Components of Patient Primary Means of Physical SEIZURES

Evaluation Examination  If seizures are well-controlled, dental procedures may be done

1. SUBJECTIVE 1. INSPECTION  Result from:
2. OBJECTIVE 2. PALPATION 1. ETHANOL WITHDRAWAL
3. ASSESSMENT 3. PERCUSSION: teeth & 2. HIGH FEVER
4. PLAN paranasal sinuses 3. HYPOGLYCEMIA
4. AUSCULTATION: click & 4. TRAUMATIC DAMAGE
crepitus of TMJ
Pregnancy
Standard Format for Recording Results of History & Physical Examinations  Create FETAL DAMAGE:
1. Biographic data 1. DENTAL IMAGING
2. Chief complaint 2. DRUG ADMINISTRATION
3. History of CC: date of onset, pain intensity, duration, location,  Acetaminophen: pain medication recommended for pregnant px
description of 1st appearance & noted changes  Management
4. Medical history o Defer treatment until after delivery, if possible
5. Review of systems: may reveal undiagnosed medical conditions o If surgery is deemed necessary before delivery, consult
patient’s obstetrician
ASA I: normal, healthy px o Avoid dental radiographs. If needed, uses proper lead
ASA II: px w/ mild systemic disease shielding
ASA III: px w/ severe systemic disease that is not incapacitating o Avoid drugs with teratogenic potential. Use local
ASA IV: px w/ severe systemic disease that is constant threat to life anesthesia only when necessary.
ASA V: moribund px o Avoid SUPINE position to prevent VENA CAVAL
ASA VI: brain-dead px whose organs are removed for donor purposes COMPRESSION

