Oral and Maxillofacial Surgery, Medicine, and Pathology for the Clinician E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 793

Veröffentlichungsjahr: 2023

Beschreibung

Oral and Maxillofacial Surgery, Medicine, and Pathology for the Clinician Single volume reference bringing together surgery, medicine, and pathology to provide relevant clinical information Oral and Maxillofacial Surgery, Medicine, and Pathology for the Clinician presents key clinical information on oral surgery, medicine, and pathology in a single, easy-to-use resource, covering procedures performed in the dental clinic in a clear but concise manner and putting key details at the clinician's fingertips. Clinical scenarios are clearly described with treatment flow paths, and to enable seamless reader comprehension, charts and algorithms also support the text. The text focuses on essential office-related topics that are not esoteric but rather common in occurrence. The book speaks directly to topics of interest that will add value to the practitioner's practice. Major surgical procedures not commonly performed by practicing oral surgeons are not included. Overall, the text contains important up-to-date information that can be immediately put to use in clinical practice. Oral and Maxillofacial Surgery, Medicine, and Pathology for the Clinician covers sample topics like: * Patient assessment and significance of medical history review, the need for antibiotic prophylaxis (when, where, and how), and review of local anesthesia * Diagnosis, treatment, and prevention of office medical emergencies and stocking in the dental office to deal with emergencies * Basic review of oral mucosal lesions and treatment, review of antibiotic, oral sedation techniques and IV sedation overview, and basic and advanced exodontia * Diagnosis and treatment of common post extraction complications and diagnoses and management of acute and chronic oral pain The full scope of oral surgery is thoroughly covered in this multidisciplinary, current reference, making Oral and Maxillofacial Surgery, Medicine, and Pathology for the Clinician an essential tool for oral and maxillofacial surgeons, general dentists, and dental students looking to build upon their foundations of practical knowledge.

Leseprobe

Table of Contents

Cover

Title Page

Copyright

Contributors

Preface

Part I: Basics

1 Patient Evaluation and Management of Medical Problems in the Oral Surgery Patient

Risk Assessment

Documentation

Management of Patients with Medical Problems

Conclusion

References

2 Risk Reduction Strategies

Methods of Risk Reduction

Faulty Record Keeping

Informed Consent

Conclusion

Reference

3 Preparing the Dental Office for Medical Emergencies: Essentials of an Emergency Kit

Staff

Equipment

Emergency Drug Kit

Summary

References

Part II: Dentoalveolar Surgery

4 Surgical Management of the Impacted Canine

Etiology

Diagnosis

Treatment and Management of the Impacted Canine

Complications

References

5 Crown Lengthening

Biologic Width

Indications for Crown Lengthening [3]

Contraindications for Crown Lengthening [1]

Procedures Carried Out Prior to Crown Lengthening [4]

Bone Sounding [2]

Sequence of Treatment for Crown Lengthening

Classification of Esthetic Crown Lengthening [2]

Postoperative Care [3]

References

Part III: Implantology

6 Bone‐Grafting Techniques and Biomaterials for Alveolar Ridge Augmentation

Bone Graft Materials and Healing Physiology

Xenograft

Ridge Preservation

Guided Bone Regeneration (GBR)

Intraoral Onlay Graft

Ridge Split

Interpositional Bone Graft or “Sandwich Osteotomy”

Distraction Osteogenesis

Postoperative Instructions

Conclusion

Vertical Augmentation Recap (Tables 6.5 and 6.6)

References

7 Maxillary Sinus Augmentation

Introduction

Maxillary Sinus Anatomy

Indications, Contraindications, Limitations

Lateral Window Approach

Transalveolar (Crestal) Approach

Bone‐Grafting Material

Complications

References

8 Technologic, Material, and Procedural Advancements in Dental Implant Surgery

Introduction

Three‐Dimensional Imaging

Computerized Implant Planning Technology

Intraoral Optical Impressions and Integration with CBCT, CAD/CAM, and Stereolithography

Surgical Drilling Guide Integration and Fabrication

Guided Navigation in Osteotomy Preparation and Implant Placement

Membranes for Bone Grafting

BMP, PRGF, and PRP

Implant‐Supported, Full‐Arch, Fixed Prostheses with Immediate Loading and “All‐on‐Four”

Zygomatic Implants

Lasers

Conclusion

References

Part IV: Trauma

9 Diagnosis and Management of Dentoalveolar Trauma

Introduction

Evaluation

History

Physical Examination

Radiographic Studies

Diagnosis and Management of Dentoalveolar Injuries

Injuries to the Dental Hard Tissue and Pulp

Injuries to the Periodontal Tissues

Dentoalveolar Injuries in the Primary Dentition

Injuries to the Gingiva or Oral Mucosa

Injuries to Supporting Bone

Follow‐Up

Conclusion

References

Part V: Pathology

10 Biopsy Technique: When, Where, and How?

Introduction

Patient Evaluation: Health History, Medications

Lesion History

Clinical Examination

Indications for Biopsies

Precancerous Lesion: “Potentially Malignant Disorders”

