0807-Maxillofacial Surgery Basics for the Dental Assistant Part 1

MAXILLOFACIAL SURGERY BASICS FOR THE DENTAL ASSISTANT: PART 1BY: NATALIE KAWECKYJ, LDA, RF, CDA, COURSE# 0807 (AGD# 310)CDPMA, COA, COMSA, CPFDA, MADAA, BA 4 CE CREDITSRevised November 2015All continuing Dental Education coursesare available to ADAA members FREEof charge at www.adaausa.org

This course has been produced in part by a grant from the American Dental Assistants Association Foundation.You will have 60 days in which to complete the course once you register for it. You will only be allowed to take the post test three times before being required to review the course again.ADAA Member (Hard copy): $19.50 Nonmember: $60RETURNS & EXCHANGES: Orders placed online are processed instantly and are available almost immediately. ADAA online courses are nonrefundable, no exceptions. The ADAA has an obligation to disseminate knowledge in the field of dentistry. Sponsorship of a continuing education program by the ADAA does not necessarily imply endorsement of a particular philosophy, product, or technique. Continuing dental education (CDE) earned from this course may also prove useful in recertification by independent testing agencies. Authorized CA Provider #RP2169 Dental Practice Management courses are not approved for credit by the CA Board of Dental Examiners The American Dental Assistants Association is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by the AGD for Fellowship/Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 6/1/2015 to 5/31/2018. Provider ID# 217389. It is unlawful to reproduce any ADAA course for educational purposes or mass distribution. For further clarification contact the ADAA Central Office at 877-874-3785.American Dental Assistants Association • 140 N Bloomingdale Rd. • Bloomingdale, IL 60108-1017 ©2015 American Dental Assistants Association 1

COURSE OUTLINEINTRODUCTION........................................................................................................................................ 3COURSE OBJECTIVES.................................................................................................................................4GLOSSARY...............................................................................................................................................5-7ROLE OF THE OMS DENTAL ASSISTANT...................................................................................................8Intraoral Responsibilities..........................................................................................................................8Client Management Responsibilities........................................................................................................8Infection Control Responsibilities............................................................................................................8CLIENT HEALTH ASSESSMENT AND VITAL SIGNS...............................................................................8-13OMS Management of Clients with Underlying Medical Conditions...................................................8-13REVIEW OF REGIONAL SURGICAL ANATOMY...................................................................................13-17Nerves.................................................................................................................................................13-15Maxilla..................................................................................................................................................... 16Mandible.............................................................................................................................................16-17ANESTHESIA AND SEDATION.............................................................................................................17-22Preoperative Client Evaluation..........................................................................................................17-18Preparatory Steps before Surgery..........................................................................................................18Client Monitoring ...............................................................................................................................18-20Administration Techniques ...............................................................................................................19-20Local Anesthesia......................................................................................................................................20Inhalation Analgesia/Sedation...............................................................................................................20Chemical Agents Used in Oral & Maxillofacial Surgery ...................................................................20-22Reversal Agents ......................................................................................................................................22Sedation Techniques ..............................................................................................................................22MEDICAL EMERGENCIES DURING SEDATION...................................................................................22-25Peri-operative Hemorrhage ..............................................................................................................22-24Management of Specific Problems Affecting Hemostasis................................................................24-25SUMMARY................................................................................................................................................ 25REFERENCES............................................................................................................................................ 25APPENDIX OF COMMON MEDICATIONS AND THEIR TRADE NAMES...................................................26ABOUT THE AUTHOR..............................................................................................................................27POST-TEST...........................................................................................................................................28-30 2

INTRODUCTIONThe specialty of oral and maxillofacial surgery, formerly known as oral surgery, is responsible for the diagnosisand surgical treatment of diseases, injuries, and defects of the oral and maxillofacial region. Specialists workwith many other dentists, general practitioners and other specialists in the total treatment of a dental client.Many people commonly associate an oral surgeon with the removal of third molars. Such procedures are only asmall part of what these specialists do. For instance, an oral maxillofacial surgeon may see a client who has beenseverely injured in an accident to reset the mandibular jaw and then work closely with the orthodontist andperhaps even a plastic surgeon to restore the patient to normal oral function. Implantology and facialcosmetic surgery are other aspects of oral surgery. The oral and maxillofacial surgery (OMS) assistant is a vitalteam member in this specialty practice.Oral surgery procedures may be practiced in the general dentistry practice, but not to the same extent of aspecialty practice. Some general practitioners have advanced training in conscious sedation and utilize theirtraining in a general practice. Some states even allow for the regulated dental assistant to assist with themonitoring and delivery of medications during the procedure.This course will review some of the preparation procedures for oral surgery, whether performed in the generaldentistry practice or specialty clinic. 3

COURSE OBJECTIVES Upon completion of this course, the dental professional should be able to: • Explain the role of a surgery dental assistant.• Describe various medical conditions and how they can affect treatment.• Explain how bacteria can cause infective endocarditis.• Explain the ASA Classification.• Explain two causes for hypoxia.• Recognize normal hematologic values.• Explain the nerve innervation of the maxilla and mandible.• Understand the differences in local anesthetics.• Describe the three techniques for pain and anxiety control.• Demonstrate how to prepare chemical agents from a multi-dose vial.• Demonstrate how to prepare the IV bag.• Explain the differences in drug actions for the agents used in sedation.• Recognize medical emergencies and know how to react.• Describe how various medications and conditions affect hemostasis.• Explain perioperative risk assessment of dental clients. 4

GLOSSARYAngioplasty — Alteration of the ally or by dilating a balloon in the vessel.Apicoectomy — Excision of the root of a tooth.Arrhythmias — Irregular heart rhythms.Asymptomatic — Without symptoms.Atrophic — Decreased in size.Auscultation — The process of listening for sounds in the body.Autoimmune — A disease produced when the body’s normal tolerance of its own antigenicmarkers on cells disappears.Bacteremia — Bacteria in the blood.Basement Membrane — Level in tissues where generation of new cells occurs.Bradycardia — Slow heart rate characterized by a pulse rate below 60 beats per minute.Bronchiectasis — Chronic dilation of the bronchus or bronchi, with a secondary infection thatusually involves the lower portion of the lung.Cannula — A tube or sheath enclosing a sharp surgical instrument, typically used with intravenousadministration.Capnograph — A machine that records the carbon dioxide level in expired air in the mechanicallyventilated individual.Cardiomyopathy — Disease of the myocardium caused by primary disease of the heart muscle.Cheilosis — Inflammation of the lip.Chorda Tendinae — The tendons that hold the free edges of the atrioventricular valves to thepapillary muscles preventing inversion of these valves during ventricular systole.Coagulation — Clotting.Congenital — Present at birth.Deficit — Deficiency.Demethylation — Removal of a methyl group (CH3) during chemical reactions.Desaturated Blood — Blood with lowered levels of oxygen.DNA — Nucleic acid containing genetic information.Dysrhythmias — Abnormal heart rhythms.Ecchymosis — Bruising of the tissue.Edema — Swelling as a result of excessive tissue fluid.Epitaxis — Nosebleed.Extracellular — Outside the cell.Fibrin — A protein formed by the action of thrombin on fibrinogen; important in blood clots. 5

Glossitis — Inflammation of the tongue.Glucose — Blood sugar.Hemophilia — A hereditary disease characterized by abnormal blood clotting.Hemostasis — The stoppage of bleeding.Hyperthyroidism — Overproduction of thyroxine by the thyroid gland.Hypertrophic — An increase in size.Hypothalamus — Portion of the brain that controls the release of hormones.Hypothyroidism — Underproduction of thyroxine by the thyroid gland.Hypoxia — Oxygen deficiency.Immunosupression — Compromised immune system.Intravascular — Within blood vessels.Intravenous — Within or into a vein.Limbic System — A group of brain structures influencing the endocrine and autonomic motorsystems.Lingula — A bony projection that forms the medial boundary of the mandibular foramen.Morbidity — State of being diseased.Myocardial Infarction — A heart attack.Neuroma — Any type of tumor composed of nerve cells.Orthopnea — Breathing difficulty in any position but upright.Parenterally — Denotes a medication route of administration other than by mouth; intravenous,subcutaneous, intramuscular, or mucosal.Petechiae — Small bruises that can appear in the oral cavity.Perioperative — Before, during and after a surgical treatment or procedure.Proviral — Before the viral stage.Pterygoid — Muscle in the cheek that attaches to the mylohyoid bone.Pulse-Oximeter — A device that records the pulse and oxygen concentration in the arterial blood.Ramus — A branching of a structure, as seen in the mandible.RNA — The nucleic acid that controls protein synthesis in all living cells and takes the place of DNAin certain viruses.Saturated Blood — Blood full of oxygen.Sialogues — Products that promote salivary flow.Sialoliths — Salivary stones.Tachycardia — An abnormally high heart rate, usually greater than 100 beats per minute in adults.Thalamus — The portion of the brain responsible for all sensory stimuli with the exception of theolfactory sensations. 6

Thrombin — An enzyme formed in shed blood from prothrombin, which converts fibrinogen intofibrin; the basis of the blood clot.Thrombocytopenia — An abnormal decrease in the amount of blood platelets.Trigone — Triangular space in the retromolar area.Vasoconstrictors — Drugs that narrow the blood vessels.Von Willebrand Disease — A congenital bleeding disorder caused by a deficiency in thecoagulation factor VIII. 7

