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Oral & Maxillofacial Surgery in the Dental Office. Gary J. Wayne DMD Diplomate American Board of Oral and Maxillofacial Surgery, Fellow America Assoc. of Oral and Maxillofacial Surgeons, Boynton Oral and Maxillofacial Surgery and Implant Center P.A. Boynton Beach , Florida. Medical History.

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oral maxillofacial surgery in the dental office

Oral & Maxillofacial Surgeryin the Dental Office

Gary J. Wayne DMD

Diplomate American Board of Oral and Maxillofacial Surgery, Fellow America Assoc. of Oral and Maxillofacial Surgeons,

Boynton Oral and Maxillofacial Surgery and Implant Center P.A.

Boynton Beach , Florida

medical history
Medical History

Biographic Data

Chief Complaint

History of the Chief Complaint

Medical History

Review of Systems

risk assessment

Risk Assessment

Overall- Medical

Dental

management of patients with comprimised medical conditions
Management of Patients with Comprimised Medical Conditions

Cardiovascular Problems

Pulmonary Problems

Renal Problems

Hepatic Disorders

Endocrine Disorders

Hematologic Problems

Neurologic Disorders

standard format for recording results of history and physical examinations
Standard format for recording results of history and physical examinations

Biographic Data

Chief Complaint and its history

Past medical history

Social and family medical histories

Review of systems

Physical examination

Laboratory and radiographic imaging/ examinations

baseline health history database
Baseline health history database

Past hospitalizations, operations, traumatic injuries, and serious illnesses

Recent minor illnesses or symptoms

Medications currently or recently in use and allergies (drugs)

Description of health-related habits or addictions,such as ETOH,Tobacco,Illicit drugs and amount and type of daily exercise

Date and result of last medical checkup/visit

common health conditions to inquire about verbally or on a health questionnaire
Common health conditions to inquire about verbally or on a health questionnaire
  • Sexually transmitted disease
  • Renal disease
  • Hypertension
  • Diabetes
  • Steroid use
  • Seizure disorder
  • Implanted prosthesis
  • Allergies (drugs/non drugs)
  • Pregnancy
  • Breast feeding
  • Angina
  • Myocardial Infarct (heart attack)
  • Heart murmurs
  • Endocarditis/Pros. Valves
  • Bleeding Disorders
  • Anticoagulant use
  • Asthma
  • Lung disease
  • Tuberculosis
  • Hepatitis
routine review of head neck and maxillofacial regions
Routine review of head, neck, and maxillofacial regions

Constitutional: Fever, chills, sweats, weight loss, fatigue, malaise, loss of appetite

Head: Headache, dizziness, fainting, insomnia

Ears: Decreased hearing, tinnitus (ringing), pain

Eyes: Blurring, double vision, excessive tearing, dryness, pain

Nose and sinuses: Rhinorrhea, epistaxis, problems breathing through nose, pain, change in sense of smell

TMJ Area: Pain, noise, limited jaw motion

Oral: Dental pain or sensitivity, lip or mucosal sores, problems chewing, problems speaking, bad breath, loose restorations, sore throat, loud snoring

Neck: Difficulty swallowing, change in voice, pain or stiffness

review of cardiovascular and respiratory systems
Review of cardiovascular and respiratory systems
  • Cardiovascular review

Chest discomfort on exertion, when eating, or at rest; palpitations; fainting; ankle edema; shortness of breath (dyspnea) on exertion; dyspnea on assuming supine position (orthopnea or paroxysmal nocturnal dyspnea); postural hypotension; fatique; leg muscle cramping

  • Respiratory review

Dyspnea with exertion, wheezing, coughing, excessive sputum production coughing up blood (hemoptysis)

preoperative physical examination of the oral and maxillofacial surgery patient
Preoperative physical examination of the oral and maxillofacial surgery patient

Inspection

Head and face: General shape, symmetry, hair distribution

Ear: Normal reaction to sounds (otoscopic exam if needed)

Eye: Symmetry, size reactivity of pupil, color of sclera and conjunctiva, movement, test of vision