Biopsy Techniques

Adjunctive Techniques

References

11 Diagnosis and Management of Recurrent Lesions of the Oral Mucosa

Introduction

Aphthous Lesions and Recurrent Aphthous Stomatitis

Herpetic Lesions

Candidiasis

Lichen Planus

Pemphigus Vulgaris

Erythema Multiforme

Fixed Drug Eruptions

References

12 Benign Pediatric Pathology: Diagnosis and Management

Introduction

Odontogenic Cysts

Non‐dontogenic Cysts

Soft Tissue Lesions

Salivary Gland Lesions

References

13 Diagnosis and Management of Salivary Gland Pathology

Introduction

Obstructive Salivary Gland Disorders

Viral Diseases

Autoimmune Diseases

Salivary Gland Tumors

Conclusion

References

14 Odontogenic Cysts and Odontogenic Tumors

Introduction

Basic Embryology

Odontogenic Cysts

Odontogenic Tumors

References

15 Osteomyelitis of the Jaw

Classification

Demographic Findings

Clinical Presentation

Laboratory Analysis

Radiologic Evaluation

Microbiology

Histologic Findings

Treatment

Case Presentations

References

16 Obstructive Sleep Apnea

Introduction

Etiology

Symptoms

Pathophysiology and Related Health Issues

Diagnosis and Classification

Treatment

Conclusion

References

17 Temporomandibular Disorders: A Clinician's Guide for Nonsurgical and Surgical Interventions

Introduction

Classification and Diagnostic Evaluation

Diagnostic Evaluation

Physical Exam

Nonsurgical Treatment Approaches

Surgical Approaches

Case Presentation

Conclusion

References

18 Postoperative Complications in Oral Surgery

Complications Arising During the Procedure

Complications after Oral Surgery

References

19 Odontogenic Infections: Anatomy, Etiology, and Treatment

Introduction

Definition

Microbiology

Clinical Presentation

Clinical Work‐Up

Pain Control

Treatment Techniques

Pericoronitis

Antibiotic Therapy

References

Part VI: Pain Control

20 Approaches to the Management of Facial Pain

Introduction

Epidemiology

Neurophysiology of Orofacial Pain

Diagnostic Approach to Facial Pain Patients

Grouping of Oral Facial Pain

Topical Medications for Orofacial Pain

Sympathomimetic Agents

NMDA‐Blocking Agents

Botulinum A Toxin

Surgical Treatment Strategies for OFP

Summary and Future Directions

References

21 Local Anesthesia: Agents and Techniques

Local Anesthetics

Nerve Block Techniques

Auxilliary/Supplemental Techniques

Reversal of Local Anesthesia

References

22 Nitrous Oxide

History

Properties

Use and Administration

Risks and Concerns

Contraindications

Interactions with Other Sedatives

Delivery

Safety Mechanisms

Monitoring

Regulation

References

Part VII: Oral Medicine

23 Antibiotic Prophylaxis in Oral and Maxillofacial Surgery: Recent Trends in Therapeutic Applications

Introduction

Rationale for Antibiotic Prophylaxis

The Problem with Biofilms

Infective Endocarditis

Prosthetic Joint Replacements

Immunologically Compromised Patients

Third Molars/Extractions

Orthognathic Surgery

Cleft lip and palate

Dental Implants

Sinus Lift Bone Grafting

Trauma

Conclusion

References

24 Management of Patients on Anticoagulation

Introduction

Vitamin K Antagonists

Heparins

Direct Thrombin Inhibitors, Direct Xa Inhibitors

Antiplatelet Agents

Nonsteroidal Antiinflammatory Drugs

Local Hemostatic Measures

Conclusion

References

25 Burning Mouth Syndrome

Introduction

Epidemiology

Etiology and Risk Factors

Primary and Secondary Burning Mouth Syndrome

Clinical Presentation

Diagnosis

Treatment

Conclusion

References

Index

End User License Agreement

List of Tables

Chapter 1

Table 1.1 Classification of hypertension.

Table 1.2 Classification of angina pectoris.

Table 1.3 Symptomatic classification of angina pectoris.

Table 1.5 Oral antiglycemic medications.

Table 1.6 Risks with poorly controlled thyroid disease.

Table 1.7 Steroid recommendations for dental procedures.

Table 1.8 Guidelines for selection of antibiotics in patients with liver dis...

Table 1.9 Drug use in patients with kidney disease (creatinine clearance <50...

Table 1.10 Common drugs used in dentistry.

Chapter 5

Table 5.1 Treatment options for crown‐lengthening procedures.

Table 5.2 Classification system for esthetic crown lengthening.

Chapter 6

Table 6.1 Growth factors [2, 5, 17, 30].

Table 6.2 Membranes commercially available for GBR dental application.

Table 6.3 The spectrum of alveolar distraction systems.

Table 6.4 Preventive measures and management of common complications in alve...

Table 6.5 Summary of horizontal and vertical augmentation [7].

Table 6.6 Summary of horizontal and vertical augmentation. overall mean weig...

Chapter 7

Table 7.1 Grading of maxillary alveolar bone and possible need for sinus lif...

Table 7.2 Valassis and fugazzotto classification of membrane tears.

Chapter 10

Table 10.1 Common systemic diseases and their clinical oral manifestations....

Table 10.2 Head and neck examination sequence.

Chapter 11

Table 11.1 Systemic conditions that would commonly present with oral recurre...

Table 11.2 Topical medications for recurrent aphthous ulcers.

Table 11.3 Medications for recurrent herpes labialis.

Table 11.4 Topical medications for oral candidiasis.

Table 11.5a Medications used for lichen planus – first line of treatment.

Table 11.5b Medications used for lichen planus – second line of treatment.

Chapter 12

Table 12.1 Odontoma.

Table 12.2 Classification of giant cell lesions.

Table 12.3 Cherubism classification.

Table 12.4 Hemangioma life cycle.

Chapter 16

Table 16.1 Staging of Patients for UPPP.

Chapter 17

Table 17.1 Disorders of TMD.

Table 17.2 Comparison of agents for intraarticular TMJ treatment.

Chapter 18

Table 18.1 Antibiotics commonly used for oral infections.

Table 18.2 Local Hemostatic Agents for Oral Bleeding.

Chapter 19

Table 19.1 Stages of an odontogenic infection.

Table 19.2 Most Common pathogens identified in orofacial infections.

Table 19.3 Clinical presentation of odontogenic infections by location.

Table 19.4 Signs and Symptoms of Ludwig Angina.

Table 19.5 Common Orally Administered Antibiotics for Odontogenic Infections...

Table 19.6 Antibiotic regimens for odontogenic infections.

Chapter 20

Table 20.1 Differential diagnosis of orofacial pain.

Table 20.2 Typical clinical presentation of patients with orofacial pain.

Table 20.3 Pharmacologic agents by location/etiology of drug action.

Table 20.4 Pharmacologic agents for neuropathic pain (episodic: trigeminal n...

Table 20.5 Complications and contraindications for injection therapy.

Chapter 21

Table 21.1 Chemical Structures of Commonly Used Local Anesthetics.

Table 21.2 Common Local Anesthetics.

Chapter 23

Table 23.1 Research Evidence Levels.

Table 23.2 Prophylactic Antibiotic Principles.

Table 23.3 Recommended Dosages for Common Prophylactic Antibiotic Dosages, H...

Table 23.4 Regimens for Dental Procedure Prophylaxis.

Table 23.5 Prophylactic Antimicrobial Agents for Patients Undergoing Hematop...

Table 23.6 Study Outcomes and Conclusions – Third Molars and Extractions.

Table 23.7 Current Antibiotic Prophylaxis Recommendations in Orthognathic Su...

Table 23.8 Cleft lip and palate repair and antibiotic prophylaxis.

Table 23.9 Current Recommendations for Implant and Bone Grafting Prophylaxis...

Table 23.10 The Role of Postoperative Prophylactic Antibiotics in the Treatm...

Chapter 24

Table 24.1 Summary of anticoagulant recommendations.

Table 24.2 Summary of local hemostatic agents.

Chapter 25

Table 25.1 Epidemiologic studies of burning mouth syndrome: US reports.

Table 25.2 Etiologic factors of burning mouth syndrome.

Table 25.3 Inclusion symptom criteria for burning mouth syndrome.

Table 25.4 Chairside, laboratory, and imaging tests in BMS.

Table 25.5 Possible causes of secondary burning mouth syndrome and managemen...

Table 25.6 Drugs used for treating burning mouth syndrome.

Table 25.7 Suggested regimen for management of burning mouth syndrome.

List of Illustrations

Chapter 1

Figure 1.1 After determining the ASA classification, follow the algorithm to...

Chapter 3

Figure 3.1 (a, b) Oropharyngeal airway and Magill forceps.

Figure 3.2 Automated external defibrillator (Defibtech LLC).

Figure 3.3 D5 1/2NS IV fluid with tourniquets, alcohol gauze, syringes, and ...

Chapter 4

Figure 4.1 Impacted canines can be prominent when smiling.

Figure 4.2 Impacted canine associated with pathology (dentigerous cyst).

Figure 4.3 Impacted canine palatal bulge.

Figure 4.4 Open passive eruption.

Figure 4.5 Closed guided eruption.

Figure 4.6 Mandibular impaction.

Chapter 5

Figure 5.1 Schematic drawing of the structures comprising the periodontium a...

Figure 5.2 Bone sounding.

Figure 5.3 Gingivectomy for crown lengthening of a type 1 case.