ROLE OF THE OMS DENTAL ASSISTANT client who is to receive surgical treatment. A written, patient-completed medical history questionnaireThe role of the dental assistant in an oral and is a legal necessity. The extent and detail of themaxillofacial surgery setting can vary. Oral surgery medical history are somewhat dependent upon theassistants may be licenseed, registered or certified surgeon’s personal preference and the type of surgicaldental assistants who have received additional services to be rendered. However, the surgeonexperience in an oral surgery setting. Some assistants must be prepared to interpret how a medical problemtake an American Association of Oral and Maxillofacial will alter a client’s response to dental surgerySurgeons home study course, which allows them to and anesthetic agents. The health assessment maysit for an examination for certification as an oral have to be abbreviated for some emergencysurgery anesthesia assistant. Dental assistants in an procedures, but it must be completed before the endoral surgery setting must be well-trained in of the initial visit. Certain conditions such as languagecardiopulmonary resuscitation and medical barriers, pain and anxiety may affect the medicalemergency procedures because many of their clients assessment interview and may need to be attendedare referred to the specialty practice due to poor to before completion of the medical assessment.health or as victims of trauma. OMS Management of Clients with UnderlyingIntraoral Responsibilities Medical ConditionsThe dental assistant is responsible for preparing Cardiovascular Diseases: Cardiovascular diseaseall of the armamentarium and in most cases, affects many dental clients. The disease may bemedications that will be used in the administration of hereditary or a result of lifestyle choices. It isanesthesia and in performing the surgical procedure. important to postpone elective treatment in thoseDuring the actual procedure, the assistant should clients who have had a cardiac episode within the lastmaintain a clear working field for the dentist or six months. If the procedure is considered ansurgeon through the use of evacuation and retraction. emergency and cannot be postponed, consultationThe assistant may also be responsible for observing with the client’s cardiologist is of utmost importance.and monitoring the client’s vital signs to ensure clientsafety during the surgery and anesthesia. Some states Ischemic heart disease is defined as a local andmay allow the assistant to remove sutures or pack and temporary deficiency in the blood supply to aremove socket medicament as well as assisting with particular region of the body, most commonly theintravenous procedures. heart. There are several factors that may lead to decreased circulation in the heart. RecommendationsClient Management Responsibilities for clients with poorly controlled ischemic heartThe surgery dental assistant plays a major role in disease, labile cardiac rhythms or potentiallyclient management. Client management duties can lifethreatening arrhythmias include the use of threerange from reassuring the client prior to surgery to percent mepivicaine or four percent prilocaine.providing pre and postoperative instructions. Thesurgery assistant may also make follow up calls to Angina Pectoris is defined as severe pain in thethe client later in the day to reaffirm client chest caused by the relative deficiency of oxygenunderstanding of the instructions given, answer supply to the heart muscle. It occurs most often afterquestions or discuss any complications that may have increased activity, exercise, or a stressful event. Painarisen. or numbness typically radiates to the left shoulder and down the left arm, and may also radiate to theInfection Control Responsibilities neck and jaw. Discomfort of myocardial ischemia isAs with any dental office, the oral and maxillofacial described as squeezing, crushing, burning orsurgery practice must use standard precautions in smothering, whereas others may describe it as ainstrument preparation, sterilization and medical shortness of breath or simply a feeling of heaviness.waste management. Because oral surgery involvesthe invasion of hard and soft tissues, proper Clients who have the stable form of angina withoutsterilization is imperative. a history of infarction generally have a much lower risk of complications than clients who have unstableCLIENT HEALTH ASSESSMENT AND VITAL angina or a history of a recent myocardial infarction.SIGNS It is important to postpone elective treatment in those clients who have had a cardiac episode within the lastA medical assessment must be taken for every six months. If the procedure is considered an emergency and cannot be postponed, consultation with the client’s cardiologist is of utmost importance. 8

The risk of a second infarction drops as low as it will fibrin thrombi. The frequency of bacteremia afterabout six months after the initial myocardial different dental procedures or activities varies. Afterinfarction. It is recommended to consult with the dental extractions or periodontal surgery it is quitecardiologist even after six months has passed. high, approximately 18%-85% and 32%-88% respectively, but it also is significant after everydayCoronary Artery Bypass Surgery is one of the activities such as tooth brushing, 0-26%, and chewingmost common surgical procedures performed in the candy, 17%-51%. The production of extracellularUnited States today. Clients who have had coronary dextran by some strains of the streptococcusartery bypass surgery are treated in a manner similar bacterium is responsible for the stickiness to dentalto post-myocardial infarction clients. Six months enamel and also the culprit in trapping circulatingshould pass before any elective surgery or dental organisms on damaged heart valves and platelettreatment is performed, and a consultation with the fibrin thrombi.medical physician is recommended. The mitral valve is the most common site of infectionPercutaneous Transluminal Coronary Angioplasty and once infection begins, rupturing of the valve(PICA) is one treatment for coronary artery disease. tissue or chorda tendinae is possible. Some virulentAfter successful angioplasty, clients are maintained bacteria (Staphylococcus aureus or some fungalon aspirin therapy, which may interfere with clotting infections) may become large enough to obstruct theduring dental surgery, therefore a consultation with orifice. Table 1 lists the bacteria most commonlythe physician is suggested prior to any treatment. associated with infective endocarditis.Congestive Heart Failure and orthopnea are common • Bacillus speciesamong older clients but can occur in younger • Bacterioides speciesindividuals. Fatigue is a common complaint as well asa history of edema and weight gain from water and • Candida speciessalt retention. Clients with congestive heart failure • Fastidious gram-negative rodsthat is well compensated through dietary and drugtherapy can safely undergo ambulatory surgery. • HaemophilusSupplemental oxygen to assist with respiration and • Neisseria gonorrheaeanxiety-reduction methods are helpful. Clients with • Staphylococcus aureuscongestive heart failure and orthopnea must be kept • Streptococcus pneumoniaein an upright position during any procedure. Surgery • Viridans streptococcifor clients with uncompensated hypertrophiccardiomyopathy is best deferred until compensation is Table 1achieved or surgical procedures can be performed in ahospital setting. Appropriate analgesic agents for pain Infective endocarditis can occur on either side of thecontrol or antibiotics for infection should be given heart. Some cases of streptococcal endocarditis canafter consultation with the client’s physician. manifest clinically within two weeks of the initiating event. The dental team’s goal is to preventClients with arrhythmias before dental surgery endocarditis from occurring in susceptible clients.have significantly increased risks of cardiac morbidity Any dental procedure that causes injury to the softand death. Clients with arrhythmias should be tissue or bone resulting in bleeding can produce areferred to a hospital-based oral surgeon or general transient bacteremia. For clients with a history ofdentistry program. In the hospital setting, appropriate infective endocarditis, antibiotic prophylaxis shouldconsultation can be obtained to optimize the client be given.prior to surgical treatment, which may be completedin one visit. Antiarrhythmic drugs are normally In 2007, the American Heart Association changed itscontinued orally through the morning before surgery, recommendations for short-term dental antibioticafter which medications will be delivered prophylaxis. The American Heart Association alongintravenously. Pacemakers pose no contraindications with the American Dental Association established theto dental surgery and no antibiotic prophylaxis is current guidelines for dentistry based on growingrequired, but electrical equipment such as electric scientific evidence that shows the risks of takingcautery should not be used. preventive antibiotics outweighing the benefits for most dental patients. Some of the risks includedInfective endocarditis occurs when bacteria enter adverse reactions to the prescribed antibiotics rangingthe bloodstream from an oral or other source and from mild to potentially severe and, in very rare cases,settle on heart valves that may already bear platelet 9

death. Inappropriate use of antibiotics has also lead to Standard general Amoxicillinthe development of drug-resistant bacteria, a growing prophylaxis for clients at Adults 2.0 gconcern in the medical community. risk: Children 50 mg/kg Given orally one hourThe new guidelines are aimed at patients who would before procedure Ampicillinhave the greatest danger of a bad outcome if they Adults 2.0 gdeveloped a heart infection. Under the new Unable to take Children 50 mg/kgguidelines, individuals who have taken antibiotics oral medications:prior to dental treatment routinely in the past but no Given by injection or Clindamycinlonger need them include conditions such as: intravenously within Adults 600 mg 30 minutes of procedure Children 20 mg/kg • bicuspid valve disease OR For clients allergic to Cephelexin or • calcified aortic stenosis Amoxicillin, Penicillin Cefadroxil or Ampicillin: Adults 20 mg • congenital heart conditions (ventricular septal Given orally one hour Children 50 mg/kg defect, atrial septal defect and hypertrophic before procedure OR car diomyopathy) Azithromycin or Given orally one hour Clarithromycin • mitral valve prolapse before procedure Adults 500 mg Children 15 mg/kg • rheumatic heart disease Given orally one hour before procedure CefazolinPreventive antibiotics prior to a dental procedure Adults 1.0 gare still advised for patients with: For clients allergic to Children 25 mg/kg Amoxicillin, Penicillin or • artificial heart valves Ampicillin and unable to take oral • a history of infective endocarditis medications: Given by injection or • certain specific, serious congenital heart intravenously within 30 conditions, including minutes before procedure • unrepaired or incompletely repaired cyanotic congenital heart disease, including those with Table 2 palliative shunts and conduits Hypertensive Disease • a completely repaired congenital heart defect It is estimated that approximately 29% of the adults in with prosthetic material or device, whether the United States have hypertension and only about placed by surgery or by catheter intervention, half of the individuals with hypertension have it under during the first six months after the procedure control. • any repaired congenital heart defect with Hypertension is clinically defined as an average residual defect at the site or adjacent to the site systolic blood pressure on a single occasion of ≥ 140 of a prosthetic patch or a prosthetic device mm Hg or a diastolic blood pressure of >90 mm Hg. Isolated systolic hypertension is more commonly • a cardiac transplant that develops a problem in seen in older adults, whereas systolic and diastolic a heart valve. hypertension is more common in men under age 55, women over age 55, African Americans of all ages, andIn general, according to the American Dental persons from lower socioeconomic groups.Association in 2015, patients with prosthetic jointimplants, prophylactic antibiotics are not Hypertensive clients should be treated in anrecommended prior to dental procedures to prevent anxiety-free atmosphere in order to prevent elevationprosthetic joint infection. of blood pressure to dangerous levels. Care must be taken in the administration of epinephrine or otherTable 2 lists the types of antibiotics used and vasoconstrictors to these clients, especially if a largetheir dosages. amount is to be administered over a short period of time. Clients with severe uncontrolled hypertension should be identified and seen for conservative 10

