedures…2. Over 23 million Americans taking them…3. 90% are from the IV form.4. Preventive dentistry – best way to reduce risks.

Indispensible

Instruments

Luxators into the PDLLuxators into the PDL

301

3 mm luxator

(straight)

Reasons for Luxators.

Prevent Fear, Prevent Fear, Pain, and DeathPain, and Death

Prevent Fear, Prevent Fear, Pain, and DeathPain, and Death

Triazolam (Halcion): One Drug Oral Sedation

Cost: A few dollars.

Effect: A few hours.

Can work and drive: The next day.

Half lives of the most commonly used benzodiazepines:

Valium: 20-50 hrs.

Ativan: 10-20 hrs.

Halcion: 2-3 hrs.

Bottom Line with triazolam:• 0.25 mg or 0.50 mg one hour before the

procedure will decrease:

– anxiety,– the perception of pain, and– postoperative recall of discomfort

without significant adverse effects. Overdose symptoms develop with four times the maximum therapeutic dose (0.50 mg) or 2 mg.

0.25 mg.

Triazolam Equivalency:

• 0.50 mg triazolam given orally 60 minutes prior to the procedure is equivalent to 10-15 mg IV Valium for decreasing anxiety and producing amnesia.

Baughman, VL, et al. 1989

Rules with oral sedation:

• Current health history

• Written informed consent

• Check pulse, BP and oxygen saturation

• A reversal agent (Romazicon) is available

• Written postoperative instructions

• Accompanied by a responsible adult before and after the procedure

US$ 400 to US$ 2000 –

Oxygen, Pulse, Blood Pressure

Maximum dose I prescribe:

0.5 mg

Mistake: Took 1.0 mginstead of 0.5 mg.

Prevent Prevent Fear,Fear, PainPain, and Death, and Death

Septocaine(Septodont)

Articaine

From top ten “Can’t Live Without.” list:

#3 Septocaine (Articaine).

Why?• More profound• Faster onset• Good for “hot” teeth,

hard to numb patients• Infiltrate lower anterior

Recent SurveyHow many have had paresthesia over

last two years from Articaine?

• Out of 300: 30 (10%)– Up to 8 times as much as Lidocaine

• Lasted over two months: 5

• Numb tongue, lip, sloughing with PDL injection…

References:

Prevent Prevent Fear, Fear, Pain, and Pain, and DeathDeath

40 pounds2 mg/lb.

80 mg max dose

Injected over 200.About 6 cartridges.

Parentheses numbers are Dr. Stan Malamed’s recommendations.

Company Recommendatio

n.

More conservative

Recommendation.

Six cartridges were fatal.

90 lbs.

90 = 7.25 (4.5)

Female with persistent ulcer.Invasive squamous cell carcinoma.

52% will die within 5 years.

23 y.o. male chews tobacco.Not cancer yet.

5-17% chance of transforming to cancer.

Male with red/white lesion.Superficially cancer.Should be OK after surgery because caught early.

90% of these red lesions:DysplasiaCA-in-situInvasive CA

No 2X2s if four quadrants numb.

Much safer. Order 3X3s or 4X4s…

Following Dental TreatmentFollowing Dental Treatment

• Black eye• Swollen eyelid• Itching• Difficulty

breathing• Scared

Prevent Morbidity of AirPrevent Morbidity of Air

Forced into a Patient’s Forced into a Patient’s

Soft TissuesSoft Tissues

• Emphysema

• Crown preps: #19, #21.

• Immediate air emphysema– Infraorbital area to anterior

neck (subcutaneous)– Also to mediastinum and

carotid sheath– Hard to breath

• Treatment– Steroids, oral antibiotics, pain

meds (no decompression)

Stanton, DC & Yepes, JF. Subcutaneous cervicofacial emphysema and pneumo-mediastinum: A rare complication after a crown preparation. Gen Dent. Mar/Apr, 2005.

Impact-Air 45

Sabra

Surgical Highspeeds: No blowing of air into the surgery site.

Aseptico AEU 17B with 2:1 increase Bien Air handpieces.