Figure 5.4 Stage 2 of type II case with provisional restorations serving as ...

Figure 5.5 Stage 2 of type III case with gingivectomy being performed 4–6 we...

Chapter 6

Figure 6.1 Implant wall classification. Tooth socket wall defect. Missing wa...

Figure 6.2 Decision tree selection of treatment strategy. Proper management ...

Figure 6.3 A #15 blade is used to separate the soft tissue from the tooth.

Figure 6.4 Atraumatic extraction using forceps.

Figure 6.5 Removal of all granulation tissue with a curette.

Figure 6.6 Apply bone graft material into the socket.

Figure 6.7 Closure performed with a figure‐of‐eight suture.

Figure 6.8 Intraoral bone harvest sites.

Figure 6.9 X‐ray shows available cancellous bone in the maxillary tuberosity...

Figure 6.10 Tuberosity harvest technique using a trephine bur.

Figure 6.11 Bone collected with a trephine bur.

Figure 6.12 Bone scraper used to collect cortical bone.

Figure 6.13 Bone‐collecting suction with internal suction trap.

Figure 6.14 Suction trap with bone collected.

Figure 6.15 Buccal wall is decorticated to allow increased blood supply to t...

Figure 6.16 Allogeneic bone is placed on the buccal defect.

Figure 6.17 A nonabsorbable titanium‐reinforced PTFE is placed with fixation...

Figure 6.18 Primary closure was possible and obtained.

Figure 6.19 Particulate material: horizontal/vertical augmentation gains....

Figure 6.20 Particulate materials: barrier material – gain and complication ...

Figure 6.21 Saddle deformity with inferior stop. The buccal defect is shown ...

Figure 6.22 A subperiosteal dissection is performed to create a “tunnel” by ...

Figure 6.23 Bone graft material is inserted between the absorbable collagen ...

Figure 6.24 Closure is performed with simple interrupted chromic gut suture....

Figure 6.25 Superior view of the lateral ramus osteotomy outline. Note cuts ...

Figure 6.26 Block grafts are each secured with two fixation screws to preven...

Figure 6.27 Hemostatic agent (i.e. bone wax) can be used to aid hemostasis....

Figure 6.28 Surgical site is closed with chromic gut sutures.

Figure 6.29 Osteotomies to outline the harvest are created with a small roun...

Figure 6.30 Allogeneic block graft.

Figure 6.31 A chisel is used to gently outfracture the bony segment.

Figure 6.32 Bone graft material is placed into the ridge split site.

Figure 6.33 Primary closure is achieved.

Figure 6.34 Sandwich osteotomy with mesial, distal, and inferior cuts. Prese...

Figure 6.35 The size of the autogenous bone harvest should be slightly large...

Figure 6.36 Autogenous bone placed between the previously prepared osteotomi...

Figure 6.37 Additional allogeneic bone was added to the graft and secured wi...

Figure 6.38 Primary closure achieved at the vestibular incision site.

Chapter 7

Figure 7.1 Lateral window approach.

Figure 7.2 Crestal approach for sinus grafting (part 1).

Figure 7.3 Crestal approach for sinus grafting (part 2).

Chapter 8

Figure 8.1 CBCT image, with the arrow indicating the position of the inferio...

Figure 8.2 Virtual implant treatment work‐up with Simplant, allowing for vis...

Figure 8.3 A static surgical pilot drilling guide with metal drilling insert...

Figure 8.4 Guided navigation dental implant surgery. The array attached to t...

Figure 8.5 Sinus augmentation surgery, with reflection of the sinus membrane...

Figure 8.6 Use of PRP in alveolar ridge augmentation.

Figures 8.7 Identification and surgical access of the anterior maxillary sin...

Figures 8.8 Exploration of the anterior maxillary sinus wall. A small perfor...

Figure 8.9 Establishment of a lateral maxillary sinus window in preparation ...

Figure 8.10 Zygomatic implant osteotomy preparation with retraction of the s...

Figure 8.11 Zygomatic implant placement.

Figure 8.12 The zygomatic implant in its final position, via the lateral max...

Figure 8.13 Zygomatic implant placement techniques: intrasinus (a), in the w...

Chapter 9

Figure 9.1 Crown fracture of the central incisor.

Figure 9.2 Lateral luxation of permanent central incisors.

Figure 9.3 Extrusion of primary central incisors with associated gingival co...

Figure 9.4 Luxation of exfoliating primary central incisors.

Figure 9.5 Avulsion of primary central and lateral incisors.

Figure 9.6 Flexible splint fabricated with acid‐etched resin and stainless s...

Chapter 10

Figure 10.1 Decision tree for treatment of oral lesions.

Figure 10.2 (a) Anterior and posterior triangles of the neck. The landmarks ...

Figure 10.3 (a) Well‐circumscribed radiolucency; dentigerous cyst. (b) Cysti...

Figure 10.4 (a) Homogenous leukoplakia. (b) Nonhomogenous leukoplakia.

Figure 10.5 (a) Speckled leukoplakia. (b) Erythroleukoplakia.

Figure 10.6 Proliferative verrucous leukoplakia. Biopsy of red lesion on the...

Figure 10.7 (a) Severe dysplasia. (b) Squamous cell carcinoma. These photos ...

Figure 10.8 (a, b) Clinical examples of erythroplakia.

Figure 10.9 Hard/soft tissue biopsy armamentarium.

Figure 10.10 Chalazion clamp. A chalazion clamp is an excellent tool for lip...

Figure 10.11 Lugol's iodine is applied to a suspicious lesion of the nonkera...

Figure 10.12 (a) Lesion of the right buccal mucosa prior to application of t...

Chapter 12

Figure 12.1 Periapical cyst. Panoramic radiograph demonstrating a 3.5 cm uni...

Figure 12.2 Compound odontoma. (a) Seven‐year‐old boy with a lesion on the r...

Figure 12.3 Unicystic ameloblastoma. (a) Frontal photograph of a 13‐year‐old...

Figure 12.4 Fibrous dysplasia. (a) A 16‐year‐old female with a slow‐growing ...

Figure 12.5 Pyogenic granuloma. Intraoral view of 2.5 × 1 cm, erythematous, ...

Figure 12.6 Hemangioma. (a) Frontal photograph of an 8‐month‐old boy with he...

Figure 12.7 Intraoral view of a ranula in the left floor of the mouth.

Chapter 13

Figure 13.1 Axial CT of distal salivary gland stones.

Chapter 14

Figure 14.1 Bell stage in tooth development.

Figure 14.2 Radicular cyst.

Figure 14.3 Histopathologic features of a residual cyst and a radicular cyst...

Figure 14.4 Dentigerous cyst.

Figure 14.5 The cyst lining of a dentigerous cyst showing nonkeratinizing sq...

Figure 14.6 Odontogenic keratocyst showing multilocular pattern.

Figure 14.7 The histologic criteria of the odontogenic keratocyst consisting...

Figure 14.8 Odontogenic keratocyst. Below the epithelial lining is a connect...

Figure 14.9 Lateral periodontal cysts.

Figure 14.10 Histopathologic features consist of the lateral periodontal cys...

Figure 14.11 CT showing a calcifying odontogenic cyst in the anterior mandib...

Figure 14.12 Histologic features of the calcifying odontogenic cyst showing ...

