Cardiovascular diseases (CVD) Symptoms of CVD in general: 1-Chest pain: First and main sign to be aware of (vip) 2-Dyspnea:

shortness of breath can be associated with CVD like Left sided heart failure/Respiratory disease *Left sided heart failure- the left side of the heart doesnt work properly so the blood will accumulate in the lung and no blood will reach the heart causing dyspnea. 3-Cyanosis (bluish discoloration)- symptom that more associated with heart failure it happens in : *Asthmatic pts. * CVD * Pts with less blood oxygenation to CNS * Children with Right-to-left shunting or Left-to-right shunting (ventricular blood will mix) 4-Palpitations: Arrhythmia like atrial fibrillation 5-Syncope:sudden loss of conscious due to decrease blood supply. 6-Edema of ankle: due to Right sided heart failure, the blood will still in the body and doesnt go to the right side causing edema in peripheries. Ischemic heart diseases(IHD) - is the most common type of hearts disease and the cause of heart attacks. -Caused by plaque accumulation along the inner walls of the coronary arteries causing ischemia. -Ischemia means a reduced blood supply, so less oxygenated blood reaches the heart. -Pt. complains of chest pain. -Pt. with IHD will have : *Angina pectoris *Myocardial infarction *Acute coronary insufficiency Angina Pectoris -Temporary myocardial ischemia due to CVD -Due to Atherosclerosis ,thrombosis, or arterial spasm which cause a partial block in coronary artery. TYPES: 1-Stable Angina: Pain only in exertion (effort) relieved in a few minutes by rest and sublingual GTN(Glyceryl Tri Nitrate) 2-Unstable Angina: Angina at rest or sudden onset with rapid increase in severity. 3-Cardiac syndrome X : Clinical features of angina but normal coronary arteries on angiogram. 4-Prinzmetal angina (Vasospastic): Caused by coronary artery spasm at rest, like Unstable angina but differs in pathophysiology. 5-Decubitus angina: Pain on laying down. -Pt feels chest pain when climbs the stairs pt. have IHD if this frequent (every week, 10 days,1 month) then its Angina pectoris send pt. to his physician.

-Mangement: Late Morning NOT at early morning High epinephrine Increase load on the heart. NOT at Evening The pt will be tired. -We can give LA comfortably in Late morning because there is less epinephrine in the blood but its debatable because generally we dont give LA intravascular so in real dental practice its make no difference. -Reduce anxiety and stress -You can use LA with or without epinephrine. -If LA with Epinephrine (1:100,000) : in Adults not more than 4 cartilages. -GA alright , but if recent attack wait for 3 months. -Emergency care: GTN, Oxygen mask ,keep setting upright if pain persist- chewable Aspirin 300mg ,Morphine. ***Epinephrine for normal people up to 0.2ml which means around 7-8 cartilages.

*For Cardiac compromised pt. up to 0.04ml.

-Medications: 1-GTN: dilate vessels very quick connection to the heart, easily absorbed from sublingual areamore blood supply to myocardium. 2-Full oxygenation mask. you can continue dental Tt. After 5 minutes if the pain subsides, if not you can suspect MI so you give pt: 3-Aspirin (Is an Antiplatlet ,It doesnt interfere with Tt. Cause the risks of stopping it more than benefits, so you dont have to stop it before treatment). * Some doctors demand stopping it 8 days before Tt. 4-Morphine. Myocardial Infarction: -Complete occlusion of one or more of coronary arteriescomplete Blood supply deficiency. -Crushing and strangling pain at Midsternal area , long duration pain (more than 5 mins), pt may have choking and vomiting. -Management: 1-GTN 2-Full Oxygen mask 3-Chewable Aspirin 300mg(Antiplatelt) 4-Morphine(Opioid)-Pain killerreduce painreduce load on the heart. -Pt position is Upright (while pt. is awake) -First there will be sweating, Fatigue and after a while loss of conscious->so you change the position to SUPINE. If the pain doesnt subside after 2-3 minutes we call for help.

