Oral surgery Final

  1. Nitrous oxide levels for Minimal sedation (Anxiolysis) are this % of NO2
    • <50%, response is normal for verbal commands
    • Cognitive function is impaired
    • M.A.C. minimal alveolar concentration, high mac means drug has low potency (NO2 is 104%), so NO2 alone is not enough for profound anesthesia.
    • Insoluble drug Blood-gas partition coefficient 0.46%
    • 99% is eliminated through lungs without being metabolized in the liver.
  2. Nitrous oxide creates this in the middle ear...
    • Moves into space of middle ear by physically replacing nitrogen and creates pressure until equilibrium is achieved.
    • Patients with Otitis media will have pain, rupture in membrane
    • CONTRAINDICATED for NO2 Otitis media.
  3. What does NO2 do to BP in children and adults?
    • Nothing, Vital signs are taken for a reference.
    • Mixture of 20% NO2 and 80% oxygen has analgesic potency of 15mg of morphine.
    • Can help with extreme gag reflex, causes relative amnesia
  4. Incrementing a drug administration to a specific level
    • Titration. Easily accomplished with NO2.
    • Full recuperation and elimination should happen 5 minutes after administration
    • Nausea and vomiting seen in children
  5. What percent is the mean dosage for ideal sedation for patient responsiveness and cooperation
    35% is a mean dose, does not always apply
  6. What are some contraindications for NO2?
    • Claustrophobia
    • Recovering or current drug/alcohol abuse
    • Otitis media or sinus infection (changes in pressure)
    • Pregnancy
    • Upper respiratory tract infection
    • COPD (severe respiratory disease, not asthma, it helps asthma because of relief of stress)
    • Cystic fibrosis
  7. Preparing for Nitrous...
    • Avoid fatty greasy foods, meals with carbs are ok.
    • Patients do not need an escort to go home, rapid diffusion of nitrous oxide is helped by applying oxygen for 5 minutes after the administration.
  8. The resevoir bag should be
    • Partially distended
    • The bag should be inflating and deflating normally.
    • Pulse oximetry should be used in concentrations over 50%
  9. Developing a differential diagnosis in salivary gland disease
    • Location (Bilateral)
    • Growth rate (slow growth, benign)
    • Mobility (fixed non-hodgkins)
    • Pain (usually infection)
    • - Also use rule of 7s, (7days infections, 7 months neoplastic , 7 yrs congenital)
  10. Parotid swelling can be...
    • Tumors: usually unilateral, benign (warthins tumor) or malignant (Lymphoma, mucoepidermoid carcinoma)
    • Viral: Mumps (most common, can be bilateral as well as other virals)
    • Granulomatous: Sarcoidosis, wegners granulomatosis (both bilateral)
    • Autoimmune: Sjogren symdome (bilateral)
    • Bacterial Sialadenitis: Parotid (usually unilateral)
  11. Imaging best used to salivary tumors
    • MRI
    • Occlusal xray for floor of the mouth stones
    • Not fully calcified stones called "mucous plugs"
    • CT used for calcified stones, less invasive than sialography (water soluble injection)
    • Ultrasound detects sialoliths
  12. Benefits of sialoendoscopy
    • Less traumatic, less post operative pain
    • Ballon style dilators can expand and remove sialoliths
    • Not always available if lith is embedded
  13. Bacterial sialadenitis is seen usually where and why?
    • Parotid gland (acute Parotitis usually in elderly because of reduced flow of saliva)
    • Chronic sialadenitits usually in submandibular (associated with sialolith)
    • Parotid usually has bacterial because mucous saliva in other glands contain antibodies and lysosomes
  14. Risks of bacterial sialadenitis
    • Obstructive (sialoliths) and Reduced salivary flow (elderly or conditions)
    • Fever, pain, dehydration, erythema
    • Initial antibiotics should be aimed at most common bacteria Staph aureus
  15. Most common salivary diseases in children
    • 1. Mumps
    • 2. Juvenile recurrent parotitis, 10x more common than adult chronic parotitis, swelling pain, no exudate
    • Unilateral swelling, resolves with puberty
    • Tx: hydration, massage, warm compress, sialoendoscopy
  16. Bilateral parotid swelling, may or may not be painful, managed by controlling underlying cause (endocrine, alcoholism- fatty infiltration of salivary gland, bulimua- increased saliva production).