Nose: Septum, mucosa, pharynx, lips, tonsils

Neck: Size of thyroid, jugular distention

preoperative physical examination of the oral and maxillofacial surgery patient1
Preoperative physical examination of the oral and maxillofacial surgery patient

Palpation

TMJ: Crepitus, tenderness

Paranasal: Pain over sinuses

Oral: Salivary glands, floor of mouth, lips, muscles of mastication

Neck: Thyroid size, lymph nodes

preoperative physical examination of the oral and maxillofacial surgery patient2
Preoperative physical examination of the oral and maxillofacial surgery patient

Percussion

  • Paranasal: Resonance over sinus (difficult to assess)
  • Oral: Teeth
preoperative physical examination of the oral and maxillofacial surgery patient3
Preoperative physical examination of the oral and maxillofacial surgery patient

Auscultation

  • TMJ: Clicks, crepitus
  • Neck: Carotid bruits
brief maxillofacial examination
Brief maxillofacial examination

While interviewing the patient, the dentist should visually examine the patient for general shape and symmetry of head and facial skeleton, eye movement, color of conjunctiva and sclera, and ability to hear. The clinician should listen for speech problems, TMJ sounds, and breathing ability.

brief maxillofacial examination1
Brief maxillofacial examination

Routine examination

TMJ Region

Nose and paranasal region

Mouth

routine examination
Routine examination

TMJ region:

Palpate and auscultate joints

Measure range of motion of jaw and opening pattern

Important: Note abnormalities in chart!

routine examination1
Routine examination

Nose and paranasal region

  • Occlude nares individually to check for patency.
  • Inspect anterior nasal mucosa.
routine examination2
Routine examination

Mouth

  • Take out all removable prostheses
  • Inspect oral cavity for dental, oral, and pharyngeal mucosal lesions; look at tonsils and uvula
  • Hold tongue out of mouth with dry guaze while inspecting lateral borders
  • Palpate tongue, lips, floor of mouth, and salivary glands (check for saliva)
  • Palpate neck for lymph nodes and thyroid size. Inspect jugular veins
american society of anesthesiologists asa classification of physical status
American Society of Anesthesiologists (ASA) classification of physical status

ASA I: A normal healthy patient

ASA II: A patient with mild systemic disease or significant health risk factor

ASA III: A patient with severe systemic disease that is not incapacitating

ASA IV: A patient with severe systemic disease that is a constant threat to life

ASA V: A moribund patient who is not expected to survive without the operation

ASA VI: A declared brain-dead patient whose organs are being removed for donor purposes

general anxiety reduction protocol
General anxiety-reduction protocol

Combining exam with the degree of surgery/dentistry

anxiety reduction protocol
Anxiety-reduction protocol

Before appointment

During appointment

After surgery

before appointment
Before appointment

Hypnotic agent to promote sleep on night before surgery

Sedative agent to decrease anxiety of morning of surgery

Morning appointment and schedule so that reception room time is minimized

during appointment
During appointment

Non-pharmacological means of anxiety control

Pharmacologic means of anxiety control

anxiety control during appointment
Anxiety control during appointment

Non pharmacologic

Frequent verbal reassurances

Distracting Conversation

No surprises (warn patient before doing anything that could cause anxiety)

No unnecessary noise

Surgical instruments out of patient’s sight

Relaxing background music

anxiety control during appointment1
Anxiety control during appointment

Pharmacologic means of anxiety control:

Local anesthetics of sufficient intensity and duration

Nitrous Oxide

Intravenous/other reliable parental anxiolytics

anxiety control after appointment
Anxiety control after appointment
  • Succinct instructions for post operative care
  • Patient information on expected postsurgical sequelae (i.e. swelling or minor oozing of blood)
  • Further reassurance
  • Effective analgesics
  • Patient information on who can be contacted if any problems arise
  • Telephone call to patient at home during evening after surgery to check if any problems exist
management of patients with compromising medical conditions
Management of Patients with Compromising Medical Conditions

Oral Surgery for the Dentist

Gary J. Wayne DMD

Oral & Maxillofacial Surgeon

management of patient with a history of angina pectoris
Management of patient with a history of angina pectoris