Congestive heart failure -Inability of the heart to pump blood needed for metabolic process. -If the affected site on * the right- right sided heart failure * the left- left sided heart failure. * the heart and lung cor pulmonale- problem in both heart and pulmonary artery or the lung itself(severest) -Mangement: *Pt. position always UPRIGHT . *Late morning *Use less epinephrine. avoid putting pt. in 60 degree chair then raising itthe pt will have hypotension -Medications: 1-Beta-blockers reduce blood pumping so decrease the load 2-Digoxin instead of normaly 60-1000, it pumps less. 3-Antihypertensive(Anti HTN)-> to reduce pressure and after load on the heart. CONTRAINDICATIONS 1- Digoxin interact with antibiotics like Erythromycin(second choice after Amoxicillin). 2-Digoxin and some Beta-blockers(Anti HTN) like Propranolol interact with Epinephrine. ** Mechanism of action: Epinephrine Increase blood pressure Beta-blockers Decrease blood pressure if two drugs interacted lead to very raise in blood pressure so decrease using epinephrine . Hypertension(HTN) -Normal blood pressure is (120-130/80-89). -Hypertensive pt has blood pressure above (140/90). -History taking is important to know how bad is the HTN- If pt take medications then its bad HTN.Mangement: * LA with epinephrine(1:100,000) up to 4 cartilages (not more than 0.04mg) *GA is alright GA contains hypotensive agents and the pt is also taking anti-hypertensive drug so this should lower the blood pressure a lot BUT in this case we dont stop the antihypertensive drug To avoid Rebound HTN after surgery. -If hypertension exceeds the limit the pt, will have a stroke. -Myocardium can stand HTN but Brain cant(there will be hemorrhage). -Reduce stress

-Sedation : Benzodiazepine(Valum). -Short Treatment duration. Rheumatic Fever -Caused by bacteria called: Streptococcus Pyogenes (Beta-haemolytic streptococci). -Untreated childhood sore throat caused by Strep. Pyogenes causes the body to produce antibodies against it, this will lead to cross-antigenicity. -Cross-antigenicity: the antibodies start attacking the bacteria and consider the heart as foreign agent. -Pt has multiarthralgia and problems in the heart. -Pt. should take prophylactic antibiotic to prevent Infective Endocarditis(IE) -Always ask the pt. if he had untreated sore throat if yes refer to specialist doctor to prescribe prophylactic antibiotic to take before the treatment. -Reduce stress- Diazepam -Short dental appointment. Infective Endocarditis -Bacterial infection leads to distortion in one of the cardiac valves. -Caused by Streptococcus Viridans which found most commonly in oral cavity. -Any pt has problems in cardiac valves in general should take prophylactic antibiotics before treatment to prevent inflammation of the valves. - if the patient had problem in one of valve like: *mitral valve stenosis *prosthetic valve * pulmonary valve stenosis *rheumatic heart valve *Previous infective endocarditis *Complex cyanotic congenital heart disease and the pt didnt take prophylactic antibiotic he will develop: *Low grade fever. * Arthralgia (pain in joint) *Cardiac problems: arrhythmia and pain- due to the bacteria that entered from oral cavity and settled in the valve and led to inflammation of the valve and total distortion to the area. -Pt with IE should enter hospital and take Antibiotics for 2 weeks, in some severe cases pt will need prosthetic

heart valve. -Greater percentage will die from IE. -Mangment : prophylactic antibiotic Always ask if the pt has allergy to penicillin: If pt dont have allergy ADULT : 4 tablets of Amoxicillin (500mg) 2g of amoxicillin Or we can give Ampicillin as liquid but Amoxicillin is better. CHILD: 50mg/kg of Amoxicillin(tablets) or liquid. Make pt return after hour to make sure that antibiotics in the blood is highest. If pt has allergy Clindamycin, Azithromycin(microlide), Cefazolin same thing for children but less dose (Azithromycin 16mg/kg,Clindamycin 20mg/kg),

Respiratory Disease -Clinical features: *Cough *Wheezing *Cyanosis *Finger clubbing( sign you can see in Respiratory, Liver and Cardiovascular disease) -The difference between signs and symptoms: Signs: Something doctor see Symptoms: Something Pt. tells you about. -GA is contraindicated. -GA for Pt with influenza-wait until recovery -GA for pt. with Asthma give cautiously . -Same thing applied to Analgesics(Pain killers), Narcotic (Heroine and Morphine), these drugs lead to respiratory depression. Asthma -Caused by : bronchospasm and Hyper-irritability . -Expiratory wheezing (inspiration us active and expiration is passive) -Less Oxygen saturation(instead 95% it will be 90%) -Difficulty in breathing.