Both OK for surgery.

Prevent NervePrevent Nerve

DamageDamage

???

Painful tongue for the last four years.Pain that brings her to tears.

Dr. Karl KoernerDr. Karl Koerner

krkoerner@comcast.netkrkoerner@comcast.net

Bleeding Problems.Patient on anticoagulants, like Coumadin.

Coumadin Anticoagulant: Choices

• 1st choice: Don’t stop it before surgery.– One appointment, local measures– Two or more appointments, local measures

– Refer

• Stop it 3-4 days before surgery. Might die.– OK, if lower risk– Or use “bridging” therapy

LocalMeasures

Choices with Coumadin:

Don’t Stop Coumadin – use local measures.

-- talk to physician,

-- know the INR (1 to 4) Age 76

INR (1-4)International Normalized Ratio)

The new “Bleeding Time”.

Normal INR

No problems!

Gelfoam

$5.00 per piece

CollaTapeCollaPlug

$10.00 per piece

Hemostatic GauzePure oxidized cellulose: no additives. Resorbs to saline and glucose.

Surgicel

$16.00 per piece

Significantlydelayshealing.

Atlas of MinorOral Surgery..Dym & Ogle.Saunders, 2001.

Bone

Wax

Bone Wax

Choices with Coumadin:

Stop Coumadin – normal clotting. (But patient may be at risk.)

-- talk to physician, know INR

• DAILY HERALD/OBITUARIES.

• Lula B. Tallo • Lula B. Tallo passed away peacefully, with her children by her side

on Sunday morning, June 27, 2004 in the Mountain View Hospital.

She had suffered a stroke on Friday.

Age: 7914 extractionsStopped Coumadin 4 days before Massive strokeDental work Thursday, stroke Friday died Sunday.

Choices with Coumadin:

Stop oral Coumadin.

A few days later, start Lovenox every 12 hours. Patient gives herself a shot.

Stop Lovenox 12 hours before surgery.

Start Lovenox 6 hours after surgery.

Start oral Coumadin again.

On Coumadin orally

Stops 3-4 days before surgery

Starts on IM Lovenox bid (12 hr. duration) but not within 12 hrs. of surgery

If no bleeding problems, another Lovenox that night and/or the next morning.

Re-start Coumadin.

UnconventionUnconventionalal

Root CanalRoot Canal

InfectionInfection

Paresthesia of the Paresthesia of the liplip

PainPain

82% successful for at least 5 years if done quickly.

Within one week, the paresthesia resolved. The tooth lasted 15 years.

IntentionalReplantation

Super-EBA cement

Straight or surgical highspeed – it doesn’t matter.

Simple Step-By-Step Bone Graft Simple Step-By-Step Bone Graft Procedure for Single SocketProcedure for Single Socket

Simple Step-By-Step Bone Graft Simple Step-By-Step Bone Graft Procedure for Single SocketProcedure for Single Socket

• Mix plaster & liquid (Calcigen Oral) in dappen dish.• Discard half of plaster.• Quickly add syringe of synthetic bone graft material

(BioGran).• Wait one minute until putty-like.• Suction, then place in socket to 1 mm from the gingival

crest. (will set-up in 3-5 minutes)• Suture over socket to better approximate soft tissue.• Patient to rinse with Peridex twice a day for three weeks.• Wait three months for bridge, one year for implant.

3i: 800-342-5454

Notes:• Romazicon: 0.2mg (0.1mg/cc) initial dose ½

inch in tissue just off midline under tongue into venous plexus. 2nd dose in 2-3 min. Can have re-sedation.

• Sublingual: 80% effect within 20 minutes.

• Patient should always be able to wake up.

Portland, Kaiser/PermanenteInsurance Group

• 100 dentists• Lido: 1 paresthesia/40,000 blocks• Septo: 1 paresthesia/5,000 blocks

Their ruling:

Don’t use Septocaine for blocks!

Dr. Karl R. KoernerDr. Karl R. Koerner

krkoerner@comcast.netkrkoerner@comcast.net

I will send it in:MicroSoft PowerPoint