    • Sialadenosis
    • HIV associated salivary gland disease, xerostomia is seen and decreased function (3 types)
  17. Three most common type of necrotic bone diseases?
    • Osteomyelitis: infection of the bone marrow, bacteria in cancellous bone, bacteria proliferates because blood cannot irrigate properly.
    • Acute: fever, trismus, leukocytosis Chronic: same but fistula is more likely with deep pain, Onion skin appearance. Surgery is necessary because Antibiotics cannot reach site.
    • Osteoradionecrosis (ORN):
    • Medication related osteonecrosis of the jaw (MRONJ)
  18. Changes in bone density can only be seen when bone reduction is over what % and what test can be used to detect osteomyelitis earlier?
    • 30% and Technetium Bone scan fused with a CT, can detect physiologic changes in bone.
    • Chronic osteomyelitis is best seen with CT, high resolution, early detection of bone changes.
    • MRI not much use for osteomyelitis
    • Antibiotic intervention 4-6 weeks is useful
  19. The 3H principle is usefor for which condition
    • Osteoradionecrosis ORN
    • Hypoxia
    • Hypovascularity
    • Hypocellularity
    • Fibroatrophic theory is the new one
  20. How many Gy required for risk of ORN
    • over 60GY
    • over 74 Gy is spontaneous ORN
    • Risk in detate from extraction or periodontal disease
    • Trismus can be seen, mandible is most likely
  21. Pre-radiation ORN prophylaxis
    • Remove all mandibular teeth in path of RT with caries, perio disease, PA lesions, root tip, mobility, etc..
    • HBO if >50Gy (20 preop dives and 10 postop)
    • Stimulates, vasculodensity, minieralization
    • ABSOLUTE CONTRAINDICATIONS: Pneumothorax and Chemotherapy, and other relative conditions, fever, pregnancy
  22. Medication-related osteonecrosis of the jaws can be caused by which 2 agents
    • Antiresorptive therapy (bisphosphonates and Denosumab, both work on osteoclasts)
    • Antiangiogenic agents inferfere with new blood vessels, can be used in caricinomas)
    • Posterior mandible is a common location
  23. Bone grafts can be these 2 types for these 2 different situations
    • Block: cortical bone (hard to vascularize but stable)
    • Particulate: cancellous bone (easy to vascularize but unstable)
  24. Bone Graphs can produce bone these 3ways..
    • Osteogenic: new bone from progenitor cells, Osteogenic cells = phase 1 bone
    • Osteoconductive: graph acts as a scaffold for the ingrowth of new bone, allograph, xenograph alloplast
    • Osteoinductive: Chemical process where mesenchymal cells ->BoneMorphogenicProtein-> osteoblasts make new bone, requires stem cells
  25. Distraction osteogenesis has various phases
    • Surgery: corticotomy and osteotomy, appliance applied
    • Latency phase: 24h-7d, early healing, appliance not activated
    • Distraction phase: rate 0.5-1mm/day, new bone formation
    • Stabilization/consolidation: 2.3x the amount of time required for distraction, mineralization of bone
    • Removal: resume ortho tx, implants
  26. Innervation of the TMJ disc and capsule comes from?
    • Primary: auricular temporal nerve
    • Secondary: deep temporal and masseteric nerves
    • First phase of movement is rotation/hinge in lower joint space
    • Second phase anterior translation occurs in superior joint space
  27. Puncture of a joint by a needle or catheter followed by lavage of joint space and manipulation of mandible?
    • Arthrocentesis: for limited opening, chronic pain, DJD, internal derangement, releases pressure of disc, inflammatory and pain mediator removal.
    • For Condylar dislocation these 2 are used...
    • Eminectomy, removal of temporal bone eminence, Doicher? prodecure fractures zygomatic arch to increase height
  28. Most effective method of treating and diagnosing TMJ
    • Arthorscopy, lavage can be done as well
    • Disc reposition can also be done, with or without grafts, and disc repairs.
    • Joint replacement can be done (total) with both condyle and fossa or partial with only 1.
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Oral surgery Final