Endocrine disorders Diabetes Mellitus -Diabetes mellitus is a disorder caused by an absolute or relative lack of insulin -there can be a low output of insulin from the pancreas or the peripheral -Persistent elevation of blood glucose level. -Normal fasting blood glucose is 100 mg/dl, anything above that is not normal even if it is an elevation of 20 mg/dl. -Glucose tolerance test is a good test to determine if a patient is diabetic ,we first check the fasting blood glucose, and then we give him glucose and we recheck blood glucose after two hours, if it is below 11.1 mmol/liter then this patient is not diabetic, if it is above he is definitely diabetic. -Fasting plasma glucose (measured before the OGTT begins) should be below 6.1 mmol/L (110 mg/dL). Fasting levels between 6.1 and 7.0 mmol/L (110 and125 mg/dL) are borderline, and fasting levels repeatedly at or above 7.0 mmol/L (126 mg/dL) are diagnostic of diabetes. ***Diabetes mellitus is a disorder caused by an absol ute or relative lack of insulin: there can be a low output of insulin from the pancreas or the peripheral tissues may resist insulin. it is Absolute when the patient has diabetes type 1, they have autoantibodies against the B- cells of Langerhans, occurs in young people, they have deficient insulin, they sustain this disease early, it is insulin dependent from the beginning, no benefit from giving oral hypoglycemic drugs, they need insulin injection .This type is genetically determined (doesnt mean it is inherented, because it is an autoantibody) . Type 2 which is non insulin dependent (there is enough insulin in their bodies), but they have resistance to the receptors of insulin (they wont let glucose get in) and it is inherent. Gestational diabetes: happens in pregnant females usually in their third trimester, they usually recover after delivery but such females are very susceptible to have diabetes in the future. P.S infants of diabetic mothers are born overweight because there is too much sugar in blood and sugar can cross the placenta without hormones, so the baby will get bigger . Oral manifestation of diabetes mellitus 1-high level of alveolar bone resorption 2-xerostomia 3-delayed or defective wound healing 4-gingivitis 5-pulpitis in non carious teeth 6- impaired sensation in tongue 7-Acetone smell (ketoacidosis): hyperglycemia-body will degrade fat (triglycerides) and supply the organs with some other nutrient---> waste products of such process are ketone bodies. Patients who reach this level are very poorly controlled.

Of course this happens in non controlled diabetic patients, controlled diabetic patients can be treated as normal people.

Dental management: *diabetic patients are given early morning appointments, we want them to come after theyve had their breakfast and medicine, and most importantly not to miss a meal. *Regarding premedication some would advise certain antibiotics as prophylaxis if the patient come as an emergency. *Make sure appointments are short (about 30 min).

Specific signs for severe anemia: 1. Koilonychias: spoon-shaped nails, usually we see it in iron deficiency anemia. 2. Jaundice may be in some types of anemia mainly hemolytic anemia(destructed RBCs will increase the bilirubin level which leads to jaundice) 3. Bone deformities; mainly in thalassemia major and sickle cell anemia. 4. leg ulcers: mainly in sickle cell anemia Classification of anemia Types of anemia Hypochromic Microcytic (MCV is low <79 fl) -RBCs on the blood film are small . -low Iron content -high iron binding capacity to compensate the deficiency. 2-Thalassemia.( pseudo plastic anemia) -inherited autosomal recessive blood disorders caused by the weakening and destruction of red blood cells -Small RBCs -Low MCV -Normal iron content-the patient source of consumption and absorption of iron is normal but the problem in the RBCs itself. Examples 1-Iron deficiency. (most common anemia) Hypochromic -RBCs are pallor than normal (low redness) Microcytic - small average RBC size

Hyperchromic Macrocytic

Vitamin B12 deficiency Malabsorption (Post-gastrectomy) Foliate deficiency , Hemolysis Aplastic anemia, Liver diseases, Hypothyroidism. Chronic diseases. Renal failure. Hemolysis. Hypothyroidism.

Hyperchromic-very reddish color of RBCsMacrocytic-large average RBC size>99 fl

Normochromic Normocytic Normal MCV

Normochromic-normal color of RBCs(red)Normocytic-normal average RBC size

Microcytic Anemia
Two types: 1-Iron deficiency anemia 2-Thalassemia 1 Iron deficiency anemia (MOST COMMON): -Microcytic, Small size RBC in blood films -MCV below <79 fl. -Hypochromic. Low Iron content -This type of anemia requires: * good diet it gives us around (15-20 mg)of iron -from vegetables around 1-10% and 10-20% from animal foods -Iron absorption occurs in duodenum and jejunum so any patient has diseases in duodenum and jejunum will be anemic. *Ferrous form of iron is better in absorption than ferric form. *Gastric acid is needed for the adequate conversion of iron salts from ferric to ferrous forms for their absorption from the proximal small intestine. - people who take anti-acids to neutralize their low acidity has less iron absorption Causes of iron deficiency: 1.Poor iron intake (the most common cause in males) 2.Pregnancy which requires an increased demand of iron (pregnant ladies must take supplements) 3.Malabsorption. 4.Chronic blood loss from:

