Oral surgery

fourth year
General idea about oral surgery………………………………………………………….....................3
Infection control in surgical practice………………………………………………………………………4
Armamentarium used for exodontia……………………………………………………...................8
Principles of exodontia………………………………………………………………………...................15
Principles of flap……………………………………………………………………………………………...…..18
Principles for open extraction………………………………………………………………………….……22
Surgical removal of wisdom tooth…………………………………………………………………...……26
Extractions of wisdom tooth………………………………………………………………………………….29
Impacted canine……………………………………………………………………………………………….…..36
Principles of suturing……………………………………………………………………………………..……..39
Wound repair…………………………………………………………………………………………………..……42
Complications of exodontia 1……………………………………………………………………………..…46
Complications of exodontia 2…………………………………………………………………………………49
Surgical endodontics………………………………………………………………………………………………52
Admission of dental patients to hospitals……………………………………………………………….54
Odontogenic infections……………………………………………………………………………………..…..58
Prevention of infections………………………………………………………………………………….….….63
Osteomyelitis …………………………………………………………………………………………………….….66
Infection of facial spaces………………………………………………………………………………………..70
Bleeding disorders………………………………………………………………………………………………....76
Lasers in dentistry…………………………………………………………………………………………………..77
Antibiotics………………………………………………………………………………………………………………80
Medical emergencies……………………………………………………………………………………………..89
Pain killers……………………………………………………………………………………………………………...93

1|Page
Dental Management of Pts with Systemic Diseases – CVS………………………………………101
Odontogenic Disease of Maxillary Sinus………………………………………………………………….104

DONE BY: LEEN AL-FARAJ

2|Page
Lecture 1
e.g. some patients have osteoporosis, bone cancer or paget’s diseases of bone, they
take multiple medication including vit D supplies, Calcium supplies and
bisphosphonates which can sometimes cause medication related osteonecrosis of the
jaw after some procedures, patients may think that bisphosphonates is supplementary
like vit D and calcium and don’t mention this during history taking.
Also diabetes patients, many patients think that hypoglycemic medication is just a
normal medication and doesn’t need to be mentioned so he may end up with
hypoglycemic shock during the procedure. If a patient has a prosthetic heart valve or
joint then I must know what instruction should be given and if I need to give
prophylactic antibiotic before the procedure.
ASA classification It is a classification made my American Society of
Anesthesiologists(ASA) to asses the fitness of the patient before surgery.

3|Page
Lecture 2 infection control
Whenever our immune system can control microrganisms then we keep our health but
if microrganisms wins(because of elevated number of it, more aggressive strains or
weak immune system) then infection will happen. In infection control, we can’t kill all
the microrganisms or make the oral cavity sterile(it is the filthiest organ in the body)
and during our practice, we open wounds in the oral cavity so there will be always some
sort of contamination, so we just try to decrease the number of microrganisms, deal
with weaker strains, have a more sterile enviroment and use sterile instruments as
much as possible.
The oral flora is a complex body formed by at least a hundred bacterial species which
can be more or less regular residents in the oral cavity. Thanks to a developing
taxonomy related to progress made in bacterial identification, these oral species can
be separated into five groups based Gram staining and morphology: the Gram positive
cocci group (Streptococcus, Staphylococcus and related geni), the Gram negative cocci
group (Neisseria, Veillonella and related geni), the Gram positive bacilli group
(Corynebacterium, Actinomyces, Lactobacillus, Methanobrevibacter and related geni),
the Gram negative bacilli group (Haemophilus, Campylobacter, Bacteroides and related
geni) and finally the spirochete group (Treponema)
n the oral cavity, it is usually filled with:
1- Aerobic gram +ve
2- Streptococcus spp.
3- Actinomyces
4- Anaerobics like prevotella spp.
5- Candida spp

In the nasal cavity, normal flora includes streptococcus.

Skin normal flora includes staphylpcoccus. We also have viruses in the oral cavity. For
infection control we mainly focus on hep B and C and HIV. It is important to know the
normal floar of every organ because if infection happened in this organ then we may

4|Page
need to give antibiotics and this antibiotics must be able to deal with the microrganisms
normally found in this organ.

So infections in the oral cavity are usually mixed infections(aerobics +anaerobics) so

antibiotics given must be susceptible to both.

Universal precaution :-
1- All of the surfaces in the clinic must be disinfected with certain materials.
2- Use disposable material whenever possible. Many materials that were sterilized in
past days are now disposable.

Materials used to disinfect surfaces:

A- Halogen compounds like iodoform which reduces the number of bacteria on the
surfaces.
B- Hypochlorite like bleach.
C- Aldehydes like formaldehyde and glutaraldehyde.

Precaution must be applied to all the patients. But if I knew that a patient has an
infectious disease, I can add some precautions. This patient should be treated the
last in the clinic, his medical waste is isolated from other’s, if one the staff is
immunocompomised that he shouldn’t deal with this patient. In the UOJ, black
backs are used for normal waste, yellow bags for medical waste and red bags for
highly infectious materials.
Sepsis : is a life-threatening condition that arises when the body's response to infection
causes injury to its own tissues and organs
Medical asepsis: an attempt to keep the health care staff and objects as free as possible
of agents that cause infection. So we can’t and we don’t aim to reach ZERO
microrganisms.
Surgical asepsis: an attempt to prevent microrganisms from entering surgical wounds.
E.g. before cutting anywound I have to disinfect the area with certain materials. In the
oral cavity, we ask the patient to rinse his mouth with mouth wash from 4-5 minutes
before the procedure.

5|Page
For skin we disinfect the area with iodine before cutting. Now we need to differntiate
between two terms, antisepsis and disinfection. Sometimes they are used
interchangeable, but disinfection is applied to the surfaces. Antisepsis is applied to
living tissues only.
Sterlity: freedom from viable(able to increase in number) forms of microrganisms.
Sanitization: reduction in number of viable microrganisms. It has standards to
cMethods of sterlization:
1- Dry heat: increase the temperature inside an oven, it is preferred if the instrument
rusts.
2- Moist heat: less temperature and time but some materials can rust. Also remember
that to use the instrument, you must wait for it’s temperature to decrease, the
higher it’s temperature, the more time it needs.
3- Gas sterilization: we usually use EO(ethylene oxide), it is effective in low
temperature, but it needs huge device so it can only used in hospitals.

For disinfection, we usually use chemicals, maily formaldehyde. Chemicals are

divided into low, intermediate and high level disinfectants. You may ask why there
are many types of disinfectants and sterilzation techniques, we use every type for
specific materials and conditions. In major surgeries, if the surgeon drops an
instrument, it needs long time to be sterilized by autoclave so there are always
formaldehyde so you put the instrument inside it for 5minutes then use it.onsider
any object sanitized.
Decontamination: same to sanitization but doesn’t have standards.

6|Page
7|Page
Lecture 3

8|Page
9|Page
10 | P a g e
11 | P a g e
12 | P a g e
13 | P a g e
14 | P a g e
15 | P a g e
Lecture 4 principles pf extraction
Contraindications includes local and systemics factors, we will start with systemic
factors.
1- Uncontrolled DM: controlled DM doesn’t have any contraindications, but if it was
uncontrolled and severe then it is contraindication for extraction.
Also you have to ask for HbA1C level. If his measures is within normal, you can go on
with the extraction but if it is not, don’t ever do the extraction.
2- End-stage renal diseases.
3- Uncontrolled leukemia and lymphomas: this patient is more susciptible to
infections. If you did the extraction, he may have severe or lifethreatning
infections.
4- Uncontrolled cardiac diseases: like eschemic heart disease. Even in case of
HTN. You have measure the blood pressure of the patient every
appointment. HTN can be: a. Severe: you never do the extraction. b.
Moderate: you do the extraction in case of emergency. 2 c. Mild: you can do
you extraction. This category is made by the heart foundation, Dr.Soukaina
didn’t mention it but I added it for further knowledge.
5- Bleeding problems: like hemophilia. Sometimes patients will not mention
that he has any problem, so you have to be careful. In Jordan, we have more
than one documented cases that patient had severe bleeding after
extraction which lead to their death.
6- Medications: I- Anticoagulants like warfarin. II- Steroids: you can give him
prophylaxis of steroids. So you can ask him to double or triple the dose for
the extraction. Extractions can cause stress, the adrenal gland produce
steroids in cases of stress but this patients have a suppressed adrenal gland.
III- Immunosuppressive agents: you can give them antibioticprophylaxis.

Now we will start with local contraindications:

A- History of radiation: cancers in the head and neck regions can be cured with
radiotherapy. Radiotherapy causes changes in vascular supply which will cause healing
problem. This increases the risk of osteoradionecrosis of the jaw after extractions. 3 So
any patient that will start radiotherapy must be evaluated first for dental treatment

16 | P a g e
needed, it he need any treatment then it must be performed before starting the
radiotherapy. You mustn’t do any procedure in the first three months after
radiotherapy ends, if you must do the extraction, then you give prophylictic antibiotic,
work in sterile invironment, you have to be atraumatic, post-operative suturing and
follow-up the patient.
B- Mobility of the teeth: I have to know the cause of mobility, if the patient
has periodontitis then I can continue my procedure without any problem.
But sometimes it can be caused by tumors. If extraction is made, then
you are helping the tumor to spread through the blood.
C- Pericoronitis: specifically in ages 18-25 years which is the ages for
wisdom teath extraction. If the patient has an infection and you did the
extraction, this wil worsen the symptoms and infection may spread to
other facial spaces.

Clinical evaluation of teeth for removal:

1- Access to the tooth: patient with scleroderma or any other connective tissue disease
have special way for extractions. In surgery, visibility is important. If you have poor
visibility or accessibility, don’t start the extraction. Not mentioned in the lecture.
The acute dentoalveolar abscess must be mentioned. Many prospective studies
have made it abundantly clear that the most rapid resolution of an infection
resulting from pulpal necrosis is obtained when the tooth is removed as early as
possible. Therefore acute infection is not a contraindication to extraction. However,
it may be difficult to extract such a tooth because the patient may not be able to
open the mouth sufficiently wide due to trismus, or it may be difficult to reach a
state of profound local anesthesia. If access and anesthesia considerations can be
met, the tooth should be removed as soon as possible. Otherwise, antibiotic therapy
should be started and extraction planned as soon as possible. 4
2- Mobility of the tooth: again, I have to know the cause of mobility.
3- Condition of the crown: crowns with large cavities or restorations are more prone
for fracture.
4- Status of the periodontium: scaling and perio treatment must be done before
extractions. This will decrease bacterial load inside the oral cavity which will lower
the possibility of infections and post operative complications.

17 | P a g e
5- Examination of radiographs: It is necessary to take radiographs for the teeth to be
extracted.

Radiographs can help in: 1- Relationship to vital structures 2- Configuration of roots.

3- Condition of sorrounding bone: there may be resorption, sclerosis or ankylosis.
Bone sclerosis can be caused by bahcet’s disease. Sometimes I can find pathologies
like granuloma or abscess.

We always do extractions while standing in front of the patient, but you can stand
behind the patient for lower right posterior teeth if you are right handed, or lower left
posterior teeth if you are left handed. If you want to extract maxillary tooth then
maxillary occlusal plane is 60 degrees to the floor. For the lower teeth, the lower
occlusal plane should be parallel to the floor.
- The height of the chair should be such that the patient's shoulder is at the dentist's
elbow level.
Firm support is essential. For maxillary teeth, thumb and index finger are used (2
fingers). For extractions in the mandible two fingers and the thumb are used (3 fingers).
Satisfactory support is eWedging action: (Putting the elevator in an areal where there
is an angel which is MB angel) qually important when using forceps or elevators.
Wheel and axle action) ‫( مبدأ العجالت‬Triangular elevator "Cryer" are used for extraction
of root stump of molars (mostly mandibular) when one root is removed, and the other
is to be removed. The working blade is introduced into the empty socket and moved
toward the remaining root piece.
you should know where to apply the elevator and what is the direction of the tooth
delivery. Concavity of the blade is engaged in the root structure. During extraction of
the tooth and while holding the forceps make sure you go buccally and lingually several
times then do rotational movement.
Elevator use: The elevator is used to detach the surrounding tissues and luxate the
tooth by the wedging action. Don’t forget that you have to respect the adjacent teeth
and oral structures during this step.

18 | P a g e
Lecture 5
Principles of complicated exodontia
However, the broad classification usually classifies these procedure according to
specific criteria:
1. the extraction where there is less than three adjacent teeth is called routine dental
extraction or uncomplicated exodontia
2. more than three teeth and osseous surgery with or without flap elevation provided
that the procedure does not extend for more than two hours, this is called MOS or
minor oral surgery,
3. if the procedure lasts for more than two hours even if the type of anesthesia used is
local, it’s called a major procedure
4. a procedure where a flap is elevated is called complicated exodontia Please note
that an MOS can be either complicated or not, depending on whether or not we elevate
a flap, and this step is usually decided during the procedure, if you feel like you’re not
gaining enough
The term flap, as used in this chapter, indicates a section of soft tissue that
(1) is outlined by a surgical incision,
(2) carries its own blood supply (to prevent its necrosis),
(3) allows surgical access to underlying tissues,
(4) can be replaced in the original position, and
(5) maintained with sutures.
1. Envelope flap (two-angled flap) there is only one insicion at the sulcular gingiva,
with no releasing insicions
2. Two-sided flap (three angled-flap) an envelope flap after you make one releasing
insicion anteriorly
3. Three-sided flap (four angled-flap) An envelope flap after you make two releasing
insicions, one anteriorly and one posteriorly .

19 | P a g e
The standard flap is the envelope, meaning you should always start with it unless there
is a contraindication, it comprises of one insicion at the sulcular attachment of the
gingiva (depth of the sulcus). It provides poor access but it’s less invasive, it’s still
sufficient for some types extractions. If you find that the envelope flap does not fullfil
its main aim (sufficient access) then you should resort to an anterior releasing incision
→ two sided flap.
In other words, you should never start with three-sided flap or three-sided, you go
systematically from envelope, to two-sided, then finally three-sided flap.

- Sometimes we go for specific types of flaps, semi-lunar is indicated for apicoetomy or

if you want to gain access for the apical area of the tooth, it provides a limited access,
less invasive than conventional flap but sometimes you don’t need a lot of it in the first
place. This incision avoids trauma to the papillae and gingival margin but provides
limited access because the entire root of the tooth is not visible. This incision is most
useful for periapical surgery of a limited extent.
-Another type is a modified semi-lunar called scalloped incision, it’s located at least
2mm away from the gingival margins and its aim is to prevent any injuries to the gingival
sulcus and future gingival recession. Usually any sulcular insicion results in a degree of
gingival recession.
-There is also a Y-incision and it’s indicated for torus palatinus located in the posterior
palatal area. It consists of a midline palatal incision, with two anterolateral extensions.
There is a rule that states that we should not have releasing incisions in the palate as
this can produce profuse bleeding from the greater palatine artery (either the patient
dies or you die). However, a releasing incision can be done in the canine area because
it only has anestomosis (terminal branches), but either way you should always keep the
vessels within the flap and you should also be prepared for major bleeding. This incision
is useful for surgical access to the bony palate for removal of a palatal torus. The tissue
overlying a torus is usually thin and must be carefully reflected. The anterolateral
extensions of the midline incision are anterior to the region of the canine tooth. The
extensions are anterior enough in this position that they do not severe major branches
of the greater palatine artery; therefore, bleeding is not usually a problem.

20 | P a g e
** no releasing incision in the palate
** no releasing incision in mental foramen area (either anterior or posterior to the
foramen, in that way, the vessles and the nerve will be carried safely in the flap)
** no releasing incision in lingual tissues (to avoid lingual nerve damage)

− To summarise the advantages of full-thickness flap: i. Minimal bleeding ii. Clear field
of view iii. Sufficient vascular bed for healing
2. Base of the flap should be wider than the free gingival margin. If you make the basal
part narrower than the free gingival margin (B) then you are restricting the blood supply
of the flap. Take a look at flap B, the only blood supply pours vertically from the apical
area to the gingival margin of the flap, but since the apical area is narrower than free
gingival margin, there will be a compromised blood supply. Some references say the
base of the flap should be at least equal to the gingival margin by making the releasing
incision straight.
3. In envelope flap, the incision should extend two teeth anterior to the tooth you’re
working one and at least one tooth posterior to the tooth you’re working on. In the
two-sided or three-sided, you can extend the gingival/sulcular insicion one tooth
anterior and one tooth posterior to the tooth you’re working on, and this is because
they both offer better access than the envelope flap.
4. The releasing insicion can spare or include the papilla, which has blood supply and
incising it would also provide poor aesthetic features afterwards.
5. Releasing incision is better to be oblique rather than straight to the root, remember
that the buccal shelf is made of thin bone, if you distribute the cut on multiple teeth by
making the incision oblique, you prevent clefting of the bone in the future.
6. Leave at least 6-8mm of sound bone after returning the flap to it’s original position.,
the margins of the flap should not be on the brittle bone that you operated on
otherwise it would collapse into the cavity and delay healing.