treatment in an anxiety-free environment only and common clinical problem. There are currently morereferred to a medical physician before any surgical than 160,000 clients on dialysis in the United Statestreatment is considered. Stress from dental and many more living with successful kidneyprocedures may increase the client’s already elevated transplants. Kidney diseases are often classifiedblood pressure to a dangerous level and a medical according to whether they produce acute or chronicconsult is recommended. renal failure. Clients with renal insufficiency requiring periodic dialysis need special consideration duringPulmonary Conditions oral surgical care. Clients with shunts should be givenChronic Obstructive Pulmonary Disease prophylactic antibiotics during surgery to prevent(COPD) is a disorder characterized by abnormal tests infection of the shunt. Elective oral surgery is bestin expiratory flow that do not change markedly over undertaken the day after a dialysis treatment hasperiods of several months’ observation. Specific been performed. This allows the heparin used duringcauses of airflow obstruction--such as localized dialysis to disappear and the client to be in the bestdisease of the upper airways, bronchiectasis and physiological state with respect to intravascularcystic fibrosis--are excluded. COPD is a chronic disease volume and metabolic by-products. Drugs dependentthat has its origins in early adulthood and possibly on renal metabolism should be avoided or used ineven early childhood. The disease does not produce modified doses.symptoms or impairment of activity until it is faradvanced, usually in late middle age or in the elderly. Disease of the LiverSurgical treatment should be rendered in an upright Hepatitis is an inflammatory condition that may beposition to avoid orthopnea and respiratory localized in the liver or may be part of a generalizeddiscomfort. There is no contraindication to the usual systemic disease. Acute hepatitis is usually ausage of local anesthetics, however bilateral self-limited disease and the main causes includemandibular blocks or bilateral palatal blocks are not viruses, drugs, and alcohol. Chronic hepatitis refersrecommended because of a possible unpleasant to unresolved hepatitis that has persisted for longerchocking sensation or difficulty in swallowing. than six months. Cirrhosis is often the mainOutpatient general anesthesia is contraindicated consequence of chronic hepatitis. Viral hepatitis is ain clients with COPD. systemic infection whose primary manifestations are hepatic. The six types of viral hepatitis that areAsthma is a disorder characterized symptomatically welldefined, separate diseases are designated types A,by cough, chest tightness, shortness of breath, and B, C, D, E, and G.wheezing associated with limitation in airflow. Thesymptoms may be acute and episodic, or may wax The production of vitamin K-dependent coagulationand wane over long periods of time. Approximately factors (II, VII, IX, X) may be depressed in severe liverone in 20 residents of the United States has asthma, disease and obtaining a prothrombin time (PT) orand it is even more common in other developing partial prothrombin time (PPT) may be useful prior tocountries. Approximately half of the asthmatics in the surgery.United States have onset of the disease duringchildhood, and about half will outgrow the disease by Diabetes mellitus is a condition characterized byyoung adulthood. The goal of the dental team is to abnormal glucose utilization and associated withprevent an acute asthmatic attack. Aspirin ingestion is elevation of blood glucose concentration. The mostassociated with a small percentage of attacks and it is common forms of diabetes mellitus are known to beadvisable not to administer aspirin-containing medica- associated with abnormalities of insulin secretiontions or other NSAIDs to clients with asthma. and concentration, with cellular resistance to insulin action, and with vascular abnormalities such asAcetaminophen can safely be used for mild to basement membrane thickening. Clients who havemoderate pain. Barbiturates and narcotics should not no evidence of complications and have their diseasebe administered because of the potential of under good medical control will require little or noprecipitating an attack. Nitrous oxide/oxygen sedation special attention when receiving surgical treatment,can be used because nitrous oxide is not a respiratory unless they should develop an acute dental or oraldepressant or irritant. In cases where general infection. Clients taking insulin and not under goodanesthesia is to be used, treatment should be medical management should be referred for aperformed in a hospital setting. consultation before surgical treatment.Renal Diseases When a dentoalveolar procedure is scheduled for theRenal insufficiency can present either as a primary morning, the client should be instructed to take therenal event or complicating another illness, and is a 11

prescribed morning dose of regular insulin and half of concomitant candidal infections. Vitamin C deficiencythe NPH (neutral protamine Hagedorn insulin) dose and hemostasis disorder may lead to spontaneousprior to the appointment. Vital signs should be bleeding, mucosal ecchymosis and petechiae.monitored and the client observed for signs of moodchange, tachycardia, hypotension, drowsiness or Inherited bleeding disorders are often reported to thehunger. Administration of oral glucose will counter dental team before treatment. For clients unsure if athe hypoglycemia. If the client will be unable to eat a bleeding disorder exists, questions about duration ofnormal meal following treatment, the morning does bleeding following minor trauma or surgicalof NPH should not be taken until regular meals can be procedures should be asked. A test of the intrinsic andeaten. extrinsic pathways, PT, and PPT is usually sufficient initially. In clients with a relative platelet inadequacy,Infection in the diabetic client is more difficult to a hematologist should be consulted. Clients withcontrol than in clients without diabetes. This is a result hemophilia A, B, C, or Von Willebrand disease shouldof the altered leukocyte function, as well as by other be given Amicar prior to any oral surgical procedure.factors that affect the body’s ability to control an Elective surgery should be planned with theinfection. Difficulty in containing infection is more hematologist to determine the best time for surgicalsignificant in clients with poorly controlled diabetes. In procedures and whether transfusion of platelets willemergency situations involving the diabetic client with be needed. Table 3 is a list of normal hematologicserious infections, hospitalization should be values for tests normally given to clients with bleedingconsidered where appropriate doses of intravenous disorders prior to surgery.antibiotics could be administered and aggressivesurgical management of the infection performed. HIV is a member of the lentivirus subfamily of humanAntibiotics may need to be given to diabetic clients retroviruses. These retroviruses code for an enzymewhen dental surgery is performed. known as reverse transcriptase. This enzyme allows transcription of viral RNA into proviral DNA andThyroid Disease subsequent integration into the host’s cellularOne of the most common endocrine conditions is the genome, leading to a persistent and latent infection.disturbance of thyroid growth and function. Excessiveproduction of thyroxine (T4) and triiodothyronine Hematologic Values(T3) results in hyperthyroidism or thyrotoxicosis, whiledecreased hormone production results in Category Valueshypothyroidism. Clients with hyperthyroidism shouldbe referred to their physician before dental surgery. Bleeding Time (ivy) 2.5-9.0 minThe hypothyroid client with mild symptoms canreceive standard treatment. PTT 25-33 seclAdrenal insufficiency is now most commonly caused PT 11-13 secby autoimmune disease and is associated with thepresence of antibodies to adrenal tissue. Other cases Thrombin Time 11-18 secare secondary to pituitary disease. A consultation withthe physician of the client with adrenal insufficiency Hematocrit 40-50%is recommended before dental surgical treatment. Male 36-44%Minor procedures require anxiety-reducing measureswhereas complex procedures may require Femalesupplemental steroidal treatment. A change in theclient’s daily steroidal medication often occurs Hemoglobin 14-17 g/dlpre- and post- operatively. Male 12-15 g/dlOther Conditions FemaleAlcoholism is a disease defined as a recurring troubleassociated with drinking alcohol. The dental concerns RBC Count 4.5-5.7x106/µlwhen treating the alcoholic client are that of bleeding Male 3.9-5.0x106/µltendencies and unpredictable metabolism of certaindrugs. Oral findings include gingival bleeding, Femaleglossitis, and loss of tongue papillae along withangular or labial cheilosis, which is complicated by WBC Count 3.8-9.8x103/µl Platelets 140-440x103/µl Table 3 Clients who are HIV-positive but asymptomatic can receive all indicated dental treatments. The physician should be consulted regarding the degree of immunosupression and thrombocytopenia. If the consultation is delayed, the client can be treated conservatively with pain medication and antibiotics. 12

If the medical consultation reveals significant REVIEW OF REGIONAL SURGICALimmunosupression and thrombocytopenia, bleeding ANATOMYtime or platelet count should be performed beforeany treatment, as the client may require platelet The most important aspect of oral and maxillofacialreplacement. surgery is a detailed knowledge of the regional anatomy. An inadvertent injury to a nerve will resultJoint replacement risks can be similar to that of in great morbidity to the client, and in a majority ofinfective endocarditis without prophylactic antibiotics, the cases, legal challenges to the surgeon. The secondand these guidelines have not changed. The bacteria and third divisions of the trigeminal nerve are thecommonly found in the oral cavity may travel through nerves most affected in oral surgery.the bloodstream and settle at the artificial joint,increasing the risk of contracting an infection. For the Nervesfirst two years after a joint replacement, all patients The maxillary nerve is made up of three divisions: themay need antibiotics for all high-risk dental pterygopalatine nerve, the infraorbital nerve, and theprocedures. High-risk dental procedures include zygomatic nerve. The pterygopalatine nerve hasextractions, periodontal procedures, regular cleanings several divisions, but the two terminal branches areif bleeding is anticipated, and some endodontic most significant to dentistry. The larger of the twoprocedures. After two years, only high-risk patients terminal branches is called the anterior palatine nervemay need to receive antibiotics for high-risk and it enters the oral cavity through the greaterprocedures. palatine foramen. At this location it splits into several smaller branches fanning out as the greater palatinePregnancy risks include injury to the fetus, so no nerve and therefore supplying the mucosa of themodifications that can cause genetic damage should hard palate to the canines. The nerve travels next tobe undertaken. All elective procedures should be the palatine artery contained by the connective tissuepostponed until after delivery. If surgery cannot be between the periosteum and the palatal mucosa.postponed, the client’s physician should be consulted Injuries to the nerve endings within the palatalbefore any treatment. Any drug to be prescribed must mucosa tend to repair themselves and clients will notbe discussed with the physician. The client should be usually be aware of any deficits in the nerve. Thisseated in a nearly upright position or turned slightly palatal tissue heals rapidly and sensory perception isto one side to prevent compression of the inferior not lost. The smaller branch of the pterygopalatinevena cava. Nitrous oxide should not be used in the nerve is the posterior palatine nerve, which travelsfirst trimester, but can be used in the second and third through the lesser palatine foramen, supplying thetrimesters with at least 50% oxygen. Lidocaine, tonsil with sensory endings.bupivicaine, acetaminophen, codeine, penicillin anderythromycin can be used in moderate amounts. In The infraorbital nerve divides out into three branchesthe postpartum phase, if the client is breast-feeding, before it surfaces at the infraorbital foramen. Theseavoidance of drugs that enter the milk is necessary branches are called the anterior, middle and posteriorand the client’s physician should be consulted for superior alveolar nerves, and supply sensory endingsguidance. Corticosteroids, aminoglycosides, and to the maxillary teeth, their periodontal membranestetracyclines should be avoided entirely. and gingiva on the lateral aspect of the maxilla. In the base of the alveolar process, the superior alveolarSeizure disorders are often identified by the nerves form a loose plexus called the superior dentalmedications listed on the client health assessment. plexus. The nerves in this plexus are the nervesQuestions about frequency of medications, anesthetized via infiltration of local anesthesia.compliance and any recent measure of drug levels Surgery in this region will not lead to any sensoryshould be asked. If the client is unable to answer any deficits.of these questions, treatment should be postponedand the physician consulted. If the client’s disorder is The terminal branches of the infraorbital nerve spreadwell-controlled, no special modifications are fan-like from the infraorbital foramen toward thenecessary. If the disorder is not well-controlled or if lower eyelid, nose and upper lip. Three or fourcontrol cannot be attained, the client should receive superior labial branches enter the lip between theintravenous sedation in an ambulatory setting, either muscles and mucous membrane, supplying theat an oral surgery office or in the hospital. mucosa of the upper lip and skin through perforation in the orbicularis muscle. Surgical disruptions of the terminal branches ending in the lip will repair themselves. During apicoectomies on the upper canine or premolar teeth, or sinus lift procedures on 13