If px is not ASA I or II, clinician can: SYNCOPAL EPISODE

1. Modify routine tx plans 1. Terminate all dental tx
2. Obtain medical consultation 2. Position px in supine w/ legs raised
3. Refuse to treat px in ambulatory (dental) setting 3. Check breathing
4. Refer px to oral-maxillofacial surgeon
If breathing ABSENT If breathing PRESENT
 Start basic life support  Crush ammonia capsule
Angina Pectoris
 Call medical assistance under nose
 Narrowing/ spasm of coronary arteries
 Consider other causes of  Administer oxygen
 Px feels heavy pressure/ squeezing sensation in SUBTERNAL REGION
syncope  Escort px home
that radiate into LEFT SHOULDER ARM & MANDIBULAR REGION
UNIVERSAL PRECAUTION: basic level of infection control
Myocardial Infarction
 Treat all human blood and certain human body fluids as if they were
 Clot formation blocking blood flow in narrowed arteries
known to be infectious
 Oral surgeries must be performed 6 MONTHS AFTER to avoid
reinfarction
NORMAL FLORA
BACTERIA
Stroke
 Placed on ANTICOAGULANTS & if hypertensive, take BP-LOWERING ORAL CAVITY AEROBIC GRAM (+) ANAEROBIC
Streptococcus spp. Candida spp.
AGENTS
Actinomyces spp.
CHF (Hypertrophic Cardiomyopathy) NASAL CAVITY AEROBIC GRAM (+)
 Myocardium unable to deliver cardiac output Streptococcus spp.
H. influenza (children)
 Symptoms
S. aureus (adults)
o ORTHOPNEA: shortness of breath when in supine
o PAROXYSMAL NOCTURNAL DYSPNEA: shortness of breath
during sleep Viral organisms significant in dentistry
o ANKLE EDEMA 1. HEPATITIS B & C
2. HIV
 MAX DOSAGE OF EPINEPHRINE = 0.04 mg
3. SARS-COV-2 (Severe Acute Respiratory Syndrome Coronavirus 2)
Asthma
Hepatitis B virus (HBV)
 Episodic narrowing of inflamed small airways
 Has the most serious risk of transmission in dental setting
 Avoid NSAIDs
 Spread by direct contact w/ any human secretions
 Dental anxiety: trigger bronchospasms
 Exceptionally resistant to desiccation & chemical disinfectants
(phenols, alcohols, quaternary ammonium compounds)
Renal Failure
 Can be inactivated by halogen-containing disinfectants (iodophor &
 Management
hypochlorite), formaldehyde, ethylene oxide gas, heat sterilization &
o Schedule px AFTER dialysis
irradiation
o Avoid drugs that needs to be metabolized by the kidneys
o Avoid nephrotoxic drugs like NSAIDs
HIV
o Monitor BP & heart rate
 Causative agent of AIDS
TYPE I DM TYPE II DM  Direct contact between virus-laden blood & mucosal surface of
potential host
Childhood Adulthood
Insulin-dependent Non-insulin-dependent
Mycobacterium tuberculosis
Diabetes Mellitus
 The only mycobacterium of significance to dentists
 HYPOGLYCEMIA: most common dental office complication of diabetes
 Transmitted through exhaled aerosols from infected px
mellitus
 Highly resistant to desiccation but sensitive to heat, ethylene oxide, &
 Px w/ poorly controlled diabetes are prone to infection because of
irradiation
ALTERED LEUKOCYTE FUNCTION. Antibiotic prophylaxis is
 Use N95 RESPIRATOR MASKS for AGP (aerosol-generating procedures)
recommended.
 Schedule px EARLY IN THE MORNING
SEPSIS: breakdown of living tissue accompanied by inflammation
MEDICAL ASEPSIS: keep px, staff, objects free of agents that cause infection
HYPERTHYROIDISM HYPOTHYROIDISM
SURGICAL ASEPSIS: prevent microbes from gaining access to surgically created
Grave’s disease Hashimoto’s disease
wounds
Tachycardia (fast heartbeat) Bradycardia (slow heartbeat)
ANTISEPTIC: applied to LIVING TISSUE
Weight loss Weight gain
 Iodophor
Exophthalmos (bulging eyes) Fatigue
 Chlorhexidine
Excessive sweating Dry skin
 Hexachlorophene
 Avoid ATROPINE & EPINEPHRINE – will trigger thyroid storm
DISINFECTANT: applied to INANIMATE OBJECTS
STERILITY: freedom from viable forms of organisms
Hereditary coagulopathies
SANITIZATION: judged safe by public health standards
 Ask for history of epistaxis (nosebleed), easy bruising, hematuria
DECONTAMINATION: not connected w/ public health standards
(blood in urine), spontaneous bleeding
 Monitor wound for 2 HOURS to ensure good clot forms Bacterial endospores: microorganisms most resistant to elimination by physical or
 Coagulation tests chemical means
1. PT (Prothrombin Time)  PHYSICAL: heat, mechanical dislodgement, radiation
2. PTT (Partial Thromboplastin Time)  CHEMICAL: antiseptics, disinfectants, ethylene oxide gas
3. Bleeding time
4. Platelet count Techniques of Instrument Sterilization
 Anticoagulants Sterilization w/ Heat
1. HEPARIN: defer surgery atleast 6 HRS reversed w/  Bacillus stearothermophilus
Protamine o Microorganism extremely resistant to heat
2. ASPIRIN: stopped for 5 DAYS o Used to check effectiveness of sterilization
 Restart drug therapy on the day after surgery  Well-packed sterile instruments can be stored for 6-12 MONTHS
3. WARFARIN: Restart warfarin on the day of surgery
 If PT < 3.0 INR, proceed surgery
 If PT > 3.0 INR, stop 2 DAYS before surgery
 DRY HEAT MOIST HEAT
Antimicrobial effect Oxidizes cell proteins Denatures cell proteins
Time to achieve sterilization LONG SHORT
Complexity and cost LOW HIGH
Tendency to dull or rust LOW HIGH
Availability for office use GOOD GOOD
Advantages ease of use, effectiveness, speed,
unlikelihood of relative availability of
damaging heat- office-proportioned
resistant instruments autoclaving equipment
Disadvantages length of time dulls & rusts
necessary & potential instruments
damage to heat-
sensitive instruments

Sterilization w/ Gas
ETHYLENE OXIDE GAS
 Most commonly used
 Highly flammable | mix w/ CO2 or nitrogen for safer use
 Effective for killing all organisms, including spores at 50℃for 3 hours
 Must be aerated for 8-12 hours at 50℃ to 60℃ or at ambient temp for
4-7 days because it is highly toxic to animal tissues
 ADV: effectivity against porous material, large equipment & materials
sensitive to heat & moisture
 DISADV: need for special equipment, length of sterilization & the
necessary aeration time