-Inside this empty space there is a functioning area that appears like collection of hair connecting the outer plate and inner plate of the skull and it contains living cells that produce nonfunctioning blood. -Thalassemic pt. will have a lot of blood borne viruses/infections due to frequent blood transfution(2-4 times a year). -LA is safe in general. -Sedation, its ok BUT- Thalassemic pt. has low functioning blood-> low blood oxygenation->he will not stand procedure's stress->so Full(100%) Oxygen mask should be supplied, to make sure that the functioning blood is saturated with Oxygen. -GA is hard in some pts. with enlarged maxilla, its difficult to introduce tube inside airway. - Enlarged Maxilla appears empty from inside due to rarefaction (due to extramedullary hematopoisis).

Macrocytic anemia.
1-Vitamin B12 Deficiency 2- Folic acid deficiency Vitamin B12 Deficiency -Vitamin B12 and folic acid deficiencies are part of the Macrocytic Anaemia (high MCV; above 98). - Intrinsic factor normally binds to vitamin B12 and carries it to somewhere in the intestine, so it ease the absorption of the vitamin in the intestine; in the ileum, -if the patient has problem with the intrinsic factor the vitamin will not be easily absorbed from that area. - Most common type of macrocytic anaemia, it is either: 1-Autoimmune disease (we call it Pernicious Anaemia) 2-due to nutritional problems.(common).

Autoimmune disease( Pernicious Anemia): -Is the presence of auto antibodies against the intrinsic factors of the parietal cells, or against the parietal cells itself that produce the intrinsic factors! In both ways we won't have intrinsic factor, so there is less Vitamin B 12 absorption. - Pts. ith Pernicious anemia will have : *autoimmune diseases like the Thyroid disease, Addison's disease. * higher incidence of gastric carcinoma. Causes of vitamin B12 deficiency: 1-Insufficient dietary intake (vegan/vegetarian) *main source of the vitamin is red meat. 2-Impaired absorption due to: * problem in stomach so no production of intrinsic factors. *will be small bowel or celiac and chron's disease ( it is an inflammatory bowel disease), tropical sprauce * bacterial overgrowth in the ileum; where the vitamin is mainly absorbed, or

Causes of Aplastic Anemia: 1-Congenital ( fanconi anaemia) it was found commonly between the people that marry their relatives, and it's still seen now. 2- Acquired due to: *ionizing radiation * radiotherapy (lymphoma) *chemicals *drugs * insecticide (farmers) 3-Infections : measles 4-Salacious infections : tuberculosis. 5-Pregnancy Clinical features: 1-Blood anaemia Bleeding tendency23-Infections: No WBCs so they can develop any sort of infection including fungal infections

Anemia of chronic disease:

Sickle Cell Anemia (Normocytic Anemia) Hemolytic Anemia: **Thalasemia is called hemolytic anemia, but Thalasemia is microcytic anemia, here we're talking about normocytic anemia. -Red cells usually survive for 120 days, but in hemolysis the RBC lives just for a short period of time then it gets lysed. This leads to anaemia and for one of the symptoms that we talked about before "Jaundice" Causes of Sickle Cell Anemia : -We ask the patients with glucose 6 phosphate not to take certain medications and they can live a normal life! these medications are: *NSAID :Aspirin, Prufin * Some Antibiotic. -We usually give aspirin as an antiplatelet. - Prufin as it's a very good dental analgesic. BUT its CONTRANDICATED in Pts having glucose 6 phosphate deficiency -Inherited : * RBC membrane defects; spherocytosis, *hereditary elepto or hemoglobin abnormality (not abnormality in the cell shape, but in the hemoglobin) - Thalasemia, Iron Deficiency Anaemia and Sickle Cell Anemia and metabolic defects such as Glucose Six Phosphate Deficiency : Glucose 6 Phosphate Dehydrogenase enzyme will be defected.