the atrophic maxilla, care must be taken not to injure neural sensation following an injury in this location isthe nerve as it exits from the infraorbital foramen. unlikely. Injuries of the nerve may also occur duringInjury in this region will lead to a traumatic neuroma the removal of sialoliths or any other surgery in theand the neurological deficit will be permanent. floor of the mouth. Following injury to the lingual nerve, surgical exploration and surgical repair isThe mandibular nerve is a mixed nerve made up of indicated when there is no evidence of recovery 30both motor and sensory fibers. Four sensor days after the initial trauma. An 80% success rate ofbranches are organized into internal, middle and non-painful sensory return can be expected fromexternal branches. The internal branch has two nerves microsurgical repairs of the lingual nerve if surgery iscalled the buccal and lingual nerves, supplying large performed within the first ninety days following injury.areas of the oral mucosa. The middle branch is theinferior alveolar nerve supplying the mandibular The inferior alveolar nerve enters the mandible at theteeth, skin, and mucosal membrane of the lower lip lingula and travels through the length of theand skin of the chin. The external branch is the mandibular canal at which point it divides in theauriculotemporal nerve, which is never anesthetized premolar region into the incisive and mental nerves.in dentistry. The mental nerve exits the mandible through the mental foramen where it divides into three to fiveThe buccal nerve enters the oral cavity at the anterior branches. The incisive branch of the nerve continuesborder of the tendon of the temporalis muscle and within the mandible as part of the inferior dentaltravels forward and downward within the fascia of plexus. These nerves supply the teeth and periodontalthe outer portion of the buccinator muscle. Branches ligaments of the mandibular teeth. The relativeof this nerve go through the buccinator muscle and position of the lingula varies with age of the client,supply the majority of the mucosa of the cheek. The beginning more posterior and superior on the ramusbuccal nerve is not encountered during surgical as the mandible grows. The inferior alveolar nerveprocedures, however it sometimes is the cause of pain will be bordering the apex of the teeth in the thirdperception during retraction when a buccal flap is laid molar region and closest to the inferior border of thein the third molar area. Local infiltration into this area mandible beneath the roots of the first molars.will alleviate the sensation. In the premolar region, the nerve is midway betweenThe lingual nerve carries sensory and taste fibers the roots and the inferior border of the mandible.starting out in close approximation with the inferior Surgical procedures planned in this area should havealveolar nerve from which it separates, approximately a panoramic film done prior to treatment to view the5 to 10 mm below the base of the cranium. This nerve exact location of the nerve. The inferior alveolar canallies anteriorly and slightly medial to the inferior is located approximately 4 to 7 mm from the lateralalveolar nerve, following the lateral surface of the cortical cortex of the mandible. Injury to the nerve inmedial pterygoid muscle to the level of the upper end this region occurs most often during third molarof the mylohyoid line at which point it curves sharply surgery. The location of the nerve in the bony canalanteriorly to continue horizontally on the upper aids in the regeneration of the nerve and return ofsurface of the mylohyoid muscle into the oral cavity. sensation if fractured fragments of the canal do notIn the most posterior part of the oral cavity the lingual block the canal.nerve is superficial and may be seen visually throughthe lingual mucosa above the mylohyoid line at the Usually three months is given for regeneration beforelevel of the third and second molars. Near the first microsurgical repair is considered. There is amolar, the nerve turns medially and goes underneath significant association between the ages of the clientthe submandibular duct, at which point it divides into and the permanency of persistent neurosensoryseveral branches that enter the tongue. deficits. In clients over the age of 40 with inferior alveolar nerve injury, 47% will have functionallyThe most exposed point for injuring the lingual nerve problematic deficits such as lip biting and droolingis medial to the retromolar trigome, and usually more than 50% of the time. Pre-surgical counselingoccurs during the removal of impacted third molars, regarding persistent, functional, neurosensoryespecially in those clients who have had several problems should be stressed in clients over fortyepisodes of pericoronitis. Multiple infections in this years of age. Age is considered a contraindication inregion can cause tissue contraction that pulls the the removal of asymptomatic impacted third molars.nerve laterally onto the alveolar crest. Research hasfound that an anomalously high position of the lingual 14nerve relative to the internal oblique ridge occurs inapproximately 10% of dental clients. Full recovery of

15

Maxilla maxillary sinus may expand into the alve- olus fromThe floor of the nasal cavity and the floor of the which teeth were lost. Recess of the sinus may reachmaxillary sinus influence minor surgical procedures far downward, becoming very thin. It is common toon the maxillary alveolar region. Typically, the see as little as 3 mm of alveolar bone below the sinusmax- illary incisors are positioned below the floor of floor. In severe cases, the nasopalatine neurovascularthe nasal cavity, the maxillary premolars and molars bundle may end up on the alveolar crest itself and theare below the floor of the maxillary sinus and the anterior nasal spine may be almost level with themaxil- lary canines occupy a neutral position between alveolar crest. Crestal inci- sions in this region arethe two cavities. The relationship of the apices of the placed toward the buccal so as to avoid theincisors to the nasal floor will depend on the length of nasopalatine structures.the incisor roots and the height of the alveolarprocess. The proximity of the teeth to the maxillary Upper lip support is progressively lost as the anteriorsinus is dependent on the alveolar recess of the maxilla decreases in size, tending to give the face amax- illary sinus. concave look or Class III facial appearance and Class III ridge relationship.Cystic lesions, abscess arising from the incisors orother pathology occurring in the anterior maxilla may Mandiblebulge into the nasal cavity and could erode the nasal The most significant structure that should befloor to involve the nasal mucosa. During surgery, the considered in mandibular surgery is the inferiornasal mucosa will appear grayish in color when alveolar nerve.compared to the oral mucosa. The medial shift of the alveolar process in theThe maxillary sinuses are located within the maxillary relationship to the bulk of the mandible causes thebones immediately below the orbits on each side of erupted third molar to lie in close proximity to thethe lateral walls of the nasal cavity. They are the lingual cortical plate with a slight lingual inclination oflargest of the paranasal sinuses and vary greatly in its axis. The external oblique ridge contributesshape and size. They are pyramidal in shape with the significant mass to the outer surface of the mandiblebase of the pyramid being the lateral wall of the nasal in this area, and there is a thick layer of cancellouscavity. The apex of the pyramid points towards the bone between the tooth socket and the outer corticalzygoma, the pterygopalatine fossa forming the plate. There is also a lateral flare of the vertical ramusposterior wall, and the anterior wall of the maxilla in relationship to the horizontal direction of theforming the anterior wall of the pyramid. Maxillary alveolus.sinuses are asymmetrical and often vary in size andshape within the same individual. Impacted third molars bring the tooth very close to the mandibular canal. When the tooth becomesThe palate is concave with the curvature being greater impacted against the distal aspect of the secondin the transverse direction. The hard palate is skeletal molar or by the bone of the ascending ramus, theand makes up the bony palatine shelf of the maxilla roots will grow deeper into the bone and will get closeand its overlying mucosa. Immediately beneath the to the inferior alveolar canal or may even growmucosa are fat globules and mucous and mixed gland beyond the level of the canal.of varying sizes. Beneath the gland of the hard palateon either side of the palatal vault lie the greater The root and canal will rarely meet because in mostpalatine arteries, nerve and vein. Surgical intervetions cases the impacted third molar is lingually inclinedon the hard palate are usually well tolerated and will and the roots pass the canal on the buccal side. Inpresent little anatomic challenge. Palatine tori are cases where the crown of the molar is buccallycommon occurrences and overaggressive surgical inclined or in distoangular impactions, the roots mayremoval of a palatine torus may result in an oronasal be right above the canal. In an attempt to removefistula. The soft palate is muscular and dental surgery these types of teeth by applying an instrument thatis rarely done in this area. exerts pressure distally, the force may lead to a fracture of the roof of the canal that may leaveThe edentulous maxilla sees many changes over time. residual bony fragments to impinge on theThe palatal vault will become shallower, and the neurovascular bundle. This type of nerve injury isanterior portion of the alveolar crest will show per- sistent if the pressure is not relieved.resorption in an upward and posterior direction. Thisoccurs because the loss in the anterior portion of The first premolar is in close approximation to thethe maxilla is mostly on the labial and inferior aspect mental nerve. Any surgical procedures done in thisof the alveolar ridge. Following the loss of teeth, the area may damage the nerve. Incision and drainage of 16

an abscess, apicoectomies, buccal flaps and other There are three definitions of pain and anxiety controlsurgical procedures may damage the mental nerve. techniques:The mental canal arises from the mandibular canal inthe area of the first premolar. This short canal runs • Conscious Sedation is defined as a minimal leveloutward, upward, and backward to open at the mental of consciousness that retains the client’s abilityforamen located between the two premolars or below to independently, continu- ously maintain anthe root of the second premolar. The mental nerve is airway, and respond appropriately to physicalsituated in the perios- teum that is tightly bound to stimulation and verbal commands. Athe opening of the fora- men and forms a thick collar pharmacological or nonpharmacologic agent or aaround the nerve. combination thereof produces this consciousness.One of the most significant changes in an edentulous • Deep Sedation is defined as a controlled state ofmandible is that the mental foramen becomes depressed consciousness, accompanied by acloser to the crest as the alveolar process decreases in partial loss of protective reflexes including theheight. As a result, the mandibular nerve is more inability to continually maintain an airwaysusceptible to injury during any attempted independently and/or respond purposefully topreprosthetic surgery in the area. In severe cases of verbal commands. A pharmacological orresorption, the mandibular nerve, the mental nerve nonpharmacologic agent or a combinationand the genial tubercle may all be located superior to thereof produces this consciousness.the crest of the mandible. In bone loss progression,vertical dimension is lost resulting in an increasingly • General Anesthesia is defined as a controlled stateClass III facial form and maxillomandibular jaw of unconsciousness accompa- nied by a partialrelationship. The mentalis muscle insertion on the or complete loss of protec- tive reflexes,mandible may be lost, resulting in a lifting of the including the inability to independently maintainmuscle and mucosa above the level of the alveolar an airway and respond purposefully to physicalridge. This muscle pull also has a tendency to roll the stimulation or verbal commands. Alower lip toward the alveolar ridge, consequently pharmacological or nonpharmacologic agent or adecreasing the amount of alveolar ridge exposed in combination thereof produces this consciousness.the oral cavity. Preoperative Client EvaluationANESTHESIA AND SEDATION When a client requires in-office parenteral sedation, the surgeon and anesthetist must thoroughly andDefining and understanding the levels of dental accurately evaluate the client. This evaluation isanesthesia and sedation are important because the divided into three parts, the history, brief physicaldifferent stages represent different degrees of examination and laboratory screening tests aspossible risk. Prior to administration of anesthesia/ indicated.sedation to a dental client, one must understand thatthe sedative effects of drugs represent a continuum The medical history is the single most importantof dose related responses. These responses can vary aspect of the client evaluation, as discussed earlier infrom light sedation to intense central nervous system this course under Client Health Assessment anddepression to death. Vital Signs. Normal Activity The next phase is the brief physical evaluation with Light Conscious Sedation focus on the respiratory, cardiac, and neurological Deep Sedation systems. This evaluation often includes blood General Anesthesia pressure, pulse rate and rhythm, respiratory rate and Coma weight. Auscultation of the lungs is necessary in Death clients with any significant pulmonary disorders in order to evaluate current respiratory condition.An individual client’s response to sedation relies not Significant pulmonary disorders include asthma,only on the dose of the drug but also on the recent respiratory infections, COPD and heavysensitivity of that client to the particular drug. An smok- ing. A cardiac auscultation should beiden- tically given dose of the same medication to two performed if there is a question of a heart murmurdifferent individuals can have two different effects. or heart valve abnormality. At this point, the client is assigned a physical status category according to the American Society of Anesthesiologists (ASA) physical status classification status. (Table 5) Clients who fall 17