Consult patient’s physician

Use anxiety-reduction protocol

Have nitroglycerin tablets or spray readily available. Use nitroglycerin premedication if indicated

Administer supplemental oxygen

Ensure profound local anesthesia before starting surgery

Consider nitrous oxide sedation

Monitor vital signs closely

Limit amount of epinephrine used (.04mg maximum)

Maintain verbal contact with patient throughout procedure to monitor status

management of patient with a history of myocardial infarction
Management of patient with a history of myocardial infarction

Consult patient’s primary care physician

Defer major elective surgery until 6 mos after infarction

Check if patient is using anticoagulants

Use anxiety-reduction protocol

Have nitroglycerin available; use prophylactically if physician advises

Administer supplemental oxygen

Provide profound local anesthesia

Consider nitrous oxide

Monitor vial signs and maintain verbal contact

Limit epinephrine use to .04mg

Consider referral to oral & maxillofacial surgeon

management of patient with congestive heart failure hypertrophic cardiomyopathy
Management of patient with congestive heart failure (hypertrophic cardiomyopathy)

Defer treatment until heart function has been medically improved and physician believes treatment is possible

Use anxiety-reduction protocol

Administer supplemental oxygen

Avoid supine position

Consider referral to oral & maxillofacial surgeon

management of asthmatic patient
Management of asthmatic patient

Defer dental treatment until asthma is well controlled and patient has no signs of a respiratory tract infection

Listen to chest with stethoscope to detect wheezing before major oral surgical procedures or sedation

Use anxiety-reduction protocol, including nitrous oxide, but avoid use of respiratory depressants

In children, consult physician about possible use of preoperative cromolyn sodium (Intal)

If patient is or has been chronically on corticosteroids, prophylax for adrenal insufficiency

Keep a bronchodilator-containing inhaler easily accessible(Proventil)

Avoid use of NSAIDs in susceptible patients

management of patient with copd
Management of patient with COPD
  • Defer treatment until lung function has improved and treatment is possible
  • Listen to chest bilaterally with stethoscope to determine adequacy of breath sounds
  • Use anxiety-reduction protocol, but avoid use of respiratory depressants
  • If patient is on chronic oxygen supplementation, continue at prescribed flow rate. If patient is not on supplemental oxygen therapy, consult physician before administering oxygen
management of patient with copd1
Management of patient with COPD
  • If patient chronically receives cortocosteroid therapy, manage patient as per adrenal insufficiency
  • Avoid placing patient in supine position until confident patient can tolerate it
  • Keep a bronchodilator-containing inhaler readily accessible
  • Closely monitor respiratory and heart rates
  • Schedule afternoon appointments to allow for clearing of secretions
management of patients with renal insufficiency and patients receiving hemodialysis
Management of patients with renal insufficiency and patients receiving hemodialysis
  • Avoid use of drugs that depend on renal metabolism or excretion. Modify the dose if such drugs are necessary
  • Avoid the use of nephrotoxic drugs, such as NSAIDS
  • Defer dental care until day after dialysis has been given
  • Consult physician concerning use of prophylactic antibiotics
  • Monitor blood pressure and heart rate
  • Look for signs of secondary hyperparathyroidism
  • Consider hepatitis B screening before dental treatment. Use hepatitis precautions
management of patient with renal transplant
Management of patient with renal transplant
  • Defer treatment until primary care physician or transplant surgeon clears patient for dental care
  • Avoid use of nephrotoxic drugs
  • Consider use of supplemental corticosteroids
  • Monitor blood pressure
  • Consider hepatitis B screening before dental care. Take hepatitis precautions
  • Watch for presence of cyclosporin A-induced gingival hyperplasia. Emphasize oral hygeine.
  • Consider use of prophylactic antibiotics, particularly for patients on immunosuppressive agents.
management of patients with hepatic insufficiency
Management of patients with hepatic insufficiency
  • Attempt to learn the cause of the liver problem; if the cause is hep B, take usual precautions
  • Avoid drugs requiring hepatic metabolism or excretion; if the use is necessary, modify dose.
  • Screen patient with severe liver disease for bleeding disorders with platelet count, PT/PTT, and Ivy bleeding time.
  • Attempt to avoid situations in which the patient might swallow large amounts of blood
management of hypertensive patient
Management of hypertensive patient

