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.
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.
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
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
What percent is the mean dosage for ideal sedation for patient responsiveness and cooperation
35% is a mean dose, does not always apply
What are some contraindications for NO2?
- Recovering or current drug/alcohol abuse
- Otitis media or sinus infection (changes in pressure)
- Upper respiratory tract infection
- COPD (severe respiratory disease, not asthma, it helps asthma because of relief of stress)
- Cystic fibrosis
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.
The resevoir bag should be
- Partially distended
- The bag should be inflating and deflating normally.
- Pulse oximetry should be used in concentrations over 50%
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)
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)
Imaging best used to salivary tumors
- 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
Benefits of sialoendoscopy
- Less traumatic, less post operative pain
- Ballon style dilators can expand and remove sialoliths
- Not always available if lith is embedded
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
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
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
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).
- HIV associated salivary gland disease, xerostomia is seen and decreased function (3 types)
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)
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
The 3H principle is usefor for which condition
- Osteoradionecrosis ORN
- Fibroatrophic theory is the new one
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
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
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
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)
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
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
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
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
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.