You should draw the blade anteriorly towards the operator, not posteriorly since that’s
the direction of slippage (imagine that you are working from the canine to the molars,
going posteriorly, any slippage of your hand will result in the blade going inside the
mouth and most likely harming the patient. While if you do it from the molars to the

21 | P a g e
canine, the slippage will result in the blade exiting the mouth, hopefully reducing the
chance of any injury)
▪ The cutting motion should be in one smooth continuous stroke while keeping the
blade in contact with the bone (full-thickness) throughout the entire insicion, this
facilitates better healing. A lacerated and irregular insicion indicates an inexperienced
surgeon.

22 | P a g e
Lecture 6 principles and techniques of open extraction
The first step for opened extraction is flap elevating using envelope flap. Two teeth
anterior and one tooth posterior to the tooth of interest. First we need to start with
the forceps. If you grasp the tooth well then you can continue, but if you couldn’t have
good grasp then you can grasp a bit of the buccal bone(up to 2mm) to achieve a good
grasp. If you didn’t achieve a good grasp even after grasping the buccal bone then you
need to use the elevator. You have to insert it in the PD space in a wiggling motion to
expand the space. The goal of this attempt is to have application point.
And this is when you feel that the bone is catching you. If you let the elevator go then
it will stand still. Once you achieve the application point, you can start elevation. If you
started elevating without having application point then the tooth will not move.
Sometimes you can’t achieve application point because of bad accessibility or narrow
PD ligamnts space, so you have to start the forth step.
The forth step is the removal of the bucco-cortical bone with bur until exposure of the
largest circumference root. Then you start using the elevator as explained in the
previous step. Sometimes you can create an application poing in the root specially if it
was ankylosed or very hard bone. The application poing need to be deep and atleast
3mm wide to apply the elevator. And this is better because you now are digging into
dental tissue, not bone.
And this is the right steps for opened extraction. To sum up:
1- Use the forceps.
2- 2- Grasp a bit of the buccal bone.
3- 3- Enter the elevator in wiggling motion until you have good application point.
4- 4- Remove the buccal bone to expose the root.
5- 5- Create an application point on the root.
Remember that we have a bifurcation between roots(trifurcation in the upper molars).
It is easier to reach the trifurcation in the upper teeth than the bifurcation in the lower
because the bifurcation is deeper.

23 | P a g e
Seperation has two types: 1- Horizontal seperation. 2- Vertical seperation.

Horizontal separation of mesial root : The result is distal root with the crown that can
be easily extracted and mesial remaining root that can be extracted with any forceps.
We use cryer elevator especialy for this cases. Cryer is indicated to extract remaining
root next to an empty socket. You insert the cryer and it’s tip should engage the
cementum. The cryer is rotated in a wheeland-axle fashion.
In horizontal seperation, it is better to separate the distal root with the crown and leave
the mesial root as remaining root because of the anatomy of the root. Distal root usualy
has 1 canal so it is conical in shape and easier to extract. In general we have to start
with the easy procedure to gain the confidence of the patient and facilitate the
remaining procedure. For the mesial root which is harder to extract, it becomes easier
when the distal root is extracted first. Some dentists may separate the whole crown
from the roots and there is no problem in this.
For the upper molars, it is easier to separate the palatal root with the crown because
it is conical in shape. The buccal roots is divergent so it becomes easier to extract each
one alone. After extraction of the palatal root with the crown you can separate the
buccal roots with the handpiece to complete your extraction.

The other type of separation is vertical separation. But here you have to make a space
to accommodate the used elevator, atleast 3mm or the crown will fracture during the
extraction. This is surgical extraction for lower 2nd molar using vertical separation.
Notice that after separating the tooth into mesial and distal parts with the
handpiece(C), the elevator is used to complete the cut. This was the surgical extraction
of the teeth or remaining roots.
.
Now sometimes we need to extract fragments of roots because of previous extraction
or fracture of the tip of this root during the extraction. During your extraction and even
if you followed the right steps, you may feel that there is a fractured tip inside the bone.
This can happen mainly in upper 1st premolar. And now you have 2 choices:

24 | P a g e
1- If the fragment was not infected and not luxated, the fragment is less than 4mm in
length and vital we can leave it. And studies support you. Remember that you must
inform the patient and make follow up schedule. If the patient refused to leave it,
you must tell the patient about the complications of the extraction and let him
decide.
2- If the fragment is more than 4mm, luxated, infected with no difficulty in
extraction(e.g. dilacerations) then you have to extract it. If the fragment is 2-4mm
you can extract it with root tip pick.
The root tip pick is teased into the periodontal ligament space and is used to gently
luxate the root tip from its socket. You must not do any extraction if you don’t have
proper vision. Sometimes the fragment is already extracted and sucked into the
suction but you didn’t notice. If you continue the extraction, you will drill into the
bone and cause more complications without any reason. If you don’t see it, don’t
do it. So start with irrigating the socket, good lightening and you should see the
fragment. It is easy to see it because dental structure is clearer than the bone. It the
fragment is longer than 4mm then we use the elevator. Remember to enter in a
wiggling motion and the elevator should be in an angle with the long axis of the
tooth or you may accidently push it into a vital structure. Now you have to follow
the same steps for extracting a single-rooted tooth. If you can’t extract it with the
elevator then drill into bone until you expose the root. Some modification is made
here. You don’t have to drill the bone along the whole socket to expose the tip, you
can just make a hole beside the tip of the fragment but you must locate it exactly.
Use radiographs to locate it. This technique is open-window technique. After making
the hole, you enter the elevator and push the fragment. In multiple extractions,
there is a debate in which tooth to start with.

** Which you should start with, upper or lower? Anterior or posterior? In our school
we start with lower before upper. Americans start with upper. It is a good advantage
to start with the upper but with just one disadvantage, blood will obscure vision of
the lower teeth. But with good hemostasis, this disadvantage can be passed.

Advantages of starting with the upper teeth:

1- Anesthesia has a more rapid onset and disappears faster.
2- 2- Maxillary teeth should be removed first because during the extraction process,
debris, such as portions of amalgams, fractured crowns, and bone chips may fall
25 | P a g e
 into the empty sockets of the lower teeth if the mandibular surgery is performed
first
3- 3- Maxillary teeth is extracted mainly with buccal force, not vertical. Mandibular
teeth need vertical force so extracting the maxillary teeth first gives us more
space to move. Tooth removal usually begins with extraction of the most
posterior teeth first. This allows for the more effective use of dental elevators to
luxate and mobilize teeth before forceps are used to extract the tooth. The tooth
that is the most difficult to remove—the canine—should be extracted last. So the
right sequence to extract the teeth: Maxillary posterior > maxillary anterior >
maxillary canines > mandibular posterior > mandibular anterior > mandibular
canine.

26 | P a g e
Lecture 7 wisdom teeth
What is the difference between unerupted and impacted ? Unerupted: still has a
chance to erupt. Like in case of permenant teeth for a 10 years old child. Impacted: it
failed to erupt.
So now, what are the reasons for impaction? The most commonly accepted theory is
the disproportion between the size of the jaw and the teeth. Last tooth to erupt is the
3rd molar so it doesn’t have any space to erupt. Genetics may play a big role here. Some
families has small jaws so they will have higher prevalence of impaction.
. We will start with clinical examination for 3rd molar extraction:
1- The patient attitude: one of the most important factors. If the patient was afraid,
we may change our plans into sedation or GA. Sedation: IV sedatives like diazepams
used as anxiolytic for afraid or phobic patients. The patient is still 100% conscious
but it makes the patient more relaxed and gives the patient partial amnesia after
the surgery. You still need to use LA beside sedation.
2- 2- Age and general fitness: bone quality changes as we age. With time, bone
becomes more calcified and less resilient which makes the elevation harder. Some
medical problems may need alteration in my treatment plan. Ethnic group may
affect my decision also.
3- 3- Presence of facial swelling and enlarged, tender lymph nodes: high percentage
of patients have pericoronitis. Pericoronitis comes in wide variations, it can be very
simple without any major problems but it can even cause systemic involvement.
4- 4- Surgical access: if the patient has trismus, we cannot operate so we have to delay
our procedure.
5- 5- Health of 1st and 2nd molars: some 3rd molars are mesially inclined which can
cause food impaction between it and the 2nd molars. This can cause periodontal
involvement, caries or pain. Sometimes we may extract others molars with the
wisdom or the source of pain is other tooth than the molar. Inclination of the
wisdom can cause bone resorption distal to the 2nd molar, after extraction this will
cause exposure of the root and hypersensitivity, so you have to inform the patient.
6- The position of the opposite 3rd molar: sometimes the patient will think that the
pain is caused by the lower 3rd molar when it is caused by the upper. So proper
diagnosis is mandatory.

27 | P a g e
 7- Possible future use as a denture or bridge abutment: now it has less importance
after implants. If I extracted lower 3rd molar, do I need to extract the upper? If the
upper is erupted, this will cause over-eruption of it which will cause further
complications in the future so it is better to be extracted as well. If it is fully impacted
so we don’t need to extract it.

Classification systems for impacted teeth:

There are many classification systems. We use this systems for proper communication
any presentation of the case. The most commonly used system depends on angulation:
1- Mesio-angular(most common and easiest to extract) 2- Vertical 3- Disto-
angular(most difficult) 4- horizontal we describe the 3rd molar angulation with regard
to the long axis of the 2nd molar.

Another classification is Bell and Gregory classification( so important ), it has two

components.
1- Relation to the anterior border of the ramus:
 Class I: M-D diameter of the crown is tottaly anterior the the anterior border of the
ramus.  Class II: one half of crown is covered by ramus  Class III: tooth completely
within the ramus
2-Relation to the occlusal plane:  Class A: occlusal surface is level (or nearly) with
occlusal plane of 2nd molar  Class B: occlusal surface between occlusal plane and
cervical line  Class C: occlusal surface below cervical line(fully impacted)

To remove or not to remove: We have to make a decisions to remove the tooth or leave
it, our decision depends on:

28 | P a g e
1- Pericoronitis: you start by giving antibiotics and cleaning the area. If the problem
stable then you can leave it. If the patient gets 2 or more episodes of pericornitis in
the year, it is better to extract the tooth.
2- 2- Unrestorable caries: for most dentists, it is better to extract any carious 3 rd
molar. It is hard and has no benefit to keep it.
3- 3- Non-treatable pulpul and periapical pathology: pulpitis, apical periodontitis,
cysts, tumors …etc
4- 4- Cellulitis or any infection.
5- 5- External or internal root resorption.
6- 6- Fracture of the tooth.
7- 7- Reconstruction surgeries for the mandible if the 3rd molar is on the way of our
construction.
8- 8- Orthodontists - imbrication of the anterior teeth, orthodontic movement of
molars distally, orthognathic surgery.
9- 9- Prevention of jaw fracture: the 3rd molar makes hollow space in the angle of the
mandible so this weakens the mandible and makes it more prone to fracture in this
area. In some sports like boxing and wrestling, they ask to extract 3rd molar for
prevention.
10- 10- Unexplained pain of unknown origin and we cannot find any cause. You can
tell the patient that we have a chance of 50% to stop the pain if we extracted 3rd
molars.

29 | P a g e
Lecture 8 extraction of wisdom teeth

1. Mesiodistal angulation: A mesially impacted third molar is the easiest to extract,

and a distally impacted third molar is the most difficult. It is easy to see the angulation
of the tooth from the initial X-ray taken on examination
2. 2. Depth
3. 3. The proximity of the ramus  Pell and Gregory classification shows the depth
and the proximity of the third molar to the ramus. The tooth can be classified according
to Gregory and Pell very easily using the Panoramic radiograph  Depending on the
tooth’s classification according to Pell and Gregory, you will decide how deep you will
put your elevator and how buccal or lingual to put it
4. 4. Density of bone: the denser the bone, the harder the extraction is going to be
and the higher the chance of fracture of the mandible or tooth itself is. This is also
evaluated using the initial X-ray
5. 5. Ethnicity: Extraction is harder in Africans and Blacks
6. 6. Surgical access: trismus and obesity cause a limitation in surgical access
increasing the difficulty of the extraction
7. 7. Root anatomy: dilacerated roots, curved roots and unusual root formation are
going to increase the difficulty of extraction.  While elevating the molar, a catch will
be felt and if you exert more force, the tooth will get fractured and the root will remain
in bone.  If the tooth gets fractured, the extraction will transform from a simple
extraction to a surgical extraction.  This can also be seen on the X-ray and you can
anticipate the difficulty beforehand and inform your patient that the extraction might
become a surgical procedure
8. 8. Proximity to the inferior alveolar nerve: you should be careful during extraction
not to injure the ID nerve and cause paresthesia. If the molar was close to the Inferior
alveolar canal, then extraction difficulty will increase
9. 9. Associated pathologies: If the molar was associated with any pathologies like
cysts, tumors like ameloblastoma or any other pathology, then the extraction
procedure will definitely be surgical. Such a procedure cannot be done in dental clinics
and should be done in the hospital

30 | P a g e
  During planning, you should consider whether you have the surgical skills to perform
this procedure or not.  You also decide whether the procedure is going to be done
under local anesthesia or general anesthesia Panoramic X-rays are 2D images of a 3D
structure. Some features may appear different than reality on the X-ray. A CBCT picture
shows you a 3D image of the same structure.

Signs that may cause you to take a CBCT image: 1. A narrowing of the Inferior alveolar
canal on Panoramic X-ray 2. A change in direction of the canal – a sign that there is an
interference from the root of the molar on the cortical bone forming the ID canal

What contraindicates extraction? 1. Extremes of ages – very young patients and very
old patients
2-Comprised medical status
3- Surgical damage to adjacent structures like the ID nerve

Basic steps of Extraction of Impacted Mandibular Third Molars

1. Reflect adequate flaps for accessibility
a. Envelope flap – “envelope flap is the preferred technique” b. Three-cornered
flap/triangular flap (maxillary and mandibular teeth)  The envelope flap is opened up
from the mesial or distal aspect of the second molar and up to the ramus distally. 
Disadvantage of the envelope flap: in patients with history of periodontal disease, poor
healing and gingival recession can be seen  The triangular flap extends from the
mesial aspect of the 7. An incision is made from the mesial papilla of the 7 up to the
sulcus then the triangle is extended down to the ramus. Be careful of injuring the buccal
branch of the facial artery located in the sulcus to prevent excessive bleeding during
extraction
2. Removing of overlying bone a. Chisel/drill – it is preferred to use a drill when the
patient is under local anesthesia only and a chisel when the patient is under general
anesthesia  The chisel and hammer look intimidating to the patient and the patient
feels discomfort from the force exerted by the chisel  The chisel exerts a lot of force
– if it was used by unskilled hands, the jaw could get fractured so try to avoid it
especially when extracting a maxillary tooth b. Lingual aspect  Sequence of bone

31 | P a g e
removal in the mandible: occlusal, mesial, buccal, then distal avoiding the lingual side.
Small holes are made on each of those aspects and when enough exposure is gained,
they are connected together  The lingual nerve is on the lingual side so bone removal
lingual to the tooth endangers it and might lead to lingual paresthesia if the lingual
nerve was injured  We try to uncover the maximum bulbosity of the tooth, then
section the tooth
3. Sectioning the tooth
 Mesio-angular  Least difficult  Distal half of the crown is sectioned to make it easier
to use the straight elevator on the mesial side of the tooth

Horizontal impaction  More difficult – horizontal retraction is more difficult  Bone

removal
Divide crown from roots – section away the crown from the roots. The roots can now
be elevated

Vertical impaction  Bone removal  More access needed  Section the tooth from the
middle and elevate each portion separately

Distoangular  Most difficult

Bone removal especially from the distal aspect to gain good access – more removal
from the distal aspect than normal  Crown sectioning – the whole crown is sectioned
away from the roots, then the roots are removed separately one by one
4. Delivery of the tooth using an elevator
5. Debridement of the wound

Basic Steps of Extraction of Impacted Maxillary Third Molars 

“The recommended incision for the maxillary third molar is also an envelope incision.
The incision extends posteriorly over the tuberosity from the distal aspect of the second
molar and anteriorly to the mesial aspect of the first molar” 
Rarely sectioned – “Impacted maxillary teeth are rarely sectioned because the
overlying bone is usually thin and relatively elastic. When bone is thicker or the patient
is older, tooth extraction is usually accomplished by bone removal rather than by tooth
32 | P a g e
sectioning”  No chisel  Good amount of bone removal will allow easy elevation using
a straight elevator  Delivery with elevator  No luxation – there is no need to luxate
all around the tooth like in simple extraction, just at the application point as the bone
around the third molar is cancellous (soft), and it is easy to push the molar into the
sinus if you are not careful.  No excessive force (maxillary and mandibular teeth) to
prevent pushing of the third molar into the sinus – “Application of excessive force may
result in unfavorable fracturing of the tooth, of excessive buccal bone, of the adjacent
second molar, or possibly of the entire mandible”

Debridement of wound
 Remove bone chips and debris – done with vigorous irrigation with sterile saline 
Irrigate with saline – Special care should be taken to irrigate thoroughly under the
reflected soft tissue flap  Smooth sharp edges so they don’t cause irritation to the
gums – “A bone file is used to smooth any sharp, rough edges of bone, particularly
where an elevator was in bony contact”  Primary closure, if possible, with resorbable
or non-resorbable sutures
Post-operative care 
Pain and anxiety control – different groups of pain killers are available, but we mostly
use acetaminophen. Potency of acetaminophen is increased by adding codeine or
caffeine – “Combinations of codeine or codeine congeners with aspirin or Application
point of the elevator on the buccal side of the mandibular tooth acetaminophen are
commonly used. Nonsteroidal anti-inflammatory drugs such as ibuprofen also may be
of value for patients to use when the discomfort is less significant” 
“The use of long-acting local anesthetics should be considered in the mandible. These
anesthetics provide the patient with a pain-free period of 6 to 8 hours, during which
prescriptions can be filled and analgesics taken” 
Steroids can be very helpful especially dexamethasone 8mg in minimizing the swelling.
It is usually given preoperatively. Dosage once is enough, and it is not necessary to take
it post-operatively  “To minimize the swelling that is common after the surgical
removal of impacted third molars, some surgeons give parenteral corticosteroids. 