-After a month (for example) you will see that the injury has healed all together-tertiary haemostasis. -When a patient comes to you for extraction, RCT or whatever, first of all you will take history. -For hemorrhagic diseases (bleeding disorders) history comes first because sometimes bleeding tendency cant be revealed with all blood tests. -So history is the primary way to know if there is any bleeding tendency. *In the history examination you will be asking the patient about different systems in the body including bleeding. How would you inquire about any history of bleeding? -Ask the patient about any previous disorders. Examples: - Have you ever get hospitalized because of bleeding that resulted from accident? - Have you ever had a long period bleeding after tooth extraction? (Normally, it stops after 24 hours). - Patient with a previous surgery and no bleeding disorders have occurred means that we are most probably not worried and the patient is fine. Extra notes (from the book): - There could be a bleeding tendency if the bleeding is unexplained by the degree of trauma or there is a previous, or family, history of excessive bleeding such as: - A previous diagnosis of a bleeding tendency. - Bleeding for more than 36 h or restarting more than 36 h after operation (however, this could indicate an infection). - Admission to hospital to arrest bleeding. - Blood transfusion for bleeding. - Spontaneous bleeding. - Convincing family history of one of the above combined with a degree of personal history - Treatment with significant drugs such as anticoagulants.

Blood tests
1. Tests-bleeding related to platelets: ** Platelet count: In the primary haemostasis, if there is no vasoconstriction or there are no platelets, the test we apply is platelet count. - Normal number of platelets is: 150-400 X 10^9/L. Extra notes (from the book): - The platelet count provides a quantitative evaluation of platelet function. - A platelet count of <150000 can be associated with major post- operative bleeding. ** Bleeding time: - The normal bleeding time is: 2-9 min. the problem with bleeding time that it has a wide range (2-9 min) so that an argument says that bleeding time is not very specific. - Bleeding time is a test used to examine platelet function. - Bleeding time is affected by: platelets count, platelets function & blood vessels. Extra notes (from the book): - The test measures how long it takes a standardized skin incision to stop bleeding by the formation of a temporary haemostatic plug.

Platelets disorders
1- Reduced production: cancer patients or patients with bone marrow diseases have reduced production with all blood cells. 2- Any disorder in the bone marrow that can kill all types of cells or either one type can predominate. Examples: * Leukemia: in some patients with leukemia you will find very high white blood cells while other sorts of blood cells are depressed. *Aplastic anemia: the patient will have a defect in anything related to the bone marrow. * Medications: Like chloramphinicol can lead to reduce production which will lead to platelet disorder as a part of many disorders-consequentially the patient will have bleeding tendency. * Sequestration hypersplenism: the platelets destination is the spleen. - There are some patients whose treatment is by splenectomy (removal of spleen). Why is that? Because when the patient has hypersplenism, the spleen will have high ability of sequestration and the body will not be able to cover the huge number of platelets. 3- Increased destruction: a well known disease for increased destruction is : **ITP- which stand for Idiopathic Thrombocytopenic Purpura that can be acute or chronic. - Purpura: A small superficial bleeding. - Intra-orally: it is called petechia. -Around the eye: it is called: Ecchymoses. ** Certain drugs: as we talked about chloramphinicol (in some patients) that can lead to over anti-bodies and can lead to Aplastic anemia destroying all cells including the platelets. **HIV: the HIV can cause an ITP-like disease as HIV thrombocytopenic purpura. **Aspirin is the prime antibiotic medication worldwide, For a patient taking aspirin, we expect to have deficient platelets for 1 week. - Aspirin shouldnt be stopped. Deficient platelets for 1 week rarely cause significant post-operative haemorrhage, stopping Aspirin can lead to other problems, Aspirin shouldnt be stopped. - Tests for Aspirin: Bleeding time (2-9 min) & platelet count. If the platelet count is normal but the bleeding time is not, means that there is a problem in the platelet function. Hess test: not used widely. - How it is performed? Pressure is applied to the forearm with a blood pressure cuff. - When the pressure is applied for Patient with platelet disorders, they will have purpra all around the extension meaning that this patient is having bleeding disorders. - Extra note: this test is neither sensitive nor specific. * Thrombocytopenia: - Platelets count below 100X10^9/L. - A patient with thrombocytopenia has a defect in primary haemostasis so that there will be petechiae and post-operative bleeding which is superficial in its majority.

*The blade used is fixed on the scalpel. In oral surgery the scalpel used is number 3 scalpel. *The rate at which a blade dulls ( becomes not sharp) depends on the resistance of tissues through which the blade cuts. -Bone and ligamental tissues dull blades more rapidly than does buccal mucosa. Therefore the surgeon should change blades whenever the knife does not seem to be incising easily. *These are some types of blades used in oral surgery:

Blade number 11: used to do an incision in an abscess to drain it.

Blade number 15: most commonly used

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Blade number 10: similar to number 15 blade but larger, usually used by general surgeons to do excisions extraorally.