Mild to moderate hypertension (systolic>140; diastolic>90)

  • Recommend that the patient seek the primary care physicians guidance for medical therapy of hypertension
  • Monitor the patient’s blood pressure at each visit and whenever administration of epinephrine-containing local anesthetic supasses .04mg during a single visit
management of hypertensive patient1
Management of hypertensive patient

Mild to moderate hypertension con’t

  • Use anxiety –reduction protocol
  • Avoid rapid posture changes in patients taking drugs that cause vasodilation
  • Avoid administration of sodium-containing intravenous solutions
management of hypertensive patient2
Management of hypertensive patient

Severe hypertension (systolic >200, diastolic >110)

  • Defer elective dental treatment until hypertension is better controlled
  • Consider referral to oral and maxillofacial surgeon for emergency problems
management of patient with diabetes
Management of patient with diabetes

Insulin-dependent diabetes

  • Defer surgery until diabetes is well controlled; consult physician
  • Schedule an early morning appointment; avoid lengthy appointments
  • Use anxiety-reduction protocol, but avoid deep sedation techniques in outpatients
  • Monitor pulse, respiration, and blood pressure before, during, and after surgery
  • Maintain verbal contact with patient during surgery
management of patient with diabetes1
Management of patient with diabetes

Insulin-dependent diabetes con’t

  • If patient must not eat or drink before oral surgery and will have difficulty eating after surgery, instruct patient to not take the usual dose of regular or NPH insulin; start an IV with D5W at 150ml/hr
  • If allowed have the patient eat a normal breakfast before surgery and take the usual dose of regular insulin but only half the dose of NPH insulin
management of patient with diabetes2
Management of patient with diabetes

Insulin–dependent diabetes con’t

  • Advise patients not to resume normal insulin dosage until they are able to return to usual level of caloric intake and activity level
  • Consult physician if any questions concerning modification of the insulin regimen arise
  • Watch for signs of hypoglycemia
  • Treat infections aggressively
management of patient with diabetes3
Management of patient with diabetes

Non-insulin dependent diabetes

  • Defer surgery until diabetes is well controlled
  • Schedule an early morning appointment; avoid lengthy appointments
  • Use anxiety-reduction protocol
  • Monitor pulse, respiration, and blood pressure before, during, and after surgery
  • Maintain verbal contact with the patient during surgery
  • If patient must not eat before and after surgery and will have difficulty eating after surgery, instruct patient to skip any oral hypoglycemic medications that day
management of patient with diabetes4
Management of patient with diabetes

Non-insulin dependent diabetes con’t

  • If patient can eat before and after surgery, instruct him or her to eat a normal breakfast and to take the usual dose of hypoglycemic agent
  • Watch for signs of hypoglycemia
  • Treat infections aggressively
management of patient with adrenal suppression who requires major oral surgery
Management of patient with adrenal suppression who requires major oral surgery

If patient is currently on corticosteroids

  • Use anxiety-reduction protocol
  • Monitor pulse and blood pressure before, during, and after surgery
  • Instruct patient to double usual daily dose on the day before, day of and day after surgery
  • On second postsurgical day, advise the patient to return to usual steroid dose
management of patient with adrenal suppression who requires major oral surgery1
Management of patient with adrenal suppression who requires major oral surgery

If the patient is not currently on steroids, but has received at least 20mg of hydrocortisone (cortisol or equivalent) for more than two weeks within past year