into the ASA I categories and II pose no unusual risks • Contact lens wearers are asked to remove theirin undergoing properly administered office sedation. lenses if sedation or general anesthesia is beingClients in categories III and IV may require additional used.evaluation, including specific laboratory tests and/or aconsultation with the medical physician. Some clients • Verification that all prescribed medications hasmay not be suitable for in-office seda- tion and may been taken.be referred to the hospital for treatment. • Confirmation of client height and weight to ASA I Normal, healthy client without systemic determine anesthetic dosages. ASA II disease • Review and confirm information on the health ASA III A client with controlled mild systemic assessment form. disease, but with no functional limitations ASA IV • Determine whether a female patient is pregnant ASA V A client with severe systemic disease with or taking oral contraceptives. functional limitations, but notTable 5 incapacitating • Determine when last meal was eaten for clients who are to be sedated or receive general A client with severe systemic disease that is anesthetic. incapacitating and a constant threat to life • Check and record vital signs before and after the A moribund client not likely to survive 24 surgical procedure. hours with or without an operation • Connect all monitors.The third component of the client evaluation is theuse of laboratory screening tests. It is the most • Provide an anti-microbial rinse before seating thecontroversial and least utilized component of the patient.client evaluation. Clients with systemic disease shouldhave the appropriate diagnostic tests based on the • Assist with the administration of all forms ofseverity and type of medical condition. anesthetic.The recommended types of laboratory tests are Client Monitoringshown in Table 6. The monitoring of clients undergoing sedation can be done by a dental auxiliary or by a machine. It isPreparatory Steps Before Surgery important that monitoring is done throughout thePreparing the client for dental surgery is often procedure to recognize abnormal changes indelegated to the dental assistant. For every client, respiration, cardiac rhythm and circulation beforethe vital signs need to be assessed. In clients who are serious complication arise.only having local anesthesia, only the blood pressureneeds to be taken. The basic preparatory steps before The respiratory system is monitored differently in asurgery include: nonintubated client, the type most likely to be found in dental clinics, than in clients who are intubated. Observation of the chest rising and falling with each breath or the movement of the reservoir bag during inhalation and exhalation can easily be done in theTable 6 nonintubated client. In the intubated client, a • Verification that the client consent form is capnograph is the most accurate way of measuring accurate and has been signed. seantdu-rtaidteadl CaOn2d. A pulse-oximeter measures the ratio of desaturated arterial blood and displays • Confirmation that a driver is present for sedated the relative saturation value, SaO2. SaO2 values of clients. 90% and higher are accept- able. Most new pulse-oximeters have an alarm that can be set to sound when the SaO2 value drops to 90% to warn against impending hypoxia. Test Under Age 40 Over Age 40 Over Age 60 On Hypertensive Or Diuretics Chest x-ray Yes (Female) Yes Yes Yes Yes Yes ECG Yes (Female) Yes Hematocrit Yes Yes BUN/glucose Yes Serum Na+/K+ 18Table 6

Monitoring of the cardiovascular system involves the gluteus medias muscle; the vastus lateralis muscle ofability to assess blood pressure, cardiac function and the lateral aspect of the anterior thigh; and the deltoidcirculation. Heart rate, dysrhythmias and ischemic muscle of the upper arm.changes are monitored with an electrocar- diogram(ECG). Pulse-oximeters can monitor the heart as well Intravenous administration allows introduction ofas oxygen saturation. Tachycardia and bradycardia the drugs directly into the bloodstream, resulting inare conditions of concern and often are points set the most rapid effect. IV administration bypasses theinternally in the alarm system. Blood pressure can be problems of variable absorption and achieves themonitored by a manual or automated most predictable and consistent blood levels. Sedativesphygmomanometer. These automated machines can agents can be given in small doses, called titration,be set to take the blood pressure and pulse at any to reach a desired effect. Three types of cannulas aredesired minute interval. available for IV administration: the tra- ditional hollow “straight” needle, a winged or “but- terfly” needle, andSedation should also include a record of anesthesia a plastic catheter. The basic tech- nique ofas well as procedure notes for the services rendered. venipuncture is the same for all three types ofMost anesthesia records are abridged versions of cannulas.the ones anesthesiologists in hospitals use. Theseversions allow for recording the time drugs are given, Preparing Medication from a Multi-dose Vialfpourlmsea,tb. lBoaosdicpirnefsosrumrea,tiSoanOs2ucahndasECclGienint graphic In some offices, the oral and maxillofacial surgery name, age, assistant may have to prepare the medicationweight, ASA classification, medications, monitors, syringes. Some oral and maxillofacial surgeons useprocedure, surgeon and vital signs every 5-15 manufactured pre-filled syringes, but most useminutes is also included in the records. multi-dose vials and draw up the needed amounts of chemical agents into each syringe. Each syringe mustAdministration Techniques be labeled so that the chemical agents are notThere are numerous routes of administration administered incorrectly. These syringes should beavailable for sedation techniques in oral and kept in a locked cabinet for protection and whenmaxillofacial surgery, including inhalation (IH), oral specified by law. When a chemical agent syringe is(PO), submucosal (SM), intramuscular (IM), prepared, the assistant should verify the expirationintravenous (IV) and rectal (PR). Of the previous six date, read the label before filling the syringe and readmodes of administration, the rectal (PR) is rarely used the label after filling the syringe to ensure that thein oral surgery procedures. proper chemical agent has been prepared. WhenFor conscious sedation, inhalation techniques are preparing syringes from a multi-dose vial, the basiclimited to nitrous oxide – oxygen. The ease of use, steps include:rapid onset, and rapid recovery are advantageous. Thetwo major disadvantages include its relative • Wipe the rubber diaphragm on the top of theimpotence and interference from the nasal hood vial with an alcohol sponge and dry it with adur- ing the procedure. sterile sponge.Oral administration is the easiest and mostconvenient sedation technique, but it is also the most • To withdraw liquid from the vial, pull back on theunpredictable. The unpredictability is the result of the plunger of the syringe until it reaches the specificeffects of gastric enzymes, stomach contents, rates of graduation mark that indicates the properemptying and gastric absorption on the drug amount of agent to be used.administered. Many of the drugs are foul tasting andcan produce vomiting following ingestion, affecting • Hold the vial with the diaphragm facing the floor,the actual dose absorbed. remove the needle cap, and pierce the rubberThe number of drugs used that can be administered diaphragm.subcutaneously for conscious sedation are few andmost of those drugs are too irritating and would cause • Push down on the plunger, ejecting the air intotissue sloughing. Two useful drugs that can be safely the vial.administered subcutaneously in the oral cavity areatropine and succinylcholine. • Pull back on the plunger to withdraw the correctIntramuscular administration has the second most amount of agent to fill the syringe.rapid rate of absorption of a parenterallyadministered drug, with only intravenously • If bubbles enter the syringe during filling, gentlyadministered drugs acting more quickly. There are tap on the side of the syringe with the needle endthree anatomic areas suitable for IM administration: of the syringe pointing upward.the most common site is the buttock, specifically the • Expel the bubbles by gently pressing the plunger forward. • After the syringe is filled with the correct amount of the agent, withdraw the needle from the vial 19

and recap using a capping device or one-handed with the anticipated need for postoperative pain scoop method. control guide the surgeon in which type of anesthetic • If additional agent is needed, repeat the process to use. with a sterile syringe. Inhalation Analgesia/Sedation Nitrous oxide is used readily in all aspects ofPreparing the IV Bag dentistry. The gas is a colorless nonirritating gas withAn assistant may be asked to prepare the IV bag and a mild, slightly sweet odor. Nitrous oxide has a blood/chemical agents. IV bags come in several sizes with gas partition coefficient of 0.47 and therefore is poorlythe most common being 250, 500, and 1000 ml. Basic soluble in the blood. It is excreted unchanged by theinstructions for preparing the IV bag include: lungs and rapidly equilibrates between alveolar and arterial concentration gradients. Because of this, both • Open and remove the packaging on the IV bag. induction and emergence times are very short. The • Hold the port end of the bag upside down so that primary disadvantage of using nitrous oxide is its lack of potency. The high- est safe concentration of nitrous the fluid cannot leak out, and pull the seal from oxide is 80%, the remaining 20% being oxygen, the the neck of the bag. same concentra- tion of oxygen found in room air. At • Remove the protective cover from the pointed this high con- centration of nitrous oxide, the deepest end of the drip chamber of the IV tubing set and plane of analgesia achieved is analgesia, or Stage I. with a twisting motion insert it into the port of the At nitrous doses of 30% to 40%, excellent analgesia IV bag. is reached. Sixty percent is generally considered the • Turn the bag so that the port and the IV tubing maximum concentration for good analgesia while still are at the bottom. allowing the client to maintain verbal contact with the • Place the bag on the stand and gently squeeze the clinician. At rates of thirty percent, the analgesic effect drip chamber of the IV tubing, filling it of nitrous oxide is comparable to 10 mg of morphine approximately half full. sulfate. At the conclusion of inhalation analgesia, • Remove the protective covering at the 100% oxygen must be administered for a minimum of opposite end of the IV tubing and allow the fluid three minutes in order to prevent diffusion to flow through the tube. hypoxia. This occurs as a result of large volumes of • When the fluid reaches the end, tighten the nitrous oxide diffusing out quickly into drive and adjustable clamp to stop the flow of fluid. ventilation. • Replace the protective cover over the end of the A scavenging system is essential for the safety of the tubing until it is attached to the IV cannula in the clinic personnel. This system removes waste gases client’s arm. and prevents their disbursement into the room air. In some states, the expanded function of nitrous oxideLocal Anesthesia monitoring can be delegated to the dental assistant.Every oral and maxillofacial surgery procedure must In other states, actual administration can be delegatedinclude local anesthesia. Local anesthesia is a with additional education.reversible blockade of nerve conduction in a specificarea that produces loss of sensation and motor Chemical Agents Used in Oral & Maxillofacialactivity. The anesthetic agents stabilize neural Surgerymembranes by inhibiting the ionic influxes required There are many chemical agents that are used in oralfor propagation of neural impulses. Local anesthesia and maxillofacial surgery for sedation. Thealso controls bleeding during surgery and aids pain prototypical narcotic is morphine sulfate, although it iscontrol immediately after the proce- dure. Current rarely used now for sedation.chemical agents used to produce local anesthesia are Barbiturates have been used since 1960, particularlyclassified as either an ester or an amide. They are methohexital (Brevital) for the induction offurther classified according to their duration of action. general anesthesia as well as an anesthetic maintenance agent for brief surgical procedures. • Short-acting — Less than 2 hours Methohexital is a short-acting barbiturate and the • Moderate-acting — 2 to 4 hours most commonly used agent by oral and maxillofacial • Long-acting — 4 to 18 hours surgeons for office-based outpatient sedation. Compared with its predecessors, thiamylal (Surital)The duration of the planned surgical procedure along and thiopental (Pentothal), methohexital is twice as potent with one half the duration of action. The cen- tral nervous system effects of barbiturates are not fully understood although they seem to depress the ascending neuronal activity through the reticular activating system in the brain. The degree of 20