Instrument Disinfection
 Chemical disinfection: alternative if instruments cannot w/stand temp
needed for sterilization
o GLUTARALDEHYDE: most common disinfectant used
o Iodophors
o Chlorine compounds
o Formaldehyde
 QUATERNARY AMMONIUM: ineffective against HBV

Surgical Field Maintenance

 MAYO STAND: platform covered w/ 2 sterile towels to hold sterile
instruments needed for surgery

Operatory Disinfection
 Wipe surface w/ hospital-grade disinfectant & cover w/ protective
shields
 0.2% CHLORINE & 2% GLUTARALDEHYDE
o Used to prevent transfer of Hepatitis virus

Surgical Staff Protection

 CLEAN TECHNIQUE: DOES NOT incise tissue
 STERILE TECHNIQUE: skin incisions are MADE
 1% iodine solution (Povidone-Iodine) have the broadest spectrum of
antiseptic action effective against gram (+) & gram (-)

Patient Preparation
 Rinse 0.12% CHLORHEXIDINE GLUCOMATE (Orahex)
 Sterile saline/ water: irrigate surgical field

Sharps Management
 Accidental needle sticks/ scalpel lacerations
o Most common risk for transmission of disease
 Disposed in rigid, well-marked receptacles & turned over to reputable
hazardous waste management company
 SCALPEL  For incising tissue | PEN GRASP
SCALPEL BLADES:
 No. 10 – for large skin incisions
 No. 11 – for small stab incisions & draining abscess
 No. 12 – incision on posterior aspect of teeth
 No. 15 – MOST COMMONLY USED, small blade to make incision
around teeth & soft tissue
No. 9 MOLT PERIOSTEAL ELEVATOR TONGUE RETRACTORS:
1. MOUTH MIRROR: most commonly used during EXO
2. WEIDER TONGUE RETRACTOR: retract medially & anteriorly

 For elevating mucoperiosteum | PRYING MOTION

 Pointed end: used FIRST to reflect dental papillae
 Rounded end: continue elevation | PUSH STROKE
TWO MOST COMMON RETRACTORS USED IN SURGERY:
1. AUSTIN RETRACTOR 2. MINNESOTA RETRACTOR

TISSUE FORCEPS:
1. ADSON FORCEPS (short) 3. COTTON PLIERS
4. ALLIS TISSUE FORCEPS: grasp large tissues during biopsies

2. STILLIES FORCEPS (long)

CURVED HEMOSTAT
 Clamp bleeding vessels
 Remove granulation tissues from tooth sockets after EXO
 Pick up small root tips & other small particles
RONGEUR HIGH-SPEED HANDPIECE
MALLET & CHISEL:
 No. 557 or 703 fissure bur
removal of lingual tori
 No. 8 round bur
 Used to cut cortical bone
 Cause EMPHYSEMA if air is forced
 Most commonly used to remove bone in into soft tissues during oral surgery
dentoalveolar surgery
 Must remove bone in MULTIPLE BITES rather than SURGICAL HANDPIECE
single bite  Used in surgery
1. side-cutting forceps  Does not exhaust air into the
2. side- and end-cutting forceps operative field
(Blumenthal rongeurs)
BONE FILE
 PARALLEL BLADES
 Used for final smoothing of bone | PULL Files have
STROKES
PERIAPICAL CURETTE
 Removing soft tissue from bony cavities
 Remove granulomas/ small cyst from periapical
lesions
SUTURE NEEDLE | 1/2 or 3/8 circle
NEEDLE HOLDER  TRIANGULAR NEEDLES: suture mucoperiosteal flaps
 To place sutures  TAPERED NEEDLES: for delicate tissues (vascular surgery)
 6-inch needle holder is  Grasped by needle holder approx. 2/3 of distance from needle
recommended for tip to prevent NEEDLE BENDING
intraoral procedures  size: smaller no. = larger diameter | 3-0 sutures common
 Beak: CROSS-HATCHED RESORBABLE
 Held w/ thumb & ring NON-RESORBABLE Natural: enzymatic degradation
finger SILK: most common Plain catgut (3-5 days)
 Index finger held along the Nylon Chromic gut (7-10 days)
length of holder to STEADY Vinyl Synthetic: hydrolysis
& DIRECT it Stainless Steel Polyglycolic acid
Polylactic acid (4 wks)
MONOFILAMENT
POLYFILAMENT
DEAN SCISSORS Difficult to handle
Easy to handle & tie
 SERRATED blades to cut sutures No wicking effect
Tend to wick
 Most commonly used scissors in
oral surgery PLAIN CATGUT
SILK
 Iris & Metzenbaum: cut soft tissues CHROMIC GUT
POLYGLYCOLIC ACID
not sutures as they dull easily NYLON
POLYLACTIC ACID
STAINLESS STEEL
FRAZIER SUCTION TIP
 Keep surgical area free
MOLT MOUTH PROP
from blood & saliva for
 Hold mouth open
adequate visualization
 Help avoid stress on
 Small tip to AVOID
TMJ
ASPIRATION of soft
tissue
 ELEVATORS
IRRIGATING SYRINGE  Loosen tooth 1. STRAIGHT TYPE
 Irrigation is important from socket  most commonly used:
DURING & AFTER any  Expand bone small No. 301
surgical procedure to facilitate  Miller & Potts: angled
 Large plastic syringe easy removal from shank; used in
w/ blunt 18-GAUGE of tooth posterior aspects of
needle is used  Handle, shank, mouth
blade
2. TRIANGLE TYPE 3. PICK-TYPE
 Come in pairs  Used to remove roots
 Useful in removing a  CRANE PICK: elevate
remaining broken root broken root
in socket & adjacent  ROOT-TIP PICK: tease
socket is empty small root tips
 Remove remaining
broken root in socket
 CRYER: most common
PERIOTOME EXTRACTION FORCEPS

