THAMAR UNIVERSITY

FACULTY OF DENTISTRY
ORAL SURGERY
THIRD YEAR OF DENTISTRY
PROFESSOR: Dr Manuel Diaz Hernandez
Oral and Maxillofacial Surgeon

LECTURE# 2: EVALUATION OF LOCAL AND SYSTEMIC DIFFICULTIES

PRIOR TO DENTAL EXTRACTION

INTRODUCTION
Previous the dental extraction the dentist should do a good
evaluation of the patients to determine if they present local factors or
compromising medical condition that difficulty the dental extraction.

LOCAL FACTORS THAT DIFFICULTY THE DENTAL EXTRACTION

1- Acute local infection: In the patients who have acute local
infections in the mouth (acute dentoalveolar abscess, acute gingivitis,
acute candidiasis, acute pericoronaritis etc), we should put treatment
to the acute local infection and delay the dental extraction or any
surgical procedure after the acute local infection disappear.

2- Malignant tumors in the place or near the place of the dental

extraction: In this case the dental extraction is contraindicated to
avoid the bleeding post extraction and the spread of the tumor.

3- Irradiated jaws: : In this case the dental extraction is also

contraindicated because the radio-therapy treatment can cause the
bony necrosis and can appear pathological fracture and bony
infection.

4- Recent fractures of the jaws: In this case the dental extraction is

delayed two years after the fracture occurring to complete the
healing of the jaw and avoid a new fracture of the jaws.

The patients that present compromising medical condition are of

surgical risk and should be identified in the mediate preoperative
period.

SURGICAL RISKS: It is defined as the possible damage or danger that

threatens a patient about to be subjected to a surgical treatment no
matter how simple or inoffensive it seems to be.

GROUP OF PATIENTS WITH SURGICAL RISKS

To this group belong:
• Diabetic patients
• Patients with antecedents of arterial hypertension
 • Cardiopaty patients
• Patients with antecedent of rheumatic fever
• Patients with leukemia
• Hemophiliac patients
• Pregnancy
• Elderly patients
• Patient with encephalopathy
• Patient with anemia
• Childhood
• Very apprehensive patients
• Allergic patient to anesthesia and drugs

DIABETIC PATIENTS
To the diabetic patients we must indicate:
• Medical consultation before the surgical treatment
• Blood test (complete blood complementary and blood sugar)
• If they are not under medical treatment or are not stabilized the
diabetic, they can’t be put under a surgical procedure no
matter how simple it might be.
• Being under treatment and stabilized, the dental extraction or
any surgical procedure can be done with previous antibiotic
prophylaxis, hours before and after the dental extraction or
surgical intervention occurs.

HYPERTENSION AND CARDIOPATHY PATIENTS

With these patients we must do:
• Adequate history and evaluation of the patients
• Medical consultation
• Electrocardiogram and chest x-ray
• Administer the local anesthesia as slow as possible
• Avoid excessive use of vasoconstrictor or use the local
anesthesia without vasoconstrictors
• The anticoagulants drugs (walfarin, heparin, etc) are used in
cardiopathy patients and in the patients operated of the heart
valves. In these patients the anticoagulant drugs must be
withdraw during 7 days, and the prothrombin time has to be
done and when it is normal then the surgical treatment can be
undertaken.
• In patients with disease or operated of the heart valves,
prophylactic treatment must be carried out with antibiotic drugs
since many hours before the surgical procedure is done

PATIENTS WITH ANTECEDENT OF RHEUMATIC FEVER

These patients need good medical evaluation, because they have
heart valves damage and are susceptible to invasion by
streptococcus viridians which is frequently present in the blood after
dental extraction or surgery.
Antibiotic therapy is indicated 1 hour before surgical treatment, 6
hours after operation and maintains the treatment 3 or more days

PATIENTS WITH LEUKAEMIA

With these patients we must do:
• Medical consultation
• Hospitalization for receive treatment
• Blood transfusion before surgical treatment
• Use of antibiotic
• Local methods of hemostasis

PATIENTS WITH HAEMOPHILIA

Hemophilia is an hemorrhagic disease and we must do:
• Medical consultation
• Hospitalization of the patients
• Use of antihaemophilic globulin before surgery
• Local methods of hemostasis

THE PREGNANCY
In the pregnancy we need to be careful in the dental treatment and
with some types of drugs, the x-ray are contraindicated in the first
trimester but the dental extractions have not contraindications
Medical and gynecologic consultation should be done and is very
important to do a good preoperative evaluation

ELDERLY PATIENTS
These patients have more health problems and frequent suffer many
diseases and function degeneration.
The principal health problems are:
- Oldness of the tissues.
- Vitamin deficiency.
- Circulatory disorders.
- Facing infection.
- Anemia.
- Hypoproteinemia.
- Traumas.

For this reason we should do before the dental extraction or any

surgical procedure:
• Medical consultation
• Good preoperative care
• Chest x ray
• Electrocardiogram
• Use of vitamins and antibiotic therapy
PATIENTS WITH ENCEPHALOPATHY
The patients with encephalopathy need medical consultation and
good preoperative care
They need to take dental treatment too and when the patients are
uncooperative the general anesthesia is indicated

PATIENTS WITH ANEMIA

The anemia is consider hemorrhagic disease therefore if the patient
has 10 or less gram of hemoglobin is better avoid the operation and
does medical consultation.

CHILDHOOD
With these patients we should have special cares and do pediatric
consultation
When they are uncooperative the general anesthesia is indicated for
dental extraction or surgical procedure no matter how simple it might
be.

VERY APPREHENSIVE PATIENTS

They need:
Medical and psychological consultation
Sedation before dental extraction
In many times is necessary general anesthesia for dental extraction
or simple surgical treatment.

ALLERGIC PATIENTS: The patients can be allergy to:

1 - Anesthesia.
2 - Drugs.

1- ALLERGIC PATIENTS TO THE LOCAL ANESTHESIA

After being tested by the allergist, we have 3 options:
• Use of benadriline (diphenhidramine) as a substitute of the
local anesthetics to carry out the dental extraction or surgical
procedure of short duration.
• Make dental extractions with acupunctural analgesia procedure.
• Administer general anesthesia only when the surgical
procedure is prolonged or of greater extent.

2- ALLERGIC PATIENTS TO DRUGS

We should do medical consultation and good preoperative evaluation.
We should avoid the use of allergic drugs.

BIBLIOGRAPHY
 Mazola C: Oral surgery. 2nd edition,2003
 Peterson U: Contemporary oral and maxillofacial surgery. 4th
edition,2004
 Laskin D M: Oral and maxillofacial surgery. Volume I and II. 3rd
edition,2003
 Fonseca J: Oral and maxillofacial surgery. Volume LVII. 2nd
edition,2002