depression is dose-related, and there is no analgesic soluble in water and less irritating to the vasculareffect of barbiturates; on the contrary, it is thought tissue. It is approximately two to three times asthat these agents are anti-analgesic and may enhance potent as diazepam and onset of action is dependentpainful stimuli. There is no specific reversal agent for upon the drug used for premedication. Even thoughbarbiturates. the half-life of midazolam is only 2 to 4 hours, clinical recovery time is the same as with using diazepam.Methohexital comes as a freeze-dried sterile powder Ketamine was introduced into the dental field asthat is reconstituted with sterile water or normal an anesthetic in 1965 in Europe and in 1970 to thesaline solution. Diffusion into the brain is quick— United States. At that time, ketamine was classifiedwithin 30 seconds of intravenous administration. as an anesthetic that produced “dissociativeThe short duration of the drug is a result of its quick anesthesia”. Ketamine is a derivative of phencyclidine,redistribution into the skeletal muscles, adipose tissue also known as PCP or “angel dust,” and is an acidicand other vessel-poor groups. Since the drug water-soluble solution that can be administereddoes not accumulate in the adipose tissue, cumulative intravenously or intramuscularly. During IVeffects are less and recovery is faster than with administration, onset of dissociative anesthesia isother barbiturates. Methohexital is eliminated 30 to 60 seconds at doses of 2 mg/kg, with durationthrough the liver via demethylation and oxidation lasting only 5 to 10 minutes. Administration should beand excreted by the kidneys. Barbiturates including over one minute to decrease the incidence ofmethohexinal produce a dose-related depression of respiratory depression and/or a hypertensivethe medullary and pontine areas of respiratory response. When administered intramuscularly, atcontrol. They also decrease the brain’s sensitivity to doses ranging from 9 to 13 mg/kg, onset of surgicalbchloeomdoprHecaenpdtoCrsOi2nlethveelscaarnodtiddeapnrdesasotrhtiec anesthesia is about three minutes with duration of 12concentration. bodies to O2 to 25 minutes. Half-life of ketamine varies from 1 to 2 hours in children and 2 to 3 hours in adults.Benzodiazepines were introduced into outpatient The central nervous system effects of ketamine aresedation in the 1960s and currently dominate the profound and “dissociative anesthesia” isfield as both single agents and as part of multiple characterized by intense analgesia, amnesia andagent techniques. Introduced in the 1980s, the two catalepsy. The dissociation component refers to themost popular benzodiazepines are diazepam disruption of the pathways in the brain, preventing(Valium) and midazolam (Versed). Benzodiazepines the higher cortical centers from receiving painfulact directly on the limbic system, thalamus and stimuli as well as auditory and visual signals.hypothalamus, and also interact with the gamma Emergency side effects can be reduced withaminobutyric acid (GABA) receptors. Although intramuscular administration and includethese receptors are the sites of action of the drug and hallucinations and delirium. One advantage to usingare responsible for the calming and antiemetic effect, ketamine is that as long as administration is slow iteuphoria, amnesia and muscle relaxation, there are has minimal negative respiratory effects, even at fullno essential analgesic properties. The cardiac effects anesthetic doses. Premedication is usually withof benzodiazepines are small and often this drug is atropine. Ketamine is used with caution in clients withused in cardiac clients as premedication and part of coronary artery disease, but can be used safely inthe induction sequence for general anesthesia. The clients with asthma.respiratory effects of benzodiazepines are the most Narcotics act directly on the central nervous system,serious when administered as part of conscious specifically on the micro-receptors that depresssedation because tidal volume is decreased and the ventilation, euphoria, sedation and spinal analgesia.respiratory rate increases. Midazolam is Used alone, narcotics will not cause the loss ofcontraindicated in clients with pre-existing diseases consciousness in a young and healthy client.such as COPD, and has a greater effect in depression Meperidine (Demerol) has been used with successof tidal volumes. All benzodiazepines are for many years in outpatient surgery. Doses rangecontraindicated in clients with glaucoma. from 25 to 100 mg with sedative and analgesic effects that are useful both during the procedure andDiazepam is mixed with propylene glycol and ethyl post-operatively. The actions of meperidine are similaralcohol prior to intravenous use because of its water to morphine, but have a quicker onset and shorterinsolubility. Use of diazepam can be irritating to duration of action. Onset is typically 3 to 5 minutes,vascular vessels and is not used in the small veins of however it is only 15% as potent as morphine.the wrist or backside of the hand. This drug is not In comparison with morphine sulfate, meperidinemixed with any other drug and is administered slowly, has less effect in depressing the cough reflex and isat a rate of 1 ml per minute. Peak onset is 3 to 5 metabolized by the liver. Because meperidine canminutes. The drug accumulates in the body fat and cause significant respiratory depression and releasethen is slowly re-released into the circulatory system, of histamines, its use is contraindicated in clientsand then ultimately metabolized. Duration of with asthma, and those who take or have takendiazepam is prolonged with the drug’s half-life of monoamine oxidase (MAO) inhibitors within two20 to 50 hours.Midazolam is shorter acting than diazepam and is 21

weeks of the procedure. Effects of meperidine can ketamine. Finally, as needed on an individual basis, anbe reversed with naloxone. amnesic agent in the form of a barbiturate is added.Reversal Agents MEDICAL EMERGENCIES DURINGCurrently, reversal agents exist only for the opioid OUTPATIENT SEDATIONand benzodiazepine classes of drugs commonlyused for office-based sedation in oral and Recognition and management of medical emergenciesmaxillofa-cial surgery. The only pure opioid antagonist is imperative during outpatient sedation. Associatedavailable for parenteral use is naloxone (Narcan). complications that arise can be secondary to eitherNaloxone reverses all effects of opioids including the sedation and/or the surgical procedure. Table 7respiratory depression, analgesia, hypotension and lists some of the most common medical emergenciessedation. Naloxone competitively binds to all of the during outpatient sedation and their treatment mo-various narcotic receptor sites in the central nervous dalities.system and the prenarcotized state is quicklyrestored. It can be administered through IV, Perioperative Hemmorhageintramuscularly or subcutaneously. The onset of Successful management of perioperative hemorrhageaction is approximately 2 minutes after IV injection, during dental surgery depends on three things:slightly slower with the other two methods ofadministration. The duration of action varies from 31 • Preoperative identification of patients with ato 81 minutes and is dose and route of administration possible bleeding diathesisdependent. A total dose of 10 mg is considered amaximum reversal dose, no additional benefits are • Minimization of blood loss during the surgicalexpected in greater quantities. procedureA recently available benzodiazepine-specific reversalagent, flumazenil (Romazicon) replaces other • Identification and elimination or correction ofnonspecific agents previously used such as the causes of postsurgical bleeding andphysotigmine and aminophylline. Flumazenil is an reestablishment of adequate hemostasisimidazobenzodiazepine that is a pure benzodiazepinein humans. It reverses the effects on the central Preoperative identification of patients with a possiblenervous system by competitively binding with the bleeding diathesis is done with the client healthbenzodiazepine receptors in the GABA complex. It assessment form. Drug usage, whether prescriptiondoes not inhibit other drugs such as barbiturates, or over the counter, is the most commonethanol, narcotics and general anesthesia. Flumazenil undocumented cause of bleeding in surgical clients.delivered intravenously will reverse amnesia, sedation, Special emphasis must be placed on nonsteroidalpsychomotor impairment and respiratory depression. anti-inflammatory drugs (NSAIDs) because they areThe degree and duration of the antagonistic effects is currently the most widely used drugs that may causedependent on dose and plasma concentration over bleeding. Anticoagulants and antibiotics are anothertime. The reversal effects are evident within 1 to 3 important group of drugs that must be considered.minutes and peak effect is reached at 6 to 10 minutes. Major risk factors for surgical bleeding include:The half-life of flumazenil is approximately 60 minutesand resedation is possible when large doses of • Bleeding with prior surgical proceduresagonists are used. Flumazenil is recommended for 1. Extraction of teeth or periodontal surgeryintravenous use only and is packaged in multi-dose 2. Excessive bleeding following any minor surgicalvials. procedureSedation TechniquesClients presenting for conscious sedation should have • Obstetric bleedingrefrained from eating solid foods for eight hours. 1. Heavy menstrual flowClear noncarbonated liquids can be imbibed up to 3hours preoperatively. The client is placed in a chair • Liver diseaseand all necessary monitors for the type of anesthesia 1. Hepatitis B and Cplanned are attached. Vital signs prior to any 2. Cirrhosisadministration are taken and recorded. Nitrous oxide/ 3. Chronic alcohol abuseoxygen inhalation is started via a nasal hood,gradually being increased to the desired level. IV • Renal diseaseaccess is obtained and continuous infusion is started. • Known hereditary diseasesThe anxyolitic agent, usually a benzodiazepine, isadministered first. After waiting a sufficient length of 1. Hemophiliatime to gauge the anxyolitic agent’s effect, the 2. Von Willebrand’s diseaseanalgesic agent is added, either a narcotic or 3. Other inherited coagulpathies 22