33 | P a g e
 Although many different regimens and protocols for intravenous steroid
administration exist, a relatively common one is the single administration of 8 mg
dexamethasone before surgery. 
This drug can then be continued in an oral dose of 0.75 to 1.25 mg twice a day for 2 to
3 days to continue edema control” Although the doctor doesn’t recommend giving
steroids postoperatively
 Antibiotics – giving antibiotic prophylaxis after surgery to extract third molars is still
debated on. Some people see that such surgeries are atraumatic and aseptic and there
is no need to give prophylactic antibiotics after.  “If a patient has a preexisting
pericoronitis or periapical abscess, it is common to prescribe antibiotics for a few days
after surgery. However, if the patient is healthy and the clinician finds no systemic
indication for antibiotics or a preexisting local infection, systemic antibiotics are usually
not indicated  The use of a topical antibiotic, such as minocycline, has been
scientifically shown to greatly lower the incidence of osteitis sicca (dry socket) in
mandibular molar extraction sites”  Swelling – dexamethasone helps with swelling
and control of bleeding intraoperatively. Ice packs put on for 15 minutes also help with
reducing edema

Complications
Intraoperatively
 Soft tissue injuries – laceration of the gum or tongue, burn of the cheek  “The most
common soft tissue injury during oral surgery is tearing of the mucosal flap during
surgical extraction of a tooth. If a tear does occur in the flap, the flap should be carefully
repositioned once the surgery is completed”  “If a puncture wound does occur in the
mucosa, the ensuing treatment is primarily aimed at preventing infection and allowing
healing to occur. If the wound bleeds excessively, the hemorrhage should be controlled
by direct pressure applied to the wound”
 Injuries to osseous structures – trauma to the alveolus and fracture of the mandible
 Fracture of the alveolar process, maxillary tuberosity or the mandible
 Oroantral communications – due to extraction in the maxillary jaw  Communication
between the oral cavity and the maxillary sinus  “The two sequelae of most concern
34 | P a g e
are (1) postoperative maxillary sinusitis and (2) formation of a chronic oroantral
fistula.”  “If a large root fragment or the entire tooth is displaced into the maxillary
sinus, it should be removed”  “The patient should be prescribed several medications
to reduce the risk of maxillary sinusitis. Antibiotics—usually amoxicillin, cephalexin, or
clindamycin— should be prescribed for 5 days. In addition, a decongestant nasal spray
should be prescribed to shrink the nasal mucosa to maintain patency of the ostium”
 Fractures of the mandible – the whole mandible  “A mandibular fracture is usually
the result of the application of a force exceeding that needed to remove a tooth” 
“Fractures may also occur during removal of impacted teeth from a severely atrophic
mandible”
 Injuries to adjacent teeth – damage to the root of the second molar if the dentist
wasn’t properly oriented  “Inappropriate use of the extraction instruments may luxate
an adjacent tooth”  “This usually requires that the tooth simply be repositioned in the
tooth socket and left alone”
 Complications with the tooth being extracted – damage to the tooth being extracted
or fracture of the tooth leaving a root behind  Root fracture, root displacement, tooth
lost in pharynx and extraction of the wrong tooth  “A small, noninfected root tip can
be left in place because it is unlikely to cause any troublesome sequelae”
 Injuries to adjacent structures like the inferior alveolar nerve, lingual nerve or buccal
artery

important
Narrowing and a change in direction of the inferior alveolar canal is seen. An apical
radiolucency is also seen around the roots of the third molar. Those signs all indicate
the presence of the molar in the canal. To deal with this case, we can remove just the
crown (coronectomy). Coronectomy is an accepted procedure in the literature and
leaving the roots in prevents damage to the nerve, but it has limitations. The roots may
move during the procedure, and this movement may cause damage to the nerve. The
other solution is to cause extrusion of the third molar; a procedure which aims to
extrude the third molar from the canal, then extract it.

35 | P a g e
Post-operative complications
 Bleeding – controlled with pressure and proper instructions, but if the bleeding was
excessive, then you have to go back to the medical history
 Delayed healing and infection  May be due to the procedure itself; the flap may
have lost some of its blood supply which caused some tissue to become necrotized.
This is very painful to the patient. Treatment consists of excision of the flap edges, and
then repositioning and suturing of the flap. You should be careful not to over-stitch 
There are two types of infection.  The first one is Frank infection which is
characterized by pus in the socket, fever, and lymphadenopathy, and treated by
antibiotics.  The second one is dry socket infection which does not display the usual
signs and symptoms of infection but is characterized by severe pain within the socket
itself.
Paresthesia, after the surgical extraction of the third molar, in most patients is
temporary and resolves within 2 weeks and up to 6 months. If Ortho-extrusion of the
third molar Although the tooth was safely extracted and no damage to the nerve
occurred, the roof of the canal was broken. The whole treatment revolved around
avoiding damage to the inferior alveolar nerve This is the patient’s CBCT The root is out
of the canal paresthesia persisted after 6 months, there is still a chance that it will
resolve a year or two later as long as the symptoms don’t become worse, but after 2
years, the paresthesia is most probably permanent. If minimal damage to the nerve
occurred, complete healing of the nerve can occur on its own which leads to resolution
of paresthesia
If sensation was completely lost due to complete severance of the Inferior Alveolar
nerve, then microneurosurgical repair of the nerve can be performed (the severed ends
of the nerve are sewn back together) – it is a hard procedure done using a microscope

36 | P a g e
Lecture 9 impacted canine
Causes of impaction:
*Local factors:
1- If the primary teeth didn’t shed, this will interfere with the eruption of the
permanent teeth generally not only canines.
2- Cleft lip & palate, usualy we have to do bone grafting for these patients at age of
9,10 or 11 yrs , we remove cancellous bone from the crest & we add it to the
cleft area in order to have bone for the canine to erupt in.
3- Tumors or cysts presence in upper or lower jaw, can interfere with the eruption of
the impacted tooth.
4- Arch length is important, if you have short arch, this will not provide enough space
for the canine to come out causing impaction. **Why could someone have short arch?
Usually it’s due to genatcs abnormality, genes are what determine the jaw’s size so they
affect the presence or absence of teeth.
5- It’s a believe that the inappropriate position of the tooth germ can lead of failure of
eruption.
6- Abnormal eruption of the lateral incisors.
7- Supernumerary teeth or odontoms can block teeth eruption (here we’re talking
about teeth generally including canines).

*Systemic factors: 1- Cleidocranial dysplasia: It affects bones especially clavicle & teeth
generally, it can cause impaction or failure in eruption.
2- Problems in endocrine system such as hypothyroidism & hypopituitarism can affect
the growth generally & teeth specifically.
3- Any febrile disease theoretically can affect teeth eruption.
4- 4- Down syndrome.
5- 5- Radiation can affect the tooth germ. * Location of the impacted canine

37 | P a g e
How to locate it?
1- CBCT which is the best.
2- 2- Usually we can determine it clinicaly if there is a bulge, the bulge indicates that
the tooth or atleast the crown is in this area. Most of the teeth are impacted
palataly but you still need to take radiographs.
3- 3- X-ray: *Slob technique ( same lingual, opposite buccal)

**What’s the management?

1-If the canine was in very high position in the maxilla, close to the nose or the vital
structures, asysmptomatic and not associated with pathologies, we leave it.
2-Extraction, if its position is not favourable, not easy to align in the arch, so we just
take it out.
3-Retraction ( to make the tooth down to its place), How? We expose the tooth & put
brackets on it (wires) for ortho treatment. Extraction Vs Retraction: it depends on age
of the patient, generally if the patient is older than 30 years-old, we prefer extraction.
Less than 20 years-old, prefer retraction.
4-Transplantation , this means removing the tooth its place in the arch & put it in its
normal position. We don’t like it because of possibility of root resorption or ankyloses
and nowadays we have implants. For thre retraction. First, we identify the location of
the tooth ( labialy or palataly)
If the tooth was labialy, we need to retract it. We make our flap, drill through bone
exposing the crown reaching the CEJ, do not go beyond it to prevent root resorption,
then we put our bracket. In the end we make apical repositioning flap. We raise out
flap to the most cervical area of the tooth to save the keratinized gingiva. keratinized
gingiva is very important, it resist infections and help to make the tooth healthy.
if the canine is impacted palataly, here we have 2 scenarios:
1- Soft tissue impaction: we make our flap, expose the tooth, put the bracket or let
the orthodontist put it.

38 | P a g e
2- 2- If it is impacted fully under bone, we do a bilateral palatal flap, from the the first
premolar all the on the cervical line of the teeth to the first premolar in the other
side, we expose the bone, remove bone to expose the tooth then bond the bracket.
There are another way for the retraction(the doctor didn’t talk about it in our lecture)
“open exposure of the canine”, ex. Window in the palate (after exposure of the canine,
we make small window & keep it open, then we close the flap, after 2 or 3 days the
crown will appear in the palate, then we apply the bracket), or in the same operation,
the orthodontist put the chain & bond it to the canine & he closes the flap, this chain
will remain showing from the edge of the flap, then the orthodontist will bind it to the
wire.

39 | P a g e
Lecture 10
Suturing

Preparing the wound: to decrease the possibility of wound infection,

 In the skin we can use betadine.  Intraorally we use mouth wash.

Debridement: I have to make sure that the wound is clean even if it was surgical. 8-
Undermining: the first step of suturing is approximation of the 2 edges of the wound,
if it was surgical wound then it can be approximated without any problem. In case of
trauma or accident that led to tissue loss the I can go for undermining, I can make
subcutaneous incision(in case of skin) or subperiosteal incision(in can of oral cavity) to
gain more tissue.

Local Lidocaine (Xylocaine)1% or 2% • Onset: 2 minutes • Duration: 1.5 to 2 hours •

Action: anesthesia and reduced muscle movement • Max dose: 4 mg/kg to 280 mg (14
ml 2%, 28 ml 1%)

Lidocaine with Epinephrine1:100,000 or 1:200,000 • Onset: 2 minutes • Duration: 1– 3

hours • Action: anesthesia and reduced muscle movement • Max dose: 7 mg/kg to 500
mg (25 ml 2%, 50 ml 1%)
Bupivacaine (Marcaine)0.25% • Onset: 5 minutes • Duration: 2 to 4 hours • Action:
anesthesia only • Max dose: 2.5 mg/kg up to 175 mg (50 ml 0.25%, 25 ml 0.5%)
There are different knot types, we use the surgeon’s knot. Our knot must be stable and
secured.
Type of suture we use is surgeon’s suture .You have to tie it atleast 3 times, 2 clockwise
and 1 anti-clickwise
. When you finish the knot, you must not keep the knot on the line of the incision, it
should be atleast 0.5mm away from the incision. If it was left on the line of the incision
it will lead to knot detection or abscesses which can increase incidence of scars.

40 | P a g e
Surgical closure guidelines:
1- Debridement: edges of the incision must be smooth, if edges were ragged then I
have to debride it and try to make it as smooth as possible.
2- 2- Hemostasis: you mustn’t start suturing before achieving hemostasis. If you start
suturing without hemostasis, site of the suturing may develop hematoma which
may cause opening of the suture and infection of the site of incision. If you can
locate the artery you can go for ligation, if you can’t then you can apply pressure
until bleeding stops.
3- 3- Atraumatic technique.
4- 4- Alignment with the relaxed tension lines: in facial skin wounds, I must make my
incision and suturing with the wrinkles not perpendicular to it. Going perpendicular
can cause bad scar.
5- 5- It is important to consider the area of the body for vascularity and tension on
the wounds. Face is highly vascular which means perfect healing and stitches will
be removed after less time. In the face, we remove stitches after maximum 3-5
days. On the hand or foot, it will take 10 days or more. On the other hand, we said
that we have to achieve hemostasis before suturing which will take more time in
facial wounds. We also have to be careful of the tension lines, edges should be
relaxed. If there is tension in the edges, it can disrupt the suture.
6- 6- Close the dead space under the incision: in deep wounds or through and through
wound, we have to make gradual suturing starting from the deeper layers going
superficially. In deep layers, I have to use resorbable suturing materials, while outer
layer I can use resorbable or non-resorbable.
It is better to use non-resorbable materials in the outer layer so I can remove it
myself. Suturing materials can cause body reaction to it since it is foreign material,
so I remove non-resorbable materials as soon as approximation is achieved,
resorbable materials need more time to resorb than needed time.

Needles can be:

1- Conventional cutting needles: triangular in cross section with the cutting end
anteriorly.
2- 2- Reverse cutting needles: triangular in cross section with the cutting end
posteriorly.

41 | P a g e
3- 3- Non-cutting needles. Cutting needles are tapered while non-cutting are blunt. In
the oral cavity, we usually use reverse cutting or non-cutting. It is better to use
reverse cutting even for loose tissue. According to the diameter of the needle:
Straight needles are not used in oral cavity, it can be used in abdominal surgeries.
In oral cavity we use ½ or 5/8 circle. The most widely used in oral cavity is 5/8 circle.
This curve help to penetrate the edges of the wound. We should hold the needle
1/3 the distance from the squad ‫الخيط‬

Suturing techniques:
1- Simple interrupted suture: it is the most commonly used suturing technique. It can
be used after incisions, laceration, biopsies and other wounds. In deep tissues, you
must use simple interrupted suture. One of the advantages of this technique that if
there is an error in one stitch, you deal with it per se, you don’t have to remove the
whole suture and start again. Again, the knots should be kept away from the line of the
incision. It is important to make to edges of the flap everted to have optimal healing.
2- 2- Continuous suture: in this technique, we make a knot in the beginning of the
wound, keep approximation edges of the wound until we reach the end of the wound.
Advantage of this technique is that it needs less operating time and distribution of
tension on both edges, but if there is an error in one knot then then wound will be
opened.
3- 3- Horizontal-mattress suture: when you ever say mattress, then every 2 stitches
have 1 knot. This technique is good because it is secured and makes tight
approximation.
4- 4- Vertical mattress suture: It is tight which is good in cases of oroantral
communication. This technique is better used than simple interrupted in cases of
oroantral communication.
5- 5- Subcuticular closure: it is used in cosmetic suturing. The squad will be under the
skin all the time.
Suturing material: Materials can be either resorbable or non-resorbable. Example of
non-resorbable is silk, nylon and prolene. One example of resorbable is polygalactic
acid(Vicryl).

42 | P a g e
Lecture 11 wound repair
What is wound healing? Natural response of the body. It's an interaction between a
complex cascade and cellular events that generate resurfacing. As we said, healing is a
natural process, but we affect it by our procedure. Cleaning the wound, suturing and
medications can improve the healing. Healing also depends on status of the patient.