Figure 14.13 Orthokeratinized odontogenic cyst in the mandibular molar regio...

Figure 14.14 Orthokeratinized odontogenic cyst showing a thin epithelial lin...

Figure 14.15 Ameloblastoma of posterior mandible with root resorption.

Figure 14.16 Follicular variant of ameloblastoma with epithelial islands.

Figure 14.17 Calcifying epithelial odontogenic tumor with scattered radiopac...

Figure 14.18 CEOT with polyhedral epithelial cells and a well‐defined border...

Figure 14.19 CEOT containing cells with calcified material, referred to as L...

Figure 14.20 Radiograph of adenomatoid odontogenic tumor with a well‐circums...

Figure 14.21 (a, b) Histologically, the adenomatoid odontogenic tumor is wel...

Figure 14.22 Squamous odontogenic tumor.

Figure 14.23 Odontogenic fibroma.

Figure 14.24 Cementoblastoma.

Figure 14.25 Odontogenic myxomas consisting of stellate to spindle‐shaped ce...

Figure 14.26 Compound odontoma.

Figure 14.27 Complex odontoma.

Chapter 15

Figure 15.1 Exposed necrotic nonhealing bone of the left mandible.

Figure 15.2 Necrotic bone.

Figure 15.3 Patterns of conventional imaging features. (a) Lytic. (b) Mixed....

Figure 15.4 Patterns based on the change of signal intensity of the bone mar...

Figure 15.5 Right mandibular osteomyelitis on 99mTc radionuclide bone scan (...

Figure 15.6 (a) Axial contrast‐enhanced CT image demonstrates marked left ma...

Figure 15.7 15 Photomicrograph showing chronically inflamed fibrous connecti...

Figure 15.8 Preoperative view of the right maxilla.

Figure 15.9 Debridement of the right maxilla.

Figure 15.10 Completion of debridement of the right maxilla to healthy bleed...

Figure 15.11 Right maxilla, 1 week postoperative.

Figure 15.12 Postoperative sagittal view CT scan.

Figure 15.13 Preoperative sagittal view CT scan of the left mandible showing...

Figures 15.14 (a) Ostectomy of the necrotic portion of the mandible. (b) Nec...

Figure 15.15 Specimens of necrotic bone removed during sequestrectomy.

Figure 15.16 Mandible, 1 week postoperative.

Figure 15.17 Postoperative sagittal view CT scan.

Chapter 16

Figure 16.1 Uvulopalatopharyngoplasty (UPPP) preoperatively and postoperativ...

Figure 16.2 Area of chin with genioglossus muscle to be advanced.

Figure 16.3 (a) Presurgical image of TMJ ankyloses and micronagthic mandible...

Chapter 17

Figure 17.1 Lateral view of musculoskeletal structures of the temporomandibu...

Figure 17.2 Sagittal medial view of the musculoskeletal apparatus.

Figure 17.3 Lucia jig.

Figure 17.4 (a) Mandibular splint with ideal occlusal contact design. (b) Ma...

Figure 17.5 (a) Resculpting (enamoplasty) of teeth to eliminate interference...

Figure 17.6 Typical orthodontic stabilization of interarch tooth contacts an...

Figure 17.7 (a) Anterior guidance, vertical dimension and BSS occlusal conta...

Figure 17.8 Sagittal view of arthroscopic instrumentation within the left TM...

Figure 17.9 Arthroscopic view of the left temporomandibular joint superior j...

Figure 17.10 Arthroscopic view of triangulating instrument removing adhesion...

Figure 17.11 Modified condylotomy procedure for the temporomandibular joint....

Figure 17.12 Preauricular approach to the right temporomandibular joint.

Figure 17.13 (a) Chronic dislocated mandibular condyle resulting in an open ...

Figure 17.14 CBCT sagittal view showing bony ankylosis of left TMJ.

Figure 17.15 CBCT 3D view of bony ankylosis of left TMJ.

Figure 17.16 Stereolithic models. (Left) The surgeon‐proposed osteotomy cuts...

Figure 17.17 Final prosthesis in place. (Left) Ramus/condyle as seen through...

Figure 17.18 Panoramic view of total joint prosthesis in place.

Chapter 18

Figure 18.1 Dental panoramic radiograph showing four third molars marked wit...

Figure 18.2 Periapical radiograph pointing toward distal root of lower first...

Figure 18.3 Dental panoramic radiograph showing third molar displaced into r...

Figure 18.4 Clinical picture of oroantral communication that will require re...

Figure 18.5 Radiograph showing close proximity of third molar roots to the i...

Figure 18.6 Dental panoramic radiograph showing dental implant at site of fi...

Figure 18.7 Delayed healing of extraction socket with exposed bone.

Figure 18.8 Dry socket paste.

Figure 18.9 Fracture of left tuberosity with palatal tissue tear.

Figure 18.10 Fracture of right angle of the mandible associated with extract...

Chapter 19

Figure 19.1 Potential extension of odontogenic infections into deep fascial ...

Figure 19.2 Panoramic radiograph of maxillofacial area.

Figure 19.3 Periapical radiographs provide help in locating periapical patho...

Figure 19.4 Soft tissue axial view of submandibular abscess.

Figure 19.5 CT soft tissue coronal view of lateral pharyngeal, masticator, a...

Figure 19.6 Aspiration of purulence from right masticator space.

Figure 19.7 Abscess in vestibule upper anterior.

Figure 19.8 Palatal abscess.

Figure 19.9 (a) Depiction of submandibular abscess.(b) Sagittal CT view ...

Figure 19.10 (a) Submandibular abscess right side. (b) Drains in place.

Figure 19.11 Submental abscess.

Figure 19.12 Sublingual abscess.

Figure 19.13 (a) Clinical view of buccal space abscess. (b) Schematic of buc...

Figure 19.14 (a) Canine space abscess. (b) Vascular pathways for spread to c...

Figure 19.15 Anatomical drawing of masticator space.

Figure 19.16 (a) Masticator space abscess. (b) CT of masticator space absces...

Figure 19.17 Ludwig angina. Note bilateral submandibular and submental swell...

Figure 19.18 (a) A simple pericoronitis.(b) Severe pericoronitis. Opercu...

Chapter 20

Figure 20.1 Sagittal view of brain depicting the trigeminal nerve pathway an...

Figure 20.2 A diagrammatic approach for a supratrochlear nerve injection.

Figure 20.3 An extraoral approach for an infraorbital injection.

Figure 20.4 A diagrammatic approach for an occipital nerve block.

Figure 20.5 A diagrammatic approach for an auricular temporal nerve block.

Chapter 21

Figure 21.1 (a) Maxillary nerve showing alveolar nerves and infra‐orbital ne...

Figure 21.2 Technique for blocking the posterior superior alveolar nerve clo...

Figure 21.3 Pterygomandibular space.

Figure 21.4 Halstead technique method 1.

Figure 21.5 Halstead technique method 2.

Figure 21.6 Akinosi technique.

Figure 21.7 Gow‐Gates technique.

Figure 21.8 Broken needle while performing inferior alveolar nerve block.

Figure 21.9 (a) NumBee from Novoject. The Numbee device has the ability to m...

Figure 21.10 Numbee's plastic blade in the gingival sulcus for proper delive...