• History of abnormal blood counts Minor risk factors to assess surgical risk for 1. Leukemia bleeding include: 2. Thrombocytopenia • History of unusual bleeding• Medication • Frequent episodes of epistaxis 1. NSAIDS • Unusual mucosal bleeding 2. Aspirin • Abuse of illicit drugs 3. Anticoagulants 4. Antibiotics 5. Chemotherapeutic agents SYNCOPE / PSYCHOGENIC SHOCK Treatment Signs and symptoms • Trendelenburg position • Pallor • 100% oxygen • Diaphoresis • Ammonia inhalants • Nausea • 0.5 mg Atropine for persistent bradycardia • Lightheadedness, hypotension • Tachycardia progressing to bradycardia Treatment • Pull tongue forward LARYNGOSPASM • Suction oral cavity and pharynx Signs and symptoms • Push on chest to break spasm if not successful give 10 mg • High-pitched “crowing” on inspiration with partial succinylcholine IV obstruction Treatment • Absence of breath sounds with total obstruction • 100% positive pressure oxygen • Suprasternal retraction on inspiration • Intubation • Epi 0.3-0.5 mg SC or 0.3-0.5 mg of 1:10,000 IV Aminophyl- BRONCHOSPASM line up to 50 mg/min Signs and symptoms • Impaired respiratory exchange Treatment • Inspiratory and expiratory wheezing • If client is coughing, allow to do so • Decreased lung compliance • If not, Trendelenburg on right side • Cyanosis • Suction/clear oral cavity, pharynx • 100% oxygen ASPIRATION • Consider intubation, activate EMS Signs and symptoms • Patient seen aspiring Treatment • Wheezing, rales and rhonchi • Sublingual nitroglycerin tablet every 5 minutes, up to 3 • Tahypnea, tachycardia, cyanosis times • Progressive hypotension • 100% oxygen • IV narcotics for pain relief ANGINA PECTORIS • If no improvement after nitro administration 3 times, con- Signs and symptoms sider myocardial infarction • Intense substernal chest pain • Pain lasts only a few minutes Treatment • Related to increased emotional stress • Sublingual nitroglycerin tablet every 5 minutes, up to 3 times MYOCARDIAL INFARCTION • 100% oxygen Signs and symptoms • Activate EMS • Severe “crushing” substernal pain radiating to left arm • IV Morphine 2-10 mg for pain relief and preload reduction • Pain not relieved by nitroglycerin • Monitor ECG and treat arrhythmias • Pallor • Diaphoresis 23 • Anxiety • HypotensionTable 7

Bleeding disorders may be either intrinsic or acquired. less and of shorter duration than aspirin. NSAIDsIntrinsic disorders are inherited and bleeding results should be stopped 2 to 3 days before surgery.from congenitally deficient or dysfunctionalcomponents of the hemostatic system. Warfarin (Coumadin) is an anticoagulant used by many as a preventative measure for embolic How the bleeding mechanism works phenomena related to several conditions. Some of the more common conditions include atrial fibrillation, • Damage to blood vessel dilated cardiomyopathy, systolic congestive heart failure with poor ejection fraction, valvular heart • Blood vessel contracts and blood flow slows down disease, metallic cardiac valve replacement and deep vein thrombosis/pulmonary embolism prevention. • Clotting factors activated Warfarin inhibits the production of vitamin K-dependent factors II, VII, IX, and X. The use of • Platelets stick to area of damage vitamin K to correct an acute bleed in this client population is contraindicated. Vitamin K will require • Prothrombin activated 12 to 36 hours before the coagulating action can be seen. Vitamin K administration will make renewed oral • Thrombin anticoagulation very difficult for several days. This exposes the client to the risk of embolism. • Fibrinogen Antibiotics used long term can cause defects in the • Fibrin Clot coagulation system because of their effect on vitamin K production and absorption. A PT (prothrombin time)Table 8 should be done. If the PT is elevated, these clients will benefit from the administration of vitamin K1. AnIntrinsic bleeding disorders include Hemophilia A initial dose of 15 to 20 mg intravenously will return theand B and Von Willebrand’s disease. Acquired PT to normal within 6 to 12 hours. Usually adisorders result because of an underlying condition or smaller dose of 10 mg intravenously ordisease. Acquired bleeding disorders include subcutaneously is used in controlling hemorrhagicdecreased production of platelets and increased episodes. The initial dose is followed by onethird thedestruction of platelets. In addition, clients taking dose every 8 to 12 hours. When vitamin K is givenheparin, warfarin, aspirin, NSAIDs; and clients with intravenously, care must be taken to administer slowlyliver disease or systemic diseases can acquire (<5 mg/min) to avoid the precipitation of ableeding disorders. hypotensive episode.Management of Specific Problems Affecting Platelets play a key role in surgical hemostasis. AnHemostasis adequate quantity and satisfactory functioning ofAspirin and NSAIDs are widely used groups of drugs. platelets is required for successful hemostasis. TheThey are taken for many reasons, whether for chronic platelet count is usually obtained as a part of the CBCpain or used as an anticoagulant. Both drugs inhibit (complete blood count). Normal platelet numbersthromboxane A2 synthesis, causing a decrease in the are 190,000 to 400,000/µl. Thrombocytopenia in theADP release and ultimately a decrease in platelet range of 50,000 to 100,000 will increase the bleedingaggregation. Aspirin can inhibit platelet function even time, but is satisfactory for minor surgical extractionsafter as low a dose as 300 mg, and its effects can and biopsies. Elective oral surgical procedures shouldlast for days until sufficient new platelets have been not be performed on clients with platelets less thanformed to correct the defect. Bleeding time is 50,000/µl.prolonged in these clients. Hemophilia A/B and von Willebrand DiseaseFor clients on a low dose aspirin therapy, consult with are congenital coagulation disorders that should bethe physician in order to stop the drug 7 to 10 days managed in conjunction with a hematologist in abefore the surgical procedure. If the risk is too high hospital setting. Procedures to follow based on ato terminate therapy and the surgical procedure is client’s risk category for surgical hemorrhage areminor, bleeding may be managed by local methods shown in Table 9. Hemorrhage control during andsuch as Gelfoam and Gelfoam soaked with thrombin. after surgical procedures will be covered in part two ofIn these cases, the Gelfoam is placed in the extraction this course.site and gingival margins are tightly secured withsutures. The sutures maintain pressure on the wound 24for initial hemostasis. For surgical sites where the useof Gelfoam is impractical, a layer of topical collagenmay be used.The effect of NSAIDs on platelets is quantitatively

Procedures to Follow Based on a Client’s Sicher H, DuBrul EL.: Oral Anatomy, ed 6, St Louis, 1975, Mosby Risk Category for Surgical Hemorrhage Gregg JM: Surgical management of lingual nerve injuries, OralRisk Category Action Required Maxillofac Surg Clin North AM4 (2):417-424, 1992Low-risk client • Proceed with surgery; no further Butterworth JF: Molecular mechanisms of local anesthetics: A investigation or laboratory testing Review, Anesthesiology 72:711-734, 1990 is required. Bennett CR: Local anesthesia and pain control in dental prac-Moderate-risk client • A more detailed history should tice, ed 7, St. Louis, 1983, Mosby be obtained and the potential risk assessed. Jorgenson NB, Hayden S: Premedication: local and general anesthesia in dentistry, Philadelphia, 1967, Lea & Febiger • Laboratory testing: PT, bleeding time, and platelet count. Consult Adriani J: The clinical pharmacology of local anes- thetics, with physician if necessary. Clinical Pharmacology Ther 1:645-673, 1960 • Optimize client preoperative: Ring ME: Dentistry: An illustrated history, St. Louis, 1986, Mosby the treatment to optimize the client will depend on the results Nique TA: Preanesthethic evaluation of the ambulatory oral of the findings that contribute to surgery patient, Oral Maxillofac Surg Clin North Am (4) 743-751, the risk factors 1992High-risk client • Consult with a hematologist. Rackow H, Salamitre E, Frumin MH: Dilution of alveolar gases • Laboratory testing: PTT, PT, during nitrous oxide excretion in man, J Aappl Physiol 16:723, 1961 bleeding time, and platelet count. University Of Minnesota Nitrous Oxide Course, Dr. James Swift – • Management of bleeding lecture notes, January 2001 problems before surgery. • Postoperative management Peterson P, Hayes TE, Arkin CF, et al.: The pre- operative bleeding time test lacks clinical benefit, Arch Surg 133:134, 1998 SUMMARY Caranasos GJ: Drug reactions; Principles and practice ofThe number of people taking medications today emergency medicine, ed 2, Philadelphia,1986, WB Saundersis likely increasing. Many of these people willeventually need some form of surgical dental Malamed, SF: Medical Emergencies in the Dental Office, St.procedure. With thorough preparation, the surgical Louis, Smith,1993, Mosbyassistant can aid the dentist or surgeon. This coursereviewed how to assess client health and risks for oral Smith RG, et al.: Dental Surgery Assistants Handbook, ed 2,surgery procedures, whether performed in the Bristol, 1993, Mosbygeneral dentistry practice or specialty clinic. Althoughthis course touched briefly on many important areas, American Heart Association Endocarditisonly further study and proper training can fully Prophylaxis Information (2008). Retrieved June 30,prepare the surgery dental assistant. 2008 from http://www.americanheart.org/presenter. jhtml?identi- fier=11086 REFERENCES American Dental Association (2003). JADA, Vol. 134, July 2003.Peterson LJ, et al.: Contemporary oral and maxillofacial surgery, ed Retrieved June 30, 2008 from http://www.ada.org/prof/resources/3 St. Louis, 1998, Mosby pubs/jada/reports/report_prophy_ statement.pdfLittel JW, et al.: Dental management of the medically compromised American Dental Association (2007). Overview: New Guidelinespatient, ed 5, St. Louis, 1997, Mosby from the American Heart Association. Retrieved June 29, 2008 from http://www.ada.org/public/topics/ antibiotics.aspAndreoli, TE et al.: Cecil essentials of medicine, ed 5, Philadelphia,2000, WB Saunders http://www.cdc.gov/bloodpressure/facts.htm accessed July 19, 2015 http://ebd.ada.org/~/media/EBD/Files/ADA_Chairside_Guide_Pros- thetics.ashx accessed July 19, 2015 25