  • Use anxiety-reduction protocol
  • Monitor pulse and blood pressure before, during, and after surgery
  • Instruct patient to take 60mg of hydrocortisone (or equivalent) the day before and morning of surgery, or dentist should administer 60mg of hydrocortisone (or equivalent) intramuscularly or intravenously before complex surgery
  • On first 2 postsurgical days, dose should be dropped to 40mg and dropped to 20mg for 3 days thereafter. Can cease administration of supplemental steroids 6 days after surgery
management of patient with hyperthyroidism
Management of patient with hyperthyroidism
  • Defer surgery until thyroid dysfunction is well controlled
  • Monitor pulse and blood pressure before, during, and after surgery
  • Limit amount of epinephrine used
management of patient with a coagulopathy
Management of patient with a coagulopathy
  • Defer surgery until a hematologist is consulted about the patient’s management
  • Obtain baseline coagulation tests as indicated (PT,PTT, INR, Ivy Bleeding, platelet count) and a hepatitis screen
  • Schedule the patient in a manner that allows surgery soon after any coagulation-correcting measures have been taken (that is, after platelet transfusion, factor replacement, or aminocaproic acid administration)
  • Augment clotting during surgery with the use of topical coagulation-promoting substances, sutures, and well placed pressure packs
  • Monitor the wound for 2 hours to ensure that a good initial clot forms
management of patient with a coagulopathy1
Management of patient with a coagulopathy
  • Instruct the patient in ways to prevent dislodgment of the clot and in what to do should bleeding restart
  • Avoid prescribing NSAIDS
  • Take hepatitis precautions during surgery
management of patient who is therapeutically anticoagulated
Management of patient who is therapeutically anticoagulated

Patients receiving aspirin or other platelet-inhibiting drugs

  • Consult physician to determine the safety of stopping the anticoagulant drug for several days
  • Defer surgery until the platelet-inhibiting drugs have been stopped for 5 days
  • Take extra measures during and after surgery to help promote clot formation and retention
  • Restart drug therapy on the day after surgery if no bleeding is present
management of patient who is therapeutically anticoagulated1
Management of patient who is therapeutically anticoagulated

Patients receiving warfarin (Coumadin)

  • Consult the patient’s physician to determine the safety of allowing the PT to fall to 1.5 times control for a few days
  • Obtain the baseline PT (INR)
  • If the PT is 1 to 1.5 times greater than control, proceed with surgery and use surgical controls
  • If the PT is more than 1.5 times greater than control, stop warfarin therapy 3 days prior (MD approval)
  • Stop warfarin therapy 3 days prior (MD approval)
  • Check PT daily, and proceed with surgery on the day when PT falls to 1.5 times control
  • Take extra measures during and after surgery, to help promote clot formation and retention
  • Restart warfarin on the day of surgery
management of patient with seizure disorder
Management of patient with seizure disorder
  • Defer surgery until the seizures are well controlled
  • Consider having serum levels of antiseizure medications measured if patient compliance is questionable
  • Use anxiety-reduction protocol
  • Avoid hypoglycemia and fatigue
management of pregnant patients
Management of pregnant patients
  • Defer surgery until after delivery if possible
  • Consult the patient’s obstetrician if surgery cannot be delayed
  • Avoid dental radiographs unless information about tooth roots or bone is necessary for proper dental care. If radiographs must be taken, use proper shielding
  • Avoid the use of drugs with teratogenic potential. Use local anesthetics when anesthesia is necessary
  • Avoid keeping the patient is the supine position for long periods, to prevent vena cava compression
  • Allow the patient to take frequent trips to the rest room
dental medications to avoid in pregnant patients
Aspirin and other NSAIDS

Carbamazepine

Chloral hydrate

Chlordiazepoxide

Corticosteroids

Diazepam and other benzodiazepines

Diphenhydramine hydrochloride

Morphine

Nitrous Oxide

Pentozine hydrochloride

Phenobarbital

Promethazine hydrochloride

Propoxyphene

Tetracyclines

Dental medications to avoid in pregnant patients
effect of dental medications in lactating mothers
Effect of dental medications in lactating mothers

No apparent clinical effects in breast feeding infants

  • Acetaminophen
  • Antihistamines
  • Cephalexin
  • Codeine
  • Erythromycin
  • Fluoride
  • Lidocaine
  • Meperidine
  • Oxacillin
  • Pentozine
effect of dental medications in lactating mothers1
Effect of dental medications in lactating mothers

Potentially harmful clinical effects in breast-feeding infants

  • Ampicillin
  • Aspirin
  • Atropine
  • Barbiturates
  • Chloral Hydrate
  • Corticosteroids
  • Diazepam
  • Metronidazole
  • Penicillin
  • Propoxyphene
  • Tetracyclines