Remove tooth from alveolar bone by LIFTING rather than
pulling from sockets
 Sever surrounding PDL of tooth for easy removal  Handle: MX = palm under forceps | MN = palm on top forceps
 Blade inserted into PDL space for about 2-3 mm  Hinge
APICALLY around tooth  Beak: placed PARALLEL to long axis of tooth
HINGE OF FORCEPS: American (horizontal) | English (vertical)
MAXILLARY EXTRACTION FORCEPS MANDIBULAR EXTRACTION FORCEPS

beak point UPWARDS (bayonet design) beak point DOWNWARDS

150 151 (MANDIBULAR UNIVERSAL FORCEPS)
MAXILLARY
UNIVERSAL
FORCEPS
For incisors,
canines and
premolars For incisors, canines and premolars
Mandibular Molars w/ FUSED, CONICAL ROOTS
150A 151A

Only for premolars Only for premolars

150S – for PRIMARY TEETH 151S – for PRIMARY TEETH

1 17
For incisors, canines and
For mandibular molars w/ BIFURCATED ROOTS
premolars

53L 53R

Face beak towards px, if pointed blade is on the right side = left forcep
88 (88L or 88R) No.87 (COWHORN FORCEPS)

For severely carious crowns For mandibular molars w/ BIFURCATED ROOTS

210S

for 2nd and 3rd maxillary molars w/ SINGLE, CONICAL ROOTS

65 69

aka ROOT-TIP FORCEPS, remove broken roots Remove root fragments & root tips

LUXATORS ELEVATORS
Facilitate atraumatic tooth EXO
Blade sharp & flat-tipped Less sharp, curved blades
PRYING motion ROTATING motion
BASIC EXTRACTION SET

1. LA syringe, cartridge, needle

2. Aspirating tip
3. No.9 Molt periosteal elevator
4. Periapical curette
5. Sterile 2x2 gauze
6. Curved hemostat
7. Towel clip
8. Cotton pliers
9. Straight elevator (small & large)
10. Weider tongue retractor
Austin retractor
Minnesota retractor

BASIC EXTRACTION SET + SURGICAL EXTRACTION SET

1. Weider tongue retractor

2. Bone rongeur
3. Adson tissue forceps
4. Cryer elevators
5. Needle holder & suture
6. Suture scissors
7. Blade & blade handle
8. Bone file
9. Handpiece & bur
BASIC EXTRACTION SET (MINUS ELEVATORS & FORCEPS) + BIOPSY SET

1. Needle holder & suture

2. Blade & blade handle
3. Suture scissors
4. Metzenbaum scissors
5. Adson tissue forceps
6. Allis tissue forceps
7. Curved hemostat

POSTOPERATIVE TRAY – to irrigate surgical site & remove sutures

1. Suction tip
2. Sterile gauze
3. Irrigation syringe
4. Cotton applicator sticks
5. Dean scissors
6. Cotton pliers