Figure 21.11 The HurriCaine solution of 20% benzocaine as an anesthetic liqu...

Figure 21.12 Cetacaine contains 14% benzocaine, 2% butamen, and 2% tetracain...

Figure 21.13 Oraqix contains 2.5% lidocaine and 2.5% prilocaine. It comes wi...

Figure 21.14 (a) Perforator for penetrating the buccal cortical plate. The i...

Figure 21.15 Kovanaze (tetracaine HCL and oxymetazoline HCL). A nasally admi...

Figure 21.16 Phentolamine mesylate (OraVerse) is used to reverse prolonged a...

Chapter 25

Figure 25.1 Approach to the diagnosis of burning mouth syndrome.

Guide

Cover

Table of Contents

Title Page

Copyright

Contributors

Preface

Begin Reading

Index

End User License Agreement

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Oral and Maxillofacial Surgery, Medicine, and Pathology for the Clinician

Edited by

Harry Dym, DDSChairman, Department of Dentistry and Oral and Maxillofacial SurgeryBrooklyn Hospital CenterBrooklyn, NY, USA

Clinical Professor, Oral and Maxillofacial SurgeryColumbia University College of Dental MedicineNew York, USA

Leslie R. Halpern, DDS, MD, PHD, MPH, FACS, FICDProfessor and Section Chief of Oral and Maxillofacial SurgeryNew York Medical College/NYCHHCNew York, USA

Orrett E. Ogle, DDSFormer Chief and Residency Program Director Oral and Maxillofacial SurgeryWoodhull Hospital CenterBrooklyn, NY, USA

Former Associate Clinical Professor of Oral SurgeryColumbia University College of Dental MedicineNew York, USA

Lecturer, Mona Dental ProgramFaculty of Medicine, University of the West IndiesKingston, Jamaica

Copyright © 2023 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.

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Library of Congress Cataloging‐in‐Publication Data

Names: Dym, Harry, editor. | Halpern, Leslie R., editor. | Ogle, Orrett E., editor.Title: Oral and maxillofacial surgery, medicine, and pathology for the clinician / edited by Harry Dym, Leslie R. Halpern, Orrett E. Ogle.Description: Hoboken, NJ : Wiley‐Blackwell, 2023. | Includes bibliographical references and index.Identifiers: LCCN 2023000304 (print) | LCCN 2023000305 (ebook) | ISBN 9781119361497 (hardback) | ISBN 9781119362555 (adobe pdf) | ISBN 9781119362562 (epub)Subjects: MESH: Oral Surgical Procedures | Dentistry, OperativeClassification: LCC RK501 (print) | LCC RK501 (ebook) | NLM WU 600 | DDC 617.6/05—dc23/eng/20230328LC record available at https://lccn.loc.gov/2023000304LC ebook record available at https://lccn.loc.gov/2023000305

Cover Design: WileyCover Image: Courtesy of Harry Dym

Contributors

Shelly Abramowicz, DMD, MPH, FACS

Section Chief, Pediatric Oral and Maxillofacial Surgery

Children’s Healthcare of Atlanta

Associate Professor and Director of Research, Oral and Maxillofacial Surgery and Pediatrics

Emory University School of Medicine

Atlanta, GA, USA

David R. Adams, DDS

Associate Professor (Clinical) Oral and Maxillofacial Surgery University of Utah School of Dentistry

Salt Lake City, UT, USA

Nathan Adams, MD, DMD, FACS

Assistant Professor

University of Utah School of Dentistry

Salt Lake City, UT, USA

Dina Amin, DDS, FACS

Clinical Associate Professor

Head and Neck Oncology and Microvascular

Reconstructive Surgery

Department of Oral and Maxillofacial Surgery, School of Dentistry

Texas A & M University, TX, USA

Ricardo Boyce, DDS

Chief and Program Director, General Dentistry and Oral Medicine

The Brooklyn Hospital Center

New York, USA

Steven Caldroney, DDS, MD, FRCS

Private practice in oral and maxillofacial surgery

Framingham, MA, USA

Michael Chan, DDS

Director OMFS

Department of Veterans Affairs, New York Harbor Healthcare System

Senior Attending OMFS

The Brooklyn Hospital Center

New York, USA

Earl Clarkson, DDS

Chairman of Dentistry and Department of Oral and Maxillofacial Surgery

The Brooklyn Hospital Center

New York, USA

Prince Dhillon, DMD, MD

Assistant Attending Oral and Maxillofacial Surgeon

Department of Dentistry

St Barnabas Hospital

Bronx, NY, USA

Jonathan C. Elmore, DDS

Former Resident

Department of Oral and Maxillofacial Surgery

The Brooklyn Hospital Center

New York, USA

Yijiao Fan, DDS

Resident, Oral and Maxillofacial Surgery

The Brooklyn Hospital Center

New York, USA

Michael A. Gladwell, MD, DMD, FACS

Assistant Professor

University of Utah School of Dentistry

Salt Lake City, UT, USA

Tarun Kirpalani, DMD

Oral and Maxillofacial Surgeon Resident

The Brooklyn Hospital Center

New York, USA

Vivian Lim, DDS

Resident

NYC Health + Hospitals/Woodhull

New York, USA

Gary W. Lowder, DDS

Associate Professor (Clinical) TMD and DSM

University of Utah School of Dentistry

Salt Lake City, UT, USA

Pushkar Mehra, BDS, DMD, FACS

Professor and Chair

Department of Oral and Maxillofacial Surgery

Boston University

Boston, MA, USA

Justine S. Moe, DMD, MD

Clinical Assistant Professor, Residency Program Director, Oral and Maxillofacial Surgery, Associate Fellowship Director, Oral/Head and Neck Oncologic and Reconstructive Surgery

University of Michigan

Ann Arbor, MI, USA

Junaid Mundiya, DMD

OMS private practice, Suffolk Oral Surgery Associates

OMS Attending, St Barnabas Hospital

New York, USA

Mihai Radulescu, DMD, FRCD(C), FACS

Assistant Professor in Surgery

OMFS Residency Attending

Geisinger Commonwealth School of Medicine

Scranton, PA, USA

Andrew R. Rahn, DDS

Adjunct Instructor

University of Utah School of Dentistry

Salt Lake City, UT, USA

Arvind Babu Ravendra Santosh, BDS, MDS

Oral and Maxillofacial Pathologist

Senior Lecturer, School of Dentistry

Faculty of Medical Sciences, The University of the West Indies, Mona, Jamaica

Research Fellow, Faculty of Dental Medicine

Department of Oral Medicine

Universitas Airlangga, Surabaya, Indonesia

Feiyi Sun, DDS

Oral and Maxillofacial Surgeon Resident

The Brooklyn Hospital Center

New York, USA

Alexander Toth, DMD

Assistant Oral and Maxillofacial Surgeon

Windsor Dental Center

New Windsor, NY, USA

Bryan Trump, DDS, MS

Associate Professor

University of Utah School of Dentistry

Salt Lake City, UT, USA

Michael Turner, DDS, MD, MSc

Chief, Oral and Maxillofacial Surgery

Mount Sinai Hospital

Program Director

Mount Sinai/Jacobi EinsteinResidency in Oral and Maxillofacial SurgeryAssociate ProfessorIcahn School of Medicine at Mount Sinai

New York, USA

Dwight Williams, DDS, MPH

Assistant Director of Oral and Maxillofacial Surgery

Woodhull Medical Center

Brooklyn, NY, USA

Owner, Optimum Dental Care

Bronx, NY, USA

Lester Woo, DDS

Oral and Maxillofacial Surgeon

Lakewood, WA, USA

Preface

The successful practice of dentistry and oral surgery requires the serious practitioner to engage in a lifelong pursuit of continuous knowledge improvement and education, while failure to do so will ultimately lead to poor patient clinical outcomes along with a diminished sense of satisfaction with their chosen profession. Textbooks such as this are a valuable resource in assisting the dentist and oral surgeon in the pursuit of up‐to‐date clinical information that can assist them in their practice.