There are 4 stages for wound healing:

1- Vascular response(hemostasis).
2- 2- Inflammation.
3- 3- Tissue proliferation.
4- 4- Maturation or remodeling.
Inflammatory stage is divided into 2 phases: 1- Vascular. 2- Cellular. Vascular phase is
the vascular response.
Vascular response
It starts at the moment of injury as lasts up to 1-6 hours after it. During this stage,
wound undergoes vascular constriction, platelet aggregation then coagulation
cascade(intrinsic and extrinsic pathways, mainly extrinsic) to end up with fibrin mesh
formation. It starts when platelets sticks the damaged epithelium. Then platelets
flattens and expand. Then platelets release ADP to produce thrombin and cause further
platelet aggregation. Thrombin activates fibrinogen to convert profibrin into fibrin to
produce fibrin mesh. In this stage, white blood cells produce histamine, prostaglandin
E1 and E2 and other cytokines. Neutrophils start to respond at this stage, but in order
to switch to inflammatory stage, neutrophils should stop responding and macrophages
start. In this stage, we end up with fibrin mesh and platelet plug. In late stages, it is
replaced with organized collagen, fibrin and elastin.
Inflammation
Starts when the vascular phase ends and lasts for 3-5 days. The cellular phase of
inflammatory stage. In this stage we have vasodilation, increased vascular
permeability, inflammatory factors, serum proteins, complement system, platelet
released growth factor and chemical attractants to the wound site. We can see the
cardinal signs of inflammation which are redness, hotness, pain, swelling and loss of

43 | P a g e
function. These signs are explained by the inflammatory stage. The most important
step in wound repair is the switching between inflammatory and proliferation stage. If
it happen in the right time then we will end with good healing with line scarring. Some
people has a problems which increases the duration of inflammatory stage, they will
end up with excessive or keloid scarring. What determines the duration of each stage
is the genetic make up.
Proliferation stage
This stage take up to 3 months. Keratinocytes start to migrate through the wound bed
to form the wound edges. Before this stage, the surface layer is fragile, so keratinocytes
start to create the stratified epithelium. Special type of fibroblasts start the contraction
of the wound edges. e As we said, the most important step of wound healing is the
switch to proliferation stage, if it happens in the normal time, this will lead to
continuation of the normal healing.
Maturation stage
It takes up to 1-2 years. Cells and fibers are already existing. In the proliferation phase,
collagen was formed. In this phase, cross-linking starts. More cross-linking gives more
strength and better wound quality. After this stage, wound healing ends, the new
tissues are assumed to have the same shape and strength of the original tissues, but it
is not. After healing tissues can reach to 80% of the shape and strength.

The difference of primary, seconday and tertiary intention. Primary intention healing:
This occurs where the tissue surfaces have been approximated (closed). An example is
surgical wound done under sterile conditions and closed with suturing. Here, healing is
perfect. Secondary intension healing: primary closure of the wound edges cannot be
achieved, this happens when we have tissue loss. This healing takes more time, produce
more scarring and have higher possibility of infections. Tertiary intention healing:
happens when there is tissue loss but we closed the wound by a graft.

Healing of extraction socket

The first step of healing is clot formation. This clot undergoes organization, and this
will be followed by bone formation.

44 | P a g e
One of the factors affecting healing of any tissue is oxygenation. That is why one of the
applications being developed for repair is hyperbaric oxygen therapy to iduce repair
and healing. This can be used for patients who have wounds or those who have
infections.
Nerve injury happen in one of 3 ways:
1- Neuropraxia: happen when we apply pressure or tension to the neuronal sheath by
mistake. This is accompanied by pressure of edema postoperative which will cause
temporary paresthesia(sensory nerve) or paralysis(motor nerve). In sensory nerves,
we have 3 levels of disruption:
A- Anesthesia: complete loss of sensation.
B- Paresthesia: partial loss of sensation.
C- Dysesthesia: abnormal sensation. Neuropraxia will usually cause temporary
paresthesia will will resolve in weeks.
2- Axonotmesis: occurs when complete cut of axon happens without loss of epineural
sheath. Caused by blunt trauma, nerve crushing or extreme traction. This problem
can be resolved by a surgery done under microscope, the surgeon try to locate the
2 nerve endings let approximate or suture it.
3- 3- Neurotmesis: complete loss of nerve continuity. Prognosis generally is poor but
can resolve if the two endings were approximated.

Factors affecting healing:

1- Patient status: healthy patient has better healing than a sick patient.
2- 2- Age of the patient.
3- 3- Foreign materialis everything the host organism’s immune system views as
“non-self,” including bacteria, dirt, and suture material. Foreign materials cause
three basic problems. First, bacteria can proliferate and cause an infection in which
released bacterial proteins destroy host tissue. Second, nonbacterial foreign
material acts as a haven for bacteria by sheltering them from host defenses and
thus promoting infection. Third, foreign material is often antigenic and can
stimulate a chronic inflammatory reaction that decreases fibroplasia
4- . 4- Tension to the edges of the wound.
5- 5- Oxygenation: ischemia can retard healing.

45 | P a g e
6- 6- Necrotic tissue: it’s presence retard healing and can serve as niche for bacterial
proliferation.

46 | P a g e
Lecture 12 complications of exodontia
These complications can be related to:
1- Tooth itself.
2- 2- Adjacent teeth.
3- 3- Adjacent bone.
4- 4- Soft tissue.
5- 5- Distant structures(e.g. TMJ).
All the complications have two causes: 1- Aggressive force. 2- Poor planning.
Soft tissue injury:
1- Tear of the flap.
2- 2- Puncture
3- 3- Scratch or abrasion(most common for beginners) because of uncareful use of
rotary instrument.

Complications related to the tooth of interest and adjacent teeth:

1- Fracture during extraction Fracture usually is caused by poor planning, the dentist
chose to go for simple extraction when the tooth need to be extracted surgically. If
fracture of the tooth happened, you can start surgical extraction.
2- 2- Displacement of adjacent teeth. This happen because of bad technique. If it
happen, inform the patient, assure him and if luxation was serious, you need to
apply a splint.
3- 3- Extraction of the wrong tooth. This usually happen after referral from ortho
department, most of the cases they ask to extract all upper and lower 4s. Maybe
orthodontist will ask you to extract upper 4s, lower right 4 and lower left 5,
sometimes maybe you will not notice it and extract 4 instead of 5. Here, you have
to contact the orthodontist, if he can modify his plan then there is no problem.
4- 4- Tooth lost in the pharynx or airway. Don’t panic, stop your procedure and try to
look for the tooth every where, maybe it is under the flap, in the suction, in the
cotton roll. If you didn’t find it anywhere then start to think about these scenarios.
If the tooth entered the airway, the patient will have sever cough. And in this cases
always ask the patient if he felt the tooth. If you are sure that the tooth entered the

47 | P a g e
 airway, put the patient in a supine position and ask him to cough to try to retrieve
the tooth, if he didn’t, refer him to the right physician. If it entered into esophagus,
just assure the patient, it will pass if it doesn’t have sharp edges.
5- 5- Displacement of the tooth into the maxillary sinus Because of uncareful
technique and poor control of the force. If it happens, stop the procedure. Patient
will feel change of pressure between the nose and the mouth at the same moment
of the injury. With good lightening and after careful suction of the sinus, if you can
see the tooth, try to retrieve it just one time, if you can’t, stop for a moment and
think. You may leave it or continue to retrieve it. If it was a small, vital fragement
and the patient doesn’t have history of chronic sinusitis, you can leave it, but inform
the patient. If not, you have to retrieve it, the best way is Caldwell luc’s procedure.
In this procedure, you open the anterolateral wall of the sinus and retreat the tooth.
you elevate a flap from the canine to the secone molar, expose the wall of the sinus,
drill a window, use suction inside the sinus, and don’t ever work blindly. Be carefull,
the roof of the sinus is the floor of the orbit and it is egg-shell thick, any trauma and
you will perforate it. This is a managable complication and has many solutions.
6- 6- Displacement of the upper 3rd molar into the infratemporal fossa. It can happen
due to excessive force during the extraction. Infratemoral fossa contain critical
nerves and blood vessels. In this case, stop your procedure, use suction, if you can
see the tooth try to retrieve it once. If you didn’t see it or you couldn’t retrieve it,
refer the patient to a maxillofacial surgeon to have a surgery after 3-4months. We
wait this period because there will be fibrosis around the tooth which will make
retrieval easier and decrease complications of the retrival.
7- 7- Displacement of the tooth into the submandibular space. This can happen
because of bad technique if you are extracting a remaining root with cryer and
applying apical forces. The probability of this complication becomes higher as you
go posteriorly, because lingual plate becomes thinner. In this case, just try to enter
with your finger into the lingual sulcus and push the tooth into socket, if you didn’t
succeed, think about leaving it or you will have to rise a lingual flap(there is a risk
for lingual nerve injury) to retrieve the fragment.
8- 8- Dislogment of a restoration. You have to inform the patient about the risk of
fracture of the restoration before the procedure. This more important if you have
a bridge or veneers beside the tooth to be extracted.

48 | P a g e
Adjacent bone You have a risk for bone fracture, especially if the roots are ankylosed.
Or because of excessive force.re The most common area with this complication is the
maxillary tuborosity when you extract upper 3rd molar. If the bone is totally fractured
and out of the periosteum, just remove it. But during the procedure, if you hear sound
of bone fracture, then stop you procedure, leave to tooth to another appointment and
extract the tooth surgicaly. Fracture of the maxillary tuborosity might lead to oroantral
communication.

49 | P a g e
Lecture 13 complications of exodontia part 2
Oroantral communication It can happen in upper posterior teeth, it has some risk
factors like pneumotization of the sinus. Most of the cases, it is caused by aggressive
vertical force to the tooth with the elevator, maxillary bone is soft so it can be fractured
easily. If this happens, when you ask the patient to rinse after the extraction, blood and
water will ooze from his nose. You can test it with nose blowing test, close the patient’s
nostrils and ask him to make pressure, if there is communication, you will notice
bubbles from the socket. X-ray will show you the communication. Risk factors of OA
communication:
1- Large antrum(cavity).
2- 2- Large roots
3- 3- Fusion of teeth.
4- 4- History of antral communication.
If it was diagnosed and treated early, then it will heal, if it was left without treatment,
this can lead to:
1- Chronic sinusitis.
2- 2- Oroantral fistula(communication will develop a tract lined by epithelium).

Management: If the opening is:

1- Less than 2mm: don’t manage it, blood clot in enough.
2- 2- 2-6mm: try primary closure with figure of 8 suture, medications and sinus
precautions. Give him sinus medication, antibiotics to prevent sinus infection, nasal
drops(e.g. ephedrine) to help discharge blood from the sinus, antihistamine to
reduce sneazing. This triad should be given to every patient to reduce possibility of
acute sinusitis.
3- 3- More than 6mm: you have to consider flaps. If the socket is small, consider
trimming soft tissue with cryer then suture it. If it is large, use buccal advancement
flap(advance the buccal mucosa to meet the lingual mucosa. Periosteum is tough
and it prevents buccal mucosa advancement, so you make a three sided flap
buccaly, then do undermining(you cut the periosteum so the flap is free) Another
option is palatal island flap, you open to finger like flap on the palate and displace it
laterally. Palatal mucosa will heal with second intention. In this cases you better use
another flaps, like tongue flap. e Tongue flap: you make a flap on the dorsum of the

50 | P a g e
 tongue, suture it on the socket and then exision will be done after a week. You can
also use the buccal pad of fat, you open the cheek, pull the fat to the socket and
suture it(you don’t cut it’s blood supply), this gives good results.

Bleeding
can be classified into:
1- Primary: at the time of the surgery.
2- 2- Reactionary: within few hours after surgery can be caused if high amounts of
vasoconstriction was given during the surgery. Bleeding will start when it wash out.
If it happens, just check for local or systemic factors, if everything is good, you just
need to control it with pressure and suturing. Remember, never suture during
bleeding, if you did so, blood will accumulate and cause hematoma.
3- 3- Secondary: up to 14days post-op and caused by infection. Bleeding can be more
if the site of extraction contained infection or granulation tissue, after extraction,
there will be heavy bleeding until debridement.

Management: 1- Suction and good visibility to look for local causes. 2- LA with
vasoconstrictor: can cause intraoperative hemostasis but increase chance for
reactionary bleeding. 3- Horizonal mattress suture. 4- Surgical: a gauze that make
artificial clot. 5- Bone wax or other materials. 6- Pressure. 7- Good postoperative
instructions. 8- Tranexamic acid 5% wash. 9- Think about referral. 10- Hematology
investigations: PT, PTT, INR.+ 11- Most important is that you control yourself, don’t
ever be nervous. 12- Have good knowledge about complications and management.

Hematoma can happen more in older patients.

Interstitial emphysema, caused by entrapment of air in facial spaces. Diagnosed by
sudden occorrence of facial swelling, crepitation on palpation. It can be caused by
using handpiece during the extraction, so always use the surgical straight handpiece.
You just have to diagnose it properly, and it is self-limiting, just reassure the patient
and you may give him prophylactic antibiotic but it is not necessary.

51 | P a g e
Dry socket
It is one of the most annoying complications, especially after third molar extraction.
Incidence is 2% generally but reach up to 20% in 3rd molar extraction. Acute pain and
foul odor start 3-4 days postoperatively. Many studies says that it is caused by loss of
blood clot and exposure of bone. Bone looks grayish without pus formation. It is
resolved in 10-14 days, you just have to irrigate the socket and give the patient pain
killers. If pain is so bad, you can give the patient alvogel, put it on a cotton and apply it
to the socket, it will lessen the pain, but it will retard healing.

52 | P a g e
Lecture 14 surgical endodontics ) cons ‫(يفضل دراستها من محاضرة دكتورة روان في‬
Types of endodontic surgery:
1- I&D (Incision and Drainage): it can be done by a qualified GP, in which we will access
the apex through the bone(trephination) and drain inflammatory exudates from it.
Trephination: opening a hole through the bone.
2- 2- Radicular surgery: can be apicectomy(most common) or root end resection.
3- 3- Repair of perforations.
4- 4- Hemisectioning or root amputation: sometimes, we need to transform a molar
into premolar. Remember, to start with this procedure, patient need to have
motivation and education, it is exhausting, time and money comsuming and success
rate drop to 50% once we start surgery.
5- 5- Intentional replantation: if a patient lost one of his teeth due to trauma mainly,
we can replant the tooth in it’s socket, it has a high success rate provided that you
stick to the guidelines.

Apicectomy: One of the most common procedures in surgical endodontics, it is the

removal of apex of the tooth with retrograde filling. We think about it in cases that
conventional endo treatment failed or cannot be done in cases of: 1- Failure of
treatment. 2- Calcified canals. 3- Severely curved canals. 4- Permanent pathosis.

Radisectomy: the removal of a single root, this can be done because of pathosis related
to a whole root causing bone resorption around it. You do this during root amputation,
the tooth will become weaker but it will serve it’s function with high success rate. You
even can do sectioning for 2 roots.

Root end resection: is used to describe the removal of the apical part of the root. It is
similar to apicectomy but the difference is the amount of root being cut. Apicectomy
includes apical 2-3mm of the root, more than that is considered root end resection.

Root cutting should be made in a slope to increase the surface area and increase
retention of the filling material. In apicectomy you do the following: A- Appropriate
53 | P a g e
exposure of the root and periapical tissue. B- Exploration of the root surface for fracture
of other pathosis. C- Curettage of the periapical tissues. D- Resection of the root apex.
E- Retrograde preparation with ultrasonic tips. F- Placement of retrograde filling
material. G- Appropriate flap exposure.

Indications for endodontic surgery:

1-Persistent pathology after conventional endo treatment.
2- Inability to clean the whole root canal because of anatomical limitation or the tooth
undergone endo treatment followed by core and post, build up then crown or bridge
placement, here endo surgery is easier.
3- Iatrogenic problems like perforations and broken instruments: here the endodontist
can determine if we better go for retreatment or surgery.

Contraindications:
1- Pathology healed after conventional treatment: we don’t need it.
2- 2- Patient medical history: we have to compare risks to benefits.
3- 3- Anatomical consideration: if the apex is close to a important anatomical
structure like the mental foramen, if I did apical surgery, the patient may end up with
paresthesia or anesthesia.
4- 4- Periodontal consideration: after cutting part of the root, I am decreasing
root:crown ratio, if the patient have periodontitis, tooth will become mobile.

Dehiscence: bone loss on the cervical part.

Fenestration: bone loss on middle of the cortical plate

54 | P a g e
Lecture 15 role of GP in the hospital

Hospitalizing patients for dental care:

1- Behavior management like phobia, autism, children or patients with psychological
problems.
2- Medical problems like:
A- Heart failure, this patients better not to undergo GA but better treated in hospitals.
B- Prosthetic heart valve, they need IV antibiotic prophylaxis.