Blade number 12: posterior area of the oral cavity, especially in the maxillary tuberosity region ( curved)

2-Use a single firm continuous stroke when incising. -Repeated incisions are not allowed because they cause damage to blood vessels and soft tissue which increases bleeding and may complicate our surgical treatment. *holding the scalpel is done using the pen grasp, for more control and tactile sensitivity, and only the wrist should be moved not the whole forearm. 3-the surgeon should carefully avoid cutting vital structures when incising And the surgeon must incise only deeply enough to define the next layer . a- incisions in the buccal area of the lower premolar should not be done to avoid injuring the mental nerve so vertical releasing incision should be distal to the tooth away from the mental nerve area b-Incisions in the lower wisdom teeth area lingually should not be done to avoid injuring the lingual nerve which is covered only by soft tissue in this area. c-when using a scalpel the surgeon's focus must remain on the blade to avoid accidents 4- incisions through epithelial surfaces that the surgeon plans to reapproximate should be made with the blade held perpendicular to the epithelial surface ( 90 degrees) . -squared wound edges that are both easier to reorient properly during suturing and less susceptible to necrosis of the wound edges as a result of ischemia -any oblique incision will cause undermining of the edges which will compromise the blood supply and subsequently interfere with wound healing. 5- incisions in the oral cavity should be properly placed. It is more desirable to incise through attached gingiva and over healthy bone. -not cross the canine eminence because this will cause dehiscence and separation of the flap margin

The surgeon can help improve the patient's chances of having normal healing of an elective surgical wound by evaluating and optimizing the patient's general health status before surgery. For malnourished patients, this includes improving the nutritional status so that the patient is in a positive nitrogen balance and an anabolic metabolic state.

Complicated exodontia
-All exodontias are surgical though the term ^simple_ is widely used. Synonyms - Simple extraction = Intra-alveolar extraction = Closed extraction = Uncomplicated extraction. - Surgical extraction = Trans-alveolar extraction = Open extraction = Complicated extraction. -simple extraction is a deceiving term though it[s used, it[s better to call it ^closed extraction_.

Pain and Anxiety (anesthesia and sedation, respectly):

*Local Anesthesia t Most commonly used is Lidocaine acts for about 2-3 hours (xylocaine, lignocaine are other names for lidocaine). when do we use lidocaine? -Maxillary infiltration anesthesia it takes a rapid onset of action(Kick-off) and it lasts for a shorter time (shorter duration of action). - I.D Nerve Block it takes more time to kick-ofF and it wears-off slowly (longer duration of action). -first tissues to be anesthetized are soft tissues then bone and teeth and, the first tissues to wear-off are the soft tissues then the bone and teeth. Sedation : whenever the patient is thought to be anxious and difficult to manage. -sedatives are not given to control pain, but they are used to reduce stress, and helps to induce sleeping - how we[re going to make the patient relaxed? We give him Benzodiazepine like: *Midazolam (I.V) and it[s given 1ml per kilogram (this is the maximum that can be given), * diazepam (Valium) orally nitrous oxide (N2 O) is also used, mainly with children.

The Indications & Contra-indications for Extraction: Idications:

1.Non- restorable teeth 2.carious teeth 3. remaining roots 4.severely periodontally-involved teeth (severely mobile teeth), 5.referral for orthodontic treatment 6.prosthetic rehabilitation 7.associated pathology

The indications for open-extraction :

1- Failed closed-extraction 2- If there[ dense bone surrounding the tooth : *racial (e.g. black people usually have denser bone than other races) *anatomical (e.g. wisdom tooth surrounded by buccal dense bone) *pathological : -Paget[s disease of bone in which there is dense bone and there[s hypercementosis 3- an old patient who has one standing tooth the bone surrounding that standing tooth will be dense, so this tooth is anchored strongly in the bone. 4- Funny roots : ankylosis , hypercementosis (as in Paget[s disease or in old people with standing molars especially if they[re not used), and dilacerations. 5- Lose condyles , as in Ehlerst Danlos syndrome or Marfan syndrome (connective tissue diseases), in general people with connective tissue diseases has lax muscles and lax joints or ligaments, in people with lose condyles, when closed extraction is used it might cause TMJ dislocation. 6- Heavily decayed tee th 7- Pneumatized sinuses , an enlarged sinus, as if the upper first molar has been extracted for a long time, the space of the tooth in the bone will be occupied by the sinus so the floor of the sinus could be easily fractured resulting in oro-antral communication but if a planned open surgical extraction was done, some bone layers wouldbe removed little by little without applying much force preserving the integrity of the sinus. ( -The palatal root of the upper first molar is very close to the sinus and can be in the sinus itself, penetrating the sinus floor and covered by the sinus membrane ).