I am grateful to all our contributors for their well‐written additions to this text. Despite their busy schedules, they have all provided valuable concise clinical information that should prove meaningful for our readers, including younger dentists as well as established dental and oral surgical practitioners.

I am indebted to my coeditor and colleague Dr Orrett E. Ogle who I have known and worked with for over four decades; he is a trusted friend and mentor. Dr Ogle is also an educator and a gifted clinician who has dedicated his entire professional career to the education of dental and oral and maxillofacial surgery residents.

Dr Leslie R. Halpern, my other coeditor, is also a dear friend who, like Dr Ogle, has spent her entire career involved in the education of dental students in the area of oral and maxillofacial surgery.

I have been privileged to spend my entire career working at the Brooklyn Hospital Center where I am Chairman of the Department of Dentistry and Oral and Maxillofacial Surgery. I am indebted to Ms Lizanne Fontaine, Chairperson of the Brooklyn Hospital Center Board of Trustees, and Mr Gary Terrinoni, President and CEO of the Brooklyn Hospital Center, for their continued support of my department.

Acknowledgment is due to my colleagues Dr Earl Clarkson and Dr Peter Sherman for their ongoing friendship; they have always been available for consultation and support.

Appreciation is due to all my past and present oral and maxillofacial surgical residents as they have been the impetus for my passion in teaching and writing.

Finally, all credit is due to my wife Freidy who has always stood by me these many decades.

Harry Dym

Part IBasics

1Patient Evaluation and Management of Medical Problems in the Oral Surgery Patient

Orrett E. Ogle

When a new patient presents for an oral surgical procedure, it is the responsibility of the surgeon to not only address the patient's dental issues but also to assess the patient's medical status to ensure that he/she can provide surgical services that is medically appropriate for each patient.

The first encounter with a new patient should always involve a medical history as part of the initial evaluation. The most efficient and commonly used method of obtaining the medical history is to use a medical questionnaire. There are several types of questionnaires available for both adults and children but it is best for the dentist to select one that is detailed and comprehensive. The more detailed the health questionnaire, the more information will be obtained and the dentist will be better able to make informed decisions. A detailed medical history will identify potential management problems (physiologic and pharmaceutical) and allow the oral surgeon to formulate a treatment plan in light of the medical status. On the questionnaire, all health questions must be answered. Pertinent positive answers must be addressed and certain negative answers, such as allergies or bleeding history, must be confirmed. The patient should be verbally questioned about the severity and control of their disease. All medications must be noted.

The purpose of taking the medical history is to achieve the following specific goals.

The identification of potential management problems (physiologic and pharmaceutical) and referral for further medical evaluation if necessary.

Assessment of risk potential.

Formulation of a dental/

oral and maxillofacial surgery

(

OMFS

) treatment plan to minimize risk in light of the medical status.

Avoidance of drug interactions.

Once the dentist has obtained the full medical history, a useful step in patient assessment based solely on the history is to assign an American Society of Anesthesiologists (ASA) physical status classification (Box 1.1). This will inform the dental team of the degree of risk the patient's physical ailments constitute and simplify decision making (Figure 1.1).

Risk Assessment

Risk (the probability that an adverse event will occur during dental treatment due to an existing underlying disease) assessment will allow the dentist to make treatment decisions, which will act as a framework to avoid complications during or after the oral surgical intervention and produce an optimal outcome. Some quick risk assessments that should be made from the medical history include the following.

The patient's physiologic reserves:

cardiovascular disease

(

CV

) assessment.

Risks of infection: diabetes mellitus, immune deficiencies.

Current medications: bleeding risks, drug interactions, medications that need to be modified before dental treatment.

Control of chronic diseases: diabetes, hypertension, heart problems, arthritis, other chronic diseases which may cause modification to routine surgical care.

Box 1.1 Modified ASA classification

ASA 1

: Normal healthy patient

ASA 2

: Patient with mild systemic disease. Patient with one systemic disease that is controlled

ASA 3

: Patient with severe systemic disease. Two or more systemic diseases – controlled or uncontrolled. One systemic disease that is not controlled

ASA 4

: Patient with severe systemic disease that is a constant threat to life

ASA 5

: Moribund patient who is not expected to survive without surgical intervention.

ASA 6

: Declared brain‐dead patient whose organs are being removed for donor purposes

Factors not listed in the ASA classification but that must be regarded as an additional risk are extreme age (more than 80 years), increased body mass index, and pregnancy that is close to the estimated date of delivery.

Source:

Modified from [1].

Figure 1.1 After determining the ASA classification, follow the algorithm to decide how the patient should be managed.

Documentation

Medical/dental notes are important to any clinical practice, and the dental practitioner is urged to keep accurate records and adequately document all encounters with patients. Chart notes should be written immediately after seeing each patient and it is good practice to write notes in full sentences that are well organized and include the pertinent data from the encounter. Acceptable medical abbreviations can be used. Good clinical notes will be very useful to the practitioner if ever having to defend a legal claim of clinical negligence. Most importantly, billing documents should not be included anywhere within the clinical notes.

As a part of the documentation, the history form must be dated and signed by the patient or parent/guardian and by the dentist. Failure of the dentist to sign the form may imply that he/she did not review it. Any medical condition that could affect dental treatment or that could be affected by dental treatment should be noted on the record treatment page under a section for past medical history. If the condition is critical (e.g., allergies or heart conditions), the external portion of the chart should be flagged with a sticker for medical alerts or annotated in red ink. Electronic records should also be flagged using the method available in the software system. For individuals with a serious illness, the name and telephone number of the primary care physician should also be obtained. Oral surgery practice will often not have multiple office visits, but if there are serious medical issues, the health history should be updated at every procedural visit (e.g., two‐stage implant surgery or serial extractions) and any changes in the condition should be noted in the record.

The patient's medical record should also list all drugs that the patient is currently taking – both prescribed and over‐the‐counter medications. The oral surgeon should know what each drug (particularly recently introduced ones) is and why it is being used. Medications are a useful indication of conditions for which the patient is being treated. Special attention should be paid to side‐effects associated with the medications, because some side‐effects may affect dental treatment. For example, heart medications, blood pressure drugs, muscle relaxants, and other medications may contribute to bladder control problems. Patients taking these drugs may need to urinate frequently and will not be able to tolerate long appointments. Thiazides, all diuretics, alpha‐blockers, and carbonic anhydrase inhibitors are examples of drugs that will cause frequent urination and urgency [2].