Preoperative patient evaluation:

1- Preoperative medical evaluation as always, you need detailed medical history.
2- Communication with the hospital staff: the hospital doesn’t know anything so you
have to contact that to inform them about the surgery, time, duration, required
instruments and you better get your own assistant to work with you. You better write
all the information on a paper to facilitate communication.
3- You should inform the head nurse about needed instruments, if it is not available in
the hospital, you need to bring your own instruments sterile and ready to be used.

Preparation of the patient:

Admission should be done 24hours prior to the surgery or the same day of surgery in
the morning if the patient is medically fit, in the period you will prepare your patient
with:
1- investigations, it can be:
A- hematological
B- biochemical like blood sugar level.
C- Microbiological like swab and blood culture.
D- Radiological like OPG, CBCT or CT.

You should pick the necessary investigations according to the case.

For small procedures, if the patient is young and healthy, maybe you will just need
radiographs to assess the case, if you suspect any diseases, you can ask for CBC.
CBC provides:
55 | P a g e
1- Hb level: if it is under 10, you cannot go for GA unless it is an emergency.
2- Platelets: normal is 150 – 450 thousand/ microliter. You can do surgery with count
as low as 50 but you have to be careful.
3- WBC count, it may also contain differential.

INR can be taken for patients who take warfarin.

hematological tests can be also like liver or kidney function, urea or electrolytes. You
ask for it according to the medical history.
2- Informed consent: Before any procedure, you need to get the patient’s informed
consent. It should be written and signed. Don’t forget to talk about complications.

3- Anxiety: it depends on the communication between the surgeon and the patient.
That can determine the difference between different surgeons regardless the results.
It can be also be controlled with sedation or medications like valium or diazepam.

4- Food and drink: we usually ask the patients to be fasting for 6-8 hours before the
surgery to have empty stomach.
If stomach was full, reflux of it’s content may happen during the surgery which may
lead to aspiration into the lung.

5- Premedications: patient should take his regular medications before the surgery like
hypertension or diabetes drugs. Sometimes if the procedure is long, anesthesiologist
may choose to change drugs.

Operating rooms protocols:

1- Root of intubation:
A- Nasal: it should be used in case we need to assess occlusion, this can be used in
cases of jaw fracture or le fort fracture.
B- Oral: can be used for 3rd molar surgery or genioplasty.

Nasal intubation is harder to the anesthesiologist and more traumatic.

2- Length of procedure: you have to inform the anesthesiologist for fluids balance.

If the surgery takes more than 4 hours, anesthesiologist should use Foley’s catheter
to monitor fluids in/out.

56 | P a g e
3- Eyes should be protected. You are working with sharp instruments that can injure it
if it fell.

Also you are using high volume of irrigation that can enter the eye.

4- Scrubbing, painting and drapping.

5- Moist throat pack

6- Surgeons should wear surgical scrub uniform, shoe cover and cap.
7- Surgical hand and arm scrub: there is usually a sink in the operating room.

Discharge:
1- Give the patient oral hygiene instructions.
2- Instructions of wound care.
3- Diet instructions: sometimes you may give the patient soft diet or ask him to take
fluids by straw if you did IMF.
4- Activity levels: you can give to patient advice to reduce the activities according to
the procedure.
5- Follow up visits.
6- Prescription.

57 | P a g e
Postoperative complications:

1- Airway obstruction or laryngeal oedema: it is not common, it happens during the

procedure.
2- Throat discomfort: It is normal for the patient to feel pain in the throat after the
surgery because of the intubation, you can give the patient analgesia.
3- Nausea and vomiting: it is common after GA, you just have to give antiemetic
drugs.

4- Fever: it is common for the patient to have fever immediately after the surgery or
within a few days, it is caused by the release of inflammatory mediators in the blood.

Infection need time to happen.

if oral temperature > 37.2 or rectal > 38, the patient has fever.

Hypotensive anesthesia: anesthesiologist decrease blood pressure to decrease

bleeding and blood loss. BP during GA can be 90/50.
You have to restore blood pressure to normal level before awakening the patient to
be sure there is no bleeding.

58 | P a g e
Lecture 16 odontogenic infections

Commensal oral flora consist of many microorganisms, these microorganisms live

commensally(peacefully) normally. Because of local or systemic conditions, these
microorganisms can become pathogenic.

There are many pathogens that cause these infections.

If you took a swab from any infection, you will commonly find three species:
anaerobic gram +ve cocci, anaerobic gram –ve rods and aerobic gram +ve cocci.
Clinical significance of knowing the causative pathogens of odontogenic infections is
the selection of proper antibiotic. These three microorganisms are commonly
sensitive to penicillin. So penicillin is the antibiotic of choice for odontogenic
infections.

Odontogenic infections undergo many stages, it start with aerobic bacteria.

Anaerobic bacteria cannot live except in specific environment, this environment is
created by the aerobic bacteria.

Aerobic bacteria will start secreting specific enzymes that will destruct mucosa and
enter the tissues to start the destruction. Dead tissues provides good environment for
anaerobes.
Anaerobes is responsible for the formation of microabscesses that will coalesce to
form the whole abscess.
As we said, these infections undergo many stages. Each stage has specific signs,
symptoms and management. It is important to know each the patient’s stage to
manage it.

59 | P a g e
During the inoculation stage, you just have to prescribe amoxicillin, you don’t even
need to prescribe metronidazole.
Cellulitis stage is the most dangerous stage of infection. During this stage, the patient
looks toxic. He may even develop toxic shock, it’s mortality is 50%.
As we said, aerobic bacteria created proper environment for the anaerobes.
Anaerobes need destructed tissues, low Ph and high oxygen consumption by aerobes.
In cellulitis stage, we have to prescribe antibiotic for aerobes and anaerobes, like
amoxicillin and metronidazole together.

Once the infection start, it will spread through the line of the least resistance.
In maxilla, buccal plate is thinner that the palatel. In the maxilla, most of infections is
buccaly placed with the exception of palatal root of 1st molar and lateral incisor due
to lingual inclination.

60 | P a g e
In the mandible:
1- It also prefer buccal side because buccal plate is thinner up to the 1st molar.
2- Both plates is equal in thickness in the area or 1st molar so according to the
anatomical variations between patients it can be placed buccaly or palataly.
3- For the 2nd and 3rd molars, lingual plate is thinner, so most of its’ infections are
lingualy placed, in the sublingual and submandibular space.

Infection in the submandibular space has 99% chance to be from the 3rd molar while
in the sublingual space is mostly from the 1st or 2nd molars.

According to anatomy, apices of 3rd molars are below the attachment of the
mylohyoid muscle, so infections will go to the submandibular space. For the 1st and
2nd molars, their apices is above the mylohyoid so infections will spread to the
sublingual space.
So now we can conclude that spreading of infections depends on anatomy of the
patient regarding thickness of bony plates and level of attachment of muscles.

So infections in buccal space means that apices are above the attachment of buccinator
muscle .

In the management of any odontogenic infection, there are many steps, you have to
go through all of it:

1- Determine the severity of the infection

So any patient comes to ICU with odontogenic infection, you have to take history,
examination and investigation if you can.
Proper history is mandatory and will be very helpful.
2- Duration of infectious process: which will help in knowing the stage of the
infection.
3- Medical history: medically compromised patients have higher mortality rate,
immune system cannot help.
4- Sequence of events.
5- Signs and symptoms.
6- Antibiotic prescribes: if it didn’t help, you will think about resistance or wrong choice
of antibiotic for this stage.

61 | P a g e
You have to do proper examination if you can.
1- Vital signs which are respiratory rate, heart rate, temperature and blood pressure,
it is very important to take it for every patient.
2- General appearance.
3- Extra- and intraoral examination of the swelling.

Investigations, you can ask for it if patient’s status is not that bad.
1- Lab tests.
2- Radiographs like CT with contrast.
You have to do everything you can so you reach proper diagnosis to start the proper
treatment.
Simple odontogenic infection can be defined as:
1- Swelling limited to the alveolar and vestibular treatment.
2- First attempt of treatment.
3- Patient is fit and healthy.
Complex odontogenic infection:
1- Swelling extending beyond these spaces.
2- Failed prior treatment.
3- Immunocompromised patient.

Severe cases should always be referred to a maxillofacial surgeon, you will think
about referral in these cases:
1- Difficulty breathing: infection is compressing the airway.
2- Difficulty swallowing: compression of esophagus.
3- Dehydration: patient cannot eat or drink because of pain.
4- Moderate to severe trismus: interincisal opening is less than 20mm, this can be
because of pain or spreading to muscles.
5- Swelling extending beyond the vestibular space.
6- Elevated temperature: above 38.3C.
7- Severe malaise and toxic appearance.
8- immunocompromised patient.
9- Need for GA.
10- Failed prior treatment.

62 | P a g e
Any patient who have odontogenic infection will have medical and surgical treatment.
In the inoculation stage, surgical can be enough.
In every stage, the most important step is the removal of the cause, either by access
cavity then endo treatment or extraction. Otherwise, patient will not recover.

You have to prescribe antibiotics for these patients, if the infection is simple and the
patient is medically fit, stick to the narrowest spectrum antibiotics like penicillin(not
amoxicillin), clindamycin(bacteriostatic) or metronidazole.
If infection is complex or the patient is immunocompromised, you should prescribe
broad spectrum antibiotics like amoxicillin, amoxicillin with clavulanic acid,
azithromycin, tetracycline or moxifloxacin.
After proper incision and drainage and prescribing antibiotics, patient should start to
recover, you have to evaluate the patient for signs of recovery, this can be noticed
through lab tests and vital signs.
Sometimes treatment can fail, this can be due to:
1- Inadequate surgery: because of poor knowledge or skills.
2- Depressed host defenses.
3- Foreign body.
4- Antibiotic problems: patient noncompliance, drug not reaching the site, drug dose
too low, wrong bacterial diagnosis or wrong antibiotic.

63 | P a g e
Lecture 17 antibiotic prophylaxis
As you notice, this definition contains 3 requirements to consider any antibiotic as
prophylaxis:
1- Given prior to the procedure: it should be given 0.5 hour prior to the surgery if given
IV, 1 hour if given orally.
5- Double the therapeutic dose: amoxicillin therapeutic dose is up to 1000mg, so
prophylactic dose is 2000mg.
6- Specific to the pathogenic bacteria: here we talk about streptococcus viridans
group, so amoxicillin is the drug of choice.

You give prophylaxis antibiotic to be available at the site of surgery due to an increased
risk of infection in the patient because of local or systemic reasons. Most of dentists
think that prophylaxis is just for protection against infective endocarditis, but it is even
to protect from infections at the site of surgery.

Factors related to postoperative infection:

1- Size of bacterial inoculum: as bacterial load increase, this increase susceptibility to
local infections and bacteremia causing systemic infections. Some studies found that
rinsing with 0.2% chlorohexidine prior to the procedure decrease incidence of
bacteremia.
2- Duration of surgery: as duration of surgery increase, postoperative infection
incidence increase.
3- Presence of foreign materials, implants or dead space.
4- State of host resistance: if the patient took antibiotics 10 days prior to the surgery,
this means that bacteria is resistant to this type of antibiotic.

On of the most important complications after dental treatment is infective

endocarditis, some patients are at risk, these patients have to be give prophylactic
antibiotics according to the AHA. Patients with prosthetic valves have what is called
sterile vegetation and turbulent blood flow which makes chronic irritation to
myocardium. These vegetations is perfect place for attachment with microorganisms.

64 | P a g e
Attachment of specific microorganisms can cause infective endocarditis, it is life
threatening disease. After any procedure that includes manipulation of gingival or
periapical tissues or perforation of the oral mucosa can cause bacteremia, in most
patients, this will not lead to any problem, but for some patients with some heart
problems, it can cause infective endocarditis.

So to sum up, factors necessary for metastatic infection:

1- Distant susceptible site.
2- Hematogenous bacterial seeding.
3- Impaired local defenses.

For AHA guidelines, you only give prophylactic antibiotics for 4 cases

NICE says that prophylaxis is not valid, because of: 1- Some patients can develop
infective endocarditis even with prophylaxis which makes the efficacy of prophylaxis
cannot be judged. 2- Even teeth brushing can make bleeding and transient bacteremia,

65 | P a g e
thus bleeding is generalized to the whole teeth unlike extract which is limited to the
extracted tooth.
Some dentists might think about giving prophylaxis for other patients out of cautions,
you have to know that some studies say that the risk of anaphylaxis on life due to the
high dose of antibiotic for prophylaxis exceeds 7 times the risk of infective endocarditis

But you have to know that NICE guidelines also says that the physician has the final
decision for giving prophylactic antibiotics. If a patient has multiple Prescriptions of
antibiotic prophylaxis for the prevention of infective endocarditis fell substantially after
introduction of the NICE guidance
This conflict is just about prophylaxis to patients at risk of developing infective
endocarditis, all the guidelines agree that you have to give prophylactic antibiotics for
the risk of surgical site infection(SSI).

The following dental procedures do not require endocarditis prophylaxis:

 Routine anesthetic injections through noninfected tissue.
 Taking dental radiographs.
 Placement of removable prosthodontic or orthodontic appliances.
 Adjustment of orthodontic appliances.
 Placement of orthodontic brackets.
 Shedding of deciduous teeth

For prosthetic joints, there is a debate, the American guidelines say that you need to
give prophylactic antibiotics in the first 2 years following joint replacement in the
presence of another morbidity like diabetes or hemophilia.

66 | P a g e
Lecture 18 osteomyelitis
Osteomyelitis: infection that affects the bone marrow not the cortex.
In most odontogenic infections, it will affect the exosteal part of the bone, not
endosteal. This is caused by the good blood supply to this part which will prevent the
occurrence of this infection.
For this reason, you will notice that osteomyelitis rarely happen in the maxilla, it is
more in the mandible because maxilla has blood supply 7 times more than the
mandible.

Ostitis: infection of the exosteal part of the bone, it is different.

Local factors: severe trauma, fracture of the jaw, radiotherapy, paget’s disease of bone,
osteoporosis, major vessel disease or other local factors will compromise the blood
supply and make the patient susceptible to osteomyelitis.
Systemic factors: immunodeficiency, uncontrolled DM, malnutrition, alcohol
consumption …etc.
As other infections, osteomyelitis usually starts as acute infection and with time is
converted into chronic. But in 20% of cases, osteomyelitis starts as a chronic infection,
this usually happen with low grade infection, low grade virulent microorganisms with
high resistance immune system.
In 80% of cases, it will start as acute infection with signs and symptoms, then because
of the immune system and the use of antibiotics, it will be converted into chronic
infection.

Classification:
1- Acute osteomyelitis: the result of this infection is always suppuration, you will
notice pus. Other signs and symptoms of inflammation can be noticed, redness,
hotness, pain, swelling.
2- Chronic osteomyelitis: in this case, and according to the strength of the immune
system, you will end up with destruction or formation.

67 | P a g e
If you continue destruction, you will notice more suppuration, you might end up with
pathological fracture or sequestration.

Sequestrum: a piece of bone that has become separated during the process of
necrosis from normal or sound bone.
If the patient’s body is strong enough, it can respond by formation of a barrier of
sclerotic bone.
So, chronic phase can be:
1- Chronic suppurative osteomyelitis: bone continue to be resorbed.
2- Chronic sclerosing osteomyelitis: accompanied with bone formation.

Remember, this infection is labeled acute or chronic according to clinical signs and
symptoms, not histopathology. so, to diagnose osteomyelitis as acute or chronic, you
need clinical signs and symptoms, not histopathology or radiographs.
In acute infection, you will not notice any sequestrum or periosteal reaction.
As we said, chronic osteomyelitis can either be suppurative or sclerotic.
Focal sclerosing osteomyelitis is also known as condensing osteitis.
Another variant of sclerotic type is diffuse sclerosing osteomyelitis.
Another variant of chronic osteomyelitis is Garre’s osteomyelitis or proliferative
periostitis.
In this type, you will notice deposition of onion-ring bone below the border of the
mandible.
Once the bacteria invade the medullary space of the bone, acute infection will start, it
will take 10-28 days to become chronic, duration depends on the immune system and
the virulent bacteria.
Paresthesia is commonly related to malignancy. So if you find paresthesia with signs
of infection in the bone, this can be osteomyelitis or malignancy superinfected. So be
careful.
Source of the bacteria in most cases is odontogenic infection, but some cases with
fracture or laceration can cause infection with staphylococci from the skin.
This will help me in the management of the infection, if I knew that odontogenic
infection started osteomyelitis then I can give the patient penicillin, infection with
skin bacteria, I will give the patient clindamycin.