Steps for The Surgical (Open) Extraction of Tee th:

All of the following steps are vital and care must be taken of them 1- MPF (muco-periosteal flap). 2- Removing bone. 3- Delivery of the tooth (how to deliver or take the tooth out after doing the flap and bone removal). 4-Irrigation and Debridement 5- Closure. 6- Post-op. care.

1-The muco-periosteal flaps three types: 1- envelope flap in which the gingiva over the alveolar crest next to the teeth is only incised (from the crevicular side of the gingival- One-sided flap, without releasing incision. -releasing or relaxing incisionmakes the flap able to be opened wider. 2-two-sided flap = triangular flap = 3 cornered flap = envelope flap with one releasing incision. 3-three-sided flap = Rhomboid flap = 4 cornered flap = envelope flap with two releasing incisions. 4- crestal flap in edentulous patient on the alveolar crest, like the envelope flap but when there is no teeth.

Triangular flap

Envelope flap: the incision is done on the sides of the teeth and there is no releasing or relaxing incision, so good access should be obtained. - good envelope flap incision is two teeth anterior and one tooth posterior to the area to be worked on,this is to make sure that the tissues can be retracted easily and nicely without making any tears. -Triangular flap, the incision is extended one tooth anterior and one tooth posterior to the tooth in question (not two teeth anterior like the envelope flap) because there is a releasing incision, the mucosa will be elevated or retracted away.

- long incision heals just like the short incision as long as it[s kept clean, and treated properly. - small inadequate incision is going to be retracted more to make access and this will cause the incision to be torn and the healing of such an incision is very slow

*on the skin we use monofilament not to cause big scar at the area of suturing . -polyester and polypropylene : monofilament so we can use them extraorally . Technique of suturing : Using tweezers and needle holder : -Needle holder :should be held by putting the thump in the first ring of the holder and the ring finger on the second ring 1-Now we catch the last 2/3 (or 1/3) of the needle by the tip of the needle holder 2-the needle should be 90 degree with the needle holder 3- we should start from the mobile part of the flap not the nonmobile and the needle should go in the flap vertically and go out vertically by the tweezers 4-knot (( . but how much knots should I do ?? -Every suture material have a special number of knots - make sure that each knot is stable - nylon needs 6 knots , vicryl needs 4 knots .
Sutures types:

A-interrupted suture (universal the most common type in oral surgery ) ,every suture knot is alone . B-continuous suture (running ) : we continue suturing all the way without stopping, the good thing in continuous suture that its stronger than interrupted suture but if one part is torn all the flap will open , not like in interrupted just that torn area of the flap will open . C-continuous locking : the aim of this suture is to make sure its water dried , thats mean it close the flap in away that inhibit water to go in it . ( this description is not real bcz it cant inhibit water from going in but this description tell us how much this suture is tight ). D-horizontal mattress : there are 2 lines on each side of the flap and tightened in one side . they are horizontal on the flap . This suture will give good closure of small flaps. E-vertical mattress : here there are 2 lines one of them near the edge of the flap and the other is away and they are vertical on the flap .

6-post-operative care: this step is vital as extraction -you should tell the pt that it might be pain and swelling -prescribe analgesic for pain, and antibiotic for infection -List of complications: *Ecchymosis: blood accumulation(large hematoma),at site of extraction or outside. *petechiae:small hematoma *swelling: its something nomal you cant inhibit it but you can reduce it by: -in extraction day : putting some cold compressors->Vasoconstriction decrease blood flow to the area>less edema -one day after extraction : putting hot compressors->vasodilatation-> edema reduction. -we can give anti-inflammatory(Steroids- Cortisol ) before procedure-> Dexomethasone. *Trismus: reduction of mouth opening -Muscle get spasmatic due to muscle manipulation -Blood may get into muscles around the face causing inflammation *Pt's food: -First day: pt should drink soaps/fluids (not too hot) avoid solid food. -the day after: pt should eat anything thats high in calories to recover soon. *Oral hygiene: 1-Extraction area should be kept as clean as possible 2-pain should be controlled 3-Prevent infection by prescribing Antibiotics, only for immune compromised patients, even if its closed extraction. 4-recall appointment should be scheduled. How to use elevators? The blade should be wedged between tooth and the bone that its supported the same tooth. -never rely on the adjacent tooth because you may luxate it. Types of elevators: 1-Coupland elevator 2-Cryer elevator 3-Apexo elevator 4-Warwick James elevator Multiple extractions: -we should start by maxillary teeth because: 1- extraction of most of the upper is by bucco-paltal movement , the lower by some sort of vertical movement so you can hit the upper if they were not extracted \ 2- to prevent any blood or whatever from going down into the lower socket . -The doctor prefer to start by the mandible because when we extract the lower teeth first, the blood will go down and the area will be clear .

