Easier

Oral Surgery
 Extractions:
Avoiding Problems
 1st Molar

Missing
Premolars

51 year old woman.

Problem #1
 us
Si n
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.

Prevent
Prevent
Prevent
Section
 Cryers

About 85% of these first molars need sectioning.

Leave some
tooth.
3rd Molar

Male, age 36.

Extract 1,16.
 Problem #2

Bridge ??
Implant ??

Maxillary Pre-molar Area

 Easy

Bone Grafts
Calcigen Oral +
BioGran
(3i Company)
 Calcigen Oral
liquid

Plaster

BioGran (bioactive glass bone graft)

Filling the
empty syringe.
Problem #3

Surgical extraction
of tooth # 3.
Buccal
Side.
Smoker.
Alvogyl placed at
day 3 for dry
sockets.

This picture: 7 days.

Problem #4
Chest
X-ray:

Standard
of Care
Problem #5

Crown in right
mainstem bronchus.
 Problem #6
80 y.o. lady.
Appears healthy.

Taking Zometa (IV)

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

bisphosphonates
 Symptoms
• 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 PDL
 3 mm
luxator
301 (straight)
Reasons for Luxators.
 Prevent Fear,
Pain, and Death
 Prevent Fear,
Pain, 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, 0.25 mg.

– 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.
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 mg
instead of 0.5 mg.
 Prevent Fear,
Pain, 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 Survey
How 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 Fear,
Pain, and Death
 40 pounds
2 mg/lb.
80 mg max dose

Injected over 200.

About 6 cartridges.
 Company More conservative Six cartridges
Recommendation. Recommendation. were fatal.

Parentheses numbers are Dr. Stan Malamed’s recommendations.

 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:

Dysplasia
CA-in-situ
Invasive CA
No 2X2s if four quadrants numb.
Much safer. Order 3X3s or 4X4s…
 Following Dental Treatment

• Black eye
• Swollen eyelid
• Itching
• Difficulty
breathing
• Scared
Prevent Morbidity of Air

Forced into a Patient’s

Soft 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

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

Sabra
Aseptico AEU 17B with 2:1 increase Bien Air handpieces.
Both OK for surgery.
Prevent Nerve
Damage
???
Painful tongue for the last
four years.
Pain that brings her to tears.
 Dr. Karl Koerner

krkoerner@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

Local
Measures

– Refer

• Stop it 3-4 days before surgery. Might die.

– OK, if lower risk
– Or use “bridging” therapy
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

ms !
obl e
o pr
N
 Gelfoam

$5.00 per piece

 CollaTape
CollaPlug

$10.00 per piece

Hemostatic Gauze
Pure oxidized cellulose:
no additives.
Resorbs to saline
and glucose.
 Surgicel

Significantly
delays
$16.00 per piece
healing.
 Atlas of Minor
Oral Surgery..
Dym & Ogle.
Saunders, 2001.

Bone Wax Bon

e
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: 79
14 extractions
Stopped Coumadin 4 days before
Massive stroke
Dental 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 onIM 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.
Unconvention
al
Root Canal
Infection

Paresthesia of the
lip

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

Within one week, the paresthesia

resolved. The tooth lasted 15 years.
Super-EBA
cement
Straight or
surgical
highspeed – it
doesn’t
matter.
 Simple Step-By-Step Bone Graft
Procedure 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/Permanente
Insurance 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. Koerner
I will send it in:
MicroSoft
PowerPoint

krkoerner@comcast.net