68 | P a g e
But in most cases, it is better to give clindamycin even after odontogenic infection,
because it has good penetration of the bone.
Steps of acute suppurative osteomyelitis:
1- Organisms entry into the jaw, mostly mandible, compromising the vascular supply.

Any infection enters deep spaces, start with thrombosis of blood vessels to
compromise the blood supply.
If a severe infection spread all over the facial spaces, it can cause DIC (disseminated
intravascular coagulation), mortality rate is high.
2- Medullary infection spread through marrow spaces.
3- Thrombosis is vessels leading to extensive necrosis of bone.

4- Lacunae empty of osteocytes but filled with pus, proliferate in dead tissue.
5- Suppurative inflammation extend through the cortical bone to involve periosteum.
6- Stripping of periosteum compromises blood supply to cortical bone, predispose to
further bone necrosis.
7- Sequestrum is formed bathed in pus, separated from surrounding vital bone.

In late phase, there will be distension of periosteum with pus. This feature is special
to osteomyelitis unlike other infections. Because periosteum is loosely attached to
the bone, it will be elevated and pus will fill the cavity below it.
In final stages, there will be periosteal reaction, there will be bone formation in the
cavity that was previously filled with pus.

Management of acute osteomyelitis:

1- Essential measures:
A- Incision and drainage.
B- Remove source of infection with extraction or RCT.(most important)
C- Empirical antibiotic treatment.
D- Bacterial sampling and culture.
E- Analgesia.
F- Specific antibiotics based on culture and sensitivity for at least 2weeks.

69 | P a g e
G- Debridement.

Complications is rare but can happen like:

1- Pathological fracture because of extensive bone destruction.
2- 2- Chronic osteomyelitis because of inadequate treatment.
3- 3- Cellulitis because of spreading of virulent bacteria.
4- 4- Septicemia in immunocompromised patients.
5- In chronic infections, before prescribing antibiotics you have to do curettage,
sequestrectomy and remove fibrotic tissues, these fibrotic tissues will prevent access
of antibiotics.

There is an opinion for some physicians that chronic infection is mainly caused by the
immune system, not the microorganisms, you have to prescribe steroids, NSAIDs or
bisphosphonates, not antibiotics.

70 | P a g e
Lecture 19 infection of fascial spaces

Fascial space: potential spaces found between fascia and underlying organs and other
tissues.
Potential means that this spaces is not found normally but it has the possibility to be
filled with pus if an infection happened.
So what will happen here is that pus will start to spread until it reaches one of these
compartments, fascia and muscles are tough connective tissues so it will not let pus
pass through it so it will start to accumulate in this compartment.

For a fascial space infection to happen, it needs a collection of 3 factors:

1- Virulence of bacteria
2- Concentration of bacteria
3- Host defense(most important).

Step of management:
1- Determine the severity of the infection: is it simple, moderate or serve infection?
This is a very important step, it will determine your next step, will you need admission
and intubation or drainage is enough? And this infection can progress fast, so you
have to know what you are dealing with.
2- Evaluate the patient’s immunity, take proper medical history and ask for needed
investigations.
3- Decide the setting of care: should the patient be treated as an inpatient or
outpatient?
4- Support medically: take vital signs, assess the case, give fluids and antibiotics if
needed. Start with empirical antibiotics. If the infection is severe then you must give
IV antibiotics.

What determine the severity of the infection?

1- Proximity to vital structures: nerves, blood vessels, airway.
2- Rate of progression: is it progressing quickly?

71 | P a g e
Fascial spaces are classified into:
1- Primary spaces like canine space, buccal space, infratemporal space,
submandibular space, sublingual space and submental space.
2- Secondary spaces.
What happens usually is that the infection starts in the periapical tissues. Normally,
immune system can control it, but because of weak immunity, infection will start to
spread to the primary spaces, in severely ill patients, it will then start to spread to the
secondary spaces.

Canine space
You will see a swelling above the canine area lateral to the nose. This swelling will
obliterate the nasolabial fold.
In normal cases, infections start to spread to the vestibular space and we can see it as
a sinus tract.
But the root of the canine is very long and the apex is beyond the insertion of the
orbicularis ores muscle so we will have pus in this space.
Boundaries:
Superiorly: levator muscle. Inferiorly: orbicularis ores.
Anteriorly: skin. Posteriorly: maxilla.
Medially: levator labii nasi. Laterally: zygomaticus major.

Canine space infection is very dangerous, because it has communication with the
middle cranial fossa via the emissary veins, it is connected by:
1- Anterior facial vein by angular vein then ophthalmic vein.
2- Deep facial vein by the pterygoid venous plexus.

By these two veins it is connected to the cavernous sinus, this can cause cavernous
sinus thrombosis and CNS complications ( remember dangerous area of the face).

Cavernous sinusitis:
Infection is the cavernous sinus, this sinus contains oculomotor, trochlear and
abducent nerves and ophthalmic and maxillary branches of the trigeminal nerve as
well as the internal carotid artery.
This infection can cause lateral rectus palsy, you may consider it as a diagnosis if you
notice this feature to start further investigations.
This infection is life threatening and should be taken seriously.
Early signs and symptoms:

72 | P a g e
1- Lateral rectus palsy due to abducent nerve damage.
2- Nausea.
3- Vomiting.
4- Photophobia.
5- Visual impairment.
6- Diplopia.
7- Amnesia.
8- Headaches.

Buccal space
Boundaries:
Superiorly: zygomatic arch. Inferiorly: inferior border of the mandible.
Anteriorly: modulus. Posteriorly: masseter muscle.
Medially: buccinator muscle. Laterally: skin.
Can be caused by maxillary or mandibular teeth but mainly maxillary.
Contents: facial artery, vein, nerve, stenson’s duct and buccal pad of fat.
Buccal pad of fat prevents spreading of infection posteriorly to the lateral pharyngeal
space.

Swelling below the zygomatic arch and above the inferior border of the mandible.
Infratemporal space
It is located behind the maxilla, boundaries:
Anteriorly: maxilla. Posteriorly: mandibular condyle.
Inferiorly: lateral pterygoid muscle.
Superiorly: base of skull.
Infections spread to this space by the upper 3rd molar commonly.

73 | P a g e
Mandibular spaces

Submental space
boundaries:
superiorly: mylohyoid muscle.
Inferiorly: skin.
Anteriorly: lingual of the mandible.
Posteriorly: hyoid bone. Median: common space.
Laterally: partly inf border of mandible, ant belly of digastric, fascia and skin.
Cause of spread of infection is commonly lower anterior teeth with long roots. But it
can be also an extension of an infection in the submandibular space.
Submandibular space
The most common space to be involved. Boundaries:
Superiorly: inferior border of the mandible and mylohyoid.
Inferiorly: hyoid bone.
Anteriorly: anterior belly of digastric.
Posteriorly: posterior belly of digastic.
Medially: hyoglossus, styloglossus and mylohyoid muscles.
Laterally: Inferior mandible, skin, subcutaneous tissue.
contents of the space:
1- Submandibular salivary gland.
2- Facial and lingual arteries.
3- Lymph nodes.

Most commonly caused by infections related to the lower 3rd molars, 2nd molars
less.
It causes swelling, redness, pain and fever.
It can lead to difficulty breathing or swallowing or trismus.
Sublingual space
Boundaries:
Superiorly: sublingual mucosa. Inferiorly: mylohyoid muscle.
Anteriorly: the mandible. Posteriorly: hyoid bone.
Medially: geniglossus. Laterally: the mandible.
Contents:
1- Sublingual salivary gland.
2- Lingual nerve.

74 | P a g e
3- Warton’s duct.
4- Hypoglossal nerve.

Infections are related to lower molars with apices above the insertion of mylohyoid
muscle.
It causes dysphagia, pain, elevation of the floor of the mouth, displacement of the
tongue, and it can spread to other secondary spaces.
Ludwig’s angina
It is caused by infection in 5 spaces.
Submental and bilateral sublingual and submandibular.
It is a life threatening infection, can compress the airway and lead to death.
Needs immediate admission and intubation, I&D to decompress it and aggressive
antibiotic therapy.

Submasseteric space
Boundaries:
Medially: ramus of the mandible.
Laterally: masseter muscle.
Superiorly: zygomatic arch.
Inferiorly: inferior border of the mandible.
Posteriorly: parotid gland.
Anteriorly: buccal space.
In this infection, the patient will have severe trismus because of contraction of
masseter muscle. It can spread to other spaces, mainly the infratemporal space.
Pterygomandibular space
It is where you deposit local anesthesia for ID nerve block.
Infection is caused by the use of contaminated needle or LA solution.
Boundaries:
Superiorly: lateral pterygoid.
Inferiorly: pterygomasseteric sling.(junction between masseter and medial pterygoid.
Anteriorly: pterygomandibular raphe posteriorly: parotid gland.
Medially: medial pterygoid. Laterally: ramus of the mandible.
Temporal space
It is a space located between the temporalis muscle and temporal fascia.

75 | P a g e
Infections in this space is an extension of other spaces like the infratemporal and
submasseteric space.
In order for this extension to happen, the patient must be severely ill and immune
system is very weak.
Cervical Spaces
Lateral Pharyngeal space(parapharyngeal space)
Spread of infection to this space can happen from the pterygomandibular,
submandibular or sublingual spaces.
This space extends from the base of the skull to the hyoid bone, medial to the medial
pterygoid muscle.
The space is bounded posteriorly by the prevertebral fascia and anteriorly by the
pterygomandibular raphe.
Infection in this space will lead to severe trismus and swelling of the neck.
This space contains important contents like internal jugular vein, internal carotid
artery and cranial nerves IX through XII.
Infection in this space can lead to thrombosis of the internal jugular vein or erosion of
the internal carotid artery and it can spread to the retropharyngeal space.
Retropharyngeal space more posterior to the lateral pharyngeal space.
Infection in this space can spread inferiorly, compressing against the alar fascia and
cause mediastinitis.

Necrotizing fasciitis
Very fast progressive condition that can affect the head and neck area, it is
polymicrobial in origin. Usually it happens as a spread from superficial to deep fascia.
It happens usually because of a breach in the skin, and will develop in
immunocompromised patients.
It will develop very fast and cause extensive necrosis within hours, and management
is excision of the whole necrotic tissues.
Steps for management will be like any other infection, starts with proper medical
history to end with elimination of source of infection.
The most important step is proper diagnosis.

76 | P a g e
Lecture 20 bleeding disorders

If your patient has a bleeding disorder, sometimes you have to ask for laboratory tests,
it the patient has problem in the platelets, you will ask for platelet count and bleeding
time (BT). If the patient has problem in the coagulation pathway, you will ask you
prothrombin time (PT), partial thromboplastin time (PTT) and thrombin time (TT). 1-
Platelet count: normal count is 100,000 – 400,000 cells / mm3 , below 100,000 the
patient is considered to have thrombocytopenia: A- 50,000 – 100,000: mild
thrombocytopenia.

77 | P a g e
Lecture 21 lasers in dentistry
Laser: standing for light amplification by stimulated emission of radiation.
The laser has 3 properties in order to proceed: coherence, collimation and efficiency .
So, after light amplification, laser is mono-chromatic, collimated, coherent and intense
beam of light produced by stimulated emission of radiation by light source.
It can be used for the following procedures, excision of malignant and potentially
malignant lesions, biopsy, stop bleeding and frenectomy so it can replace the blade.
Biopsy can be taken by direct or indirect contact with the lesion depending on the type
of laser used. Laser affects the tissues by vaporizing them, a process called laser
vaporization or laser ablation. The laser not only causes the tissue to vaporize, but also
causes hemostasis and coagulation of the vessels especially if they are less than 0.5 mm
in diameter.

The laser beam will be mono-chromatic, coherent and of very low divergence.
There are 4 types of interactions between laser and biological tissues:
1. Absorption – when laser light is directed at tissues, absorption of light occurs
through various compounds in them. Those compounds are called chromophores. The
number of chromophores in the tissue determines its absorption capacity. From
google: Simply put, a chromophore is the part of a molecule which gives it its color
2. Reflection – the beam is reflected of the surface producing no effect on the target
tissue
3. Scattering – the laser energy is scattered over a broader area or volume of tissue
thus diffusing the effect of the energy
4. Transmission – the laser beam is transmitted through the tissue resulting no
observable laser tissue reaction .
The principle effect of laser is the photothermal effect.  It depends on the
temperature rise and corresponding reaction of the interstitial and intracellular water.
 As the laser energy is absorbed, heating occurs. If the laser is in an impulse form, the
tissues will have time to cool down before the next pulse is emitted, but if it is being

78 | P a g e
continuously emitted, then the operator must seize the laser emission manually to
have thermal relaxation
The temperature effects of laser on tissue components are:
a. Tissue retraction and protein denaturation or changes
b. When the temperature is increased more, it causes the inactivation of bacteria
which reflects its effect in sterilization
c. When the temperature is increased further, more denaturation and thus coagulation
effect
d. Tissue welding when the temperature is increased even more
e. Above 100°F, vaporization of tissue occurs
f. Above 200°F, carbonization effect on tissue occurs
Soft tissue lasers – used mostly for hemostasis and coagulation: 1- CO2 laser. 2- ND-
YAG laser. 3- KTP (Potassium Titanyl Phosphate) laser. 4- HO-YAG (Holmium) laser. 5-
Photodynamic therapy. 6- Skin lasers (Tunable dye). 7- Low level lasers.
Hard tissue lasers – cuts hard tissues like bone and teeth: 1- Excimer laser. 2- ER-YAG
(Erbium) laser. 3- TEA-CO2 (Transversely Excited Atmospheric) laser.
Combination lasers: it consists of 2 combined lasers. 1- COMBO (CO2 and ND-YAG)
laser. 2- KTP/ND-YAG laser.

Possible Complications of Laser Therapy

 Immediate erythema, edema, pain, exudation, purpura  Secondary infection 
Pigmentary changes: hyper/hypopigmentation  Textural change, atrophy  Scarring,
keloid Potential

Hazard of Laser Machine

 Hazard to eye: Retina, permanent visual loss

79 | P a g e
 Hazard to skin: Severe burns & scarring
 Electrical hazard: High voltage – life threatening  Hazards from fumes & vaporized
tissues (risk of spread of HPV, HIV)

Precautions in Laser Therapy

 Safety goggles (operator & patient)  Lock the door during treatment  Never look
directly into the laser beam  Never point the laser handpiece at any person except at
treated area  Never use the laser in the presence of flammable anesthetics  Never
step on or abruptly bend the fiber-optic cable  Never move the laser machine during
operation  Do not turn the machine immediately after treatment  Do not turn off the
main electrical switch

Cryosurgery in Oral and Maxillofacial Surgery

 Definition: It is a therapeutic use of extreme cold using nitrous oxide or liquid
nitrogen

 Indication:
 Vascular malformation (hemangiomas)  Areas of leukoplakia unsuitable for excision
 Excision of hyperplastic lesions  Viral warts  Excision of mucocele  Superficial
basal cell carcinoma

80 | P a g e
 Lecture 22 antibiotics in dentistry

WRITING PRESCRIPTIONS
Drug Name (can be generic) Unit Dose
(ex: Augmentin 625mg 1x2x7))
Disp: amount of pills, milliliters (ml)
Sig: Directions for use. q24h (daily), q12h, q8h, q6h, q4h,
Prn: per need
Refills__ Signature

Name
Age
Date
The medication: amount,feequency,duration
Close the prescription
Doctors signature

 Rules for prescribing antibiotics:

 Use the write drug
 Use the write dose
 Use the correct dose schedule & correct duration.
 Most odontogenic infections are caused by mixed organisms .
 Loading dose might be needed
 Most of the drugs take their action within 2-3 days but we give an extra 2 days to
make sure that the patient has taken the drug the right way & the desired effect has
been achieved ( patient compliance).

81 | P a g e
 Antibiotics have 2 names :
 Generic name ; based on chemical components of the drug & it is not capitalized .
 Trade name ; created by the drug company & it is capitalized.

 Antibioyics used in dentistry shouid affect both Gram + and Gram – bacteria, better
for mixed infections.
 Examples: Amoxicillin, Ampicillin

COMMON PATHOGENIC ORAL BACTERIA

Necrotic pulp and apical abscesses
Obligate anaerobic bacteria
Gram negative rods
Prevotella & porphyomonas spp.
Fusobacterium spp.
Campylobacter rectus
Gram positive rods
Eubacterium spp.
Actinomycetes spp.