3-Tooth Sectioning: cutting the tooth itself, sectioning may be: Crown removal/separation from the roots Sectioning the tooth into two pieces (as if you have two separate pre- molars), and each half of the tooth is extracted separately. 4-Irrigation: after sectioning or removing the tooth * main purpose of irrigation is to : 1-decrease the bacterial in the socket). 2-flush out necrotic tissue and debris, *Irrigation alone has a very large effect on decreasing post-op infection 4- File and Debride the bone, getting rid of any sharp edges or bone spurs by burs or bone files. 5- Suturing 6-Post-Op Sequela What is the difference between post-op sequel and Post-op complications? Post-op sequela means any expected/usual occur after operation in case of 3 rd molar extraction like: 1-inflammation 2-stiffness : due to applying force to the muscles of mastication, leading to Mild trismus. 3- swelling : expected to increase up to 48hrs after surgery, after 48 hours it reaches its peak size, then begins to decrease (usually swelling is completely gone after 5 days). 4-moderate bleeding/oozing : is expected for the first 24hrs and anything above 24hrs is considered a problem. - bleeding at first 24hrs is not a free flow bleeding, but instead a slight drop -Profuse bleeding/active bleeding on the other hand is a sign of something wrong. 5-Pain: Any extraction (wisdom or other) is expected to lead to post-op pain its maximum 12 hours post operation, after which it begins to decline so prescribe good analgesic.

-giving prophylactic or post-op antibiotics leads to a decrease in the occurrence of dry sockets. - Administered antibiotics can either be: 1-local/topical -tetracycline INSIDE the socket 2- pre-op antibiotics-amoxicillin-we always give penicillins which are higly effective against streptococci viridians - except in peri-chorinitis where metro-nidazole is given - best way to prevent dry socket is proper irrigation after extraction * irrigants : normal water or saline, as long as it properly flushes the socket. -Trea tment of Dry Sockets: 1-re-irrigate the socket 2- debride gently debride the area *rough debridement will lead to removal of any blood clots which is counterproductive. 3-Alveo-gel (a eugenol/sedative based gel) placed inside the socket as a sedative only and replaced every few days,it only decreases the pain. * Alveo-gel should ONLY be used when the pain cannot be controlled with analgesia, as it is considered as a foreign body and may lead to delayed healing of the wound. 5-Nerve Disturbance: *Temporary nerve disturbance as a post-op extraction is 3% * PERMANENT nerve disturbance is very rare, less than 0.01% * nerves affected : Lingual, ID nerve, Long Buccal or the nerve to the MyloHyoid. Cause: 1-tooth itself was close to the nerve according to Roods and Shehap classification. 2- compression injury (downwards pressure onto the ID canal during) 3-Canal damage due to complete bony impaction while sectioning the tooth. 6-Displacement of Wisdom tooth during Extraction: Displacement in the Mandible: 1-towards the lingual pouch (beneath the mandible, in the sub-mandibular space). The treatment of this displacement is: * Take a Radio-Graph * Inform the patient * Leave the tooth in its position * Prescribe antibiotics

operative assessment related to patient itself: -taking history and whats we called general assessment, like the patient age and personality - stress is the main problem in extraction not pain - Extraction with sedation either with LA or under GA decided according to pt. personality and difficulty of the procedure. -if the patient is frightened his pain threshold will be very low so we have to use sedation so either LA with sedation or GA (More details later on)

Local assessment related to the tooth itself: 1-Access and width of mouth opening is appropriate for such a procedure (rima oris in Latin): PELL and GREGORY put a classification for wisdom teeth it applies for mandible and maxilla -Tow types of classes: 1-class1,2,3- applies only for lower wisdoms-related to access 2- classA,B,C- applies for upper and lower-related to depth.

Class 1,2,3 : position of the third molar related to Anterior border of the ramus *Class 1: the tooth is found completely anterior to the anterior border of ramus of the mandible. *Class 2: the tooth is found in the middle, part of it is found anterior to the anterior border of the ramus and the other part is posterior to the anterior border of the ramuss *Class 3: the entire tooth is found posterior to the anterior border of the ramus.

Rod and Shehap assement of the relation between ID canal and the mandibular third molar.

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