Generic Name Appendix IAnalgesicsAcetaminophen Common Trade NamesAspirinFentanyl Tylenol, Tylenol with CodeineHydrocodone Empirin, Empirin with CodeineIbuprofen Sublimaze, DuragesicMeperidine Lorcet, Vicodin, LortabNaproxen Advil, Motrin, PediaProfen, RufinOxycodone DemerolAntimicrobials Aleve, Anaprox, NaprosynAmoxicillin Percodan, PercocetAmoxicillin – clavulanic acidAmpicillin Amoxil, TrimoxAmpicillin – sulbactam AugmentinAzithromycin Amcill, OmnipenCefazolin UnasynCephalexin ZithromaxCiprofloxacin Ancef, KefzolClarithromycin Keflex, Keftab, CefanexClindamycin CiproDoxycycline BiaxinErythromycin CleocinMetronidazole VibramycinMinocycline Erythrocyn, E-MycinPenicillin FlagylTetracycline MinocinOthers Pen VK, Veetids, V-Cillin-KAmitrityline Achromycin, TetracynDexamethasoneDiazepam Elavil, EnovilFlurazepam DecadroneHydroxyzine pamoate ValiumMethocarbamol DalmaneMisoprostol Atarax, VistarilPhenobarbital Delaxin, RobaxinPrednisone CytotecProbenecid Barbita, LuminalProchlorperazine OrasonePromethazine Benemid, ProbalanSeobarbital Compazine Phenergan Seconal 26

ABOUT THE AUTHORNatalie Kaweckyj, LDA, RF, CDA, CDPMA, COA, COMSA, CPFDA, MADAA, BANatalie Kaweckyj lives in Minneapolis where she is part of the management team at Children’s Dental Services-a non-profit clinic serving the underserved in school based care and community settings. She has worked in many capacitiesthrough the years including administrative, program director of an accredited dental assisting program as well as alicensed dental assistant in hospital settings. Is part of the management team at Children’s Dental Services – a nonprofitclinic serving the underserved in school based care and community settings. She has worked in many capacities throughthe years including administrative, program director of an accredited dental assisting program as well as a licenseddental assistant in hospital setting. she is a Licensed Dental Assistant in Restorative Functions, Certified Dental Assistant,Certified Dental Practice Management Administrator, Certified Orthodontic Assistant, Certified Oral & Maxillofacial Sur-gery Assistant, a Certified Preventive Functions Dental Assistant, Certified Restorative Functions Dental Assistant, Masterof the American Dental Assistants Association, and holds several expanded function certificates including the adminis-tration of nitrous oxide/oxygen analgesia and orthodontic band removal. She graduated from an ADA accredited dentalassisting program at ConCorde Career Institute and completed her studies in microbiolo- gy and genetics at MetropolitanState University, University of California Berkeley, and the University of Minnesota, graduating with a BA in Biology fromMetropolitan State University. She is completing her Masters Degree in Public Health with a focus on Oral Health Educa-tion from Independence University.Natalie is currently serving on serveral Councils and Subcommittees of the ADAA. She has previously served as Chair ofthe Fellowship/Mastership subcommittee of the ADAA Council on Education, Chair of the Council on Legislation,Chair amember of the Council on Finance and various ADAA Ad Hoc Committees. Natalie is a former 7th District Trustee as wellas having served in the offices of Secretary, Vice-President, Immediate Past President, and as ADAA President 2010-2011.She is also currently serving as an ADAA Director to the ADAA Foundation. Natalie is a former 7th District Trustee as wellas having served in the offices of Secretary, Vice President, Immediate Past President. And as ADAA President 2010-2011.She is also currently service as an ADAA Director to the ADAA Foundation. In addition to serving three terms as presidentof the Minnesota Dental Assistants Association (MDAA), Natalie has served in many capacities at the local and state levelsof her state association, She is also a past president of the Minnesota Educators of Dental Assistants (MEDA) Association.In addition to her association duties, Natalie is very involved with her state board of dentistry and state legislature inthe expansion of the dental assisting profession, Natalie previously served six years on the DANB Infection Control TestConstruction Committee and is affiliated with OSAP, ADEA and the ADA’s Commission on Dental Accreditation. She hasauthored several other home study continuing education courses for the ADAA. In her spare time, Natalie continues toenjoy public speaking on a variety of topics, travel and enjoying life to the fullest. 27

0807 MAXILLOFACIAL SURGERY BASICS FOR THE DENTAL ASSISTANT: PART 1 POST-TESTTo receive 4 credits for this course please review post-test and complete the exam online. CE Credits earned online areFREE to all dues paying members of the American Dental Assistants Association. The American Dental Assistants Association is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by the AGD for Fellowship/Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 6/1/2015 to 5/31/2018. Provider ID# 217389.1. A client with severe systemic disease with functional 6. If a diabetic client eats a normal breakfast beforelimitations but who is not incapacitated would have a undergoing morning dentoalveolar proceduresclassification status of ______________ . without intravenous sedation, they shouldA. ASA V ______________ .B. ASA II A. not take any insulin that morning prior to theC. ASA IV procedureD. ASA III B. take half of the regular insulin dose C. take the morning neutral protamine Hagedorn2. Clients with severe and uncontrollable hypertension (NHP) insulin dose only should receive only______________ dental treatment. D. take the prescribed morning dose of regular A. conservative insulin and half of the NPH doseB. electiveC. prophylactic 7. Safe medical management of the asthmatic dentalD. surgical client can include the administration of ______________ . A. acetaminophen3. When treating a pregnant client in her first trimester, B. aspirin the dental team should . C. barbiturates A. avoid the use of nitrous oxide D. narcoticsB. place client in a supine positionC. proceed with any elective procedures 8. When completing the medical history interviewD. use nitrous oxide with at least 50% oxygen with new dental clients who are in severe pain upon arrival at the dental clinic, the dental team should4. When clients would be at high risk if they stopped low- ______________ . dose aspirin therapy before minor surgery, dentists and A. accept as accurate the client’s statements surgeons can consider ______________ . A. controlling bleeding with sutures only concerning the duration of pain B. giving NSAIDs B. complete the entire interview after attending to C. managing bleeding with Gelfoam and sutures D. prescribing warfarin the pain C. consider the client’s chief complaint statements to be diagnostic D. inquire about symptoms accompanying the pain5. A pulse oximeter measures _____________ blood. 9. As a warning against impending client hypoxia, A. ventral alarms on the pulse oximeters being used to B. arterial measure arterial blood oxygenation should be set at C. carotid ______________ . D. brachial A. 75% B. 80% C. 85% D. 90% 28

0807 MAXILLOFACIAL SURGERY BASICS FOR THE DENTAL ASSISTANT: PART 1 POST-TEST10. For clients needing emergency dental treatment 17. At a 60% concentration, nitrous oxide during the six months following a myocardial ____________________. infarction, the dental team should ____________________. A. allows the patient to maintain verbal contact A. avoid prescribing antibiotics B. is no longer considered safe B. postpone elective surgery C. produces an analgesic effect similar to 10 mg of C. prescribe mild analgesics for pain control morphine sulfate D. provide aggressive dental treatment D. requires a long induction time11. Which of the following is not associated with 18. The dental team should identify clients with severe, Asthma? uncontrolled, or undiagnosed hypertension because A. NSAIDs should be used to control pain ____________________. B. approximately one half of the asthmatics in the A. anxiety may decrease their endogenous U.S. have onset during childhood epinephrine production C. symptoms may be acute or episodic B. anxiety may elevate their blood pressure to D. symptoms include: cough, tightness in chest, dangerous levels shortness of breath or wheezing C. clients currently taking monoamine oxidase inhibitors should be given anti anxiety drugs12. A capnograph is the most accurate way to measure D. such clients require large amounts of exogenous ____________________. epinephrine during treatment DCBA.... reiNnen2slOdapt2–iirveteiddSaOalO2CO2 2 19. Recommendations for clients with poorly controlled13. Clients with hypothyroidism can receive standard ischemic heart disease, labile cardiac rhythms or care if they present with ____________________. potentially life-threatening arrhythmias include the A. an emergency use of ____________________. B. antibiotic prophylaxis A. anti sialogogues for all such clients C. physician’s approval B. four cartridges of epinephrine-containing local D. mild hypothyroid symptoms anesthetic per appointment C. three percent mepivicaine or four percent14. Prior to minor dental surgery, clients with prilocaine ________________ should be tested for PPT, PT bleeding D. warfarin during surgery time and platelet count. A. coagulopathy 20. During any dental procedure, clients with B. histories of liver disease ____________________ and ____________________ must be kept C. histories of malabsorption in an upright position. D. menorrhagia A. congestive heart failure and nocturia B. congestive heart failure and orthopnea15. During pregnancy and the postpartum phase, which C. COPD and nocturia drug should not be prescribed? D. COPD and orthopnea A. codeine B. erythromycin 21. For standard general antibiotic prophylaxis, C. corticosteroids ____________________ is given orally to adult clients D. penicillin allergic to amoxicillin, ampicillin and penicillin. A. Azithromycin 15 mg/kg16. Treatment considerations for clients with chronic B. Cefadroxil 50 mg/kg obstructive pulmonary disease (COPD) involve the C. Cephelexin 20 mg ____________________. D. Clindamycin 20 mg A. avoidance of anti inflammatory agents B. bilateral palatal blocks 22. As long as it is administered slowly, C. the supine position ____________________ has minimal negative respiratory D. local anesthetics effects. A. fentanyl B. ketamine C. meperidine D. midazolam 29

0807 MAXILLOFACIAL SURGERY BASICS FOR THE DENTAL ASSISTANT: PART 1 POST-TEST23. The most common heart valve to be affected by 27. The buccal nerve enters the oral cavity at the bacterial infection in endocarditis is the ____________________ border of the tendon of the ____________________ valve. ____________________ muscle. A. cardiac A. anterior/temporalis B. mitral B. anterior/myohyoid C. pulmonary C. posterior/buccinator D. tricuspid D. posterior/pterygoid24. Which of the following administration techniques 28. The lingual nerve carries sensory and taste fibers in would most likely not be used in oral and close approximation with the ____________________ maxillofacial surgery? alveolar nerve. A. IH A. inferior B. PO B. maxillary C. PR C. palatine D. SM D. superior25. The inferior alveolar nerve enters the 29. In the edentulous maxilla ____________________. ____________________ at the ____________________. A. no changes occur over time A. mandible/foramen ovale B. the palatal vault becomes higher B. mandible/lingula C. the alveolar ridge will resorb anteriorly C. maxilla/mental foramen D. the sinus may expand D. maxilla/palatine fossa 30. In the edentulous mandible ____________________.26. Diazepam ____________________. A. the alveolar process increases in height A. has a half-life of only 2 to 4 hours B. the maxillomandibular jaw relationship increases B. is soluble in water C. the mental foramen drops vertically C. is two to three times as potent as midazolam D. the vertical dimension increases D. should not be injected in small veins 30