 Gram positive cocci

 Peptostreptococcus spp.
 Facultative anaerobic bacteria
 Gram positive cocci
 Strep and Entercoccus spp.
PeriodontalDiseases
Gingivitis
Fuso, strep, & actinomycetes

82 | P a g e
 Antibiotics
 Natural penicillins
 Pen V and Pen G
 mechanism of action: Inhibit cell wall synthesis
 Dose: 250-500 mg qid x 7-10 days
 Contraindications:
 Allergies
 Poor renal function
 Adverse events: GI upset
 Drug interactions: oral contraceptives
 Pregnancy category B
 Bactericidal
 Allergic reaction: rare (4 per 100,000)
 Spectrum:
 Strep, staph, enterococcus, neiseria, treponema, listeria
 Resistance:
 Mostly staph (>80%)

 Amino-penicillins
 Amoxicillin, ampicillin
 MOA: Inhibit cell wall synthesis
 Dose: 250-500 mg q 8 h x 7-10 days
 Contraindications:
 Allergies
 Poor renal fxn
 Adverse events: GI upset
 Drug interactions: oral contraceptives
 Amoxicillin and clavulanic acid (Augmentin)
 Bactericidal
 “ampicillin” rash (4-10%)
 Spectrum:
 Strep, staph, enterococcus, neiseria, treponema, listeria, E. coli, proteus, H. Flu,
shigella, salmonella
 Resistance:
 Entero, citro, serratia, proteus vulagris, provedincia, morganella, pseudomonas
aeriginosa, acinetobacter
83 | P a g e

 Cephalexin (Keflex)
 MOA: Inhibit cell wall synthesis
 Dose: 250-1000mg q 6 h x 7-10 days
 Contraindications:
 Allergies
 Poor renal fxn
 Adverse events: mild GI
 Drug interactions: probenecid
 Pregnancy category B
 Cephalexin (Keflex)
 Bactericidal
 Spectrum:
 Gram +
 Resistance:
 Methicillin resistant gram +
 Low cross sensitivity with PCN
 Cephalosporin's, 1st generation Cefadroxil
DURICEF
Cefazolin

Cephalexin
KEFLEX
Mainly skin and soft-tissue infections
 Gastrointestinal upset and diarrhea NauseaAllergic reactions
 Cephalosporin's, 2nd generation CefaclorCefoxitin
MEFOXIN
Cefprozil
Cefuroxime
Loracarbef
 Some respiratory infections and, for cefoxitin
MEFOXIN
, abdominal infections
 Gastrointestinal upset and diarrhea,NauseaAllergic reactions
 Cephalosporin's, 3rd generation Cefixime
SUPRAX
Cefdinir
OMNICEF

84 | P a g e
 Cefditoren
SPECTRACEF
CefoperazoneCefotaxime
CLAFORAN
Cefpodoxime
VANTIN
 Cephalosporin's, 4th generation Cefepime
MAXIPIME
Serious infections (including Pseudomonas infections), particularly in people with a
weakened immune system and infections due to susceptible bacteria resistant to
other antibiotics
 Cephalosporin's, 5th generation Ceftobiprole
 Complicated skin infections, including foot infections in people with diabetes, due to
susceptible bacteria, such as Escherichia coli, Pseudomonas aeruginosa, and
methicillin-resistant Staphylococcus aureus (MRSA)

 Clindamycin (Cleocin)
 MOA: binds to the 50S ribosomal subunit and inhibits protein synthesis
 Dose: 100-450mg q 6 h x 7-10 days
 Precautions:
 Poor hepatic fxn
 Adverse events: GI upset, pseudomembraneous colitis
 Drug interactions: neuromuscular blocking agents
 Pregnancy category B

 Bactericidal or static depending on concentration
 Spectrum:
 Gram +, anaerobes, parasites
 Resistance
 Enteroccocus
*Clostridium diff. pseudomembranous colitis!!

85 | P a g e
 Azithromycin (Zithromax), clarithromycin (Biaxin)
 MOA: bind to the 23S rRNA in the 50S subunit ribosome
 Dose: 250-500 mg/day x 5-10 days
 Precautions :
 Poor hepatic fxn
 Adverse effects: GI
 Drug interactions: Cytochrome P-450
 Pregnancy category B

 Bactericidal
 Spectrum:
 Gram +, gram -, anaerobes
 Resistance:
 B. fragilis, and strep pneumo

 Doxycycline (Vibramycin)
 MOA: inhibit protein synthesis by preventing aminoacyl transfer RNA from entering
the acceptor sites on the ribosome
 Dose: 100mg qd-bid x 7-14 days
 Contraindications:
 Food
 pregnancy
 Adverse events: GI
 Drug interactions: anti-epileptics
 Pregnancy category D

 Bacteriostatic
 Spectrum:
 Broad, Gram +, -, anaerobes, aerobes, and spirochetes
 Resistance:
 Widespread, cross resistance
 PHOTO SENSITIVITY!!!

 Metronidazole (Flagyl)
 MOA: reduced intermediate interacts and breaks the bacterial or parasitic DNA
 Dose: 250-1000 mg q 6-8 h x 7-10 days
 Precautions : poor hepatic fxn
 Adverse events: GI upset.

86 | P a g e
 Drug interactions: warfarin, Li+
 Pregnancy category D

 Bactericidal
 Spectrum:
 Gram - anaerobes
 Resistance:
 Rare, H. Pylori?
 Unpleasant metallic taste

 Ciprofloxacin (Cipro)
 MOA: Inhibition of DNA gyrase, and Topo II
 Dose: 250-500 mg qd x 7-10 days
 Contraindications: <18 yrs old, pregnancy
 Adverse events: spontaneous tendon rupture
 Drug interactions: probenacid, warfarin
 Pregnancy category C

 Bactericidal
 Spectrum:
 Very broad except B. frag
 Resistance:
 MRSA, MRSE

Antifunfals

 Nystatin
 MOA: inhibit cell wall synthesis
 Dose: 5 ml swish and swallow q 4 h x 10-14 d
 GI upset
 Drug interactions: minor
 Pregnancy category C

87 | P a g e
 Clotrimazole (Mycelex), ketoconazole (Nizoral), fluconazole (Diflucan)

 MOA: inhibit cell wall synthesis

 Dose: 200-800 mg qd x up to 12 months
 GI upset
 Drug interactions: major p-450 enzyme inhibitor, interactions with many drugs
 Pregnancy category C

Drug categories
 Pharmaceutical pregnancy categories :
 Category A :
 Adequate & well controlled studies on both humans & animals have failed to
demonstrate risk to the fetus.
 Category B :
 Animal reproduction studies have failed to demonstrate a risk to the fetus & there are
no adequate & well controlled studies in pregnant women.
 Category C :
 Animal reproduction studies have shown an adverse effect on the fetus & there are no
adequate & well controlled studies in humans, but potential benefits may warrant use
of the drug in pregnant women despite potential risk.

MEDICAL STATUS OF PATIENT

EVALUATE THE RESPONSE TO TREATMENT

Diabetic Immunocompromised
Patients on Steroids
patients patients

Patients on
Patients on
chemotherapy or
Bisphosphonates
Radiotherapy

88 | P a g e
89 | P a g e
Lecture 23 medical emergencies
Cardiac arrest
what do we mean by cardiac arrest? How to know that this patient is a cardiac arrest
patient ? Cardiac arrest : is simply when the heart stops bumping blood.
A cardiac arrest patient will show the following signs :
 No pulse
 No circulation ( remember circulation is more important than breathing ) in fact it’s
the most important sign.
 No breathing
 Complete loss of consciousness
So important in viva
1) We should call emergency (911) immediately in most of the cases because 90% of
the times the cause of cardiac arrest in ventricular fibrillation and the gold standard
for dealing with it is ventriculat defibrillator, but in specific cases you should perform
1 min of CPR before calling emergency like trauma or drowning why? Because the
patient will benefit from this one minute because we know the cause which is water
in case of drowning and airway obstruction in trauma so if you clear the airway you
will solve the problem . note : make sure the patient is safe and don’t leave him alone
and go call 911 , the faster the advanced care arrives the more the chance to save the
patient life .
2) Start with CPR and as we said before circulation is more important than breathing
so you have to start chest compression then breathing ratio 30:2 3 meaning every 30
compression you give 2 breaths { 100 compression/min}, you can either perform
mouth to mouth breathing and make sure you close the nose OR mouth to nose
breathing you have to continue to do CPR until you are completely exhausted or
when help arrives . note : even if you perform CPR optimally you will only achieve
30% of the normal perfusion . but this the only choice we have in basic life support .
Basic life support is dealing with emergencies without any instrument which means
you are controlling breathing and circulation with basic measures which are
compression(heart massage) and ventilation (mouth to mouth or mouth to nose ) . If
you use oxygen mask you call it basic life support with oxygen mask Advanced life
support you are controlling breathing and circulation with defibrillator instead of
compression and tracheal intubation instead of mouth to mouth or mouth to nose
breathing . you can use oxygen mask but the gold standard is tracheal intubation . if
you can’t perform intubation you go for cricothyroidotomy in the cricothyroid
membrane by any instrument between 2 nd and 5 th tracheal rings or laryngostomy
you should know how to do it as a maxillofascial surgery . you can perform
cricothyroidotomy even if the patient is awake but you have to replace it with the
formal tracheostomy as soon as we can because it causes laryngitis and
laryngostenosis .

90 | P a g e
FAINTING (vasovagal syncope) MOST COMMON. It encounter 2% of emergencies which
is kind of high Recap: Most important : cardiac arrest Most common : fainting Fainiting
: is inadequate syncope perfusion. If it stays for more than 5 minutes that means the
patient is dying . 
Signs and symptoms of fainting :
 pale , cold, sweating ,palpitation
 blurred vision , confusion, dizziness
 can’t walk so he falls down and collapse
 transient loss of consciousness

91 | P a g e
  tachycardia followed by bradycardia
 systolic pressure high at first as a compensating mechanism followed by hypotension
in late stages so he’s a risk
 The best feature to observe in fainting is the tongue and oral mucosa you will see
pale , blanching and a very white tongue (this is because of hypotension) .

Steps of management of fainting :

1) supine position which means legs above the level of the heart to encourage venous
return to the brain , in simple fainting this will work immediately . you check the mucosa
and tongue as they will have their normal color Don’t continue working immediately
after patient recovery wait for atleast 5 min because some patient has sludge venous
valves especially if he’s diabetic or with cardiac problems . (sludge: ‫ (كسول‬Note : if
putting your patient in a supine position didn’t work you should investigate and know
the etiology and give me drugs such as atropin , edrophonium(it prolongs the acting of
Ach on its receptors) they increase blood pressure until help arrives. -it’s important to
recognize it in early stage. -if there is no complete recovery we refer it to hospital,
actually what we do is primary treatment not a definitive treatment. NEVER LEAVE
THE PATIENT UNATTENED NEEEEVEER

Anaphylactic shock : hypersensitivity reaction type 1 which is reaction between the

allergen and antibodies inducing an immune reaction charactized by :
1)Brochospasm
2) layrngoedema
3)hypotension
The most common allergen in our dental practice is LATEX , and ofcourse there are
other allergens like amalgam , monomers , penicillin , preservative in LA .
Hypersensitivity reaction ranges from mild unnoticeable reaction to severe reaction
which is called anaphylactic shock SO anaphylactic shock is the most severe form of
hypersensitivity reaction . so how to know if the patient has mild , moderate , severe
hypersensitivity reaction ? From it’s speed, you calculate the time from adminstring the

92 | P a g e
allergen to when the symptoms start to appear,so if the reaction happens quickly and
symptoms appeared 7 very fast this is anaphylaxis but if it happenes after half an hour
from adminstring the allergen this is mild hypersensitivity reaction. Signs and
symptoms : 1)Rash 2) pale skin 3) itching 4) cyanosis 5) hypotension 6) swelling 7)
flushing 8) angioedema Most important signs are layrngyeal edema & wheezing so
obstruction of airway, so the gold standard is giving an epinephrine shot because it
works on β-2 receptor and causes bronchodilation , we give epinephrine shot
intramuscular in the vastus lateralis muscle because it’s a bulky muscle with good blood
supply but you can give it in any muscle you can even give it subcutaneous , we can’t
give it inravenous but if nothing works you can . Epinephrine shot is the first line
medication . Corticosteroids and anti-histamine IV are second line medication
HYPOGLYCEMIA
Hypoglycemia: is decrease in the blood glucose level below 65 due to increase in the
hyperglycemia drug dose or no carbohydrate intake or both . Like when a patient comes
to the surgery clinic without eating or taking his medication or when he takes his drugs
without eating . Sometimes after performing a traumatic surgery(extraction for seven
teeth) the patient can’t eat but he took his hyperglycemia drugs or insulin which may
lead to hypoglycemic shock so you have to tell him to stop his drugs or half the dose ,
and tell him to always link his drugs with food and if he can’t eat he can drink anything
with glucose but never to take drug alone. Better to stay hyperglycemic rather than
hypoglycemic .

Notes : LA with epinephrine is contraindicated in asthmatic patient due to

preservatives that come with epinephrine not because of epinephrine itself

93 | P a g e
Lecture 24 pain killers
Generally, analgesics are divided into:
1- Non-opioid analgesics like paracetamol.
2- Opioid analgesics.
3- NSAIDs.
4- Neuropathic and functional pain.
5- Antimigraine drugs.

Mainly, for odontogenic pain we use non-opioids and NSAIDs, for more severe pain, we
sometimes think about opioids. The last two choices are given sometimes to subside
the pain in cases of atypical facial pain and migraine.
Non-opioid analgesics
Here we mainly talk about paracetamol(acetaminophen in some countries), MOA is
still not fully known, some studies says that it work as a COX-3 inhibitor, an enzyme
found on the CNS.

Paracetamol has no anti-inflammatory effect, and is less irritant to the stomach.

As we said, every drug has side effects, but paracetamol has minimal side effects, in
fact, it is one of the safest drugs, that’s why it is widely used and is over the counter
drug.
Indications:
1- Mild to moderate pain.
2- Pyrexia.

Side effects is found but is rare, some can complain of rash.

This drug is metabolized in the liver, so overdose can cause liver damage and less
frequently renal damage.
Doses: frequently it comes as 500 mg tablets, sometimes it can be 1000mg. in adults,
for mild pain, we can give 500mg 1x3 or 1x4, for moderate pain, 500mg 2x3 or 2x4,
maximum dose is 4.0g daily and must not be exceeded.
To enhance the effect, it can be combined with other drugs:
1- Paracetamol or Aspirin + opioid 8mg codeine phosphate.

94 | P a g e
2- Combined with caffeine.

These combination are already found in the markets, but remember, when you add
another drugs, this means more side effects.
Some brand names for drugs containing paracetamol:
1- Co-codamol: combined with codeine it either comes at 8/500, 15/500 or 30/500.
2- Kapake 30/500: also with codeine.
3- Tylex 30/500: also with codeine.
4- Panadol extra: combined with caffeine.

Drug interactions: it is one of the safest drugs but still it has minimal interactions:
1- Anti-coagulants: paracetamol can prolong the action of these drugs.
2- Lipid regulating drugs: colestyramine reduce absorption of paracetamol.

Opioid analgesics
It is used for moderate to severe pain, mainly is severe pain. One of the major
problems in these drugs is that is causes dependence and tolerance.
It has many side effects like nausea, vomiting, constipation and drowsiness, you may
think that these are mild side effects and won’t cause big problems, but these are
very severe are can alter the patient’s life. Some morphine addicts sometimes need
hospitalization because of the constipation.
Overdose can cause respiratory depression or hypertension, it also can cause death
because of overdose.

Common opioids:
1- Morphine: it is used for severe pain, it can cause euphoria or mental detachment,
oral dose is 10-50mg every 4 – 6 hours.
2- Codeine: used for moderate pain, it can cause constipation, oral dose is 30 – 60 mg
every 4 – 6 hours and maximum dose is 240 mg daily.
3- Dihydrocodeine: used for moderate pain, it can cause nausea and vomiting, oral
dose is 30 – 60 mg every 4 – 6 hours.

95 | P a g e
Codeine and dihydrocodeine can be used in cases of moderate to severe pain for
patient who cannot tolerate NSAIDs like patients who have asthma, peptic ulcer or
allergy to NSAIDs.
4- Pethidine: it gives prompt short term analgesia which is an advantage to morphine,
it causes less constipation than morphine and is less potent analgesic. Oral dose is 50
– 150 mg every 4 – 6 hours, it can be given SC or IM 25 – 100 mg every 4 – 6 hours.

Morphine and pethidine can be used for inpatients.

5- Tramadol: one of the most common opioids to be prescribed for out-patients
because of severe pain, it comes in a brand name (Tramal), it has opioid effect and it
enhances seratogenic and androgenic pathways which can cause addiction. It has less
opioid side effects and some psychiatric rxn are reported. Dose is 50 – 100 mg every 4
– 6 hours.