Management of Patients with Medical Problems

Patients will present to the dentist with one or multiple established diagnoses which will be garnered from the medical history. These conditions may alter how dental care is delivered. Medical illness may predispose the patient to acute physiologic decompensation under stress or failure to do well post treatment. Drugs prescribed by a dentist may lead to a drug interaction which may negatively compromise the medical therapy. The job of the clinician is to know how these medical problems will impact dental care or how dental care may affect the medical care. The dentist must therefore be aware of potential outcomes and what precautions must be taken to minimize risks. They must identify issues that should be addressed prior to treatment (e.g., insulin, warfarin, or aspirin use), illnesses that may cause physiologic decompensation during treatment (e.g., angina, seizure disorders, or asthma), and conditions that may affect the posttreatment phase (e.g., diabetes [infection and delayed wound healing] or aspirin use [impaired hemostasis]) [1].

Approximately one in seven Americans is over the age of 65. People 65+ represented 14.5% of the population (46.2 million) in 2014 but are expected to grow to be 21.7% of the population by 2040 [3]. This aging population will produce millions of people with systemic medical conditions that will present for dental care and they will undoubtedly become a numerically significant part of oral surgical practice in the upcoming years. It is imperative, therefore, that the dental practitioner has a full understand of the potential complications that can occur as a consequence of dental treatment of a medically compromised patient and how office management may need to be modified to prevent potential complications. Each systemic disease will affect dental care in its own unique way and there is no generalized protocol that will be applicable in all situations.

This chapter will review some of the more common medical problems that oral surgeons may encounter in their daily practice and present suggested methods for managing individuals with existing disease. There is a long list of diseases (Box 1.2) that can impact dental care, but only the more commonly seen ones can be discussed in this chapter.

Box 1.2 Diseases that may affect dental treatment

Cardiovascular disease: hypertension, coronary artery disease, stroke, heart failure, certain congenital heart diseases

Endocrine disorders: diabetes, parathyroid and thyroid diseases, adrenal gland alterations

Hepatic disease

Renal disease

Pulmonary disease: asthma,

chronic obstructive pulmonary disease

(

COPD

)

Pregnancy

Bleeding disorders: drug induced, congenital

Malignancies: chemotherapy, radiation therapy

Allergies (drugs, latex, others)

Medical conditions associated with geriatric patients

Eating disorders: bulimia, anorexia

Leukemia

Anemia

Blood‐borne pathogens: HIV, hepatitis B and C

Poor nutrition

Obstructive sleep apnea

A starting point for the oral surgeon preparing to treat a patient with a preexisting disease should be the determination of disease status. Is the patient in optimal condition despite the underlying disease; where in the continuum of disease is the patient; and, lastly, is it possible to reverse the disease? A disease that is poorly controlled, deterioration in symptoms or changes in the condition of the patient will warrant medical evaluation and appropriate referral should be made. An individual with moderate disease who has frequent exacerbations should be reevaluated at each visit. Always remember that unless it is a true dental emergency (infection, trauma, severe pain), the surgery can be delayed and the first responsibility of the clinician is to ensure that the patient is in as good a medical condition as possible. For patients whose disease is stabilized, routine office surgery will generally not present a problem.

The management of specific diseases is described below.

Cardiovascular Disease

Cardiovascular (CV) disease is America's leading health problem, and the leading cause of death. Cardiovascular problems that may cause modification of dental treatment plans and will be discussed here include hypertension, ischemic heart disease (coronary artery disease [CAD]), myocardial infarction (MI), strokes, cardiac arrhythmias, and heart failure.

Hypertension

Hypertension is a highly prevalent cardiovascular disease, with a steep increase with aging, that is frequently encountered in the dental setting. Table 1.1 summarizes the classification of hypertension from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [4].

Table 1.1 Classification of hypertension.

Classification

Systolic

Diastolic

Normal

<120

<80

Pre‐hypertension

121–139

81–89

Stage 1

140–159

90–99

Stage 2

160–179

100–109

Stage 3

≥180

≥110

Patients with stage 2 or 3 hypertension are at increased risk because the stress from surgery may further increase blood pressure and trigger a devastating complication such as stroke or cardiac arrest. To date, there are no randomized clinical trials that set a limit on the maximum blood pressure for elective oral surgical treatment. Long years of clinical practice, however, have indicated that oral surgery would only be deferred at blood pressure readings of systolic >160 mmHg or diastolic >100 mmHg [5]. Without obvious target organ disease, there are no grounds for postponing oral surgery, nor is one isolated reading of a high blood pressure immediately before surgery a reason not to do the surgery. Emergency dental procedures could be performed for stage 2 patients but should be avoided in patients with a blood pressure of greater than 180/110 mmHg. These individuals should be referred for immediate medical attention and the dental emergency managed in the hospital if severe, e.g., Ludwig angina. Hypertension is associated with several comorbidities such as ischemic heart disease, cardiac failure, strokes, and kidney disease and, as a result, the surgeon should rule out these diseases or make sure that they are stable before sedation or in‐office general anesthesia.

The most important aspect of treating hypertensive patients is effective control of pain and anxiety. Endogenous catecholamines triggered by pain and stress may increase blood pressure and cardiac output. The dental surgeon should aim at good pain control and decreased anxiety. One of the easiest and most effective methods of controlling anxiety is the use of nitrous oxide, which has excellent sedative, analgesic, and antihypertensive properties, or, preferably, IV sedation with midazolam with or without supplemental nitrous oxide/oxygen. When administering N2O to patients using beta‐blockers, hypotension may occur and the blood pressure should be monitored.

In many patients, local anesthesia (LA) is often the method of pain control and local anesthetics with epinephrine are widely used because they produce longer and more effective anesthesia. Small doses of local vasoconstrictor produce minimal change in blood pressure readings [6, 7]. The maximum recommended dose of epinephrine in a patient with cardiac risk is 0.04 mg, which is equal to what is contained in about two cartridges of LA with 1:100 000 epinephrine, or four cartridges with 1:200 000 epinephrine [8]. If adequate anesthesia is not achieved with the two cartridges containing the vasoconstrictor then the anesthesia may be supplemented with a nonvasoconstrictor‐containing agents such as mepivacaine 3%. Again, IV sedation is always an option.

The question of using local anesthetic with epinephrine in patients taking nonselective beta‐blockers (propranolol and nadolol) has been raised. The small amounts of epinephrine combined with LA used in routine dental procedures are unlikely to be a problem in patients on nonselective beta‐blockers [9]. The use of vasoconstrictors in hypertensive individuals still remains controversial. There are no absolute contraindications to the use of vasoconstrictors in dental local anesthetics, since epinephrine is an endogenously produced neurotransmitter [10]. In addition, the release of endogenous epinephrine from inadequate pain control would be far greater than the injected exogenous epinephrine. The American Heart Association and the American Dental Association issued a joint statement in 1964 stating that “the typical concentrations of vasoconstrictors contained in local anesthetics are not contraindicated with cardiovascular disease so long as preliminary aspiration is practiced, the agent is injected slowly, and the smallest effective dose is administered” [11].