To prescribe these drugs, the drug should be written on a prescription alone without
any other medication, write the diagnosis, exact amount and the prescription signed
and stamped.

If the patient is allergic to ibuprofen, will he be allergic to all types of NSAIDs?

All NSAIDs have similar MOA, so mostly the patient will be allergic to all of it, maybe
the degree of allergy will be different for different drugs, but if the patient is allergic to
one type of NSAIDs, you better not prescribe any type of it.
Drug Interactions: as we said, opioid has many severe interactions:
1- Alcohol: it can cause sedation, hypotension and even lead to death.
2- Antibacterials: like erythromycin, ciprofloxacin and rifampin, opioids can reduce
the effect of these drugs, if the patient has an infection and these drugs was
prescribed, it won’t give good effect.
3- Antidepressants.
4- Antiepileptics.
5- Antifungals.
6- Antivirals

96 | P a g e
NSAIDS:
Ibuprofen has better analgesic effect so we like it more than others. Diclofenac has
better anti-inflammatory effect so we prefer to use it in chronic diseases like arthritis.

NSAIDs is contraindicated in cases of asthma, peptic ulcer and allergy.

NSAIDs work as a COX enzymes inhibitor. A new type of drugs are selective COX-2
inhibitors which improves GI tolerance.

1- Aspirin: commonly, we don’t use it as a pain killer, but it is still an option. It is used
for mild to moderate pain and for pyrexia.
Cautions: you have to be careful in asthma patient, allergic rxn, impaired
renal(mainly) or hepatic function, avoid during viral infections

97 | P a g e
 for adolescents because of the risk of Reye’s syndrome, during pregnancy
and for elderly.
Contraindications: children < 16years, breast feeding, peptic ulcer, haemophilia(since
it acts as anti-platelet) and history of hypersensitivity to aspirin or NSAIDs.
Side effects: GI irritation, hypersensitivity and prolonged bleeding time.
Dose: therapeutic dose to control pain is 300 – 900 mg every 4 – 6 hours(100mg for
antiplatelet function) and maximum dose is 4.0 grams.
2- Ibuprofen: it is a proprionic acid derivative, it has an anti-inflammatory effect,
analgesic effect and antipyretic effect. It has less side effects than other NSAIDs. It has
weaker anti-inflammatory effect than other NSAIDs but better analgesic effect with
less side effects so we prefer to use it.

Dose: daily dose is 1.6 – 2.4 g daily, it commonly comes in tablets 400, 600 or 800 mg.
moderate pain, we prescribe 600mg 1x4. For mild pain, 400mg 1x4. For children
under 12 years old, there is a syrup and we give half the adult dose.
Brand names: Brufen, Dolaraz, Fenbid.

3- Naproxen: another proprionic acid derivative, it has more side effects that
ibuprofen
Dose: 0.5 – 1.0 g daily divided into 1 or 2 doses.
Brand names: Naproxen, Naprosyn and Synflex.
4- Ketoprofen: another proprionic acid derivative, it has similar anti-inflammatory
effect to ibuprofen but with more side effects.

Dose: 100 – 200 mg daily divided into 1 or 2 doses.

Brand names: Ketoprofen, Oruvial and Orudis.
5- Diclofenac and Aceclofenac: same action and side effects like Naproxen.

98 | P a g e
Dose: 100mg twice daily.
Brand name: Volatrol and Diclomax.
6- Diflunisal: Aspirin derivative but action similar to proprionic acid derivatives.

Dose: 500mg twice daily, it has long action duration.

Brand names: Dolobid.
7- Mefenamic acid: it has minor anti-inflammatory action, but the problem is the side
effects, it causes diarrhea and haemolytic anemia, so be careful when you prescribe
it.

Dose: 500mg three times daily.

Brand name: Ponstan.

Selective inhibitors of COX-2:

It is a new group of NSAIDs, it has less side effects on the GI tract. It is still a
contraindication to be given for patients DIAGNOSED with peptic ulcer but we can
give it to patients that have sensitive stomach. You have to take precautions when
you use it, it can affect the cardiovascular system.
1- Celecoxib: the most widely used in this group in dentistry, it has less cardiovascular
effects than other drugs.

Dose: 200 mg in 1 or 2 doses.

Brand name: Celebrex.
2- Meloxicam: common to be used in dentistry, we use it mainly for it’s anti-
inflammatory effect since it is a weak analgesic.

Dose: 7.5 - 15 mg once daily.

Brand name: Mobic.
3- Etodolac: Dose: 600 mg once daily.

99 | P a g e
Brand name: Lodinesr.
4- Refecoxib: it has more effects on cardiovascular system.

Dose: 25 – 50 mg once daily.

Brand name: Vioxx.

Drug interactions:
1- Other NSAIDs: don’t prescribe different types of NSAIDs together.
2- ACE inhibitors.
3- Anticoagulants.
4- Antidepressants.
5- Antidiabetics: mainly sulphonylureas.
6- Antiepileptics.
7- Antifungals like ketoconazole, fluconazole.
8- Antivirals.
9- Diuretics.
10- Cimetidine.
Pregnancy:
1- Paracetamol: the safest drug to be used during pregnancy.
2- Opioids: it is contraindicated, it depresses neonatal respiration.
3- NSAIDs: should be avoided unless really needed, before prescribing it, you better
contact the lady’s physician. It can cause newborn hypertension and can delay and
increase duration of labour.

Breast feeding:
1- Paracetamol: still safe, the amount is too small to be harmful.
2- Opioids:
A- Morphine: safe in therapeutic doses but still given under strict measures after
consulting the physician.
B- Codeine: Amount is low to be harmful, but still given under strict measures.
3- Aspirin: should be avoided.
4- NSAIDs: can be given, amount is low to be harmful.

100 | P a g e
5- Selective COX-2 inhibitors: should be avoided because no are informations
available.

Liver diseases:
1- Paracetamol: still the safest drug, but large doses should be avoided.
2- Opioids: should be avoided or at least the dose reduced.
3- NSAIDs: it can increase the risk of GI bleeding, can cause fluid retention and should
be avoided in severe liver disease.
Renal Diseases:
1- Paracetamol: still the safest, but reduce the dose.
2- Opioids: it should be avoided or at least the dose reduced. It can cause increased
and prolonged effect, and increased cerebral sensitivity.
3- NSAODs: should be avoided unless really needed, so you have to contact the
nephrologist first.
4- Aspirin: should be avoided.

101 | P a g e
Lecture 25 dental management of patients with systemic diseases
Ischemic heart disease: Chest x-rays can be useful to detect any congestive heart
failure. ECG can detect ST segment elevation . IHD a very common condition. Caused
by insufficient blood supply to the myocardium due to: - full or partial obstruction of
the coronary arteries - spasms in the coronary arteries It’ll eventually cause → Angina
(stable, unstable)
Stable angina: patients can function normally during their daily life, however, at
exertion of severe effort, they might experience pain, discomfort, etc.. Unstable angina:
patients experience symptoms even at rest. The risk factor leading to IHD are: Family
history, male gender, hyperlipidemia, hypertension, smoking. These patients most
probably always have their nitroglycerin tablets (used sublingually) with them to
control the symptoms of angina. As a dentist, you should always remind your IHD
patient to bring their nitroglycerin with them for their dental appointments. You
shouldn’t perform any elective surgery for a patient who has experienced IHD (mainly
MI), unless 6 months has passed since the last significant incidence, to avoid any risk of
an infarction.
Myocardial infarction:
Infarcted area in the heart that becomes non-functional due to necrosis, which will
interfere with the heart function. These patients will usually need a pacemaker to
regulate their heartbeat. They usually are on aspirin, or anticoagulant. If any history of
angina, or MI before 6 months, we can work for them, but with controlled level of
anxiety, accompanied with prophylactic glyceryl trinitrate ( prophylactic GTN).
Heart failure:
Could be right ventricular dysfunction or left ventricular dysfunction. It’s a disease
where the heart doesn’t meet the body’s blood demand, which will cause a spectrum
of symptoms like:
4 - Pulmonary edema. - Hepatic dysfunction. - Hepatosplenomegaly. - Orthopnea/
dyspnea ( where the patient cant sleep fully supine, multiple pillows are used to his
comfort) - Pitting edema in the lower limbs due to the collection of interstitial fluids .
These patients usually are in a risk for major cardiac events, this risk can be reduced by:
- Diuretic therapy - Afterload reduction - Digoxin therapy - Anxiety-reduction program

102 | P a g e
- Avoid excessive epinephrine (because of the over-activity in the sympathetic system.)
- No supine position
Coronary artery bypass grafting:
After an obstruction of the coronary artery, after an MI for example, the cardiac
surgeon installs grafts to replace coronary arteries. If a patient came in with a history
of CABG surgery, a minimum of 6 months must be waited before any elective
procedure. Also, routine minor oral surgeries can be safely performed with anxiety
reduction protocols.

Coronary angioplasty:
a procedure performed to widen a narrowed coronary artery to allow it to function in
a more efficient way. Just like angina patients, you shouldn’t perform any elective
surgery for a patient who has undergone this surgery unless 6 months has passed.

Dysrhythmias:
It’s a condition where changes of the heart's normal sequence of electrical impulses.
the heart may beat too quickly, tachycardia; too slowly, bradycardia. For these patients,
you should avoid the use of epinephrine, as it worsens the situation, so give LA without
Adrenaline. You should also make sure through the medical history that the patients
are following their medications. Anticoagulants will contraindicate your treatment.
Also, through medical history we should check for the installation of a pacemaker, if
installed, avoid using electric devices in your procedure.

Hypertension:
One of the most common conditions. Essential hypertension and secondary
hypertension are two types of hypertension. You can’t diagnose the patient with
hypertension in your clinic. Hypertension’s diagnosis is done by a cardiologist. A
cardiologist will ask the patient to measure his blood pressure a couple of times every
day for two weeks, and write it down in a journal. (Don’t forget: white coat syndrome)
Hypertension patients might take a broad spectrum of drugs including: - diuretics - ACE

103 | P a g e
inhibitors - Angiotensin receptor blockers - B-blockers - Calcium channels blockers
Avoid any elective surgeries if the patients has uncontrolled hypertension. Also, use
anxiety producing protocols.

Congenital heart disease:

It is makes 1% of live births. Lesions may involve the heart, or the adjacent blood
vessels, being isolated or compound. Symptoms of congenital heart disease consists of
cardiac failure, cyanosis, finger and toe-clubbing. You need to take good history,
including the medications, a letter from a cardiologist allowing you to perform dental
procedures may be of great help.

Dental managements include:

- Dental staff training on CPR and emergency protocol. - Patients should take their
medications on the day of their dental appointment. - Assess stability of the heart
condition. - Treat patients in the late morning or early afternoon, because heart attacks
commonly occur in early mornings, surprisingly. - Stress-reduction protocol and good
analgesia with minimal epinephrine.

Cardiovascular accidents include: - Patients on anticoagulants → an elective procedure

must be immediately stopped if the patient was to be on anticoagulants. - Blood
pressure lowering agents must be present. - Anxiety reduction protocols to lower the
level of anxiety. - Oxygen supplements must be present.

104 | P a g e
Lecture 26 odontogenic infections of maxillary sinus

The maxillary sinuses are air-containing spaces that occupy maxillary bone bilaterally,
They are the first of the paranasal sinuses (e.g., maxillary,ethmoid, frontal, and
sphenoid) to develop embryonically and begin in the third month of fetal development.
The maxillary sinus is described as a four-sided pyramid, with the base lying vertically
on the medial surface and forming the lateral nasal wall. The apex extends laterally into
the zygomatic process of the maxilla. The upper wall, or roof, of the sinus is also the
floor of the orbit. The posterior wall extends the length of the maxilla and dips into the
maxillary tuberosity. Anteriorly and laterally, the sinus extends to the region of the first
bicuspid or cuspid teeth. The floor of the sinus forms the base of the alveolar process.
(So there are vital structures surrounding the sinus)
The sinus opens in the nose in the middle meatus of the nasal cavity, between the
inferior and middle nasal conchae. If any particle entered the sinus, the cilia will move
it medialy to get rid of it in the nose (it moves toword the ostium ( the name of opening
of the sinus in the nose)).We need normal function of cilia because the cilia and mucus
are necessary for the drainage of the sinus, if we have infection or inflammation, this
motion will be abnormal, the debris will accumulate in the sinus & obstruction will
occur (blockage of the sinus),( Any disease that affect the sinus can cause sinus
congestion.

The sinus diseases can be of: 1) Odontogenic origin 2)Non-odontogenic origin.

Maxillary sinusitis is very common, mostly due to non-odontogenic origin. *Non-
odontogenic : Inflammatory diseases of the sinus such as infection, allergic reactions
or neoplastic diseases (benign or malignant) cause hyperplasia and hypertrophy of
the mucosa and may cause obstruction of the ostium (inflammation of the lining then
closure of the ostium which is the opening of the sinus) congestion will occur causing
signs and symptoms of sinusitis to appear.

*Odontogenic: Odontogenic sources account for approximately 10% to 12% of all

maxillary sinusitis. Sources of odontogenic infections that involve the maxillary sinus

105 | P a g e
include acute and chronic periapical diseases and periodontal diseases. Infection and
sinusitis may also result from trauma to the dentition or from surgery in the posterior
maxilla, including removal of teeth, alveolectomy, tuberosity reduction, sinus lift
grafting and implant placement, or other procedures that create an area of
communication between the oral cavity and the maxillary sinus. Maxillary sinus
infections of odontogenic origin are more likely to be caused by anaerobic bacteria,
but some can be caused by aerobic bacteria, so when we prescribe antibiotics.
The onset of ACUTE sinusitis is usually described by the patient as a rapidly developing
sense of pressure and fullness in the region of affected sinus. This discomfort increases
in intencity and may be accompanied by erythema and swelling, fever, malaise and bad-
smelling mucopurulent material in nasopharynx

Management of maxillary sinusitis: If you suspect infection, you have to prescribe

antibiotics, but if you suspect allergic reaction, there is no need for antibiotic. The
prescribed antibiotic should be effective against aerobic & anaerobic bacteria, such as
ppenecillin & cephalosporin. **For sinusitis we can give: 1)antihistamin 2) nasal
decongestant (epinephrine), it opens the ostium.

Right after asking the patient of his complaints we should : -tap the lateral wall of the
sinus extraorally over the prominenceof the cheekbones -palpate intraorally over the
region between canine fossa and zygomatic process. The affected sinus may be tender
to such a tapping or palpation. In unilateral disease one sinus may be considerabely
different

CALDWELL approach The goal of sinus surgery is to remove abnormal tissue from
within the sinus cavity and restore normal drainage through the ostium. Traditionally,
this was accomplished with an open approach to the sinus known as the Caldwell-Luc
procedure. You know that the lateral wall of the sinus is the anterior wall of the
maxilla, in this technique, the anterior wall of the sinus is accessed in the area of the
canine fossa. The sinus is opened, and abnormal tissue or foreign bodies are removed.

106 | P a g e
 Oroantral Communications: The most common dental complications of oral surgical
procedures that subsequently involve the maxillary sinus include displacement of
teeth, roots, or instrument fragments into the sinus or the creation of a
communication between the oral cavity and the sinus during surgery of the posterior
maxilla. The management of the oronatal communication depend on the size of the
communication, if it is less than 2mm, you can do nothing, if its 2-6mm, we can do 7
suture, if it is larger, we cam go with bone trimming, flap, finger flap or buccal fat pad.
Prevention :
 Radiographs
 Surgical extraction
 Avoid large forces

Diagnosis
• Examination of extracted tooth
• Examination of the socket
• Mouth rinsing
• Nose blowing test

Sinus precautions
• Avoid nose blowing
• Sneezing
• Sucking on straws
• Smoking

Surgical techniques

• Buccal advancement flap

• Palatal pedicled flap
• Buccal pad of fat
• Membranes
• Tongue flapes
• Bone grafts

What is the difference between the oroantral communication & oroantral fistula? 1)
when I have oronatal communication, (we have sinus epithelium & oral epithelium),

107 | P a g e
normal healing will take place by migration of the sinus epithelium from one side to
meet the sinus epithelium on the other side & the oral epithelium from one side
migrate to meet the oral epithelium on the other side to close the communication,
sometimes healing doesn’t happen this way, the sinus epithelium extend to meet the
oral epithelium leading to oroantral fistula, that can happen when we don’t do any
treatment for the communication.

2)The management: The fistula will not heal with time, but oroantral communication
might heal by itself if it is small in size ( blood clot formation which will separate the
oral & nasal epithelium so each one will migrate to contact the opposite side in a
correct way). The management of fistula: We cut the lining of the it, induce bleeding
to let ach mucosa heal in separate way from the other.

108 | P a g e