Antihypertensive drugs can have several oral manifestations such as xerostomia, oral lichenoid reactions, and gingival hyperplasia but these expressions will not alter the actual clinical management of the hypertensive patient. These drugs, however, have side‐effects that may be consequential. Angiotensin‐converting enzyme (ACE) inhibitors are associated with cough and loss of taste (ageusia) or taste alteration (dysgeusia). Patients taking enalapril, for example, may have a dry cough and may have to cough frequently. This coughing will be disruptive when it is necessary for the patient to keep their mouth open or blood is in their mouth. Diuretics may cause frequent urination or even urinary incontinence. Patients may have to make more frequent bathroom visits, making them intolerant to long dental procedures. With elderly patients, in rare cases they may need to be excused during the procedure. The antihypertensive medication should not be stopped or altered.

Other groups of patients who are not necessarily hypertensive but whose blood pressure should be monitored are: (i) diabetic patients; (ii) elderly patients in whom orthostatic hypotension is a common problem due to altered blood pressure regulatory mechanisms and autonomic dysfunction; and (iii) pregnant women, because pregnancy may alter the patient's BP values and more than 10% of pregnant women have relevant hypertension [12].

Angina Pectoris

Angina pectoris is chest pain that occurs when an area of the heart muscle is not receiving an adequate oxygen supply. It is the primary symptom of CAD, the most common type of heart disease. Angina attacks which could lead to infarction and cardiac arrest may be precipitated by dental treatment.

The risk in patients with a history of angina is that they may have an attack during dental treatment secondary to stress. The risk increases with increase in classification (Tables 1.2 and 1.3). The most dangerous complication to be concerned about with angina is a heart attack. Totally elective surgical procedures in patients with unstable angina should be delayed until they can be stabilized. Emergencies – infections, severe pain, trauma – should be treated as an inpatient in a hospital setting with monitoring of cardiac status with ECG by an anesthesiologist. Frequently, patients with unstable angina will be given anticoagulants, which will need to be addressed.

Table 1.2 Classification of angina pectoris.

Stable angina

Unstable angina

Chest pain/discomfort that occurs with a predictable, reliable amount of exertion or stress, and when that pattern has been present for more than 4 weeks

It is triggered by activities that increase cardiac demand – physical and emotional exertion or stress

The pain or discomfort is similar to past episodes of angina with similar amounts of exertion and usually resolves in less than 5 minutes

The chest pain usually stops after medication is taken or at rest

Stable angina can become unstable

Chest pain occurring for the first time, or has been happening for less than 2 weeks

If there is a change in the usual pattern of angina that occurs with exertion

Unstable angina can occur without exertion

If the symptoms stop, they usually return in a short period of time

The pain is often more severe and lasts longer than stable angina – more than a few minutes

The pain may not go away with rest or use of angina medication

Table 1.3 Symptomatic classification of angina pectoris.

Class

Description

Class I

Angina only with strenuous exertion

Class II

Angina with moderate exertion

Class III

Angina with mild exertion. Difficulties walking one or two stores or climbing one flight of stairs at normal pace

Class IV

Angina at rest

The angina patient should be scheduled for short appointments, preferably in the morning [13]. Local anesthetic with epinephrine (1:100 000) should be injected slowly after aspiration and when possible nitrous oxide‐oxygen sedation or IV sedation provided. The patient with mild or moderate angina should be advised to bring their nitroglycerin tablets to the scheduled surgical visit in case of an attack during treatment. Persons with a history of frequent attacks, or with attacks often triggered by situational anxiety should be given sublingual nitroglycerin prophylactically 5–10 minutes before injection of LA. Although not absolutely contraindicated, epinephrine should be avoided in this group as the transient tachycardia may stress the myocardium and provoke an attack. Mepivacaine would be a reasonable substitute. Angina may also be avoided by delivery of oxygen via nasal cannula at 3 L/min during the dental procedure.

If the patient develops chest pain during treatment:

loosen tight clothing around the waist to facilitate breathing

administer nitroglycerin (best to use the patient's own nitroglycerin tablets), one tablet sublingually. Positive drug action is hastened by sitting the patient upright in the dental chair and asking them to inhale deeply. Relief should follow within 1–3 minutes and reach a peak at 5 minutes

[14]

if the first tablet does not relieve the pain, wait 5 minutes and administer another tablet. Up to three tablets may be given with 5 minute intervals between each tablet

blood pressure readings should be taken after each tablet since nitroglycerin can lower the blood pressure. If the systolic pressure falls by more than 20–30 mmHG, do not administer another dose. If the chest pain is unresolved, give aspirin and call the local EMS (911) service.

For all angina patients, the dosage of epinephrine should be limited to that contained in two 1.8 mL cartridges of anesthetic containing epinephrine 1:100 000.

Myocardial Infarction

Myocardial infarction (heart attack) is the irreversible death (necrosis) of heart muscle secondary to prolonged lack of oxygen supply (ischemia) [15]. It is unlikely that a dental patient will suffer a MI without having a history of ischemic heart disease. Based on the medical history of heart disease, the dentist should be able to fairly accurately recognize an MI and take appropriate actions. When there is a suspicion of a MI, the oral surgery should attach an ECG machine as soon as possible, and monitor vital signs.

As previously mentioned, the patient's history is critical and sometimes may provide the only clue that the person could be having a MI. Patients with typical acute MI usually present with retrosternal chest pain on the left side that is intense and continuous for 30–60 minutes. The pain often radiates up to the shoulder, down to the left arm, and up to the neck and jaws. They may also complain of lightheadedness, shortness of breath, and nausea.

Physical examination findings may vary but typical clinical findings include:

profuse sweating

increased pulse which may be irregular

blood pressure is initially elevated (because of peripheral arterial vasoconstriction resulting from an adrenergic response to pain, anxiety, and ventricular dysfunction)

[15]

increased respiratory rate

peripheral cyanosis.

Not all patients will experience the same symptoms or experience them to the same degree. However, the more signs and symptoms that are present, the greater the probability that the individual may be having a heart attack. If the patient develops chest pain, administer nitroglycerin and take the blood pressure. If nitroglycerin does not decrease the pain or the pain persist for longer than 15 minutes, then suspect that the patient is having a MI. A MI will not respond to nitroglycerin.

When it is believed that the person is having a MI, have them chew a 325 mg tablet of chewable aspirin. If the chewable form is unavailable, then use regular aspirin. (Aspirin has a bitter taste, thus may be difficult to chew and may cause nausea.) Aspirin will work within 15 minutes to prevent the progression of clots in the coronary arteries and allow oxygen‐rich blood to get to the damaged heart muscle.

MONA is the classic mnemonic for the treatment of an acute MI (morphine, oxygen, nitroglycerin, aspirin). Although the mnemonic is MONA, this does not describe the order in which the drugs are used, it is only a memory guide. Treatment steps are as follows.

Stop dental procedure.

Give sublingual nitroglycerin until it is proven that the chest pain is not angina.

Take vital signs.

Call EMS.

Administer MONA (oxygen, 325 mg aspirin chewed for 30 seconds then swallowed, nitroglycerin and morphine for pain control if necessary). In addition to morphine, nitrous oxide/oxygen via a nasal cannula may be used until EMS arrives if the chest pain is severe and the morphine is not adequately controlling the pain.

Monitor vital signs every 5 minutes.

The practitioner should be prepared to start basic life support (BLS) if the patient goes on to have a cardiac arrest. The use of an AED (automatic external defibrillator) may be necessary since most deaths caused by MI occur early and are attributable to primary ventricular fibrillation (VF)